Environ Dev Sustain (2019) 21:2599–2618

https://doi.org/10.1007/s10668-018-0156-5

REVIEW

Green dentistry: a systematic review of ecological dental

practices

Sunali S. Khanna1 · Prita A. Dhaimade1

Received: 9 November 2017 / Accepted: 4 April 2018 / Published online: 28 April 2018
© Springer Science+Business Media B.V., part of Springer Nature 2018

Abstract  As climate changes become more evident, humans have become more ecologi-
cally conscious. The focus has shifted from merely development, to reducing our footprint
on the environment and bringing about sustainable development. The concept of “sustaina-
ble development” emphasizes on development along with conservation of natural resources
to meet the needs of the future generations. This principle can be successfully incorpo-
rated in the healing profession of dentistry. A  comprehensive electronic data search was
conducted in Google Scholar and PubMed search engines to identify articles instilling the
concept of sustainability in dentistry. Only original studies and review articles published
in English were considered for the following systematic review. Five hundred and ninety-
eight results were obtained from the electronic database search, of which 66 fulfilled the
eligibility criteria and were included in the study. Forty-seven of these were review arti-
cles and 19  were original studies. A number of organizations offer knowledge, member-
ship, standards and best practices to dentists willing to adopt and practice eco-friendly den-
tistry. The concept of “Green Dentistry” incorporates the 4 R’s: Reduce, Reuse, Recycle
and Rethink. While on one the hand simple substitutions and changes can curb wastage, in
some other cases it may take a little extra effort or money to adopt sustainable development
in dentistry. Dental professionals throughout the world are collectively working to reduce
the environmental impact of dental practice. The efforts of every green dental surgeon and
green dental practice are transforming the dental industry by adopting the model of green
dentistry.

Keywords  Green dentistry · Recycle · Eco-friendly dentistry · Sustainability

* Sunali S. Khanna
sunalikhanna@gmail.com
1
President,Asian Academy of Oral and Maxillofacial Radiology, Member, National Academy
of Medical Sciences, Nair Hospital Dental College, Mumbai 400008, India

13
2600 S. S. Khanna, P. A. Dhaimade

1 Introduction

Mankind’s race toward development has had grave effects on the environment. Many of
these have become evident as serious effects on human health. With this background, it has
become crucial for each individual, not only to be conscious of their carbon footprint but
also to make appropriate lifestyle changes to reduce this global burden.
In September 2000, the world leaders gathered for the Millennial Summit of the United
Nations (UN) and adopted the Millennium Declaration, committing their nations to a new
global partnership to reduce extreme poverty and setting out a series of time-bound targets,
with a deadline of 2015. These were called the Millennium Development Goals.1 Then,
on September 25, 2015, countries adopted another set of goals to end poverty, protect the
planet and ensure prosperity for all as part of a new sustainable development agenda. Each
one of these goals has specific targets to be achieved over the next 15  years.2 With the
growing environmental concerns, emphasis has shifted from merely development, to sus-
tainable development.
Sustainable development is defined by the United Nations as “development that meets
the needs of the present without compromising the ability of future generations to meet
their own needs” (see footnote 2). It encourages economic development that is conducted
without depletion of natural resources. The cooperation of countries, governments and all
individuals is required to achieve these goals.
Sustainability can improve population health by contributing to healthier communi-
ties, reducing pollution and reducing the use of community resources such as water
and energy. Sustainability can contribute to a better patient experience by improv-
ing a hospital’s environment and public perception and by promoting loyalty among
patients concerned about the environment. Finally, sustainability can reduce the per
capita cost of health care by reducing health care expenses; for example, spending
less money on utilities enhances hospitals’ ability to free up resources for patient
care. (Health Research and Educational Trust 2014; Goddard)
Today, as environmental awareness and accountability is growing to become the priority
of humanity, environmentally responsible practices have become more evident and many
organizations are encouraging eco-friendly practices. The profession of dentistry, however,
due to the obligatory use of large amounts of water, electricity and plastics has contributed
to climate change and environmental pollution over the years (Passi and Bhalla 2012; Lak-
shman 2010).
According to the Eco-Dentistry Association (EDA)’s Dental Office Waste and Pollu-
tion, each year, dental offices generate 4.8 million lead foils, 28 million liters of toxic X-ray
fixer, 3.7 tons of mercury waste, 1.7 billion sterilization pouches and over 680 million chair
barriers, light handle covers and patient drapes. Besides this, the average dental practice
uses 57,000 gallons of water each year.3 With these facts, it is established that dentistry
has a great impact on the environment and changing these principles and practices toward
a greener environment is the need of the hour. Though the profession of dentistry has seen

1
  http://www.unmil​lenni​umpro​ject.org/goals​/.
2
 Our Common Future, Chapter  2: Towards Sustainable Development, A/42/427. Our Common Future:
Report of the World Commission on Environment and Development, UN Documents Gathering a body of
global agreements, http://www.un-docum​ents.net/ocf-02.htm.
3
  http://annap​olisg​reend​ental​.com/what-is-green​-denti​stry/, http://ecode​ntist​ry.org/?offic​ewast​e.

