Phase down of Dental Amalgam through an Environmentally Sound Lifecycle Approach and multi-sectoral action

Project General Information



01492

Dental Amalgam MSP


Harmful substances and hazardous waste

Persistent Organic Pollutants

V





The global environmental and/or adaptation problems, root causes and barriers to be addressed: The WHO report on the 'Future Use of Materials for Dental Restoration' notes that globally dental caries affects 60-90% of school-aged children and the vast majority of adults. The 2013 report on the global burden of disease shows that this continues to be the case. Dental amalgam has been the mainstay of dental restorative care forover a century and this continues to be the fact in the majority of health systems worldwide. Hence WHO has concluded that "complete ban (of dental amalgam) may not be realistic, practical and achievable" and recommends "a multi-pronged approach with short, medium and long term strategies should be considered". 

Approximately 50% of dental amalgam is elemental mercury by weight. While dental amalgam separator technology significantly reduces the release of dental amalgam waste into land and water, their use and the implementation of best environmental practice is not widespread. While there are no globally recognized figures for the amount of dental amalgam waste released in land and water per year, the scale of the issue can be gauged by the fact that UNEP estimates that between 240-300 tonnes of mercury are used in the manufacture of dental amalgam per year (UNEP Global Mercury Assessment 2013, Sources, Emissions, Releases and Environmental transport). This creates a significant risk to both the environment and the human health.  It also highlights the amount of mercury that is currently held in dental amalgam fillings by the global population, potentially upwards of 100 metric tonnes, and the requirement for robust dental amalgam waste management practices to be put in place as part of a comprehensive global strategy for dental amalgam.

Poorly integrated or inadequate national legislation and regulation regarding the management and disposal of dental amalgam waste leads to a situation where facilities do not consider dental amalgam waste and its potential impact on facility and municipal waste water pipelines, and further downstream the pollution municipal and community land, as well as communal drinking water supplies. Improper dental amalgam waste disposal, including open burning increases the risk of mercury exposure for populations at risk, particularly vulnerable populations in nearby communities.

The continuing predominance of restorative approach to managing dental caries is a major barrier to phasing down the use of dental amalgam. The restorative approach influences the health system (orientation of dental services and reimbursement models), as well as the education and training of dental professionals (curricula, competences and skills). Insurance policies and programmes often favour dental amalgam over quality mercury free alternatives. These policies and programmes are frequently standalone and as the WHO Oral Health resolution (2007) noted "in most low- and middle-income countries, investment in oral health care is low and resources are primarily allocated to emergency oral care and pain relief”. By its very nature this traditional restorative model often does not encourage caries management across the full spectrum of dental caries ie. early non cavitated carious lesions. Such an enhanced and expanded prevention orientated model would favour non invasive dental caries management, and promote opportunities for integrated disease prevention and health promotion throughout the life course, for example in early childhood care and development.”

The absence of a recognized global consensus on the selection and use materials for dental restoration across the full spectrum of dental caries is a gap both in terms of the quality of dental professional education and training, and the delivery of quality services and care. There are two significant gaps with respect to dental caries management in dental professional education and training; i. managing dental caries throughout the life course (currently paucity of oral health services integrated into maternal health and early childhood care and development), and ii. the provision of promotive, preventive, curative and rehabilitative across the full spectrum of dental caries, including early caries ie non cavitated lesions. The lack of science based guidelines or even global consensus in this area prevents dental professionals from maximizing the use of evidence to ensure consistent, high quality science based care for patients, and compromises information exchange on health, public health and the environment with the Public.

Similarly the WHO report on the 'Future Use of Materials for Dental Restoration' highlighted the paucity of science around the toxicology and eco-toxicology of materials for dental restoration, and the fact that the study of environmental and occupational health is not a requirement in dental professional undergraduate education and training and continuing professional development, nor a dental materials research priority. As a consequence dental professionals are disadvantaged in terms of having the capacity to provide science based information on the human health and environmental effects of dental amalgam and its quality mercury free alternatives both to the members of their team and their patients. This knowledge gap also impacts the ability of the Public to make informed health choices in consultation with their dental professional with regard to restorative dental care.

Dental materials research is very costly and requires long term commitment, so is often confined to the domain of major universities and global medical device companies of the industrialized countries. Research that addresses in-country and for-country needs of the African region (which mirrors many other resource challenged and constrained countries) has not been recognized as a priority in dental materials research.

It will be important to have consensus on pathways for reduction of amalgam usage that are common for developed and in developing countries, along with a set of priorities and challenges differentiated at the national level.  This also applies to the current state of science of amalgam and other restorative materials that would form the basis of a communication and outreach strategy to support pathways for reduction of amalgam usage, need and demand. 

