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].

Challenges to ‘a sustainable oral healthcare supply chain’

• There is a lack of recognition of the supply chain as a single entity, with each stakeholder working in a disjointed manner with little impact beyond the core business model.
• There is conflict between business models and sustainable practice. Some performance imperatives can sometimes be seen as conflicting with the need for improved environmental performance (e.g. investment and operational cost of reducing emissions and waste, minimising hygiene risks versus minimising waste – disposable versus reusable).
• The is an absence of collaborative work between stakeholders to manage waste generated upstream and downstream.
• The current lack of communication and collaboration between front-line services, suppliers and patients means that issues (e.g. waste management) are often viewed locally rather than across the whole spectrum.
• Stakeholders are working solely within the structure of their internal corporate responsibility or ESG frameworks and, in doing so, failing to engage more widely with the supply chain.
• The legislative frameworks for manufacturing, packaging, distribution and safe clinical care inadvertently hamper or challenge sustainability.
• It is a challenge to design and develop a product that is fit for purpose and at the same time environmentally sustainable. The concern focuses on the perceived higher costs and the possible need for consumers to pay a premium.
• Companies in the supply chain identify with the need for unbiased and open inter- and intra-stakeholder communication within the supply chain for effective collaboration on sustainability. This apparently simple premise is a challenge due to:

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  A perceived ‘silo mentality’ of some stakeholders with different maturity levels of understanding of key sustainability issues.

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  Short-term commercial interests make information sharing sensitive; the need to engage in transparency around common issues.

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  Lack of accurate and timely data that prevents agreement of KPIs and priority targets.

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  The need to establish networks and ways to collaborate that include the whole supply chain.

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  The need for a legislative framework relating to antitrust or other potentially anti-competitive or collusive behaviour.

Challenges to ‘operating in a circular economy’

• Identification and implementation of a framework that engages the whole supply chain is difficult. This framework should be based on the creation of socially equitable funding models, infrastructure, culture and a sustainability mindset that will promote and permit practical recovery and recycling schemes.
• The environmental sustainability of products (and associated transport and packaging) entering and leaving the company within the supply chain is difficult to manage.
• There is a need to understand that neither providers nor customers wish to compromise performance for more sustainable options.
• It is important to engage all stakeholders, and in particular end-users (private citizens and professionals) with a sustainable culture with respect to healthcare provision. Healthcare is considered ‘exempt’ (by the general public) from sustainable practices under the perceived assumption that the pollution footprint from healthcare is an unavoidable consequence.
• There is a need to manage resources at every level of the supply chain (especially energy and water), and in particular the waste management of disposed waste products.
• There is a requirement for manufacturers to make products and associated packaging more recyclable, while ensuring appropriate recovery of these products for subsequent recycling.
• We need to understand and work with existing stringent legislation and healthcare laws that require medical products to be safe for the end-user: a factor closely associated with a litigation-averse culture. External legislation and internal ESG frameworks can sometimes be seen as a constraint rather than as an enabler, because they focus attention on compliance with specific ‘legislated’ issues only.

Generic drivers for a more sustainable supply chain

• Strongly established social ethical responsibilities within companies and the dental practices, which are also promoted at an individual level.
• Promotion of a positive image of the dental profession and supply chain in a world where environmental sustainability performance is a big contributor to a positive image.
• The need to establish strategic alliances with actively pro-environmental stakeholders up and down the supply chain and work to achieve significant benefits from full and comprehensive engagement.
• The status of the company on the world platform of commerce is very important to drive good practice through leadership and example. For example, one stakeholder stated:
• 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.
• The status of the company as a sector leader in sustainability is critically important to drive sustainability more widely, through education, knowledge and education, and a focus of inspiration.
• Stakeholder sustainable practice is key to maintaining staff morale, demonstrating that the company goes beyond being a commercial business enterprise and has a social consciousness that is real and impactful.
• Within the context of oral healthcare providers, there is a business driver for further engagement – ‘Sustainability makes business sense for dentistry’ [35].
• Company employees see the status of their company within the industry as an important opportunity to promote sustainability in the sector.

