By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

If you’re concerned about sustainability in dental clinics and offices, chances are you care about waste: the endless stream of plastic wrap, gowns, gloves, and all the other single use items that we throw away each day. I have to admit, until recently I hadn’t given sufficient thought to dentistry’s broader environmental footprint.

That changed in 2023, when I attended the annual meeting of the Association for Dental Education in Europe (ADEE). I was struck by how seriously the Europeans take sustainability. They aren’t just focused on disposables. They are looking at how teledentistry can reduce the profession’s carbon footprint and at prevention as the ultimate sustainability strategy. What’s more, they are implanting these ideas into the future dental workforce by adding “sustainable practice” to the list of competencies for The Graduating European Dentist, with the expectation that dental graduates will understand the environmental impact of their clinical practice, demonstrate respect for the environment, critically evaluate current practices, and seek practical solutions within an ethical framework.

Here at Home

Europeans are far ahead of the U.S. dental community, but that’s not to say that nothing is happening on this side of the pond. 

• The American Dental Education Association (ADEA) has formed a special interest group (SIG) focused on sustainability.
• And at several U.S. dental schools, concerned students and faculty have lobbied for innovative clinical practices and curricula related to sustainable dentistry.
• The American Association of Dental Office Managers offers tips on greening dental practices and has initiated a Green Leader Initiative sponsored by the Henry Schein Cares Foundation.

Jennifer Luca, DMD, MS, a Michigan-based pediatric dentist, is chair of the ADEA Sustainability SIG and was a student leader in sustainability at the Harvard School of Dental Medicine (HSDM). She cofounded and led HSDM’s “Green Team” and conducted a survey of student and faculty attitudes towards sustainability at more than a dozen dental schools. The respondents were overwhelming interested, she told me, but “no one had any idea what to do.”

At HSDM, the “Green Team” lowered the school’s carbon footprint by setting the hoods in the bench lab to close automatically when research was not taking place and transitioning from plastic to paper for patient goody bags. At Nationwide Children’s Hospital in Columbus, Ohio, where Dr. Luca did a residency in pediatric dentistry, she formed an employee resource group that attracted 120 members. “We planted trees. We picked up trash. We had green physicians and anesthesiologists and facility workers present to the group.” Dr. Luca also estimated the environmental impact of treating early childhood caries and discovered patients’ travel-related emissions and the use of nitrous oxide, a potent greenhouse gas, had the greatest impact. Now she is focusing her research and advocacy on reducing the environmental impacts of anesthesia use in pediatric dentistry.

Dentistry’s Carbon Footprint

A widely cited 2016 estimate attributes 10% of U.S. greenhouse gas emissions to the nation’s health care sector. Of that, 3% is often attributed to dental care, and a report quantifying the environmental impact of dental care in England supports that figure. That may not sound like a lot, but in the aggregate, the impact is much harder to dismiss.  An estimated one billion plastic toothbrushes are discarded each year in the United States alone, and because most are made from composites, they can’t be recycled.

The amount of waste generated by dental offices is also substantial, and dental school clinics, because they are teaching environments, generate even more. In recent months, students and faculty at NYU Dentistry have conducted waste audits in the oral surgery and some general dentistry clinics. Leena Manzoor, a third-year student, led the audit with her classmate Mona Jahangirvand and with Mahsa Salmasi, a second-year student who serves as greening representative to the college’s student government. All three are in the group practice led by Bapanaiah Penugonda, BDS, MS, an associate professor and one of the college’s most vocal advocates for sustainable practice.

The students shared the results of one audit during the college’s recent Research Day, and the results were eye-opening. Their six-day audit of discarded unused materials in the oral surgery clinic found 268 burs, 244 restorative materials, 203 anesthesia components such as carpules and needles, and an assortment of other items. The estimated cost based on this brief audit? $828.

If that sounds like a lot, the audit team discovered even more waste in Dr. Penugonda’s general dentistry clinics that took part. Paul R. Baker, DDS, clinical assistant professor of oral and maxillofacial surgery and one of the professors who encouraged the waste audit, attributes his clinic’s better performance to the unit’s supply clerks, who “constantly ask students, ‘Do you need this? If you’re taking a handful, are you going to use this?’”

Even before the audit, Dr. Baker had made a point of exposing students finishing their oral surgery rotations to the unused items typically discarded in his clinic each day and their costs. While some of the students who are just starting their clinical rotations roll their eyes, he says those on the cusp of graduating are stunned by the financial implications for their future practices.

