GENERAL VERIFIABLE CPD PAPER

Green dentistry: the art and science of sustainable

practice
P. Mulimani1

In brief
Provides a comprehensive overview on ‘green
dentistry’, by way of describing how the practice
of dentistry has an impact on the environment
and systematically outlining the practice measures
that can be implemented at every step, to mitigate
these effects.
Highlights the current status of sustainable dentistry
in theory and practice, with particular emphasis on
the steps taken by the NHS and UK government,
thus far.
Identifies issues and the gaps which need to be
addressed in the relatively new area of sustainable
dental practice, in order to stimulate the initiation of
concrete action by the dental fraternity, leaderships
and organisations in this direction.

Dentistry is highly energy and resource intensive with significant environmental impact. Factors inherent in the profession such as
enormous electricity demands of electronic dental equipment, voluminous water requirements, environmental effects of biomaterials
(before, during and after clinical use), the use of radiation and the generation of hazardous waste involving mercury, lead etc have
contributed towards this. With rising temperatures across the world due to global warming, efforts are being made worldwide to
mitigate the effects of environmental damage by resorting to sustainability concepts and green solutions in a myriad of ways. In such
a scenario, a professional obligation and social responsibility of dentists makes it imperative to transform the practice of dentistry
from a hazardous to a sustainable one, by adopting environmental-friendly measures or ‘green dentistry’. The NHS in the UK has
been proactive in implementing sustainability in healthcare by setting targets, developing guidance papers, initiating steering groups
to develop measures and implementing actions through its Sustainable Development Unit (SDU). Such sustainable frameworks,
specific to dentistry, are not yet available and even the scientific literature is devoid of studies in this field although anecdotal
narratives abound. Hence this paper attempts to present a comprehensive evaluation of the existing healthcare sustainability
principles, for their parallel application in the field of dentistry and lays out a blueprint for integrating the two main underlying
principles of sustainability – resource use efficiency and eliminating or minimising pollution – in the day-to-day practice. The article
also highlights the importance of social values, community care, engaging stakeholders, economic benefits, developing policy and
providing leadership in converting the concept of green dentistry into a practised reality.

Introduction
One of the major challenges of the twenty-first
century has been global warming induced
climate change, proven unequivocally as
the cause of unprecedented drastic weather
events across the globe, not observed over the
past decades or millennia.1 The first climate
change risk assessments (CCRA) carried out
for the UK in 2012 predicted drier summers
with heat-waves, winters with greater rainfall
leading to flooding, and higher air pollution.2,3
Human activity is said to be the dominant
1
Melaka Manipal Medical College, Orthodontics, Jalan Batu
Hampar, Bukit Baru, Melaka, Melaka 75150, Malaysia
Correspondence to: Dr Priti Mulimani
Email: mulimanipriti@gmail.com
Refereed Paper. Accepted 10 April 2017
DOI: 10.1038/sj.bdj.2017.546
cause of this observed warming since the
mid-twentieth century. Exponentially increas-
ing energy demands are met by progressively
burning greater amounts of fossil fuels, which
release greenhouse gases in amounts greater
than what can be neutralised by the natural
eco-systems of earth. These are in turn being
depleted, consequent to excessive exploitation,
in the process of creating products for human
consumption and degraded by the toxic pol-
lutants released in them, thus rendering them
unable to arrest the vicious cycle of global
warming.1
Heightened environmental awareness or eco-
consciousness in recent times, has translated
into a gradual global movement to mitigate
environmental damage, leading to ‘green’ trans-
formations, where ‘green’ is defined as ‘having
positive environmental attributes or objectives.’4
In the UK the government has legally binding
requirements to reduce carbon emissions by
80% by 2050 compared to 1990 levels.5 The
healthcare sector through the NHS aims to con-
tribute to this target, by reducing its emissions
by 34% by 2020.6 The Sustainable Development
Unit (SDU) of NHS England and Public Health
England facilitates achieving this by develop-
ing tools, policy and research for sustain-
able practices which reduce carbon emissions,
minimise waste and pollution and make best
use of scarce natural resources.6 Dentistry lacks
such information, evidence or even studies on
sustainable practices7 which is why efforts on
greening practices have been scant and mostly
been founded on compiled lists of general sug-
gestions.8 Therefore, the aim of this paper is to
describe a broad range of areas where dentistry
has an impact on the environment and where
interventions could be targeted to incorporate
sustainability principles.

