Climate change is a complex issue affecting humans, ecosystems and the economy. Climate change is associated with shifting weather patterns, rising sea levels, rising sea temperatures, extinction of species and changing natural systems. The ‘hidden pandemic’ is expected to cause 150,000 deaths per year and by 2050, 250,000 additional deaths yearly (WHO, 2021). Recently, there has been a shift in focus due to a new health crisis, the COVID-19 pandemic which resulted in at least 3 million deaths worldwide (WHO, 2023). Deviating from the climate crisis to cope with a global health crisis slowed progress in achieving sustainable development. Whilst some countries such as the United Kingdom have legislated to reduce carbon dioxide gas emissions, New Zealand (NZ) and Australia have chosen to strive for carbon neutrality by 2050. The strategic change the government is aiming for is to create a more circular economy by minimising waste, resource recovery and maximising the value of renewable resources.
The practice of sustainability emphasises the value of living within biophysical limits and avoiding overconsumption of natural resources. However, this is not seen consistently across different sectors or the public. In its current form the healthcare industry including dentistry is a major contributor to greenhouse gas emissions. Dentistry is a high energy and resource-intensive industry that involves high demand for supplies, water, energy and the use of single-use plastics (SUPs). Oral healthcare (OHC) is mostly delivered without considering treatment-related impact on the environment. Therefore, there is a need to support research and development into more sustainable PPE and recycling, which aligns with achieving a more circular economy. A call for action was issued recently by the FDI, “dentistry, as a profession, should integrate sustainable development goals (SDGs) into daily practice and support a shift to a green economy in the pursuit of healthy lives and wellbeing for all, through all stages of life” (FDI, 2021). FDI shared best practices on how the dental profession can reduce carbon emissions which focuses on four domains: preventative care, operative care, integrated care and ownership of care. According to the FDI, providing high-quality dental care and focusing on preventative care will help to ensure environmentally sustainable practice, therefore, achieving good oral health outcomes and reduced environmental impact. Prior to the pandemic, environmental sustainability in general was finding a good momentum. However, prioritising environmental sustainability during and post COVID-19 pandemic has been a challenge for the dental industry worldwide due to rigid infection control protocols.
There is growing interest amongst oral health practitioners to become more environmentally friendly but there is a lack of motivation due to unclear guidelines and gaps in knowledge (Martin et al., 2021; Grose et al., 2016). The dental industry needs to address environmental sustainability issues and improve policies. This requires a collaborative and interdisciplinary approach to accelerate efforts in reducing emissions and achieving carbon emissions reduction targets.
Environmental impact of COVID-19 pandemic
Over the last decade the sustainability efforts in dentistry have gained attention and produced action. Unfortunately, the growing awareness created through these past efforts has largely disappeared due to the Covid-19 pandemic. The highly infectious virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of deaths world-wide. Healthcare workers were more at risk of becoming infected through airborne transmission than the general population because of direct contact with patients. Transmission is an even greater risk for aerosol generating procedures (AGP) which are commonly seen with dental treatment. Aerosols are generated with the use of ultrasonic scalers, rotary instruments, hand pieces and air-water syringes. Dental practices are considered a high-risk environment for transmission and cross-infection.
Full personal protective equipment (PPE) such as sterile face masks or respirators of the correct specifications, gloves, shields, caps, bodysuits, gowns or aprons became critical items for carrying out AGPs. The COVID-19 outbreak resulted in a significant increase in the use of PPE by the healthcare sector, general public, food industry, transport industry and other essential workers; exacerbating the plastic pollution and negatively impacting efforts to reduce waste. WHO estimated that 89 million masks, 76 million gloves and 1.6 million safety glasses were required each month in the global response to the COVID-19 pandemic. In the years 2019 and 2020, 2.3 billion PPE items were distributed in England alone (Zhang et al., 2021). During the pandemic some US states, Portugal and UK loosened environmental policies to allow manufacturing of plastics to help stop the spread of the virus, slowing down or even reversing years of efforts in these jurisdictions to reduce plastic pollution. Around the world there is growing evidence of discarded masks and gloves ending up in the ocean, on beaches and nature trails, and if disposal patterns continue it will result in about 75% of COVID-19 related PPE waste ending up in the environment (Zhang et al., 2021). Such plastic-based single use items are not biodegradable and can stay in the environment for long periods of time; around 450 years before fully decomposing. In addition, micro plastics in the oceans are ingested by wildlife and can enter the human food chain which could cause adverse health effects (Zhang et. al., 2021). With the ongoing pandemic and the uncertainty of new variants of SARS-CoV-2 emerging, high-usage of PPE and disinfectants will most likely continue in the foreseeable future (Zhang et al., 2021). According to Singh et al., (2020) masks could see a 20% increase in supply from 2020 to 2025. In UK studies it was estimated that there would be 66,000 tonnes of plastics generated in a year if each person wore one mask per day (Dean, 2020). This will be a challenge to manage sustainably if immediate actions are not taken to coordinate strategies that will address the manufacturing and waste lifecycle (Singh et al., 2020). For that reason, we as the dental profession should not underestimate the impact of this and advocate for a more effective waste management system. Healthcare professionals and their organisations have a moral, ethical and social responsibility to protect the public from harm. There is much need to increase the knowledge base of all healthcare professionals to support the shift to practicing sustainably and integrate SDGs into daily practice.
The increasing demand for PPE exacerbates issues relating to production and disposal which can cause added risk to the environment and atmosphere (Ahmadifard, 2020). Firstly, increased PPE production increases the demand for raw plastics which may lead to increased fracking or petrochemical manufacturing, both of which are toxic for the environment and add to carbon emissions (Ahmadifard, 2020). Secondly, since PPE is a ‘clinical waste’ its disposal is heavily regulated, often requiring incineration which releases toxins into the air. Incineration still doesn’t guarantee complete elimination and micro particles of plastic may still exist. Collectively, dental practices use of SUPs and PPE can have a considerable environmental impact. The shift in priorities from acting sustainably to solely protecting self and public during the new health crisis is hindering progress in reaching SDG goals. Plastic consumption needs to be reduced which requires maximising its management whilst also reducing the burden on the waste management sector. A step forward would mean improving existing waste management infrastructures and developing a circular economy that allows for PPE to be recycled, reused and processed, minimising damage to the environment.