The Africa region is particularly sensitive to the issue of dental amalgam use. Weak, limited or inadequate national legislation and regulation covering the supply, trade and commerce of mercury for dental use both fuels and increases the risk of diversion into others sectors, most notably that of artisanal and small scale artisanal gold mining (ASGM). As more industrialized countries reduce their use and reliance on dental amalgam, African countries who currently lack the capacity, technical expertise and appropriate technology to transition away from dental amalgam to quality mercury free alternatives are very likely to be burdened with the human health and environmental consequences of continued use of dental amalgam. 

Efforts to phase down the use of dental amalgam must be mindful of the causative factors and complex inter-sectoral challenges. In the absence of a coordinated strategy and approach as described and proposed in this project, there is a risk of 'vertical' decision-making processes in the selection of measures (Part II, Annex A). The consequences would be increased environmental and health inequalities, particularly between urban and rural communities, most acutely felt in already vulnerable and disadvantages communities.       

Baseline scenario and associated baseline projects: The 2012 - 2013 East Africa Dental Amalgam Phase-Down Project (EADAP) created a consortium, under the UNEP Global Mercury Partnership, to investigate the challenges faced by developing countries in implementing the ‘phase-down’ approach to dental amalgam. It provided valuable lessons learnt, and brought together a variety of stakeholders, who investigated the supply and trade patterns, created awareness of preventive dental care, encouraged the promotion of alternatives, and promoted environmentally sound waste management practices.

A total of 196 dental personnel in the three countries, Kenya, Tanzania and Uganda benefitted from capacity building and training activities provided by UNEP, World Health Organization, WHO, International Dental Manufacturers, IDM and the FDI World Dental Federation, FDI. Training topics included hazards of mercury, oral health promotion and clinical preventive dentistry, promotion of alternatives, and environmentally sound management (ESM) of dental amalgam waste.

Awareness raising materials were developed by WHO and UNEP. Three dental amalgam separators provided by IDM and the Dental Recycling North America, DRNA. DRNA separators were installed in one health care facility in each participating country. Currently DRNA has supported the collection and disposal and measurement of dental amalgam waste from 2 of the selected facilities in Tanzania and Uganda. While efforts to collect dental amalgam waste from facilities in all three of the countries are currently underway, collection and disposal has not extended to public health centres in the rural settings or to private dental clinics in and outside major urban areas.

Dental restorative materials are a significant part of a health science institutions budget in many African countries, many of which are publically funded. By its very nature, the training of dental professionals involves greater quantities of materials than would be used by a experienced dental professional in a similar practice situation.

At present the current costs of quality alternatives to dental amalgam notable resin composites are a barrier to wider selection and use in dental undergraduate education and training.  The effective transition from teaching on dental amalgam to quality mercury free alternatives requires the coherent and sustainable faculty development and leadership programmes along with access to quality education and training. While EADP has implemented demonstration projects the results have emphasized the need for a more systematic and country wide approach.    

The project has provided countries in the East African region with preliminary baseline data on the amount of dental amalgam waste that dentists and hospital providing restorative dental services / care generate and a clear assessment of the methods used in disposal of this hazardous waste.

A summary of findings noted that; national trade and waste surveys that showed that most of dental restoration materials are imported but exact importation data is not available; alternatives to dental amalgam are available but some dentists still demand dental amalgam; suppliers to East African region are from China, US, Australia, Turkey, Iran, Germany and India; dental amalgam is readily available in encapsulated form and most dentists use this form; national hazardous wastes legislations are in place but enforcement is lacking; Kenya and Uganda have hazardous wastes treatment facilities that could serve as temporary storage for dental amalgam and other mercury waste; Tanzania does not, it is currently mixing its hazardous wastes with general wastes.

Phase II of EADAP is now beginning, and will focus on pilot testing a new training module for dental professionals. One tested, this module for dental professionals will be utilized by the MSP.  


 

Medium-sized Project(MSP)

Global


Africa


Kenya


GEF Trust Fund

Stage Grant to UNEP Grant to other IA Co-Financing UNEP Fee Other IA Fee


No







DTIE

Executing Agency Category

Partner Category

Name Category Period

Low Risk




Not Applicable

0





Fiscal Year Project activities and objectives met

Output 1.1: Standardized guidance, tools and resources that support the phasing down of the use of dental amalgam;

The project will both facilitate and promote the shift to preventive model of caries management encouraging caries prevention at early carious lesion stages, as part of people centred care and integrates services. This is in line with the objectives of the WHO Global Oral Health Programme, which have been reoriented according to the new strategy of disease prevention and promotion of health. Greater emphasis is put on developing global policies in oral health promotion and oral disease prevention, coordinated more effectively with other priority programmes of PND and other clusters and with external partners.

