3) Martin Et Al.

Journal of Dentistry 112 (2021) 103735
Contents lists available at ScienceDirect
Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent
Review Article
Awareness and barriers to sustainability in dentistry: A scoping review

Nicolas Martin *, Madison Sheppard, GaneshParth Gorasia, Pranav Arora, Matthew Cooper,
Steven Mulligan
School of Clinical Dentistry, The University of Sheffield, S10 2TA, UK
A R T I C L E I N F O A B S T R A C T
Keywords: Objectives: (i) To undertake a comprehensive scoping review of the literature that addresses the research question
Sustainability ‘What is the current state of environmental sustainability in general dental practice?’ (ii) To provide an effective
Dentistry baseline of data that will consider general awareness, barriers and challenges for the implementation of sus
Awareness
tainable practice.
Barriers
Scoping review
Data & sources: The scoping review was conducted for all published literature in the English language that ad
dresses 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 ac
cording 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.
1. Introduction that climatic change currently causes over 150,000 deaths globally per
year and between 2030 and 2050 this will increase to 250,000 addi
Evidence that climate change is anthropogenic in nature is estab tional deaths per year [6,7].
lished [1,2]. Four out of nine planetary boundaries (safe operating limits Health care delivery is currently not environmentally, socially or
of planetary health) have been crossed, including climate change, loss of financially sustainable due to high amounts of CO2e (carbon dioxide
biosphere integrity, land-system change and altered biogeochemical equivalent) and waste generation [8]. It is paradoxical that healthcare,
cycles (phosphorus and nitrogen) [3]. Global average temperatures are with a central tenet to support and protect health and life, contributes to
now significantly higher than pre-industrial levels, an effect that cannot climate change with consequent increased deaths and reduced quality of
be explained without human activity and greenhouse gas emissions [4]. life through unsustainable practices. Oral healthcare in particular, has
The impacts of climate change include increased ocean and atmospheric previously focused on solely providing optimal patient care, without
temperatures, the associated impacts of altered precipitation patterns, consideration of environmental impact. This is changing with an
rising sea levels, acidification of the oceans, increase in the frequency increasing awareness of the need for sustainability at all levels of society,
and intensity of extreme weather events and severe flora and fauna government and industry. For example, the signing of the Paris Agree
species-level extinction. Climate change has also been described as ‘one ment of 2016, national legislation such as the U.K.’s Climate Change Act
of the biggest global threats to human health of the 21st century’ [5]. of 2008 and global climate change activism. Accordingly, there is a call
Human health is intrinsically linked to the environment. It is estimated for Dentistry as a profession, to integrate sustainable development goals
* Corresponding author.
E-mail addresses: [email protected] (N. Martin), [email protected] (S. Mulligan).
https://doi.org/10.1016/j.jdent.2021.103735
Received 4 May 2021; Received in revised form 6 June 2021; Accepted 18 June 2021
Available online 25 June 2021
0300-5712/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
N. Martin et al. Journal of Dentistry 112 (2021) 103735
into daily practice and support a shift to a green economy in the pursuit PRISMA-ScR (PRISMA extension for Scoping Reviews) was used [10,
of healthy lives and well-being for all through all stages of life [9]. As we 11].
strive to implement more sustainable practices, there is a need to un A thematic analysis as described by Braun & Clarke (2006, 2014) was
derstand the current knowledge base, to increase awareness, identify employed to analyze the emerging themes in accordance with the six-
barriers and opportunities to implementation; alongside examples of point phases described [12,13]. Through a thematic analysis we have
best practice that can be implemented and translated into wider organized, described and interpreted our data set. Themes were identi
contexts. fied from common patterns in the included papers. A patterned response
Sustainability within oral healthcare is an emerging topic with a relates to ‘prevalence’, in terms of space within each data item and of
significant volume of literature outputs covering multiple facets of this prevalence across the entire data set. Items of low prevalence, or that
domain. It is therefore important to review and compile this existing captured something important in relation to the overall research ques
knowledge in a structured manner to establish a baseline, that will tion, were also included. In this scoping review, we have gone beyond an
inform and support further research, fill knowledge gaps, drive inductive process of thematic coding and analysis (Frith and Gleeson,
engagement and establish parameters of best practice. 2004) to a more detailed semantic approach (Knafl and Patton, 1990)
A scoping review of the current literature base is considered the most [14,15]. In this way, the data is organized according to semantic con
appropriate tool to accomplish this by asking the research question, tent, and is then summarized and interpreted, with an attempt to
‘What is the current state of environmental sustainability in general theorize the significance of the patterns and their broader meanings and
dental practice?’ The aim of this study is to undertake a comprehensive implications. A thematic analysis was used to identify, analyze and
scoping review of the literature to address the research question. report patterns (themes) that arise through the review process.
Through this process we have undertaken a thematic analysis that de The search strategy for the scoping review was undertaken in a series
scribes the general professional and societal awareness of the problem; of distinct steps (Fig. 1). An initial search included published literature,
identifies the barriers or challenges to the implementation of sustainable internet web resources, all topics and all types of documents. A multi
care; considers the drivers and opportunities to develop and engage with disciplinary research platform (Web of Science, ClarivateTM-Institu
sustainable practice and reviews recommendations and examples of best tional licence) was employed for this task as it enables simultaneous
practice. cross-searching of a range of citation indexes and databases (Table 1)
[16]. Web of Science identified relevant literature, with no restriction on
2. Method study design, article type (e.g., opinion pieces, editorials or patents etc.),
source or date; and these were filtered later. No limitations were placed
The methodology established by Arksey & O’Malley and the on the year of publication but only papers in the English language were
Fig. 1. Flow chart for record retrieval and inclusion (All outputs up to 30th April 2021).
2
Table 1 Table 2
Search databases, search domains and search terms through web of science (16). Inclusion and exclusion search criteria.
Database Search domains Inclusion criteria
Web of Science Core Publications: Journals (including open access), Direct relation to dentistry
Collection (1900-2021) conference proceedings, patents, and books.Sources: English language
Science Citation Index Expanded (1900–2021); Discussed sustainability in relation to the environment (not durability or other
Social Sciences Citation Index (1900–2021); Arts & meanings)
Humanities Citation Index (1975–2021); Conference All types of sources, including commentaries, opinion, reviews, reports and research.
Proceedings Citation Index- Science (1990-2021); Exclusion criteria
Conference Proceedings Citation Index- Social Contained search terms in a different context to the research question
Science & Humanities (1990–2021); Book Citation Poor use of English language, poorly written or poorly translated, that prevented
Index-Science (2005–2020); Book Citation Index– understanding
Social Sciences & Humanities (2005–2020); Papers not relevant to the research question
Emerging Sources Citation Index (2015–2020); Research papers with absent or inadequate methodology
Current Chemical Reactions (1985-2020) [includes
Institut National de la Propriete Industrielle structure
data back to 1840); Index Chemicus (1993–2021). and not relevant at initial review (false positives) (615 papers). Further
BIOSIS Citation Index Publication: Journals (including open access), outputs were identified by the investigators from the bibliographies of
(1926-2021) meetings, patents, and books.Domains: Pre-clinical
and experimental research, methods and
the systematic and narrative reviews (n = 95). This process yielded 324
instrumentation, animal studies records, for which the full texts were retrieved.
BIOSIS Previews (1969- Publication: Journals (including open access), The full text papers were randomly divided into four groups to be
2021) meetings, patents, and books.Domains: Pre-clinical analysed by four of the investigators (MS, GG, PA, MC). Each investi
and experimental research, methods and
gator individually read and critiqued a share of papers, summarising
instrumentation, animal studies.
Current Contents Connect Publication: Complete tables of contents and each with relative merits. The papers were tabulated in a spreadsheet to
(1998-2021) bibliographic information from the world’s leading enable thematic analysis and coding with further filtering according to
scholarly journals.Domain: Social & Behavioural the inclusion/exclusion criteria (Table 2). Subsequently, the four in
Sciences (1998–2021); Clinical Medicine vestigators, working in pairs, cross-checked every paper. At this point,
(1998–2021); Life Sciences (1998–2021)
Data Citation Index (1900- Publication: Research data sets and data studies.
further papers were excluded. This process resulted in a final count 128
2021) Domain: Science (1900–2021); Social Sciences & outputs to be included in the review.
Humanities (1900-2021) The 128 papers included in this scoping review consisted of: Com
Derwent Innovations Index Publication/Domain: Combines patent information mentary [Letters, editorials, communication and opinion] (n = 39);
(1963-2021) indexed in the Derwent World Patent Index
Research (n = 60); Literature reviews (n = 25); Reports [Policy and
(1963–2020) with patent citations indexed from the
Derwent Patents Citation Index (1973–2021). legislation] (n = 4). Each record included was analysing for emerging
KCI-Korean Journal Publication: Bibliographic information for scholarly themes as described. Key themes from each paper were coded against
Database (1980-2020) literature published in Korea.Domain: National identified themes (Table 3, Fig. 2). Tabulated outputs up to the 31st April
Research Foundation of Korea and contains 2021 were included as the cut-off date from this scoping review
MEDLINE® (1950-2021) Publications: Comprehensive bibliographic database.
Domain: Life sciences database: The U.S. National
(Table 4).
Library of Medicine® (NLM®), NCBI databases and
PubMed Related Articles 3. Results
Russian Science Citation Publications: Selected and provided by the Scientific
Index (2005-2021) Electronic Library (eLIBRARY.RU)Domain: Across all
The outputs are described thematically in eight separate headings as
domains
SciELO Citation Index Publications: Open access journals from Latin per Table 3. These are further divided into sub sections, where possible,
(2002-2021) America, Portugal, Spain, and South Africa.Domain: to enable the reader to focus on specific points according to their general
Across all domains relevance. These subsections are detailed in two sequential publications:
- Awareness and barriers to sustainability in dentistry: A scoping
review. This publication considers the literature with a focus on: Back
included; as this is considered to be the main publishing language for
ground, where appropriate; Awareness of society and the profession to
scientific articles, governmental and national and international NGO
the impact of oral health professional activities; and Barriers to develop
reports. Since sustainability is an umbrella term which encompasses
and engage with sustainable practice.
multiple subjects (e.g., climate change, carbon emissions, the use of
- Drivers, opportunities and best practice for sustainability in
plastics and many others), numerous searches were carried out with the
dentistry: A scoping review [17]. This complementary publication
aim to include as many relevant interpretations of sustainability as
considers the same body of the scoping literature review with a focus on:
possible. The search terms used were: Carbon footprint; climate change;
Drivers to develop and engage with sustainable practice; Opportunities to
environmental impact; green dentistry; life cycle analysis or LCA; pro
develop and engage with sustainable practice; Recommendations & Best
curement; sustainable healthcare; sustainable dentistry; reduce, reuse,
practice for effective sustainable dental practice, based on guidance and
recycle or 3rs; reduce, reuse, recycle, rethink or 4rs; recycl*; single use
real examples.
plastics; waste management; and waste hierarchy. All search terms
except sustainable healthcare and sustainable dentistry were com
pounded with the additional search term: Dentistry or dental care or
Table 3
dental practice or dental office. The search strategy was designed and
Themes identified in the review of the literature.
agreed following consultation with the research team. The search was
conducted between April 2020 to 30th April 2021 with this latter date Code Theme Topic
1 Environmental impacts - CO2e, air and water
marking the cut off for inclusion. This initial search identified 944
2 Reduce, reuse, recycle and rethink
records. 3 Policy and guidelines
Further screening was conducted by reviewing titles and abstracts 4 Biomedical waste management
with the authors working in pairs according to the inclusion/exclusion 5 Plastic (SUPs)
criteria and reaching consensual decisions (Table 2). Outputs were 6 Procurement
7 Research & Education
further excluded if they were duplicates (n = 44), irretrievable (n = 56) 8 Materials
3
ash, major contributors of dioxins in the environment; with a reported