13
Green dentistry: a systematic review of ecological dental… 2601

many recent advances, unfortunately, some of the materials that are currently in use includ-
ing heavy metals and biomedical waste still pose potential challenges to the environment
(Hiltz 2007). In the desire to maintain asepsis and reduce contamination, dental health
professionals along with their medical counterparts have turned to a multitude of single-
use and disposable plastic equipment. However, the true question here is that, is plastic
really disposable? And if so, are the current practices of segregation and waste manage-
ment adequate to handle the amount of plastic waste that is being generated (Nasser 2012).
Fortunately, a number of studies indicate the changing attitudes and practices of dental
health-care professionals toward the environment and growing acceptance to the strategies
of “eco-friendly” or “green dentistry” (Goddard; Popa et al. 2015; Al-Qarni et al. 2016).
Green dentistry is a high-tech approach that reduces the environmental impact of dental
practices and encompasses a service model for dentistry that supports and maintains well-
ness. A few organizations have developed models for eco-friendly dentistry that are not
only environmentally conscious but also emphasize on patient well-being and thus help
dentists incorporate advanced dental innovations into serving the needs of green dentistry
consumers. One such organization is the Eco-Dentistry Association (EDA) which offers
knowledge, membership, standards and best practices to dentists willing to adopt and
practice eco-friendly dentistry (Lakshman 2010; Adams 2007).4 The EDA defines green
dentistry as: Reducing waste and pollution-saving energy, water, and money-incorporating
high-tech-wellness-based (Passi and Bhalla 2012; see footnote 4). The practice of green
dentistry is based on the model of four R’s—Reduce, Reuse, Recycle and Rethink. These
principles adapt dental innovations into everyday practice and encourage the efficient use
of time and resources, reducing supply costs, curbing wastage and eventually preventing
pollution. Ultimately even patients benefit, receiving quality treatment with a reduction in
treatment costs. The key concepts of a green dental practice are simply conservation of
resources like water and energy (Damle 2016). However, even decades after the develop-
ment of the concept of “green dentistry,” there is only limited research available on the
knowledge and practices of dental students and dental practitioners about “eco-friendly
dentistry.” This paper attempts to review such studies and highlight the recommendations
and strategies that can transform dentistry into an eco-friendly profession.

2 Materials and methods

A comprehensive electronic search using search engines “Google Scholar” and “Pub-
Med” was conducted in February 2018 using the keywords “green dentistry,” “eco-
friendly dentistry,” “recycling dental waste” and “sustainability in dentistry.” Inclusion and
exclusion criteria were established. The study was carried out according to the PRISMA
GUIDELINES.

2.1 Inclusion criteria

• Original studies
• Review articles
• Articles published in English

4
  What exactly is green dentistry? Available from: http://www.ecode​ntist​ry.org/.

13
2602 S. S. Khanna, P. A. Dhaimade

2.2 Exclusion criteria

• Short communications
• Letters to the editor
• Articles published in languages other than English

3 Data extraction and results

The electronic literature database search resulted in a total of 598 articles. The titles and
abstracts of these resultant articles were reviewed to identify any common results, and 296
articles were shortlisted. The shortlisted articles were then identified and reviewed manu-
ally and individually by both the authors to extract relevant articles. A total of 66 relevant
articles were identified and reviewed in detail which included 47 review articles and 19
original research studies. Out of the 19 original studies, 8 were questionnaire-based studies
scrutinizing the level of knowledge and awareness about the concept and practices of green
dentistry and their implementation of eco-friendly strategies. Five studies were identified
as exposure studies assessing the ill effects of amalgam exposure to dental patients, prac-
titioners and dental students. Other 6 studies were centered on the environmental impacts
of disposable vs. reusable and recyclable materials, the different protocols to recycle, and
some studies audited the quantity and quality of dental waste to identify the fraction that
can be recycled or reused. See Fig. 1.

