This month, Saba Qureshi discusses how orthodontics is contributing to the climate crisis and whether it can be more sustainable.
The climate crisis is real and as we experience more extreme weather events and rush to ‘do our part’ before it’s too late, it begs the questions, where does orthodontics as a profession fit into all of this? And how can it help tackle climate change?
In England, the health and social care system is associated with significant resource use and carbon emissions, accounting for approximately 4–5% of England’s total carbon footprint. Dentistry alone accounts for 3% of the NHS’s total carbon footprint, so it’s not hard to see why sustainability in healthcare has become a hot topic.
Energy and resource intensive
The Climate Change Act (2008) was introduced in the UK to provide the legal framework to reduce carbon emissions by 80% by 2050 (from a baseline set in 1990). It was then revised in 2019 to net zero greenhouse gas emissions by 2050, putting the onus squarely on the NHS to formulate a plan.
And they did… in October 2020, the NHS became the first health service in the world to commit to net zero carbon, as defined in Providing a net zero health service report setting two goals:
- 80% reduction in emissions controlled directly by the NHS from 2028 to 2032, reaching net zero by 2040
- An 80% reduction in emissions could affect the NHS from 2036 to 2039, reaching net zero by 2045.
Dentistry as a profession is energy and resource intensive with significant environmental impacts, and while current studies show that awareness of green dentistry is high among orthodontists, there is a lag in implementing such strategies.
Well, let’s see what can be done.
Green dentistry is based on the four Rs model:
- Rethink
- Restrict
- Reuse
- Recycle.
For purpose-built orthodontic clinics, implementation of these basic principles can begin at start, allowing maximum use of natural light and materials with organic ingredients, installation of equipment with the lowest electricity consumption and clean energy sources such as solar panels.
However, many of us work in already established practices in buildings with limited opportunities for modification. But this does not mean that there is no room for improvement.
There are several areas where dental health contributes to CO₂ emissions, a key factor in global warming, that need to be addressed:
1. Travel and transportation
Travel and transport make up an incredible 13% of the total carbon footprint of the healthcare system and a staggering 64.5% of dentistry’s contribution. Tackling this will prove vital in the fight against climate change.
Within NHS orthodontics, it is reasonable to assume that treatment for the majority of patients will take around 18-24 months, involving many short appointments. This equates to anywhere from 10 to 17 appointments per patient over the course of treatment, depending on the recall interval, and not taking into account additional unscheduled appointments such as those for lost retainers or broken brackets.
And let’s not forget, following the tendering process and the end of many NHS orthodontic contracts, many patients are forced to travel further for their braces.
If your practice is easily accessible by public transport then you already have an advantage and patients and staff can be encouraged to use it as an alternative to driving.
Depending on where you live in the UK, you may already have had to modify your vehicle to reduce carbon emissions and comply with LEZ (Low Emission Zone) and ULEZ (Ultra Low Emission Zone) regulations, which of course , it helps.
Perhaps those who cycle may be more willing to do so if they know there is provision for safe storage of cycles at the practice.
Reduce travel
In addition, practices may wish to take advantage of teledentistry, which has rapidly evolved during the COVID-19 pandemic to become a popular means of communication with both patients and staff.
Many practices that adopted teledentistry during COVID-19 continue to implement aspects of it in their practices, such as virtual consultations, virtual follow-up, and the continuation of online platforms for staff meetings and continuing professional development. All of this helps reduce the amount of travel required, thereby reducing the carbon footprint of the practice.
Despite the need for regular appointments for orthodontic patients, unscheduled extra appointments can be avoided with a combination of remote monitoring and thorough patient care instructions, particularly on how to manage orthodontic emergencies.
Also, given the continued rise in popularity of alignment processing, we can’t ignore the impact that importing devices from overseas has on our carbon footprint.
However, the widespread use of intraoral scanners within the orthodontic community completely eliminates a branch of the appliance transport chain, negating the need to collect impressions from the office, which is definitely a win.
2. Construction and supply of materials
Procurement of goods and services accounts for 72% of the carbon footprint of health services.
To address this, the British Dental Industry Association (BDIA) requires members to “demonstrate a commitment to environmentally sound processes” by implementing an environmental policy. This encourages reducing the need for fresh natural resources by using existing ones efficiently, reducing hazardous waste and emissions resulting from the production process, and implementing measures such as reforestation and rainwater harvesting.
Where possible, clinics should support those companies that demonstrate a strong commitment to providing environmentally friendly products and processes over those that do not.
3. Waste generated and its disposal
Studies have shown that about 97% of clinics Orthodontic waste is incinerated, with the main areas of unnecessary waste identified as:
- Conventional impression capture
- Archwires that are too long
- Packing
- Disposable items with reusable alternatives.
Perhaps discussions with orthodontic material companies will lead to optimized arch lengths and reduced packaging. In addition, consideration should be given to revising HTM 07-01 to include a recycling protocol for packaging given the amount of waste generated in relation to it.
Fortunately, the adoption of intraoral scanners by orthodontic clinics has greatly reduced the waste associated with impression taking, which accounts for approximately 32% of orthodontic clinical waste.
Looking at the braces themselves, a survey conducted by the British Orthodontic Society revealed that nearly 50% of orthodontists recycled metal braces for use on other patients. However, many did so without informing the patient.
As many patients have a highly negative psychological reaction to the use of recycled abutments, one must proceed with their use with caution, ensuring that clinicians are informed of the latest evidence, regulations and studies on the instructions for use of remanufactured devices, as well as records for quality checks, recycling services and patient consent. Some patients may be happy to have recycled arms fitted if there is a relative reduction in treatment costs.
I’m not at the stage of recycling mounts yet, but I wouldn’t hesitate to reuse one of my own patients for repair after a good cleaning and sandblasting of the mount, as opposed to using a brand new arm.
Aligners
Aligners are also a concern. As previously mentioned, they have become increasingly popular with both patients and clinicians, with patients receiving multiple sets of aligners throughout their treatment.
The problem is that they are made from thermoplastic hydrocarbons derived from petroleum, which are non-biodegradable and harmful to the environment when burned.
However, they are considered medical waste, so they cannot be disposed of in general recycling. Fortunately, some companies like Terracycle will collect used aligners (along with their packaging) and recycle them into items like outdoor furniture and bins, which is great.
All healthcare providers have a responsibility to reduce the impact of climate change, as this is ultimately an extension of the duty of care we owe to our patients (Duane et al, 2019).
While the transition to eco-friendly orthodontics may not be easy, the important things in life rarely are. So let’s join forces, start small, dream big and make a difference for ourselves and the generations to come.
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