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1. Eco-Friendly Infection Control-
Understanding the Balance
practical applications for going green
and “doing no harm”

2. What does going green MEAN?
Adopting practices that reduce your overall impact on
the environment. Adding sustainability principles and
considerations into the planning process of work or
personal lifestyle.
10/7/2010 2

3. What is Dentistry’s Environmental
Footprint – More than you think
The Environmental Impact of Dentistry Every
Year Dental Practices Generate
•680 million disposable infection control
barriers
•1.7 billion instrument and sterilization pouches
•28 million liters of toxic x-ray fixer
•4.8 million lead foils Dental vacuum systems
waste 9 billion gallons of water a year.
Reference Eco Dentistry

4. Issue 1: Amalgam Is the Most
Important Problem
• EPA estimates 3.7 tons of mercury waste per
year from dental offices
• Only 11 states and 19 localities require
amalgam separators
• EPA’s separator requirements only in 10 states

5. Issue 2: Photochemical Waste

6. Issue 3: Reducing Your Carbon
Footprint

7. What if it was really simple?
• I am the ONLY person RESPONSIBLE for my
behavior.
• I choose to change the environment…to make
the world better place for everyone.

8. Amalgam Solution – Very Simple
and Greatest Step Towards Green
• Capture and recycle
• Install an Amalgam Separator.
• Switch to Composites.

9. Amalgam– Capture & Recycle
• Scrap amalgam and amalgam waste include any left over bulk amalgam, spent
capsules, and disposable chairside-traps.
• Dentists should collect and store all contact and non-contact scrap amalgam for
recycling.
• It is important to note that not all recyclers can handle mercury. Indeed mercury
waste cannot be landfilled or incinerated as this releases the toxins in the
atmosphere and groundwater.
• Mercury waste needs to be sent to an approved recycler that can reprocess the
mercury.
• These need to be appropriately labeled and stored in tightly closed containers for
recycling.

10. Amalgam – Install a Separator
• Install an Amalgam Separator
The BENEFITS:
• Amalgam separators are solids collectors installed on the vacuum lines of dental offices. They
capture the amalgam before it reaches the sewers.
• The ADA estimates that 25% of amalgam waste still makes it to the wastewaters even after
the use of chair-side traps and other capturing methods.
• The ADA’s best management practices (BMP) recommend the use of amalgam separators
which are certified to collect over 98% of amalgam waste.

11. Amalgam – Separator Solutions
• Install an Amalgam Separator
Available Solutions
Show SolmeteX and ECO II
PureLife Incentive Program

12. Amalgam - Regulations
• Install an Amalgam Separator
The Regulations
• Current States
• EPA Regulation

13. Amalgam Alternatives – Switch to
Composites
• Switch To Composites
• Switch to Composites. One sure-way of reducing mercury waste is to switch from mercury
amalgam to non-mercury alternatives (i.e. composites, gold, ceramics). These are certainly
more challenging to do as procedures but also carry with them higher price premiums (from
1.5x to over 8x compared to amalgam as shown in the exhibit below) and so can be accretive
to a practice’s top line. But mercury alternatives can be slightly less resistant to wear and tear
and in the case of composites or glass monomers have been know to have lower longevity,
not to mention higher costs to the patient. As such, mercury amalgam remains pervasive in
the dental industry and measures need to be put in place to control the extent of amalgam
related pollution. It is also important to note that all-composite practices that perform
procedures on patients with amalgam fillings

14. Photochemical Waste Solution
• Shift to Digital X-Rays
• About 50% of dentists have already shifted to digital x-ray equipment. Digital x-rays do not
require film fixer and developer, both of which are known for creating highly toxic waste.
While typical digital X-ray systems are capital intensive, costing on average 3-4x conventional
film X-ray systems, they have lower operational costs namely due to reduced amount of
consumables (fixer, developer etc.) associated with the development of film X-ray, not to
mention significant cost savings in reduced waste management and recycling. In fact
depending on the office, digital X-ray systems can pay for themselves in as little as 2-3 years.
Digital systems also provide more tools for the dental practitioner and offer an enhanced
service to the patient. Digital X-ray systems also deliver up to 80% less radiation to the
patient. For more information on the potential cost savings afforded by the shift to digital x-
ray, please refer to <our Lean Mean and Green article…>

15. Photochemical Waste Solution
• Implementing a Proper Waste Compliance
Program.
• Waste from x-ray procedures such as fixer, developer, lead-foil and lead aprons are toxic and
potentially harmful and need to be handled, stored and disposed of or recycled in accordance
with strict and detailed OSHA compliance rules, which can vary from state to state. Solutions
are available from many recyclers in the form of pickup services or more affordable mail-in
services. Not all recyclers will deal with all types of waste and so, practices need to balance
for themselves the pros and cons of using one single provider and whether the added
convenience of a pick up service outweighs the extra costs vs. mail-back programs. Most
programs also include a sharps/bio-hazard service which is mandatory by law.

