**Consensus on Environmentally Sustainable Oral Healthcare:**

A Joint Stakeholder Statement

**Sustainability in Dentistry**

**Read more about the FDI** 

**Sustainability in Dentistry project**

The fi ve founding partners of the Sustainability in Dentistry project are Colgate, Haleon, Procter & Gamble, Dentsply Sirona and TePe

measurable environmental outcomes in the sector.

address the sustainability issues facing the whole sector.

more sustainable manner.

people and the planet.

The Oral Healthcare community, including clinical professionals and industry, acknowledges the shared responsibility to deliver products and interventions that improve oral health in a

To deliver this, the community is working in alignment with the UN Sustainable Development Goals. Key to establishing this collaborative stakeholder consensus is a deep contextual understanding of the challenge. This is achieved through a comprehensive account of the levels of awareness of the environmental impacts, the challenges to resolve these impacts

This report concludes with a strategic action framework that makes specifi c recommendations and identifi es best practice to achieve these goals. The promotion of excellent oral healthcare and the development of a circular economy are core to this strategy. Additionally, it is also important to recognise the opportunities to collaborate across the sector, and throughout supply chains, to develop and promote sustainable practices to achieve meaningful and

In this context, the FDI World Dental Federation convened the development of this volume, Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement. This consensus statement brings together a global coalition of stakeholders, representing all aspects of industry, health professionals, experts, legislative authorities and governments. The statement uses a truly collaborative, multi-stakeholder approach to identify the major challenges facing oral healthcare, the complex drivers that underpin current behaviours and practices, and the best opportunities to improve and deliver sustainable oral healthcare for

Concluding with an impactful and robust strategic action plan that crosses all boundaries, the statement identifi es a series of actions and recommendations for best practice that

between the FDI-Sustainability in Dentistry Task Team and the project founding partners (Colgate-Palmolive, Dentsply Sirona, Haleon, Procter & Gamble and TePe) with the wide

participation of stakeholders throughout the oral healthcare supply chain.

Written by The University of She eld colleagues Prof Nicolas Martin, Dr Steven Mulligan, Hon. Prof Ian J Shellard and Prof Paul V Hatton, Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement is the result of a collaborative working partnership

together with the drivers and opportunities to promote sustainable practices.

# **Consensus on Environmentally Sustainable Oral Healthcare:**

A Joint Stakeholder Statement

Nicolas Martin, Steve Mulligan, Paul V. Hatton, Ian J. Shellard

# **Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement**

Nicolas Martin, Steven Mulligan, Ian J Shellard and Paul V Hatton

**Ratified March 2022**

Published by White Rose University Press (Universities of Leeds, Sheffield and York) University of York, Heslington, York, UK, YO10 5DD https://universitypress.whiterose.ac.uk

Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement Produced by the authors for FDI World Dental Federation

Text © the Author(s) 2022

First published 2022

Cover design: FDI World Dental Federation

Cover images: Shutterstock.com Cover images credit: Photograph in large circle: SewCream/shutterstock.com, 2022 Photograph in small top circle: Mr.Music/shutterstock.com, 2022 Photograph in small middle circle: Gorynvd/shutterstock.com, 2022 Photograph in small bottom circle: Kirillov alexey/shutterstock.com, 2022

ISBN (Paperback): 978-1-912482-44-3 ISBN (PDF): 978-1-912482-45-0 ISBN (EPUB): 978-1-912482-46-7 ISBN (MOBI): 978-1-912482-47-4

DOI (volume): https://doi.org/10.22599/OralHealth

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Example citation: Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. York: White Rose University Press. DOI: https:// doi.org/10.22599/OralHealth. CC BY 4.0, https://creativecommons.org/licenses/by/4.0/

To access this work freely online via the White Rose University Press website, please scan this QR code or visit https://doi.org/10.22599/OralHealth

# **Table of Contents**



# **Preface**

This document is divided into sections, which enables the reader to readily access areas of interest.

**Contributors** to the Stakeholder Statement are acknowledged at the outset together with a **glossary of the terms and definitions** used throughout.

A **Joint Stakeholder Statement** for Environmentally Sustainable Oral Healthcare is established. This sets the tone and construct for a detailed and comprehensive operational **Strategic Action Framework** (Section V) for all stakeholders in the supply chain.

The **Strategic Action Framework** is an operational framework that provides a series of principles and action points that have been reached through consensual agreement. This forms the basis for proactive engagement in worldwide environmentally sustainable oral healthcare. A synopsis concludes this section.

The Strategic Action Framework is founded on a comprehensively developed **Frame of Reference** (Section IV) for the concept of sustainability in oral healthcare. In doing so, it highlights the levels of awareness, the challenges, the drivers and the opportunities involved in achieving this goal. It also identifies and considers the various routes to sustainability identified in the literature.

The whole process has been developed through a robust and detailed **Research Framework** (Section III) that identifies the background to the study, the main aim and objectives and the actual methodology that has been used to reach the Strategic Action Framework.

The document concludes with the relevant **Bibliography** and the **Appendix** for the mapping exercise that matches the United Nations' Sustainability Development Goals to those reached in this oral healthcare sustainability statement.

This stakeholder statement was ratified in March 2022 by the contributors as identified.

# **Contributors and acknowledgements**

This publication, *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*, was made possible through the passion, hard work and dedication of many people and organisations. Their individual and collective contributions are duly recognised under the following headings.


The authors also wish to acknowledge and give special thanks to Dr Ghislaine Caulat and Andy Copeland from Black Gazelle Consulting for the professional facilitation service throughout the consultation process with partners and participants. The artwork created by Hannah Martin for the linear and circular economy illustrations is gratefully acknowledged.


# **FDI Sustainability Task Team**


## **Founding Partners of the FDI 'Sustainability in Dentistry Project'**


## **Participants**



### **Participants**

# **Glossary and definitions**

# **Acronyms and abbreviations**



# **Terminology and definitions**


# SECTION I

# **A Joint Stakeholder Statement**

Through this statement, we recognise that the oral healthcare sector – as a whole supply chain – has a responsibility to undertake its activities in a manner that seeks to improve the sustainability of oral healthcare products and interventions.

Through our collective ambition to reduce the environmental impact of oral healthcare, we recognise that there is a substantial opportunity and desire to work collaboratively across the sector, to engage in sustainable practices with all stakeholders for the benefit of society. We recognise the need to establish a strategy to achieve meaningful and measurable environmental outcomes throughout the oral healthcare supply chain.

Ratified March 2022

**How to cite this book chapter:** 

Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. Pp. 1. York: White Rose University Press. DOI: https://doi.org /10.22599/OralHealth.a. CC BY 4.0

# SECTION II

# **Executive Summary**

Climate change and environmental pollution are among the greatest health threats affecting the planet, humanity and biodiversity. This is recognised in the 2030 United Nations Agenda for Sustainable Development, which includes an urgent call for action from all sectors. The entire oral healthcare community, including clinical professionals and industry, recognises that we have a responsibility to deliver products and interventions that improve oral health in a sustainable manner. We also recognise the need to address this environmental challenge within the context of huge oral health inequalities across the world. The actions taken to address sustainability goals need to be balanced with the need to manage these avoidable inequalities and the associated preventable diseases.

Towards this objective, the FDI World Dental Federation convened an expert group to produce this *Consensus Statement on Environmentally Sustainable Oral Healthcare*. This brings together a coalition of stakeholders that includes leading figures from industry, health professionals, academic experts, legislative authorities and dental associations, with the clear intent to identify an impactful and robust strategic action framework that crosses boundaries and takes a truly collaborative, evidence-based approach. In doing so, the work of this panel represents an important continuum of the pioneering statement adopted by the FDI General Assembly (August 2017, Madrid, Spain) [5].

Through this document, we identify the collective views across the whole supply chain, where all are equally committed to further improving sustainability without compromising healthcare benefits. This work is in close alignment with the UN Sustainable Development Goals, and recognises that both excellent oral healthcare and the development of a circular economy are two key pillars in delivering sustainability. We further recognise that there are opportunities to collaborate across the sector and throughout supply chains, to develop and promote sustainable practices that achieve meaningful and measurable environmental benefits.

This joint stakeholder statement recognises the major challenges facing oral healthcare, the complex drivers that underpin current behaviours and practices, and the best opportunities to improve and deliver sustainable oral healthcare for people and the planet. The statement further emphasises the routes to sustainability in oral healthcare, drawing on evidence from the published literature [6, 7]: reduce, reuse, recycle and rethink; legislation, policy and guidelines; waste management (including SUPs); procurement and logistics; research and education; and materials for clinical use.

#### **How to cite this book chapter:**

Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. Pp. 3–5. York: White Rose University Press. DOI: https://doi .org/10.22599/OralHealth.b. CC BY 4.0

Each of these routes is considered in a three-step process that sequentially informs future strategy, including positive actions that should be implemented across the sector:


Knowledge of the impact of oral healthcare on the environment is not uniform, with significant awareness among manufacturers but relatively little insight from end-users including oral healthcare professionals, patients and consumers. CO2 emissions and plastic waste, packaging and end-user single-use plastics (SUP) are recognised to be among the main contributors to unsustainable practice. Companies across the supply chain have identified that impactful solutions will only come about through unbiased and open inter- and intrastakeholder collaboration and communication within the supply chain. Companies recognise that they will have to work differently and often together to address key issues. The dental industry seeks to do this through engagement with policymakers, healthcare professionals, manufacturers, distributors and the public as a major stakeholder and end-user of these services. There is a further opportunity for all stakeholders to identify and embrace every element of sustainable practice and in this way, through multiple individual activities, achieve significant cumulative positive benefits.

This consensus statement recognises the importance of legislation to ensure products are fit for purpose while driving sustainable practice. Designing and working with the duality of this legislation is challenging at all levels, but especially so for end-user/oral healthcare providers that have to work within the constraints of stringent regulations that promote patient and workforce safety. There are undoubtedly opportunities to work with legislative authorities at all levels to seek effective remediation strategies.

The greatest opportunities for sustainable practice are through reduction, reuse and recycling:


There is broad agreement that stakeholders in the dental sector could potentially make significant reductions in the volume of waste generated, most notably from manufacturing processes, packaging, and the high prevalence of single-use products (mostly plastic). Most of the contaminated biomedical waste impact lies downstream of the supply chain, with the oral healthcare professionals, patients and end-user consumers. This waste problem is further compounded by the increased use of personal protective equipment (PPE).

Recycling remains a challenge at the patient end-user level, but less so with packaging and uncontaminated SUPs. For both scenarios, there is an opportunity to engage in robust research that will drive the required knowhow and supporting technologies.

Education is considered the fundamental component of any action strategy, with a focus on increasing awareness and identifying solutions for each sector and for the supply chain as a whole. Any strategic educational framework should be based on strong and robust research that provides an objective and unbiased representation of the facts that contribute to environmental sustainability in the oral healthcare industry. The oral healthcare industry has a responsibility to promote innovation and high-quality research and to harness best operational models to identify and support sustainable activities within the supply chain.

In conclusion, this statement establishes a consensus opinion on the most promising approaches to reduce the environmental impact of oral healthcare without compromising patient welfare. This is in response to a recognition of the value of implementing sustainable practices, in alignment with the United Nations agenda. While recognising that our sector makes a significant contribution to oral health, which improves the quality of life for millions of people worldwide, this statement also acknowledges that there is an opportunity to further improve sustainability. Specifically, this consensus statement demonstrates clearly the potential for far greater future impact as a direct result of improved coordination and collaboration between diverse stakeholders. Implementation of the approaches presented here will deliver the twin benefits of a sustainable, circular economy with improved global oral health.

# SECTION III

# **Research Framework**

#### **Introduction**

The 2030 Agenda for Sustainable Development, 'adopted by all United Nations Member States in 2015, provides a shared blueprint for peace and prosperity for people and the planet, now and into the future'.

At its heart are the 17 Sustainable Development Goals (SDGs), which are an urgent call for action by all countries – developed and developing – in a global partnership. They recognize that ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth – all while tackling climate change and working to preserve our oceans and forests [9].

In keeping with this 'urgent call for action', the oral healthcare industry has come together and joined forces, under the continued leadership of the FDI World Dental Federation, to collaborate with a strong and genuine ambition to engage with this UN Agenda for Sustainable Development.

