Does Dentistry Have an Ethical Obligation to Be More Sustainable?
Dentistry has a plastics problem, and not many people are talking about it. In the garbage dump the size of Texas floating in the Pacific Ocean, there are not only plastic straws and water bottles but also plastics we use in practice every day. Plastics can be found in any part of our oceans, even in places as remote as Antarctica, and they are wreaking havoc on wildlife and the food chain. Our profession must contend with its contribution to this problem. Even those of us practicing in the heartland, far removed from the coasts, are complicit. Trash is shipped great distances based on the availability of local facilities and politics, and waste seeps into the environment in landfills across the country. No matter our location, we are all connected by this issue. The problem seems overwhelming and insurmountable; finding the balance between patient safety and environmental stewardship is not going to be easy. But the time has come to look carefully at this issue and collectively strategize solutions. Dentists have an ethical obligation to do so.
Regardless of differing opinions on conservation politics, everyone can agree that leaving the world a better place for our children and grandchildren is a good idea. Single-use plastics are a significant contributor to the crisis our world is now facing. However, dentistry is increasingly reliant on unit dose systems packaged in plastics for medicaments, restorative materials, dressing materials, and medication administration. Undeniably, the motivations for this movement are patient safety, infection control, and convenience, but this practice may be causing more harm than we realize. A healthy person requires a healthy environment. The byproducts of plastic waste and microplastics in our environment have had a proven effect on the food chain at its most basic levels. The long-term health effects of a contaminated environment are yet to be determined, but it appears the problem may be making us sick.1
It is hard to fathom running a dental practice or living life without plastic. Complete elimination of plastic may not be currently feasible, but decreasing its use is. Even if a paradigm shift should occur tomorrow, it is going to take time to make a significant difference. Some would argue that time is the most precious resource of all and that if we don’t act quickly, it will be too late. The entire healthcare industry—and the massive amounts of waste it generates and discards—poses an urgent threat to the environment. Significantly more research dollars should be allocated to investigating and solving this global problem within our field. In the meantime, prudent use of resources is appropriate.
It is eye opening to step back and observe the sheer amount of plastic and other waste generated in dental offices on a daily basis. For example, it is common to put nonrecyclable plastic bags over the dental chair, X-ray tube heads, tray delivery systems, and other equipment for the sake of infection control, replacing them after each patient. Consider all of the tiny unit dose composite compules and plastic wells used and discarded in a single day. Think about disposable brushes, impression material syringes, high-speed suction and saliva ejector tips, and all the other nonrecyclable materials in a typical dental office.
The problem is even more profound in other sectors of the healthcare industry. Consider hospitals, for example. According to the American Hospital Association, the majority of the materials procured by a hospital ultimately become waste, creating nearly 7,000 tons of waste every day and costing $10 billion annually in disposal fees.2 All told, US healthcare facilities generate about 14,000 tons of waste per day; up to 25% is plastic.3 The impact is daunting.
The term sustainability was first coined in 1987 in Report of the World Commission on Environment and Development: Our Common Future, also known as the Brundtland Report.4 This report explored the connection between social equity, economic growth, the environment and policy. The Brundtland Report is most known for characterizing sustainable development as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”4 In 2015, the United Nations and each of its Member States adopted 17 Global Sustainable Development Goals (SDGs) as part of the 2030 Agenda for Sustainable Development, which provides a “shared blueprint for peace and prosperity for people and the planet, now and into the future” (Figure).5
The SDGs recognize that5:
. . . ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth—all while tackling climate change and working to preserve our oceans and forests.
More recently, in 2017, the FDI World Dental Federation General Assembly adopted a significant policy statement.6 The document provides guidance to the dental profession in this new era of sustainability initiatives, emphasizing that6:
Dentistry must be practiced ethically, with high levels of quality and safety, in the pursuit of optimal oral health. Sustainability integrates a broader commitment of the oral health professional to social and environmental responsibility. The right of future generations to a world with adequate natural resources must be respected.
Similar to the Brundtland Report, the FDI statement defines sustainability as “the degree to which a process or enterprise can be maintained or continued while avoiding the long-term depletion of natural resources.”6 The document advises on key issues such as the life cycle of dental products, suggesting ways to limit single-use and disposable materials without compromising patient safety or treatment quality. This document clearly equates sustainable practices in dentistry with an ethical obligation to respect the natural environment in the course of providing patient care and doing business.6
Although the tides are turning slowly, awareness is rising about the need for more sustainable business practices in dentistry and the healthcare industry in general. The American College of Dentists recently dedicated an entire journal issue to sustainability.7 Other dental journals have also dedicated space to this topic. Dental continuing education courses on making your practice eco-friendly are popping up at various regional meetings, and there is even an organization dedicated to eco-dentistry.8 It’s a start.
