Environmental sustainability: the attitudes and experiences of UK students in the oral health care profession.

Objective This study aims to provide insight into the attitudes and perspectives of undergraduate dental students from UK dental schools regarding environmental sustainability in dentistry (ESD) and the manner and extent in which ESD is included in the current undergraduate oral health care curricula.Methods This study is a multi-centre, nationally representive study involving a cross-sectional online survey of undergraduate Bachelor of Dental Surgery and dental hygiene and therapy students in UK-based dental schools. Data analysis was conducted through descriptive statistics and thematic analysis.Results In total, 263 students from 13 UK schools completed the survey, resulting in a national school response rate of 68.4%. Key findings are: 97.3% of students believe that the dental profession should be more actively engaged in environmental sustainability but students currently have very little exposure to ESD at an undergraduate level; and 76.8% of students expressed that they are concerned about the impact that oral health care provision has on the environment, but only 23% of students have independently researched ESD.Conclusions Students identify that oral health care professionals should become more engaged in efforts to mitigate the negative impacts from our activities on the environment, principally via education at all levels. The data from this study provide insight into the current level of awareness and concerns for the environmental impacts of oral health care provision, and are a powerful driver for the inclusion of ESD into the undergraduate curriculum in UK based dental schools.

The environmental consequences of oral healthcare provision by the dental team.

OBJECTIVES: To undertake a comparative ecological impact (Total lifetime carbon footprint and single use plastics (SUP) waste generation) derived from the provision of professional oral healthcare (Dentists and hygienist) to five different patient categories up to the age of 50 years, representative of different levels of progressive dental disease and treatment experience. METHOD: CO2e and SUP waste generated was calculated for five patient categories with common preventable diseases; that are representative of different levels of progressive dental disease and treatment experience. The assessment is based on the average restorative care levels for 50-year-olds in the UK. The number of appointments for each procedure was calculated using current evidence-based guidelines. The total lifetime carbon and the SUP waste analysis was calculated using published peer-reviewed data. RESULTS: The total carbon footprint follows a progression with low impacts for individual persons with very low disease and treatment experience (285 KgCO2e), escalating to very high impacts (approximately 2,170 KgCO2e) for people with high levels of disease and treatment experience. SUP waste follows a similar linear rise across the different cohorts of dental experience over a lifetime (6-50 years), from 1,382 items and 4.6 Kg for patients in a the very low dental experience, to 12,200 items and 33.8 Kg for patients in the cohort of very high dental experience. CONCLUSIONS: The provision of all oral healthcare carries an environmental impact in the form of carbon footprint and SUP waste. The cumulative lifetime environmental impact of oral healthcare is proportional to the disease and treatment experience of the individual person for these preventable diseases; with a x8 difference between the two extremes of experience. CLINICAL SIGNIFICANCE: All forms of oral healthcare have an environmental impact. The most effective way to mitigate these impacts is through the promotion and provision of effective evidence-based preventive oral healthcare.

Sustainability as part of a quality framework for the organisation of oral healthcare.

This paper aims to highlight to the reader that the organisation of dentistry at a system level lags behind other healthcare professions in regulation, policy, education and research. It argues that seeing sustainability as being as important as safety in oral healthcare quality would begin to rectify this. For the practitioner, it also identifies existing guidance on practising sustainably and reinforces that it does not require radical change but evidence-based care.

Embedding environmental sustainability within oral health professional curricula-Recommendations for teaching and assessment of learning outcomes.

The FDI World Dental Federation suggests that "dentistry, as a profession, should integrate Sustainable Development Goals into daily practice and support a shift to a green economy in the pursuit of healthy lives and wellbeing for all, through all stages of life." This article reports on the recent activity of the Association for Dental Education in Europe Special Interest Group for Sustainability in Dentistry. Following on from the group's previous activities, which explored current educational practice, this work aimed to reach a pan-European consensus on a number of learning outcomes for environmental sustainability, in order to (i) support institutions in designing and delivering their curriculum, and (ii) to further harmonise the delivery of oral health professional education across Europe. This article presents specific learning outcomes relating to environmental sustainability and recommendations relating to curriculum development, including methods of teaching and assessment.

