Review of Norwegian experiences with the phase-out of dental amalgam use

Rapport 2011/28

John Magne Skjelvik

Review of Norwegian experiences with the phase-out of dental amalgam use

Kategori	Rapporter
Underkategori(er)	n/a
År	2011
Rapportnummer	28
Forfatter(e)	John Magne Skjelvik
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Report xx/xx from Vista Analysis AS
 	
 	
 
Review of Norwegian experiences with the phase	-out 	
of dental amalgam use 	 	
John M. Skjelvik	 	
Vista Analysis 	29 May 2012

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	1 	
Document Details	 	
Vista Analysis AS	 	Report number 	2011	/28	 	 	
Title 	 	Review of Norwegian experiences with the 
phase	-out of dental amalgam	 	
 	
ISBN	 	978	-82	-8126	-042	-9 	 	
Author	 	John M. Skjelvik	 	 	
Finished date	 	May 29, 2012	 	 	
Project Manager	 	John M. Skjelvik	 	 	
Quality Control	 	Karin Ibenholt	 	 	
Client	 	Norwegian Climate and Pollution Agency	 (Klif)	 	 	
Access	 	Public	 – www.vista	-analyse.no	 	 	
Published 	 	May 29, 2012	 	 	
Key	words	 	Mercury, environment, cost assessment

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Preface	 	
Vista A	nalysis has been asked by the 	Norwegian Climate and Pollution Agency 	(Klif) 	to 	
review	 the experiences from the phase	-out of the use of 	dental 	amalgam as tooth filling 	
material in Norway, and make an assessment of the costs to the society from the actions 
taken to limit the release of mercury. The purpose is to show how Norway has carried 
out this policy.	 	
The final report is written by John M. Skjelvik, and Eirik Schou Grytli has contributed to 
the interviews with dentists and other data collection. Karin Ib	enholt has been the 	
internal quality controller. 	Potential errors and misunderstandings 	are 	Vista Analysis’s 	
responsibility. 	 	
 
Oslo, 	29 May 2012	 	
 
John M. Skjelvik	 	
Proje	ct Manager	 	
Vista Analys	is AS

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Content	 	
Prefac	e ................................	................................	................................	................................	................................	. 2 	
Executive Summary	 ................................	................................	................................	................................	........	 6 	
Sammendrag	 ................................	................................	................................	................................	.....................	 9 	
1 	Introduction	 ................................	................................	................................	................................	..........	 12	 	
1.1	 	Mercury risks	 ................................	................................	................................	..............................	 12	 	
1.2	 	Mercury in tooth fillings 	is one of the largest sources	 ................................	................	 12	 	
1.3	 	Norway has phased out the use of dental amalgam	 ................................	....................	 13	 	
1.4	 	This report review the actions taken	 ................................	................................	.................	 13	 	
2 	Dental amalgam	 ................................	................................	................................	................................	... 14	 	
2.1	 	What is dental amalgam?	 ................................	................................	................................	.......	 14	 	
2.2	 	Alternatives to dental amalgam	 ................................	................................	...........................	 14	 	
3 	The use and release of mercury from tooth fillings in Norway	 ................................	........	 16	 	
3.1	 	Dental amal	gam was first addressed as a health problem	 ................................	........	 16	 	
3.1.1	 	A long history of dental amalgam use	 ................................	................................	...........	 16	 	
3.1.2	 	There are potential health impacts from dental amalgam use	 ...........................	 16	 	
3.1.3	 	Increased public focus on the negative sides of dental amalgam use	 ..............	 17	 	
3.1.4	 	Dental health improved	................................	.....	 Feil! Bokmerke er ikke definert.	 	
3.1.5	 	Occupational health problems from mercury recognized	 ................................	....	 17	 	
3.2 	Regulatory actions	 ................................	................................	................................	....................	 18	 	
3.2.1	 	Actions taken by the health authorities	 ................................	................................	.......	 18	 	
3.2.2	 	Actions taken by the environmental authorities	 ................................	......................	 19	 	
3.3	 	Use and release of mercury subst	antially reduced	 ................................	......................	 21	 	
4 	Main experiences with the new materials in Norway	 ................................	..........................	 24	 	
4.1	 	Some scepticism in the early days	 ................................	................................	......................	 24	 	
4.2	 	Recent observations show few negative impacts 	of new filling materials	 .........	 24

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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4.3	 	The new materials are considered good alternatives to dental amalgam, but in 	
some cases more challenging to use	 ................................	................................	................................	 25	 	
4.4	 	Swedish assessment generally positive to a ba	n ................................	..........................	 26	 	
5 	Costs and benefits from phase	-out	 ................................	................................	...............................	 27	 	
5.1	 	All costs and benefits should ideally be included	 ................................	.........................	 27	 	
5.1.1	 	Benefits are measured through mercury emission reductions	 ..........................	 27	 	
5.1.2	 	Cost components that should be included	 ................................	................................	.. 27	 	
5.1.3	 	Assumptions	 ................................	................................	................................	...........................	 28	 	
5.2	 	Costs of waste collection and handling	 ................................	................................	.............	 29	 	
5.2.1	 	Cost assessm	ent before dental amalgam collection was made mandatory	 ... 29	 	
5.2.2	 	Nordic assessment showed high waste handling costs	 ................................	.........	 29	 	
5.2.3	 	Removal costs of mercury from drainage pipes could be rather high	 .............	 30	 	
5.2.4	 	Current Norwegian costs for waste handling are in line with some 	
international studies	 ................................	................................	................................	..........................	 30	 	
5.2.5	 	Summary of waste handling costs	 ................................	................................	..................	 32	 	
5.3	 	Current extra costs for den	tists from dental amalgam ban are declining	 ...........	 32	 	
5.4	 	Treatment costs for dental patients have increased over time	 ...............................	 34	 	
5.4.1	 	Summary of costs of phasing out dental amalgam use	 ................................	..........	 36	 	
5.5	 	Crematoria	 abatement costs	 ................................	................................	................................	. 36	 	
5.5.1	 	Mercury emissions are assumed to be some 5 g/cremation	 ...............................	 36	 	
5.5.2	 	The regulations have speeded up the restructuring of the crematoria	 ...........	 37	 	
5.5.3	 	Mercury abatement filter costs are relatively low	 ................................	...................	 38	 	
5.5.4	 	Abatement costs could be higher when no other regulations are in place	 ....	 39	 	
5.5.5	 	Danish cost estimates are rather 	similar to the above findings	 .........................	 40	 	
5.5.6	 	Data from UK show rather similar abatement costs as in Norway	 ...................	 40	 	
5.5.7	 	Summary of total abatement costs for crematoria	 ................................	..................	 41	 	
5.6	 	Socioeconomic impacts in Norway	 ................................	................................	.....................	 42	 	
6 	Conclusions	 ................................	................................	................................	................................	...........	 43

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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6.1	 	The experiences with the new materials are generally positive	 ............................	 43	 	
6.2	 	Total abatement costs for mercury from den	tal amalgam use	 ................................	 43	 	
6.3	 	Dental amalgam phase	-out should be seen in a long term perspective	 ...............	 44	 	
6.4	 	Comparisons across countries using Purchasing Power Parities (PPP)	 ..............	 45	 	
References	 ................................	................................	................................	................................	.......................	 47