The FDI has assumed the responsibility of this leadership role, in its capacity as the World Dental Federation, which serves as the principal representative body for more than one million dentists worldwide, some 200 national dental associations and specialist groups in over 130 countries [10]. The FDI has convened the development of a joint stakeholder Consensus Statement on Environmentally Sustainable Oral Healthcare. This has been achieved through a unique working partnership between the FDI Sustainability in Dentistry task team, five project founding partners and the wide participation of stakeholders in the oral healthcare supply chain (see *Contributors*).

This consensus statement seeks to identify, understand and establish an improvement strategy that will address our responsibilities, both as individual stakeholders and as part of a global supply chain to address the goals identified.

The WHO has established that oral health 'is a key indicator of overall health, well-being and quality of life' [11]. This sentiment is echoed by the FDI World Dental Federation in its definition of oral health,

#### **How to cite this book chapter:**

Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. Pp. 7–10. York: White Rose University Press. DOI: https://doi .org/10.22599/OralHealth.c. CC BY 4.0

**Figure 1:** Prevention and maintenance as a key route to environmental sustainability. "SewCream/Shutterstock.com" 2022.

highlighting that it is 'vital to general health and well-being' [12]. The hard and unavoidable reality is that the world population is far from achieving oral health, with oral diseases affecting nearly 3.5 billion people worldwide (approximately 50% of the world population) [13]. This situation poses 'a major health burden for many countries and affects people throughout their lifetime, causing pain, discomfort, disfigurement and even death' [14]. Oral diseases are most commonly expressed in the form of caries (the most common health condition) [15], severe periodontal disease (affecting almost 10% of the world population) [11] and oral cancer (among the most common forms of cancer worldwide [16]). The WHO further states that 'Most oral health conditions are largely preventable and can be treated in their early stages' [11].

It is in this context that **we need to focus the efforts of the oral healthcare professions and the associated oral health industry to reverse this undesirable situation with the provision of good oral health for all**, largely through effective prevention and maintenance regimes that minimise the need for interventions and operative treatment (*Figure 1*). In the last decades, the combined efforts of the oral healthcare profession and the oral health industry have been extraordinarily successful in the delivery of a sophisticated understanding and knowledge of diseases, treatment strategies and modalities, including the innovation and development of excellent technologies, materials and products to provide this care. These combined efforts have, to date, been largely focused on the end goal: preventing and managing oral diseases.

Today, we have a further understanding that these laudable intentions and efforts are having the unintentional consequence of contributing to the global net rise in CO2 e emissions and pollution. The recently published draft COP26 special report on climate change and health highlights the impact of healthcare on the environment [17], with evidence of how 'health professionals worldwide are already responding to the health harms caused by this unfolding crisis' [18]. Significant progress in this field has been made by the American Society for Testing and Materials, with the important recent publications *Standard Practice for Managing Sustainability in Dentistry* (2015, 2021), written in response for 'a consensus-based practical guidance document in support of the cost-efficient integration of generally recognized sustainable development principles into day-to-day management of dental practices both for individual dental professionals as well as dental service organizations' [19, 20].

Healthcare systems are responsible for around 5% of global greenhouse gas emissions, of which oral health is an important contributor [21, 22]. The delivery of general healthcare is currently not environmentally, socially or financially sustainable owing to high amounts of CO2 e and waste generation [23]. It is paradoxical that healthcare, with the central tenet of supporting and protecting health and life, contributes to climate change through unsustainable practices and, in doing so, to negative health impacts and inequalities.

The oral healthcare industry is keen to address this challenge and ensure that, through the actions of both individual stakeholders (companies, associations and other entities) and the entire supply chain acting in unison, we reduce and limit our environmental impact to ensure sustainable planetary health. The whole oral healthcare supply chain (inclusive of the manufacturing industry, distribution, care professions and waste management) has a vital role to play in climate change mitigation efforts through a comprehensive engagement in sustainable practice. Not only would sustainable oral healthcare potentially result in substantial CO2 e reductions but it could lead to enhanced patient care, staff satisfaction, cost savings and improved quality of life [24, 25, 26].

To improve the sustainability of oral healthcare services, all stakeholders have identified and recognise the urgent need to work together synergistically, collaboratively and in a non-partisan manner to build knowledge, identify remediation opportunities and share good practice. The dental industry seeks to do this through engagement with policymakers, healthcare professionals, manufacturers, distributors and the public as a major stakeholder and end-user of these services.

Sustainability in relation to oral healthcare is comprehensively defined by the American Society for Testing and Materials (ASTM) in the document *Standard Practice for Managing Sustainability in Dentistry E3014–15* as:

Sustainable development is about integrating the goals of a high quality of life, health, and prosperity with social justice and maintaining the earth's capacity to support life in all its diversity. These social, economic, and environmental goals are interdependent and mutually reinforcing. Sustainable development can be treated as a way of expressing the broader expectations of society as a whole [19, 20, 27].

The FDI World Dental Federation, in its *Sustainability in Dentistry Statement* (2017), has also adopted a series of relevant definitions for sustainable development, green economy and sustainability [5].

For the purpose of writing this consensus statement and providing a practical operational framework, the partner and participant stakeholders have agreed a **definition for sustainability in oral healthcare** that establishes **why** we need to engage, **what** we are trying to achieve and **how** best to accomplish this work.

**Sustainable oral healthcare** is the provision of equitable, ethical, high-quality, inclusive and safe care with appropriate, effective and efficient use of resources. Through this, the healthcare opportunities of current and future generations are respected and protected by actively minimising negative environmental impacts.

#### **Aim**

To respond to the United Nations' 'urgent call for action by all countries – developed and developing – in a global partnership' through the establishment of a global, unified and recognised working consensus opinion that is representative of participating key stakeholders in the provision of oral healthcare and which will reduce and minimise our environmental footprint.

## **Objectives**


#### **Methodology**

The FDI World Dental Federation Sustainability in Dentistry Task Team has led this research process [28]. The process was based on an iterative series of drafts informed by a comprehensive three-wave Delphi inquiry [29, 30], undertaken with the key stakeholder focus group (partner companies) from May to October 2021 and supported with appropriate published literature. A series of workshops (November 2021) with the multidisciplinary worldwide participation of key stakeholders followed, to add further perspectives from other key supply chain stakeholders (see *Appendix*). The additional participant workshop data was categorised thematically and included in the relevant sections of the document with further revisions from the partner companies. The final approved joint stakeholder statement was released at the FDI Sustainability in Dentistry Summit (March 2022).

The consensus statement sought to identify common ground between all the key stakeholders, with all the findings and inclusions agreed in a consensual and non-partisan manner. The statement is set out in the manner of a *concept journey*, commencing with an awareness of the problem, exploring the challenges, drivers and opportunities to solutions, and concluding with an action plan in the form of a remediation strategy.

	- *• Awareness* among all stakeholders of the impact of oral health professional activities on the environment.
	- *• Challenges* to develop and engage with sustainable practice.
	- *• Drivers* to develop and engage with sustainable practice.
	- *• Opportunities* to develop and engage with sustainable practice.
	- *• Recommendations and best practice* for effective sustainable dental practice.

In this consensus statement, the agreements detailed are representative of the oral healthcare supply chain as individual stakeholders and acting as a single entity. As such, we have sought to include representation from each stakeholder group, acting as an individual organisation (within their internal environmental, social and governance – ESG – framework) and also beyond their internal boundaries to engage and influence other stakeholders in the supply chain.

A recent and comprehensive scoping review identifies the range of themes that capture all the broad topics for consideration [6, 7]. These are: environmental impacts, CO2 e, air and water; reduce, reuse, recycle and rethink; policy and guidelines; waste management (SUPs); procurement; research and education; and materials for clinical use. The consensus statement considers the literature included in this scoping review and additional relevant literature as appropriate. Accordingly, statements of fact that are not cited are attributable to the findings from the scoping review.

The process was financially sponsored by the five partner companies (Colgate, Dentsply Sirona, Haleon, Procter & Gamble and TePe), each providing equal financial contributions and operating within a framework of antitrust procedures as a fundamental part of the methodology. The overall participant engagement is representative of all sectors of the oral healthcare supply chain with global representation (see *Contributors*).

# SECTION IV

# **Frame of Reference**

# **Sustainability in oral healthcare**

This consensus statement recognises the need to align the combined efforts of the oral healthcare industry to the Sustainable Development Goals stipulated in the UN 2030 Agenda for Sustainable Development [9] (*Figure 2*).

**Figure 2:** Sustainable Development Goals stipulated in the UN 2030 Agenda for Sustainable Development. Artvictory/Shutterstock.com, 2022.

#### **How to cite this book chapter:**

Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. Pp. 11–36. York: White Rose University Press. DOI: https://doi.org /10.22599/OralHealth.d. CC BY 4.0

We have identified that our activities have a strong alignment with eight of the goals, presenting a real opportunity for positive sustainability action (see *Appendix*):


The ability to engage with these UN SDGs is founded on a comprehensive understanding of the background levels of awareness of these issues, the challenges to changes, the drivers to engage with change and the opportunities to do so in an effective way. The following broad exploration of the levels of *awareness*, *challenges*, *drivers* and *opportunities* makes reference to the evidence identified in the scoping review by Martin et al. (2021) [6, 7].

#### *1 – Awareness*

The environmental impacts (carbon emissions, air and water pollution) associated with the entire oral healthcare supply chain have not been comprehensively determined and, as such, are largely unknown. The only assessments that have been made for CO2 emissions are those directly associated with commuting travel and transport centred around the direct provision of clinical care (i.e. patient and staff travel). In the UK, this alone accounts for approximately two-thirds of all emissions from the oral healthcare sector and about 8% of the total UK NHS air pollution attributable to travel [31]. Energy use from all sectors in the supply chain is high and much of this is indirectly attributable to the individual patients and users of the products. Again, most of the published evidence for energy use focuses on activities in the dental practice, with little in the public domain for organisations and other stakeholders in the supply chain.

Specific contributions to **CO**<sup>2</sup>  **emissions** from the healthcare industry are increasingly being understood. This accounts for a significant percentage of national emissions (e.g. accounting for approximately 5% of emissions in the UK), with significant effects on the health of the human population and planetary biodiversity. Petrol and diesel vehicles are a major contributor to air pollution, from travel and commuting of staff and patients but also from distribution/procurement.

In oral healthcare, the major contributions to air pollution arise from the incineration of waste, anaesthetic gases and CO2 emissions associated with travel and transport at the point of patient care. Oral healthcare presents with higher levels of patient and staff transport than other medical specialisations. This is partly due to the need for regular oral health maintenance, where other specialisations tend only to treat illness, and partly due to the more dispersed nature of secondary care in dentistry, e.g. dental hospitals.

**Water** is an invaluable resource and its supply is, at best, becoming unpredictable and, at worst, it has completely disappeared in areas of the world through human activities and desertification. There is an awareness of the need to conserve this and there is also a realisation that, by virtue of the large and rapidly increasing global human population (nearly eight billion as of March 2022), the practice of dentistry and personal oral healthcare is a significant consumer. If we estimate that half the world population cleans their teeth once per day and uses 600ml each time [66] the daily global water usage from cleaning our teeth equates to 2.4 billion litres or 480 Olympic swimming pools per day (*Figure 3*). This figure is in addition to the consumption of water up and down the supply chain, all of which is undocumented.

**Figure 3:** Need to conserve water during toothbrushing. Sergey Polishchuk/Shutterstock.com, 2022.

Beyond actual environmental impacts, we should also consider the demographics of our population, at a global and regional level. Ageing populations in medium- to high-income countries (MHICs) are increasingly dentate and in need of complex oral healthcare, which requires multiple (often of increased complexity) interventions and associated travel. There is a lack of awareness of the impact of this in terms of workforce requirements and the associated environmental impact of this. Equally, inadequate or disjointed care provision, cumbersome logistics and inadequate waste disposal services in low- to middle-income countries (LMICs) adds a further environmental burden to the existing baseline sustainability problem of oral healthcare.

Sustainability affects everybody in the supply chain, including the patient as a co-creator of their own oral health, through the choices and actions they make that influence their treatment needs and therefore environmental impacts. In this way, the public in a patient capacity has a role to play in reducing the impact of the oral healthcare on the environment.

