Go Green - It's the Right Thing to Do

The ADAA has an obligation to disseminate knowledge in the field of dentistry. Sponsorship of a continuing education program by the ADAA does not necessarily imply endorsement of a particular philosophy, product, or technique.

What exactly is "going green"? What does it mean to the practice of dentistry? Dental healthcare professionals know the importance of preserving the environment and the environment's contribution to overall health and well-being. Research has shown there is a rising consumption of diminishing natural resources. Air and water pollution, growing landfills and the effects of global warming have added to this decline. Dentistry can lessen the combined environmental impact by utilizing the "Four R's of Going Green," namely, "Reduce, Reuse, Recycle, and Rethink."¹ This course will include the parameters needed to initiate a program for your dental practice that is simple and practical to implement.

Concept

The concept of conserving natural resources in the U.S. dates back to the 1800s. However, it wasn't until 1970 that the first Earth Day was established.⁹ Increasing consumption of diminishing natural resources, air and water pollution, ever growing landfills, and the effects of global warming makes saving our environment imperative. Going green, simply put, is the right thing to do. The concept of going green involves a person, family or group becoming more conscious of the destruction of the environment. The color green is used because it reminds us of the outdoors and the environment. When a person adopts practices that help reduce waste or become more energy efficient, they are "going green."

Making any significant change is not always easy or fun. Any dental professional leading an effort for change should make sure that the team knows the importance of each step and has a general acceptance of the initiative. It is necessary to engage the entire dental healthcare team in any going green initiatives. Making the initiative important, fun and reasonably convenient is critical to a successful outcome.

Beginning Steps

Appoint a coordinator. According to Chris Miller's book Infection Control and Management of Hazardous Materials for the Dental Team, he thinks that you need to know what procedures you are doing first which would be the responsibility of the infection control coordinator. The infection control coordinator should begin by:

• Taking an inventory of the procedures being done in the office. 
• Developing ideas for the best way to incorporate the initiative. 
• Assigning specific staff to tasks (i.e. office recycling team). 
• Taking before and after pictures of initiatives. 
• Including information on the efforts in the practice newsletter and website. 
• Getting local press coverage of the initiatives. 

One of the easiest ways to start a going green initiative is to develop a waste reduction plan. Whenever possible, waste reduction plans should include the four Rs: recycle, reduce, reuse and rethink. (Figure 1)

Waste Reduction

Recycle

According to the EPA 2013 report, 34.3% of the material that makes it to the landfill is recycled (https://www.epa.gov/smm/advancing-sustainable-materials-management-facts-and-figures). Recycling materials diverts 87 million tons of waste from landfills. Think of the yearly impact an office could make just by recycling materials that end up in a landfill. An office can begin by recycling all aluminum, glass, plastic and paper; including cardboard by utilizing recycling containers. Recycling containers must be visible and located in areas of easy access for best results. Dental reception areas are a great place for clean covered aluminum and paper recycling containers.

The location of the office's recycling containers must not add extra steps and time for an already busy dental team. A container to hold lead foil from film packets should be in the darkroom or next to the automatic developer. A container for packing materials should be near the area where supplies are checked in for storage. A container for paper recycling can be placed near the printers and fax machine. A container for paper and plastics should also be in the office break room to collect items after lunches or staff meetings. It is a misconception that recycling containers will look dirty and messy. Clean, attractive, covered containers show patients the practice is environmentally concerned and they will appreciate the efforts. (Figure 2)

Another way to recycle is to always use recycled toner and inkjet cartridges and it is a great cost saving measure for the practice. Recycled toners and cartridges are less expensive than new ones. Many improvements have been made in this type of recycling, making the quality of the recycled toners and cartridges excellent. If the office is not using recycled cartridges, it can at least recycle the ones being currently used. Most manufacturers have convenient return plans in place and some even offer rebates for used cartridges.

In the office break room, discontinue the use of disposal kitchenware or make sure to only use biodegradable plastic ware. Washing and reusing basic kitchenware will reduce plastic waste. Labeling personal cups, plates, etc., with staff names also prevents the spread of illness between co-workers reusing unlabeled permanent kitchenware.^1,3 (Figure 3)

Additional ways to recycle is to purchase recycled materials such as toilet tissue, paper towels and office furniture, when possible. Buy rechargeable batteries for digital cameras and flashlights, and re-tip or transform broken instruments for other purposes also aid in recycling efforts.