4 Discussion

The first documented reference to the term “eco-friendly dentistry” can be traced back to
April 2007 when Dr. Ali Farahani and Mittale Suchak from University of Waterloo pub-
lished a study on it (Farahani and Suchak 2007). They defined eco-friendly dentistry as an
“approach to dentistry that implements sustainable practices by keeping resource consump-
tion 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”
(Farahani and Suchak 2007).
Sixty-six publications were included in this systematic review which consisted of a wide
range of articles including questionnaire-based studies, exposure studies, literature reviews,
audit studies and guidelines and recommendations to practice eco-friendly dentistry. Fara-
hani and Suchak (2007) conducted a “survey and interview”-based study among 6 den-
tal offices in Ontario, Canada. Five of these offices worked on conventional models, and
one worked on the green model. This study aimed to present tangible data and emphasize
the environmental cost of conducting general dental practice (Farahani and Suchak 2007).
Their results showed how dental offices can reduce their environmental footprint by adopt-
ing some simple, practical and reasonable alternatives. As a part of this study, a number
of “green” recommendations were provided that would allow dental health professionals
around the world to practice “green” or “eco-friendly” dentistry (Farahani and Suchak
2007). In 2013, Al Shatrat et al. (2013) conducted a cross-sectional questionnaire survey
among 150 private dental practitioners in Jordan and concluded that although the level of
knowledge about eco-friendly dental office strategies was high for amalgam, radiology,

13
Green dentistry: a systematic review of ecological dental… 2603

Fig. 1  Data Extraction and Compilation process

paper waste, infection control, conservation of energy and water; majority of Jordanian
dentists showed low level of implementation of these eco-friendly strategies. Popa et  al.
(2015) showed in their prospective questionnaire study that while various dental person-
nel and students possessed interest in eco-friendly alternatives, the concept of “green den-
tistry” was not well understood. On the other hand, the KAP (knowledge, attitude and prac-
tice) study conducted among Indian dental practitioners by Zaharunnissa et  al. in North
Bangalore (Zaharunnissa et al. 2017) and Prathima et al. in Hyderabad and Secunderabad

13
2604 S. S. Khanna, P. A. Dhaimade

(Prathima et al. 2017) showed positive attitudes toward adopting measures of “green den-
tistry.” All of these original questionnaire-based studies are tabulated in Table 1.
Another category of original studies included studies measuring the exposure and ill
effects of toxic chemicals, primarily dental amalgam and mercury to the dental practi-
tioner, dental students and patients. Refer Table 2. These studies collectively conclude that
the dental practitioner, staff and students are at a high risk of suffering from the ill effects
of mercury released from dental amalgam. These complications were faced primarily dur-
ing the appropriate and safe disposal of amalgam waste (Pohl and Bergman 1995; Tezel
et al. 2001; Hylander et al. 2006).
Grose et  al. (2016) carried out a mixed method study using a practice scoping exer-
cise and qualitative interviews with dental staff from the National Health Services (NHS)
dental teams and private dental clinics in North Devon, UK. They noted that the staff was
aware of the concept of sustainability in dentistry and paid primary focus to the waste man-
agement protocol. The study also indicated how stringent infection control guidelines had
caused the incline toward the disposable plastic equipment. Finally, although the subjects
in the study were positively inclined toward the concept of sustainable dentistry, they criti-
cized of a lack of clear guidance for the same.
Another study carried out in the UK, by Richardson et al. (2016) in the same year, used
an audit approach of dental clinical waste to prove that sustainable dental practices can be
adopted and carbon emissions can be reduced by implementing environmentally inclined
waste management strategies. Similar results were obtained from the study carried out by
Momeni et al. in Iran in 2017, which showed how majority of the waste generated from a
dental clinic was semi-household waste that can easily be recycled. They also found that
over half of the dental clinics involved in the study did not have any programs implemented
for reducing or recycling waste (Momeni et al. 2018).
While (Sadasiva et  al. 2017) demonstrated that amalgam scrap from preclinical labo-
ratories can be used to recycle mercury and silver, de Oliveira Correia et  al. (2017) in
their study showed that stainless steel orthodontic brackets can be reused after appropriate
reconditioning treatments. An interesting study carried out by Unger SR in 2014 included
a comparison of “all cradle-to-grave aspects of single-use and reusable burs.” It comprised
of aspects like raw material extraction, manufacturing, packaging, distribution, reuse and
disposal. The results from this study showed that reusable burs had 40% less of an envi-
ronmental impact than burs used on a disposable basis, provided that the ultrasonic cleaner
and autoclave were loaded optimally (Unger and Landis 2014).
Finally, in a unique study, Duane et al. (2017) used a secondary data analysis to deter-
mine the carbon footprint of the National Health Services (NHS) dental service in England.
Besides the original studies, the various review articles from different parts of the world
simplified the 4 principles of “green dentistry,” i.e., Reduce, Reuse, Recycle and Rethink
(Pockrass and Pockrass 2008) and put forth some simple yet effective recommendations to
reduce the environmental impact of practicing dentistry.

