|Year : 2017 | Volume
| Issue : 1 | Page : 22-27
Eco-friendly dentistry: Need of future. An overview
Savy Arora, Sanjeev Mittal, Veronika Dogra
Department of Prosthodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
|Date of Web Publication||2-May-2017|
H. No. 376, Sector 7, Panchkula - 134 109, Haryana
Source of Support: None, Conflict of Interest: None
In today's world, it is very necessary to understand the importance of being eco-friendly in every facet of our lives. The color “green” has healing power and denotes renewal, growth, and hope. “Eco-friendly dentistry” attempts to reduce the detrimental impact of dental practices on the environment and promote environmental awareness and sustainability to patients. This paper attempts to cover all possible aspects of making a dental practice eco-friendly, both in a dental perspective as well as a general perspective. While establishing an eco-friendly dental workplace, the dentist needs to assess his choices in planning the infrastructure and purchasing of equipment and dental materials. Eco-friendly dentistry is 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. There are two main avenues for implementing eco-friendly dentistry: (1) appropriate policy development and implementation and (2) dentists taking responsibility/ownership in the absence of policies and regulations. Although in some cases, it may take a little extra effort or money; dentists throughout the world are doing their best to reduce the environmental impact of the dental practice. Although the commitment of one small dental office cannot save the planet, certainly, the collective efforts of many small offices as well as large dental hospitals/colleges can ensure that dentists, at least, will not be responsible for destroying it. This article discusses various factors that can be incorporated into dental practice that can help make dentistry eco-friendly.
Keywords: Dentistry, eco-friendly, environment, green
|How to cite this article:|
Arora S, Mittal S, Dogra V. Eco-friendly dentistry: Need of future. An overview. J Dent Allied Sci 2017;6:22-7
| Introduction|| |
It is identified that humans are the biggest threat to their own race. Our own attitude toward our environment is affecting our health and well-being on a large scale. Thus, it is essential for each individual to be aware of his carbon footprint and the changes that can be incorporated in his lifestyle to reduce the global burden. According to WHO, SEARO, the 11 South Asian countries produce a total of about 35,000 tons of health care waste annually and about 1000 tons daily. There is a need for dentists to be conscious environmentally and go the eco-friendly way.
The term “eco-friendly dentistry” was coined by Dr. Malden Kralj, the founder of Ora Dental Studio, America's first green dental group. Eco-friendly dentistry is an approach to dentistry that implements sustainable practices by keeping resource consumption in line with nature's economy, by safeguarding the external environment by virtue of eliminating or reducing outgoing wastes and by promoting the well-being of all those in the clinical environment by conscious reduction of the chemicals in the breathable air.
Worldwide, various organizations have recognized the need to regulate and monitor the dental offices on an environmental basis. Leadership in Energy and Environmental Design was developed in 2000 by the US Green Building Council. It is a rating system which reflects sustainable site development, water saving, energy efficiency, materials selection, and indoor environmental quality. In June 2009, the Eco-Friendly Dentistry Association (EDA) was launched internationally. In India, The Ministry of Environment and Forests (MoEFs) has promulgated Hazardous Wastes (Management and Handling) Rules, 1989 and amended the same in 2000 and 2003 for proper management and handling of hazardous wastes in the country.
National Green Tribunal, an Indian association, has issued various directions for protection of environment and human health including control of environmental pollution by the way of
- Adopting clean technology
- Recycling and reuse of waste material
- Installation of pollution control equipment
- Better housekeeping and work practices including of waste minimization techniques.
| Why Green Dentistry?|| |
The color “green” denotes renewal, growth, and hope. Green dentistry is not only environment-friendly but also conserves money and time by reducing waste, conserving energy and decreasing pollution with the use of latest techniques and procedures. Green dentistry, therefore, protects the environment and humanity from the hazards of rapid urbanization, especially in the developing countries.
| The Four R's of Being Eco-Friendly|| |
The four R's include reduce, reuse, recycle, and rethink. It is common to think that “recycle” is the best eco-friendly way. However, “rethink” is the first step to being eco-friendly and “reduce” and “reuse” are more effective than “recycle.”