A comparative life cycle assessment of dental restorative materials.

OBJECTIVES: Different types of direct-placement dental materials are used for the restoration of structure, function and aesthetics of teeth. The aim of this research investigation is to determine, through a comparative cradle-to-gate life cycle assessment, the environmental impacts of three direct-placement dental restorative materials (DRMs) and their associated packaging. METHODS: Three direct-placement dental materials; dental amalgam, resin-based composite (RBC) and glass polyalkenoate cements (GIC) are assessed using primary data from a manufacturer (SDI Limited, Australia). The functional unit consisted of 'one dental restoration' of each restorative system under investigation: 1.14 g of dental amalgam; 0.25 g of RBC (plus the adhesive = 0.10 g); and 0.54 g of GIC. The system boundary per restoration included the raw materials and their associated packaging materials for each DRM together with the processing steps for both the materials and packaging. The environmental impacts were assessed using an Egalitarian approach under the ReCiPe method using Umberto software and the Ecoinvent database. Nine different impact categories were used to compare the environmental performance of these materials. RESULTS: Dental amalgam had the highest impact across most of the categories, but RBC had the highest Global Warming Potential. The highest sources of the environmental impacts for each restorative material were: Amalgam, derived from material use; RBC, derived from energy use in processing material and packaging material; GIC, derived from material and energy use for packaging. SIGNIFICANCE: Less intensive energy sources or more sustainable packaging materials can potentially reduce the impacts associated with RBC and GIC thus making them suitable alternatives to dental amalgam.

Exploring attitudes towards more sustainable dentistry among adults living in the UK.

Introduction Despite evidence that public pressure can promote sustainability in various domains (for example, retail and travel), no research has considered the public's attitudes towards sustainability in dentistry.Methods A questionnaire was developed to measure attitudes towards sustainable dentistry among adults living in the UK and their willingness to make compromises to reduce the impact of their dental treatment on the environment. In total, 344 adults completed the questionnaire that also measured pro-environmental identity and concern, general willingness to make compromises for the environment, and the tendency to engage in ecological behaviours.Results Participants reported positive attitudes towards sustainable dentistry, and were willing to compromise their time, convenience and durability of their dental treatment, as well as pay more, to reduce the impact of their dental work on the environment. Participants were not willing to compromise their health or the aesthetics of their teeth. There was also evidence that participants' current oral health shaped their attitudes towards sustainable dentistry, such that better oral health was associated with more positive attitudes towards more sustainable dentistry.Conclusions Given that public pressure can be a significant driver of change, these findings provide valuable insight into the kind of compromises that may be accepted by the public in order to improve the sustainability of dental services.

The safety and biocompatibility of direct aesthetic restorative materials.

Restorative dental materials are among the most important medical devices in terms of the numbers of patients who benefit and the technical sophistication of the products. Many though contain toxic or noxious substances, including potentially sensitising resin monomers, photoinitiators, acidic polymers and glass or ceramic filler particles. Despite this, dental materials are among the safest medical devices in use today, with very few reports of adverse reactions or injuries among both patients or the dental team. This paper considers the potential for adverse reactions to dental materials, current evidence for harm and finally examines the reasons why in real-world clinical use the likelihood of an adverse event is extremely low. Medical devices regulations, responsible manufacture and clinical vigilance all appear to play important roles in ensuring that dental materials do not cause or present a risk to patients. While this excellent in-practice safety record is welcome, there is now increasing interest in the 'macro' scale biocompatibility of dental materials and their packaging in the environment, subjects that have been relatively neglected until recently. It was concluded that this should be a priority for future research and development and support is needed from governments alongside the manufacturing industry and the profession.

Resin-based composite materials: elution and pollution.

