A preliminary survey of knowledge, attitudes and practices in relation to environmental sustainability

Design

This was a cross-sectional survey using a bespoke online questionnaire. Ethical approval was obtained from the University of Leeds Dental Research Ethics Committee prior to commencing the study (DREC ref: 250522/SB/354). The study was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent was obtained from all individual participants included in the study.

Methods

The population of interest was orthodontists working in the UK. This included orthodontic specialists, consultants, dentists with a special interest in orthodontics and orthodontic speciality trainees working in either primary and/or secondary care providing NHS and/or private treatment.

Potential participants were invited to complete an online questionnaire via email using mailing lists held by the British Orthodontic Society (BOS). Following study review and approval from the Clinical Governance Lead for BOS, the administrator distributed an invitation email to all eligible members. The email included an explanation of the research and a link to the online questionnaire. A reminder email was sent 2 weeks and 3 months after the initial email. No incentive was offered for participation.

Data were collected via an online questionnaire tool (www.OnlineSurvey.ac.uk), which is a UK-based GDPR-compliant academic survey tool. No personal details were required to take part and data were collected anonymously. Participants were given an option to provide an email address if they were interested in being contacted about future research relating to environmental sustainability. Email addresses were separated from the research data to maintain anonymity. Data were collated in Microsoft Excel v16.23 for analysis.

The questionnaire used in this study was developed de novo because no suitable tool currently existed. The process for developing and testing the questionnaire involved a literature review, advice from an expert in environmental sustainability and pre-testing with the target population (Figure 1). The content of the questionnaire and response format is summarized in Table 1. Free text boxes were provided to allow respondents to provide detail or explanation to their answers. The full questionnaire is included in the supplementary material.

Data were analysed descriptively to report responses and sample characteristics. Categorical data such as attitudes and practice were reported using frequency. Free text answers were examined to identify common sentiments or explanations for ratings, and illustrative quotes were included.

Results

The questionnaire was open from 12 July–12 November 2022. The email invitation was sent to 1427 BOS members, of whom 146 responded, giving a 10% response. The respondent characteristics are given in Table 2. The majority of respondents were consultants and specialists from England, with a spread of ages and a 3:2 female:male ratio.

Attitudes to environmental sustainability

More people rated the importance of environmental sustainability higher in general than in the delivery of orthodontic treatment (Figure 2). Free text comments suggested that most of the respondents who rated environmental sustainability to be critically important felt a responsibility to act now to reduce the negative impact on the environment in order to positively affect our future generations.

‘We owe it to society to leave a legacy where future generations don't have to pay for the conscious omissions of their predecessors. Being conscientious shouldn't be seen as an inconvenience, but rather an expectation – like professionalism is integral to what we do, so should this be.’

A number of potential concerns were raised including the conflict between environmental sustainability and economic viability, insincerity in proclamations of support and the limited feasibility of change.

‘Too often, the ‘bottom line’ is the sole consideration in businesses. Environmental sustainability seems only to be considered if the bottom line will not be affected.’

‘I feel we all pay lip service to this issue’

‘Sustainability is important, but I don't think it's realistically achievable in all aspects of medicine/dentistry or life in general.’

The respondent who answered ‘Not sure’ provided an extensive and thoughtful answer, highlighting the complexity of the topic and issues around unintended consequences, hypocrisy and misinformation.

‘This is a vastly complex topic, but it is often over simplified and politicised. Agreeing with this statement is almost mandatory if you wish to be a ‘good respectable person’ in society. There is a degree of conditioning to ‘nudge’ people into making ‘good choices’. What are ‘good choices’, and who decides? What is particularly egregious is when politicians and celebrities lecture us ‘the plebs’ from Davos or the UN and then carry on swanning around in private jets and the like. The big problem is the law of unintended consequences. This can be surprising and lead to unforeseen sequalae, just one example; there are a load of children who have been told that basically ‘we are all going to die as us bad adults are wrecking the planet’. What does this do to the psychology of children who are impressionable and aren't mature enough to assess a complex question… I am not saying these aren't legitimate issues but there is a lot of misinformation by the ‘important people’ which has had a massive effect on how the debate (sorry opinion control) is framed and therefore action needed that has had a massive effect on our lives’

When asked about the importance of environmental sustainability in relation to orthodontics, many identified key issues in orthodontics such as non-essential treatment, travel, use of plastics and unnecessary waste.

