Healthy Mouths, Healthy Planet Inside View 18/03/2022 • Ihsane Ben Yahya, Nicolas Martin & Steven Mulligan Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to print (Opens in new window) Dental procedures produce a hefty amount of carbon emissions. In honour of World Oral Health Day, 20 March, three leading voices from the World Dental Federation highlight the unexpected linkages between the health of your mouth and that of the planet. It will come as a surprise to most people that the healthcare sector has a significant environmental impact. Healthcare systems are responsible for around 5% of global greenhouse gas emissions, of which oral healthcare is an important contributor. Indeed, if the healthcare sector was a country, it would be the fifth largest greenhouse gas emitter on the planet. Oral healthcare contributes to this environmental burden with air pollution arising from the release of CO2 associated with travel and transport, the incineration of waste, the greenhouse gas impact of anesthetic gases such as nitrous oxide and the high consumption of water. Specific to dentistry, the most routine procedures, all come with a hefty carbon price tag. Tooth-coloured fillings for instance, produce around 15 kilograms of CO2eq (carbon dioxide equivalent) per procedure, according to Public Health England, whose National Health Service has done some of the most extensive carbon footprint modeling of healthcare delivery in the world. A single root canal treatment, meanwhile, produces 23 kilograms of CO2eq, dentures between 58 and 71 kilograms CO2eq. Use of the anesthetic gas nitrous oxide (laughing gas), in a procedure, meanwhile, is responsible for 119 kilograms CO2eq. Nitrous oxide N2O, the most commonly used inhalation dental anesthetic, is a greenhouse gas with far more climate warming potential than CO2. Just one kilogram of nitrous oxide is equivalent to 298 kilogrammes of CO2 and 25 kilograms of methane – another powerful greenhouse gas. Meanwhile, silver amalgam fillings contain mercury. While more and more rarely used today, and still considered safe for dental treatments, there is an environmental impact through the release of residual mercury into sewage during procedures, as well as throughout its life cycle. Prevention is better than cure Ways to maintain good oral health. The dental industry has a collective responsibility to reduce these impacts – while also expanding access to oral healthcare. How can we do both? One simple solution is to look at how we can best minimize what we might label as “avoidable” oral procedures. Prevention is always better than cure and it is the most impactful and practical way of reducing the need for clinical interventions and their associated environmental impacts. This is best achieved through the promotion of good oral hygiene, a healthy diet and the avoidance of smoking. When treatment is required, oral healthcare also should focus on the provision of durable fillings, using high quality products and materials that will last longer and/or require fewer replacements. Legislation around water fluoridation for instance, complemented by targeted public health policies can help prevent tooth decay (caries) and ultimately cavities. The recent banning of TV and online advertising of junk food in the UK before 9pm is an indirect example of encouraging better diet. So too the campaign by UK footballer Marcus Rashford to promote healthier school lunches. At the same time, while many dental problems such as caries and periodontal (gum) disease are common preventable diseases, no amount of prevention can make them go away entirely. There will always be a need for accessible dental check-ups and treatments to facilitate good oral health. And it remains important to expand access to such treatments among disadvantaged groups as well as in many low- and middle-income countries so as to reduce inequalities in healthcare provision. Less trips to the dentist would also mean less travel and water consumption Dental procedures require a lot of water, which can be reduced by practicing good oral healthcare. Oral healthcare has higher levels of patient and staff transport than other medical specializations and this is partly due to the need for regular oral health maintenance, whereas other specializations tend only to treat illness. In the UK for instance, staff and patient commuting and travel accounts for approximately two thirds of all emissions from the oral healthcare sector and about eight per cent of the total UK NHS air pollution attributable to travel. This can be reduced significantly, through the maintenance of good oral health, that requires fewer interventions and consequently fewer trips to the dentist. Simple transport habit changes can have a great impact. For example, in October 2021 the Sustainability Committee at Harvard School of Dental Medicine (HSDM) implemented a `Step Challenge´ that encouraged staff, students and faculty to walk, or take public transport rather than drive during that month. They amassed over one million steps in total, preventing the release of approximately 0.28 metric tons of CO2. The practice of dentistry and personal oral healthcare is a significant consumer of water. As a conservative estimate, a bathroom tap delivers about four litres/minute. If we estimate that half the world population cleans their teeth once a day and runs the tap for one minute, the daily global water usage equates to 6,400 Olympic swimming pools. This figure is in addition to undocumented water consumption up and down the oral healthcare manufacturing and distribution supply chain. Reducing dental use of single use plastics and packaging Measures to reduce carbon footprint in dental offices. So