- To “reduce” is to minimize the amount of waste sent to landfills. One can reduce waste production by reusing and recycling maximum amount of materials. Packages constitute 30% of the garbage. Thus, purchase of products with minimal packaging and use of plastic containers can help
- To “reuse,” single use items should be replaced by reusable items
- To “recycle,” paper, metal, and gypsum can be recycled. Identification of existing recycling programs is necessary
- Most importantly, rethinking at every step is the key to an eco-friendly practice. Before buying any material for your clinic, think of environmentally better options. While using any material during a procedure, use the material judicially and dispose it off following proper protocols or prefer recycling.
| Categories of Dental Waste|| |
The four possible waste sources in dental offices include (a) mercury-containing dental material (b) X-ray developer and fixer solutions, lead foil of X-ray film, (c) infection control barriers including disinfectants and disposable barriers, and (d) conventional vacuum saliva ejector systems.
Thus, various dental wastes can be divided into these categories:
- Biomedical waste
- Nonanatomic waste such as gloves, and dental materials
- Anatomic wastes including extracted teeth
- Silver-containing waste including used fixer solution and unused X-ray films
- Lead-containing wastes-lead aprons and lead foils in the X-ray films
- Mercury-containing wastes-element mercury, scrap amalgam
- Chemicals-disinfectants and sterilizing agents.
| Waste Management|| |
The term biomedical waste has been defined as “any waste that is generated during the diagnosis, treatment, or immunization of human beings or animals, or in the research activities pertaining to or in the production or testing of biological and includes categories mentioned in Schedule I of the Biomedical Waste (Management and Handling) rules 1998.” These rules make it mandatory for the health care establishments to segregate, disinfect, and dispose of their waste in an eco-friendly manner. There may be increased risk of nosocomial infections in patients due to poor waste management. The best disposal options are to prevent or minimize disposal of toxic substances from dental clinics into the environment.
The World Bank's health-care waste management guidance, note lists four steps to health-care waste management:
- Final disposal.
All the generators of biomedical waste should adopt universal precautions and appropriate safety measures while doing therapeutic and diagnostic activities. The plastic bags which are used for waste disposal are special nonchlorinated bags which are incinerable and are color coded according to the waste to be disposed in them [Table 1].
The chemical hazards in dental sector include:
- Dental amalgam
- X-ray cleaner
- Lead foil and shields
- Cements containing zinc phosphate
- Acids and caustics
- Fluorescent and mercury vapor light bulbs
- X-ray fixer and developer solutions
Teeth without amalgam restorations and other tissues can be placed directly into a biohazard bag or a sharps container, which can then be sterilized. Teeth with amalgams could release mercury vapor during sterilization, thus, they should be neutralized through disinfection ideally, immersion for 30 min in a fresh solution of a tuberculocidal disinfectant held within a sealed container. Items heavily soiled with blood/saliva can be placed into sharps containers. However, it may be easier to store them in small biohazard bags until treated. Used anesthetic capsules should be placed into sharps containers. Impression compound, agar, dental waxes, green stick compound, impression pastes, shellac base plates should be kept in a “yellow plastic bag” then sent for either incineration or deep burial. Rubber base impression material, investment material, pumice, acrylic, metal dust, alginate, old models, and casts, old acrylic dentures and teeth kept in a “black plastic bag” and dispose of in municipal dump.
| Best Management Practices for Amalgam Waste|| |
Dental amalgam particles are a source of mercury which is a proven neurotoxic, nephrotoxic, and bioaccumulative element.
