MINIMAL INTERVENTION ORAL CARE AND SUSTAINABILITY
This month, Davinder Raju, the Eco Dentist, explores how prevention, minimal intervention treatment, and using fewer resources are important for the environment.
Once in a while, I’m asked where the idea of setting up an eco-friendly dental practice and practising greener dentistry came from.
And I respond by saying ‘connection’. Please let me elaborate.
I studied for my part-time, blended-learning master’s degree in advanced minimum intervention restorative dentistry (AMIRD) at the faculty of dentistry, oral & craniofacial sciences at King’s College London. While studying, I realised the impact of an unbalanced/unhealthy oral environment.
A homeostatic healthy oral microbiome is crucial to health. But if it becomes unbalanced through lifestyle choices, it can cause oral and systemic diseases.
The connection between an unhealthy pathological oral microbiome and the host's health made me consider my practice's impact on our connected host. Namely the environment.
Fortunately, other members of the profession are on the same wavelength. They have also seen the connection and are becoming increasingly aware of dentistry's significant impacts on the environment.
In addition, the profession has begun to embrace a culture of sustainability. As a result, they have responded by making sustainable dentistry a higher priority for their practices.
This could include switching to renewable energy providers, purchasing eco-friendly supplies and equipment, and opting to use autoclavable devices over single-use plastic devices.
Of course, there are many practical ways a dental practice can mitigate its impacts on the environment.
Prevention-based minimum intervention oral healthcare: it’s good for your patients, and it’s good for the environment
Still, without prioritising prevention and minimally invasive operative dentistry we risk contributing more to the climate crisis and not acting in our patients’ best interests. These are both key domains in the minimum intervention oral care (MIOC) team-delivered approach to our patient’s oral healthcare.
That’s because the prevention of oral disease should be set as the gold standard and recognised as the most sustainable way to ensure optimal oral health with minimal impact on the environment for the duration of our patients’ lifetime.
After all, the most effective way to reduce the environmental impact of oral healthcare activity is to avoid needing to do it at all.
When patients with early signs of active oral disease are presented, a thorough risk/susceptibility assessment is required where all risk factors are identified and addressed.
‘The good physician treats the disease; the great physician treats the patient who has the disease’ – William Osler.
As I learned on the KCL AMIRD programme, some of these risk factors play critical roles in other diseases.
By interrupting them, we as a profession can help our patients’ overall well-being. This will reduce the patient’s all-inclusive burden on the healthcare system and simultaneously its environmental impact.
Patients must also value their oral health and accept responsibility for their disease. In addition, when empowered by the oral healthcare team, it’s important that they take a more significant role in managing their disease.
When the patient takes responsibility for their disease, the clinical oral healthcare team can focus on less resource-intensive minimum intervention oral care (MIOC) strategies for preventing further harm.
These can include:
Remineralise demineralised enamel and dentine. Tooth tissue should be conserved and not removed unnecessarily.
Preserve existing tooth tissue to keep sound teeth sound.
Establish effective oral hygiene measures to manage periodontal disease and caries.
The evidence clearly shows that nearly all dental and periodontal diseases can be prevented at low environmental cost with preventive measures; there is an ethical and moral imperative to prevent what is preventable and reduce clinical intervention to a minimum.
Furthermore, a growing body of evidence supports the relationship between bacteraemia and inflammation due to periodontal disease and systemic diseases such as cardiovascular disease, colorectal cancer, diabetes mellitus and Alzheimer’s disease.
Again, it is clear that the prevention of periodontal disease will not only positively improve our patients’ long-term quality of life but also reduce the healthcare’s overall environmental impacts throughout the patient’s lifetime by not having to deal with non-oral systemic diseases.
Minimally invasive operative intervention
When active caries lesions need surgical intervention, minimally invasive operative interventions should be adopted.
This approach leaves as much residual dentine thickness over the pulp as possible by removing caries-infected dentine only. It also leaves the cavity restored with bio-compatible restorative materials which seal the tooth-restoration interface.
An increased dentine thickness over the pulp with a peripherally sealed restoration is less likely to cause pulp-related problems and so less likely to require further treatment in the future.
In contrast to a minimally invasive approach to caries management, , the traditional, interventionist approach to ‘managing’ dental caries lesions over-treats the sequela of disease rather than tackling the cause of disease.
In such cases, caries-affected dentine is treated like gangrene and removed entirely, thus jeopardising the long-term health of the pulp tissues and the strength of the remaining tooth structure.
The tooth death spiral
Fillings can fail. This is mainly when risk factors haven’t been addressed.
Also, subsequent replacement fillings get more extensive and complex each time they are replaced, using more environmental resources.
Additionally, more pulp-related problems will likely occur with more extensive restorations necessitating root fillings or extractions.
This cycle of refill and refill is known as the ‘tooth death spiral’.
Dentures, bridges or implants then replace tooth loss. And, of course, the environmental burden also spirals with each intervention.
Treatment options with reduced environmental impacts for managing failing restorations
Again, I have adopted a minimally invasive approach which also happens to have a ranked environmental cost.
When managing deteriorating or failing direct restorations (a significant component of general dental practice), I follow the ‘5-R’s:
Review minor defects which will not benefit from operative intervention
Refurbish by removing plaque-retentive defects or improving the aesthetic appearance of composites by polishing
Reseal open margins to reduce the risk of caries
Repair where possible rather than replace filling in its entirety. Evidence has shown that the long-term survival of repaired defective restorations is as good as that of replaced defective restorations
Replace only when outcomes cannot be achieved using the first four points.
As members of the dental profession, we need to recognise the connection between delivering healthcare and its impact on the climate and ecosystems.
After almost 30 years of clinical practice, I know that prevention is the best dentistry for our patients and the environment.
And, if we need to intervene surgically, priority should be given to options with the lowest biological and environmental impacts and carried out to the highest standard to ensure long-term longevity.
Why not join the growing movement toward sustainable dentistry and choose prevention-based minimum intervention oral healthcare to reduce environmental impacts?
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Banerjee A (2017) ‘Minimum intervention’ MI inspiring future oral healthcare? Brit Dent J223:133-135
Banerjee A (2020) Minimum Intervention oral healthcare delivery – is there consensus? Brit Dent J 229(7):393-395
Banerjee A, Watson TF (2015) Pickard’s Guide to Minimally Invasive Operative Dentistry 10th edition. Oxford University Press
Green D, Mackenzie L, Banerjee A (2015) Minimally Invasive Long-Term Management of Direct Restorations: the ‘5 Rs’ A. Dent Update 42:413–426JULY 24, 2022