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135]

Review Article

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

Abstract
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.

Key words: Dentistry, eco‑friendly, environment, green

Introduction Worldwide, various organizations have recognized the need to

regulate and monitor the dental offices on an environmental
It is identified that humans are the biggest threat to their own
basis. Leadership in Energy and Environmental Design was
race. Our own attitude toward our environment is affecting
developed in 2000 by the US Green Building Council. It is
our health and well‑being on a large scale. Thus, it is essential
a rating system which reflects sustainable site development,
for each individual to be aware of his carbon footprint and the
water saving, energy efficiency, materials selection, and indoor
changes that can be incorporated in his lifestyle to reduce the
environmental quality.[2] In June 2009, the Eco‑Friendly
global burden. According to WHO, SEARO, the 11 South Asian
Dentistry Association (EDA) was launched internationally. In
countries produce a total of about 35,000 tons of health care waste
India, The Ministry of Environment and Forests (MoEFs) has
annually and about 1000 tons daily. There is a need for dentists
promulgated Hazardous Wastes (Management and Handling)
to be conscious environmentally and go the eco‑friendly way.[1]
Rules, 1989 and amended the same in 2000 and 2003 for proper
The term “eco‑friendly dentistry” was coined by Dr. Malden management and handling of hazardous wastes in the country.[4]
Kralj, the founder of Ora Dental Studio, America’s first
National Green Tribunal, an Indian association, has issued
green dental group.[2] Eco‑friendly dentistry is an approach
various directions for protection of environment and human
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 Address for correspondence: Dr. Savy Arora,
H. No. 376, Sector 7, Panchkula ‑ 134 109, Haryana, India.
or reducing outgoing wastes and by promoting the well‑being E‑mail: savy376@gmail.com
of all those in the clinical environment by conscious reduction
of the chemicals in the breathable air.[3]
This is an open access article distributed under the terms of the Creative
Access this article online Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
Quick Response Code: allows others to remix, tweak, and build upon the work non-commercially,
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For reprints contact: reprints@medknow.com

DOI:
10.4103/2277-4696.205446 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.

22 © 2017 Journal of Dental and Allied Sciences | Published by Wolters Kluwer - Medknow
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Arora, et al.: Eco-friendly dentistry: Need of future. An overview
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.[5]
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.”[2]
• 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.[5]
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
• Sharps
• Silver‑containing waste including used fixer solution and
unused X‑ray films
Journal of Dental and Allied Sciences  ¦  Volume 6  ¦  Issue 1  ¦  January-June 2017
• 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.[4]
The World Bank’s health‑care waste management guidance,
note lists four steps to health‑care waste management:[4]
1. Segregation
2. Transportation
3. Treatment
4. 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
• Batteries.
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
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Arora, et al.: Eco-friendly dentistry: Need of future. An overview

Table 1: Color coding of waste disposal bags/containers

Category Type of waste
I (yellow) Human/animal anatomical waste
Soiled waste
Expired/discarded medicine
Chemical waste
Chemical liquid waste
Discarded linen, mattresses,
beddings contaminated with
blood or body fluid
Microbiology, biotechnology and
other clinical laboratory waste
II (red) Contaminated waste (recyclable)
such as tubing, bottles,
intravenous tubes and gloves
III (white or Waste sharps such as blades,
translucent) scalpels and needles
IV (blue) Glassware (like vials) and
metallic body implants
Type of bag/container
Yellow colored
nonchlorinated plastic bags
Yellow colored
nonchlorinated plastic bags
Yellow colored
nonchlorinated plastic bags
Yellow colored containers or
nonchlorinated plastic bags
Separate collection system
Yellow colored
nonchlorinated plastic bags
Autoclave safe plastic bags
or containers
Red colored nonchlorinated
plastic bags or containers
Puncture proof, leak proof,
tamper proof containers
Cardboard boxes with blue
markings
Disposal treatment
Incineration or plasma pyrolysis or deep burial
Incineration or plasma pyrolysis or deep burial
Yellow colored nonchlorinated plastic bags incineration/
encapsulation/plasma pyrolysis
Incineration/encapsulation/plasma pyrolysis
Pretreated before mixing with other wastewater. Sludge from
effluent treatment plant given to common biomedical waste
treatment facility for incineration or to hazardous waste treatment,
storage and disposal facility for disposal
Nonchlorinated chemical disinfection followed by incineration or
plasma pyrolysis
Pretreat to sterilize with nonchlorinated chemicals on‑site thereafter
for incineration
Autoclaving or micro‑waving/hydroclaving followed by shredding
or mutilation or combination of sterilization and shredding
Autoclaving or dry heat sterilization followed by shredding or
mutilation or encapsulation. Final disposal to iron foundries or
sanitary landfill or concrete waste sharp pit
Disinfection (by soaking the washed glass waste after cleaning with
detergent and sodium hypochlorite treatment) or through autoclaving
or microwaving or hydroclaving and then sent for recycling

waxes, green stick compound, impression pastes, shellac Electronic Wastes

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.[4]
Best Management Practices for Amalgam
Waste
Dental amalgam particles are a source of mercury which
is a proven neurotoxic, nephrotoxic, and bioaccumulative
element.[7]
• 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.[6]
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.[8]