- Switch to precapsulated dental amalgam
- Use a “mercury spill kit” if you have a spill of elemental mercury
- React unused elemental mercury with silver alloy to form scrap amalgam
- Elemental mercury should never be washed down the drain
- Use a sponge type mercury disposal container to store the scrap amalgam
- Use an amalgam separator on the suction lines to remove over 95% of the contact amalgam before entering the sewer system. Amalgam separation technology is based on sedimentation, filtration, or centrifugation of the dental amalgam particles from the wastewater.
| Electronic Wastes|| |
Electronic waste includes obsolete computers, color cathode ray tubes (CRTs), and other electronic appliances like television sets. A television and a CRT monitor contain about four pounds of lead on an average. The British Environmental Agency found that developing countries not covered under the Basel Convention, preventing the export for disposal of hazardous waste, were receiving E-waste without the means for proper disposal. It has been reported that in 2004, 23000 tons of electronic waste was exported to developing nations from the UK.
In developed countries, municipalities, public and private organizations like Dell and HP accept used/waste computers and other electronics for recycling. It is reported that 1.6 million kilograms of electronic material are recovered by HP in US and Europe, which is 98% by weight of all material received from the customers.
Reusing and recycling raw materials from obsolete electronic products help in natural resource conservation and to reduce air and water pollution. It also reduces greenhouse emissions caused during the manufacturing process of these equipment. By donating used electronics to the schools, nongovernment organizations and lower income families, which cannot afford new purchases, the society can be benefitted. The USA provides additional tax benefits for such donations. It should also be encouraged in our country.
| Legislations and Regulations for Hazardous Waste|| |
Hazardous Waste (Management and Handling) Rules, 1989, were notified in India under the Environment Protection Act, 1986 for management and handling of hazardous wastes in the country. These rules were further amended in 2000 and 2003 to bring these in line with the Basel Convention and to improve and update them according to the practical needs. Apart from MoEFs, Central Pollution Control Board, State Pollution Control Boards/Pollution Control Committees have been delegated powers for control and regulation of hazardous wastes. The MoEFs is the nodal agency for environmental matters in India. It also exercises control over imports of hazardous wastes under the Hazardous Waste Management and Handling Rules.
The Basel Convention deals with the trans-boundary transport and hazardous waste disposal as well as other chemical wastes by regulating and keeping in check of transport of hazardous wastes. India ratified this convention in 1992, showing its commitment to solve the problem of transboundary export and import as well as dumping of hazardous wastes through international cooperation. The Hon'ble Supreme Court of India has been playing a very important role for proper environmental safeguarding in India.
After the Bhopal Gas Tragedy, in 1984, USA enacted the “Emergency Planning and Community Right to Know Act” 1986, which is considered a pioneering legislation. As in USA, in India also Toxic Release Inventory should be made available to the common people by way of printed reports, computer discs, and telephone support and services.
| Establishment of Dental Offices|| |
- Use stratica or linoleum flooring: Natural linoleum is bio-based, highly durable, nontoxic, anti-microbial, and easy to maintain. It is made from solidified linseed oil (linoxyn), pine rosin, ground cork dust, wood flour, and mineral fillers such as calcium carbonate. Stratica offers unrivaled environmental benefits including no chlorine, no plasticizers, no detectable volatile organic compound (VOC) emissions, a low VOC adhesive and simple maintenance. It is made from 20% postindustrial waste
- Use high efficacy air conditioners, geysers, etc.: Energy efficiency and renewable energy are said to be the twin pillars of sustainable energy policy
- Use LED for illumination: Compact fluorescent lights (CFLs) use two-third less energy and may last 6–10 times longer than incandescent light bulbs or halogen bulbs. However, fluorescent bulbs contain mercury which is, released when they are broken, disposed off in a landfill, or combusted LED technology offers many additional advantages - such as exceptionally longer life span (60,000 h), enormously lower energy usage (90% more efficient), reduced maintenance costs and higher safety. A LED bulb lasts 2–4 times longer than a CFL, is more energy efficient due to minimal wasted energy, has a smaller size, greater durability, and reliability
- Save energy: Set a main switch for the whole dental office so that all electrical switches can be turned off after working hours with a single switch
- Use tinted glasses for windows to avoid heating up of the office ,
- Utilizing the authoritative benchmarks set forth by the Green Guide for Health Care and the EDA. Offsetting carbon dioxide with certified carbon offsets and investment into reforestation campaigns. Formulating a green team with designated responsibilities and goals.
