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, 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.

Figure 1: Prevention and maintenance as a key route to environmental sustainability. “SewCream/Shutterstock.com” 2022. (Figure not reproduced here; see the original article.)

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 CO₂e 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 CO₂e 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 CO₂e 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

1. Raising awareness and outline the opportunities relative to decreasing carbon emissions, improved choice and use of materials, improving waste generation and management, and other environmental impacts relating to oral healthcare.
2. Promoting impactful research and educating all sectors of the supply chain, to ensure broad consensus around sustainable oral health practice and sustainable lifestyle habits.
3. Acknowledging individual and joint responsibilities to understanding and seeking to minimise the environmental impact of our activities while improving the quality of products and healthcare provision.
4. Seeking to work jointly and proactively, to achieve environmentally sustainable solutions for the good of our profession, the population we serve and the environment we share globally.

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.

1. Awareness and challenges
   • Awareness among all stakeholders of the impact of oral health professional activities on the environment.
   • Challenges to develop and engage with sustainable practice.
2. Drivers and opportunities
   • Drivers to develop and engage with sustainable practice.
   • Opportunities to develop and engage with sustainable practice.
3. Strategic Action Framework
   • 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, CO₂e, 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).