ECO-FRIENDLY DENTISTRY

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ECO-FRIENDLY DENTISTRYTHE ENVIRONMENTALLY-RESPONSIBLE DENTAL PRACTICEBy: DR. ALI FARAHANI & MITTALE SUCHAKAPRIL 3, 2007

TABLE OF CONTENTSPageExecutive Summary 2Introduction 2Literature Review 7Methodology 8Results 12Analysis and Discussion 17Green Recommendations 37Conclusion 38

Executive SummaryThe aim of this project was to present tangible data to dentistsin private general practice so that the environmental cost ofconducting the practice of dentistry would be emphasized. Presentedwith this data, it is hoped that dentists will be stimulated to takeproactive actions using the environmental alternatives presented.A survey technique was used to create a case study comparing theenvironmental burden from conventional dental offices to a proposed“green” dental office.The results indicated that many reasonable, practical and easyalternatives do exist which would reduce the environmental footprintof a dental office were it to follow the “green” recommendations. Forexample, from our survey conventional dental offices used thousands ofsheets of paper per year in excess of a “green” model.This report concludes that dentists should take a leading role insociety by implementing “green” initiatives to lessen their impact onthe environment.This report provides a series of “green”recommendations that dentists around the world can implement to becomeleading stewards of the environment.Introduction“The ultimate purpose of business is not, or should not be,simply to make money. Nor is it merely a system of making and sellingthings. The promise of business is to increase the general well-beingof humankind through service, a creative invention and ethicalphilosophy.” (Paul Hawken, 1993; The Ecology of Commerce)Environmental awareness and accountability are rapidly moving tothe forefront of humanity‟s consciousness.Naturally, the developmentof environmentally-responsible practices is increasingly evident.Many businesses are in fact striving to alter their practices by

taking environmental responsibility either voluntarily or due toregulatory pressures.The healthcare sector is an area not often associated withburdening the environment.Nor should this association be a criterionupon which to base a “green” healthcare movement.In dentistry,particular research interest has been devoted to minimizing theenvironmental impact from mercury.Aside from mercury, to date therehas been relatively little reported on dentistry‟s other environmentalpollutants.Excluding mercury, this report will outline many otherenvironmentally-friendly alternatives and practices that can beimplemented.“This sustainable approach to dentistry incorporatesecologically sustainable materials and practices that reduce theimpact of medical procedures on the environment as well as protectingclients from toxic materials” (Desai, 2003-2006, p.17).Most dental offices are privately-owned small businesses and haveno financial advantage to invest in many environmentally-friendlypractices.There are no funds or grants available to assist in makingan office “green”.business owner.It is essentially up to the consciousness of the“Setting out to redesign or start up a business sothat it does maintain a holistic relationship between economy andecology, the ethical entrepreneur is handicapped financially since hebears the costs of the additional responsibilities he‟s assumed.”(Paul Hawken, The Ecology of Commerce, 1993). For this reason, moreresearch is needed to find cost-effective environmental alternativesin dentistry.Purpose Statement of ProjectThe purpose of this project is to raise widespread awareness ofenvironmental alternatives in the dental community and to stimulateaction based on the recommendations made.This is achieved by firstassessing the typical environmental impact from five dental offices.Comparisons are then made to one possible “green” model using amethodological approach based on quantitative and qualitative

research.A “green” list of practical eco-friendly recommendationswill then be generated.This will facilitate the adoption of positivechanges to minimize dentistry‟s environmental impact and to promote aleading role for dentistry in environmental stewardship.As such,this project is intended for the consumption of both the dental andthe general community.Boundaries of ProjectThe scope of this project will be limited to three dental officesin the City of Waterloo, one dental office in Haldimand County, onedental office in the City of Oshawa and one future dental office inthe County of Perth that will begin its operation in the spring of2007.The data will be collected over a typical work week.Thisresearch will exclude the environmental impact from the use of mercuryin dentistry.Given the small scale of this project, both in terms offunding and manpower, this project is meant to be an initial forayinto the area of eco-friendly dentistry.Target AudiencesA variety of eco-dentistry guidelines and alternatives will bepresented in this paper.It is our intention that these “green”recommendations be made accessible to each and every dentist in theworld.To achieve this, this paper will be submitted to the Journalof the Canadian Dental Association (JCDA) for publication.The Importance of Eco-friendly dentistryIt is our belief that there should be no such term as“environmentalists.”To refer to a segment of society who cares aboutthe health and welfare of the planet as such is akin to using the term“human rightists” for those who show compassion and offer aid to theirfellow human beings.