Strategies for Change

So, what can be done about all this waste?  The students who conducted the audit have made three policy recommendations, which they hope the college will adopt later this year.

1. Reduce waste by standardizing how many supplies students can access for each type of procedure.
2. Reuse discarded burs in the sim lab. These come individually wrapped, so only the packaging would need cleaning.
3. Incorporate sustainability in the curriculum throughout the four years, not just in the final practice management course.

Given our crowded curriculum and the universal sense that students feel stressed for time, this last request is particularly notable.

How can U.S. dental practices reduce waste? While plastic materials are convenient and cheap, there are alternatives. In our clinics, perhaps we can replace disposable plastic nozzles with metal ones that can be sterilized, and we can encourage our patients to use more sustainable oral hygiene products in their homes. Bamboo toothbrushes, biodegradable floss, and toothpaste tablets that obviate the need for plastic tubes are all currently being marketed, and industry heavy weights are striving to make their packaging and manufacturing processes more environmentally friendly.

In most practices, electronic health records have reduced paper waste.  Meanwhile 90% of dental practices have adopted digital radiography, eliminating the waste associated with film stock and development chemicals. A 2021 survey suggested half of dentists were also using intraoral scanners, with two-thirds of those remaining planning to acquire one.

Beyond Waste Reduction

To reduce its carbon footprint, dentistry must also examine a range of other activities that produce emissions. Chief among these is travel. The report on dental care in England I mentioned above attributed more than 60% of the country’s dental carbon footprint to patient and staff travel. The energy used in dental facilities and procurement (production and transport of materials) ranked second and third at almost 20% each.

The establishment of the LEED rating system for design and construction has helped to make many newer buildings more energy efficient, but the facilities we work in are typically beyond the control of most oral health professionals. We could, however, take steps to reduce the amount of travel associated with our provision of care. We could reduce the number of patient trips by offering telehealth consultations, scheduling family members on the same day, and completing adjacent restorations in a single visit. Larger practices can also open satellite clinics in more remote areas to take care to patients, rather than the other way around.

Most importantly, we can double down on prevention — the most sustainable form of oral health care. In some cases that will mean bucking administrative and payment systems that don’t always reimburse for patient education or give dentists flexibility in scheduling procedures for irregular blocks of time. We should take on these challenges, not just because it’s good for the environment, but because avoiding the need for restorative dental care is what’s best for our patients.

Are We Ready to Commit?

It’s hard to say how ready U.S. dentists are to embrace sustainable practices, but I was pleased to see Toni M. Roucka, DDS, MA, FACD, current editor of the Journal of the American College of Dentists, assert this spring that dentists have an ethical responsibility to practice sustainably.

As healthcare providers, dentists must consider the broader impact of their practices on their patients’ overall health and well-being, including the health of the environment and the mitigation of climate change, often described as the greatest public health challenge of the 21^st century.

Many dental students already share this view and are putting their beliefs into action. At NYU, they have petitioned the college, along with Dr. Baker and Dr. Penugonda, to create an official sustainability committee, which they anticipate will begin influencing policy this fall. They hope the integration of sustainable dentistry principles in the clinics and curriculum will not just benefit them but influence practice far beyond the dental college. As Mona Jahangirvand put it, “There are almost 380 NYU Dentistry graduates each year. So, if 400 dentists in America implement these practices, I feel like we will be able to see a change in the field even within the next decade.”

Given the enthusiasm for sustainable dentistry I’ve witnessed at NYU and read about elsewhere, I’d say that’s a strong possibility.

Learn More

The FDI World Dental Federation Sustainability in Dentistry website contains:

• A free, online, three-hour course to help oral health professionals understand the importance of sustainable practice and their own role in tackling sustainability issues
• An interactive sustainability toolkit
• Infographics and journal articles on a range of sustainability topics
• FDI’s Consensus Statement on Environmentally Sustainable Oral Healthcare
• A pledge with signatories from around the globe.

Several of my colleagues also recommend The Sustainable Dentist by Beverly Oviedo-Allison and Marylou Shockley. It provides concrete advice to practice owners on operating their businesses more sustainably.

Those working in large health systems will find additional resources on the Health Care Without Harm website, which seeks to reduce health care’s environmental footprint worldwide.