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Journal of the

American Collegeof Dentists

Sustainability

Summer 2018

Volume 85

Number 3

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A publication advancing excellence, ethics, professionalism,and leadership in dentistryThe Journal of the American College of Dentists(ISSN 0002-7979) is published quarterly by the American College of Dentists, Inc., 839JQuince Orchard Boulevard, Gaithersburg, MD20878-1614. Periodicals postage paid atGaithersburg, MD, and additional mailing offices. Copyright 2018 by the American College of Dentists.

Postmaster—Send address changes to:Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

The 2018 subscription rate for members of the American College of Dentists is $30, and is included in the annual membership dues. The 2018 subscription rate for nonmembers in the United States, Canada, and Mexico is $40. All other countries are $60. Foreign optional airmail service is an additional $10.Single-copy orders are $10.

All claims for undelivered/not received issues must be made within 90 days. If the claim is made after this time period, it will not be honored.

While every effort is made by the publishersand the Editorial Board to see that no inaccurateor misleading opinions or statements appear in the Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, etc., herein are the responsibility of the contributor. Accordingly, the publishers and the Editorial Board and their respective employees and officers accept no liability whatsoever for the consequences of any such inaccurate or misleading opinions or statements.

For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, number, and page. The reference for this issue is:J Am Col Dent 2018; 85 (3): 1-44.

Journal of the

American Collegeof Dentists

Communication Policy

It is the communication policy of the American College of Dentists to identify andplace before the Fellows, the profession, and other parties of interest those issuesthat affect dentistry and oral health. The goal is to stimulate this community toremain informed, inquire actively, and participate in the formation of public policyand personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promotespecific views at the expense of others. The positions and opinions expressed inCollege publications do not necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists

THE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop good human relations and understanding, and extend the benefits of dental health to the greatest number, declares and adopts the following principles and ideals asways and means for the attainment of these goals.

A. To urge the extension and improvement of measures for the control andprevention of oral disorders;

B. To encourage qualified persons to consider a career in dentistry so that dental health services will be available to all, and to urge broad preparation for such a career at all educational levels;

C. To encourage graduate studies and continuing educational efforts by dentistsand auxiliaries;

D. To encourage, stimulate, and promote research;

E. To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

F. To encourage the free exchange of ideas and experiences in the interest of better service to the patient;

G. To cooperate with other groups for the advancement of interprofessionalrelationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge theacceptance of them;

I. To encourage individuals to further these objectives, and to recognizemeritorious achievements and the potential for contributions to dental science,art, education, literature, human relations, or other areas which contribute tohuman welfare—by conferring Fellowship in the College on those personsproperly selected for such honor.

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Sustainability

5 Sustainable Dentistry: A New Dental EthicBeverly Oviedo, MS

8 The Business Case for Sustainable DentistryBob Willard, PhD

15 Sustainability in Dentistry: Construction of a New ParadigmClaudio Pinheiro Fernandes, PhD

23 Full Sustainability in DentistryRobert “Tito” Norris, DDS

27 Attaining and Strengthening Sustainability in Your Dental Practice:A System-Oriented Thinking, Approach, and RealizationWilhelm Wang, MD

33 Aligning Values and Business Strategy to Achieve Organizational Change: Using The Five Ps to Embed Sustainability in Your Dental PracticeSheila L. Margolis, PhD

Gies Ethics Project

38 The ADA News and ADA MembershipDavid W. Chambers, EdM, MBA, PhD, FACD

Departments

2 Guest Editorial What’s Wrong with Alice?

4 Readers Respond Letters to the Editor

EditorDavid W. Chambers, EdM, MBA, [email protected]

Managing EditorTheresa S. Gonzales, DMD, MS, MSS

Editorial BoardR. Bruce Donoff, MD, DMDGreg Chadwick, DDS, MSBrook Elmore, DDSNanette Elster, JD, MPH Geraldine Ferris, DDSNancy Honeycutt, CAE Robert Lamb, DDS, MSD Richard J. Manski, DDS, MBA, PhDAlec Parker, DMD, PAPhilip Patterson, MA, PhD Carlos Quiñonez, DMD, MSc, PhDLindsey A. Robinson, DDS

Harriette Seldon, DMDRobert Sherman, DDSClifton Simmons, DDSRonald Tankersley, DDS

Design and ProductionAnnette Krammer, Forty-two Pacific LLC

CorrespondenceAddress correspondence relating to the Journal to: Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Letters from ReadersComments concerning any material appearing inthis journal are welcome at [email protected] should be no longer than 500 words and willnot be considered after other letters have already been published on the same topic. The editorreserves the right to refer submitted letters to the editorial board for review.

Business OfficeJournal of the American College of DentistsTel. (301) 977-3223; Fax. (301) 977-3330

OfficersRichard F. Stilwill, Jr., PresidentThomas J. Connolly, President-electStephen A. Ralls, Vice PresidentJoseph F. Hagenbruch, TreasurerBert W. Oettmeier, Past PresidentTheresa S. Gonzales, Executive DirectorDavid W. Chambers, Editor

RegentsMark A. Bauman, Regency 1David A. Anderson, Regency 2Barry L. Langley, Regency 3Richard E. Jones, Regency 4Charles F. Squire, Regency 5Robert M. Anderton, Regency 6Gary S. Yonemoto, Regency 7Lawrence R. Lawton, Regency 8Teresa A. Dolan, At LargeRobert A. Faiella, At LargeStephen M. Pachuta, At LargeLeo E. Rouse, At Large

Phyllis Beemsterboer, ASDE LiaisonMichael C. Meru, SPEA LiaisonMarcus K. “Ken” Randall, Regent Intern Cover image Is green the new color of dentistry?

© 2018 spyderskidoo, istockphoto.com. All rights reserved.

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evolved as materials we use continueto change with the development of composites, new materials forceramic crowns, and even 3D printedproducts. The regulatory environmenthas evolved as dentists are now subjectto many more rules governing theirpractices than in 1920. For example,gloves wouldn’t be mandated byOSHA in the United States until 1991and their use was even challenged by the ADA until a court decisionsupported OSHA’s position in 1993(ADA v. Martin 1993). Advertisingand business practices have changed,with dentists’ advertisements nowcommonplace across all media.Companies backed by nondentistinvestors are also present.

With all of this change in the dentalfield, how have dental organizationsevolved? One notable change is thegrowth in the number of dentalorganizations since 1920, as there arenow organizations catering to theneeds of a variety of clinical, business,and demographic interests. Thisinherently leads to greater competi-tion between organizations formembership and volunteer time andeffort. It also fragments the narrativethat dentistry tells the rest of theworld. On the other hand, specificmessages, interests, and initiatives can become the central focus of thatparticular membership. For example,

In Chapter 6 of Lewis Carroll’s Alice’sAdventures in Wonderland, Alice

comes to an intersection where shemeets the Cheshire Cat and has thefollowing exchange:

“Would you tell me which way I ought to go from here?”“That depends on where you wantto get to,” said the Cat.“I don’t much care where —,” said Alice.“Then it doesn’t matter which wayyou go,” said the Cat.“— so long as I get SOMEWHERE,”Alice added as an explanation.“Oh, you’re sure to do that,” said theCat, “if you only walk long enough.”This exchange is representative

of many situations found in society. Sure, Alice’s path may be eventful and fun, but solving the “where”questions is crucial to avoid walkingaimlessly through the winding pathsof life. The destination is often hard toidentify for individuals, businesses,and organizations. In many situations,including with the ACD Board, I findmyself returning to the followingquestions: Where are we now? Where are we going? How do weknow when we get there?

Where Are We Now?

As we all know, dentistry is a muchdifferent world than it was when the ACD was founded in 1920. Theclinical practice of dentistry has

2 2018 Volume 85, Number 3

Editorial

Guest Editorial

What’s Wrong with Alice?

