Oral healthcare and the environment – how do we make sustainable attainable?

Steven Mulligan MCGDent, a founding member of the FDI World Dental Federation Sustainability in Dentistry Task Team, discusses the work they have undertaken and shares practical suggestions to foster a more environmentally conscious practice.

I am a practicing general dentist in South Yorkshire, and I work within the University of Sheffield as a clinical teacher. For the last few years, I have been involved in research around sustainable oral healthcare. Upon starting my dental career, I recognised that the science behind dental materials and its role in rehabilitating oral disease fascinated me as understanding what is in the dental materials we use is key to understanding their successful implementation. I have often considered that we would not cook and present someone a meal without knowing the ingredients, or the consequences of their use!

I have recently completed a PhD which primarily looked at the environmental impact of resin-based composite (RBC). The premise of the research was that as amalgam is being phased-out based on environmental pollution issues, with RBC consequently acting as the major direct-placement dental material in dentistry, what are the environmental pollution impacts with the use of RBC? Like any research, once you start looking, the more you see. Regarding RBC, the simple answer is yes, RBC has negative environmental pollution impacts. RBC can never be fully polymerised through normal use, and monomers elute for months and years from restorations into the environment.1 When RBC restorations are replaced, polished or adjusted, microparticulate waste, akin to microplastics are released into the environment.2 Manufacturing, distributing, using and disposing of RBC generates a significant carbon footprint. The sundry items required to use RBC, such as applicator brushes, dental dam, sleeves for light curing units are all single-use plastics (SUPs), contributing to dentistry’s waste burden. Comparing the environmental impact of RBC and amalgam is easy, RBC is less bad for the environment.

It was an easy link when considering the environmentally sustainable use of dental materials to consider other aspects of sustainable oral healthcare. But what does sustainability in this respect mean? Sustainable oral healthcare is basically providing care that does not jeopardise the equivalent care of future generations, and ensuring we are acting ethically, not just to our current patients but also to subsequent generations of patients. Global warming, climate change and environmental pollution is a reality and as healthcare professionals we contribute to it. Can we provide optimal care that is also environmentally sustainable?

To answer this, multiple research opportunities arose, and generated publications with interesting insights. Did you know we generate around 2 billion items of SUP annually in the UK dental sector, weighing around 14 tonnes?3 Or that the average UK 50-year old’s dentistry has a carbon footprint of around 1.2 tonnes CO2e, which would need over 130 trees planted to off-set it?4 Or that patients are willing to pay more for more environmentally sustainable oral healthcare?5

A few years ago, the FDI World Dental Federation (FDI WDF) contacted me as they were interested in establishing the FDI WDF Sustainability in Oral Healthcare Task Team. My colleague at the University of Sheffield, Professor Nicolas Martin, took the reins as Chair and we co-founded the team, which currently comprises of Asst. Prof Donna Hackley (Harvard Dental School, USA), Assist. Prof Duygu Ilhan (Istanbul Medipol University, Turkey), Dr Hasan Jamal (Saudi Arabia) and Dr Mick Armstrong (UK).

The FDI WDF acts as the global voice of the dental profession, representing over one million dentists worldwide, working with 191 Member Associations in over 130 countries. The Sustainability Project aims to increase awareness and guide the profession towards environmentally sustainable outcomes, working alongside industry partners such as Colgate-Palmolive, P & G, Kulzer Mitsui Chemicals Group, Haleon, SDI, Dentsply Sirona and Sunstar.

The FDI Sustainability project has delivered multiple resources, including the first Consensus Statement on Sustainable Oral Healthcare which was an evidence-based perspective of the current status quo, with suggested opportunities for implementing sustainable actions.6

In addition, the FDI developed a Toolkit, based around 18 topics and 150 actions that range in how impactful they are and how easy they are to implement. There are things that you can do in practice that are easy to carry out and have a significant impact on improving environmental sustainability, it is a simple process to enrol on and is a great starting point for anyone interested in the topic. The Toolkit aims to help oral healthcare professionals start (or continue) providing more environmentally sustainable care provision, via a structured approach.