While it certainly helps, sustainability involves more than just recycling. Currently, the recycling of medical waste is complicated due to waste management protocols and concerns about contamination and infection control. As mentioned earlier, it is estimated that approximately 25% of medical waste is plastic, and a good portion of it is recyclable.3 However, the safety regulations of agencies such as the Occupational Safety and Health Administration, the Environmental Protection Agency (EPA), and Drug Enforcement Administration prevent the recycling of medical waste.2
Dental schools may be the perfect place to start a sustainability movement within the profession and lead research in this area. The average age of first-year dental students in the United States is 24 years, and millennials are widely considered the most ecologically aware generation of adults to date, having grown up hearing conversations about climate change and witnessing extreme climate events.9,10 According to one survey, 87% of millennials “believe companies should help address social and environmental issues.”11 Subsequent generations will be equally attuned to these issues, if not more so.
Those of us involved in dental education have an opportunity to acknowledge this shift and incorporate sustainability content into dental school curricula. In addition, role modeling sustainable practices within dental education programs could go a long way in developing environmental stewardship within students, who may go on to promote these practices when they graduate. Adding such content to already full dental school curricula may be a challenge, but it is a challenge that can be met. It does not take an environmental expert to speak to these issues. With a little research and administrative support, interested faculty could easily tap into the growing number of resources available to create a valuable lecture or two to complement the ethics or practice management components of any curriculum.
If the profession itself does not take the initiative to change, the government may make those decisions for us. Amalgam regulations are a perfect example of federal policies put in place to protect the public and reduce environmental waste generated in dental offices. The newest federal amalgam regulations state that all nonexempt practitioners must install an EPA-compliant amalgam separator by July 14, 2020, even if they do not use amalgam in their office.12 Offices that began operating on or after July 14, 2017, must already be in compliance.12 Ironically, many of the receptacles on the market for chairside amalgam waste collection are made of plastic. In light of the new FDI policy statement and growing awareness of the plastics problem in healthcare, it would be wise for the dental profession to be proactive and develop meaningful solutions instead of maintaining the status quo until the federal government decides to impose further regulations on practitioners.
As dentists and healthcare professionals, our primary ethical obligation is to care for the health and well-being of our patients—inside and outside the walls of a practice. Environmental concerns permeate our identity as dental professionals. They exist in our homes, our communities, and the larger world in which we live and work. To be whole as a professional is to tend to all facets of our duty with pride. Ultimately, I believe this duty extends to the prudent care of our planet. Without health, a patient suffers, but on an unhealthy planet, humanity suffers. The world is in dire need of strong healthcare leaders to take on this responsibility. Dentists can be a driving force in creating more sustainable healthcare practices and, in turn, advancing the ethics of the profession.
Author information
Dr Roucka is the Associate Dean for Academic Affairs, University of Illinois at Chicago (UIC) College of Dentistry, a fellow of the American College of Dentists (ACD), and liaison to the ACD board for the American Society for Dental Ethics. She is also the faculty advisor for the UIC College of Dentistry Eco-Educator student organization.
References
1. Thompson A. From fish to humans, a microplastic invasion may be taking a toll. Scientific American. September 4, 2018. https://www.scientificamerican.com/article/from-fish-to-humans-a-microplastic-invasion-may-be-taking-a-toll/. Accessed January 3, 2020.
2. American Hospital Association. Sustainability Roadmap for Hospitals. Waste. http://www.sustainabilityroadmap.org/topics/waste.shtml#.XhZ_2UdKjD4. Accessed January 8, 2020.
3. Gibbens S. Can medical care exist without plastic? National Geographic. October 4, 2019. https://www.nationalgeographic.com/science/2019/10/can-medical-care-
exist-without-plastic/#close. Accessed February 10, 2020.
4. United Nations. Report of the World Commission on Environment and Development: Our Common Future. March 20, 1987. http://www.un-documents.net/our-common-future.pdf. Accessed January 3, 2020.
5. United Nations Department of Economic and Social Affairs, Division for Sustainable Development Goals. Sustainable Development Goals. https://sustainabledevelopment.un.org/?menu=1300. Accessed January 3, 2020.
6. Sustainability in dentistry: adopted by the FDI General Assembly: August 2017, Madrid, Spain. Int Dent J. 2018;68(1):10-11.
7. Chambers DW, ed. Sustainability. J Am Coll Dent. 2018;85(3, theme issue):1-44.
8. Eco-Dentistry Association. https://ecodentistry.org/. Accessed February 7, 2020.
9. González G, Anderson E, Novak KF, Valachovic RW. U.S. dental school applicants and enrollees, 2009 entering class. J Dent Educ. 2011;75(8)1133-1157.
10. Farrell SS. Millennials and Their Impact on Sustainability. Sustainability Management School (SUMAS). January 22, 2019. https://sumas.ch/millennials-and-sustainability. Accessed January 3, 2020.