| Switch to Reusables over Disposables|| |
- Use gowns made of cloth instead of disposable gowns
- Use cloth patient bibs instead of plastic ones
- Use stainless steel glasses instead of plastic glasses
- Use glass syringes for irrigation instead of plastic ones
- Use autoclaving cassettes and cloth pouches instead of sterilization pouches made of paper on one side and polythene on the other
- Use autoclavable stainless steel suction tips instead of disposable plastic ones
- Use reusable stainless steel prophy cups instead of disposable ones
- Use autoclavable stainless steel impression trays instead of plastic disposable ones
- Use instrument sharpening stones instead of disposing dull instruments.
| Switch to Latest Technologies to Save Time, Material, and Increase Efficiency|| |
Switch to digital computographic record keeping for patients in dental offices. A folder for each patient can be made, and radiographs and photographs kept with payment records. Records on paper can be misplaced and occupy unnecessary space in the office. Computographic records are more organized and eco-friendly.
The lead foil in X-ray films and lead aprons contain a toxin that can result into defilement of soil and groundwater in landfill areas after disposal. The X-ray fixer is considered hazardous because of its high silver content. Spent X-ray fixer used in dental clinics to develop X-rays is a hazardous material that should not be rinsed in the drain. Furthermore, X-ray cleaners contain chromium. Digital radiography requires 70%–90% radiation as compared to conventional radiography. Thus, the use of digital radiographs not only reduces the radiation exposure but also eliminates the use of biohazardous materials.
Sectional trays and dual arch impression trays are to minimize wastage of impression material. Nowadays, trays made of biodegradable material are also available. Digital optical impressions eliminate the need to make impressions with the conventional method. Conventional dental impressions do not provide adequate detail reproduction and might require remaking at times, leading to wastage of material. Digital impressions significantly increase accuracy and productivity, and the impression can be sent through e-mail to the dental laboratories. Combined with computer-aided design/computer-aided manufacturing, digital impressions/models are helpful to minimize wastage of material and provide high accuracy.
| Recycling of Dental Materials|| |
Waxes are widely used in dentistry in so many forms such as modeling wax, inlay wax, utility wax, casting wax, beading and boxing wax, baseplate wax, sticky wax, and bite registration wax. Some of the waxes are naturally obtained (carnauba, Candela, and beeswax) and some are petroleum products (ceresin and paraffin wax). In most of the procedures, Maximum amount of wax is not consumed, but used and rejected. About 80%–90% of wax can be recycled without affecting their properties using a simple laboratory procedure of removing the impurities. As this is an in vitro procedure, no biocompatibility issues exist.
In dentistry, alloys are used in fabrication of metal copings, crowns, and bridges, cast partial denture frameworks, metal denture bases and implant-supported frameworks and crowns. 50%–60% of the alloy remains as wastage in the form of buttons and sprues in this process. The remaining wasted materials can be effectively reused for fabricating new restorations or appliances by proper cleaning techniques (sand blasting, electropolishing). There is only 5%–10% decrease in their mechanical properties even after 20th recast. However, the only concern is biocompatibility. Thus, these materials can be redirected to other engineering areas for the fabrication of cutting tools, oil well drilling bits, dredging cutters, hot trimming dies, internal combustion engine valves, gas turbine vanes, buckets, etc., These alloys are termed as super alloys in engineering fields due to their high strength and high corrosion resistance.