Editorial

Ken Randall practices inChattanooga, Tennessee, and isthe current ACD Regent Intern;[email protected].

Another misconception,

in my opinion, is confusing

actions with results.


developments in management of sleepapnea are not and should not be thecentral focus of the American DentalAssociation, but specific organizationshave formed with furthering ourunderstanding of this subject as theirprimary goal.

The ACD was founded by a group of leaders who believed that“dentistry must look beyond todayand plan for the future.” The object of the organization at that time was“to elevate the standards of dentistry,to encourage graduate study, and togrant fellowship to those who havedone meritorious work.” (Graduatestudy referred to what we now know as continuing education orlifelong learning.) The vision for theorganization at the time was very clear,and strategic initiatives were carriedout by the leadership to further thatend. Multiple efforts were made overthe following decades to improvedental education and journalism. Inthe 1930s through the 1970s, advocacyefforts evolved to look at access to careand prevention. The 1980s saw ethicsbecome a primary focus of improvingthe profession, and those effortscontinue today.

Over the past 40 years, the ACDhas published multiple resourcesrelated to ethics in dentistry. Onechallenge we face is measuring whatimpact, if any, these efforts have hadon the profession. Can we concludethat dentistry as a whole is moreethical than it was in 1980? How doesone measure ethical conduct?

Where Are We Going?

The current mission statement of theACD is to “advance excellence, ethics,professionalism, and leadership indentistry.” How do we successfullyfulfill our mission? What happens in a perfect world if ACD is able tocompletely “solve” problems related toethics? Professionalism? Leadership?Would “solving” leadership issues in dentistry mean that all dentists(fellows and pre-fellows) hold electedoffices? Does the title one holds define leadership? Is it okay to have a spectrum of leadership skills in aperfect world? Defining the end goalis crucial to achieving it.

One of the challenges I observe inmany organizations, ranging fromgovernment to national dental organi-zations to local nonprofits, is that ofachieving results. Most organizationsstate that they have a mission orpurpose and are happy to talk about it.The challenge becomes defining atangible vision and putting the wordsinto results. Another misconception,in my opinion, is confusing actionswith results. Actions are events thatoccur (e.g., speaking to a group ofdental students, hosting a fundraiser,etc.). Results are what happens as aconsequence of those actions.

In the case of the ACD, we cancertainly continue shouting ourmission statement and feel good thatwe support “excellence, ethics,

3Journal of the American College of Dentists

Editorial

professionalism, and leadership indentistry.” If we really want to achieveresults, we need to further envisionwhat results we want to achieve. Oncethe vision is concrete, actions becomemore directed and more impactful. We can walk forward with purposeand avoid having to ask the CheshireCat which way to go.

How Do We Know WhenWe Get There?

I would welcome your comments on measurable results for which theACD should look to achieve at thenational, regency, and individual levels.The ACD Board is concerned aboutthis as well.

Without knowing where we’regoing as an organization, it’s easy tokeep walking without reaching aworthwhile destination. A commontheme across many organizations ishaving discussions and producingcontent without having any measurableoutcomes to determine whetherefforts have been productive. In orderto make an impact on society for thegreater good, remain relevant in achanging world, and better supportour fellows, the ACD looks forward to answering these questions andwalking with purpose toward adefinable destination.


To the Editor:

According to the paper by MarcAckerman in the spring 2018 issue ofthis journal, teleorthodontics desiresto claim its throne as dentistry’s“disruptive technology.” Why wait forlegislative changes to approve a newbusiness model, when it’s easier tocircumvent regulatory compliance and argue that they don’t apply, whenchallenged? The corporate world’sinsatiable thirst for dollars was notsatisfied by the revenue streamscoming from orthodontics and generaldentists, so now they want directengagement with patients.

If access to care is the primarydriver for these new ventures, thenwhy open teleorthodontics centers incities where patients already haveaccess to many orthodontists?

Yes, teleorthodontics can improveaccess for some, and will allow for acheaper alternative by eliminating the middleman, but at what cost topatients and to our profession?

Aligner technologies were adoptedas the standard of care by the laypublic because skilled and trusteddental professionals introduced thetechnology and then stood behindtheir results, knowing they could

provide other corrective options, ifnecessary. We let the genie out of the bottle. As a profession we haveaccepted that a Class I occlusion,devoid of interferences with jointsseated in their most superior position,is no longer the standard of care fororthodontic patients. Teeth aligned

in the arch of a patient that canaccommodate to a new occlusion isnow acceptable. Dentistry has allowedpatients and corporations to dictatewhat is tolerable, instead of articulatingthe limitations of alignment dentistryand demanding better results fromthese modalities. We bent ourstandards to conform.

Individuals should realize they arebypassing the traditional dental modelby taking impressions in the privacy of their own homes and mailing themoff for aligner fabrication. Theseindividuals assume the risk byagreeing to follow a recommendedtreatment protocol, which mayinclude documenting the case withselfie posts on social media. Ourprofession should, however, take issuewith other forms of teleorthodonticsin which salespeople in alignmentstorefronts, mistaken for “providers,”are taking digital scans of patient’steeth, then outsourcing the alignment

configuration to an undiscloseddentist, hidden from reproach.

As a profession, do we feel patientshave a right to pretreatment exams,disclosure of findings, a diagnosisfollowed by proper informed consent,and treatment options, includingdoing nothing? Do we want to allownondentists to file dental claims andaccept payment without providerdisclosure or license status revealed?What recourse is available toteleorthodontic patients whentreatment does not produce desiredresults or if they are harmed?

Orthodontists and dentists arebound by the Hippocratic Oath andsubject to sanctions from the stateboard of dentistry and the legalsystem. Do state dental boards haveany jurisdiction over teleorthodonticentities? Do HIPAA laws apply tothese entities? Dr. Marc Ackermanwould have better served ourprofession by answering thosequestions and advocating for ateleorthodontic patient’s bill of rights,instead of professing a Trojan horseargument and poison pill. The freemarket dictates to corporations andMain Street economies, yet dentistrycontinues to be eroded by “in thename of access” policies. Why?

Dr. Dag ZapateroVirginia Beach, Virginia [email protected]


Letters to the Editor

Readers Respond

Letter to the Editor

We let the genie out

of the bottle.

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Beverly Oviedo, MS Seven years ago, Eve Cuny, thethen-Director of Environmental

Health and Safety at Pacific’s ArthurA. Dugoni School of Dentistry, and I approached ASTM International(American Society for Testing andMaterials), one of the world’s largestvoluntary standards organizations,about creating a standard for dentistrythat could help dental practitionersmitigate environmental issues relatedto the profession. Once we receivedASTM’s approval and established aworking group, this mission quicklyexpanded to incorporate the value ofsustainability as a whole instead of justone of its components. On May 1,2015, this standard received 100%approval by ASTM’s members andeventually culminated in the firstglobal conference for managingsustainability in dentistry, organizedby my nonprofit organization, HKAProjects for Sustainability. It has alsoled to this opportunity to collaboratewith the American College of Dentistson this journal project and featuresome of the speakers who presented atan international conference this yearin Reykjavik, Iceland.

So what is sustainable dentistry?To begin answering this question, let’sfirst define sustainability. According toFritjof Capra (2015), “sustainability”involves sustaining the self-regulating,living systems on which our long-termsurvival depends. It is taking a“systems view of life,” which holdsthat networks are life’s basic

organizational pattern and that ourmaterial world consists of threefundamental components: thematerial, the cognitive, and the social.When one adopts this systems-styleapproach to the living world, a meshof interrelated systems reveals itself.For example, humans live withinsocial systems and ecosystems, andeven have ecosystems nested withinthemselves. Underlying these systemsis the proverbial “breath of life,” ourmetabolism, which as Capra notes,maintains the continuous flow ofenergy and matter as well as produceswaste. This waste ultimately becomesthe food of other organisms, such asplants—hence the concept, “zerowaste.” For Capra, the issue ofsustainability is an ecological onewhere social institutions, such as thedental profession, need to align theiractivities to maintaining the intricateweb of life that supports this planet.