‘Environmental sustainability should be considered for everything but especially non-essential treatments such as straightening teeth’.

‘This reflects my opinion that there are more important things than straight teeth and without a world for the next generation to grow up in, a large proportion of orthodontic treatment becomes inconsequential. I think we need to gain some perspective and stop jumping on a bandwagon that buys in to a perfect appearance creating a perfect life. We would do better to develop healthier attitudes to ourselves, others and the world.’

‘Increased use of aligners and in the wake of the pandemic there is now an unprecedent amount of disposable waste in ortho.’

‘We have lots of waste and a high carbon footprint for travel.’

There was some concern related to the amount of importance regulatory bodies place on environmental sustainability and the lack of meaningful system change led by government.

‘Ask the CQC whether they are sustainable. They don't care about sustainability.’

‘without government intervention on an international industrial global level in renewables and true carbon taxation and without a significant culture shift in recycling and reduced consumption across the entire first and second world, we will be virtue signalling at worst and salving our conscience at best.’

When asked whether it is important to consider the environmental impact of different treatments when discussing options with patients, 48% said ‘Yes’, 24% said ‘Sometimes’ and an equal proportion said ‘No’ or ‘Unsure’. Although the question explicitly acknowledged that this information is not yet available, a number of respondents expressed concern about being able to provide this information accurately. Many respondents felt a discussion about environmental impact could form part of an informed decision-making process but the risk of including this information without understanding how it could affect choice was highlighted.

‘As part of informed consent and shared decision-making, if there is a significant environmental difference between the two options, then yes it should be discussed.’

‘I think it is an important area to explore but before we include this information, I think we need to understand what the unintended effects of this conversation might be e.g. make people refuse treatment out of guilt.’

For those who did not feel it should be discussed or were unsure, concerns included the impact on the complexity of treatment discussions, disbelief that treatments may vary in environmental impact, a belief that clinical outcome should be prioritized, and a belief that other changes would be more beneficial.

‘You need to read the person as at the end of the day you are running a business and need to listen to your patients. Generally I find that you need to find ways to counterbalance the treatments that impact the environment badly as whilst there is a lot of plastic waste with aligners, the patients need fewer appointments, and hence travel less miles for their appointments, you use fewer instruments and hence sterilise fewer instruments etc..’

‘I think the optimal orthodontic outcome and efficient mechanics are the overriding considerations but the manufacturers of aligners need to be put under pressure to recycle their waste.’

‘Can't see how a significant impact on the environment can be achieved by different treatment modalities. Changes should be made at practice level, energy usage etc rather than thinking about different treatments.’

Perceived importance of different environmental strategies

The ratings given to the importance of different environmental strategies are summarized in Figure 3. Most support was expressed for reducing the use of plastics and single-use items, recycling consumables, rethinking waste management and legislation and policies, and green procurement. Comments indicated some awareness that travel is a significant contributor, but difficult to address.

‘Staff and patient travel has the biggest impact on the environment according to a webinar I listened. Though this is hard to believe when you consider the huge impact of clinical waste and rubbish there that is produced on a daily basis, day in, day out!’

‘Staff and patients should not be told how to travel!!!!!!!’

‘How can we make more sustainable travel with practical insight. It is a novel idea but looking at our transport system it is not quite possible in next 15–20 years in reality.’

The environmental impact of current UK cross-infection requirements was highlighted as a potentially important area.

‘The excessive and unnecessary decontamination procedures mandated in the U.K. are the single biggest waste of energy money and materials in the delivery of orthodontics in the U.K. washer disinfectors in particular burn enormous amounts of energy and are completely unnecessary.’

‘I see no evidence of environmental risk:benefit analysis in the current cross-infection control regulations… I cannot believe that there is any significant increased benefit to patients or reduction in cross infection risk with this. However the financial and environmental cost is huge.’

Practice and policies

Knowledge about specific workplace policies and practices was variable (Figure 4). Policies most commonly related to recycling consumable, staff travel and waste management, while practices most commonly related to reducing single use plastics and paper, recycling consumables and sustainable travel.