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‘Green dentistry’ also described as eco-
friendly dentistry, has been described by Dr
Ali Farhani as 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.’9
The term ‘eco-friendly dentistry’ was patented
and trademarked by Dr Goran Kralj, Dr Steven
Koos, and Mladen Kralj, the founders of ORA
Dental Studio, a green group dental practice.10
They describe that ‘eco-friendly dentistry,
through green design and operations, protects
the immediate health of patients and team
members, protects the health of the surround-
ing community, and protects the health of the
global community and natural resources.’10
These concepts are based on the principle of
sustainable development which is defined
as development that ‘meets the needs of the
present without compromising the ability of
future generations to meet their own needs.’11
The main document on sustainable
health practices in the UK is the Sustainable
Development Strategy for the Health, Public
Health and Social Care System 2014-2020.12
It highlights eight key areas for implement-
ing sustainability in healthcare which are:
i) Carbon hotspots; ii) Commissioning and
procurement; iii) Sustainable clinical and care
models; iv) Healthy, sustainable and resilient
communities; v) Metrics; vi) Innovation,
technology and R&D; vii) Creating social
value; and viii) Leadership, engagement and
development.12,13 The underlying principles of
sustainability in these eight key areas will be
used to outline the action plan for a sustainable
practice customised to dentistry.
Carbon hotspots
These are sources with a high level of carbon
emissions, which in healthcare, have been
identified as: 1) Pharmaceuticals, medical
devices and gases; 2) Energy; 3) Travel and
transport; 4) Waste; and 5) Anaesthetic gases.14
By targeting these domains, significant reduc-
tions in the carbon footprint can be achieved
through strategies, which are discussed below.
1. Pharmaceuticals, medical devices
and gases
In dentistry biomaterials are the equivalent
of medical pharmaceuticals, and these fall in
one of the three categories of polymers, metals
or chemicals. Their environmental impact
includes emissions generated by businesses in
manufacturing the products and transporting
them, their impact during clinical use and
post-usage end-of-life disposal. The three Rs,
‘Reduce, Reuse, and Recycle’, apply to sustain-
able biomaterial usage. In recent times, ‘energy
recovery’ and ‘molecular redesigning’ have also
been added to make up the five Rs.15
Polymer products are integral to the practice
of dentistry, be it as a bonding agent or impres-
sion material or the plastic packaging in which
materials are supplied. Table  1 shows their
impact and environmentally-friendly use.
Metals in the form of instruments and wires are
also the mainstay of dentistry. Toxic by-products
released while mining and refining the natural
resources to obtain metals in usable form, and
their continued leaching into the environment
after their disposal, are their environmental
hazards.18 Instruments being amenable to
sterilisation are constantly reused, however,
reusing or recycling orthodontic appliances like
brackets, bands and wires remains a contentious
issue due to the significant clinical, financial,
ethical and legal issues associated with it.19 A
survey of British Orthodontic Society members
revealed that 47.5% of respondents recycled
metal brackets, with 96% of consultants and
92% of specialist practitioners not informing
their patients that they used recycled brackets.19
Patients have a highly negative psychological
reaction towards reuse with 33–57% being
unwilling to permit the use of recycled brackets
and 85% stating there should be a reduction in
fees for those who are treated with recycled
brackets.20 Hence, while reusing orthodontic
brackets in other patients, clinicians should keep
themselves updated with new studies, evidence,
legislation or guidelines with respect to the use

Table 1 Biomaterials used in dentistry: environmental impact and mitigation measures

Materials used Environmental effects Methods to reduce their adverse environmental impact
in dentistry