Reduce

The easiest way to have more of a resource is to use less of it; for example reducing the consumption of disposable items used in dentistry would help in the preservation of the environment. Ways to reduce usage can include an initiative to use water sparingly. Teaching patients to turn off the water until needed during tooth brushing will save water and money. Purchasing water-saving toilets and instrument washers when replacement is needed will lead to additional savings. By drinking tap water from personal water bottles, the office will reduce plastic bottle waste and save money.

The ultimate way to reduce in the dental office is to go "paperless." Going paperless involves the office using computer and digital technology whenever possible to create, use and store office records. This can be done in many ways, such as creating electronic patient records, sending electronic dental claims and using digital radiography. Although an initial investment is involved, the cost can be recouped when estimating the savings in paper, film and developer costs, and mailing costs.

As technology advances, there are many ways to reduce paper waste until the practice can convert to a paperless office. The office can use marketing materials that do not require envelopes or print and copy on both sides of a sheet of paper. Sending and receiving faxes via computer eliminates the need to print documents, as does communicating with patients and vendors through emails.

Make sure the patients are aware of the new communication policy and the reasons behind it. Always give them the option to receive printed versions. (Table 1)

Other ways to reduce include:

• Eliminate the use of plastic bags by using paper when possible.
• Purchase all copy paper with a minimum of 50% Post-Consumer Wastepaper Content (PCWC).
• Purchase janitorial paper with a minimum of 35% PCWC.
• Use paper processed chlorine free (PCF).
• Remove practice from junk mail lists.

Reuse

Reuse paper when appropriate. Shred used paper to use as packing and/or reuse packaging materials. Create scratch pads from used paper for quick notes. If using scratch paper from the office, ensure that HIPAA rules are followed. Another initiative includes reusing mailing envelopes with special "reuse" labels.

Some dental supply companies have recycled products for dental practices trying to conserve. Look for special catalogs or online sections available that promotes items that have been recycled for reuse.

Rethink

Rethinking office practices and protocols may reveal ways to reduce, reuse, and recycle. Stopping to consider the many changes possible is engaging in the re-thinking process of "going green" in a dental practice. Think about what methods can work best for the practice and discuss them with the team as a viable option. Implementing small, affordable changes will still make a significant impact on long-term environmental sustainability.

Energy Conservation

Conserving energy in a dental practice is very similar to conserving energy at home and is definitely a worthwhile cost-saving measure. Take time to become familiar with the manuals that come with all office equipment, including heating and cooling units, lights, compressors and water heaters; basically anything that is connected to a source of electricity. These manuals usually include energy saving tips to incorporate into the office protocols. Installing ceiling fans where appropriate in business areas reduces heating and cooling cost and conserves energy. Keep doors closed to rooms kept at different temperatures.

Water Heaters

Most hot water heaters come preset at a higher temperature than is needed. Lowering the temperature on water heaters is a quick and easy step. Check the manufacturer's recommendations regarding water temperatures for equipment, such as the office uniform and instrument washers. Always use the cold rinse cycle in the washer for laundry.

Programmable Thermostat

One of the best things than can be done is to use a programmable thermostat that is inexpensive and easily installed. The thermostat(s) can be programmed to run on different temperatures at different times of the day. Depending on the outside temperature, adjust the temperature while the office is closed to conserve electricity. While this is a step that can be done manually on a regular thermostat, there are advantages to a programmable thermostat, such as:

• No need to remember to turn up or down the thermostat when you leave the office.
• The thermostat can be programmed to a comfortable temperature before staff and patients arrive.

Windows

There are coatings/films that can be placed over windows to reduce solar heat gain while still enjoying the sunshine and view from windows. Check around windows and doors for cold or hot air escaping into or out of the building. Use weather stripping or re-caulk in areas where leakage is found.

Maintenance

Regular equipment maintenance ensures more efficiency and can be a troubleshooting measure for an oncoming failure. Efficiently running equipment uses less energy. Up-to-date maintenance on the high-volume evacuation (HVE) system, autoclave and handpieces are just a few ways efficiency can be improved. Also regularly check items such as furnaces and air conditioning units. Permanent filters should be cleaned according to a schedule and replaceable filters should be changed out every two months, or according to manufacturer's instructions. Perform more extensive maintenance on large equipment at least twice a year.⁴ The temperature of the supply and personal refrigerators can be monitored to ensure they are running efficiently. It is always best to maintain all equipment according to manufacturer's direction.

Appliances

Purchasing appliances that have an ENERGY STAR^® label and rating will conserve energy and save the practice up to 1/3 on energy costs.⁵ In addition, the practice may be eligible to receive a tax credit for purchasing energy-efficient appliances. Check with the tax laws at the time of purchase for eligibility.