The Toolkit is the direct result of two peer-reviewed scoping review publications that explored the awareness, barriers, drivers, opportunities and best practice for the delivery of sustainable oral healthcare. These key publications identified over 250 actions that can be carried out by dental professionals.7 8

The content within the toolkit is arranged in a way that reflects three aspirational challenge levels: Bronze, Silver and Gold. The criteria considers two parameters for each environmental sustainability (ES) activity: (i) The importance of the task as an ES measure and (ii) the level of implementation difficulty that the implementation of the task presents. Some examples of tasks include:

  • Putting recycling bins in staff areas.
  • Education of colleagues regarding appropriate recycling is an easily achieved, important task and compliance using the Toolkit can be demonstrated by uploading the minutes from a staff meeting that highlighted this. An example and a suggested task within the Toolkit is the separation and recycling of plastic and paper from sterilisation packets.
  • Rethinking the use of resources is another aspect of sustainability and is highlighted in the Toolkit via the use of paperless meetings, double sided printed when necessary, cancelling junk and unsolicited mail that the practice receives and the use of adjunctive technology in the practice such as tablets to record and update medical forms and intraoral scanners/ digital radiography to rethink the need for other disposable resources.
  • Reviewing how we provide care daily by carefully planning procedures before carrying them out and deciding what equipment is required to prevent waste and unnecessary reprocessing of instruments is another example of smart sustainability.
  • Selecting products with minimal packaging that is easy to recycle, selecting eco-friendly alternative sundries, products or equipment and choosing durable office equipment that has been sustainably manufactured.
  • Transport between dental clinics and dental laboratories can be optimised in order to reduce journeys and improve sustainability. The use of digital scanners and CAD CAM allows improved efficiency of transport between dental clinics and laboratories is one example.
  • Communicating with patients the importance of good oral health that not only benefits them directly but also the planet.

The Toolkit integrates not only sustainability messages but also other important issues within dentistry. An example is the requirement to reduce unnecessary use of antibiotics, not just for the vitally important prevention of antimicrobial resistance. This has a sustainability impact as there is a significant carbon footprint attached to the manufacturing, distribution and disposal of waste medicines.

The FDI WDF has also developed a Massive Online Open Course (MOOC) on Sustainability in Dentistry which consists of three hours of interactive learning modules that helps users understand the impacts of oral healthcare on the planet and how to use evidence-based dentistry to improve the oral health of patients in an environmentally conscious way. A final assessment at the end of the course provides certification of its completion, module one is currently available with future modules to follow.

All the above FDI WDF resources, including infographic posters on the importance of good oral health and its links to environmental sustainability (for use in patient waiting areas), are free to access and another patient-focused poster that highlights your practice’s involvement in this important facet of oral healthcare provision will soon be available to display.

As a practicing dentist, I believe the best way we can be environmentally sustainable is by implementing high-quality preventive and operative care that gives patients ownership of their oral health and an understanding that by having a healthy mouth, they can also improve their impact on the environment. This results in fewer interventions, less travel and less lab-work with reduced overall carbon emissions. It’s a win-win situation.

Dental professionals, patients and other non-clinical members of the dental team are often surprised that dentistry has a significant environmental impact as it may never have occurred to them previously. To that end, increasing awareness around this topic by communicating and engaging with others is a brilliant first step in improving the environmental sustainability of oral healthcare.

Everyone can do something, and even if it seems like something small (like promoting patients to use public transport or booking family appointments to cut down patient journeys or even turning off unused electric items or lights), cumulatively these small measures have a big impact on making dentistry more environmentally sustainable.


1 Mulligan S, Hatton PV, Martin N. Resin-based composite materials: elution and pollution. Br Dent J. 2022 May;232(9):644-652. doi: 10.1038/s41415-022-4241-7. Epub 2022 May 13. PMID: 35562466; PMCID: PMC9106581.

2 Mulligan S, Ojeda JJ, Kakonyi G, Thornton SF, Moharamzadeh K, Martin N. Characterisation of Microparticle Waste from Dental Resin-Based Composites. Materials (Basel). 2021 Aug 8;14(16):4440. doi: 10.3390/ma14164440. PMID: 34442963; PMCID: PMC8402022.

