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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 4  |  Page : 251-257

Eco-friendly dentistry: Preventing pollution to promoting sustainability


Department of Prosthodontics, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India

Date of Submission24-Jan-2020
Date of Decision15-Mar-2020
Date of Acceptance14-Jul-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Reena Mittal
Department of Prosthodontics, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_12_20

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  Abstract 


In today's world, being eco-friendly is a part of every profession. Medical profession is concerned with maintaining general health and well-being of the individual. Dentistry is dedicated toward maintenance of oral health and enhancing function. However, it has a huge impact on environment due to generation of large amount of waste including metallic waste and excessive use of water and electricity. Practicing green dentistry involves judicious use of water and electricity, decreasing waste production, and decreasing pollution with the use of the latest technologies. Oral health workers should recognize the significance of contributing in the interests of sustainability. They share the moral responsibility toward the society to provide optimal oral health services, maintain patient safety as well as reduce their impact on natural resources. This study reviews some practical suggestions for making dental practice eco-friendly by enhancing the use of newer technologies and reducing the use of disposables and paper and eco-friendly waste management.

Keywords: Eco-friendly dentistry, pollution, sustainable development, waste disposal


How to cite this article:
Mittal R, Maheshwari R, Tripathi S, Pandey S. Eco-friendly dentistry: Preventing pollution to promoting sustainability. Indian J Dent Sci 2020;12:251-7

How to cite this URL:
Mittal R, Maheshwari R, Tripathi S, Pandey S. Eco-friendly dentistry: Preventing pollution to promoting sustainability. Indian J Dent Sci [serial online] 2020 [cited 2020 Dec 3];12:251-7. Available from: http://www.ijds.in/text.asp?2020/12/4/251/298026




  Introduction Top


In today's world, the word “green” has become a trend with every other industry that is trying to create and sell green products. Media continues to highlight increasing environmental concerns about increasing carbon emissions, rise of temperature, and melting of ice caps. Dental personals are interested to become environment friendly but are not aware of the ways to accomplish this.[1],[2]

“Eco-friendly” and “green” are often used synonymously and indicate several things, such as renewability, sustainability, and energy efficiency, no toxicity, being minimally invasive, and having a reduction in carbon footprint. In health-care sector, it includes sustainable and eco-friendly practices, designing of hospitals and offices as well as management of waste.[3] Sustainable dentistry integrates dentist's commitment to society and environment.[4]

Green dentistry refers to practicing dentistry using technologies, procedures, and materials that do not cause any harm to the environment.[5] It can be done by conservation of water and energy, use of nonhazardous products, reduction of waste, and elimination of hazardous chemicals that negatively affect patients and the environment and promoting increased usage of green products. All these features can be summarized into four Rs – Rethink, Reduce, Re-use, and Recycle.[6],[7]

One of the key challenges of developing countries is the management of hazardous waste including dental waste which poses a safety problem for both public and the environment.[8] The present review focuses on environmental consideration in dental facilities and provides practical suggestions to minimize waste production and reducing the impact of the profession on the environment.[9] The aim of writing this review is to make dental professionals understand the need of practicing green dentistry and measures which can be taken to achieve that aim.


  Definition Top


Green dentistry has been defined by the Eco-Dentistry Association (EDA) as “a high-tech approach that reduces the environmental impact of dental practices and encompasses a service model for dentistry that supports and maintains wellness.”

Eco-friendly dentistry term is coined by Dr. Gorankralj and Dr. Stevenkoos. They defined it as a newly evolving practice of dentistry, which encompasses a simultaneous devotion to sustainability, prevention, precaution, and a minimally invasive patient-centric as well as global-centric treatment philosophy. Eco-friendly dentistry features practicing green dentistry in all dental specialties by incorporating green design and operations. This will protect the immediate health of patients and dental team members, protect the health of the surrounding community and global community, and preserve natural resources.


  History Top


The idea of “green dentistry” stems back to the 5th European Dental Students' Association Congress of Belgrade, Serbia, in March 2003, when the Greek delegation set the outline and proposed the adoption of the project by the assembly. Currently, the countries which have adapted this project are Croatia, Sweden, the Netherland, the UK, and Greece. Its main domains are:[10]

  1. Increased environmental awareness and sensitivity among the dental professionals
  2. Encouragement of procedures/regulations/policies compatible with sustainable development strategy of EU
  3. Establishment of a network of cooperation, exchange information, and opinions concerning the environmentally friendly dental practice in Europe and internationally.