It has been said that it is not possible to have healthy peopleon a sick planet.Reducing waste, changing patterns of consumptionand limiting the amount of adverse chemicals entering the breathableair of a dental office are achievable and realistic goals.Thisproject will demonstrate that though the non-mercury relatedenvironmental impact of dentistry is not abundantly documented, it isnevertheless worthy of the profession‟s attention.Aim of the StudyThe aim of the study is to present tangible consumption data(e.g., number of patient bibs used per year) to dentists in privatepractice so that the environmental cost of routine dental practice canbe highlighted.Given concrete data (e.g., number of trees saved), itis hoped that dentists will be catalyzed to adopt if not all, many ofthe recommendations from the “green” list.The following four key questions will be addressed in thisproject:By using the “Environmental Assessment Questionnaire,” whatis the non-mercury related environmental burden from aconventional dental office?In comparison, what is the non-mercury relatedenvironmental burden from a prospective “green” dentaloffice?Based on the obtained results, can eco-friendly dentalpractices be universally recommended?In what ways can a typical dental office implementsustainable environmental practices?

Background Information on Eco-friendly dentistryEco-friendly dentistry is an approach to dentistry thatimplements sustainable practices by keeping resource consumption inline with nature‟s economy, by safeguarding the external environmentby virtue of eliminating or reducing outgoing wastes and by promotingthe well-being of all those in the clinical environment by consciousreduction of the chemicals in the breathable air.Hiltz (2007) states:“Dentistry is a profession dedicated to promoting andenhancing oral health and well-being.To accomplishthese goals, dentists use a variety of materials andequipment.Unfortunately, some of the materials thatare currently in use – including heavy metals andbiomedical waste – present potential challenges to theenvironment” (p.59).The Teleosis Institute (2006) states:“In Green Health Care, toxic-free buildings, literacyaround local environmental health issues, and the useof safe, effective, precaution-based medicine are allintrinsic parts of a new system of healthcare that isgood for people and the environment.”

Literature ReviewEco-friendly dentistry is a relatively new term and an emergingconcept in dentistry.It is part of a larger movement towardsecologically-sustainable healthcare. In dentistry, a large volume ofresearch has been devoted to the environmental aspects of mercury.And rightly so given that mercury is a significant environmentalpollutant.Chin G, Chong J, Kluczewska A, Lau A, Gorjy S, Tennant M. Aust Dent J. Theenvironmental effects of dental amalgam. 2000 Dec;45(4):246-9.Arenholt-Bindslev D. Adv Dent Res. Dental amalgam – environmentalaspects. 1992 Sep; 6:125-30.Recently, more attention has been given to other sources ofenvironmental pollutants in addition to mercury.Hiltz M. J Can Dent Assoc. The environmental impact ofdentistry. 2007 Feb; 73(1):59-62.More recently, the term “Eco-dentistry” has been pioneered which hastaken dentistry beyond the point of preventing pollution to a place ofpromoting sustainability.Pockrass F, Pockrass I. Journal of Ecologically Sustainable Medicine, Symbiosis, 17.“Eco-dentistry”: A model of mercury-free dentistry.To date, there has been no published data on the quantitative benefitsof an eco-friendly approach to dentistry. It is an accepted socialmeaning that to act environmentally sound is preferable to being anecological liability but how much difference is it really making if anoffice recycles paper, plastics and uses energy-efficient lights? Cana valid comparison be made between conventional models and a new“green” one?

That is precisely the research objective of this paper. We believethis is the first published investigation of its kind. Given thelimited financial and human resources of this project, it is meant tobe an initial attempt to derive quantitative data, however limited inits scope.The area of eco-friendly dentistry is in great need of more researchin the area of economical analysis of traditional versus a “green”dental model. Furthermore, many of the survey items may be expandedinto individual research projects.MethodologyoAll dental offices are in Ontario, Canada.oFive conventional dental offices were selected.oThree of the five dental offices were in the Region of Waterloo.oOne was in Haldimand County.oOne was in Oshawa.oThe “green” dental model will be in the County of Perth.oReasons for choosing the five dental offices:oConvenienceoLocalityoConventionalDr. Farahani chose to survey two dental offices with which he wasfamiliar.I chose to survey three dental offices because of locality.I do not have access to a car in Waterloo.Therefore, I had to choosethe dental offices close to where I lived.The purpose was to choosefive conventional dental offices and in the end, that purpose wasachieved.