11. CONE. 2017 CONE Gen Z CSR Study: How to Speak Z. 2017. https://www.conecomm.com/insights-blog/2017/9/18/announcing-the-2017-cone-gen-z-csr-study-how-to-speak-z. Accessed February 7, 2020.
12. American Dental Association. Amalgam. https://success.ada.org/en/regulatory-legal/amalgam. Accessed January 3, 2020.
Regardless of differing opinions on conservation politics, everyone can agree that leaving the world a better place for our children and grandchildren is a good idea. Single-use plastics are a significant contributor to the crisis our world is now facing. However, dentistry is increasingly reliant on unit dose systems packaged in plastics for medicaments, restorative materials, dressing materials, and medication administration. Undeniably, the motivations for this movement are patient safety, infection control, and convenience, but this practice may be causing more harm than we realize. A healthy person requires a healthy environment. The byproducts of plastic waste and microplastics in our environment have had a proven effect on the food chain at its most basic levels. The long-term health effects of a contaminated environment are yet to be determined, but it appears the problem may be making us sick.1
It is hard to fathom running a dental practice or living life without plastic. Complete elimination of plastic may not be currently feasible, but decreasing its use is. Even if a paradigm shift should occur tomorrow, it is going to take time to make a significant difference. Some would argue that time is the most precious resource of all and that if we don’t act quickly, it will be too late. The entire healthcare industry—and the massive amounts of waste it generates and discards—poses an urgent threat to the environment. Significantly more research dollars should be allocated to investigating and solving this global problem within our field. In the meantime, prudent use of resources is appropriate.
It is eye opening to step back and observe the sheer amount of plastic and other waste generated in dental offices on a daily basis. For example, it is common to put nonrecyclable plastic bags over the dental chair, X-ray tube heads, tray delivery systems, and other equipment for the sake of infection control, replacing them after each patient. Consider all of the tiny unit dose composite compules and plastic wells used and discarded in a single day. Think about disposable brushes, impression material syringes, high-speed suction and saliva ejector tips, and all the other nonrecyclable materials in a typical dental office.
The problem is even more profound in other sectors of the healthcare industry. Consider hospitals, for example. According to the American Hospital Association, the majority of the materials procured by a hospital ultimately become waste, creating nearly 7,000 tons of waste every day and costing $10 billion annually in disposal fees.2 All told, US healthcare facilities generate about 14,000 tons of waste per day; up to 25% is plastic.3 The impact is daunting.
The term sustainability was first coined in 1987 in Report of the World Commission on Environment and Development: Our Common Future, also known as the Brundtland Report.4 This report explored the connection between social equity, economic growth, the environment and policy. The Brundtland Report is most known for characterizing sustainable development as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”4 In 2015, the United Nations and each of its Member States adopted 17 Global Sustainable Development Goals (SDGs) as part of the 2030 Agenda for Sustainable Development, which provides a “shared blueprint for peace and prosperity for people and the planet, now and into the future” (Figure).5
The SDGs recognize that5:
. . . ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth—all while tackling climate change and working to preserve our oceans and forests.
More recently, in 2017, the FDI World Dental Federation General Assembly adopted a significant policy statement.6 The document provides guidance to the dental profession in this new era of sustainability initiatives, emphasizing that6:
Dentistry must be practiced ethically, with high levels of quality and safety, in the pursuit of optimal oral health. Sustainability integrates a broader commitment of the oral health professional to social and environmental responsibility. The right of future generations to a world with adequate natural resources must be respected.
Similar to the Brundtland Report, the FDI statement defines sustainability as “the degree to which a process or enterprise can be maintained or continued while avoiding the long-term depletion of natural resources.”6 The document advises on key issues such as the life cycle of dental products, suggesting ways to limit single-use and disposable materials without compromising patient safety or treatment quality. This document clearly equates sustainable practices in dentistry with an ethical obligation to respect the natural environment in the course of providing patient care and doing business.6
Although the tides are turning slowly, awareness is rising about the need for more sustainable business practices in dentistry and the healthcare industry in general. The American College of Dentists recently dedicated an entire journal issue to sustainability.7 Other dental journals have also dedicated space to this topic. Dental continuing education courses on making your practice eco-friendly are popping up at various regional meetings, and there is even an organization dedicated to eco-dentistry.8 It’s a start.
While it certainly helps, sustainability involves more than just recycling. Currently, the recycling of medical waste is complicated due to waste management protocols and concerns about contamination and infection control. As mentioned earlier, it is estimated that approximately 25% of medical waste is plastic, and a good portion of it is recyclable.3 However, the safety regulations of agencies such as the Occupational Safety and Health Administration, the Environmental Protection Agency (EPA), and Drug Enforcement Administration prevent the recycling of medical waste.2
Dental schools may be the perfect place to start a sustainability movement within the profession and lead research in this area. The average age of first-year dental students in the United States is 24 years, and millennials are widely considered the most ecologically aware generation of adults to date, having grown up hearing conversations about climate change and witnessing extreme climate events.9,10 According to one survey, 87% of millennials “believe companies should help address social and environmental issues.”11 Subsequent generations will be equally attuned to these issues, if not more so.