link to an increased risk of non-Hodgkin lymphoma and serum organo-
chlorine concentrations [35]. Incineration of plastics is a recognised and
significant contributor to the release of hazardous dioxins [36].
3.1.1.2. Patient and staff travel. Travel and transport accounts for 13%
of CO2 emissions associated with UK-NHS health, public health and
social care. Travelling to and from practice by both patients and health-
care providers is the highest emission source (64.5%) [8,9,18,36–40].
The air pollution impact of travel related to dentistry is also signif
icant and equates to around 8% of the total UK NHS air pollution impact
from travel [21]. One tenth of air pollution emissions are from health
care systems [36,41].
Dental-associated travel affects air quality, releasing over 443 tonnes
of nitrogen oxides (NOx) and 22 tonnes of particulate matter (PM2.5)
Fig. 2. Themes identified according to the number of records. Clockwise, red
annually. The associated reduction in air quality reduces over 325
(most) to yellow (least) (For interpretation of the references to color in this
quality-adjusted life years (QALY) per year and costs £17.5 million a
figure legend, the reader is referred to the web version of this article.).
year [8,30]. There is a realisation that the profession’s management of
carbon emissions needs to be an integral part of normal sustainable
3.1. Theme 1: Environmental impacts-CO2e, air and water
practice [31].
3.1.1. Background
3.1.1.3. Energy use. The energy use of buildings makes up 15% of the
A series of recent articles by Duane et al., consider sustainability in a
carbon footprint of primary dental care [9,36,39]. Without ‘green’ en
comprehensive manner and provide a very helpful contemporary
ergy saving features, buildings contribute to 24% of the total UK NHS
context to this domain [18–25]. The introductory article highlights the
healthcare system carbon footprint by consuming more than £410
relationship between planetary health and human health, focusing on an
million worth of energy [36]. The annual carbon footprint of NHS dental
increased professional awareness to be environmentally sustainable but
electricity use is 51,939 tCO2e and for gas 51,649 tCO2e; this equates to
matched by an inability to act on this through lack of knowledge and
7.7% and 7.6% respectively of the total carbon footprint of NHS dental
tools [18]. This article also provides a series of useful definitions of
services in England [19,37]. Older smaller clinics, with no air condi
greenhouse gases, global warming potential and CO2e. The topics of air
tioning and fewer meeting rooms generated lower carbon footprints
pollution, energy and water use, have a heavy predominance in the
than newer clinics. This suggests that new buildings are not necessarily
literature of this theme. There is a need to consider sustainability in
more energy efficient [19]; the energy saving building features need
dentistry within a wider context of modernisation of the dental profes
have to be balanced against usage. A study by Duane et al. (2019) in
sion and the services that it provides [26].
cludes a useful comparative table of energy use within the dental
practice [19]; e.g. autoclaves, washer disinfectors and ultrasonics use a
3.1.1.1. Air pollution. At a societal international level, the management
lot of energy, although for a relatively low time through the day [19].
of air pollution on a world-wide basis is led through the United Nations’
Building regulations and advisory groups can assist building owners to
body, The Intergovernmental Panel on Climate Change (IPCC) [27]. The
rate or create healthy, efficient and cost saving buildings; e.g., LEED
IPCC aims to ‘provide policymakers with regular scientific assessments
(Leadership in Energy and Environmental Design) system in the UK or
on climate change, its implications and potential future risks, as well as
TERI in India [19,32,33,42–44]. A recent LCA that considers the overall
to put forward adaptation and mitigation options.’ Air pollution impacts
environmental impact of dental examinations highlights their relative
every living being on planet Earth and every human citizen has a per
low impact, with the caveat for the need to consider the magnifying
sonal responsibility for managing this at an individual level. The pro
effect of the number of these procedures undertaken every year [45].
fessional literature has highlighted this point, noting that global
greenhouse gases need to drop by 45% from 2010 levels in the next 12
3.1.1.4. Water consumption. Water consumption also contributes to the
years [18].
carbon footprint; although compared to other activities, the direct
A major contributor to air pollution arises from petrol and diesel
impact on carbon emissions from oral care provision is lower. The water
vehicles with significant health effects particularly on young children
industry in the UK contributes 0.8 per cent of annual UK greenhouse gas
and people with respiratory and cardiovascular disease. Increased short-
emissions [46]. The proportion of the carbon footprint directly attrib
term exposure to elevated particulate matter can have adverse health
uted to water use in the provision of oral healthcare is only 0.09% of the
effects [28]; in the UK, air pollution kills 40,000 people every year [9].
overall carbon footprint [34,37]. Water is a very precious resource that
Healthcare is identified as a major contributor to CO2 emissions and in
should be managed more effectively in dental practices. The European
the UK this is estimated to account for 5% of the national emissions [8].
Dental Association (EDA) reports that dental offices consume 57,000
At the level of professional activities in oral health care, air pollution is
gallons (259,000 litres) of water a year [32], with an average water
increasingly being understood and should not be underestimated [18,
consumption estimated at around 33,000 litres per surgery per year
30–34]. This arises from a number of different sectors, mainly inciner
[34]. Other reports estimate that the use of water in dental practices
ation of waste, anaesthetic gases and CO2 emissions associated with
from tooth brushing at plaque stations and hand washing is presumed to
travel and transport; these are all considered separately in this report.
be 17,000 gallons (77,284 litres) a year per dental surgery [47]. The
Waste management through incineration further contributes to air
indirect impact is significant, as the water used in dental offices needs to
pollution. Medical waste incinerators release toxic air pollutants and
be treated before and after in water and sewage works; both requiring
4
Table 4
Thematic description of the literature (Eight tables: One table per theme). The 128 papers included in this scoping review are all published literature and consist of:
Commentary [Letters, editorials, communication and opinion] (n = 39); Research (n = 60); Literature reviews (n = 25); Reports [Policy and legislation] (n = 4). Tables
include outputs with primary focus (normal font) and secondary focus (italic font).
Author Title Year Type Subject matter reported Location
reported
Theme 1: Environmental impacts-CO2e, air and water (n = 21)
Borglin et al. [45] The life cycle analysis of a dental examination: Quantifying the 2021 Research Advice Sweden
environmental burden of an examination in a hypothetical dental practice
Duane et al. [8] Sustainability in Dentistry: A Multifaceted Approach Needed 2020 Research Advice-System approach UK
Wilson et al. [40] What impact is dentistry having on the environment and how can dentistry 2020 Commentary Advice, opportunity UK
lead the way?
Verma et al. [30] Knowledge, Attitude and Practice of Green Dentistry among Dental 2020 Research Perceptions India
Professionals of Bhopal City: A Cross-sectional Survey
Duane et al. [18] Environmentally sustainable dentistry: a brief introduction to sustainable 2019 Review Overview UK
concepts within the dental practice
Duane et al. [22] Environmental sustainability and biodiversity within the dental practice 2019 Review Advice, opportunity UK
Duane et al. [19] Environmentally sustainable dentistry: energy use within the dental practice 2019 Review Advice UK
Duane et al. [23] Environmental sustainability: measuring and embedding sustainable 2019 Review Advice UK
practice into the dental practice
Duane et al. [21] Environmental sustainability and travel within the dental practice 2019 Review Awareness, opportunity UK
Nagpal et al. [51] Green Dentistry: Daunting for Developing Countries 2019 Commentary Challenges UK
Duane & Dougall [41] Guest Editorial: Sustainable Dentistry 2019 Commentary Advice, challenges and UK
opportunity
Hurley & White [37] Carbon modelling within dentistry 2018 Report Recommendations UK
Phillipson J. [39] The need for sustainable dentistry 2018 Commentary Advice UK
Grose et al. [149] Developing sustainability in a dental practice through an action research 2018 Research Advice UK
approach
Duane et al. [38] An estimated carbon footprint of NHS primary dental care within England. 2017 Research Assessment UK- England
How can dentistry be more environmentally sustainable?
Sachdev et al. [133] Green route indeed a need for dental practice 2017 Review Advice India
Aggarwal et al. [150] Go green: A new prospective in dentistry 2017 Commentary Advice India
Mulimani et al. [151] Green dentistry: The art and science of sustainable practice 2017 Review Awareness, advice UK
Richardson et al. [29] What’s in a bin: A case study of dental clinical waste composition and 2016 Research Awareness UK
potential greenhouse gas emission savings.
Carney et al. [47] The D Word 2015 Commentary Awareness USA-
California
Duane et al. [152] Green Dentistry - Motivating change 2014 Commentary Challenges and advice UK
Holland C. [153] Greening up the bottom line 2014 Commentary Advice UK
Avinash et al. [132] Going Green with Eco-friendly Dentistry 2013 Commentary Advice UK
Duane et al. [31] Taking a bite out of Scotland’s dental carbon emissions in the transition to a 2012 Research Awareness UK- Scotland
low carbon future
Theme 2: Reduce, reuse, recycle and rethink (n=17)
Bowden et al. [101] Evaluating the environmental impact of the Welsh national childhood oral 2021 Review Awareness UK-Wales
health improvement programme, Designed to Smile
Su et al. [154] Additive manufacturing of dental prosthesis using pristine and recycled 2020 Research Awareness China
zirconia solvent-based slurry stereolithography
Lyne et al. [25] Combining evidence-based healthcare with environmental sustainability: 2020 Research Awareness Not reported
using the toothbrush as a model
Ahmadifard A. [72] Unmasking the hidden pandemic: sustainability in the setting of the COVID- 2020 Commentary Awareness UK
19 pandemic
Duane et al. [24] Incorporating sustainability into assessment of oral health interventions 2020 Research Awareness Not reported
Duane & Dougall [41] Guest Editorial: Sustainable Dentistry 2019 Commentary Attitudes Not reported
Khanna et al. [155] Green dentistry: A systematic review of ecological dental practices 2019 Review Awareness, advice Not reported
Harford et al. [9] Sustainable Dentistry: How-to Guide for Dental Practices 2018 Commentary Advice Not reported
Grose et al. [50] Developing sustainability in a dental practice through an action research 2018 Research Advice Not reported
approach
Phillipson J. [39] The need for sustainable dentistry 2018 Commentary Awareness, advice Not reported
Eram et al.[156] Eco Dentistry: A new wave of the future dental practice 2017 Commentary Awareness, advice Not reported
Pithon et al. [148] Sustainability in Orthodontics: what can we do to save our planet? 2017 Commentary Awareness, advice Not reported
Kakkar et al. [43] Go green: a new prospective in dentistry 2017 Commentary Awareness, advice Not reported
Sachdev et al. [133] Green route indeed a need for dental practice: A review 2017 Review Advice Not reported
Ranjan et al. [79] Awareness about biomedical waste management and knowledge of effective 2016 Research Awareness Not reported
recycling of dental materials among dental students
Rupa et al. [53] Taking a Step Towards Greener Future: Practical Guideline for Eco-Friendly 2015 Commentary Overview Not reported
Dentistry
Chadha et al. [157] Establishing an Eco-friendly Dental Practice:A Review 2015 Review Advice Not reported
Rastogi et al. [110] Green Dentistry, A Metamorphosis Towards an Eco-Friendly Dentistry: A 2014 Commentary Awareness Not reported
Short Communication
Chopra et al. [33] Eco Dentistry: The environment-friendly dentistry 2014 Commentary Awareness, advice Not reported
Rahman et al. [158] Green Dentistry - Clean Dentistry 2014 Commentary Awareness, advice Not reported
Al Shatrat et al. [103] Jordanian dentists’ knowledge and implementation of eco-friendly dental 2013 Research Advice Jordan
office strategies
Garg and Guez [42] Trends in Implant Dentistry - Green dentistry 2010 Commentary Awareness Not reported
Anderson et al. [106] Creating an environmentally friendly dental practice 1999 Commentary Awareness Not reported
(continued on next page)