Solutions arise from a deep and conceptual understanding of the levels of awareness and the challenges that present at two levels: for each stakeholder as an individual enterprise and as part of the larger supply chain, of which they are a key element.

**The provision of oral healthcare is a joint effort that involves every stakeholder in the whole supply chain, from manufacturers to end-users, including professionals and patients.**

As a supply chain, we are presented with the choice of operating in the manner of a linear economy that is wasteful of resources with an accompanying high pollution cost (*Figure 4*) or as a circular economy that seeks to recover and recycle waste products that are created along the whole process, with a consequential reduced burden on virgin resources and reduced pollution (*Figure 5*). The current, mostly linear supply chain economy presents a barrier to reducing the impact of the industry on the environment.

**Figure 4:** Linear economy in oral healthcare. A point-to-point journey for products with all resulting waste with zerovalue: mineral extraction, production and synthesis of raw materials >>> manufacture of equipment, materials and sundries >>> packaging >>> product distribution and logistics >>> product procurement >>> clinical and consumer healthcare >>> waste collection with different levels of contamination >>> waste disposal through landfill and incineration. Copyright Hannah Martin, Sheffield, UK, 2022 Sheffield, UK, 2022, CC BY 4.0.

**Figure 5:** Circular economy in oral healthcare. Reduced reliance on the extraction and synthesis of raw materials and disposal in landfill or incineration. Waste from materials and packaging is diverted back into the supply chain through mechanical and chemical recycling. Copyright Hannah Martin, Sheffield, UK, 2022, CC BY 4.0.

#### *Stakeholders*

**Companies are increasingly aware of the need to include the impact of CO2e, air and water, SUPs (including packaging), distribution and procurement, and waste management into their ESG frameworks.** This generally extends to include suppliers that are either already committed to sustainable operations or showing increasing awareness of this need. Nevertheless, there is a widely held view, based on qualitative observation, that the level of awareness of the impact of oral health on the environment and the need for sustainable practices is much lower downstream of the supply chain, i.e. the end-user community (dental professionals, patients and consumers).

**Within companies, sustainable practice has to date been driven by clear internal company strategy and effective communication.** Corporate responsibility has a distinct inclusion of environmental responsibilities through internal structures, corporate ESG frameworks (*Figure 6*) or through the alignment with the UN Sustainable Development Goals [9]. The strength of this movement is such that it is increasingly framing and providing a context for the business models of the companies. Much of this alignment is focused on the activities that are directly attributable to the manufacturing of products. Good practice in the dental industry points to the delivery of high-quality products that maintain the correct balance between product performance and sustainable positive impacts. Reputable (large and small) companies are actively engaged in sustainable practices, with a strong and clear ambition to integrate sustainability into the fabric of the business, at all levels. This is clearly expressed in the internal 'modus operandi' of the companies, establishing a high level of awareness with the activities that are directly attributable to the manufacturing of products and through internal communications and active employee participation.

**Figure 6:** Environment, social and governance framework used by industrial companies and organisations. Superstar/Shutterstock.com, 2022.

**Companies mostly recognise the benefit and need to characterise and understand environmental impacts arising from the core business.** This is derived from various sources, which include: leverage insights from life cycle analysis (LCA) studies, published studies and research work with internal and external experts, NGOs and research organisations; third-party verification of footprint by category; studies completed on all major product formats; and reviews and data collected from manufacturing energy use, processing and waste management. There is a recognition, though, that many companies and industrial stakeholders have a limited understanding and ability to effectively implement LCA studies.

**There is a notable lower, but improving, level of awareness of impacts outside the companies, up- and downstream of the supply chain, with the important inclusion of end-users (the dental profession or the consumer).** End-users are generally considered to be poorly engaged in sustainable practices, but this is not quantified. There is a need to change behaviour at home and at the workplace [8, 32]. Within this low level of awareness in the oral healthcare sector, there is a wide range between different challenges in different world regions, each with its own specific challenges. Anecdotal evidence indicates that this is a particular problem in LMICs, with high levels of product packaging, associated high shipping and transport needs, and limited recycling infrastructure.

**There is a recognition of a need to engage with regulatory bodies**, such as the International Organization for Standardization Technical Committee 106 Dentistry (TC106 Dentistry) [33] and the International Dental Manufacturers Association (IDM) [34], to ensure an alignment of manufacturing and sustainability.

**There is a perceived lack of awareness among the whole of the industry that the single most effective route to sustainable care is through the provision of good-quality care, which includes prevention at its core.** Essentially, good oral healthcare, through prevention or delivery, results in fewer interventions and a reduced environmental impact [8, 28].

#### *2 – Challenges*

**The greatest barrier to the implementation of sustainability is 'set behaviours and attitudes' within the profession**, and other major barriers are a lack of economic feasibility and knowledge base. Most countries and autonomous authorities have strong guidance or statutory requirements set by local or governmental legislative authorities to manage the toxic or directly polluting environmental impact of their activities. This, however, does not fully extend to the impact of the goods provided, associated with the high volume produced and/or the impact associated from energy and water use, or the use of non-recyclable materials downstream of the supply chain.

Industry recognises that a significant challenge to developing impactful measures is the **lack of a 'joined-up' engagement of the supply chain with other stakeholders up- and downstream on any focused and single aspect**, whether it be energy use, SUPs, packaging, distribution, policy and legislation or waste management. This has a notable impact on the ability to develop and create a circular economy. The development of a circular economy remains a major 'conceptual' challenge for stakeholders across the whole supply chain (*Figure 5*). Underpinning this challenge is a lack of 'understanding' for how any individual stakeholder can engage with the supply chain to create a circular economy and how these impact on a business model. These challenges are, thus, common and inherent to the whole supply chain and also specific to the development of a circular economy in oral healthcare.

**Companies recognise the difficulty to ensure business models are both profitable and environmentally sustainable.** The challenge is balancing sustainability attitudes with practical implementation. Setting and achieving bold commitments and targets is not easy work and, while balancing costs and priorities is a challenge, if done correctly it enhances the company's trust and value. Nevertheless, it is acknowledged that, despite the challenges, sustainability is increasingly one of the biggest priorities for corporate businesses.

**Communication and collaboration are recognised to be both a challenge within the wider supply chain and an opportunity to drive change and find sustainable solutions and work towards a circular economy.** The main recognised difficulties in this area are:


# *Challenges to 'a sustainable oral healthcare supply chain'*

	- A perceived 'silo mentality' of some stakeholders with different maturity levels of understanding of key sustainability issues.
	- Short-term commercial interests make information sharing sensitive; the need to engage in transparency around common issues.
	- Lack of accurate and timely data that prevents agreement of KPIs and priority targets.
	- The need to establish networks and ways to collaborate that include the whole supply chain.
	- The need for a legislative framework relating to antitrust or other potentially anti-competitive or collusive behaviour.

### *Challenges to 'operating in a circular economy'*


### *3 – Drivers*

It is important to recognise the specific drivers that will encourage and enable individual stakeholders to make changes. Drivers are an enabling force for change and, like awareness, these can operate at the level of individual stakeholders and spread out to the broader supply chain. These are classified as generic, affecting the whole supply chain, or stakeholder-specific.

#### *Generic drivers for a more sustainable supply chain*


Our global reach, our understanding of the billions of consumers we serve, and our innovation capabilities give us a unique ability to make a positive difference promoting conversations, influencing attitudes, inspiring behaviour change and driving positive impact on society and the environment.


# *Drivers focused on the stakeholder*

1. **Company employees see the drive to sustainability as a positive endeavour** rather than 'a box-ticking task'. This positivity is a strong internal driver that can be harnessed and used to good effect by the following actions:


2. **The strong local, regional, national and international pressures on all industries to improve sustainable practice.** Environmental sustainability is embedded in the operational ethos of companies, at a corporate and individual employee level. These are aligned with internal structures, corporate responsibility strategy or the UN SDGs [9]. This strong pervasive level of engagement is a major driving force for sustainable practice in companies, as part of the corporate 'mission' for companies.

# 3. **The increased levels of legislation aimed at protecting the environment, sustainability targets and awareness of a need to engage in sustainable practice or risk losing public confidence.**

4. **The 'lead' set by stakeholder companies that have implemented a series of key measures or interventions for improved sustainability within the company.** There is uniform agreement on the need to have a clearly defined and well-formed sustainability strategy that is considered essential, and should have the following characteristics:


5. **Improvement of oral health is a recognised key driver for environmental sustainability.** The provision of high-quality care with prevention at its core will deliver immediate and impactful environmentally sustainability outcomes. This will have an impact on end-users and across the supply chain, with notable reduction in CO2 emissions and waste generation [8, 28].

# *4 – Opportunities*

Based on the levels of awareness, a number of opportunities have been identified for engagement in sustainable practice. These are considered generically in this section and subsequently within each specific theme.

#### *Environmental impacts – CO2 e, air and water*

Companies have an opportunity to develop a carbon-positive supply chain by **identifying and engaging with opportunities that promote and implement a circular economy**, working with stakeholders and expertise to provide guidance, and seeking opportunities at both individual stakeholder level and as a 'joined-up supply chain – from mineral extraction to waste management', promoting, inspiring, helping and engaging upstream and downstream with environmental sustainability, for example focusing on strategic decisions that have a clear ambition, product and materials expertise.

### *Opportunities for communication and collaborative engagement*

**All stakeholders identify the importance of effective communication, dissemination and participation, as key to keeping staff engaged and equipped with the sustainability ethos of the organisation** (*Figure 7*). Reaching out to the whole workforce through sustainability champions, employee surveys and education programmes is considered an effective and motivational action for this objective.

**Manufacturing companies** (with competing business interests) recognise that they **can operate in an unbiased and non-partisan manner to promote open inter- and intra-stakeholder communication within the supply chain**. This is considered **essential for effective collaboration** that seeks to share knowledge, good practice and influence behaviour change. This can be achieved through:


**Collaboration is a key opportunity to work towards a circular economy and have a true impact on sustainability.** A key and acknowledged driver for positive societal and environmental change is the promotion of communication and being a positive influential role model to inspire behaviour change. Nevertheless, such a collaboration requires:


## **Companies should contribute resources to collaborative partnerships to drive sustainability**; these may be:


**Figure 7:** Collaboration with effective communication, dissemination and participation is essential to promote environmental sustainability. ASDF\_MEDIA/ Shutterstock.com, 2022.

#### *Leadership in good practice*

**Acknowledge that established and reputable companies are well placed to provide strategic sustainability leadership.** Companies have the capability to engage with the end-to-end supply chain, to identify and improve sustainable operations with impactful outcomes. For example, the promotion of awareness and activities through comprehensive and targeted education programmes; the establishment of partnerships to drive change and find sustainable solutions; and working towards a circular economy.

**The manufacturing industry can promote wider engagement with all stakeholders**, so that, for example, end-users can influence product design choices or for legislators to design better regulations. For this, the manufacturing industry needs to lead in a proactive manner and convene discussion and events to raise its profile and drive decision-making. The aim of this is to gain a common understanding of how the whole loop needs to be closed in order to reach sustainability and that everyone has a role to play.

**Upstream suppliers can share innovations across the whole supply chain.** Companies and their suppliers can share ideas and improvements across the whole supply chain in a more effective manner in some of the following ways:


**Opportunity for engagement** across all sectors with practical and impactful solutions.


# *Ethical responsibility*

**Each stakeholder organisation and individual person should realise that every sustainable practice, however small, will have a net positive environmental impact.** This is the concept of *cumulative incremental gains*. Each action is multiplied by the millions of oral healthcare providers around the world and across a population of nearly eight billion people as end-user consumers of oral health products. Nevertheless, there is a recognition that, owing to global inequalities, not every person is a direct consumer and the true figure will probably be lower, but still significant. Each sustainable practice undertaken at individual levels will act as a seed and catalyst for engagement with further more impactful practices in a snowball fashion.

# **Routes to sustainability in oral healthcare**

Sustainability in oral healthcare can be through different routes, ideally considered in a collective and synergistic manner. Any potential action strategy needs to be based on a sound understanding of the existing levels of awareness among the various stakeholders and the inherent challenges that exist, both in the systems they represent and in the supply chain as a whole. Equally, there is a need to understand the factors that drive any change and the opportunities that exist, to enact positive sustainability actions.

