Dentistry and Sustainability

Fiona Collins BDS, MBA, MA, FPFA

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Dentistry and Sustainability

As the world population has grown,1Worldometer. Current World Population. Available at: https://www.worldometers.info/world-population/. demands on natural resources and our planet have increased exponentially and unsustainably. While we are currently dealing with a disastrous coronavirus pandemic and pressing needs, in the long-term sustainability and health promotion will need to be increased and a continued focus. As defined by the United Nations World Commission on Environment and Development, sustainability refers to ‘development that meets the needs of the present without compromising the ability of future generations to meet their own needs.’2United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the 80 General Assembly on 25 September 2015. A/RES/70/1. General Assembly, Agenda items 15 and 116, 81 2015. Available at: http://unctad.org/meetings/en/SessionalDocuments/ares70d1_en.pdf The Environmental Protection Agency includes the creation and maintenance of conditions ‘under which humans and nature can exist in productive harmony’ in its definition.3Environmental Protection Agency. Learn About Sustainability. Available at: https://www.epa.gov/sustainability/learn-about-sustainability#what.

The World Dental Federation (FDI) notes that sustainability includes the promotion of global oral health and oral disease prevention, while also reducing the impact of dentistry on natural resources and the environment.4World Dental Federation. Policy Paper. Sustainability in dentistry. Int Dent J 2018;68:10-11. Available at: https://www.fdiworlddental.org/resources/policy-statements-and-resolutions/sustainability-in-dentistry. The FDI further addresses sustainability in the context of stakeholders, including oral health professionals, manufacturers, distributors, and ancillary/associated dental services. National dental organizations also support sustainability.4World Dental Federation. Policy Paper. Sustainability in dentistry. Int Dent J 2018;68:10-11. Available at: https://www.fdiworlddental.org/resources/policy-statements-and-resolutions/sustainability-in-dentistry.,5Australian Dental Association. Policy Statement 6.21 – Dentistry and Sustainability. Available at: https://www.ada.org.au/Dental-Professionals/Policies/Dental-Practice/6-21-Dentistry-and-Sustainability/ADAPolicies_6-21_DentistryandSustainability_V1. Conservation of natural resources; prescribing stewardship; environmentally-friendly production, use and re-use of products for optimal, effective and safe oral care; waste management and recycling all play a role in sustainability. (Table 1) This paper highlights some aspects of sustainability that are measurable, reachable and doable.

Table 1. Factors in sustainability in dentistry
Conservation of natural resources
Prescribing stewardship
Environmentally-friendly production
Use and re-use of products for optimal, effective and safe oral care
Waste management and recycling

Conserving Water

Droughts, burgeoning populations and water shortages highlight the need for water conservation, which involves minimizing the use of water and reducing wastewater. A number of initiatives in the dental office and at home can conserve water, including simple steps such as checking for leaky faucets which result in an estimated 10,000 gallons of water being wasted annually by an average American household.6United States Environmental Protection Agency. Water Sense. Available at: https://www.epa.gov/watersense. (Figure 1) Leaky faucets and running toilet tanks should be repaired. In addition, leaving faucets running while performing hand washing or when brushing your teeth results in significant waste. The flow rate of a standard faucet is 2.2 gallons/minute.7United States Environmental Protection Agency. Water Sense. Bathroom Faucets. Available at: https://www.epa.gov/watersense/bathroom-faucets. As such, twice-daily brushing for 2 minutes with the faucet running would waste 8.8 gallons/day per person. (Figure 2) Although faucets are available that reduce water flow by 30%, that would still equate to almost 6 wasted gallons/day per person. Campaigns help to educate patients on water conservation, including turning off the faucet while performing oral hygiene.8Colgate. Save Water. Available at: www.colgate.com/savewater Dental professionals can help by educating patients on this easy way to conserve water. According to one survey, global messaging started in 2016 on turning off the faucet while brushing had resulted in 53 billion gallons of water saved by 2018.8Colgate. Save Water. Available at: www.colgate.com/savewater Automated faucets with motion sensors that control water flow from the faucet can also be used. Providing smaller (and biodegradable) cups with less water for rinsing also reduces water consumption and drinking potable tap water rather than bottled water may reduce water consumption, wasted water and plastic waste.

In addition, when hands are not visibly soiled, routine hand hygiene can be performed using alcohol-based handrubs containing 60% to 95% alcohol instead of soap and water.9Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings – 2003. MMWR 2003;52(No. RR-17):1-66. Available at: https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdfCdc-pdf. This has the added benefit of resulting in less loss of epidermal moisture than hand washing.10Boyce JM. Using alcohol for hand antisepsis: dispelling old myths. Infect Control Hosp Epidemiol 2000;21(7):438-41. Using a dry (waterless) vacuum pump is reported to preserve up to 360 gallons/day.11DeMello MC, Clancy RM, McMillan J, McMillan R, Henry K, Bommhardt C et al. Going.going.going.gone green. Making your dental practice environmentally friendly. J Mass Dent Soc 2010;59:29-32. Further, the above measures conserve energy by reducing requirements for wastewater management (pumping, aeration and filtration).12Avon Water. Conservation. Wastewater. Available at: https://www.avonwater.com/conservation.

