Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Dental Facilities. This supplement is designed to keepyour product up to date. Your next supplement will be in May 2015.

If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 ore-mail customerservice@hcpro.com. At HCPro, customer comments and suggestions are very important to us—let usknow how we can serve you better.

Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.

FILING INSTRUCTIONS

Rev. 3/15 OPMFDF Supplement to OSHA Program Manual for Dental Facilities

VISIT www.hcmarketplace.com for the latest compliance and training information.

Remove Insert Reason for Change

Title page Title page updated

i through viii i through viii Master List of Program Items for Customization—updated,

front matter repaginated

ix/x and xv/xvi ix/x and xv/xvi OSHA Program Manual Contents—updated

Tab 6 Contents Tab 6 Contents updated

6-1 through 6-28 6-1 through 6-33 Tab 6: Hazardous Chemical & Radiation Safety—updated

March 2015 Revisions

About the AuthorMarge McFarlane, PhD, MT (ASCP), CHSP, CHFM, HEM, MEP, CHEP, is an independent safety consultant

with more than 38 years of healthcare experience. She has provided education, emergency management

and safety plan review, life safety, and infection prevention facility surveys for healthcare and businesses

in Wisconsin and across the nation since 2005. She is the author of The Compliance Guide to the OSHA

GHS Standard for Hazardous Chemical Labeling, 2014 and the OSHA Training Handbook for Healthcare

Facilities, Second Edition, 2014. 15C

©2005–2015. HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their

agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information.

However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their

agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally,

or consequentially by the information in this publication. This publication cannot and does not provide specific information

for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the

assistance of legal counsel regarding their particular situation.

HCPro, a division of BLR75 Sylvan Street, Suite A-101

Danvers, MA 01923Tel: 800/650-6787Fax: 800/639-8511

www.hcmarketplace.com

OSHAPROGRAMMANUALfor Dental Facilities

OSHA Program Manual for Dental Facilities is published by HCPro, a division of BLR.

Copyright © 2015 HCPro, a division of BLR.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-60146-744-7

No part of this publication may be reproduced, in any form or by any means, without prior written consent of

HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately

if you have received an unauthorized copy.

HCPro, a division of BLR, provides information resources for the healthcare industry.

HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO

and Joint Commission trademarks.

Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, HEM, MEP, CHEP, Author

Sheila Dunn, DA, MT (ASCP), Contributing Editor

John Palmer, Managing Editor

Mike Mirabello, Fulfillment Specialist

Glenn Stefanovics, Content Management Specialist

Matt Sharpe, Senior Manager of Production

Elizabeth Petersen, Vice President

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or

clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro, a division of BLR

75 Sylvan Street, Suite A-101

Danvers, MA 01923

Telephone: 800-650-6787 or 781-639-1872

Fax: 800-639-8511

E-mail: customerservice@hcpro.com

Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com

3/15

i

Important Information About the Use of This Program

This product is intended for use in one facility and is copyrighted for this purpose. Please do not copy the con­tents or print additional copies for use in other facilities or for teaching anyone other than your em ployees. This manual may not be transferred to another workplace without the written consent of HCPro, Inc.

As an OSHA Program Manual owner, you may call or e­mail us anytime you have OSHA­related ques tions specific to your practice. HCPro also publishes a monthly newsletter, Medical Environment Update, to help you keep your OSHA Program Manual current from year to year. Should OSHA pass a revised or new regula tion, we will inform you of that change through Medical Environment Update. We will also provide forms, in structions, posters, and advice through this newsletter to help you keep your practice up to date and in compliance.

Follow these steps to determine if your manual is up to date:1. Check for the three­character code in the lower right­hand corner of the box on the title page of

this manual.

2. Then log into your HCPro account on your Medical Environment Update subscription page at www.hcpro.com/login-3265. If you have not established a username/password or have forgotten it, you may retrieve by clicking the link on this page.

3. Once logged in to the Medical Environment Update subscription page, find the most recent issue.

4. There you will find an update file. If the file has the same code as on the title page, your manual is up to date.

5. If the update code is different, open the file and chose from the appropriate pdf to download for your manual (medical or dental).You also have the choice of printing your update pages one­sided or two­sided, depending you your printing capabilities.

6. Print the updated pages and replace the old pages.

Should you have difficulty logging in or accessing the updated pages, contact HCPro customer service: Telephone: 800/650­6787

E­mail: customerservice@hcpro.com Thank you for your business. Let us know how we can help.

HCPro, a division of BLR75 Sylvan Street, Suite A­101

Danvers, MA 01923Telephone: 800/650­6787

Fax: 800/639­8511www.hcmarketplace.com

ii

iii

How to Customize this Program

To come into complete OSHA compliance, the information in this program must be customized to reflect the actual circumstances in your workplace. For easy tracking, initial and date when you complete an item.

Item Initials Date

Post the “It’s The Law” poster in a place that is visible to all employees. This poster, OSHA #3165, is located in the front pocket of this manual.

↓

Hang the eyewash station sign located in the front pocket of this manual. Make sure it is clearly visible above or next to the eyewash.

↓

Designate the evacuation route, and post in several locations. Be sure to post the route in the reception area and break room. See Tab 3, page 3­18, 3­18A for details.

↓

Read each tabbed section and verify that the policies and procedures described apply to your practice.

↓

Remove or strike through any procedure

you don’t perform!

iv

Item Initials Date

Either cross through the unused procedures, and initial and date your deletion.

OR

Remove the pages from the manual.

↓

Throughout, fill in all blanks with information specific to your facility. A master listing of “blanks” is on pages iv – v. Spaces to Initial and date are provided on the master listing.

_______

↓

Use the Monthly and Annual Checklists to organize your OSHA activities.

↓

Document all activities performed. See Tab 8 for master copies of all forms.

↓

Make photocopies of forms and logs that are used repeatedly. To customize any form, see the enclosed CD.

↓

Keep this manual up­to­date! Download updates and insert them into this manual immediately upon receipt of the current issue of Medical Environment Update Newsletter which explains how to access the update Web page.

v

Master List of Program Items for Customization

Throughout this OSHA Program Manual, blanks are included for you to fill in information specific to your facility.

The following pages contain “blanks” for you to customize. Enter your initials and the date you made the entry in the far right columns. This way when you do your annual review you can quickly tell if you need to update old information.

Page Item Information Needed Initials Date

2­2 Key Contacts for the OSHA Safety Program

Safety officer name, employer name, phone numbers, safety manual location

2­8 Workplace Hazards Record other hazards found in facility

2­22 Annual Review Safety officer to record reviews of safety program

3­2 Emergency Phone List Fill in emergency contact phone numbers

3­15 Systems Failure Record names and numbers to call in the event of a systems failure

3­16 Evacuation Procedures Determine and record evacuation procedures

3­18 Evacuation Route Draw floor plan of your facility noting exits and fire safety equipment

3­20 Emergency Preparedness Supplies

Determine emergency supplies you will keep on hand and record their location

3­24 Severe Weather Record safest location in building (Note: 3 blanks)

3­273­33 Violence Prevention Details of your Violence Prevention Plan (Note:

6 blanks and 2 lists that require checkmarks)3­343­35 First Aid Kit Identify items included in your facility’s

first aid kit

3­37 3­41

Drug­Free Workplace Program

Details of your Drug­Free Workplace Program (Note: if no options selected on 3-37, other customizations not necessary)

3­44– 3­47 Holiday Decorations Details of your combustibles decoration policy

(Note: this is not a required policy)3­51– 3­53

Slips Trips and Falls Risk Assessment

Review of slip, trip and fall hazards in your facility

5­9 Exposure Prone Procedures

Note procedures performed in your facility that could expose employees

5­11Form 7 BBP Determination List Record all employees who have definite risk

of exposure (class I)5­13

Form 8 BBP Determination List Record all employees who have possible risk of exposure (class I)

5­14 Restricted Access Areas Record restricted access areas

vi

Page Item Information Needed Initials Date5­16 Handwashing Locations Record handwashing locations5­19 Sharps Recapping Record instances when recapping is allowed

5­20 Safety Sharps Record instances when safety sharps are not used

5­22 Bleach Contact Time If you use bleach for decontamination, check and document state specific contact time

5­23 Housekeeping Schedule Record your facility’s cleaning methods and frequency

5­30 Eyewash Stations Record eyewash locations and types

5­31 Biohazardous Waste Record name of company and phone for your facility’s biohazardous waste pick­up

5­33 Laundry Note how biohazardous laundry is cleaned or whether you use only disposables at your facility

5­34 PPE Locations Record PPE provided in your facility and its location

5­39 When to Wear PPE Read PPE required at your facility and add additional PPE in space provided

5­42 Hepatitis Vaccinations Record name of provider and location for HBV vaccine

5­50 BBP Post Exposure Testing Record name of provider for medical evaluation and lab testing in case of an employee exposure

6­23 Chemical Exposure Record facility name and phone for exposure medical follow­up

7­5 Form 21 TB Risk Assessment Gather information and record TB Risk Assessment

7­7 Early TB Identification Record procedures to ID active TB patients and where they are referred for treatment

7­9 Managing TB Patients Record location where suspected TB patients will wait and facility they will be transferred to

7­10

N­95 Masks Medical Powered Air Purifying Respirators (PAPRs)

Note whether your facility provides N­95 masks Note whether your facility provides PAPRs

7­13 Form 22 TST Record Record each employee’s TST details

7­15 Employee TB Infections Record name of facility where employees with positive TST or symptoms of TB will be referred

7­16 Form 24 TB Exposure Log Record names of employees only if exposed to TB

7­18 Pre­pandemic PlanningRecord name and title of individual to be designated as Response Coordinator. Also record name and contact information of key agencies

7­19 Pre­pandemic Planning (con’t)

Record communication plan, name of person responsible for PR and Educational Coordinator.

7­21 Influenza Staff Shortage Calculate and record number of staff needed during a shortage and record who will cover

7­21 Influenza Reporting Note the frequency of reporting during a pandemic and record who will review reports

vii

What Is Included in This Program

Contents at a GlanceOccupational Safety and Health Administration (OSHA) regulations protect employees from unsafe/at­risk working conditions. This includes on­the­job exposure to infectious diseases, such as HIV, hepatitis and tuberculosis, and hazardous substances such as glutaraldehyde, formalin, isopropyl alcohol and medical gases.

This OSHA Program is intended to help outpatient dental facilities develop their particular policies and procedures in order to achieve compliance with the major federal OSHA regulations that impact dental practices.

Here’s what you’ll find inside:

TAB 1: What Is OSHA?This first section provides a quick look at OSHA, including what types of people and workplaces are protected under the agency’s jurisdiction, and what to expect from an OSHA inspection.

TAB 2: Injury & Illness Prevention ProgramTab 2 introduces medical facilities to administration of an OSHA Program, including appointing an OSHA Safety Officer, establishing the duties and authority of the OSHA Safety Officer, and organizing compliance duties.

TAB 3: General Facility SafetyThis section provides an overview of the general workplace requirements applicable to dental facilities, including fire safety, slip/trip and fall prevention, electrical safety, exits and building evacuation, workplace violence, first aid and emergency action plans which includes bomb threats and severe weather. There is also an overview for a drug­free workplace program.

TAB 4: Ergonomics in the Dental WorkplaceFind out how to protect employees from repetitive motion disorders in the workplace in this section. Though OSHA’s Ergonomics Standard was rescinded, Tab 4 provides common­sense measures to prevent the musculoskeletal disorders most frequently found in healthcare employees.

TAB 5: Bloodborne Pathogens Exposure Control PlanBehind Tab 5 is a “fill-in-the-blanks” Exposure Control Plan for compliance with OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030). Once customized, this becomes your facility’s policies to protect healthcare employees from occupationally acquired exposure to certain infectious organisms such as the human immunodeficiency virus (HIV) and hepatitis viruses (especially hepatitis B and C). The Bloodborne Pathogens Standard has been in effect since 1992, and was amended January 18, 2001 to include the requirement for sharps with built­in safety features.

viii

What is Included in This Program, cont.