To reach this type of human-ecosystem equilibrium, orhomeostasis, however, the socialsystems need goals; they requirebenchmarking and models to achievethose objectives. In 1987, the UnitedNation’s World Commission onEnvironment and Developmentproduced a report titled, Our CommonFuture, also known as the BrundtlandReport. In this report, the UN


Sustainability

Sustainable Dentistry

A New Dental Ethic

Beverly Oviedo is Founder at HKA Projects for Sustainabilityand Sustainable Solutions byDesign, Monterey, California;[email protected].


generalizes Capra’s view by defining“sustainable development” as“development that meets the needs of the present without compromisingthe ability of future generations tomeet their own needs.” In 2015, theUN established a collection of 17sustainable development goals (SDGs)that it wanted to achieve by 2030.“Transforming our World: The 2030Agenda for Sustainable Development,”or the “2030 Agenda” for short, seeks to, for example, end poverty and hunger, conserve and restore ourenvironment, foster decent work andeconomic growth, and strengthenglobal partnerships to reach thesegoals (United Nations, 2015).

To the UN, the concept ofsustainable development rests on threepillars: the environment, the society,and the economy. For businessprofessionals, these three pillarsbecame the foundation for corporatesustainability and, consequently, anaccounting framework known as the“triple bottom line.” Unlike thetraditional bottom line in business that focuses on financial performance,the triple bottom line expands thisconcept to include social wealthcreation and environmental responsi-bility. By expanding this concept, theparadigm for organizations shifts from one that simply tries to appeaseshareholders to one that evaluates the actions of an organization basedon how they directly and indirectlyimpact all stakeholders. The beliefbehind this way of thinking is thatorganizations can create value andlong-term stability while stillcontributing to society at large.

Today, this framework has become the gold standard to which corporatesocial responsibility professionals tryto align their organizations’ activities.For the dental profession, the path toreaching these goals has also becomemuch clearer in recent years.

In 2017, FDI World DentalFederation decided to become a globalpartner to the UN and established itsown umbrella policy for sustainabilityin order to align the dental professionwith the goals established by the UN.They saw that the dental professionremained a silo while the social systemsof the world became increasinglyintegrated. Thus, in order for thedental profession to thrive in the 21stcentury, dental practitioners needed tocollaborate with more stakeholders,such as governments, manufacturers,and scientists, so that they couldreevaluate and modify their processesand practices. They needed toestablish a new ethic within thecommunity based on sustainability’sthree pillars; and, they needed tocreate a voluntary standard to helpdental practitioners realize that ethic.Fortunately, through ASTMInternational, our working group had already created that road map.E3014-15 is a management systemthat provides a framework forintegrating corporate socialresponsibility into the organizationalcultures of dental organizations.

To better explain how thismanagement system operates, we need to first grasp the concept of“sustainable dentistry.” Sustainabledentistry is when a dental organizationvoluntarily embeds corporate socialresponsibility into its organizationalculture through the creation of asustainability policy that outlines itscommitment to and strategy forinternally and externally focusing allits activities on realizing a triplebottom line, i.e. economic prosperity,

social responsibility, and environ-mental stewardship. Managingsustainability in dentistry, therefore, isthe implementation, monitoring, andadjusting of what this sustainabilitypolicy entails within a dentalorganization. Based on this under-standing, our management system is a top-down commitment that beginswith the character of the individualdental practitioner striving forcontinuous growth within his or her practice.

For Aristotle, behaving ethicallywas less about following principles and more about developing goodhabits. By focusing on developing ourcharacter, behaving ethically wouldbecome our natural way of being.Moreover, by learning how to behaveethically, we would know how tocreate the conditions for others to dothe same. Building a sustainable dentalorganization starts with the characterof an individual dental professional. Ifsustainability is a guiding principle inthat person’s life, then it will certainlymanifest in his or her organization.Take Dr. Jason McMillan, founder ofMint Dental Works, as an example.McMillan founded the nation’s firstLEED-certified dental practice inPortland, Oregon. By wanting toestablish a practice that reflected hispersonal values, he worked withbuilders to construct a high-performance green facility. This typeof practice resonated with the localcommunity; and without an initialmarketing budget, Mint Dental Worksbecame a national leader for referrals.

Just as with individuals,organizations also have characters,which are more commonly known as “cultures.” Thus, once thecommitment towards creating asustainable dental organization ismade, the corresponding values must


Sustainability


be embedded within the organizationto foster the desired cultural outcome.Dr. Robert “Tito” Norris, founder ofStone Oaks Orthodontics, the nation’sfirst LEED-certified orthodonticspractice, is a perfect example of thisattitude. Even without a guideline, henaturally applied systems thinking tothe nine areas of dentists’ lives. At ourconference this year, Norris began hispresentation by discussing the valuesthat his parents engrained within him.He continued by talking about howthese values influenced certaindecisions about, for instance, hisattitudes towards health and family.These attitudes carried over to hispractice, where he illustrated howthose values became entrenchedwithin his organization, promoted jobsatisfaction among his staff members,endeared him to his patients, andestablished him within his community.For Norris, orthodontics is not just ameans to financial well-being, it is aconduit for increasing the socialwealth of his community and a vehiclefor expressing his passion, love, andrespect towards the living world.

Whether a dental practitionerstrives towards building a BCorporation or simply wants to better his or her community, theprocess of building a sustainabledental organization can be daunting.Fortunately, help exists. Throughoutthe rest of this journal issue, speakersfrom our conference and those whowere involved with formulating theASTM standard and FDI WorldDental Federation’s policy will expandon the concepts that I just exploredand discuss the models and methodsneeded to make a commitment, craft a sustainability policy, embed valueinto one’s organization, strive towards

continuous improvement, aligninternal and external actions withsustainable development, and evaluatethe effectiveness of those actions. Asyou read these articles, I encourageyou to consider how the dentalcommunity can collectively advancethis cause and applaud those of youwilling to take on this challenge, forour world is in great need of ethicalleaders—the future of humanityrequires it. n

References

Capra, F. (2015). The systems view of life: aunifying conception of mind, matter, and life.Cosmos and History: The Journal of Naturaland Social Philosophy, 11, (2), 242-249.

United Nations (2015). Transforming ourworld: The 2030 Agenda for SustainableDevelopment. Resolution adopted by the 80General Assembly on 25 September 2015,A/RES/ 70/1. General Assembly, Agendaitems 15 and 116, 81.

Online Sources1 ASTM E3014-15, Standard Practice for Managing

Sustainability in Dentistry, ASTM International, West Conshohocken, PA, 2015. www.astm.org

2 United Nations World Committee on Environmentand Development, Our Common Future, Report ofthe World Commission on Environment andDevelopment, G.H. Brundtland, (Ed.). www.un-documents.net/wced-ocf.htm

3 FDI World Dental Federation, “Sustainability in Dentistry,” Resolution adopted by FDI GeneralAssembly in Aug. 2017.www.fdiworlddental.org/resources/policy-statements-and-resolutions/sustainability-in-dentistry


Sustainability

Thus, in order for the

dental profession to thrive

in the 21st century, dental

practitioners needed to

collaborate with more

stakeholders, such as

governments, manufacturers,

and scientists, so that they

could reevaluate and

modify their processes

and practices. They needed

to establish a new ethic

within the community.