By 2018, global messaging started in 2016 on turning off the faucet while brushing had resulted in 53 billion gallons of water saved.

Conserving Energy

Significant amounts of energy are consumed in the course of providing dental care. A recent study calculated the energy usage of a range of devices used in the dental office, based on the amount of time they were anticipated to be in use daily for 190 days.13Duane B, Harford S, Steinbach I, Stancliffe R, Swan J, Lomax R et al. Environmentally sustainable dentistry: energy use within the dental practice. Br Dent J 2019;226(5):367-73. For devices such as printers, amalgamators, curing lights, X-ray machines negligible amounts of electricity were consumed (0 to 0.02kWh/day). Between 0.30 and 0.8 kWh/day was consumed using a dental chair, computer monitor, ultrasonic cleaner and desktop computer. (Figure 3) The most energy was consumed by instrument washer-disinfectors, air conditioners and autoclaves based on anticipated usage. (Figure 4) The desirability of energy-efficient devices is clear, and right-sizing your choice of required instrument reprocessing devices based on volume and anticipated need can help to conserve energy. Further, only running devices such as instrument washers and autoclaves with full loads (without overloading the device) helps to reduce the number of uses, conserving both water and energy.

Figure 3. Lower-energy use devices based on anticipated use


Figure 4. Higher-energy use devices based on anticipated use

Running devices such as instrument washers and autoclaves with full loads helps to reduce the number of uses, conserving both water and energy.

For other devices, a number of tactics help to conserve energy. Examples include turning off lights, computers and other devices when not being used; using low-energy bulbs;14Lux C. Sustainability: Dentists Urged To Reduce Carbon Footprint, February 3, 2020. Available at: https://blueandgreentomorrow.com/environment/environmental-waste-and-sustainability-within-dental-practice/. and, using motion sensors for lighting.13Duane B, Harford S, Steinbach I, Stancliffe R, Swan J, Lomax R et al. Environmentally sustainable dentistry: energy use within the dental practice. Br Dent J 2019;226(5):367-73. In addition, using thermostats and timers, increasing/decreasing the temperature slightly to conserve energy, weather-proofing the area (e.g., removing draughts), and efficient use of space further contribute to energy conservation.15Duane B, Harford S, Ramasubbu D, Stancliffe R, Pasdeki-Clewer E, Lomax R, Steinbach I. Environmentally sustainable dentistry: a brief introduction to sustainable concepts within the dental practice. Br Dent J 2019;226(4):292-95.16Laycock A. Unprecedented ways dental offices are prioritizing the environment, January 2020. Available at: https://blueandgreentomorrow.com/environment/unprecedented-ways-dental-offices-are-prioritizing-environment/ (Table 2)

Table 2. Tactics to conserve energy in the dental office
Energy-efficient devices
Right-size reprocessing devices based on volume, anticipated need
Run devices such as instrument washers and autoclaves with full loads
Turn off lights and devices when not in use
Use thermostats and timers, adjust temperature
Weather-proofing
Efficient use of space

Managing Materials and Waste

Figure 5. Opportunities for waste reduction

Multiple waste streams exist in the dental setting, including general trash, regulated medical waste, hazardous waste and pharmaceutical waste. Regulated waste streams must be segregated and handled in accordance with Federal, State and local regulations. In addition, some single-use devices are required by law, or recommended by guidelines and considered best practices for the health and safety of patients, staff and the community9Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings – 2003. MMWR 2003;52(No. RR-17):1-66. Available at: https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdfCdc-pdf.. However, there are other opportunities to reduce waste by using digital technologies, through prescribing stewardship, water conservation, reducing use of packaging within the dental office and by patients, purchasing reusable products and those with a reduced and improved environmental footprint, and, where possible, through recycling. (Figure 5)