TAB 6: Hazardous Chemical & Radiation SafetyEverything you need to know to comply with the Globally Harmonized System (GHS) update to the OSHA’s Hazard Communication Standard (29 CFR 1910.1200) is in this section. This Standard (also called the “Right to Know”) has been in effect since 1987 for all dental facilities, and is designed to protect employees from on­the­job exposure to hazardous chemicals. The GHS update effective March 2012 is to ensure that workers have the “right to understand” the chemical hazards in their workplace.

TAB 7: Infection and Prevention ControlTab 7 contains a “fill-in-the-blanks” TB Exposure Control Plan to protect employees from occupational exposure to Mycobacterium tuberculosis. It also contains measures to protect employees from respiratory infections, such as influenza, and a Pandemic Plan. There is an expanded section on preventing the spread of multidrug resistant organisms with the Centers for Disease Control and Prevention guidelines for outpatient facilities and the most recent governmental guidelines for infection control in a dental setting.

TAB 8: Master Record Forms This section contains master copies of Record Forms that will be needed repeatedly, from Accidental Reports to Bloodborne Pathogens, and HazCom Records to Employee Training Records. Be sure to photocopy the original form before removing it from this section. These forms are also included on the CD Rom in the front pocket of this OSHA Program.

TAB 9: OSHA Regulations & Key ContactsTab 9 contains copies of actual OSHA regulations pertinent to dental facilities and key contacts for selected Federal agencies.

OSHA Regulations That Are Not Included in This Safety ProgramThe following OSHA Standards are not addressed in this manual, since they do not apply to the activities in typical dental facilities:

Chemical Hygiene Standard (*29 CFR 1910.1450). Laboratories within dental facilities that use hazardous chemicals in bulk amounts must comply with this regulation.

Formaldehyde Standard (*29 CFR 1910.1048). Dental facilities that work with bulk quantities of formaldehyde (pouring it into specimen containers and/or processing specimens contained in formalin) may be required to comply with this regulation.

Hazardous Waste Operations and Emergency Response (HAZWOPER) (29CFR1910.120), applies to workplaces that store, treat and dispose of large volumes of hazardous waste, or respond to emergencies caused by the uncontrolled release of infectious material.

ix

IntroductionImportant Information About the Use of This Program ............................ iHow to Customize this Program ................................................................. iiiMaster List of Program Items for Customization ...................................... vWhat Is Included in This Program ............................................................... vii

TAB 1: OSHA Jurisdictions & InspectionsA Quick Look at OSHA ................................................................................. 1-1

States with OSHA­Approved Plans ..................................................................................... 1­1OSHA Consultative Services Division ................................................................................. 1­2OSHA’s Jurisdiction ............................................................................................................. 1­2OSHA’s General Duty Clause .............................................................................................. 1­2

Employee or Employer? ............................................................................... 1-3Employer Responsibilities Under OSHA .............................................................................. 1­4

Overview of OSHA Standards ...................................................................... 1-4OSHA Inspections ......................................................................................... 1-5

Employee Complaints .......................................................................................................... 1­5If an On­site OSHA Inspection Occurs ................................................................................ 1­6During the Inspection ........................................................................................................... 1­7What OSHA Inspectors May Ask Employees ...................................................................... 1­7The Typical OSHA Inspection .............................................................................................. 1­8The Closing Conference ...................................................................................................... 1­8

OSHA Sanctions ........................................................................................... 1-10Whistleblower Protection ............................................................................. 1-11Students and Volunteers .............................................................................. 1-13

OSHA PROGRAM MANUAL

Contents

Front Pocket OSHA Poster 3165: IT’S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self­Adhesive Labels CD­ROM (MS Word for Windows 2000) with Master Record Forms (Tab 8) from this Manual

for Customization.

Page

x

Contents

TAB 2: Injury & Illness Prevention ProgramInjury & Illness Prevention Plan .................................................................. 2-1

Management Leadership and Employee Involvement ........................................................ 2­1Key Contacts for the OSHA Safety Program ....................................................................... 2­2Location of the OSHA Safety Program ................................................................................ 2­2

Duties of the OSHA Safety Officer ............................................................... 2-2Accident/Incident Investigation & Reporting Procedure .......................... 2-3

Definition of an Accident/Incident and/or Near-Miss Event ................................................. 2­4When to Investigate an Accident/Incident ........................................................................... 2­4How to Document an Accident/Incident ............................................................................... 2­4Recording Accidents or Injuries for OSHA ........................................................................... 2­5Correcting Unsafe or at Risk Conditions ............................................................................. 2­5

Recordkeeping Requirements ..................................................................... 2-5Equipment & Facility Records ............................................................................................. 2­5Bloodborne Pathogens Records ......................................................................................... 2­6Hazard Communication Records ........................................................................................ 2­6TB Records/Respiratory Protection Program ...................................................................... 2­6Employee Medical Records ................................................................................................. 2­6Evaluating Exposure Incidents ............................................................................................ 2­7

Workplace Hazard Analysis ......................................................................... 2-7Employee Training ........................................................................................ 2-9

Checklist for an Effective Safety Training Session .............................................................. 2­9Interactive Safety Training Exercises .................................................................................. 2­10

General Safety ............................................................................................................ 2­10Fire Safety ................................................................................................................... 2­10Bloodborne Pathogens Safety ..................................................................................... 2­10Chemical Safety ........................................................................................................... 2­11TB Safety ..................................................................................................................... 2­11

Annual Employee Retraining ....................................................................... 2-11Bloodborne Pathogens Annual Training Contents ............................................................... 2­12Respiratory Protection Annual Training Contents ................................................................ 2­13Hazard Communication Annual Training Contents .............................................................. 2­13

New Employee Orientation .......................................................................... 2-13Documenting Employee Training ............................................................... 2-13OSHA Annual Retraining Sample Test Questions ..................................... 2-14Practical Ideas for Administering the OSHA Safety Program .................. 2-17Organizing OSHA Compliance Duties ........................................................ 2-17Weekly Facility Review Checklist ............................................................... 2-19Monthly Facility Review Checklist .............................................................. 2-20Annual Facility Review Checklist ............................................................... 2-21Annual OSHA Safety Program (Exposure Control Plan) Review Form ... 2-24

xv

Contents

Titering Employees after the Hepatitis B Vaccination .......................................................... 5­42How to Determine Employee Immunity ....................................................................... 5­42Testing Employees Vaccinated before the Titer Requirement ..................................... 5­43

Types of Hepatitis B Tests ........................................................................... 5-43Interpreting Hepatitis B Test Results .................................................................................... 5­44

New Employee Hepatitis B Virus (HBV) Vaccination Flow Chart ............. Supplement

Post-exposure Evaluation & Follow-up ...................................................... 5-45What Is an Exposure? ......................................................................................................... 5­45What to Do after an Occupational Exposure ....................................................................... 5­45

For HCV Exposures .................................................................................................... 5­47For HBV Exposures ..................................................................................................... 5­47For HIV Exposures ...................................................................................................... 5­48When to get Expert Consultation for HIV Post­exposure Prophylaxis ......................... 5­49

Confidentiality of Post-exposure Procedures ...................................................................... 5­49Employee Counseling/Precautions ..................................................................................... 5­50

Occupational Exposure Management Resources ..................................... 5-50Incident Report/Sharps Injury (Form 11) .................................................... 5-51Post-exposure Checklist (Form 14) ............................................................. 5-53Post-exposure Medical Evaluation Declination Form (Form 15) .............. 5-54Injection Safety ............................................................................................. 5-55

Information for Providers ..................................................................................................... 5­55Unsafe Injection Practices and Disease Transmission ........................................................ 5­56

Frequently Asked Questions: Injection Safety FAQs for Providers ......... 5-56Overview .............................................................................................................................. 5­56Injection Procedures ............................................................................................................ 5­57Resources ............................................................................................................................ 5­60

Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens ..................... Supplement

Bloodborne Pathogens Resources ............................................................. 5-61

TAB 6: Hazardous Chemical & Radiation SafetyA Quick Look at HazCom ............................................................................. 6-1

Determining Which Chemicals Are Hazardous ................................................................... 6­2Routes of Exposure to Hazardous Chemicals ..................................................................... 6­3

Safety Data Sheets ....................................................................................... 6-3Examples of Chemicals Requiring an SDS ......................................................................... 6­4Chemicals Not Requiring an SDS ....................................................................................... 6­4SDS Flowchart Determination ............................................................................................. 6­4Information Required on an SDS ........................................................................................ 6­5How to Get SDSs ................................................................................................................ 6­10

xvi

Contents

Where to Keep SDSs .......................................................................................................... 6­10HazCom Recordkeeping ..................................................................................................... 6­11

Classification of Hazardous Chemicals ..................................................... 6-11Flammable Liquids .............................................................................................................. 6­11

Storage of Hazardous Chemicals ............................................................... 6-12Special Hazard Communication Requirements for California ............................................. 6­13

Hazardous Chemicals With Permissible Exposure Limits (PELs) ........... 6-13Avoiding Overexposure to Hazardous Chemicals ............................................................... 6­14

Beryllium­Containing Alloys .......................................................................................... 6­14Glutaraldehyde ............................................................................................................ 6­15Sterilant Safety Handout .................................................................................... SupplementGlutaraldehyde Spills .................................................................................................. 6­17Testing the Potency of Glutaraldehyde ....................................................................... 6­17Disposing of Glutaraldehyde ....................................................................................... 6­18Mercury ....................................................................................................................... 6­18Nitrous Oxide .............................................................................................................. 6­19

Monitoring Employees for Exposure ................................................................................... 6­20

Labeling Hazardous Chemicals .................................................................. 6-20HazCom Pictograms and Hazard Statements ..................................................................... 6­20Pictograms .......................................................................................................................... 6­20NFPA Label System ............................................................................................................ 6­21

Safety Tips for Working with Hazardous Chemicals ................................. 6-22Chemical Spill Cleanup Procedures .................................................................................... 6­22Chemical Exposure to Skin ................................................................................................. 6­22

Medical Consultation and Injury Evaluation .............................................. 6-23Hazardous Chemical Waste Packaging and Disposal .............................. 6-23Special Precuations for Dental Labs .......................................................... 6-24

Silicosis ............................................................................................................................... 6­24Tasks in a Dental Lab that Can Cause Silica Exposure .............................................. 6­25Controlling Exposure to Silica ..................................................................................... 6­25Other Potential Health Hazards Associated with Working in a Dental Lab ................. 6­25

Allergic Reactions to Dental Products .................................................................................. 6­26

Gas Cylinder Safety ...................................................................................... 6-26Electrosurgical Safety (Lasers) .................................................................. 6-28

Safe Laser Practices ........................................................................................................... 6­29

Radiation Safety Policies ............................................................................ 6-29Radiation Safety in Dental Practice ..................................................................................... 6­30Protecting Staff from Unnecessary Radiation Exposure ..................................................... 6­30Ionizing Radiation Exposure Limits ..................................................................................... 6­31Limiting Exposure to Women of Childbearing Age ............................................................... 6­31Employee Training ............................................................................................................... 6­31Miscellaneous Ways to Minimize Radiation Exposure ......................................................... 6­32Regulation of the Medical Use of Nuclear By­Products ...................................................... 6­32Nuclear Regulatory Commission .......................................................................................... 6­33

TAB 6: HAZARDOUS CHEMICAL & RADIATION SAFETY

Contents

A Quick Look at HazCom ................................................................................ 6-1Determining Which Chemicals Are Hazardous ...................................................................... 6-2Routes of Exposure to Hazardous Substances ..................................................................... 6-3

Safety Data Sheets .......................................................................................... 6-3Examples of Chemicals Requiring an SDS ........................................................................... 6-4Chemicals Not Requiring an SDS .......................................................................................... 6-4SDS Flowchart Determination ............................................................................................... 6-4Information Required on an SDS ........................................................................................... 6-5How to Get SDSs ................................................................................................................... 6-10Where to Keep SDSs ............................................................................................................. 6-10HazCom Recordkeeping ........................................................................................................ 6-11

