ADA, EPA, NACWA MEMORANDUM OF UNDERSTANDING

1. ADA, EPA, NACWA MEMORANDUM OF UNDERSTANDING Jerry Bowman Public Affairs Counsel State Government Affairs American Dental Association

2. You Need To Know Us • The ADA, Amalgam, Separators and Regulation • Our Perspective and Positions

3. Who Are We? • The American Dental Association represents over 155,000 dentists throughout the United States. • Over 70% of all U.S. dentists are members of the ADA.

4. Our Structure • “TRIPARTITE” • ADA • State Dental Society • Local Dental Society

5. What Is Our Role? • Two Key Roles: • Resource for State Societies • Facilitator

6. Amalgam • Dental amalgam remains a safe and effective treatment option.

7. Amalgam and Public Health Issues • The availability of dental amalgam plays an important role in assuring access to care. • Amalgam is less expensive and more durable than the primary alternative. • Beazoglou, T., et al., “Economic Impact of Regulating the Use of Amalgam Restorations,” Public Health Reports, vol. 122, p. 657,659 (Sep’t-Oct., 2007).

8. Amalgam: So Why (Else) Do We Care? • Patient choice • Durability • Cost • Aesthetics • Dentist-Patient relationship • EPA Policy on Patient Choice “EPA recognizes that the decision to use dental amalgam is a medical decision that is best made by dental professionals and their patients.” • 1/5/06 B. Grumbles’ letter to Rep. Manzullo, referencing G. Grubbs’ 10/8/03 testimony to a House subcommittee.

9. Doing our Share! • Dentistry is committed to doing its share to protect our environment. • While dentistry contributes less than 1% of the mercury in the environment, we can do more to recycle.

10. ADA Policy: Amalgam and the Environment • ADA included amalgam separators as part of the ADA Best Management Practices (“BMPs”) in October 2007. • We favor voluntary programs. • We work to promote separator use among U.S. dentists. • BMPs

11. Why Voluntary Programs? • They Work! The ADA is fully behind these efforts now—a change since separators were added to BMPs. A powerful tool to reach dentists. • They Are Efficient! POTWs avoid the time, energy and money needed to manage a new program. Dentists avoid (pardon!) bureaucratic headaches. • Even simple (pre-separator) BMP outreach will accomplish a lot! • .

12. Organized Dentistry’s Efforts Are Recognized • “The dental community, including ADA and state and local dental associations, has taken action to reduce amalgam wastewater discharges to POTWs. The ADA has evaluated the effectiveness and cost of amalgam separators, contributed to the development of the ISO separator standard, advised the dental community concerning installation and maintenance issues, and conducted outreach and education programs concerning reduction of discharges of amalgam wastewater. In 2007, the ADA updated its voluntary best management practices for dentists (ADA BMPs) to include the purchase and proper use of an amalgam separator, in order to increase the recycling of amalgam.” ADA, EPA, NACWA Memorandum of Understanding (emphasis added).

13. Some Science—Separators and BMPs

14. Just What Do Separators Do? • The Key (To Us): Separators allow waste amalgam to be captured in the dental office so that the mercury may be recycled. --Clear and Indisputable • Separators reduce mercury in biosolids. • But if you want to convince dentists to use separators, do not make scientifically dubious claims.

15. What They Do Not Do • Separators do not measurably, or at least, regularly, lower effluent mercury levels. • According to the best studies—NACWA (field study) and Vandeven, AN ASSESSMENT OF MERCURY IN THE FORM OF AMALGAM IN DENTALWASTEWATER IN THE UNITED STATES, Water, Air, and Soil Pollution (2005) 164: 349–366 (theoretical)

16. NACWA Separator Study • AN EXAMINATION OF MERCURY LEVELS AT CLEAN WATER AGENCIES 2003-2006 • The Facts: The influent, effluent, and biosolids mercury concentrations from twelve POTWs in the United States and Canada, in various stages of requiring dental facilities to install amalgam separators, were measured on a monthly basis from July 2003 through July 2006.

17. NACWA Separator Study Conclusions • “…increasing amalgam separator installations does not necessarily lead to a decrease in effluent mercury concentrations.” • “According to the results, separator installation does not generally appear, at least within the timeframe of this study, to significantly reduce effluent mercury concentrations. However, amalgam separator installation does generally appear to result in reductions in biosolids mercury concentrations.”