Bob Willard, PhD

Abstract

Sustainability makes business sense fordentistry. All organizations adapt in order to do the right thing, to take advantage ofnew opportunities, and to avoid or mitigaterisk. Dental offices can achieve all threeadvantages through a sustainabilityapproach. Typically, organizations are in oneor another of the following five stages ofembracing sustainability: (a) pre-complianceor cutting corners on existing regulations and hoping not to be caught; (b) complianceor doing all that is legally required but little more; (c) beyond compliance whereinnovative elements of sustainability areintroduced; (d) with an integrated strategy,offices rebrand themselves, makingsustainability a recognizable feature thatdifferentiates the office; and (e) a final stageof purpose and values where the office places sustainability at the highest level ofreasons for existing.

Twenty or thirty years ago, if youwere to ask most executives why

they weren’t more environmentallyand socially responsible, they’d think itwas a trick question. The answer wastoo obvious. They would be at acompetitive disadvantage if they triedto become too “green” or became toodistracted by helping the underservedin their communities. It would be toocostly. Just keeping up with all theworkplace and pollution regulationswas a burdensome expense. There wasno business case for doing more.These companies were stuck at earlystages in their sustainability journeys.Most still are. Maybe some dentalpractices are, too?

Sustainable dentistry is aboutcontributing to the well-being of theenvironment, society, and theeconomy. It is about intentionallycontributing to the achievement of the17 Sustainable Development Goals(SDGs).1 They define the goals weneed to achieve if we want to continueto have a sustainable human societyon our finite planet, forever. Byaddressing waste issues and promotinggood oral health habits in patients andsociety, dentists can make a significantcontribution to protecting theenvironment and providing inclusive,productive and healthy lives insocieties around the world—whilebeing more successful businesses—in the 21st century.

This article will explain how that ispossible. First, we’ll review the bigthree justifications that are used tosupport any business decision in any

industry sector, and how their relativeimportance has changed from 20-30years ago. Then we’ll show how thethree justifications are weighteddifferently as dental offices progresson their journeys to being sustainabledental practices, and how each step on the journey enables the dentaloffice to reap more business benefits.

The Big Three Justifications

There are just three reasons thatcompanies undertake anything new: do the right thing, captureopportunities, and mitigate risks. Thejustifications are weighted differently,depending on the situation, but somecombination of them is always in playwhen making big decisions. Theyframe the business case.

Figures 1-2 illustrate the dominantmental model in the business com-munity in the last two centuries.Unfortunately, it is also the dominantmindset still taught in most businessschools. It positions being a steward of the environment and society as an either-or choice: either do theethically right thing for society and the environment, or aggressivelycapture financial opportunities andmitigate risks.

In the 21st century, doing theethically right thing has moved fromthe margins into the mainstream.Improving company impacts on theenvironment and the community canlead to capturing new financialopportunities and mitigating new


Sustainability

The Business Case for Sustainable Dentistry

Dr. Willard is ChiefSustainability Champion andFounder, SustainabilityAdvantage; [email protected].


risks. It is now an if-then relationship,not an either-or trade-off. Doing theright thing has morphed from beingan anchor in the old businessparadigm to being a driver of success.

The Five Stages of Business Sustainability

The five-stage sustainabilitycontinuum applies to any business.Companies mature from anunsustainable business model inStages 1 and 2, to a more sustainablebusiness model in Stage 3, to a verysustainable business model in Stages 4and 5. During the journey, executivemindsets evolve from thinking of“green,” “environmental,” and“sustainable” initiatives as expensiveand bureaucratic hassles, torecognizing them as catalysts forstrategic success.

Now, let’s examine how the threejustification factors might be weightedfor a dental clinic in each of the fivestages of its sustainability journey.

Stage 1: PrecomplianceIt’s risky to linger here. In this phase, a dental clinic flouts environmental,health, and safety regulations. It cutscorners and tries not to get caught if it breaks the law or uses exploitativepractices that cheat the system. Itemploys unqualified staff and forcesthem to work in a dysfunctional,abusive workplace. It may usequestionable sterilization practices,perform sloppy dental work, andquietly evade taxes. It is careless withits biomedical and amalgam waste.

These businesses happilyexternalize their negative ecologicaland social impacts.

This stage is associated withcorrupt jurisdictions in undevelopedcountries. In developed countries,80% of the motivation to move toStage 2 is to avoid or mitigate risks.That’s the business case. Society isstarting to demand that all businessesbe more accountable for theircollateral social and environmentaldamage. Whistleblowers areencouraged. Social media leaves noplace to hide. If these clinics don’tclean up their acts, they will beexposed and put out of business byregulators, professional dentalassociations, or clients who leave forbetter clinics. The weight of thecapture opportunities justification forthe move to Stage 2 is about 20%—the opportunity is to stay in business.The do-the-right-thing justification isnot on the radar screen.

Stage 2: ComplianceHere, the dental office manages itsliabilities by obeying all labor,environmental, health, and safetyregulations. It respects dental collegeand dental professional organizationstandards, regulations, and by-laws. Itdoes what it is legally or professionallybound to do. The office complies withlocal regulations for the handling of itswaste (dental amalgam, lead, silver,and biomedical and general officewaste). Its staff is professionally


Sustainability

FIGURE 1.Big Three Justifications:Traditionally

Do the Right Thing

Capture Opportunities

Mitigate Risks

FIGURE 2.Big Three Justifications:21st Century

Do the Right Thing

Capture New Opportunities

Mitigate NewRisks

Enhanced Reputation Innovation

$


qualified, respected, and well-treated.But extra environmental efforts andphilanthropic provision of dental careto the underserved is given lip service,at best.

A Stage 1 dental office’s actions areillegal, unprofessional, and unsustain-able. A Stage 2 office’s practices arelegal and professional, but they’re still unsustainable. They may stillcause environmental harm with theirwaste practices, water use, energysources, and supply chains, but theyare not legally required to stop or to be restorative. They don’t feel anystewardship for the oral health andwell-being of their communities, sincethey are not legally or professionalbound to do more than look after theirpaying patients. They are compliant.

Their missions are to grow thebusiness and to improve their bottomlines. Ironically, that makes up 80% of their motivation for moving beyondcompliance to Stage 3. They want tocapture opportunities to save moneyand generate more income. Whowouldn’t? Risk mitigation may be abackground justification (10%) fordoing more, if the dental office startsto sense that its social license tooperate may be in jeopardy if itsbehaviors do not reflect the growingunease of its patients and communityabout environmental and social issues that require attention. And thedo-the-right-thing justification maybe starting to stir (10%).

Stage 3: Beyond ComplianceA dental office voluntarily moves toStage 3 when it realizes that it can savemoney with proactive, operationaleco-efficiencies. It’s in this stage thatthe practice earns the label “eco-friendly” or “green” as it embracesrenewables, energy efficiency, direct


Sustainability

FIGURE 3.Five-stage Sustainability Journey

FIGURE 4.Dominant Justifications for Moving to the Next Stage

1. Precompliance

2. Compliance

3. Beyond Compliance

4. Integrated Strategy

5. Purpose and Values

1. Precompliance

2. Compliance

3. Beyond Compliance

4. Integrated Strategy

5. Purpose and Ethics

Mitigate

Mitigate

Mitigate

Do the Right Thing

Capture Opportunities

Mitigate Risks


or indirect greenhouse gas reductions,water efficiencies, and wastereduction. Eco-friendly dentistry,through green design and operations,protects the health of naturalresources, the health of patients andteam members, and the health of thelocal community.