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Executive Summary	 	
Mercury is among the most 	hazardous	 substances. 	Dental 	amalgam 	is the	 largest use 	
area of	 mercury	-added products 	worldwide 	and a significant 	source	 of 	mercury release 	
to the environment	 in 	Norway	. Norway	 has a	 national 	goal of eliminating 	use and 	
release	 of mercury 	by 2020	. 	
Background	 	
New filling materials	 were introduced	 in Norway in the 1	970s	, and were gradually 	
preferred for aesthetic reasons. 	Focus on 	dental 	amalgam as an environmental p	roblem 	
emerged 	during the	 19	80s	 as part of a broader policy to limit emissions of mercury. 	In 	
1991 t	he health authorities issued guidelines	 recommending	 dentists	 to reduce the use 	
of 	dental 	amalgam, and new guidelines from 2003 required that other material	s than 	
dental 	amalgam should be considered as the first choice in tooth fillings. 	Preventive use 	
of fluoride 	has also contributed to 	improved dental health and 	reduced use of 	dental	 	
amalgam. 	 	
A requirement to have an approved 	dental 	amalgam separator	 insta	lled	 in all dental 	
clinics was 	introduced 	in 1994	. Requirements to control the mercury air emissions 	from 	
crematoria 	with more than 200 cremations per year 	were	 implemented in	 2007	. 	
Norway introduced a general ban on the use of mercury in products from 2	008. 	Limited 	
exemptions	 for dental amalgam	 use 	were 	applied 	until the end of 2010	. 	
Main conclusions	 from the review	 	
From 	this 	review of t	he experiences from the phase	-out of the use of amalgam as tooth 	
filling material in Norway the following conclusio	ns	 are presented	: 	
Use and release of mercury are substantially reduced	 	
The 	estimated 	use of mercury in tooth fillings has been 	considerably	 reduced 	over the 	
years	. Early 	sources indicate that the use of mercury in 	new 	tooth fillings 	was as high as 	
2 000 	kg in 1985. 	 In 1995 the use of mercury in 	new 	tooth	 fillings was 840 kg, and was 	
then gradually reduced 	close 	to zero in 2008 when the 	general 	use was banned (Klif 	
2010a, 2010c). 	 	
The mercury release	 to water from dental amalgam 	use 	was significantly 	red	uced 	from 	
1995 to 2008	. This is partly	 a result of the requirement to install amalgam separators in 	
dental clinics 	from 	1994. 	 	
Amalgam fillings have long 	durability	. The quantity of amalgam in 	the population	 	
represents approximately 10	 ton	s of mercury 	in 	Norway today	 (the total 	Norwegian 	
population is close to 5 million	 people	). People 	over	 fifty years 	have 	considerable 	
amounts of	 amalgam fillings. As 	people pass away or 	the fillings are replaced with 	other 	
materials	, the quantity of mercury in 	the populat	ion	 will 	decline	. It is expect	ed	 that 	
mercury 	release 	from existing 	fillings 	will continue 	for up to 	at least 	30 years	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Experience	s with the 	alternatives to dental amalgam	 are	 generally 	positive	 	
The 	interviews 	performed 	among dentists 	for this report, 	as	 well as 	earlier 	assessments 	
by others 	show that 	dental personnel	 and patients generally 	are 	satisfied	 with the 	
alternatives to dental amalgam	. The most common material used now is 	resin	-based	 	
composites, but various glass ionomers and ceramic	-based materi	als are also used to 	
some extent. 	The necessary technical equipment and 	basic skills	 to use the alternative 	
materials	 have been established 	over	 long	 time	. 	
The main advantages 	with the 	alternatives	 from the dental personnel’s point of view 	are 	
that	 the m	aterials	 have good adhesive properties, implying that 	one needs to remove 	
less amounts of the 	sound 	tooth 	substance 	compared to when using amalgam. 	
Th	erefore, it 	sometimes 	takes less 	time to use the alternative materials in small fillings. 	
However	, larger	 fillings are some	what	 more time	-consuming	 to apply	 and can take 	15	-	
45	 minutes	 longer	 time	, depending on the dentist	’s skill	 and the complexity of the filling. 	
For the economic assessment 	presented in this report,	 15	-30 minutes	 is used	 in the 	
calculations	. An important advantage 	for 	dental personnel’s 	health 	is 	that amalgam is 	
not used	 in the working environment.	 	
A disadvantage	 is that 	the 	alternative	 material	s can	 be challenging	 to use	, especially in 	
larger fillings	. Another disadvantage is that bacteria a	re more easily formed 	on the 	
surface of	 the filling, thus requiring more follow up from both the patient and the 	
dentist. 	Because of this and less “chewing	-strength” the composite fillings do not 	yet 	last 	
as long as the amalgam fillings (some say half the 	life	time of amalgam fillings), but the 	
longevity 	is increasing and approaching the 	longevity 	of amalgam fillings. 	 	
When introduced	, the 	alternative 	materials 	were	 reported 	to cause some allergic 	
reactions in the mouth of patients and 	in the hands of the 	de	ntal 	personnel	. However, 	
the number of reported adverse impacts from the use of resin	-based fillings has not 	
increased to the same degree as the increase in the use of these materials. 	 	
Abatement 	“end	-of-pipe”	 costs 	lower than dental amalgam phase	-out cost	s 	
The 	interview	s for this 	report 	show	s that the 	marginal 	costs of	 measures aiming at 	
reducing 	the 	emissions from dental clinics and crematoria are generally 	substantially	 	
lower than the 	marginal 	costs related to phasing out the use of amalgam in tooth fill	ings. 	
Abatement costs for a dental amalgam separator are calculated to NOK 8,000 	– 12,400 	
(€ 1,000 	– 1,5	50	)/kg mercury, and emission reductions from crematoria are estimated 	
to cost around NOK 29,200 	– 122,000 (€ 3,6	50	 – 15,250)/kg mercury. 	In comparison, 	
costs 	of phasing out the use of amalgam in new fillings are calculated to some NOK 	
67,000 	– 533,000 (€ 8,	375	 – 66,625)/kg mercury	 or 	some NOK 67 	– 533 (€ 8.5 	– 	
67)/filling	 and are	 not including costs related to more frequent replacement	s of fillings. 	
In Norway 	the costs are 	mostly borne by the 	adult 	consumers	. 	
The substitution 	of 	dental amalgam started 	as a result of public awareness and 	
guidelines from the health authorities 	before 	the 	general	 ban on mercury in products 	
was introduced	 by the environmental auth	orities	. Thus, it is difficult to assess 	the total 	
costs 	of the ban itself	. However, 	policy actions	 have 	been important	 in the	 substitution	 	
process	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Most of	 the costs related to the phase	-out of dental amalgam are 	related to 	increased 	
time spent 	at denta	l clinics	 when using the 	alternatives	, and to more frequent change of 	
fillings	. Also, composite fillings 	are improving and 	will likely l	ast longer 	in the future 	and 	
thus reduce 	the 	need 	for filling changes	 and the total costs associated with 	it. 	
Dental am	algam phase	-out should be seen in a 	broader 	perspective	 	
Assessing the various interventions purely from a	n abatement	 cost comparison could 	
easily 	lead to 	the	 conclusion that 	dental amalgam separation/collection and 	abatement 	
of 	emissions from crematoria sh	ould 	be	 required	, and that the 	choice 	of filling materials 	
should be left 	to the dentist and patient. 	 	
However, 	since 	the overall, long term goal is to eliminate the	 use and 	release of mercury 	
to the environment, the use of mercury has to be addressed. The	refore, the use of dental 	
amalgam should be phased out, and at the same time the actions towards the release of 
mercury from	 existing	 tooth fillings have to be implemented. 	In the future, when 	there is 	
no mercury left in tooth fillings	, the	 need for dental	 amalgam separation/collection and 	
abatement of 	emissions from crematoria 	will cease	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
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Sammendrag	 	
Kvikksølv er blant de farligste helse	- og miljøskadelige stoffene. 	Dentalt a	malgam 	er 	på 	
verdensbasis 	den største	 produkt	gruppen	 som inneholder k	vikksølv og	 er 	en betydelig 	
kilde	 til utslipp av kvikksølv. Norge har et 	nasjonalt 	mål om å eliminere bruk og utslipp 	
av kvikksølv innen 2020. 	 	
Bakgrunn	 	
Nye fyllingsmaterialer ble introdusert	 på 1970	-tallet	, og 	er etter hvert blitt 	foretrukket 	
av estetisk	e årsaker	. Fokuset på dentalt amalgam som et miljøproblem vokste gjennom 	
1980	-tallet 	som del av en mer omfattende politikk for å begrense utslippene av 	
kvikksølv. 	Helsemyndighetene utga i 1991 retningslinjer 	som anbefalte	 tannlegene å 	
redusere bruken av de	ntalt amalgam, og nye retningslinjer i 2003 slo fast at andre 	
materialer enn dentalt amalgam skulle være førstevalget i tannfyllinger. Bruken av 
dentalt amalgam 	har 	også 	gått 	gradvis ned på grunn 	av	 bruk av fluor	 som har ført til 	
bedre 	tannhelse	. 	
Et krav 	om å installere godkjent amalgamavskiller 	i alle tannklinikker ble innført i 1994. 	
Krav om å kontrollere u	tslippene av kvikksølv til luft fra krematorier med flere enn 200 	
kremasjoner per år 	ble innført i	 2007. 	 	
Norge introduserte et generelt forbud mot b	ruk av kvikksølv 	i produkter fra 2008. Et 	
begrenset unntak for dentalt amalgam gjaldt til utgangen av 2010	. 	 	
Hovedkonklusjoner	 	
Fra gjennomgang	en	 	av	 	erfaringene 	med	 	utfasingen 	av amalgam som 	
tannfyllingsmateriale i Norge kan det trekkes følgende hove	dkonklusjoner: 	 	
Bruk og utslipp av kvikksølv er betydelig redusert	 	
Den anslåtte bruken av kvikksølv i tannfyllinger er betydelig redu	sert 	over årene. 	
Tidlige	 kilder antyder at bruken av kvikksølv i 	nye 	tannfyllinger var så høy som 2	 000 kg 	
i 1985. I 1995 	var bruken av kvikksølv i nye tannfyllinger 840 kg, og den ble så gradvis 	
redusert til 	tilnærmet 	null i 2008 da	 den generelle	 bruken ble forbudt	 (Klif, 2010a, 	
2010c)	. 	
Utslippene av kvikksølv	 til vann fra dentalt amalgam	 ble 	betydelig 	redusert fra 	1995 til	 	
2008. Dette er delvis et resultat av påbudet om godkjent amalgamavskiller i 
tannklinikkene fra 1994. 	 	
Amalgamf	yllinger har lang levetid. 	Mengden 	amalgam i eksisterende tannfyllinger i 	
Norge i dag representerer ca. 10 tonn kvikksølv	 (den totale befolkni	ngen er på nesten 5 	
millioner)	. Personer	 over femti år har store mengder amalgamfyllinger	 i tennene	. Etter 	
hvert som folk dør eller fyllingene ers	tattes med andre materialer vil	 denne mengden 	
reduseres	. Det må imidlertid forventes at kvikksølv forts	att vil	 slippes ut fra 	
eksisterende fyllinger i minst 30 år framover.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	10	 	
Erfaringene med 	alternativene til 	dental 	amalgam	 er generelt p	ositive	 	
Det mest brukte materialet i bruk i dag er plastbaserte kompositter, men ulike 
glassionomer og keramikkbaserte material	er brukes også i noen grad. 	En 	intervjurunde 	
blant	 tannleger	 for denne studien 	viser	 at 	både tannhelsepersonell og pasienter generelt 	
er 	fornøyde med de 	alternative 	materialene	 Det 	nødvendige tekniske utstyret og 	
grunnferdighetene blant personellet 	for å h	åndtere de nye materialene er 	blitt utviklet 	
over 	lang 	tid. 	 	
Hovedfordelene med alternativene til dental amalgam sett fra tannhelsepersonellets 
side er at materialene har gode festeegenskaper, 	noe som betyr at en kan nøye seg med 	
å fjerne mindre av den f	riske tannen enn om en bruker dentalt amalgam. Derfor tar det 	
noen ganger mindre tid å	 bruke de alternative materialene i små fyllinger	. Større 	
fyllinger er 	imidlertid 	noe mer tidkrevende	 å legge og kan ta	 mellom 	15	-45	 minutter 	
mer tid avhengig av tannlege	ns dyktighet og fyllingens kompleksitet.	 I denne 	
kostnads	beregn	ingen er 15	-30 minutter vært brukt. 	En viktig 	helse	fordel	 	i 	
arbeidsmiljøet er at amalgam ikke lengre brukes.	 	
En u	lempe er at 	de 	alternative	 materiale	ne	 kan	 være krevende	 å bruke	, spesielt for	 store 	
fyllinger	. En annen ulempe er at bakterier lettere dannes 	på overflaten av en 	fylling, noe 	
som krever noe mer 	grundig 	oppfølging av pasienten og tannlegen. På grunn av dette og 	
mindre «tyggestyrke»	 	varer komposittfyllingene ennå ikke så lenge som 	
am	algamfyllingene (noen påstår at de varer halvparten så lenge som amalgamfyllinger), 	
men de fleste tannleger hevder at levetiden 	øker 	og nærmer seg levetiden for 	
amalgamfyllinger. 	 	
I de første årene de nye materialene var i bruk ble det rapportert noen alle	rgiske 	
reaksjoner i munnen på pasienter og i hendene til tannhelsepersonellet. Men antallet 
rapporterte bivirkninger fra bruk av de nye materialene har ikke økt i like stor grad som 
den økte bruken av disse materialene. 	 	
 Rensekostnadene lavere enn kostnad	ene ved å fase ut bruken av dental amalgam 	 	
Undersøkelsen i denne studien	 viser at d	e marginale 	kostnadene ved tiltakene som tar 	
sikte på å redusere 	kvikksølv	utslippene fra tannklinikker og krematorier 	generelt 	er 	
mye lavere enn de marginale kostnadene kny	ttet til å fase ut bruken av amalgam i 	
tannfyllinger. 	Tiltakskostnadene for en amalgam	avskiller	 er beregnet til rundt NOK 	
8.000 	– 12	.400 (€ 1	.000 	– 1.550	)/kg 	kvikksølv	, og utslippsreduksjoner fra krematorier	 	
er anslått å koste rundt	 NOK 29	.200 	– 122	.000 (€ 3	.650	 – 15	.250)/kg 	kvikksølv	. 	
Kostnadene v	ed å fase ut bruken av amalgam i	 nye fyllinger er til sammenlikning 	
beregnet til 	NOK 67	.00	0 	– 533	.000 (€ 8	.375	 – 66	.625	)/kg 	kvikksølv	 eller ca. NOK 67 	– 	
533 (€ 8,5 	– 67)	/fylling	, ikke inkludert kostnadene ved hyppigere skifte av fyllinger	. I 	
Norge belastes 	kostnadene i all hovedsak 	de voksne 	konsumentene	. 	 	
Substitusjon av	 dentalt amalgam 	sta	rtet 	som et resultat av offentlig oppmerksomhet og 	
retningslinjene fra helsemyndighetene 	før 	miljø	mynd	ighetene	 innførte 	det generelle 	
forbudet mot kvikksølv i produkter	. Det er derfor vanskelig å vurdere de totale 	
kostnadene 	ved forbudet	. Men tiltakene har	 vært	 viktige i 	substitusjon	sprosessen	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	11	 	
Det meste av kostnadene ved utfasingen av dental	t amalgam er relater	t til 	høyere 	
tidsbruk hos 	tannklinikkene	 når de bruker de 	alternative 	materialene, samt til 	
kostnadene ved hyppigere skifter av fyllinger. Komposi	ttene må	 også forventes å få 	
lengre levetid	 i fremtiden 	og dermed redusere 	behovet for	 skifte av fyllinger	 og 	
kostnadene knyttet til dette	. 	
Utfasing av dentalt amalgam må sees i et 	bredere	 perspektiv	 	
Vurder	ing av	 tiltakene kun ut fra en sammenlikning av 	tiltaks	kostnadene 	kan 	lett 	lede til 	
en konklusjon om at separering/innsamling av dentalt amalgam og rensing av 
utslippene fra krematoriene burde 	gjennomføres	, og at 	valget 	av 	materialer 	i fyllinger 	
kan	 overlat	es	 til tannlegene og pasientene. 	 	
Ettersom det 	overordnede, langsiktige målet er å 	eliminere bruk og utslipp	 av kvikksølv 	
til omgivelsene	, må bruke	n av kvikksølv også adresseres.	 Derfor 	bør	 bruken av dentalt 	
amalgam fases ut, samtidig som tiltakene rettet mot utslippene 	fra	 eksisterende 	
tannfyllinger gj	ennomføres. Når det i framtiden ikke er noe kvikksølv igjen i 	
tannfyllingene vil det ikke lenger være behov for 	amalgamavskillere og tiltak mot 	
utslipp fra krematoriene	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	12	 	
1 	Introduction	 	
1.1	 	Mercury 	 	
Mercury is one of the most 	toxic	 pollutant	s and is a global threat to 	human health and 	
the environment	 (UNEP, 2008)	. Dietary intake of and contact with various mercury 	
compounds 	may	 cause permanent brain damage, particularly in the fetus. Mercury 	
exposure 	may	 also increase heart rate and blood pre	ssure, and thus cause 	
cardiovascular disease. Inorganic mercury can cause kidney damage. Exposure to 
mercury can also lead to contact allergy and cause acute poisoning.	 Mercury is not 	
degradable, and accumulates in food chains.	 	
There are several different 	chemical forms of mercury: eleme	ntal mercury, 	organic and 	
inorganic mercury	. The health and environmental problems associated with mercury 	
are mainly a result of	 bacterial 	conversion of inorganic mercury 	under anaerobic 	
conditions 	in aquatic systems 	to the	 highly	 toxic organic compound 	methyl mercury	. 	
Methyl mercury 	accumulates in the food chain and 	is found in fish, where it is stored 	
largely i	n the muscle tissue	. Dietary intake of fish and other seafood	 is an important 	
source for 	human exposure to mercury	. 	
Methyl	 mercury is mainly absorbed through the digestive tract. 	Mercury vapor is mainly 	
absorbed by the lungs. 	The body processes these forms of mercury differently and has 	
different levels of tolerance for mercury vapor and methyl	 mercury. 	Methyl	 mercur	y is	 	
more toxic than mercury vapor.	 	
Mercury is transported over long distances with ocean currents and in the atmosphere.	 	
Pollution thus spreads to areas far from emission sources, especially to the highly 
vulnerable	 Arctic environment. 	Deposition of atmos	pheric, long range mercury in 	
Norway was in 2008 calculated to approximately 2,200 kg. This was 2.5 times the 
national emissions to air, water and soil that year, or about 3 times the national 
emissions to air (	Norwegian Pollution Control Authority (	Klif	1, 2010b	). 	
Despite the fact that many countries have	 taken steps to reduce mercury pollution, more 	
action is still needed to reduce global pollution	. The	 UNEP’	s2 Mercury 	Programme 	was 	
established in 2003 on the basis of the conclusions from a global risk as	sessment	 of 	
mercury	. International negotiations on a legally binding instrument on mercury 	started 	
in 2010	 and the	 goal is to complete the negotiations by 2013.	 	
1.2	 	Dental amalgam	 is 	one of the largest sources	 of	 mercury pollution	 	
The use of 	mercury	 in tooth	 filling materials has been 	some of 	the largest 	use 	areas of 	
mercury	-containing	 products	. Mercury is used to bind the alloy particles together into a 	
strong, durable, and solid filling. 	Mercury’s unique properties (it is the only metal that is 	
a liquid at 	room temperature and that bonds well with powdered 	metal 	alloy	s) have 	
mad	e it an important component of dental amalgam that contributes to its 	longevity	. 	
 	 	 	
1Former Norwegian Pollution Control Authority (SFT) 	 	2 United Nations Environment Programme

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1.3	 	Norway has phased out the use of 	dental 	amalgam	 	
Other dental filling 	materials were introduced	 in Norw	ay in the 19	70s. 	In 199	1 the 	
health authorities 	issued guidelines 	in order 	to reduce the	 use of 	dental 	amalgam, and 	
new guidelines from 2003 required that other materials than amalgam should be 
considered as the first choice in tooth fillings. The use of a	malgam in tooth filling was 	
prohibited from 	1 January 	2008 as part of a general ban of the use of mercury in 	
products.	 Requirement	 to install 	dental 	amalgam 	separator	s in 	the waste water stream 	
from dental clinics 	entered into force	 in 1994, and limits fo	r mercury emissions to air 	
from crematoria were 	implemented 	in 2007. Together all these actions have 	
substantially 	reduced the importance of 	dental 	amalgam	 as a source for	 mercury 	
emissions 	to air, water and soil 	in Norway. 	 	
1.4	 	This report review	s the action	s taken	 	
This report presents the results of 	a review	 of the experiences with the phase	-out of 	
dental 	amalgam use in Norway, and estimates the costs to society of the various actions 	
taken. The benefits from the actions in the form of reduced releases of me	rcury to the 	
environment are described. The 	review	 has focused on 	the advantages and 	
disadvantages for dental 	treatment 	personnel and patients 	from	 using tooth fillings with 	
alternative materials to amalgam. 	 	
Costs for the dental clinics and the patients a	nd costs of installing 	dental 	amalgam 	
separator	s and mercury air emissions abatement measures 	in crematoria 	are estimated 	
and compared to previous cost assessments and international data. Since many of these 
actions were taken several years ago it has been	 hard to find good Norwegian cost data 	
for some of the actions. 	The results are presented in the form of costs per unit (dental 	
clinic, filling, cremation) and per kilogram (kg) mercury emissions removed	. Some 	few 	
estimates 	of total costs 	to	 the Norwegian 	society from the actions are also presented.	 	
Data have been gathered from dental clinics, material and equipment suppliers, 
crematoria, local and central authorities etc. Another important data source	s has been 	
various 	reports from Klif	 and	 UNEP on 	Norwe	gian and international evaluations, cost 	
assessments and other documents	, see 	the 	reference list	. 	
Through the UN negotiations 	Norway is 	actively pursuing a 	legally binding 	global 	
agreement on the reduction of the use and release of mercury. A ban on 	the 	use of 	
products containing mercury is one of the areas Norway will focus on in particular. 
Thus, the results from this 	review	 show the 	experience	s from actions taken in Norway 	
and the related costs. Therefore, 	the report also present 	estimated 	costs for s	ome 	
selected countries calculated by using purchasing power parity (PPP) exchange rates.

