November 10, 2024

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Getting serious about sustainability in dentistry

Getting serious about sustainability in dentistry
Getting serious about sustainability in dentistry

Key points

  • Encourages readers to reduce their carbon footprint and environmental impact in the clinical dental office.
  • Provides readers with practical suggestions to make their dental offices more sustainable.
  • Encourages readers to consider sustainability as one of their societal obligations.

Abstract

As healthcare professionals in a developed country, we can no longer ignore the environmental consequences of our professional activities. The pandemic only served to increase the amount of waste we produce in delivering our services in a safe manner. This paper encompasses a literature review from 2014-2023 that identifies interventions that can most effectively mitigate environmental impact created by dentists via their advocacy and actions in both their professional and personal lives.

The climate crisis is the greatest health threat of the 21st century; healthcare is responsible for 4.4% of global net carbon emissions. The healthcare sector would rank as the fifth-largest emitter on the planet if it were a country. Our mission is to both promote and protect health and well-being; it, therefore, follows that we have an important role to play in alleviating the climate crisis.1 Anthropogenic environmental change has had a negative effect on human health and further increases demands on healthcare systems; it is imperative to move towards actions and strategies that are based on the highest level of evidence and science in an effort to create sustainable healthcare systems globally. 2

Materials and methods

This paper addresses interventions that can be applied by dentists within the clinical setting, by both professional and personal advocacy to reduce GHGs (greenhouse gas emissions) and environmental impact. A multimedia approach was used to streamline information transfer and facilitate learning and access to practical suggestions.3 Consideration was given to greatest impact, as well as feasibility (ease of implementation), and cost. Interventions were categorized in terms of leadership, prevention, supply chain, transport, buildings and energy, drugs and devices, food waste, and natural systems. A relevant literature review was conducted. Estimations of GHG emissions are based on the best available information and current knowledge; the accuracy of this field continues to change and improve.4,5

Results

A summary of the interventions and their estimated GHG emission impact, feasibility, and costs are summarized in Table 1 and Figure 1. Links were provided such that the reader can investigate further which interventions they may choose to implement.

Table 1

Table 1 Legend

Five areas of action were identified that are low cost, low effort, and have high GHG impact. These include: demonstrating leadership by creating a sustainability plan for your office, refusing bad products that generate unnecessary waste and CO2 emissions, coordinating patient bookings to decrease transportation footprint, promoting active travel for yourself, your staff and your patients, and implementing the Choosing Wisely guidelines (judicious prescribing of pharmaceuticals and imaging, and implementing ethical treatment guidelines with respect to “old” or amalgam restorations).

Figure 1

Discussion

Leadership: Improving environmental impact and reducing greenhouse gas emissions in the dental office begins with knowledge and advocacy. Creating both public and professional awareness are the greatest drivers to influence positive change in behaviour and attitudes towards sustainability.6 There are several courses available online to improve general knowledge about sustainability in dentistry, in particular, and in healthcare in general, some at no cost.7,8,9

We need to be aware of the inequality that exists in global CO2 emissions: on average, a person from a high-income country emits more than 30 times that of an individual from a low-income country.10 This is mentioned to provide context, and to highlight the need for us all to consider decreasing our environmental impact in our professional lives, where possible, while still keeping our patients safe, as well as considering the consequences of our personal decisions. Global tourism accounts for up to 8% of global greenhouse gas emissions and financial investing can have serious negative impact on the environment if fossil fuel investments are part of one’s portfolio.11,12,13

Prevention: Promoting prevention for our patients is essential for sustainability; by educating our patients, we decrease the need for unnecessary treatment, thereby improving sustainable outcomes. Advocating for behavioural change requires repetition and is labour intensive if it is to be effective.14,15 Although we are not properly compensated for taking the necessary time to carry this out properly, we have a responsibility as healthcare professionals to educate our patients with respect to good oral hygiene practices and the impact of dietary decisions regarding sugar intake. Consider the use of paint-on topical fluoride varnishes or gels for all high caries rate situations (without the use of unnecessary trays), as well as the use of paint-on silver diamine fluoride, which is an inexpensive and efficacious method of arresting caries for all age groups.16,17,18,19