18. Missouri Research project--BMPs MAXIMIZING VOLUNTARY REDUCTIONS IN DENTAL AMALGAM MERCURYReduction in Mercury DischargesEPA # E0000127PI-98765101-0 Marie Steinwachs, Director, Environmental Assistance Center, University Of Missouri Extension Fred Eichmiller, ADA Foundation • Funding and support was provided by: • U.S. Environmental Protection Agency • American Dental Association Foundation • Springfield Public Works Department • Greater Springfield Dental Society • The University of Missouri Extension’s Office of Waste Management (now the Environmental Assistance Center)

19. Goals • Determine whether significant reductions in mercury discharges from dental offices could be achieved through voluntary best management practices (BMPs) [Prior Version of ADA BMPs] • Determine what effect BMPs have on mercury load to wastewater influent, effluent and biosolids

20. Design • Influent and effluent samples collected at two treatment facilities using EPA method 1669 • Total mercury determined by EPA method 1631 at Frontier Geosciences lab • Biosolid analysis done on monthly blended samples using EPA method 245.1 • Pre-BMP sampling on wastewater done for 4 months, biosolid for two years

21. Biosolid Results—How Odd No significant difference in biosolid levels after the April 2006 BMP training

22. Influent Results A significant change after BMP training for SW plant with 90 dental offices. (No significant change after BMP training for NW plant with 3 dental offices.)

23. Effluent Results No significant change in effluent loading after BMP training for either treatment plant

24. Conclusions • BMP training resulted in a measurable and significant reduction in mercury load to the influent wastewater of the treatment plants. • BMPs did not result in a measurable change in biosolid mercury levels. Unexpected and may be due to study limitations. • BMPs did not result in a measurable change in mercury load to effluent treatment water, similar to NACWA data.

25. Conclusions • The education and training provided to area dental offices resulted in an overall increase in the use and understanding of BMPs. • There were significant increases in the recycling of used amalgam capsules and scrap amalgam, and corresponding decreases in the disposal of these wastes as regular trash. • This was before separators were in BMPs, but model could be modified with new BMPs.

26. Regulatory Approaches

27. BMP’s: One Way to Go • “[G]ood examples of situations where BMPs may be appropriate”: “requirements for dental facilities to follow BMPs to control mercury Discharges from dental amalgam where individual monitoring on a large scale is impractical and where Discharges are episodic in nature.” • 70 Fed. Reg. 60134, 60148 (Oct. 14, 2005) (Streamlining Rule)

28. Current Regulatory Climate • 11 states and at least 19 localities have mandatory pretreatment programs that require the use of dental mercury amalgam separators. • Voluntary programs are being created.

29. The Best Approach • Know Your Audience! • The Easy Way or the Hard Way: Dentists will react well to efforts at collaboration. Work together; Educate them. Dentists react negatively to “interference” without science basis

30. Possible EPA Action • In 2008, EPA studied a possible national pretreatment standard for dental offices. If enacted, such a standard would likely mean a nation-wide separator mandate. • EPA concluded it was not necessary, in part because dentistry was already taking voluntary steps on its own (e.g. adding separators to BMPs).

31. The Memorandum of Understanding

32. Memorandum of Understanding on Reducing Dental Amalgam Discharges • The Environmental Protection Agency, the American Dental Association and a national wastewater treatment association have signed an agreement to promote voluntary use of the ADA's best management practices for handling amalgam waste.

33. What Does the MOU Have to Say? • Memorandum of Understanding (MOU) between the U.S. Environmental Protection Agency (“EPA”), the American Dental Association (“ADA”), and the National Association of Clean Water Agencies (“NACWA”) to establish and monitor the effectiveness of a Voluntary Dental Amalgam Discharge Reduction Program • As of 2005, amalgam use had declined to one third of the 1979 level (52.5 million amalgam restorations (31.6% of all restorations) compared to 157 million amalgam restorations performed in 1979).

34. Memorandum of Understanding on Reducing Dental Amalgam Discharges • The Key to the MOU: Promote use of separators • First: Baseline data on separator usage • Then: Show progress towards greater use of separators!

35. Promote Separators • Develop Tools for the States (Grassroots) (Some listed later) • News Stories, Brochures, Presentations • Member Outreach

36. Baseline • Purpose: A baseline from which to measure progress • Harder than it looks! • ADA member data (over multiple years) • Manufacturer data (incomplete and conflicting) • EPA estimates

37. Dental Amalgam Separators – Made Easy to Install, Easy to Use, Easy to Maintain • There are resources available: • ADA.ORG (search “amalgam separators”) • Separator manufacturers (turnkey operation) • State Dental Society

38. ADA.ORG • Free downloadable copy of the BMPs • “Evaluating Amalgam Separators Using an International Standard” (July 2006) • “Purchasing, Installing and Operating Dental Amalgam Separators: Practical Issues”  (August 2003)

39. ADA.ORG • Dental Amalgam Separators in the ADA Professional Product Review—Fall 2007—Product reviews, buyer’s checklist, expert discussion • Directory of Amalgam Recyclers • Laboratory Evaluation of Amalgam Separators  (May 2002)

40. Questions? Comments? Jerry Bowman Public Affairs Counsel American Dental Association bowmanj@ada.org 312-440-2877