Polymers Polymers are non-biodegradable,15 bio-
accumulative, transported across placental
barrier to be transmitted to foetuses and
new-borns,16 release highly toxic dioxins and
furans which are ‘potential carcinogens’, and
on disposal in landfills continue to leak harmful
chemicals in the environment.17
Bulk-orders within and between practices to reduce packaging.
Using right amount of material and reducing wastage.
Using reusable materials where possible instead of disposable, example - reusable cloth instead of individual
plastic pouches for sterilisation of instruments, reusable plates, cups, glasses, drapes etc.
Monitoring inventory judiciously.
Enhancing clinical skills to reduce repetitions and wastage.
In orthodontics, thoughtful usage of elastics and e-chains during treatment and creating patient
awareness in appropriate usage.

Chemicals Hazardous chemicals in disinfectants,
sterilants or radiographic processing
solutions may cause cancer, reproductive
disorders, respiratory ailments, eye and
skin irritation, central nervous system
impairment, and other health effects.
Implement environment-friendly, chemical management policy – classify chemicals as hazardous or non-
hazardous. Monitor hazardous chemicals from procurement to usage and hand over to recycling agencies
for disposal after use, reduce their use as much as possible or replace them with non-hazardous options.
Digital radiography eliminates environmentally-hazardous lead foils in films and chemical processing
solutions of conventional radiography for developing and fixing X-ray images. It has prevented disposal
of at least 200 litres of toxic x-ray fixer and 17,200 lead foils in just five years in one practice.21
Online resources for sustainable chemical management are available like Guide to Choosing Safer
Products and Chemicals: Implementing Chemicals Policy in Health Care’22

Radiation Radiation causes molecular changes in the
cells which may persist for years to several
generations resulting in disorders affecting
growth and development to organ damage
to mutations, cancers and teratogenicity.23
The British Orthodontic Society (BOS) in 2008, published the third edition of Guidelines for the use
of radiographs in orthodontics. These new guidelines eliminate the need for taking wasteful, routine
radiographs, hitherto considered necessary for maintaining records, if no clinical indication exists.24
Thus, the dual strategies of digitisation and indicating radiographs only on careful case-by-case
evaluation are both patient and environmentally-friendly.

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of reconditioned appliances, maintain docu-
mented records for quality checks and using
recycling services, limit the number of reuses,
obtain informed consent from patients and offer
a reduction in fees. Chemicals, radiation, indoor
air quality, dental operatory environment, paper
and electronic usage contribute to significant
environmental impact in dental practices and
measures to mitigate the same are discussed in
Tables 2 and 3.
2. Energy
In the healthcare system, energy usage contributes
to 15% of the carbon footprint, with a significant
component attributed to buildings.35 This can be
reduced by increasing energy efficiency, reducing
unnecessary usage and using low carbon energy.
‘Green buildings’ incorporate design features
which enhance energy and resource efficiency
by 40–45%, and consequently reduce energy
demand, energy bills and emissions, compared
to traditional buildings.36 Without green features,
buildings contribute to 24% of the total health-
care system carbon footprint by consuming
more than £410 million worth of energy.37 The
UK Climates Impact Programme has published
information for construction of new healthcare
buildings.38 The UK government has set a target
for new public sector buildings to be zero carbon
from 2018 onwards, and the NHS healthcare
buildings aimed to be low carbon by 2015.39,40

Table 2 Air quality: environmental impact and mitigation measures

Environmental effects Methods to reduce their adverse

environmental impact

General indoor air General furnishing materials like furniture components, fabrics,
quality surfaces and dyes may contain harmful components like volatile
organic compounds, added urea formaldehyde, heavy metals,
hexavalent chromium, perfluorinated compounds (PFCs),
halogenated compounds, flame retardants etc,25 which are the
source of hazardous indoor pollutants and emissions.
Implement ‘environmentally preferable purchasing’(EPP) policy where
environmentally preferable is defined as ‘products or services that have
a lesser or reduced effect on human health and the environment when
compared with competing products or services that serve the same purpose’.
Applying EPP ensures a healthier indoor air quality, for example, using heavy
metal or VOC free paints