Discussion

The results from this survey demonstrate that there is complexity in attitudes to environmental sustainability. For the majority, it is an area that people appear to be passionate about because they feel it is both a professional and personal responsibility to ‘take action’. A strong sentiment was expressed around legacy, with people emphasizing that preservation was important for future generations. These findings reflect public opinion expressed in a 2021 Office for National Statistics (ONS) survey, which found that three-quarters of respondents were worried about climate change and were particularly concerned for future generations.¹³ There was, however, also recognition in both our survey and the ONS survey that it can be challenging to make meaningful changes and there can be a sense of helplessness where people feel unclear where and how to take action. Orthodontists reported that their perceived lack of control arose from a lack of knowledge, but also from a reliance on higher bodies to approve changes and restrictions caused by bureaucracy and red tape.

Hypocrisy in messaging by organizations, government and key figures about general climate issues was highlighted by respondents, as well as frustration towards the lack of leadership by dental regulators, such as the Care Quality Commission and General Dental Council. Concerns about hypocrisy and virtue signalling are commonplace in mainstream media, for example, ‘champagne environmentalism’ from celebrities and leaders and the fallacy of ‘eco-leadership’. Discordance between talk and action by prominent individuals and bodies can be highly damaging because it can lead to guilt and shame, disengagement, false beliefs and distraction from the important messages.¹⁴ Knowledge does not necessarily always reflect in actions,¹⁵ highlighting the need to bridge the gap between simply knowing and implementing knowledge.

Unintended negative consequences from environmental sustainability messaging were raised by respondents in terms of the potential effect on individual choices or behaviour, but also on businesses. A recent literature review examining sustainability messaging in advertising discussed the complexity in effectively creating and delivering information for people with different beliefs.¹⁶ A large survey in the United States found that emphasizing the role of climate change in natural disasters may engage those who already believe in climate change, but at the same time cause greater resistance from climate change sceptics.¹⁷ These papers demonstrate the need to engage stakeholders when developing communications about controversial or emotive topics.

The same careful thought is required when deciding if, when, and how orthodontists should discuss the environmental impact of orthodontic treatment with patients. Reducing demand is a key principle in environmental sustainability, however, the discussion about whether a treatment is justified is complex and must take into consideration the individual's concerns and preferences, combined with clinical judgement and knowledge of the effectiveness of treatment.¹⁸ The relative benefit of treatment varies between individuals and depends on both objective oral health benefits and subjective psychosocial gains, but this information is not always easy to elicit to determine whether a treatment is strictly ‘necessary’.

Studies on the environmental impact of dentistry^19,20 highlight that research has the potential to influence the decisions we make and encourages discussions about sustainable measures with patients and other stakeholders. A study by Baird et al investigated the public's attitude to sustainability in dentistry and what personal compromises people would be willing to make.²¹ The study showed a generally positive attitude to more sustainable practices in dentistry and indicated an openness for discussion. The study, however, acknowledges that theoretical willingness to make compromises may not reflect in actual behaviour. In other disciplines, such as financial investments and policy-making, the impact of including environmental information on hypothetical or observed decision-making has been investigated.²² No studies investigate the actual decisions made by patients following discussions about the environmental impact of dentistry and orthodontics. Research in other sectors has shown public pressure can be a driver for change,²³ therefore, measuring the impact of including environmental information on patient decisions about dental care and specifically orthodontic care could be an interesting and important area for future research.

The research to date in sustainability in healthcare shows that one of the most significant negative environmental impacts is the carbon footprint – a term used to describe ‘the sum of greenhouse gas emissions (carbon emissions) released in relation to an organization, product or service’.³ Research suggests healthcare is responsible for up to 5% of global greenhouse gas emissions.²⁴ Within the NHS in England, dentistry is accountable for 3% of the overall carbon footprint. Some of the biggest contributors to greenhouse gas emissions are patient and staff travel and for ‘resource intensive treatments, procurement’.³ There are no specific data related to the contribution of orthodontics, but it has been reported that within dentistry in the NHS, travel is accountable for around 65% of the carbon emissions.²⁵ In this study, however, when asked to comment on barriers to implementing change, there were relatively few comments about changing patient and staff travel. There may be a number of reasons for this. First, it may be that while general societal awareness about travelrelated carbon emissions is anecdotally high, translation into the working world is not as pervasive. Alternatively, awareness about the relative contribution of different pollutants in the dental and orthodontic world may be less known or understood, or clinicians may feel that there are other more important to areas for change.

