29 Oct Single-Use Plastic in Dentistry | Getting to the Root of the Problem
Do single-use items cause unnecessary pollution?
A few weeks ago, Pearl Dental Software posted a link on social media. The link took you to a story being run by the BBC about the number and volume of singe use items being used in dentistry. This story generated quite a bit of interest, so I’ve taken a look at what we as dental professionals could realistically do to reduce this. And while we could make great progress, in the short-term, it’s not good news.
There are two types of single-use item in dentistry – ‘disposables’ and single-use instruments. Let’s start with what we’ve termed ‘disposables’.
Disposable items are things like PPE (gloves, masks, cups, aprons, bibs, etc.), pouches and cleaning materials (tray liners and wipes). Their use is largely bounded and mandated by legislation and standards, such as HTM01-05 (revised 2013). So to avoid using them would require dental professionals to ignore these fundamental rules.
Unfortunately, these rules have been developed over many years to enforce patient and staff safety. Without them in place, it would be impossible to safely treat a patient who might be carrying HIV or Hepititus, or any other blood-borne infection.
And because we treat every patient equally, that effectively means ANY patient.
What happens to our waste now?
Clinical waste is disposed of by incineration. This ensures that all organic compounds, including plastic, blood and pathogens, are completely destroyed. The process creates waste products of its own – carbon dioxide and carbon monoxide from the fuel used to create the necessary heat, and further carbon dioxide, carbon monoxide and other gases from the oxidation of the waste. All that’s left is ash and the remnants of metal components.
Sharpes are also incinerated, but they are separated because they are obviously more dangerous to handle, and also more likely to be contaminated. However, because they are more likely to contain metals, it is theoretically possible that some of those metals can be reclaimed and recycled.
Most of these items are made of plastic. Unfortunately, the term ‘plastic’ covers many very different materials, and even more versions of the same materials made to different specifications. To be recycled, these materials would need to be separated.
For instance, Latex (as used in gloves) might refer to a material made from natural rubber, or it could be made by polymerizing a monomer such as styrene (I hope you did GCSE Chemistry). But gloves may also be made from an entirely synthetic material such as neoprene (produced by polymerization of chloroprene).
So with just one item one on our list we’ve hit a problem. Even if we separate gloves (which to be fair, we use a lot of) from other waste, any waste disposal system in place to recycle them has to be able to;
- Deal with them safely as they are clinical waste and carry an infection risk
- Be able to identify and separate gloves of different materials into compatible groups so hey can be recycled
- Not take up too much time, space or money as to be impractical for surgeries to get involved in their recycling
- Find a use and a market for the recycled product
Now multiply that across all the other ‘disposables’ used in surgery and in decon. Pouches (for example) would need two separate bins (for the clear section and the backing) even if every pouch in every size were made the same way using the same two materials – which they are not, by the way.
Recycling metals reclaimed from incineration is not without its problems either. Although some metals such as tungsten and gold are relatively valuable, they are mixed in with larger quantities of aluminium, stainless steel, copper, and a vast range of alloys (materials made by mixing two or more metals together). Separation and recovery processes are therefore complex and expensive.
So at the moment, I think there is very little room for reduction or recycling of items we’ve classed as ‘disposables’.
One of the problems with single-use instruments is that they are designed for that single-use only. The choice of materials and the design makes them impossible to re-sterilise, so they must be disposed of. So when it comes to instruments, we have to look at why they are made to be used only once.
There are two reasons for single-use instruments;
- They are used within the pulp cavity and therefore reuse would carry a risk of resilient infections such as CJD (Creutzfeldt–Jakob disease)
- They are cheaper than reusable versions of the same instrument
The horror of CJD
Although it’s widely accepted that you can’t re-use and re-sterilise instruments used within the pulp cavity, it may not be obvious why. The answer is CJD. CJD is a rare and fatal condition that damages the brain, rapidly worsening over time.
The CJD crisis reached its peak only around 10-years ago, and Britain was at the epicentre of this horrific disease. About 220 cases world-wide were recorded, 170 of them in the United Kingdom. It’s control required huge changes in farming, meat production and surgery of all kinds – including dentistry.
As a result, any dental instrument that enters the pulp chamber, and therefore could come into contact with nerve tissue, should be destroyed as CJD is known to survive normal dental sterilisation procedures.
But what about instruments that are disposable because they are cheaper to make that way? Well, the problem is usually again plastic.
The cost of plastic is cheaper then metal. By replacing parts of the instrument with plastic, instrument makers can make instruments that are cheaper to buy new than it costs to run the autoclave and re-sterilise them.
But we re-sterilise some plastic instruments, right? Yes, we do. But see my point above. Plastic is a generic term for many synthetic materials that have widely varying properties. Some can be very heat resistant. Some are actually intended to distort in heat. And some become brittle and therefore unable to carry the load they were originally designed for. That means if you put them in an autoclave you have no idea what will happen the next time that instrument goes in a patient’s mouth.
So how do we improve our ‘plastic footprint’?
I think the BBC’s story throws down a real challenge to Dentistry, and it’s one that we must respond to. But it also shows, as I hope this article does, that there are real limitations in what we can currently do.
For example, when nursing, at the end of the day I currently have to take three separate types of waste to the collection point. If we were to recycle the separate types of plastic we use, I would have to take dozens of bags and make sure they were all properly sorted and separated.
Because I nurse in many locations, I know that some sites might be able to physically do this, but many simply don’t have space. And anyway, why should I have to spend even longer clearing up than I do now?
I think the answer has to come from regulation.
As I said above, many of the items that are single-use are effectively mandated by HTM01-05 and similar regulations. But they only look at one side of the coin, implementing cross-infection controls to reduce the risk of cross-contamination and control disease. They don’t look at reuse and recycling from an environmental perspective.
Perhaps the simplest thing to do would be to mandate (where possible) instruments that can be reused are designed to actually be reused, therefore eliminating unnecessary single-use instruments. This would obviously incur a cost for the practice, but if it’s implemented everywhere in the UK, how can anyone truly object?
More complex would be to mandate standards for materials used in ‘disposables’.
If we reduced the number of different types of plastic used it would be possible to improve recycling rates. If they had some sort of colour coding, it would be easy to sort them. And in fact, it might be possible to automate sorting during waste handling rather than in the surgery. My father-in-law is a (retired) packaging technologist and thinks this is entirely possible (and father-in-law knows his plastics).
Unfortunately, the dental supply industry is massively fragmented, and our governing bodies do not seem very excited about dealing with this problem. But it would be great if someone in a position of influence could take a stand on this issue and make some progress.
Our plan is to continuously develop Pearl Dental Software, and we will continue to add options and improve the automation features in future releases. We are also building an ‘ecosystem’ of like-minded specialist dental suppliers, and look forward to being able to recommend a ‘dental supplies’ business with innovative and practical support for reduced environmental impact.
PearlPad is an additional software option included in our standard subcription (you only need to purchase a Windows Tablet- your subcription won’t cost more to use them). If you already run Pearl Dental Software you can add PearlPad by simply calling the Support Team who will switch-on the appropriate options and talk you through the simple set-up routines.
We are always finding new ways to save on paper by extending features within PearlPad into other areas of practice management and the patient journey. We’re also looking at ways to add paper saving features into the main program itself, a recent addition being automatic feedback forms emailed to patients at the end of treatments rather then filling them out on paper at the practice.