3 Martin N, Mulligan S, Fuzesi P, Hatton PV. Quantification of single use plastics waste generated in clinical dental practice and hospital settings. J Dent. 2022 Mar;118:103948. doi: 10.1016/j.jdent.2022.103948. Epub 2022 Jan 10. PMID: 35026356.

4 Martin N, Hunter A, Constantine Z, Mulligan S. The environmental consequences of oral healthcare provision by the dental team. J Dent. 2024 Mar;142:104842. doi: 10.1016/j.jdent.2024.104842. Epub 2024 Jan 17. PMID: 38237717.

5 Baird HM, Mulligan S, Webb TL, Baker SR, Martin N. Exploring attitudes towards more sustainable dentistry among adults living in the UK. Br Dent J. 2022 Aug;233(4):333-342. doi: 10.1038/s41415-022-4910-6. Epub 2022 Aug 26. PMID: 36028699; PMCID: PMC9412765.

6 Martin N, England R, Mulligan S. Sustainable Oral Healthcare: A Joint Stakeholder Approach. Int Dent J. 2022 Jun;72(3):261-265. doi: 10.1016/j.identj.2022.02.008. Epub 2022 Mar 29. PMID: 35365320; PMCID: PMC9275086.

7 Martin N, Sheppard M, Gorasia G, Arora P, Cooper M, Mulligan S. Awareness and barriers to sustainability in dentistry: A scoping review. J Dent. 2021 Sep;112:103735. doi: 10.1016/j.jdent.2021.103735. Epub 2021 Jun 25. PMID: 34182058.

8 Martin N, Sheppard M, Gorasia G, Arora P, Cooper M, Mulligan S. Drivers, opportunities and best practice for sustainability in dentistry: A scoping review. J Dent. 2021 Sep;112:103737. doi: 10.1016/j.jdent.2021.103737. Epub 2021 Jun 26. PMID: 34182061.


Visit our sustainable dentistry page for further free resources to help dental practices understand and reduce their impact on the environment.

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Leading for change: sustainability review published

The College has published Sustainability in dentistry: Leading for change, a scoping review to inform and engage the dental profession, industry, and wider oral health and dental care infrastructure on the environmental sustainability of practicing dentistry.

With the sub-title Environmentally sustainable dentistry to address the climate crisis, the review is organised thematically to provide an in-depth exploration of a wide range of factors such as legislation, health service emissions targets, prescribing, procurement, education and regulation, and makes recommendations for change that can be undertaken by each part of the system. It also presents case studies of exemplar efforts made to address the environmental impact of dental care and oral health services, and includes suggestions for further reading.

The review was written by a team of eight Clinical Fellows working at national dental organisations as part of the Chief Dental Officer for England’s Clinical Leadership Scheme, with input from expert contributors from academia, dental practice and government organisations.

Produced with the support of the Office of the Chief Dental Officer for England and the College of General Dentistry, it aims to inspire positive change by all those involved in the provision of oral healthcare related products, services and policy.

On behalf of the authors, Amarantha Fennell-Wells, Senior Clinical Policy Manager at the Office of the Chief Dental Officer England, said:

“Dental care creates a significant carbon footprint, and we owe it to current and future generations to contribute to emissions reduction by making our dental practice as environmentally sustainable as possible. Each practice and all staff can play their part in delivering sustainability in dentistry, and our review synthesises information which we hope will be educational and inspiring of collaboration to achieve a more sustainable future for the profession and dental patients.”

The document is freely available to download via a new College webpage which signposts a selection of free e-learning resources, guidelines and other tools which dental practitioners and practices can use to understand and reduce their environmental impact.

New sustainable dentistry resources hub

The College has published a new webpage bringing together resources which dental practitioners and practices can use to understand and reduce their environmental impact.

Sustainability has been defined as “meeting the needs of the present without compromising the ability of future generations to meet their own needs”, and for dental practices, this means minimising adverse effects on the environment and helping to conserve natural resources.