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:

• Promoting company sustainability leadership and the idea that both external as well as internal recognition are important to them.
• Reinforcing the perception that sustainability is a growth driver and that doing good (or being sustainable) is good for business.
• Empowering employees to be part of the change; helping them contribute and feel meaningful.
• Promoting behaviour change through education, supporting/praising engagement and recognising success.
• Engaging with employees to create a feeling of ownership.
• Proactively influencing and making a difference in everyday work.

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:

• Being based upon sound data with specific targets. Targets should be achievable that are both generic and core to the company operation and the supply chain.
• Being designed to raise awareness (through education) and embed a sustainability culture across all functions of the company.
• Being designed to drive the quality of the engagement across the business.
• Promoting individual responsibility.
• Integrating sustainability throughout the company business with identification of areas of strongest impact.
• Building sustainability into the business growth strategic plan.
• Working in line with the UN Sustainable Development Goals [9].

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].

Environmental impacts – CO ₂ 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.

Figure 7:

Collaboration with effective communication, dissemination and participation is essential to promote environmental sustainability. ASDF_MEDIA/Shutterstock.com, 2022.

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:

• The leverage of the global footprint of commercial companies and partnerships to drive healthier habits for the planet. Especially related to promoting more responsible consumption of resources such as water and electricity and encourage sorting and recycling in the bathroom.
• A focus on specific areas that identify opportunities or a responsibility to act on brands with purpose, embedding sustainable business practices and improving healthcare and wellness outcomes as a company and through commercial brands. For example, harness the voice of commercial brands and via partnership with dental professionals and organisations.

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:

• Active and strategic collaboration and clear procurement policies with clear key performance indicators (KPIs) and matched expectations.
• A collaborative approach to distribution and use of products that focuses on energy, water efficiency and reduction.
• Building the mastery, incentives and the means to adopt more sustainable practices with regard to materials, renewable electricity in operations, diversity and ethical practices across sourcing and manufacturing, etc.
• Analysis of need through a materiality assessment and SWOT or similar analysis.
• A clear, focused effort on reducing the carbon footprint.
• Transportation, end-of-life and choices of material alongside ensuring safe and fair working conditions.

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

• Knowledge, expertise and research.
• Expert resources: human; communication, materials, consumer behaviour; logistical learning/scale.
• Funding (to the extent that it is feasible and makes sense for the business).
• Partnership and ideas. Companies understand their challenges and can work with other stakeholders to provide new points of view and solutions.
• Education, communication, engagement, support.

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:

• Through trusted partners and trade associations, for example CGF, EMF, EPR, RSB and WRI (see Glossary).
• Helping suppliers understand and define goals for themselves.
• Engaging, discussing and finding mutual positive feasible business value.
• Establishing closer dialogue and networking.

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

• Obtaining baseline measurement of individual stakeholder carbon impact, to identify opportunities and to enable activities that will reduce this.
• Rewarding engagement and impact through awards.
• Establishing ‘supply innovation centres’ to serve as a hub for collaboration with networks of local suppliers, technology companies, R&D institutions and high-ranking universities to develop solutions to decarbonise our global supply chain.
• Establishment of internal sustainability ‘road maps’ towards net zero carbon that will indicate a practical, prioritised, challenging and impactful route.
• Reducing the impact of patient travel through (i) the promotion of prevention that results in improved oral health and a reduced need for complex procedures; and (ii) improved patient care logistics at the point of care delivery [28].
• Leverage of end-users (dental professionals, patients and consumers) as part of the solution to drive positive change.

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.

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.

Figure 8:

Reduce, reuse and recycle are central tenets of an environmentally sustainable circular economy. Superstar/Shutterstock.com, 2022.

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 twenty-one (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:

• Creating a roadmap with fixed targets in the use of recyclable, reusable or compostable plastic packaging.
• A reduction of the use of virgin plastic in products, packaging and marketing material (where safety and quality allow).
• Actively exploring use of recycled materials and circularity.
• Establish external alliances etc. to find solutions that improve effective recycling at scale.
• Develop corporate-level EHS management systems that will help define, implement and drive strategic improvement.
• Support and commit to the principles of organisations and alliances that seek a reduction of plastic use (e.g. the Ellen MacArthur global commitment [39]).

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.

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.

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).

