Sustainable Dentistry: Making a Difference

Acknowledgements
Contents
List of Figures
List of Tables
List of Boxes
1: Sustainable Dentistry: An Urgent Need for Change
	1.1	 An Urgent Need for Change
	1.2	 Healthcare Systems Cause Planetary Health Deterioration
	1.3	 How to Read This Book
		1.3.1	 Environmental Impact Categories
			1.3.1.1	 Climate Change: Climate Change Total
			1.3.1.2	 Ecosystem Quality: Freshwater Ecotoxicity
			1.3.1.3	 Ecosystem Quality: Freshwater Eutrophication
			1.3.1.4	 Resources: Dissipated Water
			1.3.1.5	 Human Health: Respiratory Effects, Inorganics
			1.3.1.6	 Resources: Land Use
			1.3.1.7	 Human Health: Photochemical Ozone Creation (POC)
			1.3.1.8	 Human Health: Ozone Layer Depletion
			1.3.1.9	 Human Health: Non-carcinogenic Effects
			1.3.1.10	 Human Health: Ionising Radiation
			1.3.1.11	 Resources: Fossils
			1.3.1.12	 Human Health: Carcinogenic Effects
			1.3.1.13	 Ecosystem Quality: Marine Eutrophication
			1.3.1.14	 Ecosystem Quality: Terrestrial Eutrophication
			1.3.1.15	 Ecosystem Quality: Freshwater and Terrestrial Acidification
			1.3.1.16	 Resources: Minerals and Metals
		1.3.2	 DALYs (Disability-Adjusted Life Years)
		1.3.3	 Normalised Figures
	References
2: Building a Sustainable Dental Practice
	2.1	 Introduction
	2.2	 Environmental Impact
	2.3	 To Build or Not to Build (Retrofit)
	2.4	 New Build Dental Surgery
		2.4.1	 Energy Efficiency
		2.4.2	 Energy Production
		2.4.3	 Heating System
		2.4.4	 Ventilation
		2.4.5	 Water Management
	2.5	 Habitat Level Considerations for Build Options
		2.5.1	 Greenspace Area for Biodiversity
		2.5.2	 Greenspace Areas That Facilitate Adaptation to Extreme Weather Events
		2.5.3	 Non-traditional Greenspace Areas
	References
3: Planning the Location, Skills Mix and Method of Delivery of Care, and Reducing Your Travel Emissions for Sustainable Dentistry
	3.1	 Environmental Sustainability and Travel Within the Dental Practice
	3.2	 The Contribution of Dentistry to the Travel Footprint
	3.3	 Improving Sustainable Travel
		3.3.1	 Combining Appointments
		3.3.2	 Only Undertaking Evidence-Based Dentistry
		3.3.3	 Preventative Dentistry
		3.3.4	 Appropriate Dental Examination Scheduling
	3.4	 Using Information Technology
		3.4.1	 The Basics of Teledentistry
		3.4.2	 Capturing the Data
		3.4.3	 Store and Forward Teledentistry
		3.4.4	 Security, Accuracy, and Acceptance
		3.4.5	 Cost-Effectiveness of Teledentistry
	3.5	 Mode of Travel
		3.5.1	 Active Travel
		3.5.2	 Public Transport or Car Sharing
		3.5.3	 Rent a Car and Use It only When You Need It
		3.5.4	 Electric Vehicles
		3.5.5	 Improving the Sustainability of Conventional Car Travel
	3.6	 Travel Policies
	References
4: Reducing the Energy Needs of Your Dental Practice
	4.1	 Introduction to Energy and Water
	4.2	 Quantity of Each Utility Used in the Dental Practice
		4.2.1	 Quantity of Water Used in a Dental Practice
		4.2.2	 Environmental Outcomes of Water
		4.2.3	 Environmental Consequences of Energy Used in a Dental Practice
	4.3	 How Demand Can Be Minimised
		4.3.1	 Building Anew or Reconfiguring Existing Building
		4.3.2	 Space Utilisation
		4.3.3	 Energy Efficiency Can Be Improved in a Number of Ways in the Dental Practice
		4.3.4	 Sealing and Draught Proofing
		4.3.5	 Double Glazing
		4.3.6	 Blinds and Curtains
		4.3.7	 Timers and Thermostats
		4.3.8	 Radiators and Closing Doors
		4.3.9	 Smart Meters
		4.3.10	 Boiler Efficiency
		4.3.11	 Air Conditioning
		4.3.12	 Water Heating
	4.4	 Choosing Sustainable Appliances
		4.4.1	 Energy Use of Different Appliances
		4.4.2	 High Energy Appliances
			4.4.2.1	 Computers
			4.4.2.2	 Water Coolers
			4.4.2.3	 Televisions
			4.4.2.4	 Lighting
			4.4.2.5	 Fridges
			4.4.2.6	 Dental Suction
			4.4.2.7	 Autoclaves, Washer Disinfectors, and Ultrasonic Cleaners
		4.4.3	 Moderate Energy Appliances
		4.4.4	 Low Energy Appliances
		4.4.5	 Turning Off Appliances