5
Table 4 (continued )
reported
Theme 3: Policy & Guidelines (n=5)
Wolf et al. [26] Changing Dental Profession—Modern Forms and Challenges in Dental 2021 Commentary Awareness, advice Not reported
Practice
Wilson et al. [40] What impact is dentistry having on the environment and how can dentistry 2020 Commentary Awareness, advice UK
lead the way?
Australian Dental Policy Statement 6.21 – Dentistry and Sustainability 2020 Report Awareness Australia
Association [159]
Chopra et al. [160] Green Dentistry: Practices and Perceived Barriers Among Dental 2017 Research Awareness, advice India
Practitioners of Chandigarh, Panchkula, and Mohali (Tricity), India
Arora et al. [44] Eco-friendly dentistry: Need of future. An overview 2017 Review Awareness, advice India
Chadha et al. [104] Establishing an Eco-friendly Dental Practice: A Review 2015 Review Awareness, advice South East
Asia
Fan et al. [124] Laboratory evaluation of amalgam separators 2002 Research Awareness, advice USA
Theme 4: Biomedical waste management, including amalgam (n=49)
Musliu et al. [63] The use of dental amalgam and amalgam waste management in Kosova. An 2021 Commentary Awareness, barrier, Kosova
environmental policy approach opportunity
Wolf et al. [26] Changing Dental Profession—Modern Forms and Challenges in Dental 2021 Commentary Awareness Not reported
Practice
Martin et al. [49] Waste Plastics in Clinical Environments: A Multi-disciplinary Challenge 2020 Research Awareness, barrier UK
Akkajit et al. [189] Assessment of Knowledge, Attitude, and Practice in respect of Medical Waste 2020 Research Awareness, barrier, Thailand
Management among Healthcare Workers in Clinics opportunity
Tompe et al. [83] A Systematic Review to Evaluate Knowledge, Attitude, and Practice 2020 Review Awareness, barrier, Asia
Regarding Biomedical Waste Management among Dental Teaching opportunity
Institutions and Private Practitioners in Asian Countries
Subramanian et al. [85] Biomedical waste management practice in dentistry 2020 Research Awareness, opportunity India
Choudhary et al. [161] Assessment of Knowledge and Awareness About Biomedical 2020 Research Awareness, barrier, India
WasteManagement among Health Care Personnel in a Tertiary Care Dental opportunity
Facility in Delhi
Aghalari et al. [162] Determining the amount, type and management of dental wastes in general 2020 Research Awareness, best practice Iran
and specialized dentistry offices of Northern Iran
Makanjuola et al. [163] Managing the phase-down of amalgam amongst Nigerian dental 2020 Research Barriers, opportunity Nigeria
professionals and students: A national survey
Duane et al. [34] Environmental sustainability and waste within the dental practice 2019 Commentary Awareness, drivers, Not reported
opportunities
Duane & Dougall [41] Guest Editorial: Sustainable Dentistry 2019 Commentary Awareness, Drivers Not reported
Sultan et al. [164] Establishing mercury-free medical facilities: a Malaysian case study 2019 Research Barrier, opportunity Malaysia
Phillipson J. [39] The need for sustainable dentistry 2018 Commentary Drivers, opportunity Not reported
Mulligan et al. [105] The environmental impact of dental amalgam and resin-based composite 2018 Review Awareness, opportunities Not reported
material
Ilić-Živojinović et al. Knowledge and Attitudes on medical waste management among Belgrade 2018 Research Awareness barriers, Serbia
[165] medical and dental students opportunity
Singh et al. [68] Awareness of Biomedical Waste Management in Dental Students in Different 2018 Research Awareness barrier, Nepal
Dental Colleges in Nepal opportunity
Momeni et al. [73] Composition, Production Rate and Management of Dental Solid Waste in 2017 Research Opportunity, awareness Iran
2017 in Birjand, Iran
Teixeira et al. [166] Waste diagnosis in public dental facilities in Recôncavo Baiano county: 2017 Research Awareness, opportunity Brasil
contributions to integrated waste management
Sachdev et al. [133] Green route indeed a need for dental practice: A review 2017 Review Opportunity Not reported
Eram et al. [93] Eco Dentistry: A new wave of the future dental practice 2017 Education Opportunity Not reported
Richardson et al. [29] What’s in a bin: A case study of dental clinical waste composition and 2016 Commentary Awareness, opportunity UK
potential greenhouse gas emission savings.
Khwaja et al. [136] Mercury exposure in the work place and humanhealth: dental amalgam use 2016 Research barriers, opportunity, best Pakistan
in dentistry at dentalteaching institutions and private dental clinics practice
inselected cities of Pakistan
Ranjan et al. [79] Awareness about biomedical waste management and knowledge of effective 2016 Research Awareness barriers, India
recycling of dental materials among dental students opportunity
Abhishek et al. [62] Awareness-Knowledge and Practices of Dental WasteManagement among 2016 Research Barriers, opportunity India
Private Practitioners.
Shah et al. [167] Knowledge, Attitude and Practices of Interns,Graduates and Postgraduate 2015 Research Awareness, Barriers India
Students at PrivateDental Colleges in Ahmedabad RegardingBio Medical
Waste Management
Rupa et al. [53] Taking a Step Towards Greener Future: Practical Guideline for Eco-Friendly 2015 Commentary Opportunity Not reported
Dentistry
Allen [142] Disposing of clinical and dental waste 2015 Commentary Awareness, opportunity UK
Bathala et al. [168] “There′ s plenty of room at the bottom”: The biomedical waste management 2014 Commentary Awareness India
in dentistry
Chopra, et al. [33] Eco Dentistry: The environment-friendly dentistry 2014 Commentary Opportunity Not reported
Singh et al. [77] Mercury and Other Biomedical Waste ManagementPractices among Dental 2014 Research Awareness, barriers, India
Practitioners in India opportunity, best practice
Rastogi et al. [110] Green Dentistry, A Metamorphosis Towards an Eco-Friendly Dentistry: A 2014 Commentary Awareness, opportunity Not reported
Short Communication
Unger et al. [89] Comparative life cycle assessment of reused versus disposable dental burs 2014 Research Opportunity, best practice Not reported
6
reported
Holland C. [58] Greening up the bottom line 2014 Commentary Opportunity Not reported
Govan P. [86] Waste management in dental practice 2014 Commentary Drivers, best practice, South Africa
opportunity
Kapoor et al. [169] Knowledge and awareness regarding biomedical waste management in 2014 Review Awareness, barriers, India
dental teaching institutions in India- A systematic review opportunity
Bansal et al. [70] Knowledge, Attitudes and Practices of dental care waste management among 2013 Research Awareness, barriers, India
private dental practitioners in Tricity (Chandigarh, Panchkula and Mohali) opportunity
Avinash et al. [132] Going Green with Eco-friendly Dentistry 2013 Commentary Barriers, opportunity, best Not reported
practice
Nabizadeh et al. [82] Composition and production rate of dental solid waste and associated 2012 Research Awareness, best practice Iran
management practices in Hamadan, Iran
Koolivand et al. [66] Investigating composition and productionrate of healthcare waste and 2012 Research Barriers, opportunity Iran
associatedmanagement practices in BandarAbbass, Iran
De Souza et al. [112] Improper Waste Disposal of Silver-Mercury Amalgam 2012 Research Awareness barriers, Not reported
opportunity
Agarwal et al [94] Waste management in dental office - Letter 2012 Commentary Awareness, best practice India
Yasny & White. [141] Environmental Implications of Anesthetic Gases 2012 Review Opportunity, best practice, Not reported
Rudraswamy et al. [78] Staff’s attitude regarding hospital waste management in the dental college 2012 Research Awareness, barriers India
hospitals of Bangalore city, India
Kumar [109] Green dentistry; eco-friendly dentistry: beneficial for patients, beneficial for 2012 Commentary Barriers, opportunity Not reported
the environment.
Sood & Sood. [71] Dental perspective on biomedical waste and mercurymanagement: A 2011 Research Barriers, opportunity India
knowledge, attitude, and practice survey
Muhamedagic et al. Dental Office Waste - Public Health and Ecological Risk 2009 Review Awareness, opportunity Not reported
[125]
Cocchiarella et al. [57] Report of the Council on Scientific AffairsBiohazardous Waste Management: 2009 Report Barriers, opportunity USA
What the Physician Needs to Know
Guedes et al. [128] First detection of lead in black paper from intraoral filmAn environmental 2009 Research Awareness, opportunity Not reported
concern
Al-Khatib et al. [59] Dental solid and hazardous waste management andsafety practices in 2009 Research Barriers Palestine
developing countries: Nablusdistrict, Palestine
Sudhakar and Dental health care waste disposal among private dental practices in 2008 Research Awareness, barriers India
Chandrashekar. [80] Bangalore City, India
Al-Khatib & Darwish Assessment of waste amalgam management indental clinics in Ramallah and 2007 Research Barriers, opportunity Palestine
[137] al-Bireh cities inPalestine
Hiltz [170] The Environmental Impact of Dentistry 2007 Commentary Awareness, opportunity Canada
Iano et al. [171] Optimizing the procedure for mercuryrecovery from dental amalgam 2007 Research Opportunity Brazil
Batchu et al. [134] Evaluating Amalgam Separators Using and International Standard 2006 Research Best Practice, opportunity Not reported
Batchu et al. [130] The effect of disinfectants and line cleaners on the release of mercury from 2006 Research Awareness India
amalgam
Hylander et al. [116] High mercury emissions from dental clinics despite amalgam separators 2005 Research Barriers, opportunity Not reported
Ozbek & Sanin [56] A study of the dental solid waste produced in a school of dentistry in Turkey 2004 Research Awareness Turkey
Journal of Irish Dental Update on Waste Management for the practice of dentistry 2004 Commentary Background, best practice Ireland
Association [76]
ADA Council on Managing silver and lead waste in dental offices 2003 Report Opportunity, best practice USA
Scientific Affairs
[147]
Fan et al. [124] Laboratory evaluation of amalgam separators. 2002 Research Best Practice USA
Wilson N. [35] Dental practice and the environment 1998 Review Awareness, opportunity Not reported
Theme 5: Plastics (SUPs) (n=6)
Bardolia et al. [108] The environmental impact of dentistry 2019 Commentary Awareness, opportunity Not reported
Zeri et al. [172] Floating plastics in Adriatic waters (Mediterranean Sea): From the macro-to 2018 Commentary Awareness Not reported
the micro-scale.
Nesic et al. [173] Chitosan-triclosan films for potential use as bio-antimicrobial bags in 2017 Research Opportunity Not reported
healthcare sector
Nasser et al. [174] Evidence summary: can plastics used in dentistry act as an environmental 2012 Review Awareness Not reported
pollutant? Can we avoid the use of plastics in dental practice?
Palosuo et al.[175] Latex Medical Gloves: Time for a Reappraisal 2011 Commentary Barriers: Not reported
Sasaki et al. [176] Salivary bisphenol-A levels detected by ELISA after restoration with 2005 Research Awareness Not reported
composite resin.
Theme 6: Procurement (n=2)
Joy et al. [100] Mercury in Dental Amalgam, Online Retail, and the Minamata Convention on 2020 Commentary Awareness, opportunity Not reported
Mercury
Wilson et al. [40] What impact is dentistry having on the environment and how can dentistry 2020 Commentary Awareness, opportunity, UK
lead the way? barriers
Duane et al. [20] Environmental sustainability and procurement: purchasing products for the 2019 Commentary Awareness, opportunity Not reported
dental setting
Phillipson J. [39] The need for sustainable dentistry 2018 Commentary Drivers, opportunity UK
7
reported
Theme 7: Research & Education (n=8)
Borglin et al. [45] The life cycle analysis of a dental examination- Quantifying the 2021 Research Awareness Sweden
environmental burden of an examination in a hypothetical dental practice
Duane et al. [177] Environmental sustainability in endodontics.A life cycle assessment (LCA) of 2020 Research Awareness Not reported
a root canaltreatment procedure
Lyne et al. [25] Combining evidence-based healthcare with environmental sustainability- 2020 Research Awareness Not reported