5 Recommendations

5.1 Reduce

This is the foremost and one of the simplest principles of green dentistry. Simply by reduc-
ing the amount of resources utilized, we reduce the amount of waste that we generate, both

13
 Table 1  Questionnaire-based original studies n = 8
S. no. Author (year) Type of study Subjects Region Results and inference

1. Farahani and Survey and interview-based 6 Dental offices {5 con- Ontario, Canada The results indicated that many reasonable,
Suchak (2007) study ventional dental offices practical and easy alternatives do exist which
and 1 green model} would reduce the environmental footprint of
a dental office were it to follow the “green”
recommendations
2. Al Shatrat et al. Cross-sectional questionnaire 150 Dentists working in Amman, Jordan Level of knowledge about eco-friendly dental
(2013) survey private dental practices offices strategies was high for amalgam, radiol-
ogy, paper waste, infection control and energy
and water conservation, but the majority of
Jordanian dentists showed low level of imple-
mentation of eco-friendly dental offices strate-
gies. The most frequently identified barriers to
implementation of eco-friendly dental offices
strategies were cost and lack of incentives from
the government
3. Popa et al. (2015) Prospective questionnaire study 159 Respondents {132 Cluj-Napoca, Romania A significant percentage of the medical staff
Green dentistry: a systematic review of ecological dental…

dentistry students, 19 manifested concern regarding the exposure to

dentists and 8 dental noxious pollutants in dental office, segrega-
technicians} tion and collection of household waste and
waste from dental practice. The results showed
a lack of complete understanding of the
methods of waste neutralization, practitioners
showed awareness about the danger that waste
represents for the environment (46%) and a
significant percentage (33%) was interested in
knowing the possibilities for recycling/reuse/
reintegration. The results showed that the
concept of “green dentistry” is not completely
understood, but the subjects are interested to
be informed about this topic
2605

13
 Table 1  (continued)
2606

S. no. Author (year) Type of study Subjects Region Results and inference

13
4. Zaharunnissa et al. KAP (knowledge, attitude and 150 Dental practitioners North Bangalore Knowledge and practice level of eco-dentistry
(2017) practice) among dental practitioners indicated that 62
and 38% had moderate and adequate knowl-
edge and practice level, respectively. Attitude
toward eco dental practitioners showed that
56.7 and 43.3% had moderate, respectively
5. Al-Qarni et al. Cross-sectional pre-education 160 Participants {100 King Khalid University, Saudi Statistically significant gain in knowledge post-
(2016) survey and the post-education doctors, 50 students Arabia educational presentation.
survey and 10 dental auxil- (p = 0.00001)
iaries}
6. Ranjan et al. (2016) Cross-sectional study 500 Dental students Bhubaneswar, Odisha (India) 44% of the dental students were not aware about
the management of biomedical waste, 22%
were moderately aware, 21% slightly aware,
7% very aware and 5% fell in extremely aware
category. Similarly, (61%) participants were
completely unaware regarding recycling and
reusing of biomedical waste.
7. Grose et al. (2016) Qualitative aspect of a mixed Staff in dental practice North Devon, UK It was noted that dental staff and dentists both
method study using a practice from primary dental care and private facilities
scoping exercise and qualita- possessed some information about sustainabil-
tive interviews with staff. ity in dentistry. These concerns were centered
on the quantity of waste generated and efficient
waste management. They also indicated that
waste had increased as a result of stringent
infection control guidelines and were posi-
tively inclined toward implementing changes.
It was also agreed upon the fact that there was
a lack of clear guidance for the same.
S. S. Khanna, P. A. Dhaimade
 Table 1  (continued)
S. no. Author (year) Type of study Subjects Region Results and inference
8. Prathima et al. Cross-sectional questionnaire 800 Dental practitioners. Hyderabad and Secunderabad, Among the total sample, only 13.1% were aware
(2017) survey. Telangana, India of EFD Association. 76% (608) of the total
KAP (knowledge, attitude and sample reported that they were aware of harm
practices study) done to the environment by dental practice.
Among the total participants, majority 57.9%
reported that they implement the strategy of
proper protocol for waste disposal. Among
the total sample, 91.9% (735) of them gave
positive opinion on emphasis to be made on
implementing these strategies
Green dentistry: a systematic review of ecological dental…
2607

13
2608 S. S. Khanna, P. A. Dhaimade

of which help in conserving the environment. By reducing consumption, we can prevent

the depletion of natural resources and meet the goals of sustainable development. Follow-
ing are a few ways in which consumption of resources can be reduced in dentistry (Passi
and Bhalla 2012; Sachdev et al. 2017; see footnot 4).