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Arora, et al.: Eco-friendly dentistry: Need of future. An overview
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.[8]
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
Journal of Dental and Allied Sciences  ¦  Volume 6  ¦  Issue 1  ¦  January-June 2017
(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[3,5]
• 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.[9]
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.[9]
Switch to Latest Technologies to Save Time,
Material, and Increase Efficiency
Patient records
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.[3]
Dental X‑rays
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.[6] 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.[3]
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Arora, et al.: Eco-friendly dentistry: Need of future. An overview

Dental impressions soluble nitrates of silver and copper are produced. If pure
Sectional trays and dual arch impression trays are to copper or any other metal having lower electrode potential is
minimize wastage of impression material. Nowadays, added to this silver nitrate solution, silver gets displaced and
trays made of biodegradable material are also available. is easily recovered.[10]
Digital optical impressions eliminate the need to make
Dental instruments
impressions with the conventional method. Conventional
Since many years, Hu‑Friedy has been running a program
dental impressions do not provide adequate detail reproduction
called “environ‑dent” in which dentists can recycle old hand
and might require remaking at times, leading to wastage
instruments and receive free new instruments. Instruments
of material. Digital impressions significantly increase
should be sharpened regularly, thus, reducing the need for
accuracy and productivity, and the impression can be sent
discarding old instruments.[10]
through e‑mail to the dental laboratories. Combined with
computer‑aided design/computer‑aided manufacturing, Gypsum:
digital impressions/models are helpful to minimize wastage It is a universally accepted fact now that gypsum when
of material and provide high accuracy.[3] discarded in landfills, the reduction of its sulfate cause
production of hydrogen sulfide, having a characteristic rotten
Recycling of Dental Materials egg smell. The respiratory tract and nervous system are
the most sensitive targets of hydrogen sulfide toxicity. Few
Dental waxes symptoms include irritation to the eyes, nose, or throat. It
Waxes are widely used in dentistry in so many forms such
may also cause difficulty in breathing for some asthmatics.
as modeling wax, inlay wax, utility wax, casting wax,
Headaches, poor memory, tiredness, and balance problems may
beading and boxing wax, baseplate wax, sticky wax, and
also occur. Permanent or long‑term effects include headaches,
bite registration wax. Some of the waxes are naturally
poor attention span, poor memory, and poor motor function. In
obtained  (carnauba, Candela, and beeswax) and some are
the UK, gypsum to gypsum recycling projects has been started
petroleum products (ceresin and paraffin wax). In most of the
which include demolition waste and other gypsum products.
procedures, Maximum amount of wax is not consumed, but
It is claimed that the recycled gypsum powder is 99% as good
used and rejected. About 80%–90% of wax can be recycled
as virgin gypsum.[11]
without affecting their properties using a simple laboratory
procedure of removing the impurities. As this is an in vitro
procedure, no biocompatibility issues exist.[10] Conclusion
An eco‑friendly dentist need not be an environmentalist, just
Casting alloys
a rethinker. It is a matter of choice for the dentist to choose
In dentistry, alloys are used in fabrication of metal copings,
eco‑friendly products and practices and save as much paper,
crowns, and bridges, cast partial denture frameworks, metal
water, material, and energy as possible. Dentistry is such a
denture bases and implant‑supported frameworks and
noble profession that our efforts should always aim toward
crowns. 50%–60% of the alloy remains as wastage in the
the betterment of the society and not harm it. In developing
form of buttons and sprues in this process. The remaining
countries like India, it is important that we realize the
wasted materials can be effectively reused for fabricating
importance of being environment‑friendly and understand that
new restorations or appliances by proper cleaning techniques
the efforts of each individual count. More research and funds
(sand blasting, electropolishing). There is only 5%–10%
are required to regulate and promote eco‑friendly practices.
decrease in their mechanical properties even after 20th recast.
Dental practitioners should be trained in Workplace Hazardous
However, the only concern is biocompatibility. Thus, these
Materials Information System.[7]
materials can be redirected to other engineering areas for the
fabrication of cutting tools, oil well drilling bits, dredging Financial support and sponsorship
cutters, hot trimming dies, internal combustion engine valves, Nil.
gas turbine vanes, buckets, etc., These alloys are termed as
super alloys in engineering fields due to their high strength Conflicts of interest
and high corrosion resistance.[10] There are no conflicts of interest.

Silver amalgam
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
References
1. Chadha  GM, Panchmal  GS, Shenoy  RP, Siddique  S, Jodalli  P.
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2. Avinash  B, Avinash  BS, Shivalinga  BM, Jyothikiran  S, Padmini  MN.
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Sci Oral Rehabil 2013;1:5‑6.
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Arora, et al.: Eco-friendly dentistry: Need of future. An overview

“There’s plenty of room at the bottom”: The biomedical waste
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11. Fairweather  RJ, Barlaz  MA. Hydrogen sulfide production during
decomposition of landfill inputs. J Environ Eng 1998;124:353‑61.

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