using the toothbrush as a model
Duane et al. [178] Embedding environmental sustainability within the modern dental 2020 Commentary Awareness, opportunity Europe
curriculum— Exploring current practice and developing a shared
understanding
de Leon [179] Barriers to environmentally sustainable initiatives in oral health care clinical 2020 Commentary Awareness, barriers Canada
settings
Wilson et al. [40] What impact is dentistry having on theenvironment and how can dentistry 2020 Commentary Awareness, barriers, UK
leadthe way? opportunity
Verma et al. [30] Knowledge, Attitude and Practice of Green Dentistry among Dental 2020 Research Awareness, knowledge, India
Professionals of Bhopal City: A Cross-Sectional Survey attitude
Ilić-Živojinović et al. Knowledge and Attitudes on medical waste management among Belgrade 2018 Research Awareness, knowledge, Serbia
[81] medical and dental students attitude
Bansal et al. [70] Knowledge, Attitudes and Practices of dental care waste management among 2013 Research Awareness, knowledge, India
private dental practitioners in Tricity (Chandigarh, Panchkula and Mohali) attitude
Prathima et al. [102] Knowledge, attitude and practices towards eco-friendly dentistry among 2017 Research Awareness, knowledge, India
dental practioners. attitude
Theme 8: Materials (n=20)
Shiyo et al. [180] Recycling of Plaster of Paris 2020 Research Opportunities Not reported
Makanjuola et al. [139] Managing the phase-down of amalgam amongst Nigerian dental 2020 Research Barriers, opportunity Nigeria
professionals and students: A national survey
Amir Sultan et al. [127] Establishing mercury-free medical facilities: a Malaysian case study 2019 Research Opportunities Malaysia
De Bortoli et al. [181] Ecological footprint of biomaterials for implant dentistry: is the metal-free 2019 Review Best practice, opportunity Not reported
practice an eco-friendly shift?
Mulligan et al. [182] The environmental impact of dental amalgam and resin-based composite 2018 Review Awareness, opportunities Not reported
material
Gavrilescu et al. [28] The advantages and disadvantages of nanotechnology 2018 Review Barriers, opportunity Not reported
Teixeira et al. [140] Waste diagnosis in public dental facilities in Recôncavo Baiano county: 2017 Research Awareness, opportunity Brasil
contributions to integrated waste management
Bakhurji et al. [183] Dentists’ perspective about dental amalgam: current use and future direction 2017 Research Attitudes Not reported
Pithon et al. [148] Sustainability in Orthodontics: what can we do to save our planet? 2017 Commentary Opportunities. Not reported
Sachdev et al. [133] Green route indeed a need for dental practice: A review 2017 Review Opportunities Not reported
Kakkar et al. [43] Go green: a new prospective in dentistry 2017 Commentary Opportunities Not reported
Sadasiva et al. [184] Recovery of Mercury from Dental Amalgam Scrap-Indian Perspective 2017 Research Awareness India
Khwaja et al. [136] Mercury exposure in the work place and human health: dental amalgam use 2016 Research Barriers, opportunity, best Pakistan
in dentistry at dental teaching institutions and private dental clinics in practice
selected cities of Pakistan
Chadha et al. [104] Establishing an Eco-friendly Dental Practice: A review 2015 Review Opportunities Not reported
Singh et al. [77] Mercury and other biomedical waste managementpractices among dental 2014 Research Awareness, barriers, India
practitioners in India opportunity, best practice
Rekow et al. [185] What constitutes an ideal dental restorative material? 2013 Commentary Opportunities Not reported
Panasiuk & Głodek. Substance flow analysis for mercury emission in Poland 2013 Research Awareness, opportunities Poland
[129]
Bayne et al. [186] The challenge for innovation in direct restorative materials 2013 Commentary Barriers, opportunities Not reported
Erdal & Orris [121] Mercury in dental amalgam and resin-based alternatives: A comparative 2012 Research Opportunities Not reported
health risk evaluation
de Souza et al. [112] Improper Waste Disposal of Silver-Mercury Amalgam 2012 Research Awareness, barriers Not reported
Sawair et al. [187] Observance of proper mercury hygiene practices Jordanian general dental 2010 Research Barriers, opportunity Jordan
practitioners
Muhamedagic et al. Dental office waste - public health and ecological risk 2009 Review Awareness, opportunities Not reported
[125]
Al-Khatib & Darwish. Assessment of waste amalgam management in dental clinics in Ramallah and 2007 Research Barriers, opportunities Palestine
[137] al-Bireh cities in Palestine
Iano et al. [115] Optimizing the procedure for mercury recovery from dental amalgam 2007 Research Opportunities Not reported
Jokstad et al. [126] Amalgam waste management 2006 Commentary Awareness Not reported
Batchu et al.[134] Evaluating amalgam separators using and international standard 2006 Research Best practice Not reported
Hylander et al. [116] High mercury emissions from dental clinics despite amalgam separators 2005 Research Barriers, opportunities Not reported
Hörsted-Bindslev. Amalgam Toxicity - environmental and occupational hazards 2004 Commentary Awareness, background Not reported
[119]
Journal of Irish Dental Update on Waste Management for the practice of dentistry 2004 Commentary Awareness, best practice Republic of
Association [76] Ireland
ADA Council on Scientific Managing silver and lead waste in dental offices 2003 Report Awareness, opportunities USA
Affairs. [147]
Drummond et al. [188] Mercury generation potential from dental waste amalgam 2003 Research Opportunities Not reported
Fan et al. [124] Laboratory evaluation of amalgam separators. 2002 Research Best practice Not reported
Chin et al. [114] The environmental effects of dental amalgam 2000 Review Awareness Not reported
Anderson. [106] Creating an environmentally friendly dental practice 1999 Commentary Opportunities Not reported
8
reported
Arenholt-Bindslev Environmental aspects of dental filling materials 1998 Review Awareness Not reported
[111]
Westman et al. [131] Amalgam waste management - Issues and Answers 1994 Review Awareness Not reported
Arenholt, Bindsley. Dental amalgam-environmental aspects 1992 Review Awareness, best practice, Scandinavia
[118]
significant energy and further contributing to CO2 emissions. footprint of the NHS in England. The highest proportion of these emis
These CO2 emissions contribute in a circular manner to unpredict sions is caused by travel, followed by procurement, energy, nitrous
able water precipitations associated with climate change, creating pe oxide, waste and water [18,37,39].
riods of draught and desertification [48]. An earlier study for National Health Service (NHS) dental services in
Scotland (2004) estimated a contribution of 17.9 kg CO2eq per patient
3.1.2. Awareness appointment [31]. Both studies provide a breakdown, with travel
General individual awareness for carbon emissions and their impact commute making the largest contribution (46% for Scotland and 64.5%
on the environment is high, albeit translation into the professional oral for England) that accounts for 3% of the overall carbon footprint of the
health domains is not as pervasive. Evidence for the effect of the carbon NHS in England [21,50]. These studies are indicative of the size of the
footprint of dentistry is noted with an appreciation for lack of practical problem and have the limitation that they do not include full LCA of
action and the need for education of the profession at all levels [2]. procedures as there is insufficient data to support this type of study.
Wealthier countries are the largest contributors to carbon footprint but Some data collection for calculating water and waste are performed only
are least affected by the consequences [31]. in small regional areas and cannot be considered to be fully represen
The provision of oral healthcare, like any other business or inter tative of the whole population. Nevertheless, these studies provide an
vention, creates a significant carbon footprint that is not limited to the invaluable insight into the nature and the size of the CO2 emissions.
actual intervention itself, but it is the sum of the emissions created by Equivalent services in USA and Australia contribute 10% and 7%
each stakeholder in the supply chain. The linear economy supply chain is respectively to total CO2 footprint [18]. In 2014, Health and Social Care
considered as a continuum from mineral extraction, processing and agreed to reduce the carbon footprint of the NHS in England by 80% by
synthesizing of raw materials, to manufacturing and ultimately waste 2050 from the 2008 baseline in accordance with the Climate Change
management; with oral healthcare and dentistry included within it, as Act. [31,36–40].
the principal intended beneficiaries of these services and products [49] A practical guide has been developed by the Centre for Sustainable
(Fig. 3). Healthcare in the UK with suggestions on how dental practices can
In the UK (2013–14), the Government through Public Health En become more sustainable through travel, supplies, energy waste man
gland conducted a comprehensive calculation of the carbon emissions of agement, biodiversity and green space. It includes real life examples of
NHS dental services in England to identify the types of dental procedures suggestions made in dental practices and considers cost, return on in
which are responsible for large amounts of greenhouse gas emissions vestment, environmental benefit and ease of implementation of each
[37,38]. This included patient travel, staff commuting, business travel, suggestion [9].
procurement, gas and electricity use, waste disposal, water use and
nitrous oxide release. In 2013 to 2014, the total greenhouse gas emis 3.1.3. Barriers to change
sions of NHS dental services in England were 675,706 tonnes of carbon The problem of implementation of sustainability behaviours and
dioxide equivalents (tCO2e). This is equivalent to flying 50,000 times attitudes is a significant challenge and even more so in in developing
from the UK to Hong Kong and makes up 3% of the overall carbon countries; where the greatest barriers are a lack of economic feasibility
and knowledge-base [51].
Broad sustainability aims and guidance are beginning to be intro
duced into healthcare contracts, but these are neither sufficiently
pervasive nor enforceable by the employer or law. For example, in the
UK, the NHS England standard contract, contains three clauses which
currently are not applicable to primary healthcare [18]: Providers must
take all reasonable steps to minimise their impact on the environment;
demonstrate their progress on climate change adaptation, mitigation
and sustainable development; and provide annual summaries of this to
commissioners. Considering travel, the alternatives to the use of private
cars, of cycling and walking are not readably available options for many
due to the lack of infrastructure that facilitates this [21].
When it comes to the choice of most commonly used dental mate
rials, amalgam and resin-based composites are the greatest exponents.
However, the comparative carbon footprint of these two materials is
unknown with an absence of more concrete life cycle analysis data for
each material. There is a requirement to provide this analysis so that
informed choices can be made by the profession and the public [38,40].
Fig. 3. Linear economy supply chain: Mineral extraction, processing and syn Ultimately, the decision-making for oral healthcare professionals of
thesizing of raw materials >> Manufacturing and packaging of the dental re
cost and inconvenience vs positive impact on the environment is highly
storatives, sundries and equipment products >> Distribution and purchase of
subjective and lacks sufficient evidence that will support strong argu
these products >> Clinical procedure with further energy expenditure, water
use and use of materials >> Collection and disposal of waste (associated with
ments [21].
different levels of contamination), mostly managed through landfill and
incineration.
9
3.1.4. Biodiversity segregation need to be managed; availability of waste recycling facilities