Classification of Hazardous Chemicals ........................................................ 6-11Flammable Liquids ................................................................................................................. 6-11

Storage of Hazardous Chemicals .................................................................. 6-12Special Hazard Communication Requirements for California ................................................ 6-13

Hazardous Chemicals With Permissible Exposure Limits (PELs) .............. 6-13Avoiding Overexposure to Hazardous Chemicals ................................................................. 6-14

Beryllium-Containing Alloys ............................................................................................ 6-14Glutaraldehyde ............................................................................................................... 6-15Sterilant Safety Handout .................................................................................... SupplementGlutaraldehyde Spills ..................................................................................................... 6-17Testing the Potency of Glutaraldehyde .......................................................................... 6-17Disposing of Glutaraldehyde .......................................................................................... 6-18Mercury .......................................................................................................................... 6-18Nitrous Oxide ................................................................................................................. 6-19

Monitoring Employees for Exposure ...................................................................................... 6-20

Labeling Hazardous Chemicals ..................................................................... 6-20HazCom Pictograms and Hazard Statements ....................................................................... 6-20Pictograms ............................................................................................................................. 6-20NFPA Label System ............................................................................................................... 6-21

Safety Tips for Working with Hazardous Chemicals..................................... 6-22Chemical Spill Cleanup Procedures ...................................................................................... 6-22Chemical Exposure to Skin .................................................................................................... 6-22

Page

Medical Consultation and Injury Evaluation ................................................. 6-23Hazardous Chemical Waste Packaging and Disposal ................................. 6-23Special Precuations for Dental Labs ............................................................. 6-24

Silicosis .................................................................................................................................. 6-24Tasks in a Dental Lab that Can Cause Silica Exposure ................................................. 6-25Controlling Exposure to Silica ........................................................................................ 6-25Other Potential Health Hazards Associated with Working in a Dental Lab .................... 6-25

Allergic Reactions to Dental Products .................................................................................... 6-26

Gas Cylinder Safety ......................................................................................... 6-26Electrosurgical Safety (Lasers) ...................................................................... 6-28

Safe Laser Practices .............................................................................................................. 6-29

Radiation Safety Policies ................................................................................ 6-29Radiation Safety in Dental Practice ....................................................................................... 6-30Protecting Staff from Unnecessary Radiation Exposure ........................................................ 6-30Ionizing Radiation Exposure Limits ........................................................................................ 6-31Limiting Exposure to Women of Childbearing Age ................................................................. 6-31Employee Training ................................................................................................................. 6-31Miscellaneous Ways to Minimize Radiation Exposure ........................................................... 6-32Regulation of the Medical Use of Nuclear By-Products ......................................................... 6-32Nuclear Regulatory Commission ............................................................................................ 6-33

Contents

6-1

OSHA Program Manual for Dental Facilities

TAB 6: HAZARDOUS CHEMICAL & RADIATION SAFETY

A Quick Look at HazComOSHA’s Hazard Communication Standard (HazCom) has been in effect since May 1988, and is also called the “Right to Know” Standard. Its intent is to protect healthcare workers from hazardous substances in the workplace. The HazCom Standard May 2012 updates align the OSHA standard with the United Nations’ Globally Harmonized System (GHS) for chemical classification and labeling. While the basic requirements of HazCom are still in place, the intent was to provide employees the right to “understand” the hazards of the chemicals in their workplace. The purpose of the GHS is to ensure quality and consistency of labeling by using pictograms, signal words, and hazard and precautionary statements in an international economy. GHS is meant to unify all the different and sometimes conflicting systems of labeling and identifying hazardous chemicals throughout the world, thereby reducing trade barriers. The advantages of the GHS as stated by OSHA include:Reduced confusion about hazard classifications Increased understanding about safety precautions to take, approved use, proper storage

and disposal of chemicals and mixtures Increased downstream risk management by increasing understanding of the risks of

hazardous chemicals Facilitated training with uniform safety data sheets (SDSs) and well-defined hazard classesEnhanced worker understanding, especially for low-literacy workers and those workers

where English is a second language Improved worker safetyEnhanced international trade

The GHS update adds appendices to the Hazard Communications Standard that better define health and physical hazards, require that mixtures of chemicals be assessed for hazards, and require that a pictogram for each hazard class be placed on the label of each chemical container received or each secondary container used in the workplace.

There are key elements of the original Hazard Communication Standard that are still in effect. This includes the need for a written Hazard Communication Plan that is reviewed annually. Other items that remain include:An accurate, frequently updated list of chemicals in the facilityA safety data sheet (SDS) (formerly a material safety data sheet (MSDS)) for each

hazardous chemical that is readily accessible at all timesTraining for all workers before they are potentially exposed to hazardous chemicals and

when new chemical hazards are introduced Identification and training on required Personal Protective Equipment (PPE)

6-2

OSHA Program Manual for Dental Facilities

Knowledge of signs and symptoms of exposure to hazardous chemicals in their areaProper segregation and storage of all chemicalsSpill kits/emergency equipment for each class of hazardous chemicalEmergency response and first aid proceduresMedical evaluation protocols in cases of overexposureArchiving MSDSs and SDSs no longer in use for 30 years

To ensure that information about the dangers of hazardous chemicals used in this facility are known by all affected employees, this Hazard Communication program has been established and requires the transition to the use of uniformly formatted SDSs and new labeling requirements for all for all hazardous chemicals. These standardized SDSs are to be fully implemented by December 2015 and all existing MSDSs will be replaced as soon as SDSs are available.

Until that time either the current MSDS or the new SDS is acceptable as long as employees are trained on the information currently available in the healthcare facility. Although the initial training was completed by December 2013, all employers must continue to maintain the updated SDSs, review the current hazard communication program and update it as new health/risk Information becomes available. Additional training will be needed to ensure that all employees understand the meaning of the new labels and pictograms.

Determining Which Chemicals Are Hazardous

Chemical exposure may cause or contribute to many serious health problems such as heart ailments; central nervous system, kidney and lung damage; sterility; cancer; burns; and rashes. Some chemicals may also be physical safety hazards and have the potential to cause fires, explosions, and other serious accidents.

To determine whether any chemical in a dental practice needs an SDS, use the following criteria:

1. Is the chemical hazardous?2. Are employees exposed to it?

Check all locations for chemicals, liquid or aerosol drugs and medications (tablet and capsule forms are exempt), disinfectants, and x-ray developers. (Note that the use of digital films eliminates the need for hazardous developer and fixer chemicals.)

Examine the label of each to see if a statement is present, such as “flammable,” “danger,” or “warning.” The pictograms on the new labels will indicate if the chemical is a health hazard, an irritant/sensitizer, corrosive, oxidizer or toxic. If a hazard statement and/or pictogram is present, the chemical is considered hazardous by OSHA and is regulated under the HazCom Standard. By June 1, 2015, all labels from chemical manufacturers will be required to have a product identifier, pictograms, a signal word, hazard and precautionary statements, and supplier identification. Distributors, however, have until December 1, 2015, to comply with the new labeling requirements and to use up stock with the old labels.

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Determine whether employees are involved with the products in such a way that they could be exposed. For instance, do employees administer medications to patients or do they simply give the bottles to patients to take home? If the latter is the case, then you do NOT need an SDS for that medication, since there is no chance of employee injury.

If employees administer or handle a particular product check the product label or package insert that accompanies it. If there is a health, flammability or “warning,” or “danger” listing, then an SDS is required. Imagine an employee accidentally getting the solution in their eye or on their skin. What would need to be done in this instance? The answer is on the SDS in Section 4 (first aid measures). Any employee handling that product would need to know what to do.

Routes of Exposure to Hazardous Chemicals

The safest way to prevent chemical injury is to know the routes of entry that each chemical may take into the body and take precautions to ensure that contact is not made. In general, routes of exposure of a substance fall into one of the following categories:

1. Inhalation. Many occupational exposures result from breathing chemical vapors. These substances may affect the respiratory track or pass from the lungs to other organs by way of the blood stream or lymphatic system. The type and severity of the effect depends on the nature of the chemical, the amount of chemical absorbed, the rate of absorption, individual susceptibility, and other factors.

2. Ingestion. This route of exposure may occur if the worker is not using preventive measures such as gloves and proper handwashing techniques, or is eating food or consuming drink in the work area. This mode of exposure is far less common in dental surroundings than inhalation.

3. Skin Contact. This is a frequent mode of chemical exposure, often resulting in localized irritation. A wide variety of substances can penetrate the skin and produce skin hypersensitivity, including latex, formaldehyde and phenols. Skin is abundantly supplied with blood vessels, which facilitate the absorption of chemicals into the body.

4. Eye Contact. Eyes are very sensitive to contact with most chemicals, resulting in irritation. Eyes are vascular organs and rapidly absorb many chemicals. Alkaline materials, phenols, and strong acids are particularly corrosive and can cause permanent loss of vision.

5. Injection. This route of exposure can occur inadvertently through mechanical injury from glass or metal contaminated with chemicals, or when toxic chemicals are handled in syringes with needles.

Safety Data SheetsA key requirement for compliance with HazCom is the availability of SDSs for hazardous chemicals. An SDS contains emergency, precautionary and general information about hazardous chemicals and chemical mixtures.

Compile a master list of all hazardous substances using the Hazardous Chemical List located behind Tab 8: Master Record Forms (Form 16) in this OSHA Program Manual.

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Examples of Chemicals Requiring an SDS

Drugs and pharmaceuticals except those in solid, “final form” (tablets, pills, capsules) for direct administration to the patient. Tablets or pills designed to be dissolved or crushed by employees prior to administration are not in “final form” and require SDSs. Package inserts and the Physicians’ Desk Reference cannot substitute for manufacturers SDSs.

A product containing a hazard warning that is available commercially to the general public.Bleach.All disinfectants Alcohol hand sanitizers.Dry socket paste.Amalgam alloy.

Chemicals Not Requiring an SDSAny product that does not bear a hazard warning.

YES

YES

YES

YES NO

NO

NO

NO

Is the chemical (drug) labeled as hazardous or dangerous?

Can employees be exposed to it?

Is the chemical used according to the label instructions?

Is the chemical (drug) a common consumer (household) product, and is it used with the same frequency as a

consumer would use it?

MSDS not required. MSDS is required.

SDS flowchart determination

Source: A Common Sense Approach to Chemical Safety for Medical and Dental Settings, Quality America.

SDS is requiredSDS is not required

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Information Required on an SDSSDSs will have a specified 16-section standard format and include the following information.

Section 1: IdentificationThis section: Lists the chemical name as well as any other common names by which the product is

known Identifies the recommended uses for the product Identifies any restrictions on use as recommended by the supplier/manufacturerGives the chemical manufacturer or supplier address and contact information

Example: isopropyl alcohol, 70%, is frequently used in healthcare as a topical antiseptic Other listed names for this chemical include 2-propanol, isopropanol, rubbing alcohol,

or IPA Identified uses include cleaning of skin prior to procedures, as in venipuncture

or injection. Identified restrictions include not using isopropyl alcohol on internal wounds or for

drinking (ingestion).

Section 2: Hazard(s) identificationThis section identifies all of the different hazards of a chemical and the appropriate warning information associated with each of those hazards. This section changed from a performance-based orientation to a specific criteria for the classification of health and physical hazards. The information will also provide specific criteria for the classification of mixtures. GHS will require that mixtures are classified by the percentage of each component included, and a revised hazard rating be provided. These specific criteria will help to ensure the evaluations of hazardous effects are consistent across manufacturers, and that labels and SDSs are more accurate as a result. The information will include all the information that will be required on the container label:The hazard classification of the chemical, i.e. flammable liquidSignal word (Danger or Warning): a single word to indicate the relative severity

of the hazard “Danger” is used for more severe hazards, while “warning” is used for less

severe hazardsHazard statement(s) describes the nature of the hazards and the degree of hazard, i.e.,

may cause liver or kidney damagePictograms for each hazard class: a symbol intended to convey specific information

regarding the hazard of a chemicalPrecautionary statement(s) related to minimizing or preventing adverse effects resulting

from exposure and improper storage or handling of a chemical

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Description of any hazards not otherwise classified or of unknown toxicity. This is a change from previous HazCom information, as the statement of acute toxicity would be relative to the percentage of the ingredients in the mixture, and is not just a statement about that ingredient alone.