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:

• A lack of a forum that enables discussions and engagement with policy regulatory bodies, end-users and other stakeholders up- and downstream.
• Conflicting regulation for the promotion and enforcement of different aims – this is a recurring issue and also identified as a challenge to the creation of circular economies.
• Lack of coherent legislation for:

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  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.

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  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.

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 end-user. 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.

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:

• Unlocking 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.
• Following a more desirable SUP circular economy that focuses on a reduced consumption of finite resources (such as oil-derived plastics) that designs ‘plastic waste’ out of the systems.
• Defining plastic waste as a resource that is part of a circular economy rather than waste.
• Including core knowledge on plastic, its forms and recycling opportunities to enable stakeholders to make more sustainable choices when using it (for example, if it is fossil-based or bio-based, or a combination of the two).
• Accepting joint and shared responsibility for the management of this waste with all sectors of the supply chain, including the recycling industry.
• Establishing collaborative partnerships and communicate effectively with peers, NGOs and other stakeholders that will drive and enable innovation and new designs, build infrastructure and secure quality recycled plastics.
• Influencing consumers’ mindsets, but with the required infrastructure in place that enables the consumer to act in a responsible way.
• Developing a fully circular supply chain that can handle small-format items at commercial scale.

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:

• Including sustainability as a factor for the selection of vendors.
• The use of efficient distribution and procurement logistics with shared facilities.
• Collaboration on logistics between competitors with more unification on warehousing and transport of products to save journeys and transport.

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

• Sustainable operational sustainable practices with increased efficiency require less energy, water and distance travelled, and produce fewer CO₂ emissions and waste, which results in cost savings.
• The production of better, more sustainable products and highlighting this through increased consumer engagement produces product loyalty.
• Sustainably marketed products have grown much faster than traditionally marketed products (e.g. car manufacturers offering hybrid technologies).
• Investing in sustainable solutions can/should result in smarter production and eventually lower energy consumption.

Sector leadership, stakeholder collaboration, sharing best practice and engagement in ‘procurement summits’ 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:

• Effective workforce planning.
• The nature of the target population (e.g. schools, care homes, population hubs…).
• The provision of core care principles (prevention and screening).
• Travel for providers and patients.
• The structure of the facilities.
• Collaborative engagement with industry for logistical support.
• Reduced packaging.
• Effective waste recovery/recycling.

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.

Awareness and challenges

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:

• Stakeholders to understand the benefits for themselves. Sustainability is a hugely marketable commodity for practices.
• There being scope for increased efficiency and clinical success through alternative workflows.
• The need to align outcome measurements to prevention.
• The requirement to shift from a focus on current clinical pathways, with the adoption of new servicing models that avoids inequality. A focus on prevention is needed.

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]:

• disposal to landfill of expired materials;
• incineration of waste materials;
• microparticulate waste from use of dental materials [53, 54];
• elution and excretion from restorations into sewerage and water systems;
• interment and/or cremation at end of life.

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:

• preventive programmes;
• the implementation of good-quality practice, with good materials, used appropriately in accordance with the manufacturer’s instructions;
• effective maintenance programmes.

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:

• The cost of materials and acceptance by consumers to drive behaviour change.
• The availability of new materials.
• Product safety considerations.
• High testing requirements to meet quality standards (including stability and consumer acceptance for example) and the time to undertake these.
• Availability at scale while maintaining a low environmental impact profile.
• Understanding the complexity of sustainability and its actual impact (the product or material).
• Accurate characterisation and understanding trade-offs/compromises, which must be evaluated and understood in order to determine the best options from an overall sustainability perspective.
• Understanding that durability is key to sustainability, so that replacements are reduced or obviated during the lifetime of the patient.

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:

• Reviewing and challenging the shelf life of materials – e.g. replacing with a concept of functional versus optimal performance of materials.
• Fit-for-purpose materials that are very durable and do not require multiple replacements will have a net lower environmental impact.
• Reviewing the value of glass ionomer and improvements in longevity for treating elderly patients.
• Undertaking standardised LCAs of materials will help to identify opportunities and acceptable trade-offs/compromises.
• Reviewing the expiry and shelf life of materials versus packaging style (compules).
• Reviewing and considering the current suitability of shelf life testing protocols.
• Due consideration should be given to the material and the associated packaging.
• Sharing of knowledge and experience of outcomes between parties.