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2 	Dental amalgam	 	
In this 	section	 we give a brief overview of the use of 	dental 	amalgam and its substitutes. 	 	
2.1	 What is 	dental 	amalgam?	 	
Dental amalga	m is a dental filling material used to fill cavities caused by tooth decay. It 	
has been used for more than 150 years in hundreds of millions of patients	 worldwide	 	
(FDA, 20	09	). Dental amalgam is a mixture of metals, consisting of liquid mercury and a 	
powder	ed alloy composed of silver, tin, and copper. Approximately 50	 percent	 of dental 	
amalgam is elemental mercury by weight. 	Amalgam fillings are also known as “silver 	
fillings” because of their silver	-like appearance.	 	
When placing dental amalgam, the dentist	 first drills the tooth to remove the decay and 	
then shapes the tooth cavity for placement of the filling	. Then	 a softened 	dental 	amalgam 	
putty is placed in the prepared cavity, where it hardens into a solid filling. 	Two types of 	
dental amalgam were used	 in Norway	; 1) copper amalgam where 	the 	amalgam tablets 	
were softened by heating and triturated before placed in the cavity	, and 2) dental 	
amalgam where mercury was mixed with alloy powder	 in closed devises or through the 	
use of multi	-use capsules with pre	-dosed amounts of mercury. 	In	 recent years 	mostly 	
single time use, disposable capsules were used.	 The 	copper amalgam	 was not used in 	
Norway after 1994.	 	
2.2	 	Alternatives to d	ental	 amalgam	 	
Other materials can also be used to fill cavities caused by dental decay.	 Like dental 	
amalgam, these direct filling materials are used to restore the biting surface of a tooth 
that has been damaged by decay (FDA, 20	09	). 	The primary alternatives to dental 	
amalgam are as follows:	 	
 	Composite resin f	illings	 	
 	Glass 	ionomer 	fillings	 	
Composites consisting of plastic materials were introduced	 already	 in the 1970s. 	
Initially, they were only used in teeth without chewing pressure. But their technical and 
chemical properties gradually improved to be used in molars. 	The use of these mater	ials 	
increased	 for aesthetic reasons and because of the 	risks	 associated with 	the use of	 dental	 	
amalgam	. 	
Today 	compo	mers	, giomers, and dental porcelain	 inlays, gold inlays	 and full crowns 	are 	
also	 viable alternatives to 	dental 	amalgam. Below some of the p	roperties of these 	
materials are elaborated	. 	
 	Composite resin fillings	 are the most common alternatives to dental amalgam. 	
They are sometimes called “tooth	-colored” or “white” fillings because of their 	
color. Composite resin fillings are made of a type of 	plastic (an acrylic resin) 	
reinforced with powdered glass.	 The color (shade) of composite resins can be 	
customized to closely match surrounding teeth. They easily blend in with 
surrounding teeth and require minimal removal of healthy tooth structure for 
placement compared with dental amalgam. 	Composites require a bonding system 	
for micromechanical adhesion to the tooth structure. 	But they may be less 	
durable than 	dental amalgam and may need to be replaced more frequently. They

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	15	 	
also tend to cost more than so	me other types of dental filling materials, notably 	
amalgam.	 	
 	Glass ionomer cement f	illings	 are based on the reaction of silicate glass powder 	
and polyalkenoic acid. These tooth	-coloured materials were introduced in 1972 	
for use as restorative materials for	 small cavities. Glass	 ionomer cements have 	
the ability to bond chemically to dental hard tissues and to release fluoride for a 
relatively long period	. Their chief disadvantage is that they are limited to use in 	
small restorations	 due to low resistance to 	fracture.	 	
 	Resin	-modified glass ionomers	 combine the traditional glass ionomer with a resin 	
material. Such materials undergo both an acid	-base ionomer reaction 	
supplemented by a second resin polymerization initiated (usually) by a light	-	
curing process. Thes	e materials are more fracture resistant than glass ionomers 	
and combined with the ability of chemical bond to tooth substance, they are used 
for small restorations, especially in pediatric dentistry, in addition to the same 
indications as glass ionomers.	 	
 	Compomers	 have a composition similar to that of a dental composite modified 	
with glass ionomer, making it a polyacid	-modified composite. Compomers still 	
require a bonding system to bond to tooth tissue and are less force resistant than 
composites. It is use	d for small restorations in pediatric dentistry and serves as 	
an alternative to resin	-modified glass ionomers in such cases.	 	
 	Giomer 	is a subgroup of	 composite resins	 using fluoride containing fillers. They 	
are infrequently in use	. 	
 	Dental porcelain	 and gol	d alloys	 is 	used for inlays and onlays and requires 	
manufacture in a laboratory, so called indirect technique. Despite 	excellent 	
properties for dental restoration 	gold alloys and 	dental porcelain is less 	
frequently 	used because of its costs 	and time	-consum	ing procedure. 	 	
The experiences 	with the use of the various filling materials 	in Norway 	are discussed in 	
section 4.

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3 	The use	 and release	 of 	mercury	 from	 tooth fillings in Norway	 	
In this 	section 	we present an overview of the 	development of the 	regulat	ions of the use 	
of amalgam in tooth fillings in Norway, and the various measures taken to reduce the 
release of mercury from tooth fillings to the environment. 	 	
3.1	 	Dental a	malgam was first addressed as a health problem	 	
3.1.1	 A long history of 	dental 	amalgam use	 	
In	 Norway, 	dental 	amalgam has been used as a restorative material in dentistry for more 	
than a	 century, and has helped to eliminate class distinctions with regard to the dental 	
health of	 the population	 (Norwegian Board of Health, 1999)	. Most Norwegians 	today	 	
aged	 50 	years and older	 have many and extensive	 amalgam fillings in their teeth, for 	
which reason they are often referred to as the “fillings	 generation”. However, despite 	
many cavities they were enabled to retain their teeth. This	 was largely 	due	 to the 	
availability of such a cheap and durable restorative material as 	dental 	amalgam. 	 	
3.1.2	 Dental health improved 	 	
Since the 1970s 	dental health	 in general and 	of children and youth	 in particular has 	
improved	, largely 	as a result of 	preventive use of 	fluoride.	 A su	rvey showed that in 1985 	
50 per	cent of all five	-year	 olds	 had caries	-free teeth; in 1997 	this figure had risen to 70 	
per	cent. The corresponding	 figures for 18	-year	-olds 	for the same years were 1 percent 	
and 13 per	cent	, respectively (Norwegian Board of Heal	th, 1999)	. 	
3.1.3	 Potential health 	impacts from 	dental 	amalgam use 	 	
It is recogni	zed that amalgam fillings release mercury 	which	 is absorbed by the 	human 	
organism. Furthermore, i	t has been broadly agreed that mercury from amalgam fillings 	
constitutes a considera	ble part of the general population’s mercury exposure 	
(Norwegian 	Directorate	 of Health, 20	03). The amount of mercury vapo	r released from 	
amalgam fillings increase with increased chewing, tooth brushing etc. 	Humans with high 	
concentrations of mercury in the	 blood and/or urine because of intensive use of 	
chewing gum are reported (Norwegian 	Directorate	 of Health, 2003). 	 	
It is documented 	in Norwegian and international studies 	that mercury f	rom amalgam 	
fillings could be t	ra	ced in various parts of the human bod	y, see	 for instance	 the 	
Norwegian 	Directorate	 of Health (2003)	. The amounts of mercury in the brain of 	
deceased people are correlated with the number of amalgam fillings. Mercury passes 
placenta, and the mercury concentrations in fetu	ses are correlated wit	h the number of 	
amalgam fillings of the mother. 	People with amalgam fillings have more mercury in their 	
body liquids than persons without such fillings	. 	
The Norwegian 	Directorate	 of Health (2003)	 state	 that:	 	
“The available evidence is inadequate to establ	ish that exposure to mercury in amalgam 	
fillings leads to health effects other than allergic reactions. However, risk analysis indicates 
that there is some possibility for adverse health effects caused by mercury from amalgam 
fillings in a small minority o	f the population.	” 	
In 	Life Science Research Office (	LSRO	, 2004) the results of a comprehensive review of 	
scientific studies of these issues are presented. 	The report concludes that there is little

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	17	 	
evidence to support a causal relationship between mercury 	fillings and human he	alth 	
problems. The authors note	, however, that many research gaps existed, which, if 	
addressed, may settle the dental amalgam controversy once and for all.	 	
However, risk assessments indicate that 	potential	 health impacts from mercury i	n 	
dental 	amalgam 	could not be excluded 	(The Norwegian Directorate of 	Health	3, 2003). 	
Some of the most common symptoms 	associated with amalgam	 exposure	 are joint and 	
muscular pain, lethargy, debility, dizziness, headache, stomach and intestinal ailments, 
visual disorders and loss of short	-term memory. 	It is very difficult to ascertain the extent 	
of the problem because:	 	
 	there is no accepted way of making a diagnosis;	 	
 	many of those who ascribe their 	health problems	 to amalgam fillings may be 	
suffering from oth	er 	illness	es	 with simil	ar symptoms of a general nature, and	 	
 	some 	patients	 may be allergic to one or more of the components used in dental 	
restorative materials without being aware of it.	 	 	
3.1.4	 Increased 	public 	focus on the negative sides of 	dental 	amalgam	 use	 	
During the 	1980s 	and 	1990s 	a debate 	on	 the use of 	dental 	amalgam as a restorative	 	
material in dentistry 	became	 especially intense	 in the media.	 The Norwegian Dental 	
Patients Association (Forbundet Tenner og Helse) 	was	 a driving force in 	this debate	. The 	
association represents people who believe that their health	 has been impaired as a 	
result of dental treatment	. In Sweden a similar debate even more intense than in 	
Norway emerged. 	 	
The media often feature	d interviews	 with people claim	ing that their he	alth problems	 	
were	 caused by amalgam fillings, and who have	 regained their health after replacing 	
their amalgam fillings	 with a different material. Some scientific studies 	also	 report	ed	 	
that patients have been	 restored to health after having had the	ir amal	gam fillings 	
replaced.	 However, these studies were heavily disputed. 	 	
3.1.5	 Occupational health problems from mercury 	in c	opper amalgam 	
recognized 	 	
The heating	 of mercury 	without 	a 	vent pipe and personal protection equipment	, and 	
blending the metal 	powder 	alloy 	by hand	, resulted in inhalation of 	mercury 	vapor 	by the 	
dental 	treatment 	personnel. They have for years complained about long term health 	
damages similar to those claiming damages from mercury fillings, and requested 
compensation for their sufferings. 	 	
The	 Norwegian Knowledge Centre for the Health Services	 (Kunnskapssenteret) was 	
asked by the authorities to look into this issue by reviewing	 scientific studies. In t	heir 	
report (Kunnskapssenteret, 2011) they conclude that 	dental	 treatment	 personnel in 	
Norway 	were	 exposed to mercury to variable 	degrees in the 1960s, 1970s and 1980s	. 	
The highest exposure is found 	in the 1960s.	 Mercury concentrations 	found 	in urine	 and 	
in other body tissues were 	generally higher in dental 	treatment 	personnel th	an in 	
 	 	 	
3 The N	orwegian Directorate of Health is the former 	Directorate of Health and Soc	ial Affairs

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unexposed con	trol groups, 	both in Nordic and international studies.	 Dental 	surgery 	
assistants	 in general had higher concentrations of mercury	 in urine 	than	 dentists	. 	
As a result of this process m	ercury 	is now accepted 	in Norway 	as 	the source of 	an 	
occupational health p	roblem for dental 	treatment 	personnel who work	ed	 with the 	
material	. Also, the question of compensating those who suffer from this is about to be 	
solved on an individual basis. 	 	
3.2	 	Regulatory actions	 	
3.2.1	 Actions taken by the h	ealth authorities	 	
Guidelines for dent	al filling therapy introduced in 1991	 	
As a resu	lt of the	 debate 	on 	mercury risks,	 the Norwegian Directorate of Health	 in 1991 	
introduced 	guidelines	 with the purpose of reducing 	the use	 of dental amalgam	, based on 	
the precautionary principle	 (Norwegian Dire	ctorate of Health	, 1991)	. Although 	no	 	
connection between	 dental	 amalgam and health	 problems	 were scientifically proven	, it 	
seem	ed	 probable that 	for 	a small segment of the population exposure to mercury may 	
lead to	 adverse health effects. Nor could	 response	s to other dental restorative materials 	
be 	excluded	 (Norwegian Board of Health, 1999).	 	
The Norwegian Directorate of Health	 recommended in the	 gui	delines	 that extensive 	
dental 	amalgam therapy should be avoided 	for	 pregnant women for reasons of general 	
prev	ention. The guidelines also 	stated	: “As a contribution to reducing the environmental 	
impact of mercury, the Directorate recommends that the use of	 dental	 amalgam be 	
reduced successively”	. It was also 	underlined	 that dental 	treatment 	personnel who 	
handle 	de	ntal	 materials run a greater risk of developing allergies. 	 	
New guidelines in 2003 requires justification of any dental amalgam use	 	
The n	ew	, updated	 “National Clinical Guideline for the Use of Dental Filling Materials	”, was	 	
published by the 	Norwegian 	Dire	ctorate of Health in 2003. They specify that 	dental 	
amalgam should usually not be the first choice for any indication of filling therapy, and 
especially not 	as a filling mat	erial when treating pregnant women, children and 	young 	
people up to the age of 18 y	ears under the auspices of the Public Dental Health Service.	 	
Generally, the use of 	dental 	amalgam should be limited as far as possible out of 	
consideration for the environment and potential damage to health. 	Restraint should be 	
exercised in using 	dental 	am	algam on persons with	 specific health problems, e.g.	 	
persons suffering from allergies or renal (kidney) ailments. 	The use of 	dental 	amalgam 	
should	 be justified in the patient records and the patient 	should	 give his or her consent	. 	
The guidelines also inclu	de precaution for the dental treatment personnel:	 	
“Every effort should be made to reduce the exposure of patients and dental health care	 	
personnel to chemical substances during dental treatment, both when placing and 
removing dental fillings. 	Water cooling	 and suction shall be used when removing old dental 	
fillings. Contact with materials before they are hardened should be avoided.	” 	
The 	Norwegian	 Dental Biomaterials Adverse Reaction Unit established in 1993	 	
Another action was the establishment of 	the	 Denta	l Biomaterials Adverse Reaction Unit	 	
(Bivirkningsgruppen) 	at the University of Bergen, which	 commenced its activities in

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	19	 	
1993 and is funded by the Norwegian government.	 In 1999 the Dental Biomaterials 	
Adverse Reaction Unit was organized within Uni Research	 AS, a research company 	
owned by the University of Bergen. 	It was the first	 such body in the world. The unit is 	
active in three main areas	, covering both 	dental 	amalgam and other materials	: 	
 	registration	 of adverse reaction reports	 	
 	research and 	 information	 activities	 	
 	clinical examination	 of referred patients	 	
The work of the unit has been and is closely followed abroad, which shows that Norway 
was breaking new ground	 with this unit	. In 1996 Sweden opened	 an adverse	-effects 	
register along the same lines as 	No	rway	. 	
The Nordic Institute of Dental Materials (NIOM) is the Nordic Cooperative Body for 
dental biomaterials. The Institute’s activities in research, materials testing, 
standardization	 and research	-based consulting are directed towards dental health 	
servic	es and health authorities in the Nordic countries. The Institute is owned jointly by 	
UniRand (a wholly owned subsidiary of the University of Oslo) and the Norwegian 
Ministry of Health and Care Services. Activities are financed by 	the Nordic Council of 	
Mini	sters,	 the Nordic ministries for health services	, m	aterials testing and consulting 	
services.	 	
3.2.2	 Actions taken by the e	nvironmental authorities	 	
Steps to limit 	mercury 	discharges	 to the environment 	from dental treatment	 were taken 	
by the 	environmental authoriti	es	 as	 part of a broader policy to limit emissions of 	
mercury to air, water and soil,	 and the long run goal	 to phase	-out the use of mercury in 	
various 	products. 	An important part of this was	 to establish “	The substitution principle	”, 	
which 	state	s that the	 users of hazardous sub	stances are expected to replace these with 	
alternatives that entail less risk, and as a general rule to discontinue use of the most 
dangerous substances if less hazardous alternatives are available	. 	
Mandatory 	dental 	amalgam separato	rs introduced in 1994	 	
A requirement to have an approved 	dental 	amalgam separator	 installed	 in 	all 	dental 	
clinics was 	introduced 	in	 1994	 as set out in 	the Norwegian	 Pollution Regulations, section 	
15A	-6. Older separators 	must	 be type	-approved, while	 a minimu	m efficiency of 95	 	
percent	 was	 required for those installed after 2006.	 This led to significant reductions in 	
mercury discharges into municipal sewers. 	 	
There will be some discharge of mercury even after purification	, regular emptying and 	
inspection of the	 dental 	amalgam separators that are necessary to achieve a 95 	percent	 	
degree of purification. All waste and sludge containing 	dental 	amalgam must be 	
delivered 	to certified collectors of hazardous	 waste.	 	
Regulations of mercury emissions from crematoria fr	om 2007 	 	
The discharge of mercury into the air from the largest crematoria 	has been regulated 	
since	 2007	. The 	regulation	, which is	 set out in the 	Norwegian Pollution Regulations	 	
section 10, 	was	 introduced in 	2002	, and 	applies	 to crematoria established aft	er 1 	
January 2003. For crematoria that existed before 1 January 2003, purification 
requirements apply from 1 January 2007. 	The largest crematoria 	(more than 200