Those of us involved in dental education have an opportunity to acknowledge this shift and incorporate sustainability content into dental school curricula. In addition, role modeling sustainable practices within dental education programs could go a long way in developing environmental stewardship within students, who may go on to promote these practices when they graduate. Adding such content to already full dental school curricula may be a challenge, but it is a challenge that can be met. It does not take an environmental expert to speak to these issues. With a little research and administrative support, interested faculty could easily tap into the growing number of resources available to create a valuable lecture or two to complement the ethics or practice management components of any curriculum.
If the profession itself does not take the initiative to change, the government may make those decisions for us. Amalgam regulations are a perfect example of federal policies put in place to protect the public and reduce environmental waste generated in dental offices. The newest federal amalgam regulations state that all nonexempt practitioners must install an EPA-compliant amalgam separator by July 14, 2020, even if they do not use amalgam in their office.12 Offices that began operating on or after July 14, 2017, must already be in compliance.12 Ironically, many of the receptacles on the market for chairside amalgam waste collection are made of plastic. In light of the new FDI policy statement and growing awareness of the plastics problem in healthcare, it would be wise for the dental profession to be proactive and develop meaningful solutions instead of maintaining the status quo until the federal government decides to impose further regulations on practitioners.
As dentists and healthcare professionals, our primary ethical obligation is to care for the health and well-being of our patients—inside and outside the walls of a practice. Environmental concerns permeate our identity as dental professionals. They exist in our homes, our communities, and the larger world in which we live and work. To be whole as a professional is to tend to all facets of our duty with pride. Ultimately, I believe this duty extends to the prudent care of our planet. Without health, a patient suffers, but on an unhealthy planet, humanity suffers. The world is in dire need of strong healthcare leaders to take on this responsibility. Dentists can be a driving force in creating more sustainable healthcare practices and, in turn, advancing the ethics of the profession.
Author information
Dr Roucka is the Associate Dean for Academic Affairs, University of Illinois at Chicago (UIC) College of Dentistry, a fellow of the American College of Dentists (ACD), and liaison to the ACD board for the American Society for Dental Ethics. She is also the faculty advisor for the UIC College of Dentistry Eco-Educator student organization.
References
1. Thompson A. From fish to humans, a microplastic invasion may be taking a toll. Scientific American. September 4, 2018. https://www.scientificamerican.com/article/from-fish-to-humans-a-microplastic-invasion-may-be-taking-a-toll/. Accessed January 3, 2020.
2. American Hospital Association. Sustainability Roadmap for Hospitals. Waste. http://www.sustainabilityroadmap.org/topics/waste.shtml#.XhZ_2UdKjD4. Accessed January 8, 2020.
3. Gibbens S. Can medical care exist without plastic? National Geographic. October 4, 2019. https://www.nationalgeographic.com/science/2019/10/can-medical-care-
exist-without-plastic/#close. Accessed February 10, 2020.
4. United Nations. Report of the World Commission on Environment and Development: Our Common Future. March 20, 1987. http://www.un-documents.net/our-common-future.pdf. Accessed January 3, 2020.
5. United Nations Department of Economic and Social Affairs, Division for Sustainable Development Goals. Sustainable Development Goals. https://sustainabledevelopment.un.org/?menu=1300. Accessed January 3, 2020.
6. Sustainability in dentistry: adopted by the FDI General Assembly: August 2017, Madrid, Spain. Int Dent J. 2018;68(1):10-11.
7. Chambers DW, ed. Sustainability. J Am Coll Dent. 2018;85(3, theme issue):1-44.
8. Eco-Dentistry Association. https://ecodentistry.org/. Accessed February 7, 2020.
9. González G, Anderson E, Novak KF, Valachovic RW. U.S. dental school applicants and enrollees, 2009 entering class. J Dent Educ. 2011;75(8)1133-1157.
10. Farrell SS. Millennials and Their Impact on Sustainability. Sustainability Management School (SUMAS). January 22, 2019. https://sumas.ch/millennials-and-sustainability. Accessed January 3, 2020.
11. CONE. 2017 CONE Gen Z CSR Study: How to Speak Z. 2017. https://www.conecomm.com/insights-blog/2017/9/18/announcing-the-2017-cone-gen-z-csr-study-how-to-speak-z. Accessed February 7, 2020.
12. American Dental Association. Amalgam. https://success.ada.org/en/regulatory-legal/amalgam. Accessed January 3, 2020.