Such a paradigm shift would reduce the need, demand and use of all dental restorative materials as stated in the FDI World Dental Federation policy statement (2010) "ensure the phase up of effective prevention for dental caries and associated health promotion programmes. This should be linked to preventive disease management, which will result in the phase down of use of current restorative materials, including dental amalgam".

The following activities are planned:

- Publish science based global consensus for the selection and use of materials for dental restoration across the full spectrum of dental caries including early lesions;

- Publish science based best management practices for dental amalgam and its quality mercury free alternatives, including considerations for comparable data monitoring and its interoperability;

-  Develop recommendations for setting national objectives for integrated caries prevention and health promotion using the appropriate normative protocols and tools, as developed by WHO;

-  Conduct assessment of the national health workforce using the appropriate normative protocols and tools, as developed by WHO;

-  Establish educational and training resource that supports the adoption and use of global consensus for the selection and use of materials for dental restoration, and the dispose of dental amalgam waste in an environmentally sound manner;

- Support the development of a dental materials research agenda that contributes to the phase down of dental amalgam in the Africa region

Output 1.2: Institutional action and enabling tools to encourage insurance policies and programmes to favour integrated people centred health services, and the use of quality alternatives to dental amalgam for dental restoration;

This output speaks to intersectoral and systems activities around health equity and health systems strengthening. Two key activities listed below and feedback from other outputs would support 'whole government, whole society' action.

The following activities are planned:

- Assessment of legislative and regulatory issues with respect to the trade, supply and commerce of quality alternatives to dental amalgam;

- Develop recommendations to guide and inform institutional action to encourage insurance policies and programmes to favor integrated health services, and the use of quality alternatives to dental amalgam for dental restoration;

- Recommendations that inform COMTRADE coding for trade of dental amalgam;

-  suite of tools, that allows countries and key stakeholder groups to examine the economic and social costs and benefits, as well as the potential payback time for wide scale adoption and uptake of the phase down of the use of dental amalgam

Output 1.3: Capacity building that enables people to make informed choices with respect to the selection of dental restorative materials in consultation with their dental professional;

This output is the brings together the results of all the other outputs to drive and deliver effective change. Again three key activities underpin this output informed by continuous feedback from monitoring and evaluation.  

The following activities are planned:

- Develop outreach strategy and website;

- Develop and disseminate awareness raising and information materials with the active participation of government, professional associations, civil society, local communities, patient groups and industry-

- Develop and roll out action plan to train dental professionals on the use and selection of materials for dental restoration, and best management practices for dental amalgam and its quality mercury free alternatives

Output 1.4: Demonstrate environmentally sound management of dental amalgam wastes in a sustainable manner and quantify reduction of dental amalgam wastes to land and water at selected pilot sites;

This output will build on the significant success and progress achieved in EADP. Activity 4.4 listed below provides for compatibility and interoperability of quantifying and measuring whether the dental amalgam reduction target has been achieved.

The following activities are planned:

- Select national pilot sites

- Select best environmental practices for dental amalgam waste most appropriate for conditions and circumstances at identified pilot sites

 

- Implement best environmental practices for dental amalgam waste 


$ 0.00

Project Objective: To increase national capacity to reduce the need, demand and use of dental amalgam, at the same time reducing the releases of dental amalgam wastes to water and land in a measureable and sustainable manner

Project Components/

Programs

Financing Type[1]

Project Outcomes

Project Outputs

Trust Fund

(in $)

GEF Project Financing

Confirmed Co-financing

 Enhanced capacity for the sustainable and equitable phase down of the use of dental amalgam in line with the Minamata Convention  

      

Increased adoption and use of standardized guidance, resources and tools to reduce the need, demand and use of dental amalgam, and dispose of dental amalgam waste in an environmentally sound manner

 

     

Output 1: Standardized assessment tools and management protocols aimed at preserving tooth substance within people-centred and integrated health service approach;

Output 2:  Institutional action to encourage insurance policies and programmes to favour  the use of quality alternatives to dental amalgam for dental restoration;

 

Output 3: Awareness raising activities to promote oral health and alternative approaches and materials enabling people to make informed choices with respect to the selection of dental restorative materials in consultation with their dental professional

 

Output 4: Promote and demonstrate environmentally sound management of dental wastes at

selected pilot sites

 

1,819,000

     

4,750,000

     

      

     

     

     

     

Subtotal

 

1,819,000

4,750,000

Project Management Cost (PMC)[2]

181,000

     

Total GEF Project Financing

 

2,000,000

4,750,000

 



[1] Financing type can be either investment or technical assistance.

[2] For GEF Project Financing up to $2 million, PMC could be up to10% of the subtotal;  above $2 million, PMC could be up to 5% of the subtotal.  PMC should be charged proportionately to focal areas based on focal area project financing amount in Table D below.


No