16. Reduce CO2 FootPrint
• 3.1 Buy Eco-Friendly Products
• 3.2 Improve Energy Efficiency
• 3.3 Source from Eco-Friendly Suppliers

17. Reduce CO2 FootPrint
• 3.1 Buy Eco-Friendly Products
• 3.2 Improve Energy Efficiency
• 3.3 Source from Eco-Friendly Suppliers

18. Reduce CO2 Footprint
• Buy Eco-Friendly Products
• Products featuring reduced packaging or recyclable packaging with lead-free ink
• Products made from biodegradable or recyclable materials – focus on high volume disposable
items (i.e. barrier sleeves, syringe tips, plastic cups etc.)
• Autoclavable products vs. disposables when practical (i.e. stainless steel suction tips, prohy
angles and prophy cups)
• Certified carbon neutral or carbon free products – products whereby the manufacturer or
distributor has donated a portion of profits to offset or cancel the effects to the environment.

19. Reduce CO2 Footprint
• Improve Energy Efficiency
• Install energy efficient HVAC system
• Use natural light as much as possible
• Use efficient lighting (i.e. halogen or LED) when possible
• Install energy efficient windows, save over 30% of energy costs
• Turn off all electrical equipment when not in use

20. Reduce CO2 Footprint
• Source from Eco-Friendy Suppliers
• Use suppliers that have taken real tangible steps towards being more eco-friendly
• Use suppliers with eco-friendly products
• Use carbon-neutral suppliers with offset programs
• Important Note: Always consider patient care first when considering green products – not all
green substitutes areappropriate within an infection control and dental setting.

21. Some other Simple Ideas that Work
• Source from Eco-Friendy Suppliers
• Use suppliers that have taken real tangible steps towards being more eco-friendly
• Use suppliers with eco-friendly products
• Use carbon-neutral suppliers with offset programs
• Important Note: Always consider patient care first when considering green products – not all
green substitutes areappropriate within an infection control and dental setting.

22. Get a Recycling Bin
66 million tons of Garbage NOT in the
Landfill

23. Plastic bags..
Don’t have
to be eaten
to harm the
animals

24. Statistics on the Amount of Time Items
Take to Decompose
Paper: 2.5 months
Milk Carton: 5 years
Cigarette Butt: 10-12 years
Plastic Bag: some say 10-20 years…other sources say 100 years
Disposable diapers: 75 years -450 years
Tin Can: 100 years-200 years
Plastic Bottle: 450 years
Glass Bottle: 1,000,000 years
Styrofoam: NEVER

25. Other Benefits of Going Green
• Save Green

26. Other Benefits of Going Green
• Benefits of Digital X-Ray

27. Other Benefits of Going Green
• Benefits of Energy Efficiency

28. Other Benefits of Going Green
• Some Companies Offer Subsidies

29. Other Benefits of Going Green
• Improve and Grow Your Practice

30. Green Infection Control and
Understanding the Balance
Your Responsibility

31. Goals
• Define the concept of going green and its
relevance to infection control in the dental setting
• Understand the practical application of the chain
of infection to going green
• Identify the solutions for maintaining infection
control standards and going green
• Develop a plan for changes in infection control in
the dental setting to minimize the impact on the
environment

32. OUR responsibility
• Follow the Medical Model-Wellness based
• Reduce and Save
• Stay up to date

33. Where did you start?
Medical Model
• Good
• Better
• Best
10/7/2010 33

34. Going Green Means
• You uses the safest materials available that
have the least impact on the environment
• Going green means you do not cross
contaminate and end up sending someone to
the hospital!

35. Misconceptions
• Green products cost more
• Green products are not as effective
• Green cleaning is too complicated
• Green is difficult to implement

36. Reality
• Green products are competitively priced/cost
neutral “green saves green”
• Green products can be more effective and
have higher return on investment
• A good program is easy to monitor, train and
maintain
• You may already be doing some green things
you do not know about

37. But what about doing no harm?
“Green infection control and safety is disease
prevention and safety procedures and
products that further reduce adverse health
and environmental impacts”. Chris Miller DDS

38. SO what next?
• Reduce waste where possible and when not
possible use environmentally friendlier
supplies that feature recyclable materials or
packaging.
• Buy from suppliers who are environmentally
friendly or have eco-friendly initiative such as
carbon offset programs as a way to reduce
waste or offset that waste.