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	20	 	
cremations per year) 	must fulfil 	limits 	for	 mercury concentration in the flue gas	. No 	
specific 	requirements apply to the smallest crematoria, 	as	 their mercury emissions are 	
small	 (Klif, 2010	a). 	
In 2008 the	 mercury emissions 	to air	 from crematoria was 	58	 kg. The number of 	
cremations per annum varies 	between	 14	,000 	and 	15	,000	, constituting	 35	 percent	 of the	 	
total number of deaths per year 	(Klif	, 2010a	). Without regulations 	the 	mercury 	
emissions from crematoria 	were	 expected to 	increase significantly towards 2020, and 	
then gradually 	decline with the decline in the number of amalgam fillings	 in	 the	 	
dece	ased	. 	
General ban on mercury in products from 2008	 	
On 1 January 2008, Norway introduced a general ban	, with few 	and mainly time	-limited 	
exemptions	, on the production, import, export and placing on the market of mercury in 	
new products	 (including dental am	algam)	, which is set out in the 	Norwegian 	Product 	
Regulations	, section 2	-3. This	 decision was based on an overall evaluation of the risks to 	
people and the environment posed by sources of mercury pollution in Norway	, and the 	
long	-term	 goal to phase	-out emi	ssions and use of mercury	. 	
Prior to the ban an impact assessment 	was made, see SFT (2006). It referred to the 	large 	
reduction in 	dental	 amalgam	 use,	 and 	also 	referred to a survey indicating that the 	
dentists preferred the alternatives to 	dental 	amalgam	 (N	orwegian Directorate of Health, 	
2003)	. According to the assessment, 	aesthetic dental treatment has gradually become a 	
concept that excludes the use of dental amalgam. Possible adverse effects, patients’ 
increased interest in filling material	s and patients’	 preferences had	 probably also 	
accelerated the development away from 	dental 	amalgam	. 	
The 	Norwegian 	Directorate 	of Health consider	ed	 that 	a ban 	would	 not lead to any 	
treatment	-related consequences for the most common dental treatment performed, as 	
dental 	amalgam 	was	 little used. 	 	
The comments from the 	consultations	 of the 	proposed 	ban led to a 3	-year	-exemption	 on 	
the use of 	dental 	amalgam for two patient groups	. One exemption was	 for patients that	 	
need	ed	 dental treatment under general an	aesthesia	. General a	nesthesia in itself 	pose	s a 	
certain risk	 and 	the time spent 	for a patient 	should 	be as limited as possible. Dental 	
amalgam 	was considered to take	 less time to 	use	 than 	other restorative materials. 	It 	was 	
also 	difficult to keep 	the filling area	 sufficiently	 dry	 when treating a patient w	ho is under 	
general anaesthesia	, which is necessary when using composites	. The second exemption	 	
was for patients that are allergic to 	components in 	mercury	-free fillings. 	 	
From 1 January 2011	 these 	exemptions expired and the 	ban on the use of dental 	
amalgam 	now is	 total	. However, it is possible to apply for a	n exemption	 from the 	
Norwegian Climate and Pollution Agency	 (Klif) 	for 	the use of 	dental 	amalgam for 	a single 	
patient	. Very few	 applications for such use have been received	 by Klif	. 	
In Sweden, since 1 	June 2009 	dental 	amalgam 	could	 only 	be used in special medical 	
circumstances rather similar to 	those in Norway before end 2010. I	n June 2010 only 	
three of 	a total of 68 hospital dental clinics that could still use 	dental 	amalg	am had 	
actually done so (	Kemi	, 2010).

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Vista Analysis AS	 	21	 	
Although the use of 	dental 	amalgam 	is now banned in Norway, it will take 	many years	 	
before all existing 	amalgam fillings	 are 	removed	. This makes i	t important to have good 	
waste collection 	and emission control 	systems 	to prevent release of mercury to the 	
environment.	 	
3.3	 	Use and release	 of mercury 	substantially 	reduced	 	
Mercury 	use in pr	oducts and emissions of mercury 	ha	s been substantially reduced over 	
the years	. The most important 	action	 in Norway in the 1980s was to limit	 mercury 	
emissions from industry. 	Norway’s national target 	is 	to 	continue	 this development	 with 	
the goal of eliminating 	use and release	 of mercury 	by 2020 (Klif, 2010	a). According to 	
the	 national action plan 	from	 2005	, the	 limitation on	 use of mercury in p	roducts	, and 	
especially dental amalgam, was considered an important measure.	 	
From 1995 to 2008, releases 	of mercury 	from incineration plants, crematoria and 	
combustion of landfill gas dropped by 33 percent 	according to data from 	The Climate 	
and Pollution C	ontrol Agency (Klif)	. Furthermore, discharge	s to water via municipal 	
sewers and sludge from dental clinics was reduced from 490 kg mercury in 1995 to 15 
kg mercury in 2008 (Klif, 2010c).	 	
Table 3.1	 	Use of dental 	amalgam. Kg Mercury.	 	
 	1995	 	2000	 	2001	 	20	02	 	2003	 	2004	 	2005	 	2006	 	2007	 	2008	 	
Use	 	840	 	275	 	263	 	230	 	139	 	137	 	96	 	80	 	43	 	0 	
Source: Klif	 	
Table 	3.1 shows that the use of mercury in tooth fillings gradually has been reduced 	
since 1995	. Some	 sources indicate that the use of mercury in tooth fillings was as h	igh as 	
2,000 kg in 1985 (Scandpower, 1994	), 	showing	 a large 	reduction of 	dental 	amalgam use 	
before 	1995. 	 Amalgam fillings 	are durable and the	 quantity of	 amalgam in 	the 	
population	 represents approximately 10	 ton	s of mercury 	in Norway today. 	It is 	
estimate	d 	that 	1.5 million Norwegians	 of a total of 5 million citizens	 (i.e. 30 percent)	 	
have amalgam fillings (Norwegian Board of Health, 1999). 	As 	people pass away or 	the 	
fillings are replaced with 	other materials	, the quantity of mercury in 	the 	population	 will 	
fall. 	Nevertheless, 	it should be	 expect	ed	 that some mercury will be released 	to the 	
environment	 for up to 30 years	 after phase out of the use of dental amalgam	.

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Vista Analysis AS	 	22	 	
Table 	3.2 	 Use of mercury in products in 1995 and 200	9. Kg Mercury.	 	
 	 	 	
 	199	5 	200	9 	
Dental amalgam	 	840	 	0 	
Batteries	 	215	 	5 	
Light sources	 	130	 	118	 	
Thermometers	 	90	 	0 	
Measuring devices	 	55	 	0 	
Laboratory chemicals	 	40	 	37	 	
Mercury switches and relays	 	5 	0 	
Mineral fertiliser	 	3 	2 	
Flat screens	 	0 	4 	
 	 	 	
Total	 	137	8 	166 	
Source: Klif	 (2011)	 	
Table 	3.2 shows that 	the largest use of mercury in products 	in 1995 	was in 	dental 	
amalgam	, comprising 	73	 percent of mercury consumption	 in products 	that year	. 	
Consumption of dental amalgam was reduced by 	approximately 95 percent during the 	
period 1995 	– 20	07	, i.e. the year	 before t	he general ban went into force.	 Table 	3.2 also 	
reveals that total consumption of mercury	 in products	 is reduced by 	approximately 	88 	
percent from 1995 to 2009	. Consumption of mercury 	in	 all 	products	 except 	flat screens	 	
has been red	uced in this period.

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Figure 	3.1 	Norwegian releases of mercury (excluding those from contaminated 
sites, sediments and shipwrecks) in the period 1995	–2008, and 	
projected releases in the period 2008	–10	 	
 	
So	urce: Klif (	2010	a) 	
 
Figure 	3.1 shows that even if the release of mercury has been substantially reduced in 	
Norway, there is still 	some 	way to go to eliminate these emissions by 2020 as the official 	
goal says. 	 
0
2
4
1994	1996	1998	2000	2002	2004	2006	2008	2010	
tonnes /year
 	
50 % reduction	 	
90 % reduction

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4 	Main experiences	 with the 	alternatives to d	ental amalgam	 	
In this 	section	 we 	present results of various assessments of the experiences with 	
alternative materials to	 dental	 amalgam, including 	telephone 	interv	iew	s for this report 	
among 	selected operating dentists and county dentists (fylkestannleger	) in Norway.	 	
4.1	 	Some s	cepticism in the early days	 	
Interview	s among	 dentists, 	physicians 	and the general public on 	their views of 	the 	
restorative materials used in dentistry	 were 	performed in 	199	8 (Norwegian Boa	rd of 	
Health, 1999	). More doubt 	regarding possibl	e harmful effects of 	dental 	amalgam	 existed	 	
in the general public	 than among doctors and dentists. 	The 	interview 	showed	 that 	
dentists 	favoured 	dental 	amalgam or gold if they needed to replace a large filling in a 	
molar, whereas physicians and people in gen	eral preferred composite fillings.	 	
A survey conducted by the	 Norwegian	 Directorate for Health in 2002 revealed that 	
dentists 	at that time	 prefer	red	 to use composite	s as a filling material. 	This survey 	
showed that	 the proportion of	 amalg	am fillings 	used 	for	 children and young people 	was 	
reduced	 by	 around 90 	percent	 since 1995 	(Norwegian 	Directorate 	of Health, 2003	). 	
4.2	 	Recent observations 	show few	 negative	 impacts	 of 	alternative	 filling 	
materials	 	
The 	resin	-based 	materials 	mostly	 used to replace 	dental 	ama	lgam in 	Norway 	contain 	
small ceramic particles	 in order to 	achieve sufficient strength 	for	 the fillings 	to	 	
withstand	 the pressure from chewing. These	 composites are 	delivered uncured 	and thus 	
need a polymerization reaction to harden. 	The	 composite m	aterial	s that contain 	acrylate	 	
monomers	 may 	leak	 unreacted components 	in days/weeks 	after the dental filling has 	
been polymerized	. In addition to	 allergic reactions, 	laboratory studies have shown that 	
these monomers have a potential for biological effects (Samuel	sen 2011). It is, however, 	
not yet documented that the monomer exposure in such concentrations as found after 
polymerization is high enough to cause health effects	. 	
The	 use the new materials seemed to cause some allergic reactions in the mouth of 	
patients	 and 	in the hands of	 dental	 treatment	 personnel	. Both the patients and dental 	
treatment 	personnel should thus avoid skin contact with the material before it is 	
hardene	d. 	
Particular attention ha	s been paid to	 harmful substances like 	bisphenol A and/or 	
bisph	enol A	-derivatives	 which 	may	 leak from the materials. 	These substances are 	
endocrine disrupt	ors and it has been shown that they have an effect resembling that of 	
oestrogen. At present 	there is	 little knowledge of whether exposure to low doses of 	
bisphenol 	A can result in adverse health	-related effects. 	 	
However, the quantities of 	monomers from resin	-based materials	 emitted are small	 and 	
the risks 	for toxic reactions are 	considered 	negligible. Studies from Norway show that	, 	
these substances are traceable 	in 	the 	saliva 	only 10 minutes after the filling is made, and 	
after 7 days no substances are detected. 	 	
The Adverse Reaction Unit of Dental Biomaterials	 has	 closely 	followed the 	transition 	
from the use of	 dental 	amalgam 	to 	the increased use of 	resin	-based 	toot	h filling 	
materials. In Bivirkningsbladet (2010) they present a summary of the experiences so far.

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The number of reports about potential adverse 	effects 	from	 the use of 	resin	-based tooth 	
filling material	s have	 increased somewhat in recent years up till 201	0, while the share of 	
reports related to impacts from	 dental	 amalgam use has declined somewhat. 	Since the 	
use of dental amalgam was prohibited from 2008 this development 	is as 	expected. 	
However, t	he number of reported adverse impacts from the use of 	resin	-based 	fillings 	
has not increased 	to	 the same degree as the increase in the use of these materials. 	It is 	
claimed	 that this could be a random variation in the reporting, and 	that 	it is too early to 	
draw any conclusions.	 	
In addition to 	chemicals 	that star	t the polymerization process	 in the composites,	 a 	
special light is also used to get a quick hardening when the material is put into the tooth	. 	
This light 	may 	cause harm to the eyes if they are not properly protected	 	
(Bivirkningsbladet, 2010). 	 	
The first we	eks after a composite filling is laid it is not unusual 	to 	feel pain and “icing” 	
when chewing or drinking cold drinks. This usually vanishes after a short time. The 
sealing systems that are used today will probably reduce these 	effects	, since they give a 	
better sealing of the rims (Bivirkningsbladet, 2010). 	 	
4.3	 	The 	alternative	 materials are 	considered 	good alternatives to dental 	
amalgam	, but 	in some cases 	more challenging to use	 	
The general impression from 	the 	interv	iew	 performed for this 	report 	is that denti	sts are 	
satisfied with the alternative materials. The most common material used now is 	resin	-	
based composites, but various glass ionomers and ceramic	-based materials are also 	
used to some extent. These materials have been used for years, long before the ba	n on	 	
dental	 amalgam use 	entered into force	. Thus, the necessary technical equipment and 	
basic skills among the personnel have been established for long.	 	
The main advantage	 from the dental 	treatment 	personnel’s point of view 	is that they 	
have good adhesiv	e properties, implying that 	the dentist needs to 	remov	e less amounts 	
of the fresh tooth compared to when using 	dental 	amalgam. 	This can offset some of the 	
extra time needed for hardening of these 	materials	 especially for small fillings, and 	some 	
dentists e	ven claim that they use less time than when using amalgam. Larger fillings are 	
some more time	-consuming than when using amalgam	. The dentists 	in 	the	 review	 for 	
this study	 claim that they 	use 	15	-45	 minutes more	, depending on the dentist 	experience	 	
and the c	omplexity of the filling. 	For the economic assessment presented in this report, 	
15	-30 minutes is used in the calculations. 	Patients seem to like the 	alternative 	materials 	
because of their 	tooth	-like appearance.	 	
The disadvantages are that the	 alternative 	materials 	cou	ld be challenging to use	, 	
especially for larger fillings	. They need a completely dry environment to seal properly.	 	
Another disadvantage is that bacteria are more easily formed 	on the surface of 	the 	
filling, thus requiring some more follow up f	rom both the patient and the dentist. 	
Because of this and less “chewing	-strength” the composite fillings do not last as long as 	
the	 amalgam fillings (some say half the time of amalgam fillings), but the 	longevity	 is 	
increasing and approaching the 	longevity	 of amalgam fillings. 	Since the 	alternative 	filling 	
materials are sensitive to the techniques used	, the skills and experiences of the dental	 	
treatment	 personnel are 	important	 to get a good result. Especially the sealing, i.e. the

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Vista Analysis AS	 	26	 	
intensity of	 the light use	d for sealing and the wave length	 of the light are important 	in 	
order 	to achieve a good filling.	 	 	
4.4	 	Swed	ish assessment	 generally positive	 to a ban	 	
Sweden 	introduced	 a general ban on the use of mercury in products from 1 June 2009. 	
However, dental am	algam may be supplied to the Swedish market for patients in special 	
need for it until 31 December 2011, and may be used for this purpose until 30 June 
2012. A total ban applies to the use of 	dental 	amalgam on children and adolescents	 	
(Kemi, 2010)	. 	
An asse	ssment of the impacts of a ban	 performed in 2004 by the 	Swedish Chemicals 	
Agency	 conclud	es that for the general tooth treatment a ban on the use of 	dental 	
amalgam would not have any negative impacts	, see Kemi (2004). 	The analysis showed 	
that there are othe	r materials 	on 	the market that can replace	 dental	 amalgam, and 	that 	
these materials were already use	d in 95	-98 percent of all new tooth fillings. However, 	
they 	also 	point	ed	 to the 	possibility	 of increased risks for caries for patient	s with 	
improper 	mouth 	hygiene. 	 	
Kemi (2004) also points to the fact that there are clinics treating patients under general 
anaesthesia 	that never use	 dental	 amalgam. Instead they use various composites, and 	
this take no longer time than when using 	dental 	amalgam. 	Dental a	mal	gam corrodes and 	
can thus expand and break the tooth. The risks for such consequences and the need for 
new, comprehensive tr	eatment would be reduced when a dental	 amalgam ban is 	
introduced. 	 	
In the middle of the 1990s the number of skin damages and aller	gies among dental 	
treatment 	personnel in Sweden increased because of the increased use of acrylat	e-based 	
composites and binding materials that were used to 	seal the gap between 	the filling 	and 	
the tooth. However, the reported damages of these kinds in dent	al clinics were reduced 	
from 38 in 1997 (the year with the highest number) to 5 in 2000. In 2001 the number 
was 11. 	In Kemi (2004) it is	 therefore conclude	d that a ban on 	dental 	amalgam should 	
not increase these damages, since the p	ersonnel learned to hand	le the	 materials and the 	
producers changed the packaging to reduce the risk.