A recent UNEP report [52], highlights that climate change is causing (especially in developing economies); and a lack of cultural under
an ‘unprecedented’ and ‘accelerated’ rate of species extinction across the standing of the need and benefits associated with recycling [34,59,79,
world with a profound effect on biodiversity that can have catastrophic 125].
consequences. Within the UK, 15% of around 8,000 species assessed are
facing extinction [22]. In addition to our contribution to global warming 3.3. Theme 3: Policy
through CO2 emissions, some of our activities in dentistry have a direct
negative impact on biodiversity; such as the presence of mercury in 3.3.1. Background
waste-water works from dental practices that don’t use traps. Mercury is The provision of healthcare in dentistry and the management of
neurotoxic and teratogenic; it can accumulate as it rises through the food waste arising from this, has to operate within the boundaries of legis
chain and it can also impact the microbiological activity in soil. lative regulation to ensure safety and sustainable practice; thus, pre
Manufacturing and distribution of supplies has an environmental impact senting a conflicting challenge. These frameworks vary both in their
via mining and procurement of raw materials, manufacturing environ remit from guidelines to legally enforceable laws, and across countries
mental impacts and transport in the supply chain. This can affect [56,57]. Given that they are designed to operate within their own
emissions, land and water pollution and changes to landscapes resulting country, they are normally published in their native language, and thus
in changes to biodiversity [9]. are excluded from this review if not in English. There is a need to protect
Every sector can contribute in a positive manner by promoting the public from communicable infectious diseases, with increased use of
biodiversity within their own operational environments. Biodiversity SUPs and PPE in dental practices that has a deleterious effect on envi
refers to the variety of living species which interact with one another to ronmental sustainability in dentistry. An example of this was the
form ecosystems: This means, the promotion of the growth and devel introduction of new infection control guidance that was introduced in
opment of green spaces for habituation of insects and animals [9]. England and Wales (2009 and revised in 2013) under the Health Tech
Dental practices can consider gravel or grass instead of tarmac; that has nical Memorandum HTM01-05; that focused on management of
an impact on insects (essential building block for biodiversity) and cross-infection control with no consideration to sustainable practice [29,
lowers the risk of flooding. Trees provide shelter and shade, and in this 58]. An in-practice study identified a 58% increase in waste manage
way contribute to a reduction in a building’s energy budget, through ment costs over a four-year period following the introduction of
reduced air conditioning usage and improved solar gain. Reduction of HTM01-05 [29]. In the UK, the Control of Substances Hazardous to
the use of harmful pesticides when caring for practice gardens/lawns Health Regulations (COSHH) requires all dental employers to control
also improves biodiversity [44,53]. Green roofs help mitigate the urban exposure to hazardous substances to prevent ill health [9].
heat island effect (an urban area is significantly warmer than the sur Concerning the management of waste, there is an abundance of
rounding countryside), and help with both energy conservation and legislation surrounding the use of hazardous substances in healthcare.
stormwater management [9]. In addition to the above, dental pro The main basis for dental waste management in the European Union is
fessionals can offset CO2 emissions by investing in reforestation cam the Waste Framework Directive that requires Member States to take
paigns [43]. There is a need for effective quality research that necessary measures to ensure waste is disposed of without endangering
demonstrates the cost benefits of providing a biodiverse space [22]. human health or the environment. Directive 91/689/EEC addresses
hazardous waste and by Decision 2000/532/EC a list of wastes was
3.2. Theme 2: Reduce, reuse, recycle and rethink adopted, which includes dental amalgam waste [59]. Waste manage
ment in the UK is governed by the Environmental Protection Act (1990)
3.2.1. Background that imposes legal ‘duty of care’ requirements on waste producers, to
Within the setting of the dental surgery, the complex and mostly ensure the appropriate safe handling and disposal/treatment of waste
contaminated nature of the waste produced in the delivery of oral [60]. The Hazardous Waste Regulations (England and Wales) 2005
healthcare makes it difficult or impossible in some instances to imple outline the legally binding requirements for hazardous waste which
ment policies of reuse, reduce and recycle. Many of the polymers used must be properly segregated, packaged and labelled [34].
are highly cross-linked and processed so that they may not be easily In the UK, confusion often arises around interpretation of HTM01-05
broken down into the constituent raw materials or derivatives. Polymer making cross-infection and appropriate waste management difficult to
devices used in a clinical environment are at high risk of contamination, follow. This creates an unnecessary burden and frustration in the ability
and the nature of the polymers and/or the complex shape of the devices to engage with sustainable practice with fear of litigation [40,61,62].
makes it costly and difficult to clean, disinfect and sterilize [49,54,55]. Other examples cite the need for effective legislative frameworks for the
Items that are currently easily recycled (e.g., paper, plastic and glass safe and environmentally sustainable management of amalgam waste
products) should be also be recycled in the workplace, to help reduce the [63]. When designing policy and regulatory frameworks, there is a need
depletion of natural resources and lower carbon emissions [34]. Sus to consider sustainability in dentistry within a wider context of
tainable activity through the recognised strategies of reduce, reuse, modernisation of the dental profession and the services that it provides
recycle and rethink are considered in the literature. Although commonly [26].
grouped together, the individual distinct focus of each strategy, requires
that they should be considered as separate entities in the review of the 3.4. Theme 4: Biomedical waste management
literature and are considered in detail under the headings of opportu
nities and best practice in the second part of this review [17]. 3.4.1. Background
The term biomedical waste has been defined as “any waste that is
3.2.2. Barriers generated during the diagnosis, treatment, or immunization of human
Difficulties and barriers to recycling are the main reason for lack of beings or animals, or in the research activities pertaining to or in the
engagement. The following have been identified that affect oral production or testing of biological and includes categories mentioned in
healthcare provision: The need for additional storage space and the cost Schedule I of the Biomedical Waste (Management and Handling) rules
of transport for moving waste; staff training and co-operation are 1998 [64–70]. Biohazardous waste has been referred to as medical
essential; the (real and perceived) risks associated with waste waste, infectious waste, red bag waste, biomedical waste, and regulated
10
medical waste. Most agencies and states assume that biohazardous increased regulation creates confusion with regards to managing sus
waste is waste capable of transmitting infectious disease, and therefore tainability [39].
includes materials sufficiently contaminated with blood or body fluids to
transmit disease. In a physician’s office, this would include supplies or 3.5. Theme 5: Plastics
disposable materials saturated with blood or body fluids [57].
Waste management is a significant and expensive problem for the 3.5.1. Background
healthcare sector [49,55]. This is due to the complexity of the waste Plastics are an integral and essential part of modern life and the
generated and its contaminated/infectious status. The volume of global economy and exhibit a range of properties that make them
biomedical waste (BMW) produced across the world is staggering, with a invaluable in clinical settings. Polymers can be assembled in a wide
reported 5.5kg of waste/patient/day in the UK-NHS and 0.4 kg/pa range of combinations using compound multi-layered structures and
tient/day in Germany [39]. According to WHO and SEARO, the forming highly specific complex shapes, that create a clinical item or
South-East Asian countries, collectively produce approximately 1000 packaging with optimised properties. Plastic items and devices provide
tonnes a day (approx. 350,000 tonnes of BMW a year) [71]. These are clinical and public confidence of using a new clean and/or sterile device
pre-COVID pandemic figures and will be much greater during the every time. The low cost of raw materials and bulk fabrication means
pandemic with the increased use of single-use disposable PPE that has that a wide variety of single-use products may be manufactured at
been necessary [72]. exceptionally low costs. The combined manufacturing versatility,
Biomedical waste has steadily increased in oral healthcare over cleanliness/sterility guarantee and cost effectiveness of plastic devices
recent decades due to the increased use of plastic barriers, gloves and makes reusing and/or recycling economically unattractive, with
masks [37,73]. For example, the Eco-Dentistry Association [74], esti disposal being the more likely solution [49,55]. This results in a highly
mated that 1.7 billion sterilization pouches and 680 million patient wasteful linear economy for Single Use Plastics (SUPs) with significant
barriers were disposed by US dental practices every year [31,73,75]. It is environmental impacts and greenhouse gas emissions affecting biodi