Be aware of the benefits of a sugar tax; the WHO has recommended such a tax on sugar-sweetened drinks to decrease the negative impact such beverages have on both children and adults, those impacts being: increased dental caries, type 2 diabetes, weight gain and obesity, as well as potential heart disease, stroke, and cancer. Along with mitigating poor health outcomes (that would otherwise increase treatment needs and thereby reduce sustainability), such a tax provides a resource for healthcare costs.20 Newfoundland has implemented such a tax.

Although there is some dispute within the dental community regarding the potential negative impact of community water fluoridation, years of research and countless studies do not bear this out; the government of Canada provides a fact sheet about the benefits of community water fluoridation. All age groups with high caries rates can benefit from this cost-effective method of decreasing caries incidence, thereby improving sustainable outcomes.21,22,23

Supply Chain: Refusing products that have more negative environmental impact can be challenging, since it is difficult to ascertain the series of events that occurred to source the raw materials, as well as processes involved with both the manufacturing and transportation of the product to your door. Indeed, such emissions, known as “Scope 3” or indirect emissions, from sourcing and distribution of goods, are often under reported or inaccurately reported, and may be larger than anticipated.24 That said, there are tools to investigate a company’s environmental scorecard, such as InfluenceMap, an independent think tank that produces data-driven analysis regarding the impact of business and finance on the climate crisis. This site has evaluated several of the major companies involved in the dental supply chain.25 You can also use a questionnaire to engage with your suppliers to see if they are implementing environmentally and socially responsible practices.26 As a consumer, you have a voice; if your supply chain engages with over-packaging, or excessive plastic packaging, raise concern with them, such that they may consider curbing practices that unnecessarily degrade the environment. Their method of transporting goods can also have an impact; are they using or switching to electric, hydrogen-based, or hybrid vehicles? Are they sourcing products locally whenever possible, to decrease transportation emissions?

Assign a staff member to be in charge of auditing your stock; keeping a record of what you use and with what frequency, will improve the efficiency of your purchasing and positively influence your “bottom line”, while decreasing waste of unused goods and improving sustainable outcomes.27

Plastic single-use products are ubiquitous in dentistry, and indeed in our daily lives.28 There is a growing body of research indicating that plastic refuse, once broken down into small micro and nano particles, is toxic to living organisms; therefore, whenever possible, we should consider employing reusable items, such as stainless steel sterilization cassettes, high volume suction tips, prophy heads, and impression trays (if you’re not using digital impression-taking), as well as reusable versions of isolation gowns, surgical wrap for instrument cassettes, disinfectant clothes, patient bibs, and surgical masks.29,30,31,32,33 Reusable surgical wrap has been available for some time and is used in hospitals across North America; innovative Canadian companies are now producing reusable versions of several products, including Health Canada approved and licensed reusable masks, that can be washed up to 100 times, disinfectant wipes that have at least 10 uses, are made from cotton, and so do not contribute microplastics to wastewater, and patient bibs, designed by a dentist in Quebec, that only require proper disinfectant wiping for reuse and may have, according to the company website, up to 2000 uses. Buying locally made products is good for the economy and the environment. The attenuation of waste, transportation footprint, manufacturing footprint, and, therefore, greenhouse gas emissions from these products is considerable; furthermore, they have been vetted by a dental IPAC specialist.

Additionally, consider recommending more sustainable Canadian-made oral care products; there are now toothbrushes available made from scrap wood from Quebec, and reusable silicone floss distributed from Toronto.34,35 Advocating for the removal of unnecessary single use barriers, such as some of our medical colleagues have done with medical examination table paper, should be considered; are single use plastic barriers absolutely necessary?36 If dental equipment is properly wiped down with effective disinfectants in a responsible manner, will this impact patient outcomes? The cost/benefit of using single use products, with concomitant waste creation, needs to be weighed against planetary harm that results from the use of these products. Ultimately, our health and survival are inextricably linked to planetary health.