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5 	 	Costs and benefits from phase	-out	 	
In this 	section	 we assess the costs 	in Norway 	for	 the 	various involved actors and the 	
society of phasing out the use of 	dental 	amalgam	 and	 co	llecting the mercury waste from 	
dental clinics and cleaning emissions to air from crematoria. 	 	
5.1	 	All costs 	and benefits 	should 	ideally 	be 	included	 	
5.1.1	 Benefits are measured through mercury emission reductions	 	
Since the focus of this review is on mercury emission	s to the environment from dental 	
amalgam use, no other benefits are quantified. However, there could be several other 
impacts	 related to the actions ta	ken to reduce mercury emissions	: 	
 	positive or negative impacts on patients’ health	 	
 	differences in pain, al	lergic reactions etc. between the materials	 	
 	benefits for the dental clinics’ working environment	 	
 	aesthetic benefits	 	
 	benefits from reductions in emissions of other pollutants	 	
 
Some of these 	impacts	 could be substantial, and are to the extent possible descri	bed for 	
the various actions	 when relevant	. 	
5.1.2	 Cost components	 that should be included	 	
For the various actions required to 	phase	-out 	dental 	amalgam use	, handling 	waste 	and 	
control	ling emissions,	 the following costs should ideally be assessed	: 	
 	Costs of 	collec	ting and	 handling	 the waste	. The	se comprise	 investment costs for 	
installing 	dental 	amalgam 	separators	 and operating costs for 	collection and 	
treatment of the 	dental 	amalgam waste containing mercury. We conventionally 	
assume 50 percent mercury content in th	e dental 	amalgam. 	Removed drain pipes 	
etc. from dental clinics may contain	 substantial amounts of mercury	, and the 	
costs of removing and treating this should be included	. 	
 	Costs 	for the dental clinics	 of using other filling material than 	dental 	amalgam.	 	
These costs are related to: 	 	
o 	differences in purchasing costs between 	dental 	amalgam and the 	
alternative	 filling materials 	 	
o 	potenti	al investments in new equipment	 	
o 	differences between the materials treatment time in the dental clinics	 	
o 	other 	potential	 impacts	 and costs	 (e.g. training)	 	
 	Costs for the patients	 in the form of	: 	
o 	higher prices for fillings with other materials	 	
o 	different lifetimes of 	dental 	amalgam and other fillings (potentially more 	
frequent change of 	fillings with the alternatives)

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 	Costs for the	 crematoria.	 These are:	 	
o 	investment costs for the equipment to clean mercury emissions to the air	 	
o 	operating costs for the cleaning equipment 	 	
o 	potential reductions in general operating costs	 	
o 	potential increased costs because of early closing of old cremator	ia 	
 	Costs for the authorities. 	Costs of 	imposing and enforcing the regulations should 	
also be included in an overall cost assessment	 	
 
Some of these costs could not be related to 	the ban on the uses of dental amalgam	. For 	
instance, since alternatives to 	dent	al 	amalgam were introduced long before restrictions 	
were 	introduced	 on 	dental 	amalgam use, the dentists had invested in 	equipment and 	
skills for the use of the 	alternative 	materials. We have tried to correct for this, but also to 	
present what the total cos	ts could be 	when there are	 little or no experience with the 	
alternative filling materials. 	 	
Some crucial parts of the cost data are 	historic	 costs, notably for the installation of 	dental 	
amalgam 	separator	s, but also for the use of amalgam fillings in denta	l clinics compared 	
to the use of alternative materials. Since these data are 	not 	observable today, we 	had 	to 	
find people who remember these costs and/or have access to historic data.	 This and 	
other information has also to the extent possible been compared	 to 	previous 	Norwegian 	
and international 	studies	 and cost investigations. 	 	
5.1.3	 Assumptions	 	
The following exc	ha	nge rates are used:	 	
1 € = 8 NOK	 	
1 USD = NOK 5.85 	 	
1 GBP = 9 NOK	 	
1 SEK = 0.85 NOK	 	
1 DKK = 1.04 NOK	 	
All prices ar	e adjusted to the price level of	 1 Jan	uary 	2011, using the Norwegian 	
consumer p	rice	 index. Furthermore, when 	calculating annual costs for the investments 	
we are using a real discount rate of 4 percent p.a. as recommended by the Norwegian 
Ministry of Finance for these kinds of investment. 10 ye	ars 	economic lifetimes 	for 	
investments in dental	 clinics	 and 20 years for abatement investments in crematoria are 	
applied	. 	
Some of the	 costs may be financed through public budgets. For instance	, in Norway	 the 	
authorities pay for dental treatment	 for all	 persons 	until the age of 18	, for 	the mentally 	
disabled and the elderly in institutions	. The authorities 	also	 pay for their own costs 	
connected to enforcement of the regulations. The financing of these costs would have to 
be done through raising public taxes	, which	 can 	lead to 	an e	fficiency loss (deadweight

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	29	 	
loss	 or marginal cost of public funds), because they create 	a wedge between private and 	
social costs	4. 	
The efficiency loss of using general taxes to finance 	a policy/project will probably differ 	
between c	ountries. For most Nordic countries the efficiency loss is estimated to be 	
around 	20 percent of the costs, and this figure is u	sed in calculations of costs and 	
benefits. This means that all costs that are financed through public budgets by general 
taxes wi	ll be subject to a 20 percent 	surcharge.	 	
One of the	 purposes 	with this review is 	to show other countries what the costs of 	
reducing mercury emissions from 	dental 	amalgam use could be. 	Since 	the costs of dental 	
treatment in 	most	 countries are paid directly	 by the patients	, little or no	ne	 of the costs 	
are financed through public budgets. Thus, the cost of public funds is not relevant for 
them, and we have therefore not included this cost in 	the	 cost figure	s even if it should 	
have been when considered from a 	strict Norwegian point of view. 	But also in Norway 	
most	 of the costs 	for dental treatment 	are paid directly by the patients. 	 	
5.2	 	Costs of 	waste 	collection and 	handling	 	
5.2.1	 Cost assessment 	before 	dental 	amalgam collection was made 	
mandatory	 	
In 1992	 Klif	 (then ca	lled t	he Norwegian Pollution Control Authority (SFT)	) in an internal 	
memo 	made a brief assess	ment of the costs of introducing mandatory mercury removal 	
from dental clinics. 	This assessment was made 	two years 	before	 the collection and 	
treatment of mercury	-containing waste from dental clinics 	were	 required	. It was 	
estimated that installment of 	a mercury 	separator	 unit would cost 	some 	NOK 	8,700	 (€ 	
1,090) 	per treatment	 chair	 (unit) 	or 	some 	NOK 1,075	 (€ 135)	/year	. The 	separator	s were 	
assumed to have a 10 years life time. 	Maintenance and collection of the waste would 	
cost 	some 	NOK 	1,450 (€ 180) per chair per year	. Administering of the requirement b	y 	
the environmental authorities would cost NOK 	500,000	 (€	 62,500) 	per year	 or 	some 	
NOK 14	5 (€ 18)	/chair	. All amounts are 	re	calculated in 2011 price value by us. 	 	
This	 give	s total annual costs 	of 	almost	 NOK 2,	670	 (€ 335) 	per unit per year	. It was 	
assumed th	at the 	separator	s would remove ar	ound 1 ton of mercury per year	 from 	
Norwegian dental clinics	, i.e. 0.333 kg/unit	. This implies specific costs of around 	NOK 	
8,020 (€1,000)	/kg	 mercury removed.	 	
5.2.2	 Nordic assessment showed 	high	 waste handling	 costs	 	
In ECON (1997) treatment costs for various mercury	-containing waste in the Nordic 	
countries 	were	 estimated. For 	dental 	amalgam 	only the costs of collecting and treating	 	
the waste 	were	 assessed, assuming that all Nordic dental clinics would have installed 	
dental 	amalgam separators	 as this was required in all the countries by mid	-1998. 	
Therefore, the cost	 data from this study 	are	 not comparable with the costs calculated 	
 	 	 	
4 A simple example of this efficiency loss is if person A is willing to perform a service for person B for 	NOK	 	
100 and B is willing to pay 	NOK	 110 for this service, then 	both will benefit from this transaction. But if A	 has a 	
marginal tax equal to 50 percent	 he will only get 	NOK	 55 of the 	NOK	 110 person B is willing to pay, and thus 	
the transaction will not take place and the potential gain of 	NOK	 10 will not be reali	zed.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	30	 	
above, which consider all costs	 related to investments and operation of the equipment	. 	
The	 costs estimated	 in Econ (1997) are presented in table 5.1	, 	
Table 	5.1 	Current c	ollection and treatment costs for dental waste in Nordic 	
countries. NOK	 (€)	/kg mercury removed	, 2011 price level.	 	
Denmark	 	Finland	 	Iceland	 	Norway	 	Sweden	 	
32	-528	 (4	–66)	 	158	-212	 	
(€20	–27)	 	
120	 	
(€15)	 	
1,478	-2,244	 	
(€185	-281)	 	
116	-233	 	
(€15	-29)	 	
Source: ECON (1997) 	 	
The table shows that the cost estimates vary widely between as well as within most 
countries. Norway had by far the highest 	calculated costs among the countries. 	The 	
reasons for this seem to be different amounts (the smaller amounts collected the 
costlier), the conditions of the waste and the waste treatment chosen. Some of the 
countries at that time 	(including Norway) 	exported	 the waste	 for final treatment, 	which 	
increased	 the costs.	 	
For Norway 	the 	waste handling	 costs	 were	 calculated at an average of some 	NOK 1,860 	
(€ 235)/kg	 mercury removed per year	. This is 	some	what	 lower	 than the	 cost 	estimated 	
by Klif in 1992 	before 	installation of 	dental	 amalgam 	separator	s was required	 in Norway 	
(maintenance and collection costs of 	NOK 	4,355	 (€ 	545	)/kg	 mercury	). 	
5.2.3	 Rem	oval costs of mercury from 	drainage pipes	 could be	 rather high 	 	
SFT (	2004) presents the results of a 	pilot project 	from 2003 	on how to	 remove mercury 	
deposits 	from	 drainage pipes etc. 	in dental clinics. 	Five	 clinics were chosen for the pilot. 	
Removed mercu	ry amounts varied between 6 and 160 gram per treatment chair. The 	
total amount of mercury removed was 682 gram. 	 	
Total costs for the operation was NOK 1	14	,000	 (€ 14,250)	, i.e. 	around 	NOK 2	3,000 	(€ 	
2,875) 	per clinic with two treatment chairs. Cost per	 kg	 mercury removed was some 	
NOK 16	7,000	 (€ 20,8	95)	. The cost for similar activities in Sweden was around 	NOK 	
136,000	 (€ 17,000)	/kg	 mercury. 	The rather high costs 	in	 the Norwegian pilot 	was 	
probably 	cause	d by 	high transportation costs	 (a Swedish firm did the job), pre	-	
inspection of the clinics etc. The Swedish cost level is probably more realistic if this 
activity 	is 	to be carried out on a large	-scale. 	Anyway, these c	osts are very high c	ompared 	
to the costs 	of removing the mercury before it enters the drainage pipes. 	 	
5.2.4	 Current 	Norwegian 	costs for waste	 handling 	are 	in line with 	some 	
international studies	 	
A requirement	 to install amalgam separators on existing d	ent	al 	treatment 	chairs (	units	) 	
was	 implemented in Norway in 1994	. The price of such a 	separator	 today 	is estimated to 	
be NOK 	16,	000 	(€ 2,000) 	plus installation expenses. 	Assuming 2 hours are needed 	for 	
installation at an average cost of NOK 360/hour (average 	wage costs in 	Norway	) gives 	
total costs of some NOK 16,700 	(€ 2,090) 	or NOK 2,060 	(€ 260) per year	. 	
From around 1997 on, all new units 	have an in	-built centrifuge for separation of 	dental 	
amalgam	, and the price of this is included in the total 	unit 	price.	 It is not possible to