There are typically four types oflow-hanging fruit in the fruit salad ofeco-savings: reducing the practice’senergy, water, materials, and wastebills. They entice organizations tomove into Stage 3 and are allenvironmentally oriented. Thesidebars suggest ways dental officescan save energy, water, materials, andwaste as they take the 4 Rs—reduce,reuse, recycle and rethink—moreseriously. 2, 3, 4, 5, 6

Most of the suggestions in thesidebars have the potential to reducecosts. In fact, that was the rationale for moving to Stage 3. For example:

Using tooth-colored restorations•instead of silver amalgams will savea whopping $37,000 a year.7

Digital imaging and patient charting•will save nearly $9,000 a year andpay for itself in about two years.8

Switching to reusable stainless steel•tips and steam sterilization can savedentists $3,500 a year.9

Replacing disposable chair barriers•or bibs with cloth ones can save adental office $2,337 a year, since it is not constantly paying to replacedisposable items. It’s a quickturnaround, too—it takes just 4.9months to realize savings afterinvesting in the cloth items and awasher/dryer unit.10

Choosing reusable rinse cups•instead of disposable paper orplastic cups can save a practice $178 or more per year.11

These benefits arise from efforts tocontribute to the environmentally-related SDGs, which is why they are

called “eco”-efficiencies. The EcoDentistry Association’s GreenDOC™Dental Office Certification Programincludes how-to guides, action plans,and worksheets to support eco-friendly initiatives and achieve variouslevels of certification.12 As a dentaloffice approaches the end of Stage 3, it may also see benefits of increasingits contributions to the well-being ofthe local community and society atlarge. It contributes to at least some of the social and economic SDGs for a sustainable and resilient society,especially the “Good Health and Well-Being” goal.13

However, the hard-nosed businesscase to support undertaking sociallybeneficial initiatives may be morechallenging than the business case forenvironmentally beneficial initiatives.Fortunately, there are good toolsavailable to help with that. Forexample, the Sustainability ROIWorkbook is a free, open-source Excelworkbook that allows all potentialexpenses, benefits and co-benefits ofenvironmental and social initiatives tobe taken into account (Willard, 2017).In particular, the workbook helpsmonetize the potential increase inteam productivity and innovation asstaff are energized by making adifference on social issues that theycare about. This is the secret sauce ofsustainability efforts—engagedemployees. The workbook also helpsusers quantify and monetize the valueof an improved reputation. A majorityof dental patients think companieshave a responsibility to help preservethe environment and would switchproducts and services based onenvironmental benefits.14 Theworkbook helps estimate potentialincrease in revenue as new patients are attracted to a dental clinic whichshares their values. It helps craft a

holistic business case for bothenvironmental and social initiativesand monetizes the benefits arisingfrom doing the right thing, capturingnew opportunities, and mitigatingnew risks.

As dental clinics explorepossibilities in Stage 3, they discoverthe value of moving to Stage 4. Aswould any business, they come torealize that they may make 31-81%more profit if they simply implementedproven best sustainability-relatedpractices, while avoiding a 16-36%erosion of profit if they did nothing(Willard, 2012). So, the proportions ofthe three justifications that support themove to Stage 4 are roughly the sameas they were for moving to Stage 3:80% for capture (more) opportunities,10% for mitigate risks and 10% for do the right thing.


Sustainability

A dental office voluntarily

moves to Stage 3 when it

realizes that it can save

money with proactive,

operational eco-efficiencies.


Stage 4: Integrated StrategyBy Stage 4, the dental office hastransformed into a sustainablebusiness. It re-brands itself as acompany committed to sustainabilityand institutionalizes sustainabilityfactors into its governance systemsand policies. It injects sustainabilityprinciples into its values and companyDNA. It integrates sustainabilityapproaches into its business strategies,policies, and management systems, asencouraged by “Standard Practice forManaging Sustainability in Dentistry”published by ASTM International15

and the World Dental Federation(FDI) “Sustainable Dentistry Policy”.16

Cost-efficient, generally recognizedsustainable development principles areintegrated into day-to-day decision-making and dental service activities.

Stage 4 companies also set long-term goals and short-term targets fortheir environmental and social efforts.The goals and indicators may beexpressed using the consensus-basedSDG framework, the science-basedFuture-Fit Business Benchmarkframework,17 the framework used inthe B Corp Business ImpactAssessment Questionnaire,18 or others.Stage 4 businesses publish periodicreports on their progress toward theirgoals, perhaps using an integratedreport format19 to connect the dotsbetween progress on their environ-mental and social goals andimprovements in their financialresults. That is, they not only integratesustainability into their businessstrategies, they integrate it into theirmeasurement, management,governance, and reporting systems.

So what’s left? Hasn’t the dentalpractice gone as far as there is to go onits sustainability journey? Yes and no.What drives any organization to Stage 5 is the emergence of the do-the-right-thing justification. It becomes

the dominant (80%) rationale, withcapture opportunities (15%) andmitigate risks of inaction (5%) in thebackground. In Stage 5, doing theright thing really matters.

Stage 5: Purpose and ValuesDriven by a passionate, values-basedcommitment to improve the well-being of the enterprise, society, andthe environment, a Stage 5 companyhelps build a better world because it is the right thing to do. Dentistry ispractised ethically, with high levels ofquality and safety, in the pursuit ofoptimal oral health for patients andthe community—and more.

About 90% of the behaviors of Stage 4 and Stage 5 dental practiceslook similar. They both deploybusiness strategies that respect thehealth of the environment andcommunity and the ongoing businesshealth of the firm. It’s the motivationthat differs. Stage 4 companies “do theright thing” so that they are successfulbusinesses; the co-benefit is that theyalso do the right things. Stage 5companies “do the right thing” so that they fulfill their purpose andvalues; the co-benefit is that they arealso successful businesses. Thebenefits and co-benefits are flipped.The dotted line between Stage 4 andStage 5 in Figures 3 and 4 denotes thismotivational difference.

The values of Stage 5 companiesusually mirror founder/CEO values.Some founder-owned and founder-ledcompanies start and end in Stage 5without ever entering the other fourstages. Examples are Seventh Genera-tion founded by Jeffrey Hollander;Patagonia led by Yvon Chouinard; andmy publisher, New Society Publishers,founded by Chris and Judith Plant.


Sustainability

FIGURE 5.Energy-saving Ideas

• Turn lights, computers, andother appliances off when theyare not in use, especially atnight. Use smart power strips toavoid vampire/leaked/ghostenergy consumed by plugged-in appliances, even when theyare switched off.

• Use an Energy Star washer and dryer.

• Convert to fluorescent, compactfluorescent (CFL), or LED lightbulbs. Turn them off in spaceswith adequate daylight.

• Use LCD computer screens andmonitors rather than CRTs.

• Invest in solar electric panelsand water heaters.

• Use a programmablethermostat.

• Purchase reflective glass (low-E) windows.

FIGURE 6.Water-saving Ideas

• Turn off taps between uses.• Use low-flow taps and water-

efficient toilets.• Use front-loading washing

machines.• Use dry vacuum pumps rather

than water-consuming or water-recycling pumps. A waterlessvacuum pump can save as muchas 360 gallons of water aday/pump (DeMello et al, 2010).This is especially important inwater-stressed regions.


Purpose-driven dental practices maybe in a similar situation.

For example, Artisan Dental is apurpose-driven Certified B Corp co-owned by Scott Anderson and Dr.Nicole Anderson.20 Its mission is to“optimize the health and happiness ofour patients, team members, suppliers,community, and the environmentthrough exceptional quality care andsustainable business practices.” 21

Its nine values are love, wisdom,compassion, service, collaboration,creativity, ethical integrity, empathy,and fun.22 It reaps the eco-efficienciesoutlined above23 and supports localand global organizations with ownerand staff volunteer hours, free dentalservices, and ongoing financialcontributions.