5.1.1 Reducing electricity consumption

Using energy efficient lighting sources like LED lights is an effective alternative. Switch-
ing off the lights and computers when not in use instead of putting them on standby can
save a lot of energy, helping us cut down up to 10% of our energy bills (Rahman et  al.
2014).5

5.1.2 Reducing water consumption

Using efficient disinfection and sterilization equipment that does not waste water, regularly
monitoring and servicing all water taps and preventing any leaks can help us conserve sub-
stantial amounts of water. The Eco-Dentistry Association has determined that every time
the faucet is left running while brushing, up to 90 glasses of water is wasted (Pockrass and
Pockrass 2008; Rupa et al. 2015).

5.1.3 Reduce paper waste

Dental offices worldwide are using computer-based records systems and other electronic
record keeping device, which saves time while updating patient’s records and displays
the changes. This also radically reduces the number of paper prints, scratch pads, inter-
nal notes, etc., thereby helping conserve the environment (Pockrass and Pockrass 2008;
Chopra and Raju 2017; Henry 2009).

5.2 Reuse

This is a strategy that encourages finding a new purpose for an item to extend its life in
turn preventing the item from contributing to waste. By reusing products, we take the pres-
sure off of natural resources while also reducing the amount of energy needed to produce
new products. Simply by using reusable and sterilizable instruments, suction tips, patient
and chair drapes and water cups, we can reduce a huge amount of plastic waste generated
by the use of disposable equipment. This most often petroleum-derived plastic ultimately
ends up in landfills and cannot be biodegraded, thus polluting the environment for centu-
ries (Nasser 2012).
One of the options would be to use biodegradable disposable instruments made from
items like corn. The use of such disposable equipment should be limited to only when nec-
essary, as in cases where universal precautions must be taken. However, the best option is
to use stainless steel instruments that can be sterilized and used multiple times. Even after
they cannot be used anymore in dentistry, the metal can be recycled into a new purpose,

5
 Susan Beck, Director, The Eco-Dentistry Association, http://www.frien​dsofh​u-fried​y.com/WhatE​xactl​
yIsGr​eenDe​ntist​ry.asp.

13
Green dentistry: a systematic review of ecological dental… 2609

making it the least wasteful and least polluting option (Arora et  al. 2017; Avinash et  al.
2013; see footnote 4).

5.3 Recycle

Although a substantial portion of the waste from the dental office ends into landfill, a lot
of it can be recycled and reprocessed into new articles with simple segregation techniques
(Mulimani 2017). Recycling is an integral part of waste disposal and helps limit the use
of resources while also reducing the amount of waste that is being disposed into landfills
(Berg and Hager 2007).
Aluminum, glass, plastic, paper and metals like steel are some of the things that can be
easily recycled. It is estimated that 17 trees are saved for every ton of paper that is recycled.
This process also uses up a lot less energy (60%) in comparison with the process of manu-
facturing paper from timber (Rupa et al. 2015).
It is well known that the fixer used in developing traditional IOPA films has a high sil-
ver content, but very few are aware that even spent fixer solution contains approximately
4000 mg of silver per lit. Because of the high silver content, spent fixer can be recycled
easily. One efficient method is by using a silver recovery unit to recapture the silver from
the fixer. This collected silver must be transported safely by a Certified Waste Carrier for
recycling. After the separation of the silver, the solutions should be packaged and labeled
to be carried away by the hazardous waste disposal services. Undeveloped X-ray films also
contain a high level of silver. These silver containing chemicals must be considered hazard-
ous waste that can contaminate the soil and groundwater (Hiltz 2007; Chopra and Raju
2017; Anderson 1999; Abraham et  al. (2016)). Individual X-ray film packets are used in
traditional radiographic techniques. These contain a lead foil to provide an X-ray imper-
meable backing to the film. Lead is categorized as leachable toxin and is capable of con-
taminating the soil and groundwater in disposal sites. Hence, all the lead from the lead foil
should be recycled for its scrap metal content instead of being dumped into trash. The use
of digital radiography not only eliminates this lead waste, but also helps reduce the amount
of plastic casings while also abetting record keeping (Abraham et al. (2016); Palenik 2003;
Swanson et al. 1999).
Another metal inseparably linked to dentistry is silver amalgam. Amalgams are typi-
cally 50% mercury with silver, tin and other metals, and this mercury is released into the
environment when amalgam waste is disposed inappropriately (Kao et al. 2004; Chilibeck
2000). Ideally, it is advised to follow amalgam-free dentistry, but when that is not pos-
sible, practitioners are encouraged to follow “best management practices” in the handling
and disposal of dental amalgam (Hiltz 2007). The variety of amalgam wastes generated
in the dental office include elemental mercury vapors that are released primarily during
the trituration of dental amalgam alloy, dental amalgam scrap, which is amalgam parti-
cles that have not come in contact with the patient, possibly as excess restorative material,
amalgam waste that constitute the particles that have come in contact with secretions of
patients as the ones removed after carving or on instruments and finally amalgam sludge
which is made up of the finer particles that enter the wastewater through removal of old
amalgam restorations. This form of the contaminant can be efficiently trapped in chair-side
traps, vacuum filters, etc. Amalgam is a well-known health hazard due to its high mercury
content and must be separated from dental waste with the help of appropriate separators
(Hiltz 2007; Abraham et  al. 2016; Garg et  al. 2015; Naik et  al.; Hörsted-Bindslev 2004;
Chowdhry et al. 2015). The module action to prevent mercury pollution as recommended