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	31	 	
estimate the price of the centrifuge. 	Larger clinics often have installed central wet 	
centrifuges, serving several units. 	 	
The filters in the units are usually changed once a year. Prices are dependent on filter 
type, but total co	sts 	ar	e around NOK 1	,100 	(€ 140) 	for the 	separator	, NOK 600 	(€ 75) 	for 	
treatment and some 	NOK 	360 	(€ 45) 	for labour expenses	 (assuming one hour of labour 	
needed)	. This implies	 annual 	collection and treatment 	costs of around NOK 	2,06	0 (€ 	
260) 	per unit	. This is also supposed to incl	ude maintenance of the mercury collection 	
unit. 	For larger clinics 	annual 	costs 	for removing the central unit containing the	 dental	 	
amalgam are some NOK 9,360	 (€ 1,170)	, assuming one hour of work is needed for this	. 	
If there are 5 units or more per clinic,	 the costs are lower than the ones calculated for 	
single units. 	 	
The total annual costs for 	dental 	amalgam collection investment, waste collection and 	
treatment would then be NOK 4,	120	 (€ 515) 	per treatment unit or 	some 	NOK 12,	370	 (€ 	
1,545)	/kg	 mercury r	emo	ved	, assuming that the 	separator	 still collects around 0.333 kg 	
mercury/year from each dental unit.	 This amount 	is based on the emissions of mercury 	
from dental clinics before amalgam collectors were installed, and 	would likely be 	
somewhat	 high, given that	 the mercury release now only comes from the removal of old 	
fillings. 	 	
This	 calculated cost	 is more than 50 percent higher than the calculated costs in 1992	, 	
which	 is mainly 	due to	 the doubling of investment costs for 	dental 	amalgam separators. 	
One reaso	n for this could be that installing separate	 dental	 amalgam 	separator	s 	on 	
existing units 	is no longer common, since most old treatment units have been 	replaced	 	
and new ones have this equipment in	-built. Thus, there are reasons to believe that 	the 	
last	 ca	lculation	 overestimate the real, current costs of collecting	 dental 	amalgam from 	
dentist treatment 	chairs.	 	
This is confirmed by ADA (2008), who assumes that the costs in US	 of purchasing and 	
installing a dental	 amalgam separator is around NOK 7	,000	 (€ 875)	, which is more in 	
line with the 	estimate	 from 1992	. Dental a	malgam collection is not mandatory in the US. 	
On the other hand, ADA (2008) estimate	s annual capital and operating costs at some 	
NOK 4,450 (€ 555)/unit	, which is very similar to 	the	 estim	ate	 calculated here 	(NOK 	
4,120 (€ 515))	. We do not know the discount rate used or the lifetime	 for their 	
calculation	. 	 	
In a	 price example from Denmark, 	Cowi (2008) shows that 	the 	an	nual cost	 per clinic 	are	 	
around 	NOK	 3,275	 (€	 410	) for a full installatio	n 	of a dental	 amalgam separator 	and 	
service package. This price does	 not	 comprise in	-situ evaluation of filter efficiency and 	
accreditation of the services, 	which would add some NOK 800 (€ 100)	. Thus, they 	
indicate that	 a price level of 	NOK 3200 	– 4000 (	€4	00	-500	) per clinic per year seems 	
realistic.	 This is at	 the same 	level	 as 	the	 calculations	 in this report	. 	
In 1992 	Klif 	anticipated about one man	-year 	for administration of 	the	 dental	 amalgam 	
collection regulation	. According to 	the	 information 	gathered fo	r this report 	this seems 	
far too high today, and thus we do not include any such costs. Assuming the same costs 
as in 1992 would have added some NOK 145	 (€ 18)	/treatment unit per year	 to the costs	.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	32	 	
5.2.5	 Summary of 	waste handling 	costs 	 	
Table 5.2 presents the 	waste handling costs as calculated in 1992 and current costs.	 	
Table 	5.2 	Estimated c	ost	s of installing and operating 	a 	dental 	amalgam 	
separator	 in dental clinics. NOK (€), 2011 prices. 	 	
 	1992 calculation	 	Curre	nt calculation	 	
Annual cost/unit	 	2,670 (	€335)	 	4,120 (	€515)	 	
Cost per kg mercury removed	 	8,020 (	€1,000)	 	12,370 (	€1,545)	 	
Source: Vista Analysis	 	
We assume that the 1992 calculations in a better way reflect the historic costs in 
Norway from installing and ope	rating (incl	uding 	waste 	treatment) a dental	 amalgam 	
separator	 than the 	calculated 	current costs of installing such a 	separator	. Since a 	
separator	 has been embedded in new 	dental 	treatment units for many years the extra 	
costs from this are probably low, but	 unknown to us. Current costs could reflect a 	
situation when 	a dental	 amalgam 	separator	 ha	s to be installed in an old dental unit	, 	
which could be the case in many countries without such equipment. 	 	
The calculated costs are far 	lower 	than the calculated 	costs 	of removing mercury from 	
drainage pipes in dental clinics (	NOK 136,000 (€ 17,000)/kg	 mercury removed). 	 	
Total investment costs for Norway, assuming some 3,000 dental 	units 	needed	 to be 	
equ	ipped with a dental	 amalgam 	separator	, would be between 	NOK 2	6 million (€ 3.3 	
million) and NOK 	48 (€ 6	 million). Total annual costs would be between NOK 8 million 	
(€ 1 million) and NOK 12.4 million (€ 1.55 million). 	 	
5.3	 	Current 	extra 	costs 	for dentists 	from 	dental 	amalgam ban 	are declining	 	
Because	 alternatives to 	denta	l amalgam were introduced 	in Norway in the 	early 	198	0s	 	
and gradually 	took	 a larger share of the market	 before 	the ban on mercury in products	 	
was introduced	, it is hard to assess what the real costs of a ban on	 dental	 amalgam use 	
have been and what they mig	ht be if the phasing out would have to be done over a 	
shorter period	 with little or no 	pre	-experience with the alternative materials	. However, 	
in addition to assessing the costs of the Norwegian ban 	we have 	also 	tried to include 	
some or most of the costs t	hat would likely o	ccur if one was to phase	-out the use of	 	
dental	 amalgam without much experience with alternative materials. 	 	
The following costs are relevant	 when considering a ban	: 	
 	Different 	material 	purchase costs	: accord	ing to the price list	 of one mat	erial 	
supplier the cost of 	dental 	amalgam for a two	-surface 	filling	 (two	- and three	-	
surface fillings are most common, covering two and three surfaces of the tooth, 
respectively)	 is around NOK 13	 (€ 1.5)	. The comparable price for composite 	
material is some NOK 65	 (€ 8)	 per filling	, consisting of NOK 40 	(€ 5) 	for the 	
composite material itself and 	approximately NOK 25 (€ 3)	 for 	“glue”. Thus the 	
material purchase 	cost difference is NOK 52	 (€	 6.5)	/fil	ling. 	 	
 	Different treatment time	: this seems to vary widely among 	dentists. For small 	
fillings 	(i.e. one	-surface) 	the time used seems to be about the same for	 dental

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	33	 	
amalgam and composites, 	and 	some dentists even claim that they use less time. 	
For larger, m	ore complicated fillings some 	dentists claim that they need 	15	-45	 	
minutes	 extra	. We assume that 15 minutes more spent on all fillings on average 	
could be a modest estimate. Using the average hourly rates for dentists offered by 
the public dental services i	n Akershus and Troms counties (which 	are	 a central 	
and rural country, respectively) gives increased labour costs of some NOK 340	 (€ 	
43)	. 	 	
 	Investments in new equipment	: dentists need to invest in a 	curing 	lamp to be able 	
to 	cure	 the composite fillings pr	operly. However, almost all dentists in Norway 	
have invested in this a long time ago to be able to use composite fillings. The 
investment costs are 	today	 some NOK 15,000	 (€ 1,875)	. This gives c	ost per filling 	
of some NOK 2.5 	(€ 0.3) 	assuming an average of 	3 filli	ngs/day produced by the 	
dentist	. 	
 	Training	5: most dentists received a one	-day training on the use of the new filling 	
materials during the 1990s	 and into the 2000s	. There are still trainings in the use 	
of new materials coming 	into	 the market, 	but	 younger, newly educated dentists 	
are well trained in the use of these materials from the university	. We assume 8 	
hours spent on training for 	a dentist	 which	, using the same hourly rate as for the 	
treatment time (NOK 1,358	 (€ 170)	), gives a cost of NOK 12	 (€ 1.5)	/filling. 	 	
 
To calculate the mercury avoided we need the amounts of mercury in each filling. 
According to Reindl (2008) a 	one	-surface	 filling (restorations) 	typically has 0.37 g	 of 	
mercury, calculated 	from	 one	 denta	l amalgam unit wit	h 0.55 g	 mercury, minus 0.14 	g 	
waste during the f	illing process, minus 0.04 g	 in trimmings. A 	two	-surface	 filling 	starts 	
with two 	dental 	amalgam units, 	and the amount of mercury in the final filling	 is implied 	
to be 0.74 	g. Total amounts 	of avoided mercury will be the average of one and two	 dental	 	
amalgam units, i.e. 0.825 g mercury.	 Since two	-surface fillings are more common than 	
one	-surface fillings, at least when using dental amalgam, this may underestimate the 	
avoided 	mercury 	amounts s	omewhat. Therefore, we assume avoided 	emissions of 1 g 	
mercury per filling. 	 	
Some control	 could be	 necessary to follow up on the prohibition of the use and import of 	
dental 	amalgam. 	But 	since 	dentists 	long time before the ban was introduced	 voluntarily 	
switched to using alternative filling materials	 the import of 	dental 	amalgam 	were 	
already low when the ban was introduced	. Some follow	-up of the prohibition 	could 	
anyway be necessary,	 but there is reason to assume that the administrative costs 	are	 	
low	 (SFT,	 2006)	. Thus, we have not included any administrative costs in 	the	 cost 	
calculations.	 	 	
 	 	 	
5 This is relevant for countries that have not yet started to use the alternative fillings.

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Vista Analysis AS	 	34	 	
Table 	5.3 	Total extra costs per filling for dentists substituting dental amalgam 
for composites. NOK and €/filling a	nd kg mercury emissions avoided	. 	
 	NOK (€)	 	
Increased material purchase costs/filling 	 	52 (	€6.5)	 	
Increased treatment time/filling 	 	340 (	€43)	 	
Investments in new equipment/filling 	 	2.5 (	€0.3)	 	
Training/filling	 	12 (	€1.5)	 	
Total cost increase/filling	6 	40	6 (	€51.3)	 	
Total costs/kg mercury avoided 	 	406,000 (	€50,750)	 	
Source: Vista Analysis	 	
Table 5.3	 shows 	that increased treatment time is the cost component that matters, 	
accounting for 	almo	st 85 percent of	 the total cost	 increase per filling. If	 for instan	ce the 	
extra time spent on composite material fillings compared to amalgam fillings is 
increased from 15 to 30 minutes, the costs increase to NOK 745	 (€ 93)	/filling and NOK 	
745,000	 (€ 	93,125	)/kg mercury avoided	. If there is no extra time used in dental cli	nics 	
with composite materials than with 	dental 	amalgam, the 	extra 	costs are reduced to 	
some NOK 67	 (€ 8)/filling and NOK 	67,000	 (€ 	8,375	)/kg mercury avoided.	 But in 	
countries mostly using 	dental 	amalgam the extra time needed f	or dentists when 	
switching to 	alternative material	s may be 	around the 	high	er	 of these estimates	. But the 	
extra time used will likely go down in these countries when existing dentists get more 
experienced with the alternative materials and new dentists who are trained from 
school in us	ing the materials	 gradually	 enter the workforce.	 	
5.4	 	Treatment c	osts for dental patients	 have increased over time	 	
Before the	 ban on 	dental 	amalgam use was introduced 	it was	 considered that the costs 	
of 	a ban	 would	 be low, 	since the use of 	dental 	amalgam alread	y was strongly reduced	 	
(SFT, 2006)	. This was based on the assumption	 that 	a ban	 would	 not result in an 	
increase in the replacement of	 amalgam fillings. 	 	
A brief assessment 	was performed 	us	ing	 the rates from the Norwegian Ministry of 	
Health and 	Care Servi	ces for public subsidies	 for dental treatment	, to calculate an 	
estimate of the price difference for the patient between the diffe	rent dental filling 	
materials (SFT, 2006). For preparation and filling, the price difference between 	dental 	
amalgam and compos	ite	s was NOK 80 	(€ 10) 	for one	-surface and NOK 235 	(€ 29) for	 	
two	-surface filling	. I	f it is necessary to use gold as an alternativ	e filling material to 	
amalgam, 	the	 price difference would 	be much higher	. 	
The cost of the material for a filling, regardless 	of the material, rep	resented	 	
approximately 5	-10	 percent 	of the total treatment costs	 according to SFT (2006)	. They 	
 	 	 	
6 Potential reduced was	te treatment cost from reduced	 mercury use 	is not included here.

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	35	 	
claim that n	early 	75 percent	 of the costs	 are salary costs	, which is a little lower than 	
what we found in our calculations presented in table	 5.3	 (85 percent)	. The purchase 	
costs for composite material, among others,	 were	 higher than for	 dental	 amalgam and 	
the increased demand for a	lternative filling materials had then	 not led to a lower 	
purchase price from suppliers.	 	
Data gathered for this rev	iew	 found that for a three	-surface filling the price difference 	
between 	dental 	amalgam and composite fillings 	charged the patients 	has been	 in the 	
range of NOK 385 	(€ 48) 	– 575 	(€ 72) 	per filling	 (average NOK 480(	€ 60	)), which is a 	
price increase of betwee	n 33 and 50 percent compared to 	the price of 	an amalgam	 	
filling	. This is somewhat higher than the price differences from SFT (2006	). This is 	as 	
expected since a three	-surface filling is more complicated and costly. 	 	
The	 calculated 	total extra 	cost of 	NOK 4	06	 (€ 51)	/filling	 on average	 for 	all	 fillings 	for 	
dentists using 	composites instead of 	amalgam may seem a little high 	compared to	 the 	
price increase for 	large	 fillings	 (NOK 480(€ 60) on average)	. But price variations across 	
the country and competition among 	dentists could 	possibly 	explain why 	the	 calculated 	
cost increase has not fully been reflected in the increased market price. 	 	
Data from Sweden presented in Kemi (2004) reveal price differences 	ranging from 	14 	to 	
70 percent between amalgam and composite fil	lings. 	During the period 1998 till 2004 	
prices for amalgam fillings in Sweden increased more than prices for fillings using other 
materials. Based on this, the assessment was that costs would not be negatively affected 
by a ban on 	dental 	amalgam use. 	It s	hould be noted however, that in Sweden only 	
restoration work with alternative filling materials 	to amalgam 	is subsidi	zed. Subsid	ies 	
vary between local counties.	 	
Some price estimates from two Belgian dental clinics presented in Cowi (2008) show 
that prices 	charged 	from 	patients 	vary from being similar 	for amalgam and composite	 	
fillings 	to some 40 and 50 percent higher for composite fillings. Price differences were 	
generally highest for two	- and three	-surface fillings. For the clinic where the price 	
charged f	or amalgam and composite fillings was the same, it was 	however 	mentioned 	
that the clinic typically added a surcharge when extra time was required to place a 
filling. 	 	
According to Cowi (2008) t	he higher prices for composite fillings are mainly 	due to the 	
fact that 	today’s composite fillings	 must be prepared in a sequence of thinner 	
applications with intermediate curing of the	 polymer resin. Future technology 	
improvements may possibly reduce the labour intensity of	 composite fillings. In 	states 	
with generall	y lower labour 	cost	 levels than 	Western European countries	, the price 	
differences between preparation of amalgam and composite	 fillings may be lower than 	
in the cited examples.	 	
Cowi (2008) presents a hypothetical mean price increase 	when shifting from amal	gam 	
to composite fillings 	based on Danish data from 2004 	of	 NOK 	312 	(€ 39	) mainly due to 	
extra 	work 	time needed for the filling	. Considering the scarce data it appears reasonable 	
according to Cowi (2008) 	to assume a large range of 	NOK 91 (€	 11) 	to 	NOK 638 (€ 8	0) 	
extra	 price	 per average filling	, with an average extra 	price o	f NOK 3	65 (€ 46)	. The	 	
calculated estimate 	in this review 	for a cost increase for a three	-surface filling	 and the 	
data from SFT (2006) for one and two surface fillings are	 rater close to this	 calculated