Computer and Electronic Equipment

Purchase computers based on the Electronic Product Environmental Assessment Tool (EPEAT). Light Emitting Diode (LED) Monitors can cut energy consumption in half. Turn off computers at night to save on electricity consumption, as computers in sleep mode still use energy. Items plugged into surge protectors draw a small amount of energy all the time, so turn them off to save even more energy.

Lights

Turning off lights is an easy way to conserve energy. Lights can be motion activated to turn on when someone enters the room. Lights should be turned off in treatment rooms and business areas that are not in use. Replace incandescent bulbs with Compact Fluorescent Light (CFL) bulbs. Use high-efficiency T-8 or T-5 fluorescents. Use LED bulbs in exit signs. According to Arthur Rosenfeld, a physicist and member of the California Energy Commission, "If every home in the United States replaced just one incandescent light bulb with a compact fluorescent light bulb, the energy saved would prevent greenhouse-gas emissions equivalent to taking more than 1 million cars off the road." (http://whatis.techtarget.com/definition/0,,sid9_gci1310981,00.html)

Water Conservation

There are many ways to conserve water, such as not running water while lathering hands during washing or using waterless hand sanitizer when appropriate and using a dry vacuum system. Only run full loads when using sterilization equipment or the practice laundry machines. Low flow aerators can be installed on all sink faucets. Install toilets with a maximum of 1.28 gallons per flush (gpf) and urinals at 0.5 gpf. Review monthly water bills for spikes in usage which may be a warning sign for leaks. Check for leaks throughout the office every six months.

As mentioned earlier, teach patients to turn off water when brushing teeth. Ninety glasses of water per day can be saved by turning off the water while brushing teeth. This adds up to 27 billion glasses of clean water in the United States being flushed down the drain on a daily basis.⁶

Do not forget about water conservation on the outside as well. Adjust sprinklers for proper coverage so that water is not wasted on sidewalks, parking lots or when it is raining. Water the lawn and landscape during non-daylight hours, and plant drought tolerant plants and shrubs.

Pollution Prevention

Webster defines pollution as the contamination of air, soil or water by the discharge of harmful substances. There are steps that can be taken in the dental office to prevent pollution.

Steps to Prevent Pollution

• Only use low toxic cleaning products. 
• Refrain from using cold sterilization solutions. 
• Use digital radiology to eliminate processing solutions. 
• Replace all aerosols with pump dispensers and keep spill kits handy. 
• Use low- or no-Volatile Organic Compound (VOC) paint products. 
• Keep dumpsters covered and watertight. 
• Encourage staff to bike, walk or carpool to work and lunch. 
• Drink tap water. 
• Don't idle automobiles more than necessary. 
• Switch to online banking and bill payment to reduce paper use and waste. 
• Always use licensed handlers for offsite recycling of hazardous materials. 

Dental Amalgam

One of the most controversial substances used in dentistry today is dental amalgam. While the debate over the safety of dental amalgam continues, the vast body of evidence on the topic suggests that amalgam is an acceptably safe material to be used in dentistry. There are many ways to prevent the release of mercury in dental amalgam into the environment. Using high volume evacuation and water spray reduces the level of mercury dust and vapor created when amalgam restorations are removed.

Eliminate the use of bulk mercury and train staff in the proper handling, management and disposal of mercury-containing materials, including extracted teeth with amalgam restorations. Do not use bleach (sodium hypochlorite) to disinfect vacuum lines, as it speeds up the release of mercury from the amalgam.⁴

Scrap amalgam particles should not enter the sewer system. Traps or filters should be used on all drains, evacuation systems and cuspidors where scrap amalgam particles may enter. These traps or filters should be removed and cleaned frequently. Collected scrap amalgam should be stored in an appropriate sealed container.⁷

Another option is to install an amalgam separator. Amalgam separators that comply with the International Organization for Standardization (ISO) 11143, when used with traps and vacuum pump filters can achieve better than 95% amalgam removal efficiency.⁸

Information Overload

The information available to implement green measures into the dental practice can be overwhelming. When beginning the project, start with small steps and add more initiatives as the dental healthcare team becomes comfortable with the new routine. If too much change is expected early on, the team will become frustrated and be reluctant to comply. The Eco-Dentistry Association (EDA) is a great resource for information and offers a GreenDOC^™ Dental Office Certification Program. (www.ecodentistry.org)

American Dental Association Council on Dental Practice Suggestions

The Council on Dental Practice of the American Dental Association consulted with various experts in the field of environmental preservation, as well as ADA dentists serving on the "Going Green" subcommittee of the council. The Council was then asked to list their top ten ways to go green in the dental office.