Research Approaches:oQuestionnairesoInterviewsoFive interviews were conducted.in the Region of Waterloo.I surveyed three dental officesDr. Farahani surveyed two dentaloffices.oThe basic purpose of using the “Environmental AssessmentQuestionnaire” to conduct interviews was to understand theconsumption patterns of five conventional dental offices so thata thorough comparison can be made between a conventional and a“green” dental practice.The data was analyzed according to the following criteria:oThe data was divided into two categories such as qualitative andquantitative.Any question with a mathematical output wasclassified as quantitative.On the other hand, any question thatrequired secondary research to explicate its purpose wasclassified as qualitative.For example:Average number of papers in a typical chart is anexample of a specific question because I had tomake an average calculation based on fivenumerical values I had from the data I collectedfor this question.The discussion of flooring types is an example ofa generic question because secondary research wasused to determine benefits and costs of variousclinical flooring.Furthermore, the data was divided into three main categories:consumption, breathable air, and waste management.questions was placed in one of these categories.were proposed for each category.Each of the“Green” alternatives

The research went very well.Initially, I contacted more than 10dental offices in the Region of Waterloo.I collected a booklet thatcontained contact information of dental offices in the Region ofWaterloo from the University of Waterloo‟s Dental Plan Office.on that, I contacted dentists randomly by phone.BasedI gave them a briefintroduction about who I am, why I am calling, and what the purpose ofthe study is.Almost all of the dental offices I contacted wereextremely receptive because they were keen on helping me out as thisproject was a critical requirement at the University of Waterloo.Onthe whole, they were helpful and I did not have any problems.Advantages and Limitations of the chosen research approach:I divided my research approach into two main categories:oPrimary research: questionnaires and interviewsoSecondary research: literature reviewBenefits of Interviews: Create an interactive forum for the assessment of interpersonalskills, job-relevant knowledge, motivation and potential fit Allow the interviewer to:oSell the organization to qualified candidatesoGive a realistic and detailed description of the positionto candidates Interviewer can obtain supplementary information Quick and cheap if the sample is small Verifiable by replication and re-questioning ofinterviewees/respondentsLimitations of Interviews: Poor reliability/consensus between different interviewersoDifferent interviewers have their own styles and approachesoVary in how many criteria they assessoVary in the standards they use to assess and weightcriteria Poor validity/prediction of job performanceoInterviews are not very good predictors of job performance

Intrinsic limitations of the interviewoHigher degree of subjectivity Interviewer biases Interviewer errors Subjective evaluations are made Not much evidence of validity of the selection procedure Not as reliable as tests Time consuming if sample is large Closed questions may constrain the data Respondents may interpret the questions differently Response rate may be low and selection non-randomSource:Dattner Consulting, LLC (Ben Dattner, Ph.D.) andhttp://www.hr-guide.com/data/G311.htmLiterature Review:oA literature review is an account of what has beenpublished on a topic by accredited scholars andresearchers.oPurpose is to convey to the reader what knowledge and ideashave been established on a topic, and what their weaknessesand strengths are.Source: es: Accessible Helps to examine large-scale trendsDisadvantages: Lack of consistency of perspective Biases and inaccuracies cannot be checked

Results

ConsumptionDentalDentalDentalDentalDentalOffice 1Office 2Office 3Office 4Office 5AverageDentalOffice 6(GreenModel)Average #30262531.61525.516620613.316.212.36of patientsseen perdayAverage #of papersin aWaste iceOfficeOfficeOfficeOffice12345chartAverageDental Office6(Green Model)Average #20.0ofIs paper fromautoclaveautoclave bagsbags usedrecycled?per dayIs paper recycled?Average #30of patientIs recycled yN.AN.AYes25.5YesN.Aused?Are patient 2-plyIs plasticbibs2-ply from2-plyNoNo2-plyNo2-plyNoYesN.Aorautoclave1-ply? bagsrecycled?Electricity N.AIs sN.AYesN.AN.AN.AWasherYesN.AN.Aassolutionper one recycled?load ofwashIs fixer solutionrecycled?ElectricityN.AconsumptionAre biohazardsasmanagedper oneby aN.AYesN.AYesN.AYesYesN.ANoN.AN.ADryerYesloadof dry company?biohazardTypesof garbageFluorescent10 FluorescentHow many6.7lightbulbsbags (10L) areFluorescent3& HalogenFluorescentN.A6.7Fluorescent9.35& HalogenN.Apractical)filled/day?Is leadfromTypesof foilCRT-Tubex-rays recycled?computerscreensN.A Fluorescent(whereYes LCD-FlatYesPanelYesLCD-FlatNoLCD-FlatPanelPanelNo CRT-TubeN.AN.AN.A LCD-FlatPanel