	4.5	 The Environmental Impact of Energy Sources: Buying Appropriate Sustainable Energy and/or Generating Energy In-House
		4.5.1	 Transmission of Energy and Embodied Environmental Impact
			4.5.1.1	 Wood Pellets
			4.5.1.2	 Energy from Incineration
			4.5.1.3	 Solar Power
			4.5.1.4	 Wind Energy
		4.5.2	 Comparison of Fuel Types, Cost, and Carbon Dioxide Emissions (CO2e)
			4.5.2.1	 Heating the Practice with Non-renewable Energy
			4.5.2.2	 Heat Pumps
			4.5.2.3	 Solar Thermal Systems
			4.5.2.4	 Recycling of Hot Water Systems
	References
5: Prevention: The Sustainable Practice Initiative
	5.1	 Introduction
	5.2	 Caries
		5.2.1	 Public Health Measures to Prevent Caries
		5.2.2	 Diet Advice
		5.2.3	 Toothbrushing with a Fluoride Toothpaste
		5.2.4	 Fluoride Mouth Rinse
		5.2.5	 Fluoride Varnish Application
		5.2.6	 Fissure Sealants
	5.3	 Periodontal Disease
		5.3.1	 Toothbrushes
		5.3.2	 Interdental Cleaning Aids
		5.3.3	 Systemic Disease and Periodontal Disease
	5.4	 Non-carious Tooth Tissue Loss
		5.4.1	 Erosion
		5.4.2	 Attrition
		5.4.3	 Abrasion
	5.5	 Oral Cancer
		5.5.1	 Tobacco
		5.5.2	 Alcohol
		5.5.3	 HPV Infection
	5.6	 Conclusion
	References
6: A Guide to How to Reduce the Impact of PPE in Your Dental Practice
	6.1	 PPE in the Dental Setting
	6.2	 Environmental Impact of PPE
	6.3	 Opportunities to Mitigate Environmental Impact of PPE
		6.3.1	 Reduce
		6.3.2	 Reusables
		6.3.3	 Recycling and Alternative Waste Processing
		6.3.4	 Low Carbon Manufacture and Distribution
	6.4	 Challenges and Opportunities for Sustainable PPE
	References
Untitled
7: Responsible Decontamination
	7.1	 Introduction
	7.2	 Recommendations for Instrument Decontamination and Autoclaving
		7.2.1	 Washer Disinfector
		7.2.2	 Autoclave
		7.2.3	 Recommendations for Cleaning Waterlines
		7.2.4	 Recommendations for Suction System Cleaning
		7.2.5	 Recommendations for Surface Disinfection
		7.2.6	 Recommendations for Cleaning Prosthesis
	7.3	 An LCA of Hypothetical Products
		7.3.1	 Surface Wipe 1
		7.3.2	 Surface Wipe 2
		7.3.3	 Surface Wipe 3
		7.3.4	 Sustainable Wipes
		7.3.5	 Cleaning Prosthesis
		7.3.6	 Washer Disinfectant Using Chemicals Part A and B
		7.3.7	 Washer Disinfectant Using the Chemical Methyl Pentane
		7.3.8	 Sterilisation Using an Autoclave
	7.4	 Considerations About Chemicals
	7.5	 Conclusion
	References
Untitled
8: Supporting People and Their Behaviour in the Dental Setting as Sustainably as Reasonably Achievable
	8.1	 Introduction
		8.1.1	 Dental Behaviour Support
		8.1.2	 Populations Covered
	8.2	 Choices for Behaviour Support in Dentistry
		8.2.1	 Communication-Mediated Dental Behaviour Support Techniques
		8.2.2	 Inhalation Sedation
		8.2.3	 Intravenous Sedation
		8.2.4	 General Anaesthesia
	8.3	 Factors Influencing Selection and Application of Behaviour Supports
		8.3.1	 Sustainability of Different Techniques
		8.3.2	 Communication-Mediated DBS
		8.3.3	 Inhalation Sedation
		8.3.4	 Intravenous Sedation
		8.3.5	 General Anaesthesia
	8.4	 Comparing Sustainability of Alternative Modalities
	8.5	 Sustainability of Dental Behaviour Support (DBS): As Sustainable as Reasonably Acceptable (ASARA)
	8.6	 Policy
	8.7	 Leadership
	8.8	 Research and Education
		8.8.1	 Dental Education Should
	8.9	 Clinical Practice
	8.10	 Conclusion
	References
9: Buying Sustainably and Ethically for the Dental Practice (Procurement)
	9.1	 Sustainable Procurement
	9.2	 Type of Product
	9.3	 Buy Less
		9.3.1	 Stock Control
	9.4	 Buy Better
		9.4.1	 Safe for the Patient and the Dental Team
		9.4.2	 Fit for Purpose
		9.4.3	 Not Fossil Fuel Based
		9.4.4	 Grown: But Able to Be Reused Repeatedly, or Able to Be Reused with Local Processing
		9.4.5	 Supplied in Sustainable Packaging
			9.4.5.1	 Recycling and Packaging
		9.4.6	 Biodegradable into Harmless Natural Environmental Elements
		9.4.7	 Easy to Clean and Reuse, Where Possible Without Causing More Harm Than Good
		9.4.8	 Simple, i.e. Not a Complex Product That’s Difficult to Recycle