Up to 90% of microplastics in the ocean may be attributed to plastic microfibre pollution created by laundering synthetic textiles.37 A recent pilot project carried out in Parry Sound, Ontario, indicates that installing microfibre filters on washing machines is an effective method of trapping these particles.38 Although the collected mass from the filters ends up in landfill, this is more sustainable than having these particles end up in our water systems. Furthermore, employing a filter system that does not require transporting replacement filter cartridges, but merely cleaning a reusable filter, is also a more sustainable option.39

A scenario in which your office carries out on-site laundering of all scrubs, isolation gowns, surgical caps, reusable surgical wrap, and masks, is the best alternative for sustainability, eliminating the transportation footprint and manufacturing footprint of single use items, as well as mitigating the egregious amount of predominantly plastic waste created by these items. Although hiring an external laundering service for reusable items is superior to using single use items, it still involves significant carbon footprint from transportation.

While the environmental impact of amalgam has been thoroughly researched, that of resin-based composite materials is less known.40 We are now regulated to decrease amalgam contamination by installing amalgam separator units on dental equipment. Furthermore, Canada has signed on to the Minamata Convention, and amalgam use will likely be discontinued by 2030.41 However, amalgam restorations have less secondary caries and greater longevity than resin-based composite restorations in posterior teeth.42 Amalgam is also far less technique sensitive, compressible, does not require polymerization by a light source, and, therefore, is not as problematic in deep interproximal situations. The breakdown, and subsequent elution of monomers from resin-based composite materials may act as environmental pollution, and more research is required to understand to what extent, the use of these materials is creating environmental degradation and how this can be controlled.43 While we should minimize our use of amalgam, to those situations in which other materials may fail clinically, we must also be aware that resin-based composites also have environmental impact.

Unless equipment is near the end of potential usefulness, consider repairing it to decrease environmental impact; generally, the life cycle assessment of repairing outweighs replacing.44

Alternatively, if you have equipment that is no longer IPAC compliant, such as an older model autoclave, consider donating it to a developing country, where infection control regulations may not be as stringent. Be sure to dispose of electronics in a safe and responsible manner.45 Recycling the components of electronics improves sustainability.

Microplastic contamination as a threat to the environment and human health has previously been alluded to, and the need for proper disposal, and recycling, where possible, is clear.46,47 Only 9% of all plastic waste is recycled in Canada; given the potential concern for plastic waste from medical/dental environments being considered contaminated biohazardous waste, this figure is likely even less. Sadly, we seem to have a societal bias towards recycling, when in fact reducing waste is far more sustainable than dealing with waste already created. Recycling is not a “silver bullet” and should only be employed after consideration of reducing unnecessary waste, and reusing items whenever possible.48 Furthermore, the recycling process itself, can disseminate microplastic particles into wastewater.49 Recycling is also an energy-intensive and transportation-intensive process.

After discussing the caveats with recycling, it is still worth noting the free recycling program available to Canadians for used oral care products. Your office can collect your patients’ used oral care products (including toothbrushes, toothpaste tubes, floss containers, and mouthwash bottles), generate a courier label online, and ship them to a recycling facility to be down cycled into items such as park benches. This process at least keeps these items from going into landfill, it can stimulate conversation about environmental responsibility with your patients and staff and can potentially be a marketing tool for your practice.50 More transparency about such recycling processes is, however, needed.

The terms “biodegradeable,” “bioplastic” and “compostable” are tossed around fairly liberally. Items which are toted to be “biodegradable” may not actually decompose, unless very ideal conditions are employed. This has led to considerable confusion for consumers.51 One such example is so-called “biodegradable” nitrile gloves. While a special coating may indeed allow bacteria to break these items down into small particles at a far faster rate than normal (5 years versus over 100 years), the resulting particles are still fossil-fuel based environmental contaminants. One might actually argue that this process is more deleterious to the environment.