In today's world, the term “eco-dentistry” has been adapted which has gone beyond the point of preventing pollution and is now concerned with promoting sustainability.

The first international reference to eco-friendly dentistry was published in the study done by Dr. Ali Farahani and Mittale Suchak on April 3, 2007. In this study, they defined eco-friendly dentistry as an approach to dentistry that implements sustainable practices by keeping resource consumption in line with nature's economy, by safeguarding the environment through means which will help in eliminating or reducing outgoing wastes and by promoting the well-being of all personals in the clinical environment by conscious reduction of the chemicals in the breathable air.[11]

In 2008, the EDA was co-founded by Dr. Fred Pockrass and his wife, Ina Pockrass. The EDA provides education, standards, and connection to patients and dentists who practice green dentistry. The EDA aims to help dentists by suggesting some safe and reusable alternatives that lower their operating cost, for example, replacing paper with digital media whenever possible.[12]

On December 22, 2009, Dr. Steven Koos trademarked and officially defined eco-friendly dentistry.


  Need Top


Dental treatment procedures generate a variety of waste products. Most of these materials are potentially hazardous. Hence, they require special precautions for handling and disposal. The biomedical waste generated in a dental clinic includes:

  • Sharps
  • Used disposable items
  • Infectious waste (blood-soaked gauze pieces, cotton, etc.)
  • Hazardous waste (mercury and lead foils)
  • Chemical waste (such as spent film developers, fixers, cleaning solutions, and disinfectants).[6],[10]


Mercury is a hazardous material for human health and environment. During dental procedures, mercury is involved during placement, removal, and polishing of dental amalgam.[9],[13],[14] At the time of restoring a tooth with dental amalgam and also during its removal, potentially harmful waste is generated such as:[9],[15],[16]

  • Elemental mercury vapor – released from dental amalgam alloy
  • Dental amalgam scrap – those amalgam particles that have not come into contact with the patient (i.e., particles remaining the following restoration placement)
  • Amalgam waste – those particles that have come into contact with patient secretions (e.g., particles generated during carving and restoration removal procedures)
  • Amalgam sludge – the particles present in dental office wastewater (chairside traps and vacuum filters).


Dental amalgam restorations continuously release Hg0 which results in exposure in those persons having restorations of this material.[17] Organic mercury in bioavailable form can enter the food chain and tends to accumulate in organisms, particularly fish and birds. Consumption of these animals can cause adverse health effects.[9]

It has been estimated that dentists contribute a major portion (between 3% and 70%) of the total mercury content of wastewater treatment facilities. Numerous efforts are being made to completely stop its usage, the most recent being the initiative of the United Nations Environment Programme (2009).[17]

Silver is another heavy metal present in the dental waste. Although it is a component of dental amalgam also, the silver thiosulfate present in radiographic fixer can enter the water system throughout improper disposal of dental waste and presents a greater environmental challenge.[9],[18]

Lead shields contained in each film packet are a by-product of traditional radiography. Lead is also toxic and persists in the environment. Even at low levels, lead is harmful to both adult children and adults.[9]

Improper handling and disposal of dental waste can lead to needle injuries and spread of disease among health-care personnel. Other people who come in contact with them and are more susceptible to the spread of disease include children, janitorial staff, and garbage collectors. Needle sticks can result in diseases such as HIV and hepatitis. Therefore, proper disposal is needed for potentially harmful waste.[8] Apart from metallic waste, other waste products generated in a dental office include various kinds of disposable items such as latex gloves, disposable patient bibs, headrest covers, syringes, and plastic suction tips.[6] Office waste is also generated, for example, paper, cardboard, aluminum, and plastics, which is nonhazardous but adds to the bulk.