of note that high income countries produce more waste then medium versity and health (Fig. 3). Eight million tonnes of plastic enter our
and low-income countries [67]. BMW that is inadequately managed, can oceans each year, that does not naturally biodegrade but breaks down
cause water, air and soil pollution [73,76]. into smaller particles ‘micro-plastics’ [9]. Rates of plastic use have
The carbon emissions embedded in the disposal of all dental-related grown exponentially since the 1950’s, reaching 350 million tonnes (Mt)
waste streams is approximately 1,493 tCO2e, which is 0.22% of the globally in 2017. In Europe, production of plastics has been estimated at
overall carbon footprint of NHS dental services in England [37]. How 60 million tonnes in 2018, which is around 17% of global plastic pro
ever, it is important to bear in mind that it is the actual toxicity of the duction [87].
waste that may have the greatest impact on the environment, rather The amount of plastic packaging discarded by the healthcare sector
than the associated CO2 emissions [37]. Incineration of clinical waste in the UK is significant ; with over 590,000 tonnes generated annually,
releases greenhouse gases that contribute 1% of Europe’s carbon emis more than the entire municipal waste output of Luxembourg (England
sions [39]. Part of the problem is that BMW is not always effectively Chief Medical Officer Report 2016–17) [88].
managed due to practical, logistic or financial reasons, with much that In dentistry, single-use instruments are common, driven by short-
can be recycled ending in incineration and landfill [37]. Incineration of term cost and a perceived drive to infection prevention [73,89]. The
healthcare waste is linked to air pollution affecting public health [34]. A industry produces many non-reusable materials, such as single-use
rapid increase in the number of healthcare institutions, results in an plastic tubes of toothpaste, with lids that cannot be recycled [8]. The
increased burden of biomedical waste [68,70,77,78]. Generation of reasons for an increased use of plastics in dentistry are highlighted as:
BMW, despite being smaller than regular domestic waste, becomes sig Improved infection control, ability to manufacture complex sophisti
nificant when taking into account the risks associated with pathogens, cated shaped items, ease of manufacturing and ease of use and ease of
chemicals and their respective toxicities. disposal [32,76,89]. Ultimately, plastics from dentistry follow the same
Various European directives provided for specific regimes (take- fate as other plastics which are pervasive in the environment [90].
back, recovery and recycling) to deal with waste packaging, waste A recent study showed that an average of 20 SUP items are used on
electrical, electronic equipment and waste batteries [34]. average for every routine adult primary care dental procedure in the UK
[49]. The use of SUP items per adult care procedure is greatest for
3.4.2. Barriers to change routine dental fillings, followed by root canal treatment, oral surgery for
Biomedical waste is heterogenous making it difficult to manage [69]. dental extractions/minor surgical procedures, provision of crowns,
This is particularly the case of dental waste that uses a wide range of bridges and dentures and finally periodontics. The most commonly used
materials [49,61]. products are PPE for the dentist and nurse. On average, more than one
Inadequate knowledge and poor attitudes exist towards the genera pair of gloves, masks, wipes, autoclave-sterilization sleeves and tray
tion and management of biomedical waste across the world and in liners were used with each patient, independent from the type of pro
particular in some developing economies lacking adequate regulatory cedure delivered. This was compounded by the large number of items
frameworks that consider BMW to be no different from household waste. necessary for setting-up before and for decontaminating after proced
[39,59,62,65,66,77–83]. ures. In the UK, based on the number of dentists and dental therapists
A good level of knowledge, a positive attitude and effective infra registered with the General Dental Council in 2019 (n ≈ 45,000), it is
structure is key to implementing effective waste management; which are possible to use this data to extrapolate the national usage of the
often missing [62,84,85]. These are often lacking due to a lack of edu approximate number of SUPs used in a 40-week working year, working
cation, financial support and appropriate supportive legislation [34,53, four days per week and considering a conservative estimate of five
65,79–86]. procedures per day. A mean of 20 SUP items/dental procedure translates
An increase in the prevalence of infectious diseases coupled with to a conservative estimate in excess of 720 million dental SUP items/
much greater patient safety awareness, measures and regulation results year that end up as waste in the UK [91]. The SUP items identified in this
in a significant increase in the quantity of SUP solid waste generated (e. study were approximately 50:50 single plastics and multiple plastics
g., plastic barriers, gloves and masks) in dentistry. This accounts for forming compound structures [48]. This is a situation that is not sus
about 90% of the total solid waste generated [29,41,59,61,62,76]. The tainable in the long-term [76,92]. Disposal of these plastics through high
11
temperature incineration releases the carcinogens dioxin and furan [35, for more sustainable options [20]. There is a lack of knowledge and
93]. Plastics containing PVC produce acidic gases when incinerated and evidence on best practice that balances safety and sustainability for
are difficult to recycle [42,53,94]. products. The need to adhere to legally-binding regulations and laws
To address the impacts that plastics are causing a number of orga that stipulate patient safety as the main concern. The high cost of some
nizations, such as the Ellen McArthur Foundation [95] and WRAP [96], recycled products, such as recycled paper that is twice the price of
have been at the forefront in helping to push through changes in policy non-recycled paper is a barrier to its use [20]. An example for the use of
at an international and national level. The UK Plastic Pack initiative led effective procurement as a tool to reduce the use of amalgam, in line
by WRAP, largely focuses on plastic packaging, with major goals to be with Minamata phase down plans, is through sales made only to regis
achieved by 2025 for 100% of all plastic packaging to be reusable, tered practitioners via a Know Your Customer approach [100]. In this
recyclable or compostable, 70% of plastic packaging to be recycled or way the volume of sales, suitability, and risks involved can be monitored
composted, elimination of single-use plastic packaging and 30% recy more effectively.
cled content to be used in all plastic packaging.
3.7. Theme 7: Research and education
3.5.2. Barriers to change
There is an overriding requirement to protect patient safety through
3.7.1. Awareness
IPAC processes (Infection Prevention and Control) operating in an
This theme considers knowledge acquisition through research and
increasingly litigious society with sustainability concerns becoming very
knowledge delivery through education.
secondary. The need to comply with control of infection regulations that
An increasing body of research in sustainable practice is evident
focus on IPAC processes is an additional barrier [97,98]. There is an
through this literature review that pervades all the identified themes
urgent need to weigh these complex interplaying issues of environ
(Table 4). A prevailing finding is the paucity of high-quality research
mental harm and personal harm [8]. A second factor is the need to
into the provision of environmentally sustainable oral healthcare in
understand that the disposal of the actual plastic waste contributes a
general and that is linked to the requirement to provide equally high-
small percentage to the overall impact on pollution and CO2 emissions
quality patient-centred care outcomes [8,23,50,101].
that arise from plastic usage in healthcare. The major contribution
With regards to education, there is a growing awareness of a lack of
comes upstream in the supply chain from manufacturing, processing,
education in both undergraduate and postgraduate curricula, as part of
distribution and logistics [99].
formal education or informally through continuing professional educa
tion programs [30,65,70,81,102]. This educational provision is
inversely proportional to an increasing level of interest in the dental
3.6. Theme 6: Procurement
profession for education into approaches for engagement with and the
delivery of sustainable practice [18,22,30,65,62,79]. It is also set
3.6.1. Background
against a backdrop of generalised lack of awareness and knowledge in
Sustainable procurement, when applied to dentistry, is the practice
this area; as highlighted in the relevant sections for each theme in this
by which the dental surgery addresses environmental and social/ethical
review. A study in India reported that 76% of private practitioners were
considerations when they purchase goods or services [20]. ‘Green pro
aware of the harm they were doing to the environment; 95% of them
curement’ is a process whereby public authorities meet their procure
reported they felt a responsibility to not harm the environment [75].
ment needs by choosing solutions ‘that have a reduced impact on the
Some changes are beginning to take place, with evidence of sus
environment throughout their life-cycle, as compared to alternative
tainability included in the undergraduate curriculum [30,41,79,103].
products/solutions’ [20].
There is a perceived lack of encouragement from curriculum regulatory
Each stakeholder of the supply chain, has a significant impact on the
and governing bodies [18]. There is a growing and distinct need to
environment through the process of procurement of raw materials,
reverse this trend with eco-friendly curricula that focuses on the edu
manufacture, transport, distribution etc. In the UK, the carbon footprint