Examples of chemicals that fall into this category include simple asphyxiates and/or combustible dust.

Example: isopropyl alcohol, 70%:- Hazard classification: flammable liquid, eye irritation- Signal word: Danger- Hazard statements: Highly flammable liquid and vapor- Causes serious eye irritation- Causes mild skin irritation- May cause drowsiness or dizziness- Pictogram: flame and irritant (exclamation mark)- Precautionary statements:

o Keep away from heat/sparks/open flame. No smoking. o Do not breathe vapors

- In case of fire, use dry chemical (BC) or carbon dioxide extinguisher

Section 3: Composition/information on ingredients This section lists the chemical identity and common names; percentage of each ingredient if it is a mixture; chemical listing (unique identifiers); and impurities or stabilizers, which are also classified and contribute to the hazard classification of the product. A statement that a chemical is claimed as a trade secret or is proprietary would be made in this section.

Section 4: First-aid measuresThis section lists the signs and symptoms, acute and delayed effects of exposure to the chemical. This is key information and required for employee training. This section lists first aid measures for skin and eye exposure, as well as inhalation and ingestion. Required treatment listed in this section might include the use of an eyewash station for a corrosive or caustic chemical, or the need to move to fresh air and get medical attention.

Example: isopropyl alcohol, 70%, Symptoms of isopropyl alcohol poisoning or overexposure include flushing, headache, dizziness, central nervous system depression, nausea, vomiting, and loss of consciousness. Poisoning/overexposure can occur from ingestion, inhalation, absorption, or consumption of isopropyl alcohol.

First aid:Eyes: Rinse with plenty of water for 15 minutes and seek medical attention. Inhalation: Move person to fresh air and keep at rest. If breathing is difficult, give oxygen.

If not breathing, give artificial respiration. Get medical attention.

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Skin: Flush with plenty of water for at least 15 minutes while removing contaminated clothing and wash using soap. Get medical attention.

Ingestion: Do not induce vomiting! Never give anything by mouth to an unconscious person. If conscious, wash out mouth with water. Get medical attention.

Section 5: Firefighting measures This section lists suitable (and unsuitable) extinguishing media (agents like water, dry chemical, or foam), precautions, and special PPE for firefighters, as well as specific hazards arising from products of combustion (fire). Toxic byproducts from the fire and the chemical would be listed here.

Example: isopropyl alcohol, 70%, Is flammable in the presence of spark or flame. Use water spray, alcohol-resistant foam,

dry chemical, or carbon dioxide.Firefighters are to wear self-contained breathing apparatus and full protective clothing,

including eye protection and boots.Gives off toxic fumes (carbon oxides) under fire conditions. (This section also references

the Stability and Reactivity information in Section 10.)

Section 6: Accidental release measures This section references emergency response precautions and personal protective equipment needed. Appropriate procedures for cleanup of spills, leaks, or releases are listed here. It differentiates between protocols for large and small spills, where the spill volume has an impact on the level of the hazard. It will give recommendations for evacuations, methods of containment, and cleanup procedures.

Example: isopropyl alcohol, 70%,Protective Equipment: For large spills, wear chemical safety glasses or goggles,

nitrile gloves, and a lab coat or apron. (Section 8 is where one would find the PPE recommendations.)

An eyewash station or quick drench shower is recommended, since isopropyl alcohol is a severe eye hazard.

Environmental Precautions: Prevent spillage from entering drains.Methods and materials for containment and cleanup: Neutralize spill. Absorb spill with

noncombustible absorbent material, then place in a suitable container for disposal. Clean surfaces thoroughly with water to remove residual contamination. Dispose of waste in accordance with local, state, and federal regulations.

Section 7: Handling and storage This section lists precautions for safe handling, storage, and use. It includes incompatibilities—that is, how this chemical needs to be stored away from certain other chemicals.

Quick note: If one mixes ammonia with bleach, the result is chlorine gas. Inhaled chlorine gas turns into acid in the lungs. Not a recommended process, yet some facilities and laboratories like to store all their chemicals alphabetically because it looked more orderly.

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Example: isopropyl alcohol, 70%,Precautions for safe handling: See Section 8 for recommendations on the use of PPE. Use with adequate ventilation. Wash thoroughly after using. Keep container closed when not in use.

Conditions for safe storage, including any incompatibilities: Store in cool, dry, well-ventilated area. Store away from oxidizing agents (bleach) and aluminum. (What this tells me is that I should never store isopropyl alcohol in an aluminum container.) See also Section 10 for incompatible materials.

Section 8: Exposure controls/personal protectionThis section lists any regulatory exposure limits, use of personal protective equipment (PPE), work practice controls, and ventilation requirements used to minimize exposures. There are several agencies that have developed occupational exposure limits for an 8-hour workday. OSHA has Permissible Exposure Limits (PELs) which have the force of law but are somewhat outdated. National Institute for Occupational Safety and Health (NIOSH) has Recommended Exposure Limits (RELs), and the American Conference of Governmental Industrial Hygienists (ACGIH) has published Threshold Limit Values (TLVs). The NIOSH and ACGIH limits are guide-lines but have the advantage of being updated as additional hazards of chemicals become known.

Example: isopropyl alcohol, 70%,OSHA PEL = 400 ppm.NIOSH REL = 400 ppmACGIH TLV = 200 ppm

These are average exposures over an 8-hour workday where the average worker would not suffer health effects. Many of these exposures were developed for industrial settings and not healthcare.

Personal Protective Equipment:Eyes: wear chemical safety glasses or goggles. (Remember that isopropyl alcohol is a

severe eye irritant.) Inhalation: provide local exhaust.Skin: wear nitrile or rubber gloves, apron or lab coat.Other: provide eyewash stations, showers, and washing facilities.

Section 9: Physical and chemical propertiesThis section lists the properties of the chemical such as vapor pressure, specific gravity, color, odor, pH, appearance, and physical hazards of the chemical, i.e., flammability and explosive limits. This is the beginning of more technical information, but it is helpful to know what the chemical looks like (solid, liquid, green, yellow, or clear) as well as whether it has a characteristic smell.

Quick note: While smell is not an approved way to detect the extent of chemical exposure, some hazardous chemicals have good warning properties. Formalin, glutaraldehyde, bleach, and hand sanitizer all have a distinct smell. Other chemicals like ethylene oxide (a known carcinogen used for gas sterilization) have no odor at all.

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Example: isopropyl alcohol, 70%,Some of the recognizable characteristics include:Appearance: Clear, colorless liquidOdor: Alcohol-likeOdor threshold: 22 ppm (that means one can readily smell isopropyl alcohol)Solubility: readily soluble in water (that means it mixes readily with water).

Section 10: Stability and reactivity This section discusses the risks of explosion of the product in the presence of sparks, shocks, and fire. It also lists incompatible materials and conditions to avoid (like high temperature).

Example: isopropyl alcohol, 70%, Isopropyl alcohol is chemically stable. Conditions to avoid include heat, flames, and

sparks. Extremes of temperature and direct sunlight. Sunlight can warm the liquid, giving off vapors that readily ignite in the presence of a spark or flame.

Incompatible materials include aluminum, acids, and oxidizing agents such as bleach.

Section 11: Toxicological information This section discusses routes of exposure, symptoms, delayed and immediate effects, listing as to whether the chemical is toxic, a carcinogen or reproductive hazard including the OSHA permissible exposure level, any limits recommended by the manufacturer, NIOSH, ACGIH, International Agency for Research on Cancer (IARC), National Toxicology Program (NTP), and Agency for Toxic Substances and Disease Registry (ATSDR). These last three agencies report on chemicals that are stated to be toxic, carcinogens, mutagens, or reproductive hazards.

Example: isopropyl alcohol, 70%,All of the references listed indicate that isopropyl is not classifiable as a human carcinogen.

Signs and symptoms of exposure:Skin: irritation, redness, and itchinessEyes: irritation, redness, watering eyes, and itchinessRespiratory: irritation, coughing, wheezing, dizziness, drowsiness Ingestion: irritation, nausea, vomiting, diarrhea, dizziness, drowsinessChronic toxicity: may cause damage to kidneys, liver, skin, central nervous systemReproductive toxicity: Classified as a reproductive system/toxin/female and a

developmental toxin

Section 12: Ecological information This section lists any environmental impacts if known. This section is not enforceable by OSHA, but included in SDS and indicates if the product is hazardous to the aquatic environment through acute (immediate) or chronic (long-term) aquatic toxicity, or if it is hazardous to the ozone layer.

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Section 13: Disposal considerations This section indicates that users should review how to handle, manage, and dispose of the chemical waste according to applicable federal, state, and local regulations. This section is also not enforced by OSHA.

Example: isopropyl alcohol, 70%,Isopropyl alcohol may still be flammable even as a waste product. Local and state regulations would need to be consulted to determine the appropriate method of disposal.

Quick note: Some states allow flammable liquids to be recycled and used for fuel blending. Check with local and state vendors to see if that option is available in your area.

Section 14: Transport information This section lists shipping and labeling requirements for the Department of Transportation (DOT), Transportation of Dangerous Goods (Canada), the International Maritime Dangerous Goods Code, and the International Air Transport Association. All of the agencies have agreed to use the UN Code for identification of the chemical.

Section 15: Regulatory information This section lists the safety, health, and environmental reporting regulations specific for the product not otherwise listed on the SDS. This information may include any national or regional regulatory information from the Department of Transportation, the Environmental Protection Agency, or Consumer Product Safety Commission regulations.

Section 16: Other information This section includes the date of preparation or last revision. The revisions or changes may be listed here.

How to Get SDSs

SDSs are available free of charge from the manufacturer of the substance and may be sent with the shipment. SDSs are also available over the Internet at the manufacturer’s website.

Where to Keep SDSs

File SDS in the binder accompanying the OSHA Program Manual. Copies of SDS may also be kept at each location where the hazardous chemical is used, if it is distant from the central location. Be sure employees know where SDS are kept and that they have easy access to them.

It is permissible to have your SDS files online or on a computer if employees can readily access the files in the workplace. Be sure to train employees on how to access the SDS file and that there are no barriers to online access such as password locked computers. Identify backup measures in the Hazard Communication Plan in case the online system goes down.

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SDS for products no longer in use need to be kept in a file for 30 years plus the length of employment, especially for those involved in an exposure incident, which then become part of the employee exposure record. Old MSDS and SDS may be scanned into a computer file rather than be maintained in a paper format. Identify the location of the scanned files in the written Hazard Communication Plan.

HazCom RecordkeepingOSHA’s Hazard Communication Standard requires that records of employee exposures to hazardous chemicals for 30 years, so the outdated MSDS must be kept for that long. Archived or filed MSDSs that are no longer in use meet the intent of the Hazard Communication standard.

Classification of Hazardous Substances1. Health Hazards:

a. Acutely Toxic. A term that can be applied to almost any substance in quantity. A substance is considered toxic if serious biologic effects may follow inhalation, ingestion, or skin contact with relatively small amounts.

b. Sensitizer/irritant. These substances cause little or no reaction upon initial contact, but may cause a marked reaction after subsequent exposures.This category may include some adhesives, detergents and high level disinfectants.

c. Carcinogen, mutagen, teratogen. Mercury and lead are examples of “teratogenic substances” which can cause malformation of a fetus. Women who are pregnant or trying to become pregnant should be aware of teratogens in their workplace.

d. Corrosive. Corrosive substances destroy tissue and cause permanent changes in the tissue, such as scarring. Common corrosive agents may include ammonia and acids. The use of corrosive chemicals requires ready access to an eyewash station.