This section presents the various routes to sustainability, as identified in a recently published two-part comprehensive scoping review [6, 7]. Each route considers (i) factors and levels of *awareness*, together with the *challenges* that we need to overcome; and (ii) the *drivers* and motivators to make the required changes together with the *opportunities* that exist to make such changes, even if these are not overtly evident.

Routes to sustainability in oral healthcare:


#### *Route 1 – Reduce, reuse, recycle and rethink*

#### *Awareness and challenges*

**Reduce, reuse and recycle are the central sustainability tenets that enable a circular economy** (*Figure 8*). The fourth R, 'rethink', enables us to consider alternative opportunities to engage in a reduction of our environmental impacts.

There is a need to engage with these concepts at each point of the supply chain, from manufacturing to waste management. In this context, **the greatest areas of conflict are manufacturing, packaging and end-users (clinical or consumer)**. Additionally, engagement is not consistent across the industry, with varying levels of commitment.

**Manufacturers have a key role in the design of products with reduced manufacturing waste**, promoting high-quality and durable products that are fit for purpose with built-in end-of-life management strategies.

**Packaging is the single largest contributor to plastics in the dental industry** as the product travels down the supply chain to the dental surgery and end-user, with the majority (>90%) disposed of as waste for incineration or landfill [36]. The dental industry is a net contributor to this problem and has a duty of responsibility to act with global and national movements to reduce this (e.g. the UK Plastics Pact has set targets for 2025 with the headline of 100% of plastic packaging to be reused, recycled or compostable [37]).

There is a recognition that the **established strategies of reuse, reduce and recycle cannot be readily applied to the end-user** (either as a clinician or consumer), **creating an opportunity for 'rethink'**. The contaminated nature of used products and the complex shape and construction of many devices makes it impossible or very costly and difficult to clean, disinfect and sterilise, or recover for recycling. Plastic devices, for example, are often assembled from multiple polymers in multi-layer constructs and combined (glued/welded) in complex shapes, making them difficult or impossible to disassemble. There is a need to raise awareness of the actual number of SUPs that is generated at the point of clinical provision. A recent study conducted in the UK has identified a mean of twentyone (n=21) SUP items utilised in every routine adult primary care dental procedure, with a mean mass of 354g

per procedure. This figure can be extrapolated to a conservative estimate of approximately two billion dental SUP items per year (14.4 tonnes) [38]. The additional PPE required during the COVID–19 pandemic increased this figure to approximately 2.4 billion SUP items (27 tonnes) in the UK. Further studies of this type are required in alternative settings to obtain a clear baseline and to help inform remediation strategies [32, 38, 45].

**Recycling as a basis for a business model is a significant challenge that needs resolving.** There is a (real or perceived) conflict or lack of understanding of the value of using recycled materials and alternative distribution practices that are considered to be more costly or challenging to implement than virgin raw materials.

**Most oral health companies have an established or an emerging strategy for recycling** and for the use of recycled materials. This is considered a core measure of a company's overall sustainability strategy. Measures include:


A 'reduction approach' focuses on **a reduction of demand, which can be achieved through a promotion of better oral health focused on disease prevention and the provision of high-quality interventions** that do not require revising [28]. This model is an excellent fit for oral healthcare, which has a number of validated prevention protocols that can be successfully delivered as a public health initiative, professionally within the dental practice setting or by the individual at a patient-centred level. Alongside this, the use of high-quality, effective and durable oral healthcare products should be promoted as a more sustainable option, especially if recovery and recycling of waste are built into the product as part of a circular economy.

From a clinical perspective, there is a clear realisation and agreement that **sustainable practices can have a positive effect in developing and delivering successful business models**; a strong, pro-sustainability company image and sustainability strategy influence a strong positive customer response as consumers/patients increasingly consider and prioritise environmental sustainability.

**Consumers also play an important role in both the effective and safe use and the disposal of products in a responsible manner.** This requires grass roots educational programmes that emphasise citizen responsibility and the inherent value of a used product and its associated packaging.

#### *Drivers and opportunities*

As per the United Nations' waste management inverted pyramid [40], **source reduction and recycling are the most preferable options**. In this context, the main drivers for the oral health supply chain are through engagement with reduction combined with recycling (pre- and post-clinical contamination) (*Figure 9*). Reuse is not considered a viable option for SUPs that arise from primary packaging or clinical waste.

The concept of 'rethink' encourages us to consider how we can embrace reduction and recycle to overcome the inherent challenges that this presents in the oral healthcare industry.

**There is a need to critically consider and implement a reduction approach combined with innovative recycling approaches** for every pre- and post-clinical setting (manufacturing, distribution, end-user and waste management).

#### Opportunities for companies

**Engage fully with recycling opportunities with other stakeholders in the supply chain.** This must be done as a partnership and is considered an essential component of finding sustainable solutions. A materiality assessment and SWOT or similar analysis will help manufacturing companies understand where this type of activity fits within the overall strategy.

**Focus on reducing plastic waste**, mainly single-use but also non-recyclable longer-life items. It is essential to establish, through strong research, a powerful knowledge baseline of data at industry level that will enable impactful solutions.

**Undertake a systemic analysis of packaging needs** and the elimination of unnecessary wasteful packaging that works its way downstream.

**Figure 9:** Inverted pyramid for waste management (adapted from the original publication – UNEP, 2013). Copyright Nicolas Martin, Sheffield, UK, 2022, Sheffield, UK, 2022, CC BY 4.0.

**Increase our knowledge base**, with a specific focus on:


**Understand that the different supply chain stakeholders** (e.g. manufacturer, distributor and end-user) **have a shared and equal responsibility to collaborate in recycling strategies for a circular economy.** This should be achieved through:


Opportunities for end-users: clinicians, patients and consumers

**Reduction is best achieved through the delivery (by clinicians) and maintenance of good oral health, focused on prevention and high-quality interventions** [8]. This approach focuses on a reduction in the need for restorative consumables and interventive care appointments at the patient end-user level. This reduced demand can be achieved through a promotion of better health focused on disease prevention coupled with the provision of high-quality interventions that last longer and do not require revising. It is important to note that effective preventive care clearly has an environmental burden, but this is lower than that of failing dentition requiring continuous rehabilitation and supportive maintenance. The whole supply chain, including the end-user patient, benefits through this with a direct personal and environmental benefit.

**There is a requirement to understand the need to contextualise challenges and opportunities for plastic use and recycling, according to the local geographical and societal framework.** Focus should be made on plastic across the whole supply chain and not only simply oral hygiene products that use plastic. A local assessment on what is achievable is required to identify what will have the biggest impact in the different world regions or countries [27, 41]. A global code of good practice should make adjustments for global regional variations to ensure that it is practical and achievable.

**There is a need to create socially equitable funding models that will promote and permit practical recovery and recycling schemes.** The social aspect of managing plastic waste is key to achieving a circular economy. The recent Flexible Plastics Consortium activity is a good example of progress in this respect [42]. Nevertheless, there is also an acknowledgement that it goes beyond funding to include other elements such as infrastructure, culture and a sustainability mindset.

**The 'supply and demand' nature of the supply chain provides consumers and end-users** (dental professionals and consumers) **with an opportunity to influence and demand products and services** that encourage more environmentally positive solutions.

#### *Route 2 – Legislation, policy and guidelines*

#### *Awareness and challenges*

There is a clear recognition of the **requirement for all stakeholders to operate within the boundaries of legislative regulation for the safe conduct of operations and the goods produced or services provided**. These frameworks vary in their remit and across governmental authorities, from guidelines to legally enforceable laws. This legislation principally focuses on the avoidance of hazardous practices and products. The requirements to manage pollution arising from energy consumption or product waste (packaging at all levels and the item itself) is mostly not considered.

**Current regulations governing products and services may be perceived to be a barrier to the implementation of sustainable practices.** There is a recognition that this needs further scrutiny and direct engagement between the industry and the legislative bodies at global and local level.

**Products are heavily regulated at a national and international level, to ensure their safety at the consumer endpoint, with little regard to the environmental impact of this type of policy.** There is an increased recognition of the need to adapt legislation to find common ground between these conflicting priorities.

**Stakeholder companies have a real or perceived lack of control over legislation and regulations.** Specific identified issues are:

	- The sourcing of materials and failure to place sufficient pressure and resources on the procurement and use of sustainable and responsible sourcing of biomaterials and fuels.
	- The management of waste in the clinical sector; this discourages the environmentally conscious management of clinical waste.

**New legislation/regulation represents both a challenge and an opportunity for the industry.** For example, the European Commission is working on 'A European Green Deal' [43], a set of policy initiatives with the overarching aim of making Europe climate neutral in 2050. Industry needs to embrace this type of legislation and consider how it can optimise the required resource investment to maximise sustainability outputs in other company-specific sectors within its own product supply chain.

**Legislation is considered a driver and a barrier.** Some organisations use legislation as a protective blanket that justifies and excuses their inability to engage with sustainable practices. For others, stringent legislation with polarised frameworks (e.g. extreme, often illogical, patient safety measures at the expense of sustainability) is a source of frustration that serves as a deterrent to engaging with sustainable goals.

There is an agreed position among industrial companies that **legislation and/or regulation may be effective to incentivise sustainability and catalyse organisations to move in a positive direction.** In this context, legislation or regulation can work to level the playing field across the industry to ensure that all stakeholders operate to an accepted minimum common standard. Nevertheless, there is a need to be mindful of setting artificial boundaries or incentives relating to a relatively small number of sustainability aspects that could possibly hinder sustainable development in some areas of the supply chain.

**Regulatory and legislative decisions should be based on knowledge ascertained through the development of a standardised robust methodology of lifecycle analysis** that considers the broad array of variables and their interaction to improve sustainability. In this way, a robust and standardised LCA methodology should provide a more quantitative way to understand the sustainability of a component, product or company.

#### *Drivers and opportunities*

**Policymakers and legislative powers need to clarify new regulations and legislation to remove or reduce apparently conflicting drivers.** There is a conflict of interest between legislation that drives safety and the need to achieve sustainable targets. There is a recognition of the need for legislation to drive change, as profit remains the priority for businesses.

**Legislation should act as an advocacy tool, to support sustainable practice by incentivisation**, rather than limit it through regulation. In this context, legislation should seek to drive compliance and public advocacy through trade associations, rewarding best practice and informing public policies, but with care not to stifle innovation and other forms of sustainable development. As stakeholders, operating in different world platforms and settings, we need to be mindful of the different regulatory frameworks across countries and seek opportunities to translate good practice from other arenas, to influence and raise standards as appropriate.

**The provision of incentives in the form of financial impact toward compliance of more sustainable practices would be a desirable framework** that can be both carrot (preferred) and stick in nature. This would drive supply chains to comply with sustainable practices and rewarding those that take leadership in this space. Legislators will also play a role in convening public and private sector to define standards of compliance.

Effective partnerships in the industry can promote research and harness best practice research models (e.g. standardised and robust LCA methodology). This will inform legislation to improve industry sustainability profile without compromising on oral health outcomes. In this context, the implementation of common policy is considered an opportunity to guide businesses and professionals to understand the value and benefit of sustainability.

There is an opportunity to work with legislative authorities to **promote and drive a requirement for the procurement and use of sustainable and responsibly sourced of biomaterials and fuels**. Forging alliances with expert organisations, such as the Roundtable on Sustainable Biomaterials (RSB) [44], would catalyse this.

**Legislation can help drive progress across companies, industries and countries and also across the supply chain.** Having a common (and clear) legislative framework across world regions/continents for example (instead of different regulations per country) could be very helpful for the industry.

**Driving policy advocacy through trade associations** can play an important role in promoting best practice, informing public policies and regulations and developing industry standards.

#### *Route 3 – Waste management*

#### *Awareness and challenges*

**Waste is generated at all points of the supply chain**: during mineral extraction and chemical synthesis, product manufacture, packaging at all levels (primary, secondary and tertiary) and end-user consumption. The high prevalence of single-use products (mainly plastics) and the increased use of PPE adds a huge burden to this [38].

Biomedical (contaminated) waste originates downstream with the oral healthcare professionals, patients and end-user consumers. **An increase in the prevalence of infectious diseases coupled with much greater patient safety awareness, infection control measures and associated regulation results in a significant increase in the quantity of SUP solid waste generated** (e.g. plastic barriers, gloves and masks) in the oral healthcare industry. This is a widely recognised problem that is poorly addressed.