Indoor air quality in Airborne contaminants in a dental operatory include particulate
dental operatory matter made up of water, bacteria, viruses, oro-nasal
secretions, exudates, dental materials, tooth dust etc, and
hazardous vapors of mercury, nitrous oxide, etc. Activities in
the dental operatory, like using an air spray, produces bacterial
aerosols from 12 to 4,900 CFU per minute and using air turbine
handpieces produces aerosols with bacterial concentration
ranging from 53 to 8500 CFUs per minute as compared to 1
CFU for normal human activity of talking,27 thus creating an
environment highly conducive for spread of infections.
Precautionary measures to prevent infections include:
not operating on patients with active infectious diseases or who are in
prodromal stages
using slow speed handpiece and high velocity suction to roughen amalgam
using gentle water and air stream instead of blast by air-water spray to clear field
of operation
always using high velocity suction with rotary instruments
wearing protective glasses, gloves, mask and employing isolation techniques
like rubber dam.

Table 3 Paper and general electronics: environmental impact and mitigation measures

Environmental effects Methods to reduce their adverse environmental impact

Paper It is estimated that of the total
number of trees cut in a year, 35%
go to the paper-manufacturing
industries.28 Forests are the natural
sinks for absorbing carbondioxide
which is the most harmful of all
greenhouse gases. Destroying
forests increases risk of global
warming manifold, apart from
reducing other related natural
ecosystems like flora and fauna
and disrupting the weather cycles.
General The rapid technological advances
electronic drastically reduce the useful
equipment life-span of electronic devices
rendering them obsolete within no
time. Thus, waste electrical and
electronic equipment (WEEE) or
e-waste has become the fastest
growing waste stream in the world
at 3-5 % per year.31
Digitisation of all records and shifting to a paperless office.
Double-side copying and print-outs, and preferring copiers and scanners with automatic duplex setting while
purchasing; formatting for efficient paper use - smaller font size, minimum margins, and minimum white space
while keeping it readable, and editing is done on-screen instead of printing unnecessary drafts.
Reusing paper that has been used on one side for note paper, draft print-outs or photocopies for internal use.
Maintaining copying machines well and training staff properly in their usage avoid mistakes that waste paper.
Circulating documents and posting memos rather than distributing individual copies.
Using post-cards where possible for mail-outs, rather than separate sheets of paper and envelopes.
E-learning, digital libraries, electronic access to databases and electronic communication between faculties, in
academic institutions conserve large volumes of paper.
Where paper use is unavoidable, adopt environmentally preferable purchasing (EPP) policy for procuring paper
products which have 100% post-consumer recycled content, are certified for chlorine-free processing and
have been approved for sustainable forestry practices by entities like Forestry Stewardship Council (FSC) 29 or
Programme for the Endorsement of Forest Certification (PEFC).30
EPP can also be implemented for purchasing other office stationary like non-toxic toner, equipment capable of
using 100% recycled paper and recyclable printer toner cartridges.
Large scale implementation of green measures while conducting scientific conferences, conventions or
meetings.
Digitisation, sustainable paper use and promoting environment-friendly practices among its readership and in
publication process by scientific journals.
Implement ‘Green computing’ i.e. an electronic asset management plan with environmentally-responsible
procurement, use, maintenance, repair, refurbishment, reuse and end-of-life management.32
Use energy efficient appliances, donate used electronics for reuse or recycling where companies can use them
to recover precious metals, rare earth metals and engineered plastic.33
Recovery of materials from e-cycling is more effective if original electronic manufacturer (OEM) designs
products to be more amenable for end-of-life recycling.
Purchasers can identify and procure from environmentally-responsible OEMs, by using the Electronic Product
Environmental Assessment Tool (EPEAT), which is a global green electronics registry with more than 3,200
products from 45 manufacturers registered in 41 countries.34

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Table 4 Sustainable energy management strategies: increase efficiency, reduce usage, alternative low carbon sources

Increase energy efficiency Reduce unnecessary usage Increase amount of low carbon energy