How does Artisan Dental justifydoing all that it does, especially on thesocial side? Here are the top threebenefits that it realizes from being aStage 5 company:24

Trust, loyalty and brand value.•Trust is an essential ingredient incustomer loyalty. Walking the talkon its mission, purpose, and valuesbuilds customer trust with ArtisanDental’s customers and helps attractand retain its best team members.Attracting new customers.•Customers are attracted to ArtisanDental because they trust it andshare its values. Customers referfamily and friends who sharealigned environmental and socialvalues to Artisan Dental. Happily,word-of-mouth patient referralsminimize marketing costs.Cost savings and resource•optimization. Artesan Dental savescosts through energy conservationand the thoughtful use of resources.Notice that cost savings are on their

list of benefits, but the most importantbenefit is an enhanced reputation withits customers and staff whose values


Sustainability

FIGURE 7. Waste-saving Ideas

Waste is big issue in dentistry. Each year dentists in the United States are responsible for generating:• 3.7 tons of mercury waste• 1.7 billion sterilization pouches• 680 million chair barriers, light-handle covers, and patient bibs• 28 million liters of toxic X-ray fixer• 4.8 million lead foils

Here are some healthcare-sector practices to help reduce thisenvironmental burden:• Use the Blue Bin recycling program to recycle separately the paper

and plastic halves of one autoclave bag.• Install an amalgam separator to separate the fine particles of silver

amalgam (generated during restoration finishing, polishing andremoval procedures) from waste water and prevent mercury fillingmaterial from entering the water supply. Silver amalgam containsmercury, silver, and other metals that can enter the environment.Currently it has been estimated that dentists contribute between 3 to70% of the total mercury load entering waste-water treatmentfacilities (Avinash, 2013).

• Recycle autoclave bags in blue bins.• Replace single-use paper or plastic bibs with operating room (OR)

cotton towels. This avoids 5,100 pieces of plastic (back of bibs) sentto landfills each year. After use, the towels are washed in an energyand water efficient washing machine and then sterilized in theautoclave with cassettes of instruments, above.

• Use reusable stainless steel high and low volume,surgical/endodontic suction tips vs single-use disposable plastic.

• Use reusable glass irrigation syringe vs single-use disposable plasticsyringes.

• Use biodegradable disposable cups vs landfill-burdening cups.• If using traditional X-rays, recycle fixer and developer solutions and

recycle lead foil from X-rays.• Use digital radiography instead of traditional film-based X-rays, to

avoid the risk of silver and lead pollution and exposing patients to 70to 90% more radiation from traditional X-rays .

• Use stainless steel prophy cups instead of disposable prophy-containing cups. Purchase prophy paste in tubes or tubs and use onlythe amount of paste that is needed versus a predetermined amountwhich is often too much and wasteful/costly.

• Use disposable, plastic/paper barriers only as truly needed.• Use an environmentally-friendly landscape company that uses natural

growth products and no harmful pesticides.


resonate with Artisan Dental’s values.That’s the essence of Stage 5 companies—they do well because they arepurpose driven, not in spite of it.

Stage 5 companies are leaders andnetworkers. Artisan Dental is an active member of Local First in Grand Rapids,25 where it shares itspassion for people living and workingtogether in a sustainable community.It participates in the MPower BusinessChampions program26 for businessesthat want to reduce their environ-mental impact while saving costs andcreating a healthier and more engagingworkplace and community. They helpothers discover the benefits of being

Stage 5 companies. They are leaders.So, there is a strong business case

for dental offices to progressivelybecome more sustainable, regardlessof where they currently are on theirsustainability journeys. Theweightings of the three justificationswill differ at each stage, but theycombine to frame the business case for being better stewards of theenvironment, society, and the bottomline. Many dentists and their teamsentered the profession to make adifference. The business case helpsframe why that purpose does notrequire a sacrifice of their businessresults. On the contrary, it can be theenergizing driver of success. n

References

ASTM international: Farahani, A., & Suchak,M. (2007). Eco-Friendly Dentistry. Universityof Waterloo: Eco-Dentistry Association, 16-37.

Avinash, B.S., Shivalinga, B.M., Jyothikiran,S., & Padmin, M.N. (2013). Going Green withEco-friendly Dentistry. The journal ofcontemporary dental practice. 14. 766-769.

DeMello, M.C., Clancy R.M., McMillan, J.,McMillan, R., Henry, K., Bommhardt, C., etal. (2010). Going.going.going.gone green.Making your dental practice environmentallyfriendly. Journal of the Massachusetts DentalSociety, 59, 29-32.

Willard, B., (2012). The new sustainabilityadvantage. Gabriola Island, BC: New SocietyPublishers.

Willard, B. (2017). Sustainability ROIWorkbook. Whitby, ON: SustainabilityAdvantage.

Online Sources1 www.un.org/sustainabledevelopment/

sustainable-development-goals

2 www.cda-adc.ca/jcda/vol-73/issue-7/ 581.pdf

3 www.researchgate.net/profile/Avinash_Shivamallu/publication/259205315_Going_Green_with_Ecofriendly_Dentistry/links/55a

77be208ae345d61db3db6/Going-Green-with-Eco-friendly-Dentistry.pdf?origin=publication_detail

4 www.getweave.com/going-green-can-make-a-practice-more-green/

5 https://success.ada.org/en/practice-management/office-design/80-ways-to-make-your-dental-practice-green

6 http://ecodentistry.org/green-dentistry/what-is-green-dentistry/go-green-save-green

7 http://practicemanagement.dentalproductsreport.com/article/4-ways-make-your-office-more-green-and-more-profitable




11 www.ladental.com/assets/The-Explorer/explorer%20spring%202016.pdf

12 http://ecodentistry.org/greendoc/

13 https://sustainabledevelopment.un.org/sdg3

14 www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=311879

15 www.astm.org/Standards/E3014.htm

16 www.fdiworlddental.org/resources/policy-statements-and-resolutions/sustainability-in-dentistry

17 http://futurefitbusiness.org

18 https://bimpactassessment.net

19 http://integratedreporting.org/resource/international-ir-framework

20 http://artisandentalmadison.com/certified-b-corp

21 http://artisandentalmadison.com/philosophy

22 http://artisandentalmadison.com/philosophy

23 http://artisandentalmadison.com/suy

24 www.acast.com/dentistryuncensoredwithhowardfarran/946-benefits-of-b-corp-certification-with-scott-andersen-of-artisan-dental-llc-dentistry-uncensored-with-howard-farran

25 www.localfirst.com/about/mission26 http://sustaindane.org/going-sustainable/

at-work/mpower-business


Sustainability

The office complies with

local regulations for the

handling of its waste (dental

amalgam, lead, silver,

biomedical, and general

office waste). Its staff is

professionally qualified,

respected, and well-treated.

But extra environmental

efforts and philanthropic

provision of dental care to

the underserved is given

lip service, at best.


Claudio Pinheiro Fernandes, PhD

Abstract

Dentistry faces the double challenge ofaddressing growing global oral health needs at the same time it takes a responsibleposition with respect to sustaining theenvironment. A number of world bodies have issued calls for voluntary action toprotect the environment, and some of theconcerns raised relate directly to the waydentistry is practiced. Most noticeably, theWorld Dental Federation has endorsedseveral policy statements. Increasingly, the case for sustainability can be madethrough science and economics. The ISO26000 Social Responsibility standard,although broad, may provide a touchstonefor sustainable dentistry.

The dental profession is beingchallenged by the ever-increasing

demand for better oral health care formore people in more countries thanever before. At the same time, we are being required to reduce thedemands we place on the earth’s finiteresources. Our success as healthcareproviders will be judged by how well we meet these twin challenges.But we are not alone in this. Suchalignment is currently expected in allproductive areas due to a growingglobal public sentiment towardssustainable development issues. Andall professional industry now facesscrutiny over the global environmentalimpact of its production processes.