Transport: Close to 65% of the dental office’s carbon emissions are the result of travel, by both patients and staff, with emissions being greater for staff. These emissions are accompanied by pollutants, which decrease quality of life and shorten life span.52 By combining appointments for families, when possible, such that several individuals are travelling together to and from the office, and by doing several procedures at one sitting for an individual patient, when ethically possible, emissions can be reduced.53 Suggesting that staff consider carpooling or use of public or active transport and providing incentives for this, can also decrease office emissions.

Providing bike racks and ZEV chargers at your office can also promote modes of travel that decrease emissions. You may want to consider the purchase of a ZEV yourself, as there are available governmental incentives.54 In most cases there is a reduction in emissions using an electric vehicle; however, this is dependant upon vehicle size/choice, the electric grid mix (renewable energy or carbon-based), ambient temperature (ZEVs lose their charge faster in cold weather), and fuel economy (improvements in efficiency of gas-powered engines continues to improve; however, they still emit particulate pollution, which ZEVs do not).55

Promoting active travel to and from your office via cycling, either using a conventional or E-bike, or walking, decreases mobility-related lifecycle CO2 emissions, with the added benefits of being low cost, reliable, and improving physical and mental health.56 Incentives for staff to engage in active travel may further encourage this.

Consider incorporating a high efficiency heat pump, solar energy, or geothermal energy into your office and/or home. Depending on your location, there are federal, provincial, and municipal government incentives to switch to renewable forms of energy from oil.57,58 Additionally, switching your energy provider to a company that purchases renewable energy systems to offset energy use will also improve your environmental profile.59

Buildings and Energy: When designing your dental office, consider maximizing efficiency with use of space; this will ensure that your energy requirements for heating and cooling are reduced.60

Undertake an energy audit of an existing office, using a professional third-party provider, and follow through with recommendations; doing so will decrease your energy costs while reducing your greenhouse gas emissions.61,62 Switch to LED lights, a smart thermometer, upgraded low-E window systems, dimmer switches, water saving toilets, sensor-operated or low-flow faucets, energy efficient appliances and hot water heaters; ensure diligent replacement of filters in various systems, and install suitable blinds and awnings. Turn off all electrical and computer systems at the end of the day. These initiatives will save both energy and money in the long run.

Drugs and Devices: A dry vacuum system for your office will cost more up front but will save you money by reducing consumption of electricity and water, as well as requiring less repair.63 Some US states have actually banned the use of wet vacuum systems, due to their high-water usage.

Pharmaceuticals should be dispensed judiciously, as their active agents and metabolites can be excreted and impact the environment. They have been found in various locations, including ground water, drinking water, and manure.64 The “Choosing Wisely” guidelines for dentistry remind us to prescribe opiates only after exhausting alternatives, and that irreversible pulpitis and acute dental abscesses with no signs of systemic involvement do not require antibiotics. Similarly, prophylactic antibiotics are not required for patients with total joint replacement, nor for non-valvular cardiac or other indwelling devices; radiographs should only be prescribed with indication, dental restorations should not be replaced simply because they are old or are amalgam-based.65

Digital patient records (by reducing paper use), digital imaging (by avoiding use of “old school” chemicals), and digital impression-taking (by negating the need for impression materials and transportation of impressions to the dental laboratory) all improve environmental outcomes, while making integration of patient records seamless. Ideally, in the future, most impressions will be in-house 3D, creating prosthodontic (such as CAD/CAM systems currently are capable of), orthodontic, and bruxism appliances “in house”, completely eliminating the transportation footprint for individual cases.66,67,68,69

Nitrous oxide is a potent greenhouse gas that is a major source of ongoing ozone depletion.70 Some major hospitals in Ontario are removing their plumbed lines for nitrous oxide, because of the amount of gas that escapes, and are decreasing their use of this anaesthetic gas as much as possible. Dentists are moving away from the use of N2O because of potential adverse effects from long term exposure, and because there are alternatives.71 However, for pediatric dentistry, it is still a commonly used method of sedation; those who do use it, should only employ it when absolutely necessary, using well-maintained equipment with an adequate scavenger system.