Digital technologies

Digital technologies have caused a paradigm shift in dentistry. Digital radiography removes the need to use traditional X-ray film which is single-use and contains lead that must be segregated for recycling. While sensors and PSP are required for digital radiography, these can be used many times. In addition, no developer or fixer is required which further reduces hazardous waste, nor is physical archiving of X-rays required. Electronic dental records (EDR) remove the need for physical paper records, conserving raw materials and reducing potential waste. EDR also offer potential for improved and better-coordinated care.17Bhardwaj A, Ramoni R, Kalenderian E, Neumann A, Hebballi NB, White JM, McClellan L, Walji MF. Measuring up: Implementing a dental quality measure in the electronic health record context. J Am Dent Assoc 2016;147(1):35-40. doi: 10.1016/j.adaj.2015.06.023.,18St. Sauver JL, Carr AB, Yawn BP, Grossardt BR, Bock-Goodner CM, Klein LL, Pankratz JJ, Finney Rutten LJ, Rocca WA. Linking medical and dental health record data: a partnership with the Rochester Epidemiology Project. BMJ Open 2017;7:e012528. Further, EDR provide an opportunity to mine data for best practices and protocols for oral health and oral care in a real-life setting, in itself a sustainability activity.19Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63. In addition, teledentistry enables consultations without difficult/unnecessary travel,20Scuffham PA, Steed M. An economic evaluation of the Highlands and Islands teledentistry project. J Telemed Telecare 2002;8:165-77. and as we are now seeing can be helpful during a pandemic in reducing risk of disease transmission. Other digital technologies include scanning and CAD/CAM, which reduce consumable waste. In particular, 3D printing is improving, becoming less expensive and since it uses an additive layering process there is minimal waste of raw materials. However, it should be noted that CAD/CAM devices themselves require raw materials and use of energy and water during their production.

Prescribing stewardship

Prescribing stewardship helps to ensure only indicated and necessary prescriptions are written, as well as optimized doses.21Drekonja DM, Filice GA, Greer N, Olson A, MacDonald R, Rutks I, Wilt TJ. Antimicrobial stewardship in outpatient settings: a systematic review. Inf Control & Hosp Epidemiol 2015;36:142-52.,22American Dental Association announces new policy to combat opioid epidemic. Policy supports mandates on opioid prescribing and continuing education. March 26, 2018. Available at: https://www.ada.org/en/press-room/news-releases/2018-archives/march/american-dental-association-announces-new-policy-tocombat-opioid-epidemic This reduces the potential for addiction to opioid analgesics and in the case of antibiotics helps to preserve the antibacterial efficacy of medications, combats antibiotic resistance and reduces the disposal of pharmaceutical waste.

Elimination, recycling and packaging

Judicious selection of products and recycling conserves water, energy, materials and helps the environment. Recyclables include paper, some plastics, metals, glass and non-rechargeable batteries, depending on local recycling companies and municipalities. Using rechargeable batteries is preferable. If printing is necessary, recycled paper can be used for draft quality double-sided printing (which reduces use of ink by 50% and saves paper).23Pithon MM, de Faria LCM, Tanaka OM, de Oliveira Ruellas AC, de Souza Guimarães Primo LS. Sustainability in Orthodontics: what can we do to save our planet? Dental Press J Orthod 2017;22(4):113-7. doi: 10.1590/2177-6709.22.4.113-117.sar Toner cartridges can be refilled or recycled and used paper can be recycled. While patients have traditionally received plastic ‘goody bags’ containing product samples, this comes at a cost to the environment. One recommendation is to eliminate goody bags,16Laycock A. Unprecedented ways dental offices are prioritizing the environment, January 2020. Available at: https://blueandgreentomorrow.com/environment/unprecedented-ways-dental-offices-are-prioritizing-environment/ whether provided by companies or assembled in the office. Companies are supporting sustainability and recycling efforts.24Duane B, Ramasubbu D, Harford S, Steinbach I, Stancliffe R, Croasdale K, Pasdeki-Clewer E. Environmental sustainability and procurement: purchasing products for the dental setting. Br Dent J 2019; 226(6):453-8.

Judicious selection of products and recycling conserves water, energy, materials and the environment.

Packaging is challenging for consumer goods, including oral care products. Recent innovations have included redesigning packaging to reduce its volume, removing PVC from packaging, collaboration with recycling companies, and recyclable products.25Sustainability. Building a Future to Smile About. Available at: https://www.colgatepalmolive.com/en-us/core-values/sustainability. A recyclable toothpaste tube manufactured from high-density polyethylenes has been launched, and refillable skin care packaging is being tested.26Guzman F, Ries B. Colgate finally launched its recyclable toothpaste tube. It's made from the same type of plastic as milk jugs, January 15, 2020. Available at: https://www.cnn.com/2020/01/15/business/colgate-recycle-toothpaste-tube-trnd/index.html. Companies are also increasing their use of recycled materials and developing other recyclable packaging. Additionally, collaborative recycling efforts have been initiated. One example is Terracycle, which recycles plastic waste including used oral care packaging, toothpaste tubes and caps, floss containers and used toothbrushes.25Sustainability. Building a Future to Smile About. Available at: https://www.colgatepalmolive.com/en-us/core-values/sustainability. These are collected at various locations, including schools and stores. Dental offices can sign-up for collection of these items after they have been brought into the office by patients, possible through a partnership between Terracycle and Colgate-Palmolive. In one year, almost 9 million items were collected and recycled by Terracycle. Several global oral care consumer companies, including Colgate-Palmolive, Procter & Gamble and Unilever, as well as other consumer companies, have also signed a commitment under the Association of Plastic Recyclers’ Recycling Demand Champions Campaign to increase the demand for post-consumer recycled resin.27Recycling Today. APR expands its Recycling Demand Champions, February 26, 2018. Available at: https://www.recyclingtoday.com/article/apr-expands-recycling-demand-champions/.