The Oral Health Challenge

The dental profession strugglesrelentlessly to improve oral healthworldwide. Apart from the clearadvances in research and technology,unfortunately, to this date, littlesuccess has been attained on a globalscale. The Global Burden of DiseaseStudies funded by The GatesFoundation report that untreateddental decay in permanent teeth is thesingle most prevalent disease on theplanet, severe chronic periodontal(gum and underlying bone) diseasethe sixth most prevalent, anduntreated decay in deciduous teeth thetwelfth most prevalent. According tothe World Health Organization(WHO), 60 to 90% of childrenworldwide have dental caries.Unfortunately, oral diseases affect the

most vulnerable individuals: children,elderly, and members of racial andethnic minorities. The economicburden of these preventable diseases issevere. The indirect costs, such as timeaway from school and work, amountto more than US $140 billion per year,ranking the indirect costs of oraldiseases among the top ten causes ofdeath. Despite the great relevance, oral health issues often have lowpower of political influence over other medical areas. The importanceof promoting sustainable heathylifestyles is a challenge recognized bythe United Nations and included inmultilateral documents such as theUN Agenda 2030 for SustainableDevelopment, the UN Resolution71/160 recognizing sports, as afacilitator of health, education, andsocial inclusion, and the WHO call for a mandate of health literacy in the2016 Shanghai Declaration.

The largest study ever conductedon the impact of oral diseases onpeoples’ lives shows that oral diseasesare a challenge worldwide. The studyconcluded that oral health has notimproved in the last 25 years. Oralconditions continue to be animportant and growing global healthchallenge. While the prevalence of oralconditions remained relatively stablebetween 1990 and 2015, the growthand aging of the population led to adramatic increase in the burden ofuntreated oral conditions worldwide.More efforts and potentially different


Sustainability

Sustainability in Dentistry

Construction of a New Paradigm

Dr. Fernandes is Chairman of the Center for SustainableDentistry, Nova FriburgoHealth Institute, FluminenseFederal University in Rio deJaneiro, Brazil.


approaches are needed if internationaloral health goals are to be achieved by 2020.

Most dental professional educationand communication efforts still focuson technical issues and have led theoral health team to certain isolationfrom mainstream medicine and healthcare. The result is a worldwide lack ofawareness and engagement in widersocial, environmental, and politicalissues. These shortcomings have notbeen without cost. There are severeimplications for oral health providersin issues such as dental manpower,business models for health systems,

and dental-related environmentalissues. While some very largecountries, such as Brazil, with morethan 250,000 practitioners, show adentist/population ratio of less than1/1000, Africa has an average dentalratio of 1/50,000. Health-care systemsof public or private nature seldominclude universal coverage and integration with systemic health,resulting in high risks for fosteringeven deeper separation from otherhealth professions.

The EnvironmentalChallenge

Environmental impacts have become aroutine agenda for nearly all countriesaround the world, and dentistry is not

excluded from the list of impactactivities. Studies show that the waterconsumed by a dentist is eight timeshigher than the average proportionallysized household. The reason is due toold-fashioned technologies that runintraoral suction devices based onwet-ring vacuum pumps. Impact ofbiomaterials is another heavy part ofthe environmental impact of dentalfacilities. Several products thatperform adequately within the humansystem may not necessarily do sowhen released to land and water wastemedia. The latter currently ranks veryhigh among national and internationalagenda priorities, giving rise for


Sustainability

EnvironmentalA viable natural

environment

SocialNurturing

community

EconomicSufficienteconomy

Sustainable natural andbuilt environment

Sustainable economicdevelopment

Equitable socialenvironment

FIGURE 1. Sustainable development occurs at the intersection of economic,social, and environmental components.


ADOPTED by the FDI GeneralAssembly, August, 2017, in Madrid, Spain

The policy statement is the mostimportant guidance document forthe dental community to date.Following up on several years ofmaturing negotiations, the FDIDental Practice Committee hasprepared a document that defines,structures, and guides the dentalcommunity into the new paradigmof sustainability in dentistry.Composed of 4 sessions: Context,Definitions, Principles, and Policy, FDI leads the oral healthprofession to interact with societyat large to meet people’sexpectations of increased accessto health while reducing theimpact on natural resources.

FDI Policy Statement: Sustainability in Dentistry

international environmentalprotection institutions to increasinglytarget dental products as hazardous,the most notorious case being thedental amalgam, directly affected bythe Minamata Convention. Dentistsare still allowed to use dental amalgamto a greater or lesser extent, accordingto the national interpretation of thephase-down directive. However,regardless of the interpretation, it isclear that dental amalgam willdisappear as a restorative material,despite the efforts of many dentalprofessional institutions moreconcerned in “business as usual.” Thispolicy leaves a certain feeling that the dentists have not given muchattention to the environmental impact generated by the oral health-care activity.

The Future We Want

Rio+20 talks have set the politicalagenda for the urgent need ofincluding the sustainable development(SD) dimension in the activities of allsectors of human society. But althougha document was agreed upon, thereremains much concern about theabsence of significant commitment to action. Rather than defining a set of sustainable development goals(SDGs), the text, “The Future WeWant,” signed by more than 150countries, stipulates a path fordeveloping voluntary SDGs, to be ledby an open-ended working group in the UN General Assembly. Whilethe overall outcomes of Rio+20 havefallen short of expectations for broadcommon political commitment andpractical measures, health and non-communicable diseases wererecognized as essential issues forsustainable development. Evidenceand experience have demonstratedthat health and sustainabledevelopment are closely linked. While

acknowledging the considerableimprovements achieved indevelopment and poverty eradication,there has been limited progress madein bringing together historicallyindependent social, environmental,and economic policy at a national andinternational level.

One of the most relevant outcomesof the Rio+20 meetings was theconsolidation of a multi-facetintersection of social, environmental,and economic aspects that puts thesustainable development as the centerfocus (see Figure 1).

The consensus document obtainedat Rio+20 and the ongoing discussionfor UN Sustainable DevelopmentGoals points to sustainability as notthe “best” way, but as the “only” wayto survival of the human species.

The UN Sustainable DevelopmentWorkgroup established in 2012conducted a massive global effortfinalized in 2015 during the UnitedNations Sustainable DevelopmentSummit to present the TransformingOur World: 2030 Agenda forSustainable Development. Six essentialelements were used to elaborate UN’s17 SDGs (sustainable developmentgoals): Dignity, People, Prosperity,Planet, Justice, and Partnership.

Working through business, culture,education, science and technology,and accounting domains, sustainabilitywill also construct a new paradigm in dentistry. Axioms like the 4Rs:Reduce, Reuse, Recycle, Re-educatewill be the basics of thistransformation.

Sustainability Advocacy in Dentistry

The World Dental Federation (FDI) is the most comprehensive system oforganized dentistry in the world. In

over 100 years FDI has a membershipcomposed of National DentalAssociation members in more than180 countries and represents morethan one million dentists worldwide.This overarching global institution hastaken the challenge and is working toface the needs of more sustainability in the dental world.

Historically, FDI has reiterated itscommitment to the principles outlinedin the 1992 Rio Declaration onEnvironment and Development, andof Agenda 21, stating that humanhealth and well-being must be acentral tenant of any global agreement.The World Health Organizationrecognized the relevance of oral healthconditions in a World HealthAssembly resolution in 2007 and


Sustainability


adopted an action plan for oral diseaseprevention (WHA60/R17). ThePolitical Declaration of the High LevelMeeting of the General Assembly onthe Prevention and Control of Non-Communicable Diseases (NCDs),adopted in New York on 19 September2011, recognized that oral diseasespose a major health burden for manycountries and share common riskfactors with NCDs, notably unhealthydiet (particularly high sugarconsumption), tobacco and harmfulalcohol use, related to poverty andsocial inequalities. Furthermore, FDIapplauded the Political Declaration onSocial Determinants of Health,adopted in Rio de Janeiro on 21October 2011, confirming Article 16.4which identifies important policiesneeded to achieve both sustainable

development and health equitythrough acting on social determinants.FDI has also given full support to itemC.42 of the Objectives of the Rio+20conferences: “Poverty eradication andenhancement of the livelihoods of themost vulnerable deserve priority inmeasures promoting a green economytransition.”