Pollution arises from all human activity and the provision of oral healthcare using resin-based composite restorative materials (RBCs) should be considered. This paper aims to provide a comprehensive review of the potential pollutant risk to the environment from the chemical compounds found in resin-based restorative materials, by including: 1) the principal pollutant compounds present in the resin matrix; 2) the degradation process of RBCs and its consequences; 3) the methods used for the detection and quantification of monomer elution and RBC microparticles; and 4) a review of the release mechanisms of eluates and RBC microparticles into the environment.RBCs are pollutants by virtue of the compounds created during the degradation processes. These are in the form of the constituent eluted monomers and microparticles. Their impact on the environment and biodiversity is unknown. These materials are currently one of the main direct-placement restorative materials and their success is unquestionable when used and maintained correctly. Mitigation strategies for reducing the impact of pollution on the environment should be considered and implemented by all stakeholders and processes in the supply chain, from manufacturing, clinical use and waste management.

Quantification of single use plastics waste generated in clinical dental practice and hospital settings.

OBJECTIVES: To quantify (by number and mass) single use plastic waste generated from the provision of oral healthcare in primary and secondary care clinical dental settings in the UK. METHODS: An observational study of four dental practices and the clinics of a UK undergraduate dental teaching hospital was conducted. A range of routine common procedures were observed by trained and calibrated observers; these were: Examinations, endodontics, periodontics, direct placement restorations, fixed and removable prosthodontics and oral surgery. The PPE items used before and during the COVID-19 pandemic were also included. RESULTS: Routine 'surgery set up' generic items present a significant proportion of SUP plastic waste as these are used in every instance of patient treatment. An average of twenty-one (n = 21) SUP plastic waste items are used for every procedure with a mean mass of 354 g per procedure (including set up and clean up). The use of PPE increased from 14 items (pre-COVID -19) to 19 items during the pandemic. SUP items are constructed from a single plastic or from multiple plastics forming compound structures (heteropolymers); with an approximate 50:50 distribution. CONCLUSIONS: The dental profession, at the point of care, uses a high volume of single use plastic that becomes clinical waste. The use of personal protective equipment (PPE) significantly increased during the COVID 19 pandemic and this accounts for the single greatest contribution of single use plastic, as this is used for every clinical procedure. CLINICAL SIGNIFICANCE: Manufacturers, distributors and oral healthcare providers have an opportunity to consider and implement approaches that include effective waste management with reduction, recovery and recycling at its core, towards transforming oral healthcare to a circular plastics economy.

Characterisation of Microparticle Waste from Dental Resin-Based Composites.

Clinical applications of resin-based composite (RBC) generate environmental pollution in the form of microparticulate waste. METHODS: SEM, particle size and specific surface area analysis, FT-IR and potentiometric titrations were used to characterise microparticles arising from grinding commercial and control RBCs as a function of time, at time of generation and after 12 months ageing in water. The RBCs were tested in two states: (i) direct-placement materials polymerised to simulate routine clinical use and (ii) pre-polymerised CAD/CAM ingots milled using CAD/CAM technology. RESULTS: The maximum specific surface area of the direct-placement commercial RBC was seen after 360 s of agitation and was 1290 m2/kg compared with 1017 m2/kg for the control material. The median diameter of the direct-placement commercial RBC was 6.39 µm at 360 s agitation and 9.55 µm for the control material. FTIR analysis confirmed that microparticles were sufficiently unique to be identified after 12 months ageing and consistent alteration of the outermost surfaces of particles was observed. Protonation-deprotonation behaviour and the pH of zero proton charge (pHzpc) ≈ 5-6 indicated that the particles are negatively charged at neutral pH7. CONCLUSION: The large surface area of RBC microparticles allows elution of constituent monomers with potential environmental impacts. Characterisation of this waste is key to understanding potential mitigation strategies.

Awareness and barriers to sustainability in dentistry: A scoping review.