Breathable AirDentalDentalOfficeOffice 2Dental Office 3DentalDentalOfficeOffice 51AverageDental Office64(Green Model)What type ofCaviBiosurf andsurfaceWipesChaircareCavi WipesGermBiosurf,ExtraBiotext,disinfectants areCidexused in thelinesN.ASOL-U-GUARDoffice?Type of oleumVOCVOC LatexN.AVOCVOC LatexN.AUltra-low VOCin non-clinicalareasType of flooringin clinical areasType of paintLatexLatexLatexAnalysis and DiscussionVolume and Conversion Scale:Every private general dental office has a differing volume ofdental services rendered.This volume depends ultimately on thenumber of dental patients treated per day.To make our data moremeaningful to all private dental offices, we chose a baseline volumeof patients such that any dental office could create a simpleconversion scale to make the results of this study approximately

comparable to their own situation.In the “green” model, a baselineof 16 patients treated per day is used.Therefore, if an officeservices on average 32 patients per day, they can divide theirconsumption data by 2 for purposes of comparison to the “green” model.Consumption:Paper1. Average number of papers in a typical chartThe average number of papers in a typical chart between the fiveconventional dental offices is 12.3.6 papers in a typical chart.offices is 6.3 (12.3 - 6).The “green” model would useThe difference between the dentalFor a 2000-chart dental office, atany one time 12,600 papers can be saved in a digital office.This corresponds to the following:According to Save-A-Tree, “Environmental savings for using 151Lbs. of Save-A-Tree paper” include:Trees SavedWood Saved (Lbs.)1523Water Saved (gals.)Landfill Reduced (Lbs.)77082Net GreenhouseEnergy Reduced (BTU) (000)Emissions Reduced (Lbs.)1581,042

Source: http://www.unisource.ca/misc/sat/en/eco.php2. Average number of autoclave bags (e.g. Statim) used per dayIn the survey, the average number of autoclave bags used per day is23.4.Given a 200-day work year, that amounts to 4,680 (23.4 * 200)pieces of autoclave paper.One of the offices we surveyed recycledthese bags using the standard “Blue Bin” program.Since these bagsare sterilized and carry sterilized instruments up to the point ofbeing discarded, there are no biohazard concerns.The “green” model would use an Instrument Cassette Management System(Hu-Friedy IMS) that enables washing (Hydrim, Scican) andsterilizing (LISA, A-dec) the instruments. Traditionally, cassetteshave been packaged with disposable autoclave wraps (Hu-Friedy). The“green” model proposes an innovative, eco-friendly alternative:Once the cassettes have been washed, operating room (O.R.)cotton towels (Medimart) are used to wrap the cassettes.The wrapped cassette is placed in an appropriately-sizedautoclave bag (Medimart) and placed in the autoclave (seeAppendix). This process allows the O.R. cotton towel to besterilized as well as the cassette and its contents. Theautoclave bag is necessary to ensure that the vacuum phaseof the autoclave does not remove the micro-fibers from theO.R. cotton towels. These micro-fibers have been shown tocause serious damage to autoclaves. Upon completion of thesterilization, the autoclave bag is carefully opened toseparate the paper and plastic portions without tearing ifpossible. Accordingly, the paper and plastic portions arerecycled using neighbourhood Blue Bins. The wrappedcassettes are then stored appropriately for eventual usagewhile maintaining their sterilization status as they wouldwith disposable autoclave wraps.

None of the offices in the survey used the disposableautoclave wraps (e.g. „blue‟ wraps from Hu-Friedy), so wehav

“Eco-dentistry”: A model of mercury-free dentistry. To date, there has been no published data on the quantitative benefits of an eco-friendly approach to dentistry. It is an accepted social meaning that to act environmentally sound is preferable to bein

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