[Figure 1]">  Elements of Eco-Friendly Dentistry [Figure 1] Top


Dentistry can lessen its environmental impact by following the “four Rs of going green,” namely reducing, reusing, recycling, and rethinking.[6]
Figure 1: Recycle triangle

Click here to view


Reduce

Green dentistry involves reducing waste and pollution. The use of disposables should be reduced. It is necessary to reduce the waste of useful products and raw materials and reduce water pollution and air pollution from landfills and incinerators, respectively. Wastage of water should be reduced. Paper use can be reduced by going paperless. For this, the usage of computers and digital technology should be promoted whenever possible to create, use, and store office record.[19],[20]

Re-use

The usage of reusable and biodegradable materials should be promoted which will save resources and energy necessary to manufacture new things. This can be done by encouraging the prolonged use of an item. Chlorine-free, recycled paper products should be used instead of conventional ones.[19]

Recycle

Steps for recycling are represented by the recycle triangle which is represented by three green arrows. The first arrow represents collecting material which is to be recycled. The second arrow is represented by making something new out of recycled material and resale items created from recycled material which is represented by the third arrow [Figure 1]. Most of the waste material that is labeled as waste can be reprocessed and recycled into a new product.[6],[20] Many materials which are used in dentistry such as paper cups, paper, magazines, general waste, and cloths for infection control can be recycled which will reduce overall cost as well as bulk.[7]

Rethink

It means rethinking about many things while running a dental practice that can be done in a more environmentally friendly way. Rethinking about practice and protocols may help to find out new ways to reduce, re-use, and recycle.[19]

It is important to choose such green option that a dentist can practice consistently. Impression tray is a good example of such choice. A disposable plastic impression tray uses lots of energy to create and can be used just once. The eco-friendly option can be a compostable impression tray. These are made from corn and although are non disposable but can be decomposed easily. Similarly, stainless steel impression tray can be sterilized and used many times and can be recycled into a new product making it the least wasteful, least polluting option.[21]

Green dentistry mainly focuses on reducing waste production and conserving energy, water and money, promoting increased use of high-tech innovations, and wellness practices in a dental clinic. This can be done in many ways.[21],[22]

Reducing waste and pollution

The four procedures responsible for most of the dental practice waste and pollution are:[8]

  1. Placement and removal of mercury-containing dental material
  2. Conventional X-ray systems
  3. Infection control methods including disposable barriers, sterilization items, and toxic disinfectants
  4. Conventional vacuum saliva ejector systems.


The following are the ways by which this can be reduced.[6]

  • Installing an amalgam separator and ensuring that amalgam waste is properly recycled
  • Using digital X-ray instead of conventional system
  • Instructing dental suppliers to reduce packaging and combining orders to reduce shipping waste
  • Recycling old and damaged hand instruments, giving them new life as other metal items
  • Using nontoxic, biodegradable, approved surface disinfectants and cleaners
  • Using reusable stainless steel or compostable impression trays
  • Water lines should be cleaned regularly, using biodegradable or enzymatic cleaners. Chlorine bleach, however, should not be used for cleaning as it can release airborne mercury into the clinic. The entire water which is consumed in the practice should be filtered as it decreases calcium and other deposits increasing the longevity of the instruments and reducing their maintenance
  • Eliminating toxic chemical use for cold sterilization should be reduced, such as those containing glutaraldehyde, a powerful lung, and skin irritant
  • Using products which are less toxic and more eco-friendly for cleaning purpose.


All disposable items which are used in a dental clinic can be replaced by the following:[7],[18]

  • Cloth patient bib
  • Cloth headrest cover
  • Reusable cups
  • Reusable metal suction tips and saliva ejectors
  • Hospital grade cloth operatory and sterilization method.


Energy and water conservation[6]

Conservation of natural resources is critically important to follow green dentistry. Promoting the usage of energy and water saving equipment is good for dentistry's green future. Dental clinics use many types of equipment for which electricity is required such as compressors, drills, overhead lights, operatory lights, and computers. Light-emitting diode (LED) lights can reduce electrical energy consumption by 70%. Wastewater treatment plants consume a great deal of energy and use large quantities of materials. Therefore, every effort should be made to reduce both water consumption and wastewater output. Dental vacuum systems utilize tremendous amount of water leading to its wastage. Hence, it is advisable to the use of a dry vacuum system.[7],[9],[22],[23] Similarly, the efficiency rate of old boilers is very less as compared to new ones. Modern boilers are as efficient as 95% as compared to older ones having efficiency of 60%–70%.[24]

The following are energy and water saving methods that are part of eco-friendly dental clinic.[6],[19],[24]

  • Use of energy star-rated printers, computers, and other equipment
  • Installing LED and high-efficiency fluorescent lights
  • Installing motion sensors to automatically turn off lights when people leave nonmedical areas such as business offices, stores, etc
  • Assigning dental personnel who will ensure that everything is powered off at night
  • Installing LED “exit” signs and other emergency indicators
  • Adapting waterless vacuum system
  • Motivating and educating patients to turn off the tap during handwashing
  • Installing an in-office water distiller
  • Using eco-friendly hand sanitizer instead of handwashing when appropriate
  • Sterilization equipment should only be run when fully loaded
  • Regular maintenance and servicing of boilers
  • Replacing old boilers with the new one
  • Doors to air-conditioned areas should always be closed.