From the amalgam scrap, it is possible to separate mercury and silver by laboratory procedures, and thus, they can be redirected for use. Almost 100% of silver amalgam is discarded in dental teaching institutes, and 25% is discarded in dental clinics. Mercury can be recovered by heating the waste amalgam at temperature higher than 4500°C. Eventually, the evaporated mercury condenses and comes out of the mix. The remaining mix is dissolved in concentrated HNO3, after which soluble nitrates of silver and copper are produced. If pure copper or any other metal having lower electrode potential is added to this silver nitrate solution, silver gets displaced and is easily recovered.
Since many years, Hu-Friedy has been running a program called “environ-dent” in which dentists can recycle old hand instruments and receive free new instruments. Instruments should be sharpened regularly, thus, reducing the need for discarding old instruments.
It is a universally accepted fact now that gypsum when discarded in landfills, the reduction of its sulfate cause production of hydrogen sulfide, having a characteristic rotten egg smell. The respiratory tract and nervous system are the most sensitive targets of hydrogen sulfide toxicity. Few symptoms include irritation to the eyes, nose, or throat. It may also cause difficulty in breathing for some asthmatics. Headaches, poor memory, tiredness, and balance problems may also occur. Permanent or long-term effects include headaches, poor attention span, poor memory, and poor motor function. In the UK, gypsum to gypsum recycling projects has been started which include demolition waste and other gypsum products. It is claimed that the recycled gypsum powder is 99% as good as virgin gypsum.
| Conclusion|| |
An eco-friendly dentist need not be an environmentalist, just a rethinker. It is a matter of choice for the dentist to choose eco-friendly products and practices and save as much paper, water, material, and energy as possible. Dentistry is such a noble profession that our efforts should always aim toward the betterment of the society and not harm it. In developing countries like India, it is important that we realize the importance of being environment-friendly and understand that the efforts of each individual count. More research and funds are required to regulate and promote eco-friendly practices. Dental practitioners should be trained in Workplace Hazardous Materials Information System.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chadha GM, Panchmal GS, Shenoy RP, Siddique S, Jodalli P. Establishing an eco-friendly dental practice: A review. IJSS Case Rep Rev 2015;1:78-81.
Avinash B, Avinash BS, Shivalinga BM, Jyothikiran S, Padmini MN. Going green with eco-friendly dentistry. J Contemp Dent Pract 2013;14:766-9.
Dixit K, Dixit KK, Kapoor N. Eco-friendly dentistry: A reality. J Dent Sci Oral Rehabil 2013;1:5-6.
Thota MM, Bathala LR, Theruru K, Shaik S, Jupidi B, Rayapati S. “There's plenty of room at the bottom”: The biomedical waste management in dentistry. J NTR Univ Health Sci 2014;3:149-55. [Full text]
Rastogi V, Sharma R, Yadav L, Satpute P, Sharma V. Green dentistry, a metamorphosis towards an eco-friendly dentistry: A short communication. J Clin Diagn Res 2014;8:ZM01-2.
Hiltz M. The environmental impact of dentistry. J Can Dent Assoc 2007;73:59-62.
Singh H, Bhaskar DJ, Dalai DR, Rehman R, Khan M. Dental biomedical waste management. Int J Sci Stud 2014;2:66-8.
Dutta SK, Upadhyay VP, Sridharan U. Environmental management of industrial hazardous wastes in India. J Environ Sci Eng 2006;48:143-50.
Passi S, Bhala S. Go green dentistry. J Educ Ethics Dent 2012;2:10-2. [Full text]
Thopegowda NB, Shenoy K, Shankarnarayana RK, Kukkila J, Vaddya SB, Gingipalli K. Recycling of Materials used in dentistry with reference to its economical and environmental aspects. Int J Health Rehabil Sci 2013;2:140-5.
Fairweather RJ, Barlaz MA. Hydrogen sulfide production during decomposition of landfill inputs. J Environ Eng 1998;124:353-61.
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