cation of staff and students on sustainability using a range of media and
of dental services provided by the NHS, public health and social care
resources [9,23,35,40,65,68,71,79,97,104,159]
accounts for 72% of the total [36]. This impact is in the form of GHG
emissions, land and water pollution and changes to landscapes resulting
in changes to biodiversity [8,9]. Procurement is a major hotspot, noted 3.8. Theme 8: Dental materials
as the 2nd highest contributor (19%) of the UK NHS dentistry’s carbon
footprint [9,18,20,37,39]. There is a recognition to coordinate pro Dental materials, are used in various formats, either for direct clin
curement of products that use plastic as a container or packaging with ical application or indirectly associated with oral healthcare provision.
waste management that can recover and recycle this waste [49]. This The literature covers a wide spectrum of materials and in the context of
approach can have significant financial gains by mapping procured sustainability, this theme is undoubtably the one that goes furthest back
plastic (at all levels of packaging) with sustainable recovery and recy in time, with references to a number of materials used directly or indi
cling technologies. rectly for clinical care; each of these is considered individually.
Extensive and complex care plans, requiring multiple appointments Dental materials have a high pollution impact, from all levels of the
are more resource intensive. This highlights the need to promote pre supply chain: Synthesis of raw materials, manufacturing, distribution,
vention as the most effective way of managing this pollution burden [18, procurement, clinical use and ultimately waste management. It is
37]. A focus on sustainable purchasing leads to lower costs, environ indisputable that these materials are required for the provision of
mental and health benefits. Importantly, procurement should also be effective oral healthcare, but there is also a need to understand this
ethical with due regard to products originating from developing econ impact and how to affect this as a user [49].
omies with regard to labour, safety and human rights of workers [20].
3.8.1. Barriers
3.6.2. Barriers to change Life cycle analyses are possible but are not specific to the CO2 foot
The limited supply of sustainable products [36] and the user con print due to the lack of analysis of processes that are necessary to make
venience of some products (e.g., disposable gowns) overrides the desire materials suitable for healthcare. Carbon conversion factors for making
12
the manufacturing of materials are not readily available outside in amalgam [127]. Dissolved mercury is the most reactive fraction and
dustry; making it very difficult to develop appropriate strategies [9,31, should be included when considering total mercury emissions as this
37]. causes the most severe environmental effects [116]
For many decades, the dental environmental spotlight has focused on Dental separators are designed to capture amalgam waste at the
dental amalgam. A greater appreciation and understanding of the point of clinical use in the dental surgery. These are not widely used
pollutant potential of other dental materials should drive further throughout much of the world and are approximately 90% effective [9,
research in this field. Most dental suction units are evacuating by- 30,18,44,53,58,103,105,111,125,126,132–135]. The amalgam waste
products of restorations (for example, mercury and particulate waste that is not captured in a separator, will flow directly into the municipal
containing monomers) and, increasingly, derivatives of ceramic prod waste water network. Sediments are likely to accumulate in the pipes of
ucts originating from milling, yet very little research exists on their dental practices and in the sewage pipes through natural precipitation.
potential harm to the environment [8,105]. As an example, an average 1.2 kg of mercury per clinic was found during
the remediation of abandoned Swedish facilities in 1993-2003 and
3.8.2. Dental amalgam similar quantities were observed in more recent work [116]. Separators
are not 100% effective because mercury can form colloids which are
3.8.2.1. Background. Worldwide consumption of mercury is around able to pass through traps/separators [116]. Also, fine mercury particles
300 tons per annum [73]. Mercury is the heavy metal of primary are produced when using high speed handpiece, these are particularly
concern, making up to 50% by weight of dental amalgam. Mercury is hard to recover and are overlooked in ISO 11143 [116].
bioaccumulating and exposure to mercury is known to have toxic effects Mercury contamination from these routes is cited as a reason to cease
in plants, animals and humans. Mercury can be neurotoxic and terato the use of amalgam as a dental restorative material [94,111,116,119].
genic; it can accumulate as it rises through the food chain and it can also Moreover, it is difficult to control mercury waste as enters the envi
impact the microbiological activity in soil. Once in the environment, a ronment in different forms as elemental vapour, amalgam sludge,
number of factors contribute (pH, temperature, oxygen, bacteria) to amalgam scrap or amalgam waste [110,125,135].
convert it into the more toxic methylmercury that is more bioavailable Cleaners containing oxidising agents and hypochlorite (sodium hy
and can now accumulate in the food chain [32,33,44,59,61,64,73,94, pochlorite and sodium dichloroisocyanate), that are used to disinfect the
103,105–121]. dental chair and the effluent pipes potentiate the release of mercury [33,
Dental mercury accounts for 3-4% of terrestrial mercury [64,111, 92,114,130,134].
114,118,120]. The UNEP Global Mercury Assessment of 2013 revealed Mercury levels in the air were found to be higher than permissible
that in 2010 an estimated 270–341 metric tonnes of mercury globally limits in dental surgeries [136]. Reasons for this are: Difficulty in
were derived from the use of dental amalgam [122]. 75 metric tonnes of implementing best practice [107], mishandling of materials, lack of
amalgam per annum were used in the EU alone [105]. The subsequent ventilation and use of hand mixing rather than capsules [136].
2018 report notes that the category of ‘mercury-added products’ that
includes dental amalgam, remains a major source of mercury release, 3.8.2.3. Barriers to change. There is a lack of consistency at an inter
but according to the latest 2015 global inventory, these levels are in national level and across jurisdictions with regards to the availability of
decline, especially in developed countries [123]. legislation and regulation [63,113,127,137], and limited access to
Disposal of dental amalgam directly into the sewage system is collection agencies and sites for waste amalgam waste [112,113,135].
common practice around the world. A study in Chicago, revealed a The low cost of amalgam prevails over sustainability concerns [59,
discharge of 35mg of mercury (as amalgam) a day into sewers, that 113]. This is especially the case in developing economies, where
contributed around 8–14% of total mercury in wastewater treatment affordability of dental care is a major concern. In these economies, a
plants [56,124]. Notwithstanding, the mercury waste from dental switch to a more costly or complex technique or material may exclude a
amalgam, accounts for less than 1% of mercury discharged by human large portion of a population from receiving simple dental care [107,
activity into the environment [77,92]. 127,138,139]. A lack of knowledge prevails in some countries with
Beyond the dental practice, the amalgam legacy in the form of limited understanding of the merits of alternative materials [107]. An
mercury emissions from crematoria will rapidly increase until 2020. interesting observation has been raised that an increase in the use of
This is predicted to plateau around 2035; returning to the lower levels resin-based composites to replace existing amalgam restorations could
seen in 2000 by 2055 [105]. produce a spike in environmental mercury levels [112].
There is a lack of general knowledge and awareness for the man
3.8.2.2. Pollution pathways for dental amalgam. Mercury from amalgam agement of amalgam waste and disposal [65,62,81,127,139]; noting
enters the environment as dental waste from the placement and removal that a lack of education on the environmental sustainability of dental
of restorations into waste water systems, due to intra-oral degradation of amalgam in the undergraduate curriculum [136]. There is significant
amalgam and release through human excretion, incineration of clinical evidence of inappropriate disposal of amalgam in many countries, with
waste (extracted teeth with amalgam fillings) or at the end-of-life the use of a common bin followed by incineration as common practice
following burial and cremation [32,33,35,53,56,59,63,65,71,73,77,92, [30,59,61,77,103,106,115,129,137].
105–107,111,114,116–120,125–130]. A 2005 Scandinavian study The use of amalgam separators is not universal, with the main cited
revealed that the output of mercury per chair exceeded the maximum reasons being: A lack of equipment in developing countries [84,107],
recommended output [116]. The incineration of extracted teeth with resistance from the dental profession that objected to this being imposed
amalgam as clinical waste releases mercury into the atmosphere [56,59, as a mandatory requirement [117] and a combination of inadequate
71,77,81,106,111,114,121,125,126,131]. In a similar manner, inap legislative frameworks and failure to implement existing regulations
propriate disposal of Hg to landfill is a further pollution source as this [63].
can leach into the environment [77,112,121,126,129]. A 1998 study There is a need to avoid Hg pollution risks high mercury emissions
reported that end-of-life cremation accounted for 7% of Hg emissions in from dental clinics despite amalgam separators [92,103,107,109,136,
Sweden [111] and a subsequent Malaysian case study reported that in 140].
2013, 3.6 tonnes of Hg were released from the cremation of bodies with
13
3.9. Anaesthetic gases 3.12.2. Barriers