The perceived or experienced barriers to making changes related to three main areas. The first was along the theme of reduce, reuse, recycle and rethink (the 4Rs). Under ‘reduction’ many highlighted the need to reduce (1) packaging, (2) the use of single use instruments and (3) the use of plastics (including single use plastics). Many also reported that recycling was a desirable change. Comments on recycling centred on plastic aligners, packaging and non-clinical waste management. The expressed feelings of some of the respondents highlighted the challenge of the 4Rs in modern day orthodontics.²⁶ Some commented on the dilemma of whether recycling uses more or less energy compared to decontaminating a reusable item. Research about the environmental impact of using single use compared to reusable equipment has shown that reusing instruments is of greater environmental benefit.^5,27,28 These studies do not, however, comment on the environmental effect of recycling disposed instruments compared to reuse following decontamination. It can be argued that recycling contaminated complex plastics can be an onerous or even impossible task of dental waste and adequate infrastructure for waste segregation does not currently exist. Other factors to consider include availability of local facilities for recycling and local policies and attitudes.^6,29 It is accepted that in certain situations, currently some components may not be recyclable, for example the plastic tubes of toothpaste.³⁰ Martin et al highlighted practical ways to recycle more effectively.¹² This incorporates thinking about the items we choose to purchase. The ‘Consensus on environmentally sustainable oral healthcare: a joint stakeholder statement’ highlights that recycling can be facilitated if there is thought in the life cycle of equipment, including manufacturing of equipment which may be easier to recycle.³¹

The two other main barriers to sustainable changes were cross-infection control policies and the perception of governing bodies and managers. There were many comments that current cross-infection procedures and policies are not environmentally sustainable. Comments such as: ‘

exemplify the challenge in healthcare. On the one hand there is the need to protect patients and staff from communicable infectious diseases, and on the other, there is the detrimental effect of infection control regimens on the environment. An example of the conflicting challenge in England is the infection control guidance ‘HTM 01–05 Decontamination in primary dental practice’, which focuses on cross-infection control with no consideration for sustainable practice. Our results highlight that more work needs to be to design and implement frameworks in which safety and sustainability are considered alongside each other.

The perceived lack of cohesion between clinicians and their governing bodies found in our survey emphasizes clinicians’ desire for more responsibility to be accepted by all parties including industry, government, professional bodies, patients, staff and educators. Other authors have similarly identified a perceived lack of encouragement from curriculum regulatory and governing bodies;³² work is underway to help make an impact across all sectors.³¹ Education of all stakeholders at all levels is crucial, including at an undergraduate level. The recently updated intended learning outcomes for the undergraduate dental and dental therapy curriculum³³ include the requirement to consider sustainability as part of dentistry, and work undertaken to incorporate sustainable measures on a postgraduate level³⁴ are pivotal in making a positive environmental impact. Sharing common goals in relation to environmental sustainability can facilitate this change.³⁵ There is value in further exploring whether and how management systems empower clinicians to make positive changes towards environmental sustainability.

Future direction

This study provides some preliminary data about opinions and practices in orthodontics, but there are many avenues that could be pursued from here. First, it is important to understand the perspective of other key stakeholders, including managers and leaders, commissioners and policy makers, industry, and patients and families. Together this information can be used to inform policy and action. Secondly, it is important to understand effective messaging and how communication about environmental issues and solutions can lead to the desired change. Finally, there are opportunities for practical support to help the orthodontic team to identify their own goals, select appropriate strategies, devise implementation plans and evaluate the outcome.

Conclusion

Orthodontists appear passionate about environmental sustainability, but a number of barriers limit their ability to make meaningful changes in practice. This study provides preliminary information about awareness, attitudes and behaviours of orthodontists, which is useful for generating questions for future research.