High-tech innovations in dentistry

Today's high-tech innovations make the practice of dentistry more reliable, easier, and more cost-effective. Almost all high-tech innovations in dentistry have some environmental benefits also, for example, computer-aided design/computer-aided manufacturing systems. It eliminates the need of impression material which means less need for its disposal. It reduces number of patient's appointments which means low-carbon emission because of reduced travel by the patient [Table 1]. The following similar high-tech innovations are part of dentistry's green future:[6]
Table 1: Few High-tech Innovations and their benefit to the Environment

Click here to view


  • Digital imaging
  • Esthetic restorations eliminating the use of amalgam
  • In-office sharps disposal equipment
  • Steam sterilizers that eliminate the use of harmful chemicals
  • Use of computers for the storage of patient records
  • Digital patient communications such as appointment reminders through E-mail reduce paper and saving staff time
  • Diode lasers, which eliminate the need for retraction cords
  • Use of a web site as a primary marketing tool
  • Oil-free compressors.


Wellness practices[6]

Nowadays, every branch of medicine including dentistry is following a wellness-based model – one that is centered upon prevention, early detection, and minimally invasive treatment option for patients.

Few wellness-based modalities that are part of dentistry's green future are:

  • Laser diagnostic tools that enable to see caries earlier than with the naked eye
  • Oral cancer diagnostics
  • Salivary testing to determine genetic predisposition to periodontal disease and identify pathogenic bacteria
  • Laser treatment of periodontal disease
  • Homeopathic modalities which promote reduced swelling and bruising after dental procedures, with no drug interaction
  • Live, green plants in the operatory, increasing oxygenation
  • Ultraviolet germicidal, in-operatory air purifiers to remove particulates from air.



  Disposal of Waste Top


Dental practitioner is the only person responsible for the collection, storage, and disposal of all types of amalgam and other waste generated in a dental practice. Many dental clinics have chairside filtration devices, as well as secondary filters which trap larger particles of dental amalgam and protect vacuum pumps.[5],[18] Amalgam separator (International Organization for Standardization standard 11143), when used with chairside traps and vacuum pump filters, pulls the mercury out of them and has been proved to be approximately 98% effective in removing amalgam particles from the wastewater of dental clinics.[19],[25]

Staff members should be trained and should use gloves, masks, gowns, etc., while disposing of amalgam waste. Contact and noncontact amalgam waste should be sent for recycling to reprocess mercury in separate containers.[9],[18] Unused X-ray film contains unreacted silver. Therefore, it requires safe disposal. This can generally be accomplished by returning it to the supplier or a certified waste carrier for recycling.[18] In traditional X-ray systems, discarded lead foils, fixer, and developer solution waste are generated, which need to be recycled.[19]

Biomedical waste[9]

Biomedical waste includes materials which are suspected of having pathogenic organism and thus capable of causing disease. It includes blood-soaked gauze pieces, tissues, and syringes. Sharps (i.e., syringes and suture needles) should be stored in a leak-proof, puncture-resistant, well-labeled container until collection and incineration. Anatomical waste products should be stored in a properly labeled yellow bag. The authorities have defined the specific color-coded containers for disposal of waste [Figure 2].
Figure 2: Disposal of biomedical waste

Click here to view


General office waste

It includes nonhazardous waste such as paper, paper napkins, and cotton rolls. Dentists should implement various measures to reduce this waste. The usage of products made from recycled materials, for example, cotton or wool rolls and paper towels, should be promoted. Single-spaced printing and use of both sides of pages can decrease the amount of paper used in the dental office. Recycled toner and inkjet cartridge use should be promoted. Rechargeable batteries should be used for digital cameras and flashlights. Old hand instruments can also be recycled. Hu-Friedy runs a program called “Environdent” for this purpose. Free instrument is given in return for old ones.[19],[26]

Disposal of dental waste

It is important that the dental community should be aware of the environmental hazards of poor waste management in their practice. Recommended segregation of clinical and nonclinical waste can increase the cost of practice if sent altogether for incineration apart from being a potential harm to the environment. Some of the environment-friendly ways of disposal of various dental products are being listed in [Table 2].[10]
Table 2: Disposal of Dental Waste

Click here to view



  Miscellaneous Means Top


Eco-friendly options in office and building construction are available and should be followed to reduce the burden of practice on the environment.