**Each stakeholder in the supply chain has a dual responsibility: to manage their own waste and the waste that is 'passed on' downstream of the supply chain.** There needs to be a recognition of this duality of responsibility, which currently does not exist as waste that is passed downstream becomes the responsibility of the enduser. There is a recognised complexity associated with the governance of clinical waste management, which varies between jurisdictions.

Plastic packaging and single-use plastics (SUPs)

**Single-use plastic forms an essential and indispensable part of current healthcare provision at all levels and in all clinical environments** (*Figure 10*). Plastic provides a very safe and cost-effective material for packaging and products that can be combined with other materials to create complex bespoke devices or medicinal delivery vehicles. In doing so, SUPs provide the required clinical and public confidence of using a new clean and/or sterile device every time without risk of cross-infection. Thus, SUPs fulfil all the major requirements of a risk-averse industry that operates within very tight budgetary constraints and tight regulatory frameworks. The inherent versatility, safety and low cost of SUPs is also its downfall as it is a major contributor to a highly wasteful linear economy resulting from their end-of-life fate [32, 45].

**Figure 10:** Plastics are essential for the provision of safe oral healthcare in clinical environments. Superstar/ Shutterstock.com, 2022.

There is a recognition that the **reliance on SUPs creates a wasteful linear economy**, with a need to reduce their use and reliance on fossil-based constituents. **There is a need to transfer healthcare plastic from its current status of a low-value commodity in a wasteful linear life cycle to a circular life cycle as recycled, valuable feedstock for the synthesis of new plastics.** Thus, there is a need to plan for circularity as the bigger goal with full stakeholder engagement and to understand that recycling is a component of this, but not the end point.

**Plastic packaging in the healthcare sector is considered a difficult challenge to address**, primarily because it is a highly regulated sector to ensure that medical products arrive fit for purpose (protected from damage or degradation, and frequently sterile).

**Plastic packaging (at all levels) is considered a zero-value waste product at the point of manufacturing and throughout the supply chain, rather than a valued commodity that can be recovered and recycled as feedstock for new devices.** Moreover, the sustainability of the packaging is not challenged as the product moves downstream until disposal. The result is a linear business model, disconnected with respect to reducing plastic waste, hindering disruptive innovation and limiting the potential to deliver a circular economy model to reduce environmental impact.

**Stakeholder companies recognise the need to drive a reduction in the use of single-use plastic materials (packaging and consumer products).** They identify the following specific challenges to achieving a circular economy.

Challenges to achieving a circular economy through recycling and the use of recycled materials


#### *Drivers and opportunities*

There is a need to set plastics use in a broader perspective. **The solution is not just about eliminating plastic but understanding the use and ability to recycle the different kinds of plastic in use and their possible replacements.**

**There is a need to educate the public and the profession about the merits, usefulness and indispensability of plastic in the healthcare sector.**

**Oral healthcare manufacturers can work with the plastic synthesis suppliers in the design of feedstocks and materials** that meet safety, quality and durability requirements and can be accepted by recyclers.

**Oral healthcare manufacturers should seek to work with end-users to identify ways of reducing the generation of medical waste** and subsequently with recyclers on technologies that enable drive effective recycling.

**There is an opportunity to reduce (unnecessary and excessive) packaging waste**, ensuring that this is recyclable with appropriate drop-off downstream facilities.

The most effective way of reducing SUP waste is through the **promotion of good oral healthcare through preventive regimes and high-quality interventions**.

**Recycling pre-clinical plastic waste** (products and packaging) that arises from manufacturing and distribution **prior to being contaminated by end-users**.

**The supply chain, acting as a single entity, can help to manage the waste generated by end-users** (the general public or the oral healthcare profession), with a focus on materials reduction, optimised transport and distribution logistics and recycling packaging materials. Also, assuming safety requirements can be met, a reverse supply chain would enable used products and packaging to travel back to manufacturers for processing into new products.

**Opportunities for management of SUPs** should focus on overcoming the challenges listed. Further opportunities include:


#### *Route 4 – Procurement and logistics*

#### *Awareness and challenges*

**Each stakeholder of the supply chain has a significant impact on the environment through the process of procurement of raw materials, manufacture, transport and distribution.**

**Procurement is considered a major environmental 'hotspot', with the use of plastic packaging central to this.** The complex distribution and logistical requirements required to access locations with poor or limited civic infrastructure compounds this problem significantly, as is evident in LMICs.

**Companies are actively engaged and provide environmental leadership across supply chains.** Historically, this engagement has been downstream, but increasingly companies are extending their reach across the value chain, upstream to suppliers and downstream to consumers.

**Sustainable manufacturing and distribution of goods is generally considered less associated than conventional (less sustainable) practices with higher overheads.** The rationale for this is that the sustainable option may have high upfront costs for implementation but more sustainable processes tend to have lower ongoing costs (and this is likely to be more the case in the future). Also, once the investment is made and assuming availability of more sustainable materials, manufacturing and distribution processes should be pretty similar to the existing ones including economies of scale. In the future, the cost of being less sustainable could be much greater (when considering the impact of producer responsibility liabilities).

**Efficient procurement and distribution present a particular problem for the dental profession.** With the exception of large multi-practice corporates, most dental practices around the world operate as small discrete entities to meet the needs of their local population. They have very limited storage facilities, relying on daily deliveries and collections. This results in increased distribution costs involving many journeys, contributing further to CO2 emissions. There is need to consider whether the existing model of dental care is effective or whether larger centres with optimised distribution logistics, storage and dedicated transport links is a more efficient concept from a patient care, financial and sustainable perspective.

**Environmentally sustainable procurement is not understood well at the level of dental practices.** There is a need to provide educational programmes to enable smart purchasing/procurement. For example, the benefits of bulk buying would include less packaging, shared distribution costs and lower emissions from distribution.

**Distribution logistics to the end-user is disjointed and wasteful of resources.** There is an opportunity for companies to collaborate in optimisation of distribution logistics.

#### *Drivers and opportunities*

Each stakeholder needs to engage through proactive intervention in environmentally sustainable practices to disrupt the linearity of the supply chain and achieve a circular economy.

There is a need for **the supply chain to come together as an entity to develop less cumbersome systems and processes with improved logistics capacity that has sustainability as a key driver**, which will result in an improved circular economy. Examples of this are:


#### **Sustainable operations are a business opportunity for companies, with the following potential benefits.**


# **Sector leadership, stakeholder collaboration, sharing best practice and engagement in 'procurement sum-**

**mits'** that are led by major product manufacturers. These provide an opportunity for supplier engagement, identifying an opportunity to work with suppliers and improve their awareness, understanding and improving levels of engagement. Such summits should work in both directions and consider not only the 'transmit from the buyer' perspective but also the 'receive from the supplier' viewpoint.

**More efficient oral healthcare service models must be considered that meet the needs of the population, through the provision of effective patient-centred care with environmentally sustainable gains.** This service should aim for the provision improved logistics with less transport of goods, reduced commuting for the professional workforce, reduced patient travel journeys and less packaging. Thus, implementation should focus on:


**Need for greater levels of information on the sustainability credentials of a product.** This will provide the buyer with information on the environmental sourcing, ethical manufacturing, supply chain distribution and procurement.

#### *Route 5 – Research and education*

#### *Awareness and challenges*

#### Research

**There is a clear need for primary research into all aspects of our industry, which should seek to provide efficient, high-quality durable products and services that are both fit for purpose and environmentally sustainable.** Sustainability research is required to include the manufacturing of dental materials, distribution and procurement logistics, and provision of clinical services, with a focus on prevention and reduced patient-centred activity, patient care pathways, remote consultations and waste management options. For example, the last edition of the WHO–UNEP report *Future Use of Materials for Dental Restoration* (2009) highlighted the paucity of science around the toxicology and ecotoxicology of materials for dental restoration and that dental materials research is not a priority [46].

There is an increasing **awareness that the ability to combine effective oral healthcare, disease prevention and sustainable practices can only take place through strong and impactful research** that considers the various challenges and strategies [6, 7].

#### Education

There is a growing recognition across the sector of the **need for educational programmes at all levels, both within each stakeholder organisation and across the supply chain**.

There currently exists **very good practice of industrial manufacturing and distribution companies collaborating with educational providers** for the benefit of the profession and the public.

**Higher education providers** (universities, colleges, dental societies) **have a responsibility and an opportunity to integrate sustainable practices into their educational models.** There is a growing recognition of the need to urgently raise awareness of sustainability at the formative stage of individual's professional education. This requires the integration of concepts and remediation strategies in the undergraduate curricula of dental education, with current important pioneering work highlighting academic progress and student representation [47, 48, 49].

There is a recognition of the **need to balance the drivers for engagement as being both economic and health outcomes**. In essence, sustainability awareness and engagement should be taught as key aspects of running future dental practices. Tied into this, alternative care models with a focus on prevention and screening should be core to the future activities of the profession.

The same WHO–UNEP report, *Future Use of Materials for Dental Restoration* (2009), also highlighted that the study of environmental and occupational health is not a requirement in dental professional undergraduate education and training and continuing professional development. As a consequence, **dental professionals lack the knowledge and training to provide science-based information to support and engage with environmentally sustainable practices**. This needs to be addressed and changed.

**There is a low level of understanding of the value of recycling at all levels of the supply chain**, principally associated with packaging and end-user clinical waste. This low-level knowledge base is counterbalanced by a **strong recognition of a need for education at a corporate level to achieve more cooperation and collaboration at all levels within the company and with other supply chain sectors**.

**The challenges lie with 'educating' each supply chain stakeholder as an individual entity and as part of the whole chain problem**. Specifically, there is a need for:


#### *Drivers and opportunities*

**Sustainability works hand in hand and synergistically with the core principles of good-quality oral healthcare.** Thus, the central pillars **for sustainable patient-centred oral healthcare are one and the same: prevention and the provision of high-quality care** [8]. It is important that these umbrella principles are not used as a tool to discriminate against elements of society that suffer from non-preventable diseases or are unable to engage with effective prevention practices. Not all diseases are preventable in nature and high-quality care is not available universally, especially in LMICs. Appropriate care should be provided for the management of all oral diseases, even if considered unsustainable. The key messages should focus on disease prevention regimes and sustainable oral hygiene practices at home.

Educational programmes need to raise awareness of the connection between oral health and overall health, promoting better education and access. Hence, there is an **opportunity to raise awareness of highly impactful sustainability gains through the promotion of healthy oral healthcare for preventable diseases**. Consideration should be given and improvements made to how oral health preventive regimes are remunerated in the healthcare system, akin to a medical appointment where payment is made for a consultation and advice or medication. In this context, stakeholders should be aware that **there is a series of 'low hanging fruits'** (measures that are important and easy to achieve) **that can drive and act as precursors for greater engagement** (e.g. FDI sustainability infographics) [28].

Within the context of oral healthcare providers, there is recognition that **sustainability is a strong driver for successful clinical practice business models** [35] – 'Sustainability makes business sense for dentistry.' An effective business model can be a powerful driver for sustainability with the added financial incentives. This model requires an appreciation for:


#### Company stakeholders

There is an acknowledgement that **the dental industry is an influential driver and provider of professional education, which needs to include sustainability**.

Within companies, there is a **need to increase awareness, understanding brand/company loyalty and motivation of the workforce**. In this way, it is important to **foster an employee community that cares deeply about the impact of their work on the environment**.

**Engage with all supply chain stakeholders through the voice of commercial brands and via partnerships with dental professionals and organisations.** In this way the education and advocacy for the adoption of healthy oral care habits can be facilitated on a global scale.

More broadly, there is an opportunity to **engage in open and active discussion forums in all work environments that will encourage the translation of behaviours** (as private citizens) to established well-rooted attitudes in the workplace – there is a need to *normalise* conversations around sustainability in the workplace. This requires stakeholders to support activities that seek a change of mindset and behaviour, creating increased awareness, knowledge and engagement.

**Supply chain stakeholders have a responsibility to find and leverage more sustainable alternatives in their area of influence.** In this context, manufacturing companies should design and manufacture products that are more sustainable (recyclable, without excess and unnecessary packaging and the use of alternative sourcing for materials, seek ethical sourcing etc.) and work with others to develop solutions to make new products more sustainable.