39. Green Products
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40. Green Products 2
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41. Green Products 3
10/7/2010 41

42. Green Companies
PROVIDE PURELIFE PROFILE AND OTHER COMPANIES
10/7/2010 42

43. Green Companies 2
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44. Green Companies 3
10/7/2010 44

45. In the Long Run
• Improves health
• Helps reduce Worker’s Comp claims and
premiums
• Helps reduce turnover, which in turn impacts:
– Recruiting
– Hiring
– Training
– Impact of service

46. 5 Simple Steps for Change
• Determine the need
• Involve the team and Develop a plan
• Acquire “Green” products and equipment &
Provide training
• Implement the plan, products & procedures
• Re-evaluate

47. How can reductions be made?
1) Behavioural Changes
2) Policy and Process Changes
3) Technological Changes

48. How can I get others to change?
In order to make a change after receiving
information you must:
• See the need
• Know the action
• Value the action
• Repeat the action

49. UNDERSTANDING CHAIN OF INFECTION
AND STANDARDS OF INFECTION
CONTROL AND GOING GREEN

50. Chain of Infection
Pathogen
SusceptibleHost Source
Entry Mode
10/7/2010 50

51. Universal Precautions, 1980’s:
Protects against exposure to blood,
some other body fluids
 Hand washing
 Personal protective equipment
 Controls to prevent injuries
 Proper management of patient care
items and environmental surfaces
10/7/2010 51

52. Standard Precautions 1990’s:
protect against exposure to blood, body
secretions, excretions, nonintact skin,
mucous membranes
• Hand washing
• Personal protective equipment
• Controls to prevent injuries
• Proper management of patient care items
and environmental surfaces
10/7/2010 52

53. Exposure Prevention Strategies
• Engineering controls
• Work practice controls
• Administrative controls
10/7/2010 53

54. Practical Application
• Behavior and techniques
• Sustainable equipment: Recycle, Reuse
• Disposables
• Do no Harm
• Resources for Change
• Evaluation of supplies and materials green
factors
• Safe disposal of chemicals

55. Behavior and techniques

56. Washing Your Hands
The single most important
way to reduce the risk of
disease transmission.
10/7/2010 56

57. Clean Hands
Save Lives
88% of disease spread through hand
contact
10/7/2010 57

58. Update Hand washing statistics

59. Hand hygiene
• Hand washing
• Hand antisepsis
• Surgical hand antisepsis
• Hand care
• Preventive measures
10/7/2010 59

60. Hands Need to be Cleaned When
• Visibly dirty
• After touching
contaminated objects with
bare hands
• Before and after patient
treatment (before glove
placement and after glove
removal)
10/7/2010 60

61. • Transient microorganisms: acquired through
direct contact, on surface layer
• Resident Flora: Usually normal flora of skin,
attach to deeper layers
10/7/2010 61

62. Efficacy of Hand Hygiene
Preparations in Reduction of
Bacteria
Good Better Best
Plain Soap Antimicrobial Alcohol-based
soap handrub
Source: http://www.cdc.gov/handhygiene/materials.htm
10/7/2010 62

63. Gloving is not a substitute for
Hand washing!
10/7/2010 63

64. Hand Hygiene Definitions
• Handwashing
– Washing hands with plain soap and water
• Antiseptic handwash
– Washing hands with water and soap or other detergents
containing an antiseptic agent
• Alcohol-based handrub
– Rubbing hands with an alcohol-containing preparation
• Surgical antisepsis
– Handwashing with an antiseptic soap or an alcohol-based
handrub before operations by surgical personnel
10/7/2010 64

65. Hand washing
• Lathering: Pulls
microorganisms away form
the skin’s crevices and
suspends them
• Rinsing: washes them off
your hands
10/7/2010 65

66. How do we get the message out?
• Facts? Ethics? Understanding?
Culture?
• It make you sick, there are germs
involved?
• Decrease in COMPLIANCE, 2.0
female, 21.5 males

67. Everyone understands

68. Something everyone
can relate to…

69. Direct to the Point

70. Simple Concise

71. So what worked?
• Grossness
• Increased hand washing in females
26 percent 8 percent in males
• SO what do we do?

72. How does it apply?
• Preach in a toilet?
• How can I transfer this to practice?
• Do I bring gross examples with me?
• A minute in the MORNING

73. How can I get others to change?
In order to make a change after receiving
information you must:
• See the need
• Know the action
• Value the action
• Repeat the action

74. Your hands are only as clean as the
towel you use to dry them

75. Disposables

76. Barrier surface protection
• Speedy turnaround
• Safety and efficiency
• Available for almost all surfaces
• Eliminate the wait time
• Limit chemical exposure and release to the
atmosphere
10/7/2010 76

77. Barrier Protection

78. 10/7/2010 78

79. Create a Barrier
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80. 10/7/2010 80

81. 10/7/2010 81

82. Wipe wipe wipe
What are you Breathing?

83. • OSHA exposure limits to these
chemicals is governed by OSHA time
weighted average (TWA) for these
chemicals.
• For information on work place
exposure and methods for reducing
exposure go to OSHA.org

84. Toxicological, environmental and occupational
concerns associated with disinfection and
sterilization practices
 Disposal of chemical need to be addressed
 Some chemicals can be neutralized by reaction
with chemicals such as sodium bisulfite or
glycine.