13
 Table 2  Exposure studies and other original studies n = 11
S. no Author (year) Type of study
13
1. Eggleston and Examination of cadaveric
Nylander (1987) dentition and examination of
brain tissue specimens
2. Pohl and Bergman The amount of mercury vapor
(1995) in the dentist’s breathing
zone was continuously col-
lected and measured during
the cutting and filling of 50
amalgam restorations and
during the polishing of 80
restorations
3. Tezel et al. (2001) Cross-sectional study
4. Lindh et al. (2001) Metal level monitoring in
plasma and nuclear micros-
copy of isolated individual
blood cells were carried out
Subjects
77 Nonrandomized, sudden,
unexpected death subjects
One dentist at a public dental
health clinic, 16 male and 11
female patients
Dental students (n = 92) in
years I–V, clinical teachers in Turkey
restorative dentistry (n = 16)
and controls (n = 14)
Twenty-seven consecutive
patients with health problems Rudbeck Labora-
associated with dental
amalgam
2610
Region Results and inference
Los Angeles, USA Of the 77 samples only 28 were above the detectible
limit 1–4 ngHg/mg and no correlation between
mercury content and occlusal surfaces of dental
amalgam, age, sex or race could be established on
the basis of the results obtained by CVAAS
Umei University, When a high-volume evacuator is used during the
UmeB, Sweden cutting, filling and polishing operations, the mean
mercury vapor levels in the breathing zone of the
dentist are 1–2 pg Hg m-3, and if only a saliva
extractor is used during cutting per se, high mer-
cury vapor levels may be attained
Bornova Izmir, When groups were analyzed separately, the increase
in mercury concentration in the blood and plasma
measured at the beginning and at the end of the
academic year was statistically significant for each
group (p < 0.001)
Uppsala University, Significant increases in copper, iron, zinc and stron-
tium were found in patient plasma. There was no
tory, Uppsala, significant difference in plasma selenium between
Sweden the groups. Mercury was significantly increased in
patient plasma, although there was overlap between
the groups. In erythrocytes, a significant increase in
calcium and a significant decrease in magnesium,
copper, manganese and zinc were found. Calcium,
magnesium, manganese and copper increased
in patient neutrophil granulocytes. A significant
decrease was found for zinc. A conspicuous finding
was the presence of measurable mercury in a few
of the cells from the patient but not in the control
group
S. S. Khanna, P. A. Dhaimade
 Table 2  (continued)
S. no Author (year) Type of study
5. Hylander et al. Hg emissions via waste water
(2006) from dental clinics equipped
with the same type of
amalgam separator based on
sedimentation
6. Unger and Landis The system boundary included
(2014) all cradle-to-grave aspects of
both single-use and reusable
burs, including raw material
extraction, manufacturing,
packaging, distribution, reuse
and disposal
13
Subjects Region Results and inference
12 Dental clinics Uppsala, Sweden The total Hg concentration in waste water ranged
from less than 1 up to 74.1 mg −1 and was on aver-
age 15.8 mg−1 mercury found in fraction 1 made
up 87% of this Hg. When extrapolating data to an
annual base by dividing mean daily water emission