2. Physical Hazards:a. Flammable. GHS revised the definition of flammable liquids to include

any liquid with a flash point below 140 degrees F. OSHA no longer has a “combustible” category. Common flammable items are acetone and alcohol. Note that NFPA 30 still uses the former definitions for flammable and combustible. This could be the basis for miscommunication in the event of a fire or emergency.

b. Oxidizers. Chemicals that give off oxygen when heated are classified as oxidizers. These chemicals do not cause fires but contribute oxygen to the fire triangle. Bleach is an oxidizer that may be present in dental offices.

c. Gases under pressure. Cylinders of oxygen, carbon dioxide or nitrous oxide may be found in many dental offices. If tipped over or dropped, these cylinders can become missiles.

Flammable LiquidsThe adoption of GHS includes a revision of the definition of flammable liquids to include any liquid with a flashpoint below 140 degrees F. The flash points are divided into 4 categories and eliminates the combustible class previously used. It is important to note that the NFPA 30, Flammable and Combustible Liquids Code used by fire fighters has not changed the definitions and still uses Class I ABC for flammable liquids and Class II and III for combustible liquids.

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NFPA publishes consensus codes and standards while HazCom with the GHS is a federal OSHA Labor law. It is easy to see where one needs to be clear about which standard is being referenced as a GHS Category 2 is flammable whereas NFPA Class II is combustible.

Flammables Have Flashpoints Below 140° F

Category Flash Point

Boiling Point Examples

1 <73° F <95°F Acetaldehyde, Ethyl Ether, Cyclohexane.2 <73° F >95°F Acetone, Benzene and Toluene. Alcohol

hand sanitizers3 >73° F <140°F Hydrazine, Styrene and Turpentine.4 >140°F <199.4°F Acetic Acid, Naptha and Stoddard Solvent.

Storage of Hazardous ChemicalsRead all chemical labels carefully to determine other factors for the proper use and storage of hazardous liquids such as ignition temperature, explosive limits (LEL or UEL), vapor pressure, specific gravity and vapor density. Purchase chemicals in a volume that will be consumed before the expiration date.

OSHA does not require the use of flammable storage cabinets unless the total amount of flammable reaches a given amount. The amount of liquid that may be stored outside of a cabinet in any one fire area of a building cannot exceed: 25 gallons of Category 1 liquids in containers. 120 gallons of Category 2, 3, or 4 liquids in containers.

Not more than 60 gallons of Class I or Class II liquids, nor more than 120 gallons of Class III liquids may be stored in a storage cabinet. Also, not more than three such cabinets may be located in a single fire area.

Local authorities and insurance companies may require the use of flammable storage cabinets in quantities less than that of OSHA.

The exceptions to this rule are medicines, beverages, foodstuffs, cosmetics, and other common consumer products, when packaged according to commonly accepted practices.

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Special Hazard Communication Requirements for California

Dentists with 10 or more employees must post a notice sign in the waiting room that alerts individuals, including their patients, to the possibility of exposure to various chemicals used by that office.

NOTICE TO PATIENTS

Proposition 65 WARNING: Dental Amalgam, used in many dental fillings, causes exposure to mercury, a chemical known to the State of California to cause birth defects or other reproductive harm.

Root canal treatment and restorations, including fillings, crowns, and bridges, use chemicals known to the State of California to cause cancer.

The US Food and Drug Administration has studied the situation and approved all dental restorative materials for use.

Consult your dentist to determine which materials are appropriate for your treatment.

A full-size copy of the notice is also available for downloading on CDA Online, http://www.cdacompass.com/Portals/0/Documents/prop65_poster.pdf. Additionally, CDA has developed Proposition 65 FAQ documents for both dentists and patients to provide information on the issue; the FAQs are also available at CDA Online.

Hazardous Chemicals with Permissible Exposure Limits (PELs)SSome chemicals frequently used in dental facilities that have recommended or required employee exposure limits are shown below. Most dental offices will not be required to monitor these levels since exposures are well below these limits. For instance, dental facilities that store small vials of formaldehyde to transport tissue for pathology testing would certainly fall below the established limits. Glutaraldehyde, which is often used as a high-level disinfectant in dental practices, should also remain well below the permissible exposure limits when diluted in a tightly covered container.

Chemical Exposure LimitBeryllium 2 mcg/m3 Ethylene Oxide (EtO) 1 ppm over 8 hours or 5 ppm over a 15-minute period.Formaldehyde 0.75 part per million (ppm) over 8 hours or 2 ppm over a

15-minute period.Glutaraldehyde There is no OSHA PEL;0.2 ppm Is the NIOSH REL:

ACGIH TLV is 0.05 ppm as a ceiling concentration.Mercury 0.1 mg/m3 over an 8-hour shift.Nitrous Oxide 25 ppm.Silica (used in dental labs) 0.05 mg/m3

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If there is any question whether employee exposure exceeds permissible limits, contact a local industrial hygiene company to test the HVAC system. These companies will ensure that your workplace air supply system has an adequate number of air changes per hour to reduce or eliminate employee exposure to these chemicals.

Avoiding Overexposure to Hazardous Chemicals

Beryllium-Containing Alloys

Exposure to beryllium vapor or particles can range from contact dermatitis to chronic granulo-matous lung disease, known as chronic beryllium disease (CBD). In addition, beryllium and some beryllium compounds in vapor and particulate form have been shown to be carcinogenic.Potential hazards or risks from exposure to beryllium result from melting, grinding, polishing and finishing procedures. The risk is greatest during the casting process in the absence of an adequate exhaust and filtration system.

With regard to the dental office, reports of toxicity to beryllium-containing alloys are limited to a few cases of transient contact dermatitis, and no cases of CBD have been documented to date with dental practitioners, dental office employees, or patients. In cases where beryllium-containing dental prostheses are ground or polished in the dental office, precautions should be considered to minimize any exposure to beryllium-containing dust.

Recent studies suggest that exposure to beryllium at levels below OSHA’s 2 mcg/m3 PEL may have caused CBD in some individuals. Therefore, even in the dental office where exposures are likely to be considerably below the 2 mcg/m3 limit, dentists should consider providing their beryllium-exposed staff with National Institute of Occupational Safety and Health (NIOSH)-approved air-purifying respirators equipped with 100-series filters (either N-, P-, or R-type as applicable) or, where appropriate, powered air-purifying respirators equipped with HEPA filters. Clinicians should also note that short-term exposures may exceed the 2 mcg/m3 PEL. Use of a surgical type mask does not provide adequate respiratory protection because it does not seal the face or effectively filter out fine particles.

Take the following precautions when using beryllium-containing alloys for dental prostheses:

1. Obtain SDSs for all dental alloys used in the dental office. 2. Where possible, substitute alloys that do not contain beryllium for beryllium-containing

alloys in dental prostheses (a number of other non-beryllium-containing alloys have been granted the ADA Seal of Acceptance).

3. Conduct all procedures related to grinding or polishing beryllium-containing dental alloys using properly designed and installed local exhaust ventilation.

4. Equip vacuum systems and local exhaust ventilation systems with high-efficiency particulate air (HEPA) filters.

5. When possible, use local exhaust ventilation (hoods) properly to minimize the generation of dust when working with beryllium-containing alloys.

6. Use HEPA vacuums to clean equipment and the floor around the work area. 7. Monitor employee exposures to airborne beryllium dust, using personal sampling

techniques on a regular basis, to ensure that beryllium exposures are below the OSHA Permissible Exposure Limits (PEL, below 2mg/m3) and are as low as feasible.

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8. Limit the number of office staff who have access to areas where beryllium-containing alloys are being ground or polished.

9. To minimize skin contact and to reduce take-home exposures and beryllium contamination of non-work areas, ensure that protective clothing is worn in areas where dental prostheses containing beryllium alloy are being ground or polished.

Glutaraldehyde

Glutaraldehyde is used to disinfect heat-sensitive instruments. Employee exposure leads to a variety of negative health effects including asthma, breathing difficulties, respiratory irritation, and skin rashes. The most serious adverse health effect is occupational asthma. In addition to causing respiratory effects, glutaraldehyde is a contact allergen, giving rise to contact dermatitis, on the hands and occasionally on the face. Skin sensitization from contact with glutaraldehyde has been documented as well.

To avoid skin and mucous membrane contact, use the following personal protective equipment when working with any high-level disinfectant:Gloves made of nitrile or butyl rubber (latex gloves do not provide adequate protection).

Elbow-length gloves are preferred.Fluid-resistant aprons or gowns. Use sleeve protectors if gloves do not protect forearms. Goggles and mask or full-face shield with eye protection.

Always wash hands after handling glutaraldehyde.

An eyewash station must be available with 10 seconds travel of the potential exposure.

NIOSH recommends that workers not be exposed to glutaraldehyde vapor levels above 0.2 ppm as a time weighted average. The ACGIH Threshold Value Limit (TLV) is 0.05 ppm as a ceiling limit over which workers should not be exposed at any time. When working with glutaraldehyde, do so in a well-ventilated room with at least 10 room air exchanges per hour or capture velocity of at least 100 feet per minute if working In a hood. With one or two tightly covered soaking solutions in a well-ventilated room (with at least 10 air changes per hour), concentrations most likely will range from 0.01 ppm to 0.1 ppm, below the NIOSH-recommended exposure limit of 0.2 ppm but may exceed the TLV when pouring solution.

Workers’ highest risk for exposure to glutaraldehyde in a dental practice comes when the solution is poured into or out of the soaking bins and when inserting and removing instruments. Safety nozzles reduce splashing and “glugging” during pouring, thereby lowering glutaraldehyde vapor levels. Unscrew nozzles carefully after use to prevent additional aerosols. Using narrow and deep soaking bins reduces the surface area and lessens employee vapor exposure when inserting and removing instruments. Also, consider keeping rooms with soaking bins cool, as reduced temperature helps prevent vapor formation.

If glutaraldehyde is used extensively or if soaking bins are not tightly closed, employee exposure may exceed safe limits, at which time employees would be required to wear glutaraldehyde badges for a time to establish baseline air levels. If this initial reading exceeds a safe level, a fume hood or sophisticated ventilation system is necessary to reduce glutaraldehyde vapor

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levels. Purchasing automated processing equipment or mobile disinfecting stations for manual processing of instruments can also reduce staff exposure levels. Mobile disinfecting soaking stations are designed specifically for manual high-level disinfecting and provide an enclosed area for sterilizing trays, protecting employees from splashes and spills as well as controlling exposure to vapor from glutaraldehyde through the use of a ductless fume hood with a charcoal filter. Mobile disinfecting soaking stations are designed specifically for manual high-level disinfecting and provide an enclosed area for sterilizing trays, protecting employees from splashes and spills as well as controlling exposure to vapor from glutaraldehyde through the use of a ductless fume hood with a charcoal filter. Mobile stations are relatively inexpensive solutions to ventilation problems.

Symptoms of overexposure to glutaraldehyde include:Throat and lung irritation. Asthma-like symptoms and wheezing.Difficulty in breathing.Nose irritation and/or sneezing.Nosebleed.Burning eyes, tearing and conjunctivitisHeadaches and nausea

Before using glutaraldehyde, be sure employees understand follow these policies and procedures:

1. Have an SDS on file and make sure all employees know the safety precautions to take. 2. Place a warning label that states the name and hazard of the chemical on the soaking

container.3. Rinse and clean instruments to be disinfected prior to soaking. This removes bacteria and

viruses in device lubricants. 4. Those who rinse instruments must protect themselves from splashes and sprays by

wearing gowns, gloves, and face/eye protection. 5. Use in a well-ventilated area with at least 10 air changes per hour. Cover the soaking

container at all times when not inserting or removing objects. 6. After precleaning, rinsing, and drying instruments, precisely follow the manufacturer’s

instructions for high-level disinfection.7. Carefully place precleaned instruments in the disinfectant, making sure they are totally

immersed. Use a strainer basket if instruments have sharp edges. Adhere to the manufacturer’s instructions for dilution and immersion time.