Incorporating green features based on ‘sustainable
architecture’ includes the following:44,45
Heating, ventilation and air-conditioning (HVAC) is
made more energy efficient by using construction
materials with thermal resistance and heat transfer
co-efficients which inherently provide heating or cooling
in a building, sealing air leaks in the building by caulking
and weatherstripping and insulating the ductwork.
‘Cool roofs’ with high sunlight reflectivity or vegetation
cover reduce cooling requirements.
Using Chlorofluorocarbon(CFC)-free HVACs
Maximise lighting efficiency by the use of daylight
through windows, ventilators and skylights, and
automatic shades and blinds to regulate daylight.
Glass panes which are hermetically sealed single-glazed
units, or high performance glass with coating, allow
daylight through but block heat
Conservation is the crux of green management.
Energy efficient light fittings save electricity costs,
use about 70–90% less energy than standard
incandescent bulbs and last up to 15 times longer.46
Use light fittings with dimmer controls, daylight
cut-off sensors and occupancy sensors.
Incorporate flow-restrictors and infra-red sensors
for water taps, recycle grey water, use medical
grade hand sanitisers instead of washing hands
between patients.
Rainwater harvesting, where rainwater from the
rooftop is captured and stored for reuse and
on-site grey water treatment plants to treat the
water to standards suitable for selective reuse,
enhance efficient water usage..47
Conventional suctions or dental vacuum systems,
use around 24,600 gallons of water per year,
which can be saved by using high-tech, dry
vacuums instead.48
Low carbon energy sources or green power, are a cleaner
alternative to the highly polluting and non-renewable
fossil-fuels
Electricity that is generated using renewable resources
like solar, wind, geothermal, biogas, biomass, and low-
impact small hydroelectric resources and technologies
that provide the highest environmental benefit, are
defined as green power by the Environmental Protection
Agency (EPA).49
Organisations can also generate on-site green power by
using solar photovoltaic panels, wind turbines, fuel cells,
biomass combustion or recovered methane gas from a
landfill or sewage treatment plant. The Pilgrim Hospital
in Lincolnshire considerably reduced its carbon footprint
by installing a biomass boiler and a combined heat and
power plant to generate its own electricity.50 The ultimate
aim is for them to have zero-energy buildings implying
that the energy provided by on-site renewable energy
sources is equal to the energy used by the building.51