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	36	 	
mean price	 increase	, which is a good indication 	of the	 accuracy 	given that wage costs are 	
rather similar in Denmark and Norway. 	Thus, we apply the average of 	these Norwegian 	
estimates to get an average cost increase of 	NOK 	300	 (€ 3	8) per filling and some NOK 	
300,000	 (€ 	37,500	) per kg mercury	 removed. 	 	
Anothe	r potential cost for patients could be more frequent replacement of fillings, since 	
composite fillings do not seem to last as long as	 amalgam fillings. Even though the 	
duration of the alternative materials 	is increasing, they still will 	have shorter lifeti	me 	
than	 amalgam filling	s for 	many	 years. 	In cases when 	an 	alternative filling is replacing an 	
amalgam filling it will last shorter than when treating new caries with an alternative 
filling.	 We assume	 that 	people 	who otherwise would have chosen amalgam fill	ings 	in 	
general will have to replace their fillings 	at least 	once	 during their lifetime compared to 	
if they had used amalgam fillings.	 Taking the average prices for one	-, two	- and three	-	
surface fillings	 (which may underestimate these costs since two	- and t	hree	-surface 	
fillings are most common)	 from the county dentists	’ price	 lists in Akershus and Troms	 	
counties gives 	extra costs 	of 	some 	NOK 	825	 (€ 	10	3)/filling	. 	
5.4.1	 Summary 	of 	costs of phasing out 	dental 	amalgam use	 	
Table 5.4 summari	zes the 	costs 	calculated	. 	
Table 	5.4 	Costs of phasing out the use of 	dental 	amalgam	 in new fillings. NOK 	
(€).	 	
 	Low	 (no extra time)	 	Medium 	 (+15 min)	 	High	 (+ 30 min)	 	
Total extra costs/filling 	 	NOK 67 (€ 8.5)	 	NOK 300 (€ 38)	 	NOK 533 (€ 67)	 	
Total costs/kg mercury	 	
NOK 	67,000	 	
(€ 	8,3	75)	 	
NOK 	300,000	 	
(€ 	37,500	) 	
NOK 	533,00	0 	
(€ 	66,625	) 	
Source: Vista Analysis	 	
The costs vary 	according to the extra time spent on composite fillings in dental clinics 	
compared to amalgam fillings. The low alternative 	represents	 a situation where there is 	
no extra time, the medium alternative is when approximately 15 minutes extra time is 
spent, an	d the high alternative is when 	the extra time is half an hour. However, the costs 	
presented may 	underestimate the total costs of phasing out	 dental	 amalgam since they 	
do not include more frequent replacement of fillings because of shorter lifetime of 
compo	site fillings compared to amalgam fillings. 	This could give extra costs of some NOK 	
825 (€ 103)/filling.	 	
Due to lack of data 	about 	the number of fillings 	it is impossible to estimate total costs for 	
Norway from the phasing out of 	dental 	amalgam use. 	Beside	s, 	most	 of the substitution 	of 	
dental amalgam	 took 	place	 before the 	mercury 	ban	 was 	introduced	. 	
5.5	 	Crematoria	 abatement costs	 	
5.5.1	 Mercury emissions are 	assumed to be	 some	 5 g/cremation	 	
The mercury content in the cremated 	bodies	 and thus the emissions to air fr	om the 	
crematoria 	before 	any abatement actions	 is a key variable to assess the 	impacts of

Review of Norwegian experiences with the phase	-out of dental 	amalgam use	 	
Vista Analysis AS	 	37	 	
abatement measures	. In Norway	 5 g/cremation is used as an estimate for the mercury 	
content in the 	deceased	 (SSB, 2001).	 	
This emission factor	 could be somewhat high 	compared to a factor of 3 g/cremation 	
used in UK (Defra, 2003). They refer to some test cremations, where the emissions 
varied widely but the average emission was as low as 0.9 g/cremation. However, the 
study also shows that the emission factor has been st	eadily increasing over the years, 	
and is likely to increase further. 	 	
According to Defra (2003) the population could be 	divided into	 roughly the following 	
three cohorts:	 	
 	The very old with no teeth	 	
 	Those with heavily restored teeth	 	
 	The fluoride generation	 	
Defra (2003) refers to a study from	 the Netherlands 	predicting	 a doubling of mercury 	
emissions from crematoria from 1995 to 2020. The reason for 	this	 is the decreasing 	
number of older people with no teeth	 and increasing number people with large fillings	. 	
The study also reports a 	decline	 in the number of fillings in young	 people, but makes no 	
prediction about when 	this will	 affect mercury	 emissions 	from	 crematoria.	 	
Using the	 data	 referred	 above 	and information on the number of 	deaths	 in dif	ferent age 	
groups,	 Hogland (1994) calculated	 that mercury emissions from crematoria in Sweden 	
(before abatement) 	will increase from 177 kilograms a year in 1985 to 602 kg/year in 	
2020, following by a decrease to 570 in 2025.	 	
A similar development could be expected in Norway	 and other countries that have 	
experienced the same development in dental treatment	 and 	dental 	amalgam use	. 	
However, it is not clear to what extent the 	increased 	use of other filling materials than 	
dental 	amalgam 	might 	influence this development, since man	y of the ”middle 	
generation” will have their numerous	 amalgam fillings replaced with other materials. 	
This 	underlines the importance of mercury abatement requirements for 	crematoria 	
since mercury emissions 	will 	likely be a problem for many years to come.	 	
5.5.2	 The regulations have speeded up the restructuring of the crematoria	 	
Regulation	 of me	rcury 	and other 	emissions 	to air 	from crematoria	 came into effect	 in 	
2007	 in Norway	. The 	regulation separates the 	crematories in two categories; category I 	
with 	more	 	than 20	0 cremations/year, and category II with 	less	 	than 200 	
cremations/year. 	 	
Both categories 	face	 limits 	for concentrations	 in the flue gas of total dust 	and carbon 	
monoxide	 (CO)	, but only category I crematoria have limits regarding mercury 	
concentration	 and 	mu	st install 	mercury filters	 or similar 	to comply with this 	
requirement	. In many cases some extension or reconstruction of the buildings will be 	
necessary for installing flue gas cleaning.

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Vista Analysis AS	 	38	 	
Also, category I crematoria should each year ensure that control moni	toring of the 	
emissions is carried out by an independent monitoring institution, and report emission 
data etc. to the pollution authorities. For category II crematoria similar requirements 
apply 	every	 second year. 	 	
In 2002	 	there were 	35	 	crematoria in Nor	way	 	in operation according to 	
Kirkegårdsforeningen (2010)	. Several of these 	have been	 closed down and replaced by 	
new, larger crematoria	, and 	by the end of	 2010 there were 24 crematoria in operation 	
(Kirkegårdsforeningen, 2011)	. All 	building 	investments, b	oth in new or existing 	
buildings	 vary between the crematoria.	 Not all crematoria have 	completed their 	
investments 	by 	November	 2011	. 	
The emis	sion regulations speeded up the	 change in the crematoria structure	, and some 	
crematoria were closed before th	eir technical and/or economic	 lifetime	, see for instance 	
Gann	 & Rødahl Lie (2009)	. This imposes an implicit cost to the society	. On the other 	
hand	, the new crematoria also create benefits in reduced operating costs, 	mostly	 	
reduced labour costs (Gann	 & Røda	hl Lie, 2009). These costs and benefit	s are	 not 	
considered here. We only focus on those crematoria that have 	or are in the process of 	
installing 	cleaning devises to comply with the mercury regulations. Furthermore, we do 	
not take into account the impacts t	hese devises might have on	 emissions on other 	
pollutants, notably that mercury filters also remove dioxins. 	 	
5.5.3	 M	ercury abatement filter costs	 are relatively low	 	
To fulfill the emission limits for CO	, total dust and mercury	, the	 crematoria	 often	 needs	 	
to 	make the	 following investments:	 	
 	CO 	emission limits	 may require a new cremator (oven), 	 	
 	The total dust 	emission limits	 may 	require flue gas cooling and cleaning	 	
 	The mercury 	emission limits	 require a filter system	 in addition	 to the flue gas 	
cooling	, using a	ctive coal. 	 	
Total investment cost for all 	the above equipment	 today is around NOK 6 million	 (€ 0.75 	
million)	, and would 	likely 	be 	a necessary 	investment	 for a new crematorium	. Of this 	
around 50 percent are for the cremator (oven), and the flue gas cooling 	and dust 	
cleaning 	constitutes some 	35 percent of the investment	 (NOK 2.1 million	 (€ 0.25 	
mi	llion	)). Then the investment costs for the mercury 	filter	 constitutes some 1	5 percent 	
of the investment, or	 NOK 0.9 million	 (€ 0.1 million)	. 	
The latter is the marginal investment for Norwegian crematoria to comply with the 
mercury regulations, and thus th	e 	cost 	relevant to consider 	when mercury abatement 	
costs are calculated	 for Norway	. 	
The cleaning efficiency for mercury 	is 96	-99 pe	rcent according to the supplier	 of the 	
equipment. We use an average of 97.5 percent efficiency, implying that some 4.875 gr	am 	
mercury per cremation is removed by the filters.	 	
Thus, the investment costs 	for the flue gas cleaning 	would be more or less the same for 	
most Norwegian cremators in question, who most	ly have between 200 and some 1	,100 	
cremations per 	year.

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Vista Analysis AS	 	39	 	
Operating cos	ts 	for a mercury filter 	mainly consists of the purchase of coal and the costs 	
of depositing the used coal as hazardous waste. 	Coal 	purchase and deposit costs seem	 to 	
be around NOK 12	 (€ 1.5)	/cremation. 	Also some 	small	 amounts of energy (electricity) 	
are n	eede	d to operate the filter system.	 Service and maintenance costs are 	considered to 	
be 	low. 	We 	estimate	 that these operating costs all together are NOK 15	 (€ 2)	/cremation. 	 	
The annual monitoring and certification costs 	for mercury cleaning operation 	are 	
ar	ound NOK 	40	,000	 (€ 5,000)	/crematorium	. These costs 	covers	 hiring the certified 	
monitoring 	company	, reporting to the environmental authorities, inspection etc. 	 	
Table 	5.5 	Mercury a	batement costs 	for crematoria	. NOK and €. 	 	
 	NOK 	 	(€)	 	
Investment costs	 	900,000 	 (€ 112,500)	 	
Annual monitoring costs	 	40,	000 	 (€ 5,000)	 	
Total annualized fixed costs	 	106	,240 (€ 	12,655)	 	
Average fixed costs per cremation	 	127	 	(€ 15)	 	
Operating costs per cremation	 	15	 	 (€ 2)	 	
Total costs per cremation	 	142	 	(€ 18)	 	
Total abatement costs per kilo mercury	 	29,170	 (€ 3,	48	5) 	 	
Source: Vista Analysis	 	
Extending the lifetime to 30 years reduces the specific costs	 for mercury filter only	 to 	
some NOK 25	,700 	(€ 	3,210)	/kg mercury. 	Likewise	, reducing 	the discount rate to	 3 	
percent 	only 	reduces the costs to some NOK 	27,	800 	(€ 3,470)	/kg mercury	. This shows 	
that the choice of discount rate and lifetime only have marginal impacts on the cost 
calculations. 	 	
5.5.4	 Abatement co	sts could be higher when no other regulations are in 	
place	 	
As mentioned the calculated	 abatement costs are relevant 	for Norway and other 	
countries where	 crematoria have to comply 	with	 mercury 	regulations 	in addition to	 	
regulations on dust and CO. In a coun	try where there are	 no other regulations	 on air 	
emissions	, the costs of all the other equipment and eventually a new cremator and 	
building restructuring would have to be included as well. 	In this case approximately 	
NOK 3 million 	(€ 0.38 million) 	has to be invested 	in total flue gas abatement equipment	. 	
For 	new crematoria this 	constitute	s total 	abatement investment costs. 	 	
When	 rebuilding an existing crematorium to give room for the cleaning devices, some 	
additional 	NOK 	3 million 	(€ 0.38 million) 	in buil	ding works seem to have been an	 	
average investment, making the total investment 	equal 	to 	approximately 	NOK 6 million	 	
(€ 0.75 million)	.

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Vista Analysis AS	 	40	 	
5.5.5	 Danish	 cost estimates are rather similar	 to 	the above	 findings	 	
Costs for installation and maint	enance of mercury and du	st 	retention 	filter for	 	
crematoria are 	presented	 in Cowi (2008)	 based on Danish examples.	 The examples 	
include	 the installation of bag filters with carbon injection, which 	according to Cowi 	
(2008) 	is deemed	 the most relevant technol	ogy, and adaption/extension of buildings to 	
house installations. 	Typical costs for filter installation were reported to be around 	NOK 	
3.6	 million 	(€0.45	 million) per filter serving one 	cremator	, plus on average 	NOK 	0.82	 	
million (€0.1 million) per installation for needed building adjustments/extensions 
(range 	NOK 	0.2	2 – 2 million	 (€ 0.03 	- 0.25 million)	). Maintenance costs were estimated 	
at 	roughly 	NOK 14 	- 22	 (€ 1.75 	– 2.75	) per cremation performed, including consumed 	
carbon and fees for disposal of used carbon as hazardous waste. 	This gives a cost per 	kg 	
mercury	 removed 	of some 	NOK 69,200	 (€ 8,650)	, which is 	at	 the same level as 	the	 	
estimate 	in this	 review 	for flue gas cleaning 	including mercury filter 	when no building 	
adjustments are necessary. 	 	
The bag filters also act as dust retention which is required in some countries. For 
crematoria which already have suitable bag filters installed and have 	room for extra 	
equipment, the addition of a carbon dispenser would involve only limited extra 
installation costs; around NOK 	10	9,000 (€	 13,	600), plus the same maintenance costs as 	
mentioned above (	Cowi,	 2008). 	This is much cheaper than 	the	 estimated costs 	in our 	
study, which amounts to 	NOK 	900,000	 (€ 	112,500	). 	
5.5.6	 Data from UK show 	rather similar	 abatement costs	 as in Norway	 	
Several 	studies from the UK have identified abatement costs for the removal of mercury 	
from crematoria. 	 	
Defra (2003) 	discusses the advantages and disadvantages of various end	-of-pipe options 	
for removing mercury from the 	flue	 gas. 	They recommend a dry sorbent/fil	ter system or 	
equivalent as the best available technique for removing mercury from crematoria 	flue	 	
gas, after the gas has been conditioned (i.e. cooled, captured and collected) together with 
a draught fan and stack. 	It is claimed that it is possible to hav	e one gas treatment plant 	
for two cremators	 (ovens)	, but for cremators with more than 978 cremations per year 	
one gas cleaning system per cremator seems necessary	. 	
Defra (2003)	 presents	 investment costs for existing crematoria 	at NOK 2 million	 (€ 0.25 	
million) 	for one 	flue 	gas cleaning 	plant	 (comparable to the NOK 3 million	 (€ 0.375 	
million)	 for 	flue 	gas cleaning	 in Norway)	, commissioning costs 	at 	NOK 113,	500 	(€ 	
14,190) 	and civil/building costs 	at 	NOK 850	,000 	(€ 106,250) 	per single 	flue 	gas cleaning 	
plan	t. The latter varies widely between plants, but all plants will have to do some 	
changes in existing buildings to enable the installation of the 	flue 	gas cleaning unit. 	In 	
addition Defra (2003) assumes an increase in operating costs due to the 	flue 	gas 	
clea	ning of some NOK 100 	(€ 13) 	per cremation and some average periodic monitoring 	
costs of NOK 	8,500	 (€ 1,065)	/year. 	Assuming 	a removal of 4.85 g mercury/cremation 	
gives 	total costs per cremation of some NOK 370 	(€ 46) 	and total abatement costs of 	
around 	NOK 76,	290	 (€ 9,535)	 per 	kg mercury removed	. 	
Bristol City (2010) estimate far higher costs to install 	flue	 gas cleaning devises in their 	
two old cremators. 	An investment cost of 	NOK 5.2 million (€ 0.65 million) 	for the 	flue 	
gas cleaning devise alone for each of the crematoria is	 estimated, in addition costs of

