DT News - Canada - Is digital dentistry the solution to the sustainability dilemma?

Dr Les Kalman

Mon. 15 May 2023

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I think we can agree that dentistry is not the most environmentally friendly profession. Just take into consideration the number of single-use materials such as plastics, stone and plaster, barrier protection, and, of course, personal protective equipment. Are they all necessary to maintain the standard of care and appropriate infection control? Now, consider the steps in a typical analogue workflow for an indirect restoration. The impression is taken, boxed up, sent by vehicle to the laboratory and poured up. The crown is fabricated and sent back to the clinic, again by vehicle. Is this sustainable? I believe that we have tools at our disposal that can help improve the workflow and the environmental footprint.

The evolution of digital dentistry has had a significant impact on the dental profession. The acquisition of digital intra-oral impressions, scanned impressions and models has improved efficiency, accuracy and the clinical workflow. But what about sustainability? Is taking an analogue impression and sending it to a laboratory by vehicle more environmentally damaging than sending a file digitally? The digital method would immediately reduce carbon dioxide emissions; however, it would be necessary to consider the sourcing of all the materials and the fabrication of all the components required for the digital transfer based on the total cumulative energy demand throughout the life cycle of a product.

What impact does digital design have on sustainability? The analogue workflow would require impressions, casts, registration and an articulator to design and develop the prosthesis. The storage of models must also be considered. This requires physical space and utilities compliant with regulatory requirements. Digital design has a completely different workflow, allowing image capture, cloud storage, visualisation and planning on a device, all done remotely. It also provides a simple approach for design modifications and remakes.

What impact can the output or fabrication of dental prostheses have on sustainability? Initially casting required investing, melting and significant finishing and was heavily reliant on materials and time. Milling provides an accurate and predictable workflow but has limitations on design and sustainability.

How does additive manufacturing (AM) or 3D printing fit into the equation? There are a multitude of AM processes that provide accurate and efficient prostheses in plastic (resins), metals and ceramics (zirconia and lithium disilicate). These approaches can create any geometry and typically offer superior accuracy and improved sustainability. Additionally, recent research has quantified that the AM workflow is more sustainable than conventional fabrication pathways. A further advantage is that prostheses made digitally offer impressive physical properties.

The possibility of bypassing digital design by using indirect onlay restorations has also been explored. This would be a novel approach that could save an enormous amount of time, money and resources. And this is just the beginning, since artificial intelligence is already having an impact on diagnosis and treatment planning, and virtual and augmented reality are being used for education and training. Another factor to be considered is the developing metaverse.

However, digital dentistry comes with a significant caveat: the user must have an excellent understanding of its applications and limitations in a clinical setting. After all, digital dentistry provides another set of tools in the dentist’s toolbox. Clinicians must know which tool to use and when. For example, there was a recent report of a clinical full-arch implant case which included a bone reduction guide and a guide for implant placement. Both were acquired through a fully digital workflow. Unfortunately, during the surgical session, neither guide fitted well, and the clinician had to detour to a free-hand approach. Kudos to the clinician for realising the errors, but what an unnecessary environmental impact and waste of time and money!

“Digital dentistry provides another set of tools in the dentist’s toolbox”

I have heard similar stories where the implant surgical guides did not fit intra-orally owing to the patient’s limited mouth opening—another unfortunate situation in which digital dentistry was improperly used.

The last scenario I will highlight concerns a clinician who bought a 3D resin printer to complement his intra-oral scanner. In this case, all patients received a diagnostic scan and printed models for educational and marketing reasons. Is this an appropriate use of digital dentistry? How does this reflect sustainability? What happens to those models when the patients have no use for them? Are they recyclable? This scenario reminds me of that meme where a gas-powered generator is being used to charge an electric vehicle.

If we collectively strive for dentistry to have improved sustainability, we must consider the entire picture. Here are a few recommendations for implementing digital dentistry as related to sustainability:

consider the clinical workflow and assess how sustainability can be improved without compromising the standard of care;
understand and follow the fundamentals and principles of digital dentistry. It is merely a set of tools to improve the workflow;
be curious and explore new technologies;
be critical. For example, consider whether a fully guided case is essential;
consider a hybrid or fused workflow, combining the best aspects of analogue and digital, until there is a strong grasp on predictable digital workflows; and
exercise the Rs: recognise, reduce, recycle, repurpose, rethink and rejoice!

Digital dentistry is a strong technological tool that can help dentistry become more sustainable. However, dental professionals have to ask the right questions, perform due diligence and make appropriate decisions that benefit patients and the planet.

Editorial note:

A list of references can be obtained from the publisher upon request. This article was published in digital—international magazine of digital dentistry vol. 4, issue 2/2023.

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