At the core of dental practice, is the use of
various electronic equipment for diagnosis
and treatment, which by virtue of being indis-
pensable make the practice of dentistry highly
energy intensive. Hence, a cost-benefit analysis
while purchasing or replacing any equipment,
should also include energy efficiency assess-
ment. Energy audit and monitoring can help
reduce overall energy consumption, the steps
for which consist of studying the energy usage,
identifying areas of energy wastage and imple-
menting actions to plug the leaks. Plugging
can involve fixing issues like air gaps in the
building envelope, energy inefficient elec-
tronic equipment, leaking taps and faucets or
keeping lights and HVAC on at all times, even
in areas of low usage etc. Power consumption
over at least one week is recorded to obtain
a base figure against which energy improve-
ments are measured. Several online websites
provide simple step-by-step instructions for
carrying out energy audits. Real-time electric-
ity measuring devices can also be used to track
energy flow in specific areas.41
In large set-ups the Building Energy
Management System (BEMS), which consists
of a real-time monitoring network to control
and regulate the building service performances
including HVAC, compressors, air handling
units, water pumps, fans etc, can be employed.
BEMS is estimated to reduce 10% or more of
total energy costs.42 Great Ormond Street
Hospital has implemented the Smart metering
system and publishes real-time information
on their website regarding energy use in
kilowatt, hours, cost and carbon emissions,
thus providing accessible feedback to users,
stakeholders and the public.43 Energy man-
agement is a continuous process and has to be
continually appraised and repeated in cycles
to accrue major and lasting environmental
and economic gains from the same. Switching
over to cleaner, low-carbon fuels and other
strategies to reduce energy-related emissions
are discussed in Table 4.
3. Travel and transport
Travel and transport form 13% of the health,
public health and social care carbon footprint,
which can be reduced by employing alternative
sustainable options like:35
• Increasing active travel by cycling or
walking, carpooling, using mass transit
systems
• Switching over to vehicles which reduce
fossil fuel usage or run on alternate energy
sources, by staff, service users
• Selecting location of services close to public
transit systems
• Choosing manufacturers and disposal
services closer to end user to reduce carbon
emissions resulting from transportation of
goods and long supply chains52
• Employing technology for communication
and professional interactions to reduce
travel-related emissions. Teledentistry is
the use of information technology and tele-
communications. It greatly increases access
and communication between practitioners,
peers and patients, while totally eliminat-
ing the need to travel and meet in person
to discuss the same.53 Similarly, using
digital intra-oral scanners, 3D models,
digital images, and transmitting them
electronically instead of shipping their
physical counterparts to the lab or profes-
sionals, eliminates emissions resulting from
the transportation.
4. Waste
The British Dental Association guidance requires
that dentists should identify each waste product
as hazardous (including clinical waste), non-haz-
ardous or offensive and document how each
of them are handled in the practice.7 Mercury
has always raised great concerns in dentistry.
Although its use in dental fillings poses no
hazards for intra-oral application, its post-use
disposal in dental operatory and crematorial
emissions create grave environmental issues.54,55
The European Union has adopted phase-down
of the use of dental amalgam driven by these
environmental reasons.56
Green waste management additionally
advocates reduction of waste at source referred
to as ‘waste minimisation’ by: a) material elimi-
nation, change or product substitution – for
example, substituting a hazardous cleaning
solution with non-toxic biodegradable cleaner;
using multiple-use instead of single-use products;
b) Technology or process change, for example,
using non-mercury alternatives; using ultrasonic
or steam cleaning instead of chemical-based
cleaners; c) Good operating practice, for example,
improving inventory control; covering disinfect-
ing solution trays to prevent evaporative losses; d)
Preferential purchasing such as selecting vendors
with reduced packaging.57
Final disposal of hazardous medical waste
by incineration has serious environmen-
tal concerns due to production of noxious

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Fig. 1 Elements of a sustainable clinical care model

• Safe care: where people are protected from
physical, psychological or emotional harm.

SUSTAINABLE In short, clinical care delivery can minimise

embedded carbon emissions, mainly by
considering the environmental impact and
toxicity of products and pharmaceuticals,
appropriately identificatying and eliminating
Clinical waste and conserving existing resources, all
effectiveness of which have been discussed in detail in the
previous section.64