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Vista Analysis AS	 	41	 	
NOK 4.5 million	 (€ 0.56 million) 	to extend the building in one of the cremators is 	
assumed. This total investment of 	NOK 14.9	 million 	(€ 1.85 million) 	is compared with an 	
option to install three new cremators with mercury c	leaning equipment in one of the 	
existing crematoria to replace the existing ones at an estimated cost of 	NOK 15 million	 	
(€ 1.88 million)	. Using the	 same assumptions as above give	 cost	 of some 	NOK 	470	 (€ 59) 	
per cremation (3,000 cremations/year)	 and total a	batement costs of some 	NOK 97,	140	 	
(€ 12,145)	 per kg 	mercury removed	. 	 	
North Lincolnshire Council (2005)	 estimate costs 	in the region of	 NOK 5.9 million 	(€ 	
0.75 million) 	for the installation of a flue gas filter system, including 	NOK 1 million	 (€ 	
0.13 million)	 for civil works necessary to house the equipment. In addition increased 	
operating costs of some 	NOK 125 	(€ 15.5) 	per cremation 	are estimated. This gives 	total	 	
costs of 	some NOK 4	30	 (€ 54)	/cremation, 	(1	,450 cremations/year) 	or 	NOK 88,	700	 (€ 	
11,090)	 in total abatement costs	, which is also higher than in Defra (2003)	. 	
These 	abatement 	costs could be compared to the 	costs calculated from Norwegian data 	
where 	investments in 	total 	flue gas cleaning devises and building work are included, 	
which 	sh	ould be	 between	 NOK 	67	,480	 (€ 8,435)	 and 	NOK 	122	,000	 (€ 15,250)	 per kg 	
mercury removed	. It can be seen that all the abatement costs from UK are within this 	
range. 	 	
5.5.7	 Summary of t	otal abatement costs	 for crematoria	 	
Based on Norwegian data mercury abate	ment costs 	are presented in table 5.6.	 	
Table 	5.6 	Mercury abatement costs 	for crematoria 	based on Norwegian data. 	
NOK 	and 	€.	 	
 	Only mercury 
filter	 	
Filter plus flue gas 
cleaning & cooling	 	
Filter plus flue gas 
cle	aning & cooling + 	
building work	 	
Total 
costs/cremation	 	
142 (€ 18)	 	327 (€ 41)	 	592 (€ 74) 	 	
Total costs/	kg 	
mercury emissions 
reduced	 	
29,170 (€ 3,645)	 	67,	480 (€ 8,435)	 	122,	000 (€ 15,250)	 	
Source: Vista Analysis	 	
The total investment costs for Norway to fulfill	 the mercury emissions regulations for 	
crematoria could be estimated to some NOK 15 million, taking into account investments 
in mercury filters only. 	 	
The abatement costs 	in other countries 	would depend on what kind of air emission 	
regulations that 	are already in place, and what kind of building changes that would be 	
necessary to 	have enough space for the flue gas cleaning and cooling. The latter would 	
vary widely among sites, but the investment costs in abatement equipment should be 
rather similar a	cross countries.

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Vista Analysis AS	 	42	 	
5.6	 	Socioeconomic impact	s in Norway	 	
So far	 only the costs to society of the various abatement actions	 have been assessed	. 	
However, it is also of interest to assess who bear the costs and get the benefits from the 
emission reductions. It can a	lways be argued that the consumers either directly through 	
prices they face or indirectly as taxpayers pay for interventions to reduce pollution. But 
various groups of consumers could be disproportionately affected by the costs and the 
benefits. 	 	
The bene	fits from reduced mercury emissions generally affect all people in Norway and 	
to some extent also neighboring countries since these emissions are transboundary. 
Especially children and fetuses 	will	 benefit from reduced mercury 	exposure 	from 	the 	
environment	. Furthermore, dental clinic workers who have been exposed to dental 	
amalgam in their work environment also benefit. 	 	
In Norway the following categories of people have their dental treatment costs covered 
by the public budgets:	 	
 	Children and young 	people up till 18 years	 	
 	Mentally disabled in and outside institution	 	
 	Groups of seniors, long time ill and physically disabled people in institution and 
under home care	 	
The county municipalities are responsible for the public dental treatment. 	On a 	
voluntar	y basis 	they can offer wholly or partly subsidized dental care to 19 or 20 ye	ar 	
olds	, and other groups that they decide to prioritize	, and	 this 	varies somewhat between 	
counties	. The treatment is either carried out by the counties’ own 	dental 	treatment 	
pers	onnel or by private dental clinics	 that have an agreement	 with the county 	
municipality. 	 	
Other groups than those mentioned have to pay for the dental treatment in full. 	 	
Patients who 	used to have 	amalgam as a filling material 	have 	experience	d increased 	
costs when they get alternative filling materials	 instead	. Although the dental health of 	
the majority of the population is good	 there 	are	 great individual differences. Poor dental 	
health often affect	s weak groups in society who neglect treatment on account 	of the high 	
costs. For some major restoration work, the alternative to relatively inexpensive	 	
amalgam fillings 	is expensive treatment in the form of crowns.

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Vista Analysis AS	 	43	 	
6 	Conclusion	s 	
In this section we present some conclusions based on the data and discussions 
presen	ted in section 4 and 5.	 	
6.1	 	The experiences with the 	alternative	 materials are 	generally 	positive	 	
The 	interview	 performed among dentists for this report, as well as earlier assessments 	
by others show that dental personnel	 and patients generally are satisfied w	ith the 	
alternative 	materials. The most common material used now is 	resin	-based composites, 	
but various glass ionomers and ceramic	-based materials are also used to some extent. 	
Most dentists gradually started to use these materials. Thus, the necessary tec	hnical 	
equipment and basic skills among the personnel have been established over long time. 	 	
The main advantages with the 	alternative 	materials 	are that the materials have good 	
adhesive	 properties, implying that removing of less amounts of the 	sound 	tooth	 	
substance	 is necessary compared to when using amalgam. Therefore, it sometimes 	
takes less time to use the alternative materials in small fillings. Larger fillings are 
somewhat more time	-consuming than when using amalgam, from 15	-45 minutes more 	
is claime	d, depending on the dentist’s skill and the complexity of the filling. 	For this 	
economic assessment 	we 	have used 15	-30 minutes	 in the calculations	. 	
A disadvantage is that the 	alternative 	materials can be challenging	 to use	, especially for 	
larger fillin	gs	. Another disadvantage is that bacteria are more easily formed 	on the 	
surface of 	the filling, thus requiring somewhat more follow up both 	from 	the patient and 	
the dentist. Because of this and less “chewing	-strength” the composite fillings do not yet 	
last	 as long as the amalgam fillings (some say half the lifetime of amalgam fillings), but 	
most dentists claim that the 	longevity	 is increasing and approaching the 	longevity	 of 	
amalgam fillings. A few respondents claim that at least the small fillings already 	last as 	
long as amalgam fillings. 	An important advantage	 for dental person	nel’s health	 is 	that 	
amalgam in not used	 in the working environment.	 However, monomers from resin 	
based materials 	may 	pose an occupational risk.	 	
6.2	 	Total abatement costs	 for mercury fro	m 	dental 	amalgam use	 	
Estimated abatement costs for the various interventions 	performed for this study 	are 	
summarized 	in table 6.1	. Total costs for a dental amalgam separator in table 6.1 are the 	
assumed historic costs of installing and operating the devis	e (Low alternative) and the 	
calculated current costs (High alternative), and the Medium alternative is simply an 
average of these. The three alternatives for the costs of phasing out dental amalgam use 
are based on the assumptions of no extra time used by 	dentists when applying 	
alternative materials (Low), 15 minutes more time (Medium) and 30 minutes more time 
(High). The abatement costs for emission reductions from crematoria are developed 
from a situation when only a mercury filter is needed (Low), a filt	er plus flue gas 	
cleaning & cooling is installed (Medium) and when in addition building work is needed 
(High).

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Vista Analysis AS	 	44	 	
Table 	6.1 	Total abatement costs for mercury from dental amalgam use. NOK 
and €/kg mercury em	issions reduced. 	 	
 	Low	 cost	 	Medium	 cost	 	High	 cost	 	
Dental amalgam separator	 	8,010 	 	
(€ 1,000)	 	
10,190 	 	
(€ 1,275)	 	
12,370 	 	
(€ 1,545)	 	
Phasing out use of dental 
amalgam in new fillings	 	
67,000	 	
(€ 	8,375	) 	
300,000	 	
(€ 	37,500	) 	
533,000	 	
(€ 	66,625	) 	
Emission reduc	tions from 	
crematoria	 	
29,170 	 	
(€ 3,645)	 	
67,480 	 	
(€ 8,435)	 	
122,000 	 	
(€ 15,250)	 	
Source: Vista Analysis	 	
Table 6.1 shows that the abatement 	“end	-of-pipe”	 measures aiming at reducing 	
emissions from dental clinics and crematoria are generally much lower than	 the 	
abatement costs related to phasing out the use of amalgam in tooth fillings. 
Furthermore, 	the 	presented 	costs underestimate the total costs of phasing out dental 	
amalgam since they do not include more frequent replacement of fillings because of 
shorte	r lifetime of composite fillings compared to amalgam fillings. 	 	
However, the costs of phasing out dental amalgam are zero for 	those who	 voluntarily 	
have 	switched from this material to 	resin	-based composites for various reasons	 before 	
the ban on mercury	-con	taining products was introduced	. Thus, one should be very 	
careful when comparing the cost figures in table 	6.1	. 	 	
Over time, costs 	for phasing out use of dental amalgam 	will 	likely 	converge towards the 	
low alternative 	in table 6.1 	as new 	dentists who are 	trained from school in using 	
composites 	gradually 	enter 	the work	 force	. Also, 	composite fillings will likely last longer 	
in the future	. so that these costs also will go down.	 Furthermore, in the long run	 	
amalgam separators and mercury	 emission cleaning in 	crematoria will no longer be 	
necessary when all dental amalgam is phased out. 	 	
The abatement cost estimates are at the same level as those calculated in Cowi (2008). 
Cowi	 estimate	d the abatement costs of 	dental 	amalgam 	separator	s to be in the range of 	
€1	,400	-1,800 per kg 	mercury	 release reduction, the costs of	 phasing out the use of 	
dental amalgam	 to be in the range of €11,000	-78,000 per kg 	mercury	 use reduction and 	
the costs of emission reductions from crematoria	 at €17,000 per kg 	mercury	 release 	
reducti	on. It can be seen that 	the	 estimated range 	in table 6.1 	for the cost of 	dental 	
amalgam 	separator	s are somewhat lower than Cowi’s, while 	the	 dental amalgam phase	-	
out cost are very similar 	to (but a little lower than) 	Cowi’s. 	The	 high cost alternative for	 	
crematoria 	in table 6.1 	is about the same as	 Cowi’s, which is likely due to the fact that we 	
in this alternative 	have included 	full air emission abatement investments and some	 	
building work. 	 	
6.3	 	Dental amalgam phase	-out should be seen in a 	broa	der	 perspecti	ve	 	
Assessing the various interventions purely from an abatement cost comparison could 
easily lead to the conclusion that dental amalgam separation/collection and abatement 
of emissions from crematoria should be required	, and that the 	choice 	of filling mate	rials 	
should be left to the dentist and patient.

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Vista Analysis AS	 	45	 	
Since the 	overall, long term goal 	globally 	is to eliminate the use and release of mercury 	
to the environment, the use of mercury has to be addressed. Therefore, the use of dental 
amalgam should be phased ou	t, and at the same time the actions towards the release of 	
mercury from existing tooth fillings have to be implemented. When there in the future is 
no mercury left in tooth fillings there will be no need for dental amalgam 
separation/collection and abateme	nt of 	emissions from crematoria anymore	. 	 	 	
6.4	 	Comparisons across countries using Purchasing Power Parities (PPP)	 	
Purchasing Power Parities (PPPs) are currency conversion rates that both convert to a 
common currency and equali	ze the pu	rchasing power of different currencies. In other 	
words, they eliminate the differences in price levels between countries in the process of 
conversion. 	Because market exchange rates are based on short	-term factors and are 	
subject to substantial distortions 	from speculative movements and government 	
interventions, comparisons based on exchange rates, even when averaged over a period 
of time such as a year, 	may 	yield unreliable and misleading results. By establishing 	
purchasing power equivalence, where	 usually	 one dollar 	enables purchase of	 the same 	
quantity of goods and services in all countries, PPP conversions allow cross	-country 	
comparisons of economic aggregates on the basis of physical levels of output, free of 
price and exchange rate distortions.	 	
In their	 simplest form 	PPP	 show the ratio of prices in national currencies of the same 	
precisely	-defined product in different countries	 (WB, 2011)	. For example, if the price of 	
one	 kilo of oranges of a specified quality is 45 rupees in country A and 3 dollars in 	
country B, the PPP for such oranges between the two countries, when B is the base 
country, is the ratio 45 to 3 or 15 rupees to the dollar. In other words, for every dollar 
spent on oranges of the specified quality in country B, 15 rupees would have to be s	pent 	
in country A to obtain the same quantity and quality of oranges.	 	
We have used PPP conversion factors from the 	United Nations Statistical Division (UN, 	
2011)	 from 2009 for some selected countries to illustrate what the abatement costs 	
would be in their	 local currencies. The results are presented 	in table 6.2	. For all 	
countries except Canada this led to lower costs than when using official exchange rates, 
implying that the local price levels are lower than reflected in the exchange rates. 	 	
Table 	6.2 	Mercury abatement costs in some selected countries based on 
purchasing power parities. Local currencies/kg mercury emissions 
avoided.	 	
 
 Brazil (Real, BRL)	Low	Medium 	High	
Amalgam collector	1 430	 	 	1 819	 	 	2 208	 	 	
Phasing out amalgam use	14 385	 	 	64 962	 	 	115 320	 	 	
Emission reductions from crematoria	5 207	 	 	12 045	 	 	21 777	 	 Canada (Dollar, CAD)	Low	Medium 	High	
Amalgam collector	1 095	 	 	1 393	 	 	1 692	 	 	
Phasing out amalgam use	11 020	 	 	49 766	 	 	88 344	 	 	
Emission reductions from crematoria	3 989	 	 	9 227	 	 	16 683

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Vista Analysis AS	 	46	 	
 
 
 
 	
Source: Vista Analysis 	 	
 
 Chile (Peso, CLP)	Low	Medium 	High	
Amalgam collector	311 035	 	 	395 687	 	 	480 338	 	 	
Phasing out amalgam use	3 129 382	 	14 132 117 	25 087 090 	
Emission reductions from crematoria	1 132 697	 	2 620 309	 	4 737 370	 China (Renminbi, CNY) 	Low	Medium 	High	
Amalgam collector	3 478	 	 	4 425	 	 	5 372	 	 	
Phasing out amalgam use	34 995	 	 	158 037	 	 	280 544	 	 	
Emission reductions from crematoria	12 667	 	 	29 302	 	 	52 977	 	 India (Rupee, INR)	Low	Medium 	High	
Amalgam collector	16 053	 	 	20 423	 	 	24 792	 	 	
Phasing out amalgam use	161 516	 	 	729 400	 	 	1 294 818	 	
Emission reductions from crematoria	58 462	 	 	135 242	 	 	244 509	 	 Peru (Sol, PEN)	Low	Medium 	High	
Amalgam collector	1 421	 	 	1 808	 	 	2 195	 	 	
Phasing out amalgam use	14 301	 	 	64 582	 	 	114 645	 	 	
Emission reductions from crematoria	5 176	 	 	11 975	 	 	21 649

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Metadata Found
Author
Ingeborg Rasmussen
CreationDate
2012-05-29T11:37:13+02:00
ModDate
2012-05-29T11:37:13+02:00
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Microsoft® Word 2010
Pages
50