8. Wear heavy-duty utility gloves or nitrile to remove instruments from the solution. Rinse with water according to the manufacturers protocols. Then, visually inspect prior to stocking for reuse or storage. Be vigilant about areas of the instruments that have serrations and crevices. Store in a clean, dry area.

9. Change solutions at intervals recommended by the manufacturer. (See Testing the Potency below) or more frequently if solutions are degraded. Wet instruments added over time cause dilution of the disinfectant.

Sterilant Supplement Display as a quick reference guide

Sterilant Safety

1. MSDS Be aware of the safety precautions on the

Material Safety Data Sheet (MSDS) 2. Avoid contact

Gloves made of nitrile or butyl rubber (latex gloves do not provide adequate protection)

Fluid-resistant apron or gown

Goggles and mask or full-face shield Always wash hands after handling

3. Labeling

Label the soaking container with name of the chemical & hazard warning 4. Ventilation

Use in a well-ventilated area

Cover the soaking container at all times except when inserting or removing objects from the solution

5. Symptoms of overexposure

Throat and lung irritation

Asthma-like symptoms

Breathing difficulty

Nose irritation, sneezing

Wheezing

Nosebleed

Burning eyes and conjunctivitis

Rash–contact and/or allergic dermatitis

Staining of the hands

(brownish or tan)

Hives

Headaches

Nausea

Safety Data Sheet (SDS)

SAFETY DATA SHEETSDS

sdfghsdfhn

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Glutaraldehyde Spills

All glutaraldehyde spills have the potential to create vapor concentrations that exceed recom - mended exposure limits, according to OSHA’s Best Practices for the Safe Use of Glutaraldehyde in Health Care. Employers must create a plan for handling glutaraldehyde spills. The plan should consider the physical characteristics of the area where glutaraldehyde is used (e.g., type and effectiveness of ventilation, room size, and temperature) as well as the quantity and concen-tra tion of the solution. Cleanup equipment and personal protective equipment (i.e., eye, hand, body, and respiratory protection) should be readily available.

Whether a spill can be cleaned up safely without the use of neutralizing chemicals and/or a respirator will depend on the factors listed in the section above. When vapor concentrations are unknown, air-supplied, atmosphere-supplying respirators are appropriate.

OSHA’s Best Practices divides glutaraldehyde spills into drips/splashes and large spills. Drips/splashes can be cleaned up by in-house personnel using the procedures listed on page 6-14.

Following the guidance on the MSDS (SDS) drips/splashes can be cleaned with a disposable sponge, mop, or towel. Glutaraldehyde solutions can also be neutralized with an appropriate chemical agent before wiping up with a sponge, towel, or mop. Cleanup supplies should be thoroughly rinsed with large amounts of cold water prior to reuse. Rinse water and disposable cleanup supplies should be discarded according to applicable regulations. Drips and splashes may also be cleaned up with commercially available spill control kits that contain mats/wipes to absorb and neutralize small spills. The absorbed medium should be disposed of according to local, state and Federal regulations.

Large spills require either specially trained in-house personnel or hazmat professionals. Ad-ditional steps to take for large spills include evacuating the area until the spill is cleaned up and declared safe; donning respirators (if responders are fit-tested for respirator use); containing the spill with spill pillows and booms if needed; neutralizing the spill with a commercial neutralizer or appropriate chemical agents such as sodium bisulfite or glycine; thoroughly rinsing the area and cleaning up supplies with cold water after removal of the spill; and disposing of rinse water, disposable cleanup supplies, and absorbent mediums according to applicable regulations and the procedures outlined in the facility spill control plan.

Testing the Potency of Glutaraldehyde

OSHA does not address “check strips” or “test strips” to verify the potency. Only glutaraldehyde solutions at the appropriate dilution will be effective in providing high level disinfection to the equipment being processed. Follow manufacturer’s instructions for the frequency of checking solutions, or routinely test solution for strength each day of use (or more frequently) using the appropriate chemical indicator and document the results of this testing. Discard the solution if the chemical indicator shows the concentration is less than the minimum effective concentration. Document that each new bottle of test strips when first opened is tested with a “pass and fail” solution according to the manufacturer’s directions. Test strip bottles must be dated when opened. An expiration date based on the manufacturers’ instructions should also be placed on the opened bottles. Test strips are sensitive to moisture in the air and should remain tightly covered when not in use.

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Disposing of Glutaraldehyde

According to OSHA and the U.S. Environmental Protection Agency (EPA), glutaraldehyde solutions may be disposed of as ordinary domestic waste at the end of their use life. Wearing protective garments and face/eye protection, carefully pour the used soaking solution down the drain and flush thoroughly with cold water. At concentrations of less than 10 ppm in water, glutaraldehyde is readily degraded by sewage systems. If your facility is on a septic system, do not discard used glutaraldehyde down the drain.

Rinse empty quart and gallon containers before discarding. Do not reuse containers.

Glutaraldehyde is also a component of radiology film processing chemicals. The safety protocols listed above apply for preventing exposure for film processing chemicals. Good ventilation, ppe and spill and splash procedures are needed. Practices that have switched to digital films would have eliminated this potential exposure.

Mercury

OSHA requires that employees be given written informed consent before the use of mercury. Elemental mercury vapor is one of the most toxic forms of mercury and should not be breathed. Women who are pregnant should not be exposed to mercury. Any mercury exposure requires that the employee wear an approved mercury filter respirator.

The manner in which dentists operate their equipment dramatically affects the amount of mercury released. Never drill on mercury on high-dry, since levels as high as 4,000 mg/m3 have been measured 18 inches from the drill when using high-dry. Levels over 1,000 mg/m3 are measurable upon opening an amalgam-mixing capsule. If mercury is used in your office, monitor staff members for exposure using mercury sensor badges. Also, test inside storage areas and along baseboards where mercury might have been dropped. Office spills can go undetected for years and are hazardous.

The EPA and the American Hospital Association (AHA) voluntarily agreed to “virtually eliminate” all mercury-containing waste from hospitals by 2005 and to cut in half the volume of all medical waste by 2010. The American Nurses Association also supports these goals. The American Academy of Pediatrics recently asked pediatricians to stop using mercury thermometers and encourages parents to do the same.

When mercury is exposed to air, it vaporizes immediately and may reach harmful levels. If a mercury spill occurs:

1. Evacuate and restrict access to the room. 2. Put on a mask before beginning cleanup.3. DO NOT VACUUM! 4. Use one of these methods to clean up the mercury bead:

A commercial mercury spill kit. Roll the bead onto a sheet of paper. Suck up the bead with an eyedropper.

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5. Dispose of according to the spill kit instructions or call your local EPA or the health department for recommendations.

6. Use a fan to speed ventilation and open a window (if possible). Otherwise, close off the room for at least one hour.

For large mercury spills, call the Emergency Response Hotline (open 24 hours) at the Agency for Toxic Substances and Disease Registry: 800-232-4636.

Most dental offices currently use some type of basic filtration system to reduce the amount of mercury solids passing into the sewer system. The installation of amalgam separators, which generally have a removal efficiency of 95%, can further reduce discharges to wastewater. The American Dental Society has G.R.I.T.

The G.R.I.T. actions below highlight the American Dental Association’s (ADA’s) best management practices for amalgam waste. EPA encourages both dentists and dental staff to employ the GRIT actions in their practices to prevent mercury pollution.

“G”: Gray Bag It – Discard amalgam wastes into a gray bag. “R”: Recycle It – Select a responsible dental amalgam recycler who can manage your

waste amalgam safely. “I”: Install It — Install an amalgam separator to capture up to 95% of the mercury going

down the drain. This is the KEY to success. “T”: Teach It – Educate and train staff about the proper management of dental amalgam.

Nitrous Oxide

An employer needs to monitor the work environment for nitrous oxide (N2O) if staff members could potentially be exposed to concentrations in excess of 25 ppm, which is a time-weighted average permissible exposure limit (PEL) for an 8-hour day.

For dental operatories, OSHA recommends a properly installed N2O delivery system that has appropriate scavenging equipment with a readily visible and accurate flow meter (or equivalent measuring device), a vacuum pump with a capacity of up to 45 L/min of air per workstation, and masks in a variety of sizes to ensure proper fit for patients. Work practices to prevent exposures include:Testing for leaks prior to first use each day and every time a gas cylinder is changed Inspecting equipment for worn parts, cracks, holes, or tears prior to first use each dayVerifying appropriate flow rate after activating connections and turning on the

vacuum pump Placing a properly sized mask on each patientEncouraging patients to minimize talking, mouth breathing, and facial movement while

the mask is in place Inspecting the reservoir bag for changes in tidal volume and verifying the vacuum flow

during administrationUsing clinically approved methods to purge the system before mask removal

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Effective scavenging equipment, adequate general ventilation, periodic inspection of equipment, semiannual servicing and monitoring of equipment, and adherence to good work practices should keep nitrous oxide exposures within acceptable limits.

For more information on preventing exposures, see Anesthetic Gases: Guidelines for Workplace Exposures, OSHA, www.osha.gov/dts/osta/anestheticgases.

Monitoring Employees for Exposure

If an employer can document, using objective data from the manufacturer, that the PEL limit will not be reached under foreseeable conditions of use, the employer is not required to provide personal monitors. If exposure limits in your workplace fluctuate or reach permissible limits, provide clip-on monitoring badges for employees.

Labeling Hazardous Chemicals

HazCom Pictograms and Hazard StatementsHazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to relabel them upon receipt. Under the revised HazCom Standard the label must include: Identity or contents.Chemical name and common or trade name of the contents.Pictogram(s)Hazard and precautionary statements about storage, use, first aid and emergency

procedures.The name, address, and phone number of the supplier.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary, unlabeled container with the contents, dilution, and any hazardous warning, including specific effects of the chemical and target organs affected.

Advise the OSHA safety officer if there are unlabeled containers or if a label has become illegible. The OSHA safety officer assures that labels are replaced when deteriorated or illegible.

PictogramsThese pictograms must include the red diamond with the black picture and text. OSHA feels that these pictograms will be more readily understood than other means of hazard labeling.

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Health Hazard

• Carcinogen• Mutagenicity• Reproductive Toxicity• Respiratory Sensitizer• Target Organ Toxicity• Aspiration Toxicity

Flame

• Flammables• Pyrophorics• Self-Heating• Emits Flammable Gas• Self-Reactives• Organic Peroxides

Exclamation Mark

• Irritant (skin and eye)• Skin Sensitizer• Acute Toxicity• Narcotic Effects• Respiratory Tract Irritant• Hazardous to Ozone Layer (Non-Mandatory)

Gas Cylinder

• Gases Under Pressure

Corrosion

• Skin Corrosion/Burns• Eye Damage• Corrosive to Metals

Exploding Bomb

• Explosives• Self-Reactives• Organic Peroxides

Flame Over Circle

• Oxidizers

Environment(Non-Mandatory)

• Aquatic Toxicity

Skull and Crossbones

• Acute Toxicity (fatal or toxic)

The new pictograms can be downloaded from OSHA: www.osha.gov/dsg/hazcom/pictograms

NFPA Label SystemNFPA or other custom labels can be used until June 2015 when the next phase of the revised Haz Com Standard goes into effect. Until then, either the NFPA system or the pictograms and new labeling system may be used as long as workers understand both labeling systems. While OSHA never specifically mandated the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some dental facilities have adopted it to standardize hazard labels. The NFPA system offers hazard assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

In addition, each quadrant shows the magnitude of severity, graded from 0 to 4:

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indicates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, or corrosive.

Note: the GHS labeling system uses “1” as the most severe hazard and “4” as the least severe hazard.

quality-america.com 1-800-946-9956

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Labeling Hazardous Substances

Hazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to relabel them upon receipt. The label must include:

Identity or contents.

Chemical name and common or trade name of the contents.

Hazard warnings, including words, pictures, symbols, or combinations that convey the health

and/or physical hazards of the container’s contents; these warnings must be specific as to the

effect of the chemical and specific target organs involved.