Patient
experience
BEST VALUE
emissions containing dioxins, furans, fly ash
with heavy metals, etc. Alternative non-incin-
eration technologies, like autoclave, dry heat,
electrothermal deactivation, reverse polymeri-
sation, plasma pyrolysis, biological enzyme-
based reduction, etc, reduce hazardous medical
waste to unrecognisable remnants which can
then be discarded safely in a sanitary landfill.57
Waste management companies which generate
electricity or heat from waste and sometimes
even recycling the waste streams where possible,
are accredited and provide a suitable sustainable
option for dentists.8
5. Anaesthetic gases
Use of nitrous oxide combined with oxygen as
an anaesthetic in dentistry contributes to some
environmental concerns, since nitrous oxide is
estimated to contribute about five percent to the
greenhouse effect.58,59 However, only 0.35–2%,
is actually attributed to combined medical and
dental applications of nitrous oxide gas.59 SDU
statistics reveal that desflurane and nitrous oxide
caused the most global warming and sevoflu-
rane the least.60 Hence, using sevoflurane, which
was found to be a safe and effective alternative to
nitrous oxide for dental application would make
practice more environment-friendly.61
Commissioning and procurement
The procurement of goods and services repre-
sents 72% of the NHS, public health and social
care carbon footprint and over £40 billion each
year is spent on procuring large amounts of
Patient
safety
FAIR
goods, services and infrastructure.62 This offers
a great impetus for healthcare systems to ask for,
and the suppliers of goods and services to offer,
more sustainable, environmentally-friendly and
socially responsible practices. For dental product
companies in the UK, the British Dental Industry
Association (BDIA) requires member companies
to ‘demonstrate a commitment to environmen-
tally sound procedures’ by having an environ-
mental policy in place,8 which includes reducing
the requirement for fresh natural resources
by making efficient use of existing resources,
minimising production of toxic, hazardous waste
and emissions released during production and
recycling and reusing waste materials, prioritis-
ing local procurement and production factors,
making up for the natural resources consumed
by implementing measures like reforestation,
rain-water harvesting, etc.63
Sustainable clinical/care models
Delivering the highest quality of care is the
core value and intent of every dental health
service provider. Adoption of environmen-
tally-friendly measures should not be allowed
to undermine the core value, hence the sus-
tainable clinical care model should be built by
adding the following elements (Fig. 1):
• Effective care: consisting of the delivery of
the right evidence-based intervention at the
right time and in the right place.
• Positive experience: by customising
treatment to patient needs while treating
them with compassion, respect and dignity
Communities
Dental practices, organisations and boards, by
embracing sustainable practices and policies,
can contribute to the health and resilience of
their local community network, through both
simple interventions adopted in day-to-day
practice, to system-wide long-term strategies
to mitigate environmental damage. Being
aligned with their local authorities, they can
also be of help in developing cross agency part-
nerships and responding to emergencies and
extreme events at the local level by extending
coordinated collaborative working.65
Metrics
Sustainable development in dentistry has to be
measured to improve understanding, recognise
effective actions and areas needing improvement,
foster accountability and monitor long-term
progress. Examples of metrics include measuring
the amount of carbon dioxide reduction, energy
and water efficiency, recycling and waste
volumes, emissions and mileage.66 Scotland’s
NHS is probably the first in the world to quantify
emissions from dental services, which amounted
to 0.16 mega tonne (Mt) CO2eq and contributed
to 4% of the total Scottish NHS carbon footprint.
Procurement gave rise to 36% of the carbon
footprint and 18% was attributed to building
energy, with nearly half of the carbon emissions
relating to patient and staff travel.67
Although measurements can be carried out
and monitored at individual practice levels or
on smaller scales, standardisation of metrics
and sustainability impact assessments for
quantification across the breadth and depth
of all processes and actions in healthcare
is required. This is still in its infancy and
much needs to be developed. The Sustainable
Development Unit’s metrics steering group
intends to address the issue by developing
core measures, indicators and measurement
mechanisms in healthcare.66