OBJECTIVES: (i) To undertake a comprehensive scoping review of the literature that addresses the research question 'What is the current state of environmental sustainability in general dental practice?' (ii) To provide an effective baseline of data that will consider general awareness, barriers and challenges for the implementation of sustainable practice. DATA & SOURCES: The scoping review was conducted for all published literature in the English language that addresses this topic up to the 31st April 2021. The method of the PRISMA-ScR (PRISMA extension for Scoping Reviews) was followed. 128 papers included in this scoping review consisted of: Commentary [Letters, editorials, communication and opinion] (n = 39); Research (n = 60); Literature reviews (n = 25); Reports [Policy and legislation] (n = 4). Each included record was analysed for emerging themes that were further classified according to their general relevance. The scoping review is considered over two manuscripts, with this first paper focusing on awareness of the problem and barriers or challenges to the implementation of sustainable care. CONCLUSIONS: Eight diverse but closely interlinked themes that influence the sustainability of oral health provision were identified: Environmental impacts (CO2e, air and water); Reduce, reuse, recycle and rethink; Policy and guidelines; Biomedical waste management; Plastics (SUPs); Procurement; Research & Education; Materials. Barriers to implementation were identified as: Lack of professional and public awareness; carbon emissions arising from patient and staff commute; challenges associated with the recovery and recycling of biomedical waste with a focus on SUPs; lack of knowledge and education into sustainable healthcare provision and; the challenges from the manufacturing, use and disposal of dental materials.

Drivers, opportunities and best practice for sustainability in dentistry: A scoping review.

OBJECTIVE: To undertake a comprehensive scoping review of the literature to address the research question 'What is the current state of environmental sustainability in general dental practice?' To provide an effective baseline of data that will consider the drivers, opportunities and recommendations for the implementation of sustainable practice. DATA & SOURCES: The scoping review was conducted for all published literature in the English language that addresses this topic up to the 31st April 2021. The method of the PRISMA-ScR (PRISMA extension for Scoping Reviews was followed. 128 papers included in this scoping review consisted of: Commentary [Letters, editorials, communication and opinion] (n=39); Research (n=60); Literature reviews (n=25); Reports [Policy and legislation] (n=4). Each included record was analysed for emerging themes that were further classified according to their general relevance. The scoping review is considered over two manuscripts, with this second paper focusing on the opportunities, recommendations and best practice to develop and engage with sustainable practice. CONCLUSIONS: Drivers, opportunities and recommendations for best practice to achieve environmentally sustainable goals in oral health care: The lack of public and professional awareness is the greatest driver to engage with a positive change of behaviour and attitudes. Awareness through education is key at all levels and this should be the bedrock of future strategies. Reduction in staff and patient commuter travel through a reduction of the incidence of preventable oral diseases, improved patient care logistics and IT. Reducing waste and increase recycling opportunities, especially for SUPs. Engagement with legislation and policy makers. Engagement with key stakeholders across the dental materials/products supply chain for the management of manufacturing, distribution, procurement, clinical use and waste management.

Simultaneous detection of monomers associated with resin-based dental composites using SPME and HPLC.

As resin-based composites (RBC) replace dental amalgam for environmental reasons, there is a requirement to understand the environmental impact of this alternative dental restorative material. In this study we standardize the simultaneous detection of five monomeric components associated with RBCs using high performance liquid chromatography (HPLC) coupled with solid-phase microextraction (SPME). Factors affecting method performance (detection wavelength, calibration conditions, method sensitivity/accuracy/precision, extraction time/efficiency) are evaluated using standard solutions containing the mixture of TEGDMA, UDMA, Bis-GMA, BPA and HEMA. Detection sensitivity and analytical efficiency of the method is optimized for these compounds using 200 nm detection wavelength, PDMS/DVB fiber and extraction time of 90 min. Analytical accuracy of the HPLC is >95% for all monomers, with precision of 2.3-5.1%. Detection limits under the conditions described are 25 µg/L for HEMA, BPA, UDMA, Bis-GMA, and 100 µg/L for TEGDMA. The extraction time is governed by the largest molecular weight compounds.