While this encompasses a wide range of factors, carbon emissions are a critical component, and with the UK government committed to reaching ‘net zero’ by 2050, NHS-contracted practices in England should be aware that since April 2023, every Integrated Care System now has a Green Plan as part of the NHS’s own net zero commitment.

Last year, the College co-hosted the webinar Sustainability in dentistry and healthcare, which looked at the effect of healthcare on climate change and discussed some of the practical aspects relevant to general dental practice. The recording is available free of charge to College members and provides 2¼ hours of certified CPD. 

Professor Paul Batchelor FCGDent, Dental Group Chair at the Centre for Sustainable Healthcare, also published the blog Sustainability: what is it and how can the dental sector contribute? on the College website, and recently delivered a College lecture on sustainability in dentistry.

In recent years, a number of organisations have developed free materials to support greater sustainability in dentistry, and the new webpage has been created to act as a hub with descriptions and links to a selection of resources encompassing learning, guidelines and tools for the practical implementation of change.

For those looking for an introduction to the topic, the page includes a link to NHS England’s e-Learning for Health Environmental sustainability in dentistry module, which takes only around 30 minutes to complete.

For those ready for further exploration, a link is provided to the Centre for Sustainable Healthcare’s How to Guide for Dental Practices. This includes sections on travel, equipment and supplies, energy, waste, biodiversity and green space, and measuring and embedding sustainability, as well as modelled examples and consideration of the ease and costs of implementation and the financial return on investment.

Similarly Green Impact, a UNESCO-recognised organisation working with the NHS, has developed an online toolkit which offers wide-ranging information and practical advice that dental teams can implement. NHS-contracted dental practices throughout the UK which are committed to implementing change can access support through Green Impact to achieve their sustainability objectives, and can choose to work towards bronze, silver or gold level accreditation. Registration links are provided on the new webpage.

The page also includes a link to the Clinical guidelines for environmental sustainability in dentistry, which were produced by Trinity College Dublin in collaboration with the Office of the Chief Dental Officer for England earlier this year, and Sustainability in dentistry: Leading for change, a review which makes recommendations for change in each part of the dental system.

Sustainability in dentistry and healthcare

Friday 6 October 2023, 9.15am-10.00am, London

Enhanced CPD Theatre, Hall N9, ExCeL London, Royal Victoria Dock, 1 Western Gateway, London E16 1XL

This lecture explored what sustainability means and how the dental sector can contribute to sustainability goals. It will cover the work of the FDI World Dental Federation, the BDA, CGDent and organisations such as the Centre for Sustainable Healthcare, and explore how individual dental professionals and practices can best contribute.

It was delivered by Professor Paul Batchelor FCGDent, Associate and Dental Group Chair of the Centre for Sustainable Healthcare, and a contributor to the FDI’s report on sustainability in dentistry. Honorary Clinical Professor at the University of Central Lancashire School of Medicine and Dentistry and an Honorary Lecturer at University College London, he is also co-lead of the NHS Complete Care Community Programme and Chief Assessor for Intercollegiate Faculty Specialist Examination in Dental Public Health. He is a Fellow of the College of General Dentistry, the Faculty of Public Health and the Faculty of Dental Surgery of the Royal College of Surgeons of England, holds a PhD from the University of London and is Editor of the College’s Dementia-Friendly Dentistry: Good Practice Guidelines. He is a past Vice Dean, Chief Fellowship Assessor and National Research Facilitator of the FGDP(UK) and was Course Director of its Diploma in Leadership and Management. He has also served as President of the British Association for the Study of Community Dentistry, Advisor to the House of Commons Health and Social Care Committee and as an ORE examiner.

Objective:

  • At the end of the session attendees will have an understanding of sustainability and how they can contribute to addressing the issues

Learning outcomes:

  • Provide a definition of what sustainability means
  • Explore the impact that the delivery of dental care makes
  • Understand how the individual can contribute

CPD:

  • 0.75 hours

GDC development outcomes:

  • B

This lecture was free to attend for both members and non-members of the College, and is one of five College sessions at Dentistry Show London 2023, a two-day conference hosting over 100 CPD lectures, 180 exhibitors and over 3,000 dental professionals. It is not possible to register specifically for this lecture in advance, but those wishing to attend will need to register for Dentistry Show London 2023 either in advance or on the day.