Top Ten Initiatives

• Install an amalgam separator. 
• Turn off equipment when not in use. 
• Reuse paper scraps. 
• Utilize recycle bins and create a "Green Team" to bring items to recycle centers. 
• Recycle shredded confidential patient information. 
• Convert to digital technology; for example, digital radiography. 
• Install solar or tinted shades. 
• Install locked or programmable thermostats. 
• Install high efficiency light bulbs. 
• Use non-toxic cleaners and don't use too much disinfectant. 

Also available from the Council is a more comprehensive list of 150 tips. Just remember to pick suggestions from the list that will work for the practice. Each suggestion incorporated into the practice is a step in improving environmental sustainability. (Appendix A)

Summary

Green is no longer just a color. The going green movement, which is rapidly becoming a worldwide priority, seeks to address environmental contamination, waste and other critical environmental issues. Dentistry can lessen the combined environmental impact by utilizing the "Four R's of Going Green," namely "Reducing, Reusing, Recycling, and Rethinking."

The "Four R's of Going Green" can be easily applied to the dental office.

Reduce: The easiest way to have more of a resource is to use less of it.

Re-use: By re-using instead of throwing away, resources and energy necessary to manufacture new things are saved.

Recycle: According to the U.S. Environmental Protection Agency, more than 75 percent of material destined for a landfill could be recycled.

Rethink: Stopping to take notice of the obvious things in the dental practice that could be done in a more environmentally friendly way is an effective way to incorporate "Going Green" in every dental practice.

Glossary

Compact Fluorescent Light (CFL) bulb - a fluorescent light bulb that has been compressed into the size of a standard-issue incandescent light bulb. CFLs typically last at least six times as long and use, at most, only a quarter of the power of an equivalent incandescent bulb.

Electronic Product Environmental Assessment Tool (EPEAT) - a ranking of the power saving attributes of computer equipment. The ranking is based on criteria such as the device's power management capabilities, the amount of hazardous material it contains, the amount of recyclable materials used and how easily the unit can be disassembled when it reaches its end of life. Bronze, Silver and Gold ratings are awarded if the device meets all required criteria and a certain percentage of optional criteria. For more information, visit www.epeat.net.

International Organization for Standardization (ISO) - a non-governmental international-standard-setting body composed of representatives from over 160 countries. The organization promulgates worldwide proprietary industrial and commercial standards.

Light Emitting Diode (LED) - a semiconductor that emits light when a current passes through it; indicator lights on electronic equipment.

Post-Consumer Wastepaper Content (PCWC) - the amount of waste paper that has served its original purpose and has been separated from solid waste to be recycled into new paper. This is usually listed as a percentage of the total amount.

Processed Chlorine Free (PCF) - recycled paper processed using no chlorine or chlorine derivatives as a whitening product; paper not re-bleached or bleached with an oxygen-based system.

Volatile Organic Compound (VOC) - gases emitted from certain solids or liquids. VOCs include a variety of chemicals, some of which may have short- and long-term adverse health effects. Concentrations of many VOCs are consistently higher indoors (up to ten times) than outdoors. Examples include paints and lacquers, paint strippers, cleaning supplies, pesticides, building materials and furnishings, office equipment (such as copiers and printers), correction fluids, carbonless copy paper, graphics and craft materials (including glues and adhesives), permanent markers and photographic solutions.

References

1. CDP Supplement Report 1. Dental Benefits, Practice, Science and Health. Sept.2009-H

2. www.epeat.net. Accessed Mar, 2010.

3. Going Green. ADA Management Conference. July 2009. Council on Dental Practice.

4. San Francisco Green Business Program Standards. Dental Practices, April 2014.

5. ADA Business Resources. Is Your Dental Practice Green? Online Feb 26, 2010.

6. www.ecodentistry.org. Accessed Mar, 2014.

7. Blake, J. Mercury in Dentistry: The Facts. American Dental Assistants Association. 2007.

8. ADA. Best Management Practices for Amalgam Waste, Oct. 2007.

9. Newman, E. AGD Impact. Going Green, May 2010, pg. 18-22.

10. https://www.epa.gov/smm/advancing-sustainable-materials-management-facts-and-figures

About the Authors

This Continuing Education Course was jointly developed by the American Dental Association's (ADA) Council on Dental Practice (CDP) and the American Dental Assistants Association (ADAA). The ADAA would like to thank the CDP for their contributions in working toward bettering the environment.