		9.4.9	 Transported with Clean Vehicles or Locally
		9.4.10	 Produced with Renewable Energy
		9.4.11	 Manufactured in Ways That Do Not Involve Abuse of Labour
		9.4.12	 Involving Suppliers and Supply Chains That Espouse Good Environmental Management Protection
		9.4.13	 Inexpensive
	9.5	 Collaborating to Accelerate the Pace of Change
		9.5.1	 Sustainability and Ethical Procurement Questionnaire
	References
10: Responsible Waste Management: Using Resources Efficiently
	10.1	 Introduction
	10.2	 Types of Dental Waste
	10.3	 Costs and Environmental Emissions
	10.4	 Environmental Comparison of Different Waste Streams
	10.5	 Improving Waste Management Using the Waste Hierarchy
		10.5.1 Preventing the Generation of Waste
			10.5.1.1 Influencing Manufacturers and Suppliers to Produce Less Waste
			10.5.1.2 Reducing Paper Use
			10.5.1.3 Reducing Medicines Waste
		10.5.2 Preparing for Reuse
			10.5.2.1 Use of Reusable Instruments
			10.5.2.2 Durable Equipment
			10.5.2.3 Reuse and Up-Cycle
		10.5.3 Recycling
			10.5.3.1 Recyclable Waste
			10.5.3.2 Food Waste
		10.5.4 Recovering Energy from Waste (Waste to Energy)
		10.5.5 Clinical Waste and Landfill
			10.5.5.1 Location, Availability, and Type of Bins
	10.6	 Performing a Waste Audit
	10.7	 The Impact on Human Health of a Single Dental Appointment
	10.8	 Changing Waste Disposal Behaviours in the Dental Setting
		10.8.1	Barriers to pro-environmental behaviour
			10.8.1.1 Lack of Understanding
			10.8.1.2 Too Much Trouble
			10.8.1.3 Lack of Commitment/Accountability
		10.8.2 Enablers of pro-environmental behaviour
			10.8.2.1 Discussions with Industry
			10.8.2.2 Incentives and Disincentives
			10.8.2.3 Legislation
	References
11: The Future of Dentistry Products: How Can We Redesign the Products We Create
	11.1	 Innovating to Improve Sustainability
		11.1.1	 Starting with Something Simple
		11.1.2	 Simplifying Forms, Materials, and Processes
		11.1.3	 Copying Nature: Biomimicry [3]
		11.1.4	 Industrial Ecology
		11.1.5	 Develop Sustainable Product-Service Systems (SPSS)
	11.2	 Case Studies in Innovative Sustainability
		11.2.1	 Case Study 1: A Company Makes Small or Rapid Changes
		11.2.2	 Simplification, Reduction, and Maximising the Lifespan of the Toothbrush
		11.2.3	 Case Study 2: Producing an Alternative to Non-recyclable Gloves
		11.2.4	 Case Study 3
		11.2.5	 Case Studies: Summary
	References
12: Sustainability: The Need to Transform Oral Health Systems
	12.1	 Introduction
	12.2	 Six Health Systems Framework Building Blocks
	12.3	 Building Block: Service Delivery
		12.3.1	 Integrated Service Delivery Models and Packages
		12.3.2	 Consumer Engagement Influencing Demand for Care
		12.3.3	 Infrastructure and Logistics
		12.3.4	 Patient Safety and Quality of Care
		12.3.5	 Leadership and Management
	12.4	 Building Block: Health Workforce
		12.4.1	 Knowledge
		12.4.2	 Skills
			12.4.2.1	 Scope of Practice
			12.4.2.2	 Oral Health Care Integrated into Allied Health Training
		12.4.3	 Workforce Planning
		12.4.4	 Research Capacity
	12.5	 Building Block: Health Information Systems
		12.5.1	 Health Determinants, Health System Performance, and Health Status
		12.5.2	 Environmental Measures
		12.5.3	 Quality Improvement
		12.5.4	 Big Data
		12.5.5	 Travel Metrics
	12.6	 Building Block: Access to Essential Medicines and Technologies
		12.6.1	 Essential Medical Products
		12.6.2	 Access to Fluorides and Toothbrush
		12.6.3	 Access to Prevention
		12.6.4	 Access to Fluoride Varnish
		12.6.5	 Considering the Environmental Risk/Benefit of Dental Care
	12.7	 Building Block: Financing
		12.7.1	 Revenue Collection
		12.7.2	 Pooling
		12.7.3	 Purchasing
	12.8	 Leadership/Governance
		12.8.1	 Governance
		12.8.2	 Coalition Building
		12.8.3	 Inclusion of Public in Decision-Making
		12.8.4	 Appropriate Sustainability Informed Guidelines
		12.8.5	 Monitoring
	12.9	 How Do We Influence Dentistry?
	References
13: Conclusion
	Reference