Green building construction

Eco-friendly building construction tends to focus on the use of natural materials. Other commonly used terms for this include sustainable design and green architecture. It is environmental friendly and resource efficient from its designing, construction, operation, maintenance, renovation, and demolition. The Leadership in Energy and Environmental Design (LEED) is the US-based global rating system, also popular in India. Energy and research institute (TERI) conceived the Green Rating for Integrated Habitat Assessment which is a national rating system of India equivalent to LEED. Various means for green architecture are:[19],[27],[28]

  • Use less of bricks and more concrete. It leads to improved thermal efficiency which will decrease heating and cooling load
  • Flooring should be of linoleum. It is made of sustainable natural ingredient (oxidized linseed oil). It lasts for a very long time and it disposes well[29]
  • Maximize the use of solar energy and minimize its negative effects
  • Using double-wall window glasses will reduce direct heat gain while maximizing the sunlight entering the clinic
  • Use eco-friendly nontoxic paints.


Effective green building can lead to:

  • Reduced operating costs using less energy and water
  • Improved occupant health due to improved indoor air quality.


Lighting[27]

Consumption of electricity should be minimized. The use of energy-efficient light source is advisable. Traditional incandescent light bulbs are highly inefficient. In these bulbs, for every watt of energy consumed, only 10% is used to produce light. The remaining 90% is wasted. Therefore, the usage of compact fluorescent light (CFL) and LED bulbs is more promoted nowadays. Most CFL bulbs last 8–12 times longer than incandescent, at a quarter the cost per hour. They also produce 70% less heat than incandescent bulbs while illuminated.

[TAG:2]American Dental Association/council on Dental Practice Suggestions[20][/TAG:2]

The Council on Dental Practice of the American Dental Association has framed the top ten guidelines for starting up a green dental practice. These are:

  1. Install an amalgam separator
  2. Turn off equipment when not in use
  3. Reuse paper craps
  4. Use recycle bin and create a “green team” to bring items to recycle centers
  5. Recycle shredded confidential patient information
  6. Convert to digital technology
  7. Install solar or tinted shades
  8. Install locked or programmable thermostats
  9. Install high-efficiency lighting
  10. Use nontoxic cleaners and do not use too much disinfectant.



  Conclusion Top


Dental practitioners are becoming increasingly concerned about the impact of their practice on the environment. They often take voluntary measures to make their practice eco-friendly. This approach will prove beneficial for them to succeed in this era of increased environmental concern and environmentally protective legislation. It is also a moral and ethical obligation for them to maintain an environment-friendly dental practice toward:

  • The patient
  • Dental staff
  • Environment (regulated handling of solid materials, liquid waste and hazardous vapors, recycling, and energy consumption reduction).


Each staff member should be a part of the efforts done to implement practical eco-friendly changes to old, unsustainable dental practice patterns. Thus, by focusing more on prevention, precaution, sustainability, and creating awareness, a dental professional can significantly contribute to improving the health of the patients, the community, and the environment.

Dental community, especially students, should be informed on contemporary literature available on dental waste disposal and environment responsible dental practice. This can be very effective for developing knowledge and skills for tackling this issue. Some of the recommendations are:

  • Compulsory education in environmental sustainability is currently absent from UG curriculum. Dental schools should dedicate adequate curriculum, time, and emphasis on environmental awareness of dental students during their training
  • Development of adequate information for proper disposal and treatment of dental waste
  • To develop an online tool that will enable a dentist to monitor their carbon emissions to attain sustainability
  • Create awareness related to reduction in phantom power (the small amount of electricity that drains from certain appliances, transformers, and equipment such as surge-protected extension cords and instant-on devices such as television, monitors, and computers even when not in use).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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