How can orthodontics contribute to the green agenda?

This month, Saba Qureshi discusses how orthodontics contributes to the climate crisis and whether it can be more sustainable.

The climate crisis is real, and as we experience more frequent extreme weather events and rush to ‘do our bit’ before it’s too late, it begs the questions, where does orthodontics as a profession stand in all this? And how can it help tackle climate change?

In England, the health and social care system is associated with a significant use of resources and carbon emissions, comprising of around 4–5% of England’s total carbon footprint. Dentistry alone makes up 3% of the overall NHS carbon emissions, 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 cut carbon emissions by 80% by 2050 (from the established baseline in 1990). It was subsequently revised in 2019 to net zero greenhouse gas emissions by 2050, placing the onus squarely on the NHS to formulate a plan.

And they did… in October 2020, the NHS became the world’s first health service to commit to reaching carbon net zero, as laid out in its Delivering a Net Zero Health Service report by setting two targets:

An 80% reduction in emissions controlled directly by the NHS by 2028 to 2032, reaching net zero by 2040
An 80% reduction in emissions the NHS can influence by 2036 to 2039, reaching net zero by 2045.

Dentistry as a profession is highly energy and resource intensive with significant environmental impact, and while current studies show that the awareness of green dentistry is high among orthodontic practitioners, there is a lag in implementing such strategies.

So, let’s look at what can be done.

Green dentistry is based on the model of four Rs:

Rethink
Reduce
Reuse
Recycle.

For purpose-built orthodontic clinics, implementation of these core principals can begin at inception, allowing maximum use of natural light and materials with organic constituents, installation of equipment with the lowest electrical power consumption and clean energy sources, such as solar panels.

However, many of us work within already established practices in buildings with limited opportunities to modify. But that doesn’t mean there isn’t room for improvement.

There are several areas where dental health contributes to CO₂ emissions, a key factor in global warming, which need addressing:

1. Travel and transport

Travel and transport form an incredible 13% of the total carbon footprint of the healthcare system, and a staggering 64.5% of dentistry’s contribution. Addressing this will prove vital in the fight against climate change.

Within NHS orthodontics, it’s reasonable to assume that treatment for the majority of patients will last around 18-24 months, involving mutliple short appointments. This amounts to anywhere from 10 to 17 appointments per patient over the course of treatment, depending upon the recall interval, and without taking into account additional unplanned appointments such as those for lost retainers or broken brackets.

And let’s not forget, following the tendering process and termination of numerous NHS orthodontic contracts, many patients are being forced to travel further afield for their braces.

If your practice is easily accessible to public transport, then you are already at an advantage and patients and staff can be encouraged to use this as an alternative to driving.

Depending on where you live in the UK, you may already have been forced to switch your vehicle to reduce carbon emissions and comply with LEZ (Low Emission Zone) and ULEZ (Ultra Low Emission Zone) regulations, which, of course, helps.

Perhaps those who cycle may be more willing to do so if they know provision for safe storage of cycles is available at the practice.

Reducing travel

Furthermore, practices may wish to take advantage of teledentistry, which rapidly evolved during the COVID-19 pandemic to become a popular means of communication with patients and staff members alike.

Many practices who adopted teledentistry during COVID-19 are continuing to implement some aspects of it within their practices, such as virtual consultations, virtual monitoring and the continuation of online platforms for staff meetings and continuing professional development. This all helps to reduce the amount of travel required, thereby reducing the practice’s carbon footprint.

Despite the necessity of regular appointments for orthodontic patients, unplanned extra appointments may be avoided with a combination of remote monitoring and thorough patient care instructions, particularly on how to deal with orthodontic emergencies.

Also, given the continued growth in popularity of aligner treatment, we cannot ignore the impact that importing appliances from abroad has on our carbon footprint.

However, the widespread use of intraoral scanners within the orthodontic community completely eliminates one branch of the appliance transport chain, negating the need for impressions to be collected from the practice, which is most definitely a win.

2. Manufacturing and procurement of materials

Procurement of goods and services represents 72% of the health services carbon footprint.

In order to address this, the British Dental Industry Association (BDIA) requires members to ‘demonstrate a commitment to environmentally sound procedures’ by having an environmental policy in place. This encourages reduction of the need for fresh natural resources by efficient use of existing ones, reduction of hazardous waste and emissions that result from the manufacturing process, and implementing measures such as reforestation and rain-water harvesting.

Where possible, clinics should support those companies demonstrating a strong commitment to delivering environmentally-friendly products and processes in place of those that don’t.

3. Waste generated and its disposal

Studies have shown that around 97% of clinical orthodontic waste is incinerated, with the main areas of unnecessary waste being identified as:

Conventional impression taking
Excessively long archwires
Packaging
Disposable items with reusable alternatives.

Perhaps discussions with companies providing orthodontic materials may lead to optimised archwire lengths and a reduction in packaging. Furthermore, revision of HTM 07-01 to include a recycling protocol for packaging should be considered given the amount of waste produced in relation to it.

Thankfully, the uptake of intraoral scanners by orthodontic clinics has vastly reduced the waste associated with impression taking, which accounts for approximately 32% of orthodontic clinical waste.

If we look at braces themselves, a survey conducted by the British Orthodontic Society revealed that nearly 50% of orthodontists recycled metal brackets for use in other patients. However, many were doing so without informing the patient.

As many patients have a highly negative psychological reaction to the use of recycled brackets, one must execute their use with care, ensuring that clinicians are updated on the latest evidence, regulations and studies regarding guidelines use of reconditioned appliances, as well as records for quality checks, recycling services and patient consent. Some patients may be happy to have recycled brackets fitted if there is an associated treatment cost reduction.

I’m not at the recycling brackets stage yet, but I wouldn’t hesitate to reuse a patients own for a repair following a good clean and sandblasting of the base, as opposed to using a brand new bracket.

Aligners

Aligners are also of concern.As mentioned previously, they have become increasingly popular with both patients and clinicians alike, with patients receiving multiple sets of aligners throughout their treatment.

The problem is that they are made from thermo-plastic petroleum-derived hydrocarbons, which are non-biodegradable and damaging to the environment when burned.

However, they are deemed as medical waste so cannot be disposed of in general recycling. Thankfully, some companies like Terracycle will collect used aligners (along with their packaging) and recycle them into items such as 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 have to our patients (Duane et al, 2019).

While the transition to environmentally friendly orthodontics may not be an easy one, the important things in life seldom are. So, let’s join forces, start small, dream big and make a real difference for ourselves and future generations.

Catch up on previous Straight to the Point columns:

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