Conference visitors are also encouraged to drop by Stand G52 to meet College representatives.

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Sustainability: what is it and how can the dental sector contribute?

Professor Paul Batchelor FCGDent, Associate and Dental Group Chair at the Centre for Sustainable Healthcare, explores the issue of sustainability in dentistry and what practices can do to support it.

Introduction

While sustainability has entered the lexicon of everyday language, its precise meaning and the key issues surrounding it can appear vague. Without this understanding of meaning trying to address issues becomes almost impossible. This blog attempts to overcome the lack of clarity by providing a definition to sustainability and how the dental sector can potentially make a contribution to what is becoming one of the most critical issues of our time. The blog is divided into two main sections: the meaning of sustainability and the contribution that the dental system could make.  

What is meant by sustainability?

In broad terms, sustainability refers to the actions taken to ensure that the activities of the current generation in meeting their needs have no, or minimal, impact on the environment.  The key document influencing current policy on sustainability was published by the Brundtland Commission titled “Our Common Future” 1. The report recognised three pillars to sustainability: the environment, the economy and society. For the environmental pillar the underlying philosophy was underpinned by a need to reduce the current human consumption of natural resources to a level at which they could be replenished. The economic pillar, referred to the ability of communities to maintain their independence, not least to secure sources of livelihood and the third pillar, social sustainability, meant access to resources to keep their community and society healthy and secure.

The United Nations, as part of its role in sustainability, established a knowledge hub to provide guidance on sustainable development issues, one of which centres on health2. Although high level, the material presented covers a wide range of activities highlighting how individuals and agencies can help and engage in the challenges. Indeed,  FDI World Dental Federation (FDI) issued a statement on sustainability in the dental sector with policy recommendations including:

  • The prevention of oral diseases and the promotion of health should be recognized as the most sustainable way to ensure optimal, accessible and affordable oral health with minimal impact on the environment.
  • The dentist as leader of the dental team should take steps to educate all of the dental team on sustainability practices and simultaneously reinforce that the safety of the patient and the quality of care provided should always be the team’s primary concern3.

This work has been taken forward and the FDI will be publishing a consensus statement in the next month or so on the major challenges facing the oral health care sector and the opportunities to deliver sustainable oral health care.

How can the dental system contribute?

Dental care delivery is provided in the vast majority, through a series of small businesses. However, the actual dental ecosystem is far wider. The day-to-day running of a dental practice requires energy, materials and transport to name but three items.   Each of these businesses can make a contribution through initiatives that help create a sustainable environment in a logical process similar to those found in a business plan. The first step is to understand the impact that the business is having: how much waste is the business creating, issues such as energy usage within a practice, the use of materials and their packaging. A good example of this is the work by Duane et al. (2017) 4 .

Following on from understanding the issues, opportunities for  addressing the problems need to be identified and while no two dental practices are ever the same, potential solutions would have common themes. For example, are there opportunities for using (more) sustainable materials? How might energy usage be both reduced  or more reliant on renewable sources? Are there ways to explore how patients use services and do opportunities for health promotion programmes exist at differing sites as opposed to one-to-one interventions?

The dental professions can make a contribution to sustainability both within their professional roles but also as individuals. Sustainability is not simply about the environmental aspects; it also involves the economic and societal aspects. A number of these lie outside of the control of the profession but Government can make  contributions, perhaps not least with appropriate contract reform. To tackle these and other issues, including how covid-19 has impacted and what lessons are being learnt, the College is running a webinar on 28 February at 7pm ( Sustainability in Dentistry and Healthcare – watch recording here). For individuals with an interest, the Centre for Sustainable Healthcare also runs a programme on some of the key issues and how it relates to dental care (https://sustainablehealthcare.org.uk/courses/sustainable-dentistry).

Summary

Sustainability has grown in importance with the recognition of the negative impact that uncontrolled economic growth is having on the planet, the negative consequences of which would be felt not just by present generations but those of the future.