what measures can be taken at the dentist office to reduce the carbon footprint of dentistry procedures that are nonetheless essential to good oral health? The use and consequent disposal of single use plastics for many procedures is one of the biggest contributors to the environmental footprint of healthcare generally – and that holds true for dentistry as well. Among single-use plastics, in fact it is the packaging in which the needles, gloves and other oral healthcare products are encased that is the single largest contributor to such waste in the dental industry, with over 90 % ending its life cycle in an incinerator or a landfill. A more thoughtful approach to the design of such packaging – from the plastics content, manufacture and transport, to the potential for reuse, recycling or biodegradability, is therefore one obvious starting point in reducing the carbon footprint of the typical dentist’s office. This is particularly important because packaging, as such, is not “contaminated” biomedical waste that needs special treatment, post-procedure. This requires greater engagement with consumers and waste management companies to segregate, collect and recycle uncontaminated clinical single use plastics (SUPs) as a valuable commodity. It also involves the design and development of more plastic items made from mono-polymer plastics that can be readily recycled. The Flexible Plastics Consortium which represents 34 European companies looking for better plastics content and design solutions for packaging is a good example of how this might work in practice. The United Kingdom’s Plastics Pact is another good example: it has set targets with the goal of 100% of plastic packaging to be reused, recycled or compostable by 2025. Major challenges in managing single use plastic waste from oral healthcare Many single use dental items end up in the waste bin, including gloves, aprons, masks. Once the box is opened, many of the everyday products used in dentistry are only briefly used and then end up in the waste bin. These single-use plastic (SUP) items range from personal protective equipment (aprons, gloves and masks) and other disposable sundries (the mouth-rinse cup or the dental suction tube). SUP biomedical waste requires more specialized management – since these are contaminated with blood and other bodily fluids from oral health procedures. The high safety and quality requirements for these products to be legally compliant, is often incompatible with recycling and materials recovery. The complex nature of items assembled from different plastics also makes recycling difficult, as does the prevailing view that plastic is simply waste and is not considered a valuable resource. Still there are many attempts at finding solutions around the world. These include incentivization schemes and professional education courses that can help manufacturers to design products that can be safely treated and reprocessed, as well as sensitizing dental practitioners to different waste streams, and the treatment they require. Initiatives like the development of a competency-based dental waste management course being undertaken at the Copperbelt University in Zambia are a step in the right direction. Even so, the lack of good technological solutions for the appropriate collection, disinfection/sterilization and subsequent recovery or reprocessing of single use plastics used in biomedical procedures remains an ongoing barrier. We need product research to come up with safe, sustainable solutions for a circular economy, including in the healthcare sector, and governments to adopt supportive policies. Assessing the environmental impacts of oral healthcare as a first step It is important to understand the environmental impacts of materials used in healthcare. A better understanding of the environmental impacts of products and materials used in healthcare systems, from procurement to disposal, is key to any of these measures. Solutions proposed have included more life cycle analysis for all materials used in the healthcare supply chain and the development of a credible ‘sustainability index’ to inform medical supply purchasers about the sustainability credentials of a product. The index could potentially include information on environmental sourcing, ethical manufacturing, supply chain distribution and procurement. This World Oral Health Day we can celebrate the fact that the oral health sector has recognised that it has a vital role to play in healthcare-related climate change mitigation. That is the first step. The next ones will be more challenging and will need ‘teeth’. The FDI World Dental Federation´s Code of Good Practice, which is to be launched later this year, following an extensive consultation with the sector, will be a good starting point for ensuring healthy mouths also help to produce a healthier planet. Steven Mulligan Nicolas Martin Ihsane Ben Yahya Ihsane Ben Yahya is the President of the FDI World Dental Federation and professor at the Dental University in Casablanca, Morocco. Nicolas Martin is the Chair of the FDI Sustainability in Dentistry Task Team. He is also Clinical Professor in Restorative Dentistry in the School of Clinical Dentistry, at the University of Sheffield, UK. Steven Mulligan is a Member of the FDI Sustainability in Dentistry Task Team. He is also a Clinical Lecturer in Restorative Dentistry in the School of Clinical Dentistry, at the University of Sheffield, UK. Image Credits: Mass Communication Specialist Seaman Apprentice Brian H. Abel/Flickr, FDI World Dental Federation , Jan Fidler/Flickr, World Dental Federation , Mass Communication Specialist 3rd Class Everett Allen/Flickr. 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