Recent innovations have included redesigning packaging to reduce its volume, removing PVC from packaging, collaboration with recycling companies, and recyclable products.

Several companies accept used metal instruments for recycling. The Environdent international recycling program from Hu-Friedy accepts metal instruments of any brand and then works with metal recyclers.28Envirodent. Available at: https://www.hu-friedy.com/environdent. Another example is the Recycle to Receive program from American Eagle Instruments, which accepts metal curettes and scalers.29Recycle to Receive. Available at: http://am-eagle.com/recycling. A third example is Robinson Healthcare which manufactures specialist single-use instruments in the UK and collaborates with the Healthcare Environmental Group which has a surgical steel recycling program.30The value of single use dental instruments. Dental Review News, June 2 2016.Available at: https://www.dentalreview.news/technology/23-dental-equipment/1074-the-value-of-single-use-dental-instruments.

Sustainability, Dental Professionals and Consumers

Several studies have shown that there is interest in sustainability in dentistry. In a recent survey with several hundred dental team participants from dental offices and conferences in Ireland, 69% of respondents responded positively.31Diffley M, Mohamed M, Birt R, Gardiner S, Kadhim M, Maher F et al. How important is sustainability to the dental profession in Ireland? J Ir Dent Assoc 2019;65:39-43. In addition, approximately one third believed they could reduce costs through sustainability and respondents expressed a desire for more information. Including sustainability in the dental office can increase patient and employee loyalty, promote a worthy reputation, attract new patients and result in decreased costs.32Willard B. The business case for sustainable dentistry. J Am Coll Dent 2018;85(3):8-14.,33Fernandes CP. Sustainability in Dentistry: Construction of a New Paradigm. J Am Coll Dent 2018;85(3):15-22. Furthermore, in a global consumer survey conducted in 2015 with 30,000 respondents, intent to purchase consumable products was influenced by sustainability in addition to being from a trusted brand or company and other factors.34Nielsen. The sustainability imperative. New insights on consumer expectations, October 2015. Available at: https://www.nielsen.com/wp-content/uploads/sites/3/2019/04/global-sustainability-report-oct-2015.pdf. Forty-five percent, 43%, 41% and 41%, respectively, cited the product being from a company known for being environmentally friendly, its commitment to social value and the consumer’s community, and environmentally-friendly packaging. In another global consumer research study, the vast majority of respondents indicated that they would be more likely to be loyal, trust and favorably view companies involved in social and environmental concerns.35Anderson S. Examining the costs and benefits of ecologically responsible practices. Dentaltown, May 2019. Available at: https://www.dentaltown.com/magazine/article/7575/do-good-sustainability-in-dentistry

In a global consumer survey, respondents indicated that intent to purchase consumable products was influenced by sustainability initiatives.

Other considerations

While it may appear that single-use items are always wasteful and less environmentally-friendly than multi-use items, this is not always the case. A careful analysis may be indicated. For example, the manufacturing requirements for a multi-use device, including the raw materials, energy and water consumption, as well as any applicable processes, consumables and maintenance in the dental office, may indicate that a specific multi-use device is more or less environmentally-friendly than the single-use option. Unfortunately, research and information on these aspects is typically not available. In addition, the recyclability of single-use items as well as the durability and life-span of the alternative item should be considered.

Conclusions

There is an ongoing need for sustainability initiatives. In dentistry, conserving resources such as water and energy, recycling, product selection, prescribing stewardship and optimizing oral health are sustainability initiatives. In addition, companies have undertaken initiatives to reduce the environmental footprint of their products and to educate consumers on sustainability. More research is required in some categories to fully understand product selection based on environmental impact. In the meantime, there are many initiatives that are doable to improve sustainability and dental professionals can play a key role in educating patients.

References

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  • 2.United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the 80 General Assembly on 25 September 2015. A/RES/70/1. General Assembly, Agenda items 15 and 116, 81 2015. Available at: http://unctad.org/meetings/en/SessionalDocuments/ares70d1_en.pdf
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  • 22.American Dental Association announces new policy to combat opioid epidemic. Policy supports mandates on opioid prescribing and continuing education. March 26, 2018. Available at: https://www.ada.org/en/press-room/news-releases/2018-archives/march/american-dental-association-announces-new-policy-tocombat-opioid-epidemic
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