The name, address, and phone number of the chemical manufacturer.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary,

unlabeled container with the contents, dilution, and any hazardous warning, including specific effects of

the chemical and target organs affected.

Advise the OSHA safety officer if there are unlabeled containers or if a label has become illegible. The

OSHA safety officer assures that labels are replaced when deteriorated or illegible.

NFPA Label System

Although OSHA does not specifically mandate the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some

dental facilities may wish to adopt it to standardize hazard labels. The NFPA system offers hazard

assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

In addition, each quadrant shows the magnitude of severity, graded from 0 to 4:

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indicates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, or corrosive.

Safety Tips for Working with Hazardous Substances

All employees working with hazardous substances are provided with personal protective

equipment (PPE) according to specific OSHA standards or, where indicated, by material safety

data sheets. These employees receive education regarding when PPE is necessary; how to

properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

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Safety Tips for Working with Hazardous ChemicalsAll employees working with hazardous chemicals are provided with personal protective equipment (PPE) according to specific OSHA standards or, where indicated, by the SDS in section 8. These employees receive education regarding when PPE is necessary; how to properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

Other general safety rules for working with chemicals are:Avoid direct contact with hands, face, and clothing, including shoes.Never taste or smell a chemical.Do not smoke, drink, or eat in chemical use and storage areas.Never use any chemical from an unlabeled container.Keep ap propriate safety devices available for employees who work with, or in the vicinity

of, hazardous chemicals. For example, if a substance could cause eye damage, an emergency eyewash must be available in close proximity to the workstation.

If flammable liquids or vapors are present, the proper fire extinguishers must be present and readily accessible.

Chemical Spill Cleanup Procedures

1. Act quickly to contain the spill. Cordon off area if an employee or visitor might come in contact with the spill.

2. Check the SDS (see the OSHA yellow and black binder) for precautions and cleanup instructions.

3. Wear protective equipment, including heavy-duty gloves and, if necessary, goggles, mask, and gown.

4. Notify safety officer to report large or dangerous spills before attempting clean up.5. If chemical spill is toxic or gives off strong fumes, evacuate the area and get

professional help.6. Clean up spill following precautions listed in the SDS for that chemical.7. Use approved absorbent neutralizing materials or spill kit to wipe up if necessary.8. Disinfect area after cleaning. Allow to air-dry.9. Dispose of all contaminated material in proper hazardous waste container.

Chemical Exposure to Skin

1. Remove contaminated clothing as quickly as possible. 2. Check the SDS for recommendations.3. Flush the area of contamination thoroughly with large amounts of water.4. Wash area with soap and water.5. Do not use creams, lotions, or salves on the skin without asking for medical advice.

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Medical Consultation and Injury EvaluationEmployees who need medical attention due to a chemical exposure will use the health services at the following facility:

_____________________________________ _________________________ Name of healthcare facility Telephone number

If an employee requests evaluation by a personal physician, that request will be honored. Medical evaluations and consultations are performed by or under the supervision of a licensed physician without cost to the employee, without loss of pay and at a reasonable time and place.

Employees will be medically evaluated when:Signs and symptoms are consistent with a chemical exposure.Environmental monitoring reveals an exposure level above the proper threshold, if

appropriate (formaldehyde, etc.).

The OSHA Safety Officer will provide the following information to the referring physician: Identity of the hazardous chemical to which the employee was exposed.A description of the conditions under which exposure occurred.A description of the signs and symptoms of exposure.A copy of the SDS for the chemical involved.

Hazardous Chemical Waste Packaging and DisposalRead the SDS carefully for guidance on disposal of hazardous chemicals. The Resource Conservation and Recovery Act (RCRA) statutes of the Environmental Protection Agency (EPA) affect the handling of chemical hazardous waste (not infectious waste). Most dental offices are affected by RCRA (or its state-administered counterpart) because they generate chemical hazardous waste, although those that generate less than 100 kg (about 27 gallons) per month are classified as very small-quantity generators that are conditionally exempt from RCRA. Facilities that generate between 100 kg and 1000 kg per month are considered small-quantity generators and must obtain a 12-digit EPA identification number. Hazardous wastes must be tracked from the time it is generated until its disposal with a manifest system (cradle to grave) and shipped in EPA-approved hazardous waste trucks.

Typical healthcare hazardous wastes are formalin, mercury, and silver.

Regardless of your RCRA classification, do not discharge pollutants into the water/sewer system without first verifying with local publicly owned treatment works that it meets your state’s criteria for discharge. For more information about disposing of chemical hazardous waste, see the Hazardous Waste Disposal section in Tab 5, or contact your state or local EPA office.

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Effective Dates: The table below summarizes the phase-in dates required under the revised Hazard Communication Standard (HCS):

Effective Completion Date

Requirement(s) Who

December 1, 2013 Train employees on the new label elements and safety data sheet (SDS) format.

Employers

June 1, 2015* Compliance with all modified provisions of this final rule, except:

Chemical manufacturers, importers, distributors and employers

December 1, 2015 The Distributor shall not ship containers labeled by the chemical manufacturer or importer unless it is a GHS label

June 1, 2016 Update alternative workplace labeling and hazard communication program as necessary, and provide additional employee training for newly identified physical or health hazards.

Employers

Transition Period to the effective completion dates noted above

May comply with either 29 CFR 1910.1200 (the final standard), or the current standard, or both

Chemical manufacturers, importers, distributors, and employers

Special Precautions for Dental LabsSilicosisSilicosis is a disabling and incurable lung disease caused by breathing in fine dust containing crystalline silica. Once in the lungs, this dust causes damage that stops the body from using oxygen properly. Breathing in dust containing crystalline silica has been linked to other diseases such as tuberculosis, kidney disease, and lung cancer. Silicosis has been diagnosed and confirmed in dental laboratory workers.

Dental lab materials that contain silica are:

Sand Investment materials Porcelain Shop dust

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Tasks in a Dental Lab that Can Cause Silica Exposure

Casting – Exposure can occur when mixing investment materials and during divestment of castings. Investment materials often contain large amounts of cristobalite. Cristobalite is a very toxic form of crystalline silica.

Sandblasting – Sandblasting of castings can cause exposure to the investment material or the sand itself. Silica sand is often used to clean castings. It contains almost 100% crystalline silica. Exposure can also occur when the blasting box has leaks. Opening the door of the blasting box before the dust has settled or been removed by a dust collection system is dangerous.

Grinding porcelain – Silica content in porcelain varies. Exposure can occur when mixing porcelain powders or when grinding or polishing dried porcelain material.

Cleaning/Maintenance – Tasks that involve cleaning dusts that contain silica pose a major hazard if dust is raised. The same is true when maintaining local exhaust ventilation or dust collection systems.

Controlling Exposure to Silica

Substitution – The ideal method to stop exposure is to eliminate materials containing crystalline silica. This method is most feasible for sandblasting media. Aluminum oxide is one of many acceptable substitutes.

Ventilation – When there are no good substitutes, dust exposure should be minimized through the use of local exhaust ventilation systems. These systems capture dust at its source and transport it to a dust collection system.

Respirators – The worker should wear a respirator when other control methods are missing or do not work. The type of respirator recommended is, at a minimum, a half-mask air-purifying respirator with type N-100 particulate filters.

Good housekeeping – Wet wiping, wet mopping, and vacuuming with a HEPA vacuum are recom-mended. Dry sweeping, dry dusting, use of compressed air, and use of ordinary vacuum cleaners should be avoided because they reintroduce the dust into the air.

Other Potential Health Hazards Associated with Working in a Dental Lab

Methyl methacrylate – Used in making dentures and plates, it can be absorbed into the body by inhalation, through the skin, and by ingestion. It is irritating to the eyes, skin, and respiratory tract. Repeated and prolonged exposure can cause skin sensitization and asthma, as well as adverse effects on the nervous system.

Electroplating chemicals – The process of electroplating can release hazardous contaminants into the air that pose a variety of risks to the dental lab worker. The contaminants include various acid and alkaline mists that can cause respiratory and skin problems.

Metals – such as beryllium, chromium, cobalt, and nickel. These metals in alloys used for castings of bridge framework and other dental prosthesis components can cause a variety of lung problems.

Noise – grinding, sandblasting, and other dental lab machinery can make noise that may cause hearing loss.

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Chemical sterilants – These are used to sterilize impressions and prosthetic devices, received from dental offices, contaminated with blood and saliva. Sterilant chemicals include aldehydes, phenols, and quaternary ammonium compounds. These chemicals may cause lung problems and dermatitis.

Allergic Reactions to Dental ProductsType I allergic reactions can occur with:

EugenolAnestheticsGlutaraldehyde (asthma)ChlorhexidineFormaldehyde (sealers)Metals (gold, nickel)Eugenol, fragrances, flavorings

Type of Reaction Signs and Symptoms

Type I

Immediate hypersensitivity.

IgE-mediated. Protein allergy.

Within minutes of exposure, inflamed itchy redness, watery eyes, runny nose and asthma-like symptoms.

Severe reactions include skin rashes, facial swelling, breathlessness, and rarely, anaphylactic shock.

Type IV

Allergic contact dermatitis with delayed hypersensitivity.

Cell mediated.Chemical allergy.

Non-localized reaction can extend up the forearm. Red, swollen area with bumps, sores and horizontal cracks, appearing several hours after glove contact

May persist for many days.

Gas Cylinder SafetyCompressed gas cylinders are potential hazards, no matter what the size, and correct handling and use are required. Cylinders have two potential health and safety hazards: (1) Those related to pressure, and (2) Those related to the chemical properties of the compressed gas. If a com-pressed gas cylinder is punctured or broken, the gas will be released explosively, propelling the cylinder with dangerous force.

Here are some important policies for safe handling of gas cylinders:1. Have an SDS for every compressed gas. Review these sheets for the chemical hazard

present in a particular gas. Oxygen gas, for example, readily supports combustion and should be kept away from heat, electricity and combustible items.

2. Be sure cylinders are legibly marked to clearly identify their contents.

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3. Use, transport and store cylinders in an upright position, and secure by a chain, collar, or transport cart to prevent them from falling over. Covers valves when not in use.

4. Regulators are specifically designed for each type of gas to prevent incompatible gases from mixing; therefore, never interchange regulators. Regulators must be tightly secured on full cylinders before the valve is opened. Release the valve slowly, away from the face and eyes. If any hissing is heard, shut the valve immediately. Do not use regulators or fittings that leak. Soapy solutions will form bubbles over leaks and can be used to check fittings. Because gas leaks often cannot be seen, heard, or smelled, it is crucial that faulty fittings not be used.

5. Never use lubricants, sealants, or tape to fit a regulator.6. Use only in well ventilated areas. Keep away from heat sources and smoking areas.7. When gas cylinders are replaced, tightly shut the valve even if the cylinder is believed

to be empty. The pressure and flow rate on the regulator should read zero before it is removed. Train those who manipulate cylinders to discriminate the cylinder pressure gauge from the flow rate gauge and interpret their readings. Replace regulators with faulty gauges immediately.

8. Manage inventory so that only a minimal amount of cylinders required are kept at the facility. If cylinders are used infrequently, post received dates and expiration dates. Do not remove identification labels on cylinders even if the cylinder is believed to be empty.

9. Store cylinders upright in a safe, well-ventilated area away from heat and electrical wiring. The storage area must be fire-resistant and free from combustible materials. Never subject compressed gas cylinders to temperatures higher than 125°F.

10. Clearly mark empty cylinders and store as carefully as the full ones because residual gas may be present. Store empty cylinders separately from full cylinders and dispose of properly. Never place in ordinary trash, particularly if trash is to be incinerated.

In 2001, the FDA issued an alert about the dangers of accidentally connecting cryogenic vessels containing other gases to oxygen delivery systems. The agency said it received reports of seven deaths and 15 injuries over the past 4 years when patients received gases such as nitrogen instead of the intended oxygen. The FDA reported that two errors usually occur in sequence for this to happen:

A vessel is wrongly identified as containing oxygen.The connector, which is gas-specific, is adapted for use in the oxygen delivery system.