**Companies have an opportunity and responsibility to engage, promote and resource impactful research activities in the field of environmental sustainability.** These could include the need to:


Companies see an opportunity to **support knowledge transfer** from sound research and innovation in structured programmes delivered to other stakeholders, including end-users.

There is agreement across the supply chain over the **need for a science-based approach to sustainability interventions, adoption of best-in-class and sharing of best practice across the sector**, which may be based on experience as well as research.

**The inverted pyramid for waste management, with reduction and recycling as key priorities, should act as a point of discussion and engagement at all levels**, in research, knowledge transfer and core educational programmes.

#### End-users: clinicians, patients and consumers

Within the supply chain, healthcare providers are a key 'end-user', considered to be a major driver that can influence other stakeholders. In this respect, there is a strong awareness of the **need to influence business models on the economic value of sustainable practices and as an increasing requisite for positive and profitable business**.

**There is a need for education of the entire dental practice**, including reception staff, nurses, assistants, clinicians and patients as active co-participants in their care. Proactive patient engagement with preventive regimes is essential that will result in healthy oral health with low environmental impacts (low use of resources, low carbon footprint and low waste).

Patients are often the forgotten stakeholder in the supply chain – **patient participation is essential and this can only be achieved through effective education as part of the core oral healthcare education programmes**. The key messages about sustainability and patient care are: (i) sustainability affects the patient, even if indirectly; (ii) sustainability is not a separate and optional aspect of care quality or a luxury element of dentistry; and (iii) patient-centred care has an impact on the environment and most individuals have control over the magnitude of the impact. Patient information and guidelines should be provided as an intrinsic component of patient oral health education in an easy way to understand.

There is a **need to raise the profile of oral healthcare within medicine and ensure that sustainable lessons are learnt and shared**. Oral healthcare (dentistry) and general healthcare (medicine) should be considered intrinsically linked, with shared sustainable practices that translate between the two.

We need to **understand, harness and promote the value of small actions of individual clinical professionals**, and how these multiply as they are implemented across the world by millions of professionals and by billions of citizens. Small actions act as a catalyst for greater engagement. The high number of oral healthcare professionals globally presents an invaluable opportunity to disseminate influential and impactful messages. Examples of this are:


A similar opportunity presents itself by **harnessing the power of patients and individual patients and consumers** (especially when considering the current circa eight billion world population). The end-user consumer group can be engaged in sustainable practice by raising awareness and designing products and services that enable them to reduce their oral health carbon footprint, principally through the avoidance of preventable diseases, following validated oral healthcare messages.

#### Oral health professional education

**In the oral healthcare undergraduate curricula, there is a need to increase awareness and sustainable impactful actions through carefully channelled educational programmes**, a process that is currently underway that considers how sustainability can be included in the undergraduate dental curriculum [47, 48, 49]. This needs to be provided from an early point in the curriculum with an opportunity to share best practice with other dental schools. Key concepts to include in an undergraduate curriculum are:


**The promotion and integration of sustainable practice into continued professional development programmes**, such as the programme run by the Green Impact Initiative [50]. Education of patients regarding sustainability would follow with simple and non-demanding messages that focus on reduction through good oral healthcare as a key driver focusing on the message [8]. Maintenance of good oral health delivers huge personal benefits and as an unintended consequence it achieves important environmental gains that are enormously impactful as they are multiplied throughout the population. In this context, it is important to engage with the profession and patients as promotion of public health is key to achieving this goal.

There is also an **opportunity to reduce the carbon footprint of specialist practices through alternative modalities, such as tele-dentistry and remote clinical consultations** [45, 51]. Remote clinical services and tele-dentistry present an opportunity, requiring further professional engagement and associated legislation to ensure its effectiveness.

Nevertheless, it is an acknowledged fact that oral healthcare professionals look up to national associations and governments or legislatures for guidance on behaviour changes. Consequently, **national dental associations and governments need to be engaged and actively influence and support oral healthcare professionals with achievable and practical solutions.**

### *Route 6 – Materials for clinical use*

### *Awareness and challenges*

**Dental materials have an environmental impact that arises from all stages of the supply chain**: extraction of minerals, synthesis of raw materials, manufacturing, distribution, procurement, clinical use and ultimately waste management. There is an associated acknowledgement of the diversity of materials, complexity of manufacturing and distribution logistics (*Figures 4 and 5*).

The environmental impact from dental materials is not uniformly qualified or quantified. **There is recognition that an effective and meaningful data set can only be obtained through a sophisticated and standardised LCA** (cradle to gate or cradle to grave).

There is **an emerging understanding of the impact of dental materials as they find their way back to the environment through recognised pollution pathways** [52]:


**The most effective way of limiting the impact of materials on the environment is by reducing their use and making them last longer.** Reduction is achieved through:


**There is an existing high level of awareness associated with the environmental impact of dental amalgam** [55, 56, 57, 58]. The Minamata Convention on Mercury has stipulated a reduction or cessation of dental amalgam [59]. Alternative materials should be used with due consideration to their environmental impact.

**The environmental impact of other restorative materials is not well understood**, despite extensive emerging research in this field [6, 7, 60, 61].

There is a **need for continued R&D for a material that will provide effective tooth reconstruction with low operative technique sensitivity and predictable durable outcomes, and which reduces or obviates the need for replacement**. Current resin-based direct-placement alternatives are very effective when used well but their associated technique sensitivity with a need for auxiliary items and processes can negatively impact predictability of placement and therefore durability.

**The introduction of new end-user products or restorative materials with a lower environmental impact presents a series of challenges:**


**There is an increasing desire for 'cosmetic dentistry' with potential consequences for oral health**, as stated in the joint statement by UK specialist dental societies [62] 'that elective invasive cosmetic dental treatments can result in great benefit to patients but that these can also produce significant morbidities in teeth which were previously considered healthy'. It should be noted that **these elective cosmetic treatments also have an environmental impact that is potentially avoidable**.

#### *Drivers and opportunities*

The recognition of the critical need for increased effort to reduce human environmental impact has grown rapidly in recent years. Consumers, including patients, increasingly look for evidence that suppliers are making serious efforts to improve their performance.

This consensus statement provides a unique **opportunity to set a benchmark and encourage all dental materials manufacturers to work together as a unit, cross-company, along the whole supply chain, including traditional competitors**. The aim is to share knowledge and best practice on the performance indicators for successful and durable restoratives.

**Good materials that are fit for purpose are an essential element of sustainable practice.** Restorative materials should perform in a predictable manner to an accepted clinical standard, enabling effective placement and maintenance. A durable restoration will have a lower carbon footprint and associated waste by virtue of not requiring replacement. If sustainability can be built into the product, as part of a circular economy in the manufacturing, packaging and distribution, this is a further desirable goal.

**Governments across the world have made national and international environmentally sustainable commitments. They will pressure public services, including the health services, to take a leading position to achieve environmental outcomes in their sectors.**

**Some companies or services in the dental supply chain have made commitments of their own, and will bring pressure to bear on supply chain partners to support and enable these improvements.**

Effective research into sustainable materials requires **effective and meaningful life cycle analyses. LCAs need to follow robust and standardised methodologies to enable meaningful comparisons to be made.** This will enable more effective development of materials with sustainable goals. The environmental impact from dental materials is not uniformly qualified or quantified, and this can be achieved through well-designed LCAs and research.

There is an opportunity to increase awareness and engage in proactive action through the **legislation of dental materials standards, with incorporation of sustainability into the ISO dental standards**. In particular, ISO-TC106 can be used as a vehicle to incorporate sustainability into all the dental standards [33]. It might be a motherhood-type statement that applies to all current and future standards. A further option is to strive to use only the most sustainable raw materials to manufacture equipment and materials and products that use the least energy and water to function.

**The International Medical Device Regulators Forum (IMFDR), through its global reach and infrastructure, is well placed to engage in the production of a global agreement on packaging requirements between countries.** 'We strategically accelerate international medical device regulatory convergence to promote an efficient and effective regulatory model for medical devices that is responsive to emerging challenges while protecting and maximizing public health and safety' [63].

**Specific opportunities for the manufacturing industry:**


# SECTION V

# **Strategic Action Framework**

A broad strategic action framework has been developed on the basis of the previous elements of this report, which reviews and identifies:


The impact and effectiveness of this action framework arises from the strength of each of its components and statements, taken individually and as a whole in a truly synergistic manner, with the potential for real and effective outcomes. It should be noted that the strategy presented does not intend to provide detailed granular detail for specific approaches or projects.

There is an acknowledged level of health inequalities across the world, between countries and within countries. This is also particularly pertinent to oral health that presents the challenge of balancing preventive oral healthcare with sustainability goals. This challenge needs to be addressed with ingenuity and use of multiple fitfor-purpose approaches. The strategic action points that are promoted in this document **must be considered in the cultural and socio-economic contextual framework of the region in which it they are to be implemented**. Essentially, stakeholders must take note that the appropriateness of recommendations, solutions and level of impact will vary significantly according to the country and the ability to effect change within it. A local assessment is essential to consider what is achievable and what will have biggest impact.

Thus, **this collaborative and non-partisan strategy** needs to operate within a code of practice, embodied by the following principles:


#### **How to cite this book chapter:**

Martin, N., Mulligan, S., Shellard, I.J. and Hatton, P.V., 2022. *Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement*. Pp. 37–47. York: White Rose University Press. DOI: https://doi .org/10.22599/OralHealth.e. CC BY 4.0


This stakeholder action framework complements the **strategic objectives identified in the Executive Board Report by the Director-General of the WHO (January 2022)** [64]:


The strategic action framework that follows is considered in two complementary parts:


# **Enabling success**

The strategy is considered in the context of the three key principles that have been identified as core to its effectiveness:


# *1. Collaboration and leadership*

**Companies to lead the promotion of ethical and sustainable behaviours and practices (attitudes) throughout the whole sector.** This is based on a recognition of the strongly embedded social and ethical environmental responsibilities that already exist within a company. The leadership and promotion of these attitudes should be directed initially to the direct sphere of influence working through brands, within the supply chain and also through corporate leadership in the industry sector.

**Sustainability in the oral healthcare industry must be addressed as a 'supply chain' challenge with** *all stakeholders working collaboratively***.** The aim of such individual and combined stakeholder actions is to develop a *circular economy*.

**Companies to provide leadership in the drive for sustainability, working collaboratively across the whole supply chain.** Uniting around a mission or target, the oral healthcare industry needs to be able to speak with 'one voice' and have a much greater impact, principally **via the strong image of competing companies coming together in this purposeful way**.

**Company leadership can be achieved through the promotion of the following domains:**

a) Education

(i) Engage in dialogue, education and the use of proactive activities to promote wider engagement with stakeholders.


b) Showcase good practice


c) Lead industry change


There is clear recognition that **companies can bring significant resources to collaborative partnerships** to drive sustainability; these include:


#### *2. Person-centred oral healthcare*

The pursuit and achievement of **oral health, through preventive programmes, good-quality care and effective maintenance, is the mainstay of sustainability**.

**There is a need to raise awareness and normalise a sustainability culture** that sits comfortably alongside the promotion of oral healthcare as a whole 'provider–recipient' team effort.

Within the context of dental practices, there is a **need to promote the positive financial business model that underpin the provision of sustainable clinical dental practice**. There is an opportunity for the development of a multi-faceted, collaborative practical business model for the care provision stakeholders.

**Promote a greater use of digital technologies with the manufacturing and distribution industry**, which will reduce the need for personal contact and engagement should be sought to reduce unnecessary travel. At the point of clinical patient-centred care, **consider and engage with tele-dentistry and remote clinical consultations**. The adoption of these technologies needs to be carefully assessed, as they can be very resource intensive in terms of equipment, technical support and energy.

# *3. Enabling agencies*

**External organisations** (e.g. government, professional institutes, legislative authorities) **should support the development of environmental sustainability in the oral health industry.** Consider alignment to the action plan of leading organisations such as those identified by *Health Care Without Harm – HCWH* [25]. Key to this is a need to engage in a mutual, consensual dialogue that seeks to understand the challenges and identify solutions.