per clinic by number of chairs and multiplying by
220 working days per year, the initial discharge
of mercury to the community waste water system
ranged from 0.32 to 83.8 (average 14.5; n = 11)
grams of Hg per chair per year
Tempe, USA When the ultrasonic and autoclave were loaded opti-
mally, reusable burs had 40% less of an environ-
mental impact than burs used on a disposable basis.
When the autoclave and ultrasonic were loaded to
approximately two-thirds capacity, four environ-
mental impact categories favored reusable burs
Green dentistry: a systematic review of ecological dental…
(i.e., ozone depletion, smog, respiratory effects,
ecotoxicity), and four impact categories environ-
mentally favored disposables (i.e., acidification,
eutrophication, carcinogenics and non-carcinogen-
ics). When the autoclave and ultrasonic were loaded
to approximately one-third capacity, reusable dental
burs posed more negative environmental impacts in
eight of nine environmental impact categories when
compared to disposable burs
2611
 Table 2  (continued)
S. no Author (year) Type of study
13
7. Richardson et al. An audit approach was used
(2016) to quantify the nature and
quality of waste generated by
dental practice while explor-
ing the feasibility of practices
to reduce costs, recycle and
implement sustainability in
dentistry
8. Sadasiva et al. Amalgam scrap from preclini- 150 g of dental amalgam scrap Chettinad Dental
(2017) cal laboratory was collected
and subjected to vacuum dis-
tillation to separate recyclable to vacuum distillation at
mercury and silver
9. de Oliveira Correia Used stainless steel brackets
et al. (2017) were recycled and recon-
ditioned using different
protocols. The surfaces were
then evaluated using scanning
electron microscope, and
sheer bond strength was also
compared
Subjects
Clinical waste generated at
National Health Services
(NHS) and private dental
facilities was audited
from a preclinical conserva-
tive laboratory was subjected
393C
60 Reused stainless steel ortho- Sao Paulo state uni-
dontic brackets were divided
into 4 parts and subjected to
4 different protocols for recy-
cling/reconditioning. These
included aluminum oxide
(AO) 90 microns; hydrofluo-
ric acid 60 s, hydrofluoric
acid 120 s and hydrofluoric
acid 120 s + silane. Surfaces
were analyzed with scanning
electron microscope, and
sheer strength test results
were calculated
2612
Region Results and inference
North Devon, UK The results showed that sustainable dental prac-
tice can be adopted, and carbon emissions can
be reduced while still increasing profitability.
Implementation of environmentally inclined waste
management strategies is primarily driven by prac-
ticality and financial incentives
Vacuum distillation successfully collected and sepa-
College and rated mercury and silver. 150 g of dental amalgam
Research Institute, scrap yielded of 50–80% recyclable silver (purity
Tamil Nadu, India 70–80%) in a time period of 300–600 min
Recycling/reconditioning protocol using aluminum
versity, Brazil oxide and sandblasting was found to be the most
effective method and can be an efficient method to
recycle stainless steel orthodontic brackets
S. S. Khanna, P. A. Dhaimade
 Table 2  (continued)
S. no Author (year) Type of study Subjects Region Results and inference