To combat the problem, the FDA recommends that healthcare facilities:

Carefully check labels to ensure containers hold the appropriate gas. Never try to adapt containers with connectors that don’t fit properly.Train staff on use and connection of medical gas systems.Store medical and industrial grade gases in separate areas.

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Electrosurgical Safety (Lasers)During surgical procedures using a laser or electrosurgical unit, thermal destruction of tissue creates a smoke plume that can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde and bioaerosols. It can also contain dead and live cellular material (including blood fragments, although there has been no documented transmission of infectious disease through surgical smoke) and viruses.

At high concentrations, this smoke causes eye and respiratory tract irritation in healthcare workers, and creates visual problems for the surgeon. The smoke has unpleasant odors and has been shown to have mutagenic potential. Recent NIOSH research recommends ways to control airborne contaminants generated by these surgical devices.

OSHA has no standards specific to laser plume or surgical smoke, but safety from such hazards is addressed in the Occupational Safety and Health (OSH) Act of 1970. The General Duty Clause 5(a)(1) requires employers to provide a safe and healthy workplace; the section on Respiratory Protection, 1910.134, recommends use of acceptable engineering controls (such as smoke evacuators) or appropriate respirators to control occupational diseases caused by breathing air contaminated with harmful substances. Moreover, the 2005 ANSI Standard, Z136.3 “Safe Use of Lasers in Health Care Facilities” lends some guidance for employee safety.

Neither surgical masks nor respirators are optimal respiratory protection for surgical smoke. Smoke evacuators and room ventilation provide much better protection. NIOSH’s recommendation (HC11: Control of Smoke from Laser/Electric Surgical Procedures) recommends general room ventilation in conjunction with local exhaust ventilation (portable smoke evacuators or room suction systems).

Smoke evacuators contain a suction unit (vacuum pump), filter, hose, and an inlet nozzle. Use a smoke evacuator with a high efficiency in airborne particle reduction and according to manufacturer’s recommendations. Use a capture velocity of about 100 to 150 feet per minute at the inlet nozzle and choose an effective filter, such as a High Efficiency Particulate Air (HEPA) filter, to collect contaminants.

Various filters and absorbers used in smoke evacuators to remove or inactivate airborne gases and vapors require regular monitoring and replacement, and are considered a possible biohazard requiring proper disposal.

Room suction systems can pull at a much lower rate and were designed primarily to capture liquids rather than particulates or gases. If these systems are used to capture generated smoke, users must install appropriate filters in the line and insure that the line is cleared and that filters are disposed of properly. Generally speaking, the use of smoke evacuators is more effective than room suction systems to control the generated smoke from nonendoscopic laser/electric surgical procedures.

Be sure all lasers are properly classified. A standard operating procedure must be written for Class IV lasers and is recommended for Class IIIB lasers. Use the manufacturer’s safety information as the basis for this procedure as well as the information contained within this section.

Follow the manufacturer’s safety information to be sure that the control measures recommended have been implemented and that they are adequate for your circumstances. Laser treatment areas must bear appropriate signage or have labels affixed to relevant equipment.

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Train employees who work in laser areas about laser safety. Require these personnel to wear eye protection of sufficient optical density to prevent injury from the laser in use. Prescription lens wearers must use appropriate laser safety eyewear as well. Do not use damaged protective equipment.

Ensure skin protection in the form of sunscreen, lab coats and gloves. Take care that hands, arms and other body parts do not intersect the beam. Align laser optical systems (mirrors, lenses, beam deflectors) in such a manner that the primary beam or specular reflectors cannot expose the eye to a level above the appropriate intrabeam maximum permissible exposure.

Safe Laser Practices Keep smoke evacuators or room suction hose nozzle inlets within two inches of the surgical site to effectively capture airborne contaminants generated by surgical devices. Keep the smoke evacuator on (activated) at all times during surgical or other procedures when airborne particles are produced.

At the completion of the procedure, consider all tubing, filters, and absorbers as infectious waste and dispose appropriately. Install new filters and tubing on the smoke evacuator for each procedure. Regardless of the type of smoke evacuator systems you use, regularly inspect and maintain them to prevent possible leaks.

Radiation Safety Policies Restrict access to the x-ray area and mark the door to the area with the “Caution-Radioactive Materials” sign (the magenta and yellow propeller sign). Keep the doors to the x-ray area closed at all times (except for entry of authorized personnel) to prevent scattered radiation outside of the room. Ensure that dental x-ray equipment is operated only by individuals adequately instructed in safe operating procedures and who are competent in the safe use of the particular dental x-ray equipment.

Take all precautions necessary to provide reasonably adequate protection to the health and safety of those who are subject to radiation exposure. Keep necessary exposures As Low As Reasonably Achievable (ALARA); and be sure that the doses received by personnel are kept well below the allowable limits.

Provide employees who perform x-rays with individual or personal monitoring devices (film badges/pocket dosimeters), preferably on a quarterly basis. This is absolutely necessary for declared pregnant employees. An employee (not declared pregnant) may wear a monitoring device for one three-month period and the results extrapolated to determine an annual exposure. If the exposure is less than 10% of the maximum allowable dose (5 rems), then monitors need not be worn for the remainder of the year. Repeat this procedure annually*.

* Note: If your facility can demonstrate annual exposure for each employee is less than 10% of the maximum allowable dose you may choose to NOT badge operators annually. Document how it was determined that monitor badges are not necessary (usually evidence of prior monitoring for a reasonable period of time) and check with your state Nuclear Regulatory Commission office (if applicable, see state listing below) to ensure this action complies with state specific regulations.

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OSHA Program Manual for Dental Facilities

Ensure that dental personnel during patient exposure do not: Hold the patient. Hold the film in the patient’s mouth. Hold x-ray tube housing. Hold the aiming cylinder (also known as PID or pointer cone). Stand in the path of the useful x-ray beam. Stand closer than six feet from the patient being radiographed.

Radiation Safety in Dental PracticeThe Nuclear Regulatory Commission (NRC) has primary responsibility for licensing and regulating nuclear materials. Your facility may also be subject to state regulations. Some states, called agreement states, have contracted with NRC to regulate their own nuclear materials. There are currently 37 states that have an agreement with the Nuclear Regulatory Commission (NRC) to manage radioisotopes, source products and some quantities of special nuclear materials. Alabama, Arkansas, Arizona, California, Colorado, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Tennessee, Utah, Virginia, Washington and Wisconsin may have additional requirements; check with your state’s licensing agency for more details.

OSHA regulates occupational exposure to ionizing and nonionizing radiation [29 CFR 1910.96 and 29 CFR 1926.53 (See Tab 9: OSHA Regulations and Key Contacts)]. OSHA’s regulation provides that radiation exposure should not exceed permissible exposure limits, that warning signs and labels be posted outside regulated areas and on containers of regulated materials, and that employees working in regulated areas be monitored for exposure levels. Compliance with NRC regulations or the regulations of an agreement state is automatic compliance with OSHA’s ionizing radiation regulation.

Protecting Staff from Unnecessary Radiation Exposure During the exposure, dental personnel who perform dental radiography should stand behind a protective barrier. If this is not possible, they must stand at least 6 feet away from the patient and the x-ray tube, not in the path of the primary beam but preferably behind a fixed or mobile barrier such as a wall or movable leaded Plexiglas shield.

To reduce unnecessary exposures increase the distance between the patient (the source of scattered radiation) and the x-ray operator to over 6 feet.

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Ionizing Radiation Exposure LimitsFederal occupational dose levels of radioactive material must not exceed:

Whole body, head and trunk, active blood-forming organs, lenses of eyes, or gonads — 1¼ rems per quarter.

Hands and forearms, feet and ankles — 18¾ rems per quarter.Skin of whole body — 7½ rems per quarter.

Note: Dose limits apply only to occupational exposure, not to intentional exposure for medical treatment.

Keep exposure monitoring records when employees exceed limits (e.g., more than 1.24 rems of radiation to the head per calendar quarter). Keep both past and present exposures to ensure that a new dose will not cause an employee to exceed the exposure limit. Report any employee exposure above the authorized limit to OSHA within 30 days of the exposure.

Limiting Exposure to Women of Childbearing AgeTake precautions to limit exposure to young women, especially if they could be pregnant. Ensure that the dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant woman, does not exceed 0.5 rem (5 mSv). Once a pregnancy becomes known, the radiation dose of the embryo-fetus should not exceed 0.05 rem (50 millirems) in any month (excluding medical exposure).

Some studies have shown that there is an increased risk of leukemia and other cancers in children if the expectant mother was exposed to a significant amount of radiation. Consider temporary assignment for pregnant employees to tasks that involve less risk of being exposed to radiation. Require pregnant employees who continue to take x-rays to use a protective apron (full-size, half-size, wrap-around, or any other protective clothing appropriate to the situation) while actually exposing patients. Also require them to wear a monitoring device at the abdomen. Be sure the pregnant employee stays out of the x-ray room and behind the protective barrier during exposure.

Inform female employees (both orally and in writing) of possible risks so they can take appropriate steps to protect their offspring. Also, allow employees to ask questions. It is prudent to keep records of this training indefinitely.

Employee TrainingProvide information to occupationally exposed individuals regarding health protection issues associated with exposure to radiation, precautions or procedures to minimize exposure, and the purpose and function of protective devices employed. Inform employees at their initial orientation and at least yearly thereafter. Remind female workers that harmful exposure can often occur before the pregnancy is discovered.

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Give the following facts to female employees:

The first 3 months of pregnancy are the most important as the embryo-fetus is most sensitive to radiation at this time.

In most cases of occupational exposure, the actual dose received by the embryo-fetus is less than the dose received by the mother, because some of the dose is absorbed by the mother’s body.

At the present occupational dose equivalent limits, the risk to the unborn baby is considered to be small, but experts disagree on the exact amount of risk.

There is no need for women to be concerned about sterility or loss of ability to bear children from occupational exposure.

Once a pregnancy becomes known, radiation dose of the embryo-fetus should be no greater than 0.05 rem (50 millirems) in any month.

The 0.5 rem (500 millirems) dose equivalent limit applies to the full 9 months of pregnancy.

Miscellaneous Ways to Minimize Radiation ExposureOther ways to minimize radiation exposure to patients, dental personnel and the public are:

Use the fastest film (E-speed) or digital image receptors. Adhere to proper film processing. Assure adequate and proper x-ray tube filtration, kVp, mA and timer accuracy through

regular maintenance and calibration by a qualified service technician.

Regulation of the Medical Use of Nuclear By-ProductsNRC requires any facility that uses, produces, transfers, receives, acquires, owns, or possesses nuclear materials to:

1. Obtain a license to operate. 2. Comply with safety regulations-occupational dose limits, record keeping, notification

requirements, designation of a radiation safety officer, maintenance of records, and submission of reports to NRC if a radiation incident occurs.

3. Properly dispose of radioactive waste. 4. Be subject to NRC inspections and enforcement actions.

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Nuclear Regulatory CommissionNotify the NRC’s 24-Hour Headquarters Operations Center at (301) 816-5100 (NRC Headquarters, 1555 Rockville Pike, Rockville, MD 20852, www.nrc.gov) if certain incidents, misadministration, or abnormal occurrences develop.

Immediate NRC notification is required for:

Lost or stolen licensed material.Excessive exposures (levels of radiation or concentrations of radioactive material in an

unrestricted area in excess of 10 times any applicable limit).

The following incidents require notification within 24 hours:

Exposure of the whole body to ≥5 rems (roentgenequivalent-man).Exposure of the skin to ≥30 rems, or exposure of the feet, ankles, hands, or forearms to

≥ 75 rems.Releases within 24 hours averaging concentrations of 500 times the limit specified for the

particular material.

Contact NRC Headquarters Operations Center for all NRC related concerns. You may also contact NRC’s Toll-Free Safety Hotline at (800) 695-7403.