Examples of such actions are:


# **Agencies (e.g. local/national governments) and legislators should work collaboratively to enable sustainable practices at all levels.**


# **Action through the routes to sustainability**

# *Route 1 – Reduce, reuse, recycle and rethink*

*Reduce* and *recycle* should be the focus of remediation, being the most practical and readily implementable approaches.

*Reduction* **is best achieved through the delivery and maintenance of good oral health**, focused on prevention and with the provision of durable interventions, using high-quality products materials and that will last longer and/or require fewer revisions. Every stakeholder in the supply chain, from manufacturing to the clinician and end-user, has a role to play to optimise this reductionist approach, the emphasis being on ensuring high quality, fitness for purpose and durability that is more important than perceived 'greener' options of questionable effectiveness and durability.

At the point of delivery of care, *reduction* is achieved through the provision of good oral healthcare by engaging with good practice, as detailed in the four domains [8]: *preventive care*, *operative care*, *integrated care* and *ownership of care*.

• **Preventive care** – the assessment and management of systemic and local risk factors with a practical and patient-centred preventive regime.


The outcome of this integrated approach for the delivery of oral care is twofold: (i) fewer appointments, with fewer patient journeys and reduced need for professional interventions, resulting in an overall reduction in CO2 emissions; and (ii) increased longevity of restorations and a reduced need for procurement, which results in an overall reduction in waste generated.

**Reduction of packaging should be sought at all levels:** primary/container/delivery vehicle; secondary and tertiary packaging.

**Recycling** opportunities arise from:


**Companies should fully engage with recycling opportunities with other stakeholders in the supply chain.** This must be done in a partnership and is an essential component of finding sustainable solutions. A materiality assessment and SWOT or similar analysis will help manufacturing companies understand where this type of activity fits within the overall strategy.

There is need to create socially equitable funding models and appropriate infrastructure that will promote and permit practical recovery and recycling schemes. The social aspect of managing plastic waste is key to achieving a circular economy. The activity from the Flexible Plastics Consortium is a good example of progress in this respect [42].

Stakeholders in the supply chain should use their influence to increase the application of reuse or recycling, through:


# *Route 2 – Legislation, policy and guidelines*

**Policies and public health guidance should promote oral healthcare as the most important and impactful route to environmental sustainability**:

	- (i) individual disease reduction
	- (ii) public health cost savings
	- (iii) environmental sustainability gains.

### **Supply chain stakeholders should seek to engage with legislation** at two levels:


**Legislation should be derived from a fact-based decision-making process.** Based on knowledge ascertained through the development of a standardised robust LCA that considers the broad array of variables and their interaction to improve sustainability.

Stakeholders in the oral healthcare supply chain should work with legislators to influence and improve the manner in which laws and rules assist sustainable practice, through:


#### *Route 3 – Waste management*

**Educate the profession and the public about the merits, usefulness and indispensability of plastic in the healthcare sector.** Improve knowledge and attitudes towards the generation and management of biomedical waste across the world and in particular in developing economies.

**Promote and support research into recovery and recycling of all forms of plastics used by the industry.** Do so in collaboration with supply chain stakeholders up and down the supply chain to achieve a coordinated and impactful solution to the challenge. This should include effective communication and education of endusers about the ability to recycle waste plastic so that it can be repurposed as valuable feedstock in a circular economy.

**Focus research on a life cycle perspective of products/materials** that considers the whole picture of the environmental impact in the context of the intended purpose of the device, its durability and its management as eventual waste.

**Unlock the barriers that exist at each point of the supply chain**, changing systems and behaviours at a local and systemic level, and coupling waste management to innovative solutions for reprocessing. The supply chain, acting as a single entity, can help to manage the waste generated by end-users (general public or the oral healthcare profession), with a focus on materials reduction, optimised transport and distribution logistics and recycling packaging materials.

**Promote and support research into recovery and recycling of all plastics used by the industry.** Do so in collaboration with supply chain stakeholders up and down the supply chain to achieve a coordinated and impactful solution to the challenge. Need to view plastic waste as a resource that can be recycled as part of a circular economy.

**R&D collaboration between the oral healthcare manufacturing industry and the plastic synthesis suppliers to design feedstocks** (from sustainable sources) and materials that meet safety, quality and durability requirements and can be accepted by recyclers. Further down the supply chain, the oral healthcare manufacturers should work with recyclers on technologies that enable and drive effective recycling.

Management of plastic (SUPs) by means of:


# *Pre-clinical and pre-consumer SUPs (e.g. packaging)*

**Work towards a circular economy through a reduction of packaging waste** by ensuring that this is both recyclable and that there are systems in place to provide recovery and recycling opportunities further down the supply chain.

**Establish a business culture that identifies the value of all plastic packaging** (including product delivery sundries, e.g. materials compules)**, setting it as a valued commodity/resource that can be recovered and recycled**, rather than the current status of a zero-value waste product at the point of manufacturing and throughout the supply chain.

**Focus on the use of recycled plastic waste arising from manufacturing and distribution as feedstock for new products, devices and packaging.** This is considered a less challenging route to circularity than the use of clinical or consumer contaminated plastic and end-user contamination, through a combination of established mechanical (shredding) and innovative chemical (polymer breakdown) recovery methods. In this context, **all supply chain stakeholders to collaborate with equal responsibility in recycling schemes**:


# *Biomedical SUP waste (clinical and consumer)*

**Undertake an effective assessment to show varying materiality between aspects in different areas of the supply chain.** Focus the assessment on each individual area that identifies the most common key aspects.

**Stakeholders** (manufacturers, legislative authorities, end-users and waste handlers) **need to review opportunities for effective recovery and recycling of clinical and consumer plastic items.** Some plastic items (e.g. packaging) used in the oral healthcare sector, do not need to be considered medical waste if they not in direct contact with clinical environments. In addition, other plastics such as dental sundries, primary containers (e.g. composite compules, micro-brushes and dispensing pots), waste sterilised autoclave pouches and even uncontaminated gloves present further opportunities for recovery and recycling, if safely and effectively placed in the correct waste stream.

#### *Route 4 – Procurement and logistics*

**The supply chain should unite to work as a single entity** to develop less cumbersome systems and processes with improved logistics capacity with sustainability as a key driver, which will result in an improved circular economy.

**All stakeholders should engage in effective and shared auditing practice of sustainability processes and outcomes, within their own sphere of activity and across the whole supply chain** to establish a clear baseline and progression toward a gold standard.

**Companies should continue to engage and provide environmental leadership across supply chains**, extending reach across the value chain, upstream to suppliers and downstream to consumers.

**Establish more efficient logistics within the supply chain at manufacturer/distribution and end-user levels**: the creation of efficient manufacturing, distribution and procurement logistics with shared facilities. At the point of care delivery, patient-centred clinical care plans need to be managed in an effective manner.

**Procurement summits are an opportunity for sector leadership, stakeholder collaboration and sharing best practice.** This creates an opportunity for supplier engagement: identifying an opportunity to work with suppliers and improve their awareness, understanding and level of engagement.

**Consider the opportunity to include a 'sustainability index' as a means to inform purchasers on the sustainability credentials of a product.** To include information on environmental sourcing, ethical manufacturing, supply chain distribution and procurement.

**Identify mechanisms for the redistribution of equipment and materials to LMICs and educational institutions**: products nearing their use-by date and equipment that is nearing the end of its 'legislation-driven' useful life in a particular market.

#### *Route 5 – Research and education*

#### *Research*

**Establish research and innovation partnerships, in the manner of formal alliances, to jointly tackle sustainability projects**: effective recycling; the development of sustainable practices across industries; new material introduction (development of more sustainable ethically sourced alternatives to currently used materials); shared logistics; working with dental professionals to develop educational materials for patients; and sponsoring relevant and impactful scientific studies [65].

**Undertake effective scoping and mapping studies to identify fundamental research gaps.** This needs to be a continuous and live project that can respond and adapt to new emerging challenges.

**Obtain reliable and independent research data to enable prioritisation and collective action.** Circularity is viewed as a key priority area with comparative industrywide LCAs in healthcare to help identify or exclude options that will engage significant opportunities.

**Conduct combined health–economic–sustainability impact analyses** as a priority in oral healthcare. It is important to consider the intended purpose and effect of the material or product on the end-user and how this may impact on the overall sustainability impact of that individual over the course of their life.

**Engagement of national dental associations and governments to support and actively influence oral healthcare professionals** with achievable and practical solutions.

**Explore, through quality research, the effectiveness of existing and alternative service delivery models** that focus on effective and equitable (understanding the challenges of different settings) oral healthcare and sustainability as core aims.

#### *Education*

Promote behaviour change **by raising awareness** among **all stakeholders with a focus on end-users (clinical and consumers)** and undergraduate dental students as the future clinicians.

**Promotion of effective oral healthcare as the most important route to sustainability, with primary positive outcomes on individual health, public health resources and the environment** – achieved through a reduced need for interventions.

**Drive sustainable practice throughout the supply chain through education, the promotion of sustainability conversations and leading by example.**

**Educational messages should focus on:**


**Design of products and services that enable consumers to reduce their oral health carbon footprint**, principally through the avoidance of preventable diseases, following validated oral healthcare messages.

**Promote sustainability policies and support behaviour change…**


**Integrate sustainability in the undergraduate oral healthcare curricula.** This should make use of the expertise and resources of the oral healthcare industry (e.g. communication, educational programmes and good practice), educational providers and the students themselves as co-participants of their education.

#### *Route 6 – Materials for clinical use*

**Products and materials** (e.g. oral hygiene aids and dental restorative materials) **need to be 'fit for purpose', with sustainability as a core driver** (i.e. during manufacturing, distribution, use and disposal). Labelling materials and products as 'sustainable' if they are made from sustainably sourced constituents +/− recycled, is overly simplistic. **Products and materials need to be: (i) fit for purpose (effectively and predictably achieve their intended purpose), (ii) built from sustainably sourced materials, and (iii) durable, so that they can perform for a very long time and require reduced revisions and/or replacements.** In the context of restorative materials, for example, these should provide a lifetime service for the patient. A product or material that is not durable will require replacement, with the consequent environmental impacts associated with the iterative repetition of the greenhouse emissions (throughout the supply chain, including patient commutes) and pollution associated with the manufacturing, supply and provision of restorative materials or other products.

**Research focus on a simple, effective, comparable LCA process that can be used cross-industry** to support effective R&D strategies and material choice.

**Requirement for a direct partnership with waste management companies** to encourage collection, sorting and recycling of waste materials.

**Integrate environmental sustainability as an intrinsic element of the ISO standards.** To include detail of the process that a manufacturer undertakes to choose the most sustainable raw materials, to create the product, and to produce products that will use minimum amounts of energy and water to function, under the auspices of ISO TC (Technical Committee) 106 Dentistry.

#### **Strategic action – Synopsis**

Climate change and environmental pollution represent two of the greatest problems facing humanity and the planet. The whole oral healthcare sector recognises the value and positive impact of further improving environmental sustainability throughout the supply chain. To address these challenges, the FDI World Dental Federation assembled a coalition that included leading manufacturers, health professionals, academic experts, and legislative authorities to reach a consensus and prepare this *Joint Stakeholder Statement for the Provision of Environmentally Sustainable Oral Healthcare*. This endeavour was driven by a collective ambition to reduce the environmental impact that arises from the wide range of activities associated with the global delivery of improved oral health.

This statement identifies the state of awareness of the impact of oral health activities on the environment: the major challenges facing oral healthcare; the complex drivers that underpin current behaviours and practices; and the opportunities to improve and deliver sustainable oral healthcare for people and the planet. As a result of this collaborative programme, a strategic action framework has been identified that is based on defined opportunities to improve sustainability. This framework is based on the evidential and experiential knowledge alongside insights and expert opinions from the diverse stakeholder community engaged by the FDI. Furthermore, actions need to be implemented with due regard to the cultural and socio-economic contextual framework of the regions where they will be deployed. A code of practice for the implementation of these strategies has therefore also been defined, and this is considered core to effective, collaborative action.