85. And So?
• Establish a program for monitoring occupational exposure to regulated chemicals
that follows federal, state, and local regulations. This must include the key factors
to assess the risks of chemical exposure including duration, intensity, and route
of exposure.
• Ensure that no employee is ever overexposed to the TWA.
• Material and Safety Data Sheet (MSDS) information must be available for all
products that are in the dental setting. MSDS sheets include information on TWA.
• All employees must be educated, and the purpose of the HazCom standard is to
ensure that hazards of all chemicals produced or imported be evaluated and that
employers transmit the information concerning such hazards directly to
employees. Information is conveyed through a comprehensive hazard
communication program. The program includes a written clinic/office program
manual, container labeling and other forms of warning, Material Safety Data
Sheets (MSDSs), and employee training.

86. Do No Harm

87. Aspiration Pneumonia
ICU one DAY~$14,401
 An incentive spirometer is $250
 Pulse ox is $150
 Admission kit is $150,
 IV tubing is $80
 One dose of 650 mg of Tylenol is $10
 Antibiotics PRN $720
 ICU rooms are averaging $13,041 24 hours
 Staff, Transportation, uniforms, sheets, drapes, single
use supplies

88. Resources for Change

89. Safe disposal of chemicals

90. Resources
State environmental agencies
• www.epa.gov/epahome/state.htm
Healthcare Environmental Resource Center
• http://www.hercenter.org/dentistwastes.cfm
Healthcare Without Harm
• www.noharm.org

91. Sources
• recycleitnow.net
• OSAP.ORG
• DONOHARM.ORG
• CDC.ORG
• plasticsresource.com
• pbs.org/pov/borders/2004/water/water_disposable.html
• refillnotlandfill.org
• bottledwaterblues.com
• sks-bottle.com
• www.earth911.org
• www.thedailygreen.com

92. APPENDIX
10/7/2010 92

93. So what is a Carbon Footprint?
• A carbon footprint is a measure of the impact
our activities have on the environment in
terms of the amount of green house gases
produced, measured in units of carbon dioxide
equivalents (CO2e).

94. What is Carbon?
• The base for all life (as we know it)
• Graphite is soft and most common carbon
allotrope
• Diamond is very hard & expensive!
• Coal and Oil (are carbon based)
– When burnt with air causes carbon dioxide to
be emitted

95. What’s Carbon Dioxide (CO2)
• It’s a gas (at standard room temperature and pressure)
• We breathe it out
• Used by plants in photosynthesis
• Makes drinks fizz
• Colourless and odourless (in low concentrations)
• Trace gas in the Earth’s Atmosphere (0.039%)
• A Greenhouse Gas

96. Greenhouse Gases
• A “blanket” keeping our planet warm
• Without them Earth would be very different and too
cold to support life (over 30oC colder)

97. Where is the CO2 coming
from?
• 40% of gas emitted from Volcanoes is CO2
• Volcanoes emit about 130 – 230 million tCO2 /year
• Human activity is about 130x that of volcanoes
– 27 billion tCO2/year
• Other natural sources emit about 1000x as much as
volcanoes

98. Look closely at:
• Extraction
• Production and transportation of raw
materials
• Manufacture and service provision
• Distribution
• End use
• Disposal and Recycling

99. Want to know your foot print?
Resources for change…
• http://www.epa.gov/climatechange/emissions
/ind_calculator.html

100. Simple concepts
• US grown Organic Cotton
• Biodegradable
• Natural fibers chlorine free
10/7/2010 100

101. SO what next?
• Reduce waste where possible and when not
possible use environmentally friendlier
supplies that feature recyclable materials or
packaging.
• Buy from suppliers who are environmentally
friendly or have eco-friendly initiative such as
carbon offset programs as a way to reduce
waste or offset that waste.

102. How can reductions be made?
1) Behavioural Changes
2) Policy and Process Changes
3) Technological Changes

103. How can I get others to change?
In order to make a change after receiving
information you must:
• See the need
• Know the action
• Value the action
• Repeat the action