10. Duane et al. (2017) Secondary data analysis from National Health Services England The NHS dental service carbon footprint was 675
business Services Author- (NHS) England dental teams kilotons carbon dioxide equivalents
ity (BSA), Health and
Social Care Information
Center (HSCIC), Informa-
tion services Division(ISD),
National Association of
Specialist Dental Account-
ants (NASDA)
11. Momeni et al. (2018) Categorization of waste and Waste generated from 48 Birjand, Iran Of all the waste generated, maximum percentage was
evaluation of the amount of dental clinics semi-household waste and hazardous waste was
toxic/pathogenic waste gener- least among all the 5 categories used to segregate
ated to the waste that can be the waste. It also showed that 54% of the clinics
recycled using samples of had no programs implemented to reduce or recycle
waste from dental clinics waste
Green dentistry: a systematic review of ecological dental…
2613

13
2614 S. S. Khanna, P. A. Dhaimade

by the ADA(American Dental Association) for the management of amalgam waste by

dentists and dental students is “GRIT”; G—grey bag it; R—recycle it; I—install an amal-
gam separator; T—teach it (Abraham et al. 2016; Fan et al. 1997; Westman and Tuominen
2000). The mercury in amalgam is a known neurotoxin, especially to growing children,
developing fetuses, hypersensitive individuals and people with kidney impairments. The
toxicity of mercury rises with environmental interactions like changes in pH, oxygen avail-
ability, temperature and bacteria, that convert it to the more toxic “organic methyl mer-
cury.” Methyl mercury bio-accumulates in the fish cause mercury poisoning in humans
(Minamata disease) (Chin et al. 2000; Rogers 1989; Eggleston and Nylander 1987).
Enumerable studies are being carried out around the world to identify various recon-
ditioning protocols to reuse some stainless steel equipment like orthodontic brackets and
dental implants. While most of these procedures must be carried out by the manufacturer
and not by the clinician, implementation of such programs and rewards for the same will
encourage reuse and recycling (de Oliveira Correia et al. 2017; Sachdev et al. 2017; Pithon
et al. 2017). Hand instruments especially metal instruments can be recycled after they lose
their use in the dental office. An appreciable initiative is taken by many organizations to
encourage metal recycling. For example, Hu-Friedy has offered a program called environ-
ment operational from over 12 years. This scheme allows practitioners to recycle old hand
instruments and receive a free instrument for helping the planet (Chopra et al. 2014).6

5.4 Rethink

Environmentalism and sustainability are both considered states of mind. Rethinking every
decision and every step in the dental practice can help us develop a mindset and strategy
to change the existing practices. Incorporating simple strategies that decrease energy and
water consumption can help protect the environment and bring about sustainable devel-
opment (Goddard; Chadha et al. 2015). Here are a few day-to-day activities in the dental
clinic where rethinking strategies can be applied (Grose et al. 2016; Aggarwal et al. 2017).

a. Rethink sterilization As much as possible dangerous and toxic chemicals should be

avoided to reduce water pollution. Steam sterilization is used instead of cold and chemi-
cal sterilization and reusable instruments and equipment should be used instead of
disposable ones (Adams 2007; Anderson 1999). Another strategy is to switch to eco-
friendly disinfectants. Disposable sterilization pouches that are made of paper on one
side and polythene on the other should be replaced with metal trays or reusable cloth
pouches (Westman and Tuominen 2000; Garla 2012).
b. Rethink radiology Simply by switching to digital radiography, the dental clinic can
reduce the amount of waste lead foils and waste chemicals like fixers and developers
that would otherwise potentially cause serious land and water pollution all while also
decreasing the radiation exposure to patients and improving the image quality (Adappa
et al. 2015) (See footnote 4).
c. Rethink waste management Utmost attention must be paid to waste segregation, recy-
cling and waste disposal (Berg and Hager 2007). Data regarding all the waste that
gets recycled, bio-hazardous waste and annual water and energy consumptions must be

6
  Hu-friedy. Environdent. Available from: http://www.hu-fried​y.com/ programs/environdent.aspx.

13
Green dentistry: a systematic review of ecological dental… 2615

recorded. This helps to recognize where improvement is needed, and goals can be set
to be achieved in the following years (Passi and Bhalla 2012; Shetty 2011).
d. Rethink office operations Digitization of patient records, electronic claims, electronic
patient registration, follow-up, recall and reminders can save substantial amounts of
paper (Srinivasan and Chitra 2015; Ranjan et al. 2016; Lindh et al. 2001; Pandita et al.
2014).
e. Rethink energy Finally, one of the best ways to adopt green dentistry is to switch to
sustainable and renewable energy sources like solar energy to power the dental office
(Srinivasan and Chitra 2015; Glick et al. 2012; Eram et al. 2017; Pockrass and Access
2009).
f. Rethink building A green building is an architectural structure that is environmentally
responsible and utilizes resources efficient. Such a green dental building may call for
more investment initially but will definitely save more in the long run. Using concrete
instead of bricks, using double wall glass in window so as to diminish direct heat gain
but still make the most of the sunlight entering rooms, using eco-friendly nontoxic
paints, etc. are some simple measures that can help conserve resources (Chowdhry et al.
2015; Singla and Singla 2014; Shekhar 2015)

6 Conclusion

Green dentistry is a multi-disciplinary approach that emphasizes on maximum utilization

of the productivity of resources in the dental office. It follows all the 4 R’s: Reduce, Reuse,
Recycle and Rethink. Today with the help of the models devised by various organizations
every dental practice can adopt several simple changes in the clinic that will help build a
sustainable environment while also providing quality dental care to the community. This
systematic review has a number of limitations like language barriers and limited sources
of data in; it shows that, though in some cases it may take a little extra effort or money,
dentists throughout the world are collectively doing their best to reduce the environmental
impact of dental practice and practicing green dentistry.

Compliance with ethical standards 

Conflict of interest  The authors declare no conflict of interest.

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