All societies have now recognised the importance of managing the environment to help address the negative consequences of unchecked growth but also how developments in the economy and society can also contribute. Provision of health care, including oral health care, is a fundamental right and Government needs to work with the profession to ensure that care arrangements are developed in a manner which is coterminous with sustainable goals.

Each individual dental care worker can contribute to helping achieve the sustainability goals both through their professional roles and as individuals on a day-to-day basis. While such contributions may appear to be small or even insignificant, together they will make a major contribution to a better world not just for the present but also the future.

References

  1. Report of the World Commission on Environment and Development: Our Common Future. The Brundtland Commission. United Nations.(1987) Available at: http://www.un-documents.net/our-common-future.pdf (Accessed 20 February 2022).
  2. Sustainable Development Goals: Goal 3 – Good Health & Well-being. Available at: https://sdg.iisd.org/tag/global-sustainable-development-report-gsdr/ (Accessed 20 February 2022)
  3. Sustainability in Dentistry Statement. FDI World Dental Federation. May 2017, Madrid, Spain. Available at: https://www.fdiworlddental.org/sustainability-dentistry-statement (Accessed 20 February 2022).
  4. Duane B, Lee MB, White S, Stancliffe R, Steinbach I. An estimated carbon footprint of NHS primary dental care within England. How can dentistry be more environmentally sustainable? Br. Dent. J., 223 (2017), pp. 589-593. Available at: https://www.nature.com/articles/sj.bdj.2017.839 (Accessed 20 February 2022).

Further resources

For a range of online resources on sustainable dentistry including practical advice on how to reduce your practice’s impact on the environment, visit our environmental sustainability in dentistry page.

Professor Paul Batchelor FCGDent will be delivering a CGDent lecture on Sustainability in Dentistry and Healthcare on Friday 6 October 2023, 9:15-10:00, at Dentistry Show London.

The CGDent webinar on Sustainability in Dentistry and Healthcare, took place on Monday 28 February 2022 – watch the recorded webinar here. Our on-demand webinars are free to view for CGDent members and are available to non-members for a small fee.

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Sustainability in dentistry and healthcare

Recorded webinar, Monday 28 February 2022, 7pm.

CGDent members and ProDental subscribers have free access to the recorded webinar and can claim CPD hours for free.  A £20 fee will apply for non-members/non-subscribers who wish to claim CPD.

In conjunction with the Central Sterilising Club, this webinar examines how we can promote sustainability in dentistry and healthcare, addressing issues such as disposable single use items and the efficacy of decontamination and reuse on site. The current disposal of items across healthcare is not sustainable and we need to change our practices to ensure that reuse and reduce are the principles to reduce waste. Yet, there are other considerations including infection control, the ongoing risk to patients as well procurement and transport to and from our places of work.

This webinar sets out to investigate the effect of healthcare on climate change and how nurses can adopt more sustainable nursing practices. We examine how improving sustainability through reusable PPE can reduce the pressure and costs on the NHS and improve the planet, and consider how embedding sustainability within a dental practice can support and advocate change in dentistry.

Speakers:

  • John Prendergast, Senior Decontamination Engineer at NHS Wales Shared Services Partnership/Specialist Estates Services
  • Ian Mills FCGDent, former Dean FGDP(UK) and a Trustee of CGDent
  • Abhi Pal FCGDent, President of CGDent
  • Rose Gallagher MBE, Professional Lead Infection Prevention and Control at Royal College of Nursing
  • Alexis Percival, Environmental and Sustainability Manager, Yorkshire Ambulance Service NHS Trust
  • Brett Duane, Associate Professor in Dental Public Health, Trinity College, Dublin
  • Dr Jimmy Walker, Independent Microbiological and Decontamination Consultant

This webinar is part of the partnership between the College of General Dentistry (CGDent) and ProDental CPD.

Membership of the College of General Dentistry is open to all registered dental professionals. Membership for dentists is available from £94, and for other registered dental professionals from £33. The full list of CGDent membership rates is at https://cgdent.uk/membership-fees/

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