Sustainability in Orthodontics: what can we do to save our planet?

ABSTRACT The sustainability of the natural resources of our planet is a topic for worldwide debate. Mankind, during its evolution as a species, has not been greatly concerned about conserving the environment in which we live. Nowadays we are reaping the fruits of this neglect. Climatic changes and storms are good examples of this. We, humans, must re-think our attitudes in order to leave the planet in a healthy state to be used by our descendants. But thinking of orthodontics, what can we do as orthodontists? From this perspective, the authors of the present study aimed, in a clear and objective manner, to present simple and sustainable ways to proceed during our activity as orthodontists, in order to minimize the effects on nature, caused by man.


INTRODUCTION
There is eminent need for greater concern and care with regard to the management of human resources and environmental impacts arising from human activities. 1,2 From November 30 through December 11, 2015, several Heads of State of diverse nationalities met in France, during the 21st United Nations Climate Change Conference, (COP21) to discuss strategies for minimizing global warming, CO 2 emission and the use of environmental resources.
The relationship between health and ecology has, over the last few years, become an important topic to researchers in quest of measures for the preservation of life on the planet. 3,4 In this scenario, dental practice not only interacts in oral health-disease, but generates solid health residues that include heavy metals and biomedical waste potentially harmful to the environment, leading to growing concern about the management of these residues. 5,6 Therefore, arising from these factors is sustainable dentistry, which implements sustainable practices for maintaining the level of consumption of resources in harmony with the economy of nature, diminishing the environmental impacts by reducing or eliminating the dejecta and chemical products released into the environment. 3,7 The four processes responsible for the largest portion of waste and pollution from dental practice are: use of materials containing mercury (amalgam fragments and waste -mercury vapor release); conventional X-ray systems (equipment, film, silver fixer, insoluble developer solutions); infection control methods including disposable barriers, toxic products for sterilization and disinfectants; conventional vacuum saliva suction systems. 8,9 Thus, green dentistry is based on the model of four-Rs: rethink, reduce, reuse and recycle. 10 Thus, the authors' proposal in this article is to clearly and objectively present strategies that we, as orthodontists, could implement to make our clinical practice more sustainable, and consequently reduce devastation of the planet.
What should we do?
The first step towards practicing sustainable dentistry consists of rethinking consciousness and attitudes; changing the way in which the dental office is seen; implementing simple changes by taking into consideration that this is a continuous process. In addition, the team must be trained, with each member doing his/her part and knowing the sustainable practices. 7,11 This includes the manner in which the dental office is planned or when it is being refurbished. At this time, the plan should seek: to make maximum use of natural light; opt for materials with organic constituents; equipment and lighting with the lowest electrical power consumption (fluorescent or LED lamps). Another good option would be the use of solar energy that in addition to being a clean source of electrical power, will reduce the value of the bill.
Thus, sustainable practice in the dental office begins right from the time patients enter the reception, until the time of their clinical attendance. Therefore, the reception room must undergo changes for improved sustainable practice, thus diminishing the volume of trash generated by disposable materials. Other practices such as cleaning the air conditioner filters; use of a rain water collection system; use of motivational stickers against wasting water; use of a toilet basin that saves water. These are important items for performing eco-friendly dentistry. Table 1 illustrates how some habits are carried out in the reception room; how sustainable practice must be performed, and the benefit this brings to the environment. In the restrooms of the reception as well as in the reserved to the professionals, sustainable practice must also be inserted as demonstrated in Table 2. In the dental office itself, the use of lighting components is responsible for high electrical power consumption, therefore, when thinking about sustainable alternatives we are not only reducing the energy expended, but we are also saving money.
Moreover, there is a great use for uncontaminated solid residues, such as the use of disposable materials and sterilization items. Inadequate management at the time of discarding them is responsible for exacerbated trash production; therefore, it is essential to implement sustainable practices to diminish the quantity of trash produced, or for better re-use of these materials. Table 3 illustrates sustainable practices related to the sterilization process.
If water and energy consumption is not properly managed it will be responsible for eminent risks to the environment. Table 4 illustrates how sustainable practices in the dental office's consulting room may replace habits that are harmful to the planet, and what benefits come from it.    This is only one example of what we could do during our attendance. Table 5 presents other ways of performing orthodontic treatment in a sustainable manner, bringing benefits to our planet without affecting the efficacy of orthodontic treatment.
New sustainable practices can and must be added to the list described here, so that the quest for sustainability will be a constant among all of us in the practice of the profession.

Sustainable orthodontics
In orthodontic practice, it is also necessary to adopt means that reduce aggression to the environment. The materials used in orthodontics must be re-thought and chosen based on the environmental impact they may cause. Use of self-etching adhesive systems, for example, dispenses the washing step required when conventional adhesive systems are used; thus reducing water consumption in this procedure. Table 4 -The benefits arising from a sustainable practice in the dental office consulting room. Table 5 -How it is done, what must be done, and the benefits arising from a sustainable orthodontic practice.

What is done Sustainable practice Benefit
Orthodontic accessories sold in conventional packaging Brackets sold in receptacles with a larger quantity of accessories, with these receptacles being manufactured of a recyclable product Elimination of packaging made of plastic materials, being replaced with biodegradable materials (Fig 1).
Adhesive systems with acid etching Self-etching adhesive systems 13 Lower water consumption due to no need for washing and drying, with same clinical efficacy Conventional brackets Self-ligating brackets 14 Less chair time and eliminates the use of elastomers

CONCLUSION
Thus, it can be perceived that from individual and collective consciousness of the team, the practice of sustainable orthodontics, protecting the environment, is possible; saving money as well as the environment, helping in recovering the planet by reducing the environmental impacts generated by its practice, here including the care taken with the use of natural resources. Figure 1 -Orthodontic material packaging that will become garbage.