There is a lack of knowledge associated with the environmental
3.9.1. Background impacts of RBCs [20,105,121]. Early studies show tentative results and
The major atmospheric effects that may arise from the emission of conclusions with regard to how composite and BPA act in the body as
volatile anaesthetics are their contributions to ozone depletion in the well as in the environment. The impact of certain oestrogenic xenobiotic
stratosphere and to greenhouse warming in the troposphere. These effects on development, health and reproductive systems are debatable
agents are also a recognized greenhouse gas, accounting for around 6% [111].
of the heating effect of greenhouse gases in the atmosphere [35]. Nitrous
oxide (N2O) is a gas with a global warming potential of 298 times that of 3.13. Lead
CO2e [34]. N2O also causes ozone depletion [141]. Most of the organic
anaesthetic gases remain for a long time in the atmosphere, where they 3.13.1. Awareness
have the potential to act as greenhouse gases. Lead is toxic and persists in the environment. Even at low levels of
The bromide-containing agent halothane is the most destructive exposure, lead exerts adverse health effects on both children and adults
against ozone, although it is rarely used. Isoflurane and enflurane [71,94,97,108,128]. Lead waste can remain in soil for as long as 2000
(which contains only chloride and fluoride ion substitutions) have a years where it can be readily picked up by plants and enter food systems
lesser impact [141] [97]. According to the US Environmental Protection Agency (EPA),
Published atmospheric lifetimes range between 1.4 and 21.4 years dental offices generate 4.8 million lead foils a year according [145].
for sevoflurane and desflurane, respectively. N2O emissions from all of Lead foil from dental radiograph films is the main contributor and if
its various environmental sources are currently the single most impor disposed in regular domestic waste, lead can leach and persist for a long
tant ozone-depleting substance emission and are expected to remain the time in soil and groundwater [32,33,53,146].
largest throughout the 21st century [141]. On average, 163 litres of N2O
are used per patient episode, equating to around 90 kg CO2e (without 3.13.2. Barriers
considering carbon emissions of producing NO2 and cylinder rental). There is wide disparity across all dental sectors for the management
Nitrous oxide used by NHS dental services in England is responsible for of radiographic film waste lead, with reports of inappropriate disposal
1.3% of the total nitrous oxide use of NHS England and makes up 0.9% [70,73,78]. Additionally, some manufacturers only report a 5% return
of the total carbon footprint of NHS dental services in England [34]. rate of lead from film for recycling [135].
3.10. Pollution pathway 3.14. Metals
Two main pollution pathways are the anaesthetic technique and the Silver thiosulfate is a solution used to fix the image on exposed dental
actual anaesthetic machine delivery system. Incidents associated with radiographs that presents a significant environmental concern [106,108,
these routes include: Poorly fitting masks, not turning off valves 125,133,146,147]. According to the US EPA, dental practices generate
immediately once removed from patient; leakage of gas when re-filling 28 million litres of silver thiosulphate x-ray fixer a year [145]. In
tanks; gas in system may leak into the environment if not flushed wastewater treatment plants, this is converted into silver sulphide which
correctly; underinflated cuff of laryngeal mask; leaks from valves, con settles in sludge [53,76,125,147]. Higher up the supply chain, toxic
nectors in circuit, tubing, reservoir bags etc. [141]. Scavenged gas is by-products are released through mining, processing and refining the
vented into the outside environment. As anaesthetic gases undergo very natural resources and ores. These toxic by-products are leached into the
little metabolic change inside the body, upon exhalation by the patient environment creating a major source of environmental pollution [35].
these agents remain in a form that may pollute the environment [141]. Lead is toxic and persists in the environment. Even at low levels of
exposure, lead exerts adverse health effects on both children and adults
3.11. Gypsum [71,94,97,108,128]. Lead waste can remain in soil for as long as 2000
years where it can be readily picked up by plants and enter food systems
3.11.1. Background [97]. According to the US Environmental Protection Agency (EPA),
Gypsum is an essential material that is widely used in dental labo dental offices generate 4.8 million lead foils a year according [145].
ratories for the manufacture of all indirect prosthodontic devices. When Lead foil from dental radiograph films is the main contributor and if
this is disposed, it is most likely to go to landfill where it can form H2S disposed in regular domestic waste, lead can leach and persist for a long
gas. H2S gas can cause irritation to the eyes, nose, or throat and may also time in soil and groundwater [32,33,53,146].
cause difficulty in breathing for some asthmatics. Headaches, poor Other metals that are regularly used in dentistry, have the potential
memory, tiredness, and balance problems may also occur. Permanent or for re-using and re-cycling; such as orthodontic brackets and wires.
long-term effects include headaches, poor attention span, poor memory, Alternative materials with lower carbon footprints to stainless steel
and poor motor function. For these reasons, gypsum is a banned waste (6.15 kgCO2e/kg), should be considered, such as ceramics (1.14
from normal landfill in many countries, but this practice is not the norm. kgCO2e/kg) and brass (2.42 kgCO2e/kg) [32,36,53,79,148].
Gypsum waste should be disposed into a separate cell for high sulphide
waste [44,79,142,143]. 3.14.1. Barriers
A significant challenge to reusing metallic devices is a very protec
3.12. Resin-based dental composite tionist and negative psychological reaction towards reusing medical/
dental devices [36].
3.13.1. Background There is a lack of regulation and control with regard the disposal of
Resin-based composite materials (RBCs) are not inert plastic mate potentially toxic solutions. For example, silver thiosulphate x-ray fixer is
rials and they have an environmental impact associated with the release poorly regulated in parts of the world, with most of this going into the
of microparticles and elution of resin monomer components, including municipal waste water drains [59,70].
BPA that is of significant environmental concern [105,144]. There is wide disparity across all dental sectors for the management
14
of radiographic film waste lead, with reports of inappropriate disposal impact on biodiversity; such as the presence of mercury in waste-water
[70,73,78]. Additionally, some manufacturers only report a 5% return works from dental practices that don’t use amalgam traps. The
rate of lead from film for recycling [135]. manufacturing, distribution and poor waste management of equipment,
sundries and associated packaging, that are part of a linear economy
3.15. Nanotechnology & Microparticles supply chain, presents a pollutant environmental impact.
The provision of oral healthcare in a clinical setting creates complex
3.15.1. Background and contaminated waste that makes it difficult or impossible in some
Nanoecotoxicology defines dangerous exposure that considers the instances to implement policies of reuse, reduce and recycle. This is
entry routes of air, water/soil via ingestion together with the circuit of especially poignant in respect of single use plastics that are found in the
nanomaterials in the abiotic and biotic environment. Their size enables a form of different complex polymer combinations. Plastic is an indis
wide distribution and uptake by the smallest life forms and some nano- pensable component of modern safe healthcare and their use is un
particles that are not naturally present in the environment, such as nano- avoidable. Plastic items and devices provide clinical and public
silver, nano-copper and nano-zinc that have antimicrobial properties, confidence of using a new clean and/or sterile device every time. The
have the potential to pose great threat to microbial communities [28]. combined manufacturing versatility, cleanliness/sterility guarantee and
Healthcare is a significant contributor of microplastics as part of the cost effectiveness of plastic devices makes reusing and/or recycling
waste stream that can enter the food chain; these can absorb other economically unattractive. The challenge is that these devices are costly
chemicals, poisoning wildlife, destroying ecosystems and putting human and difficult to clean, disinfect and sterilize. Recovery for recycling is
health at risk [9,105]. The dangers of ingestion of particles by marine often not cost-effective, possible and not supported by appropriate
life are four-fold: toxicity from ingesting the particle itself, contaminants legislation.
leaching from the microplastics, ingestion of attracted pollutants bound The provision of healthcare in dentistry and the management of
to the microplastics and accumulation of particles within the organism waste arising from this has to operate within the boundaries of legisla
[9]. tive regulation to ensure safety and sustainable practice. There is a
recognized conflict between the need to operate within the regulatory
frameworks of safe health provision and doing so in a sustainable
3.16. Disinfectants
manner. Most states and agencies assume that biohazardous waste is
waste capable of transmitting infectious disease, and consequently its
Disinfectants such as hypochlorite, glutaraldehydes, iodophors,
management automatically favours incineration and discounts any form
phenolic derivatives, alcohol-based preparations can inactivate essential
of recovery. Waste management policies are often not sophisticated
biological systems [35,53,92].
enough to identify and compel stakeholders to establish effective path
ways for segregation of waste that enable effective recovery for recy
4. Conclusions
cling. Current waste management focuses on landfill and incineration,
both with significant environmental impacts. There is a lack of aware
This scoping review has identified 128 records that contribute to our
ness and understanding of the actual impact of disposal of plastic waste.
understanding of environmentally sustainable oral healthcare. The
Most of the CO2 emissions have occurred upstream in the supply chain.
thematic analysis highlights eight diverse but closely interlinked themes
Ease, convenience and availability of low-cost products with high
that influence the sustainability of oral health provision on a world-wide
environmental impacts override a desire for more sustainable options.
basis: Environmental impacts (CO2e, air and water); Reduce, reuse,
Procurement is also driven by the need to adhere to regulatory frame
recycle and rethink; Policy and guidelines; Biomedical waste manage
works, that focus on clinical effectiveness and do not consider envi
ment; Plastics (SUPs); Procurement; Research & Education; Materials.
ronmental impacts.
The following headline conclusions are encapsulated with a focus on the
Lack of knowledge, awareness and educational programs are
levels of awareness and the real and perceived barriers to develop and
pervasive throughout the literature and identified as a common barrier
engage with sustainable practice.
to engagement and change in all themes. There is a distinct lack of
Public awareness of the need to decarbonise and reduce pollution
quality research that supports and enables the provision of environ
from our activities on a global basis is at an all-time high and this is
mentally sustainable oral health provision.
directly proportional to the increasing urgency to engage with this
Dental materials present the highest level of pollution, at all levels of
problem. Professional awareness is much lower as there is a perceived
the supply chain, from manufacturing, through to distribution, pro
disengagement between citizenship responsibility and that of our pro
curement, clinical use and ultimately waste management. The impact
fessional activities, that are led by the aims of the core professional
from dental materials is material-specific, with much of the evidence
activities. This is a constant theme throughout the literature and
focused on dental amalgam. There is a distinct need to establish effective
undoubtably both the greatest barrier and opportunity to engage in
life cycle analysis studies to provide baseline data for key restorative
effective and impactful sustainable outcomes.
materials and subsequently identify ways to minimize their use and
The greatest forms of carbon emissions arise from patient travel, staff
facilitate recovery.
commuting, business travel, procurement, gas and electricity use, waste
disposal, water use and nitrous oxide release. Of these, patient and staff
commuter travel account for the greatest contribution to the profession’s Declaration of Competing Interest
carbon foot print. A number of studies support the preliminary evidence
that provides a heightened level of awareness into the source and The authors confirm that there is no conflict of interest.
magnitude of these emissions.
The greatest barrier to the implementation of sustainability are the Acknowledgments
behaviours and attitudes that exist within the profession and that do not
consider or prioritise sustainable practices. These are particularly This work was financially supported by the FDI World Dental
pervasive in developing countries; where the greatest barriers are a lack Federation as part of the Sustainability in Dentistry project. The support
of economic feasibility and a poor knowledge-base on the subject. and encouragement of the FDI Sustainability in Dentistry Project Team is
In addition to our contribution to global warming through CO2 graciously acknowledged. The authors thank Ms. Hannah Martin for the
emissions, some of our activities in dentistry have a direct negative graphical illustrations included in this manuscript.
15
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Journal of Dentistry 112 (2021) 103735

Contents lists available at ScienceDirect

Awareness and barriers to sustainability in dentistry: A scoping review

ash, major contributors of dioxins in the environment; with a reported

Theme 1: Environmental impacts-CO2e, air and water (n = 21)

Theme 2: Reduce, reuse, recycle and rethink (n=17)

(continued on next page)

Theme 3: Policy & Guidelines (n=5)

Theme 4: Biomedical waste management, including amalgam (n=49)

Theme 5: Plastics (SUPs) (n=6)

Theme 6: Procurement (n=2)

(continued on next page)

Theme 7: Research & Education (n=8)

Theme 8: Materials (n=20)

3.1.4. Biodiversity segregation need to be managed; availability of waste recycling facilities

3.9. Anaesthetic gases 3.12.2. Barriers

3.10. Pollution pathway 3.14. Metals

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