Food Waste: Every year, roughly one third of all food produced for human consumption is wasted, while a large number of people still suffer from food insecurity. In addition to the implied ethical considerations, the environmental impact of resources used to create food that becomes waste and the emissions from that waste should be curtailed by informing citizens and policy makers of more sustainable practices.72 Regardless of social issues, composting is a relatively easy method of reducing emissions from food waste and is an economical method of nutrient recovery.73 Food loss and waste globally, if it were a country, would place third in GHG emissions, behind the US and China. Food waste ending up in landfill creates methane (CH4) emissions, which has 28-36 times the GHG potential of carbon dioxide (CO2). The carbon footprint of uneaten food is roughly 3.3 billion tonnes of CO2.74

Given these statistics, we have a moral imperative as responsible citizens of our planet, to reduce our personal food waste as much as possible, while also considering implementation of a composting program of food waste we do generate, both in our personal and professional lives. This is not difficult, and many municipalities are already encouraging this for households and businesses. If not, creating your own office composting program is easy to do.75

Natural Systems: If you have landscaping potential at your office location, consider planting indigenous tree species and pollinators. Studies confirm the multiple benefits of doing so: improving mental and physical health, children’s attention and test scores, and property values. Trees also decrease the ambient temperature of our urban settings.76 If permitted by regulatory bodies, indoor plants or wall gardens in reception areas have similar benefits, increasing positive emotions, reducing negative feelings, and reducing physical discomfort.77

Regulatory Challenges: The policies and protocols that we as dentist are required to adhere to, must be updated by our regulatory bodies to align with the United Nations sustainable development goals.78 Our guidelines must be revisited to address climate action, recognize that the health of humanity is dependant upon planetary health, and in so doing, provide outcomes that include responsible production and consumption. This includes an awareness by our regulatory bodies of reusable alternatives that are safe for our patients and ourselves, that can significantly curb the negative environmental impact associated with the creation, transportation, and disposal of the products we use. Protocols must be based on science and proof, through the lens of sustainability, not the so-called “precautionary principle”, which ironically, was originally created to minimize pollution and environmental damage.79

Furthermore, reusable, locally manufactured products are more likely to ensure that there will be no disruption of supply chain, should a future event occur, such as the recent pandemic.

Conclusions

This article sought to create a template to help dental practitioners move towards a carbon neutral office with lower environmental impact using practical suggestions and links to facilitate this process. We identified fifteen low-cost suggestions, six low effort suggestions, and twelve high GHG impact suggestions. Five suggestions met all three criteria of low cost, low effort, and high GHG impact: creating a sustainability plan (leadership), refusing bad products (supply chain), coordinating patient bookings (transport), promoting active travel (transport), and implementing Choosing Wisely Canada guidelines for dentistry (drugs and devices).

The global climate crisis cannot be ignored; as healthcare professionals, we all need to consider our day-to-day actions in all aspects of our lives, lead by example, and demonstrate that we truly care about the consequences of both our professional and personal activities. We need to constantly question the science and efficacy behind our protocols in a manner that takes into consideration the resulting effects on planetary health. All sectors of society need to be moving towards a circular economy as much as possible if we are to mitigate the negative consequences of human activity on our planet.80 

Oral Health welcomes this original article.

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Dr. Laurie Houston, BSc, DDS is an advocate for sustainable change in healthcare, lectures on Sustainability in Dentistry, and is the founder of CanHelp Through HealthCare. She practices dentistry in Orillia, Ontario and at an Indigenous community in the Georgian Bay area. 

Dr. Sujane Kandasamy, MSc, PhD is a Health Research Methodologist and Intersectional Environmentalist who studies the early origins and prevention of chronic diseases in systemically underrepresented populations and communities. 

Fardeen Channa is a third-year undergraduate student studying at the University of Waterloo currently pursuing a BSc in Health Science. He has a passion for environmental research and wishes to aid in the fight against climate change. 

Dr. Myles D. Sergeant, PEng, MD, FCFP, is a physician, advocate, and leader of provincial and national healthcare sustainability organizations.


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