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 GENERAL

Innovation, technology and R&D
The key to maximising sustainability in
dentistry lies in the innovation of green dental
products and processes, refining available or
developing newer technologies and initiating
research in the area of sustainable practice
to generate data where none exists so far,
to guide future actions. Currently, very few
green products, for example Earth-friendly
High Volume Evacuator paper tips or non-
toxic, non-corrosive, environment-friendly
waterline treatment systems, exist in the
market.68 Demand from the dental fraternity
can spur the manufacturers to innovate, design
and supply more ‘green’ products and adopt
measures like reduced packaging.69
The emerging field of ‘green chemistry’, aims
to design fully effective chemical products
which have little or no toxicity or endocrine-
disrupting activity, and break down into
innocuous substances if released into the envi-
ronment after use.15 ‘Bioplastics’ are environ-
ment-friendly organic plastics derived from
renewable biomass sources, such as vegetable
oil, corn starch, microbiota, etc. However, their
lower emissions and higher green quotient
notwithstanding, these products pose a threat
to global food security due to deforestation
and diversion of agricultural land for alternate
purposes.70 Thus, the challenge in innovating
‘green’ products, lies in balancing eco-friendly
attributes with practicality, usability and bio-
compatibility. Research and development in
the hitherto unexplored field of green dental
biomaterial research offers new opportuni-
ties, possibilities and scope for the sustainable
future of dentistry, based on green chemistry.
Creating social value
The three domains of sustainable health delivery
are environmental, financial and social. Social
value is created not only by local commission-
ing and procurement but also through the non-
investment positive value that is added to the
community by adopting ecologically valuable
traits. An Environmental Impact Assessment
(EIA) aids in measuring the effects of a practice
or organisation on its locality and its resources
to identify opportunities and initiate action to
add more social value.8 Dental professionals by
virtue of their services which engage individu-
als, families and communities in a day-to-day
manner, have a privileged position to make a
big impact by practically, ideologically and
economically supporting the green movement.
Thus, the practice not only provides mere dental
services, but also adds positive value to the
community and environment they are rooted in.
Leadership and development
Engagement of stakeholders including staff,
patients and community for sustainable care
delivery is essential so that they understand
the value of measures being implemented and
enthusiastically participate to ensure success.
Training NHS staff to implement energy effi-
ciency measures with the intent to improve
patient experience resulted in estimated
savings of up to £800,000 on energy bills across
the trust’s £12m energy bill. In England some
Royal colleges and professional bodies have
clinical sustainability fellows, and trade unions
of the NHS have ‘green workplace’ initiatives.
Clinical services are being delivered on models
of sustainable care and junior staff have also
organised themselves into a sustainable devel-
opment training network.71
However, bringing a shift in thinking and
practice to adopt newer changes has never been
easy, and barriers are posed by lack of informa-
tion, attitudinal issues and perceptions that
sustainable practice is financially burdensome,
or increases costs.8 In reality, adopting energy
efficiency measures cuts down on energy costs,
mitigation measures to ensure a healthier envi-
ronment reduce expenses incurred due to poor
health, lost economic output and cleaning up
of toxic waste generated, sound procurement
policies strengthen economy and green energy
usage minimises effects of fluctuating global
oil prices. Working in a sustainably designed
environment has shown to bring about a
3–18% increase in individual productivity and
40% increase in organisational sales.72 Low-cost
energy efficiency measures have been proven to
be equally if not more effective than high-cost
technological applications.73 As refinements
in green technologies and infrastructure
continue, the cost of green products and asso-
ciated green services is bound to come down,
thus automatically rationalising the financials
involved. Additionally, as the momentum for
environmentally-responsible actions picks up,
and governments across the world increas-
ingly make environmental abuse unviable by
imposing green taxes, carbon taxes, or fines on
polluters, going green remains the only finan-
cially advantageous option in the long run.
Removal of barriers and adoption of guidance
are shown to be more successful when there is
strong professional support, the professionals
involved are not isolated and the evidence base is
stable and convincing.74 Restructuring and rein-
forcing new practice norms by opinion leaders,
educational outreach, educational meetings and
materials/guidelines, and associating them with
peer and reference group behaviours by empha-
sising the expectations of an external reference
group through reminders, audit and feedback
are more likely to lead to behaviour change.75
Dental bodies having failed to recognise this
critical aspect of the profession thus far, have zero
guidance, targets or framework for sustainable
dentistry. Developing the plan and providing
support and leadership to implement the same
has never been more important, since, all this
while, sustainable initiatives have been at a small
scale and adopted voluntarily by groups or pro-
fessionals as an ethical duty and practical require-
ment, in the absence of comprehensive standards
or guidelines. Efforts can begin with initiatives
like consistent data collection in practice to
enhance understanding and identify oppor-
tunities for action, developing green dentistry
benchmarks, teaching sustainability principles by
including them in training curriculums, initiat-
ing research and creating awareness.
Dentistry is a profession with serious envi-
ronmental concerns by virtue of the materials
used, waste generated and high electricity
and water consumption involved. Practising
environmentally sound and socially respon-
sible dentistry may entail a recalibration in
our understanding of the concept of ‘value for
money’ by not only thinking about value in
terms of equivalent revenue savings, but also
by taking into account the investments to save
the planet.76 A survey of the general public
found that 89% think it is important for the
healthcare system to become more sustainable
and 36% said sustainability should be adopted
in the healthcare system even if it costs more
money.77 Often, patients equate the quality of
a dental office with the quality of care, hence
the adoption of sustainability definitely helps
foster a positive practice image and values.78
Sustainable practice is beneficial not only for
practitioners, patients and local communi-
ties but also for global health and wellbeing;
a reason good enough to inspire systematic
efforts towards greening dentistry.
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