It was concluded that sustainability in the oral healthcare industry must be addressed as a 'supply chain' challenge, with all stakeholders working collaboratively wherever possible. The primary objective of these individual and combined stakeholder actions should be to develop a circular economy. Industry recognises that, by providing leadership, the potential for positive impact will be substantially enhanced throughout the whole supply chain. This partnership is also committed to sharing best practice to maximise benefits throughout the sector. This consensus statement acknowledges the need to work with the supply chain to fix the supply chain, and in time the goal must be to more closely coordinate our actions in order to further optimise efficient systems and processes alongside logistics capacity. *Reduce* and *recycle* should be the main focus of an improvement strategy as being the most practical and readily implementable approach, that is, a reduction of packaging, preclinical, and clinical/end-user plastic products and engagement with recycling as the next best strategy of waste management. Reduction of treatment needs represents a significant opportunity to improve sustainability, and can be achieved with a combination of effective preventive programmes and the provision of high-quality consumer health products with effective/durable clinical interventions when needed.

External organisations (including national governments, professional bodies and legislative authorities, including regulators) are strongly encouraged to support this development of even greater environmental sustainability across the oral health sector. This recognition and active support need to be extended to the provision of sustainable clinical dental practice. End-user consumer stakeholders should also be engaged in sustainable practice by raising their awareness and engaging in the design of products and services that enable them to reduce their personal oral health-related carbon footprint.

This consensus statement recognises the value of promoting research into the recovery and recycling of all plastics used across the sector, including in packaging. The reduction generation of associated waste streams requires 'sustainability' to be embedded in the earliest stages of product design. Reduction may also be improved through adoption of the best technological solutions (including in distribution, logistics, teledentistry and remote clinical consultations). Related to this, research programmes that have the potential to provide innovations in recycling or waste reduction should be given a high priority by governments and their agencies. High-quality and impactful research are a fundamental enabler of any effective sustainability action in the sector. There is a need to obtain reliable and independent research data to enable prioritisation and collective action at all levels. This should include a combined health–economic–sustainability impact analysis. Clinical materials and products require robust life cycle analysis research, to enable effective comparisons to be made. Sustainability through improved recycling requires that companies engage with other stakeholders in the supply chain. There may be specific benefits in creating socially equitable funding models and appropriate infrastructure, which will promote and permit practical recovery and recycling schemes. Stakeholders in the supply chain should use their position to increase the application of reuse or recycling.

There is distinct requirement to engage with legislation to drive sustainability and use incentivisation as an advocacy tool. Legislation should be derived from a fact-based decision-making process. Stakeholders in the oral healthcare supply chain should work with legislators to influence and improve the manner in which laws and rules assist sustainable practice. This statement also recognises the benefits of improving education within the professions at all levels and more widely among the public. Behaviour changes at individual and organisation level, through targeted educational programmes, are key to increasing awareness and driving sustainable practices throughout the supply chain. This should include development of sustainability polices and education of company workforces, oral healthcare professionals, whole dental practice teams, and the global public. A particular focus for educational programmes is the oral healthcare profession, which represents a key link between the dental industry and patient education. This can be enhanced through the integration of sustainability into undergraduate dental curricula with the engagement of national dental associations and governments to support and actively promote sustainability throughout oral healthcare.

In conclusion, all elements of our complex oral healthcare sector undoubtedly make a significant contribution to oral health, which improves quality of life for millions of people worldwide. While sustainability has advanced in recent years by both individual businesses and clinical professionals, this consensus statement demonstrates clearly the potential for far greater future impact as a direct result of improved coordination and collaboration between diverse stakeholders. Further engagement by governments and their agencies to improve legislation and provide support for research leading to the translation of new technologies will further accelerate the transition to a sustainable, circular economy and improved oral health.

# **Appendix**

# **Map of Consensus Statement to the United Nations Sustainable Development Goals**


**Table 1:** Number of statements or comments within each section of the Consensus Statement that relate directly to one (or more) of the 17 UN SDGs. The table is not an indication of any of the following: (i) How much focus/effort the stakeholders collectively or individually believe should be afforded to a specific CS topic or action; (ii) The relative importance that the stakeholders, collectively or individually, apply to a specific UN SDG; (iii) The speed or effectiveness with which any specific CS recommendation can be implemented.

# **Bibliography**


# **Index**

### **A**

action *see* strategic action framework aim and objectives 9 air pollution 12 amalgam, dental 34 American Society for Testing and Materials (ASTM) 9 awareness of need for sustainable practice 12

# **B**

business models, sustainability and 16, 17, 22, 29, 31, 32, 39

# **C**

challenges to sustainable practice 15 circular economy 13, 14, 15, 17, 27, 28 climate change 8 CO2 /CO2 e emissions 12, 29, 45 code of practice for a collaborative strategy 37 collaboration 16, 19, 23, 37, 38 communication 16, 19 companies awareness of environmental impacts 14 education and research 32, 38, 45 employee engagement 18, 19, 32 leadership in good practice 17, 18, 20, 29, 38 opportunities to reduce, reuse, recycle or rethink 22, 41 recycling strategies 22 resources for collaborative partnerships 39 Consensus Statement on Environmentally Sustainable Oral Healthcare 1 consumers *see* end-users

continued professional development programmes 33 COP26 8 cosmetic dentistry 35 costs *see* business models, sustainability and COVID–19 pandemic 21, 27

#### **D**

definitions and glossary xi demographics, significance of 13 dental amalgam 34 dental associations 34, 40, 44, 45 dental materials 34, 45 dental practice team 32, 45 digital technologies 40 distribution 28, 40 drivers of sustainable practice 17

# **E**

education 22, 30, 31, 32 action plan 38, 41, 44 undergraduate dental students 30, 33, 44, 45 employee engagement 18, 19, 32 end-users (dental professionals, patients, consumers) awareness of environmental impact 13, 14, 15 education 17, 22, 32, 33, 44 positive impact of individual actions 20 role in reducing, reusing, recycling 21, 22, 24, 27, 28, 41 energy use 12, 29 environmental impacts 12, 18, 20, 34 ESG (environmental, social and governance) frameworks 14, 16, 17 European Commission 'A European Green Deal' 25

### **F**

FDI World Dental Federation 9 *Future Use of Materials for Dental Restoration*  (WHO–UNEP report, 2009) 30

### **G**

global regional variations 13, 24, 25, 26, 37 glossary and definitions xi good oral healthcare 40 governments, role of 34, 35, 40, 44 greenhouse gas emissions 12, 29, 45

# **I**

inequalities 31, 37 *see also* low- to middle-income countries (LMICs); regional variations International Dental Manufacturers Association (IDM) 15 International Medical Device Regulators Forum (IMFDR) 35 International Organization for Standardization (ISO) 15, 35, 45

### **L**

LCA *see* life cycle analysis legislation 15, 16, 17, 18, 24, 27, 35 action plan 40, 41, 47 life cycle analysis (LCA) 15, 25, 34, 35, 45 linear economy 13, 27 LMICs *see* low- to middle-income countries logistics 28, 44 low- to middle-income countries (LMICs) 13, 15, 27, 28, 31, 44

# **M**

manufacturing companies 19, 20, 21, 28, 32, 35, 41 materiality assessments 27, 41, 43 materials for clinical use 34, 45 medium- to high-income countries (MHICs) 13 mercury amalgam 34 methodology of the research 9 MHICs *see* middle- to high-income countries

# **N**

national dental associations 34, 40, 44, 45 national variations 13, 24, 25, 26, 37

# **O**

opportunities for sustainable practice 18 oral health 7–8 oral healthcare, good practice 40

### **P**

packaging global agreement on requirements 35 problem of 21 reducing, recycling, reusing 22, 23, 28, 41, 43 waste management 26, 43 patients *see* end-users; travel and transport plastics and plastic waste 21, 22, 23, 24, 26, 41, 42 pollution 34, 45 population demographics, significance of 13 PPE (personal protective equipment) 21, 26 prevention of oral disease as focus for education;education 30, 31, 45 and reduction in materials and waste 22, 24, 28, 40 and reduction in patient travel 20, 41 as key to sustainability 15, 18 procurement 28, 44

# **R**

recycling *see next entry* reduce, reuse, recycle, rethink (the 4Rs) 21, 27, 31, 34 action plan 40, 43, 46 *see also* waste management regional variations 13, 24, 25, 26, 37 regulatory bodies 15, 25 remote clinical consultations 33, 40 research, need for 30, 32, 44, 46 research methodology (of the consensus statement process) 9

# **S**

safety 24, 25, 26, 27 single-use metallic instruments 27 single-use plastics (SUPs) 21, 22, 24, 26, 27, 28, 41, 43 sponsors (of the consensus statement process) 10 *Standard Practice for Managing Sustainability in Dentistry* 8–9 standards, international (ISO) 15, 35, 45 statement, joint stakeholder 1 strategic action framework 37 code of practice for collaboration 37 collaboration and leadership 38 enabling agencies 40 legislation, policy and guidelines 41, 47 materials for clinical use 45 person-centred oral healthcare 39 procurement and logistics 44 reduce, reuse, recycle, rethink 40 research and education 44, 46 synopsis 46 waste management 42 WHO oral health strategic objectives and 38

students *see* undergraduate dental education supply chain, as a single entity 13, 46 challenges to sustainability 15, 16 collaboration in recycling 23 companies' leadership role 17, 20 education 31 logistics 29 waste management 26, 28 SUPs *see* single-use plastics sustainability in oral healthcare, definition 4 sustainability indexes 44 sustainable practice awareness of need for 12 challenges to 15 drivers of 17 opportunities for 18

# **T**

tele-dentistry 33, 40 trade associations 20, 25, 26 travel and transport 12, 20, 33, 40 *see also* logistics

## **U**

UN (United Nations) Agenda for Sustainable Development 11 Sustainable Development Goals (SDGs) 11 waste management inverted pyramid 22, 32 undergraduate dental education 30, 33, 44, 45

# **W**

waste management 21, 25, 26, 42, 45 *see also* reduce, reuse, recycle, rethink water use 12 WHO (World Health Organization) *Future Use of Materials for Dental Restoration*  (WHO–UNEP report, 2009) 30 on oral health 7 oral health strategic objectives 38

The Oral Healthcare community, including clinical professionals and industry, acknowledges the shared responsibility to deliver products and interventions that improve oral health in a more sustainable manner.

To deliver this, the community is working in alignment with the UN Sustainable Development Goals. Key to establishing this collaborative stakeholder consensus is a deep contextual understanding of the challenge. This is achieved through a comprehensive account of the levels of awareness of the environmental impacts, the challenges to resolve these impacts together with the drivers and opportunities to promote sustainable practices.

This report concludes with a strategic action framework that makes specifi c recommendations and identifi es best practice to achieve these goals. The promotion of excellent oral healthcare and the development of a circular economy are core to this strategy. Additionally, it is also important to recognise the opportunities to collaborate across the sector, and throughout supply chains, to develop and promote sustainable practices to achieve meaningful and measurable environmental outcomes in the sector.

In this context, the FDI World Dental Federation convened the development of this volume, Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement. This consensus statement brings together a global coalition of stakeholders, representing all aspects of industry, health professionals, experts, legislative authorities and governments. The statement uses a truly collaborative, multi-stakeholder approach to identify the major challenges facing oral healthcare, the complex drivers that underpin current behaviours and practices, and the best opportunities to improve and deliver sustainable oral healthcare for people and the planet.

Concluding with an impactful and robust strategic action plan that crosses all boundaries, the statement identifi es a series of actions and recommendations for best practice that address the sustainability issues facing the whole sector.

Written by The University of She eld colleagues Prof Nicolas Martin, Dr Steven Mulligan, Hon. Prof Ian J Shellard and Prof Paul V Hatton, Consensus on Environmentally Sustainable Oral Healthcare: A Joint Stakeholder Statement is the result of a collaborative working partnership between the FDI-Sustainability in Dentistry Task Team and the project founding partners (Colgate-Palmolive, Dentsply Sirona, Haleon, Procter & Gamble and TePe) with the wide participation of stakeholders throughout the oral healthcare supply chain.

The fi ve founding partners of the Sustainability in Dentistry project are Colgate, Haleon, Procter & Gamble, Dentsply Sirona and TePe

**Read more about the FDI Sustainability in Dentistry project**

**Consensus on Environmentally Sustainable Oral Healthcare:**

A Joint Stakeholder Statement

**Consensus on Environmentally** 

**Sustainable Oral Healthcare:**

A Joint Stakeholder Statement

Nicolas Martin, Steve Mulligan, Paul V. Hatton, Ian J. Shellard