The FDI has decisively contributedto the United Nations EnvironmentProgramme’s (UNEP) legally-bindingtreaty on mercury—the MinamataConvention—advocating for areduction in the use of dentalamalgam (versus a ban) throughincreased attention to dentalprevention and health promotion,increased research and developmenton alternatives, and best managementtechniques for amalgam waste.

However, although the MinamataConvention gained massiverecognition in the public news, verylittle has been said about the oralhealth perspective. The expectationfor a phase down and of changingdental amalgam for a mercury-freerestorative material has been nearlythe only quote in this regard, even insome of the professional dentistrymedia. This shows how much work weneed to do in order to build a moreproactive image for dentistsworldwide. And that is not all. TheUNEP secretariat is working with thesecretariats of Strategic Managementof International ChemicalsManagement (SAICM) and otherstanding Conventions (Basel,Stockholm, Rotterdam, and Montreal)to prepare INC briefing documents on


Sustainability


other potentially hazardous materials.Dental composite resins have alreadybeen identified as potentiallyhazardous due to the inherent BPArest composition from originalpetrochemical derivatives.

UNEP’s initiatives regarding dental amalgam and composite resinshave taught us an important lesson:Dentistry needs to be preemptive, take responsibility, and meet socialdemands for reducing the strain onnatural resources and yet promotegood oral health for all. Adoptingsustainable development practices as a backbone for change to improveeconomic, environmental, and societalaspects related to dentistry will be thebaseline of our future.

The dental profession is animportant part of human life and must take responsibility for integratingSD goals into daily practice andunderwrite a shift toward a greeneconomy. Thus, in view of theincreasing importance of externalpolicies that examine dentaltechnologies and materials and passjudgment on their sustainability and safety, it is time to develop aworking agenda that will position usto effectively promote measures toimprove oral health and maintainpatient safety in a timely andconstructive manner. This presents aunique opportunity for dentists to takea leadership role regarding the healthcommunity, public authorities, and thegeneral public, for guiding sustainabledevelopment practices in all oralhealth-care segments.

At the same time, we see ageneralized growth of political,economic, and social instruments thatconverge to create a favorableenvironment for change and coping

with this difficult situation. This newcontext can be seen in the results ofthe 9th Global Conference on HealthPromotion, which brought togethergovernment leaders and UnitedNations organizations in Shanghai atthe end of 2016. The ShanghaiDeclaration pledges to make boldpolicy choices for health, emphasizingthe links between health, well-being,and the UN’s 2030 Agenda forSustainability and its SustainableDevelopment Goals. The statementhighlights the need for people to beable to control their own health—tobe in a position to choose a healthylifestyle. Noting the need for policyaction in various sectors and regions,the document highlights the role ofgood governance and health literacy in improving health, as well as theimportant role played by municipalauthorities and communities.

Sustainability Science

Science, technology, and innovationhave long been recognized as the basisfor socioeconomic development. Theyare also core contributors tosustainable development and tomeeting the SDGs. The UN has calledfor a “Seat for Science” on the high-level political forum that deals withthe UN 2030 Sustainable DevelopmentAgenda, to ensure that “science is notjust an observer but an advisor topolicymakers.”

A report conducted by Elsevier incollaboration with SciDev.Netexamined the status of sustainabilityscience as a research field, part of abroader, on-going effort to providemore evidence and analysis on the role of science, technology, andinnovation. Sustainable developmentis viewed as an umbrella term thatcovers research, programs, andcollaborative efforts contributing to sustainable development and

“sustainability science” as theunderlying research of sustainabledevelopment. The nature ofsustainability science means that it hasthe potential to contribute to virtuallyevery target listed under the 17 SDGs.The six essential elements for the UN’s17 SDGs were used as the referenceresearch themes for categorizingkeywords within sustainabilityscience—Dignity, People, Prosperity,Planet, Justice, and Partnership. Thekeywords were than were used toidentify publications relevant to eachtheme as according to the Scopussubject areas, a recognized researchanalytics system.

Key findings included:Sustainability science is a field •with a high growth rate in research output. Research output in sustainability•science attracts 30% more citationsthan an average research paper.Research in sustainability science •is highly collaborative.Sustainability science is less•interdisciplinary than the worldaverage.Health-related sustainability •science was highly represented inthe report.The research output is both global

and collaborative by definition. Forinstitutions, the results may be used toidentify research strengths within thethemes in sustainability science,potential collaborators in academiaand other sectors, and, moreimportantly, to identify gaps betweenresearch topics and societal needs. For policy makers, it is important to


Sustainability


understand that the development ofscience, technology, and innovation is critical to sustainable development.Policy that stimulates research toaddress the challenges in sustainabledevelopment is essential. It is equallycritical to include contributors fromthe research community in the policy-making process.

In the coming years, science willneed to play an important role in theprovision of the data, information, and knowledge that is required tofacilitate the successfulimplementation of the 2030 Agendafor Sustainable Development and theassociated SDGs. The 2030 Agendaexplicitly recognizes that sustainabilitychallenges are fundamentally inter-related. Focusing exclusively on singlegoals will therefore not be effective. All actions need to be assessed forpolicy coherence across the goals. This means that science and societyneed to be aware of the broad SDGspectrum to find the best pathway toprogress towards all the goals.

Finally, strong knowledgepartnerships where equal weight isgiven to academics, decision-makers,practitioners, business leaders, civilsociety and/or others might be themost efficient way to guide SDGimplementation on a regional andglobal level.

Sustainability Metrics andEconomic Perspectives

The world is currently facingextremely difficult challenges tosustainable development andenvironmental management. Thecurrent global financial and economiccrisis exacerbates the situation. High

water and energy prices negativelyimpact the production processes.Expensive logistics, complex regulatoryaspects for waste management, low-tech practices, and lack of sustainabledevelopment education policies aresome examples of areas that need to be faced in an internationalcollaborative perspective.

Such complexity inducesoperational risks and seems to indicate a reduced attractiveness forstakeholders to take the sustainablestep. A major factor for changing thisperspective has been the developmentof accounting sustainability metrics.Through well-establishedstandardized metrics of performance,the impact of a particular product,service, or process can be measuredand reported. The integratedsustainability report has become theengine behind a well-propagatedanecdotal image that “onlyaccountants can save the world.”

The benefits of adopting asustainable development and socialresponsible approach are not only tomeet with societal expectations, but itmay also be good business for all thedental-related community. The oralhealthcare system, for example, standsto gain from integrating sustainabledevelopment International StandardsOrganization (ISO) standards intotheir business from improvedcompetitiveness, as this allows savingsassociated with increased productivityand resource efficiency (lower energyand water use, decreased waste, andrecovery of by-products); enhancedreputation, greater public trust and“social license” to operate; createdinnovative working environment;enhanced employee attraction, loyalty,participation, morale, and retention as it improves health and safety; and reduced or prevented potentialconflicts with consumers aboutproducts or services. Also industry,

trade, and other dental-relatedbusinesses should look intosustainable development andcorporate social responsibility toimprove their bottom line. Manybusiness analysis resources such asGoldman Sachs, Deloitte, InterfaceInc., McKinsey, PriceWaterhouseCooper, Harvard Business Review,Economist Intelligence Unit, andothers, already recognize thatbusinesses can improve short- andlong-term profitability through theadoption of sustainable practices inthe areas of operational efficiency ofnatural resources, energy, managementof human resources, financialoperations, marketing, and communi-cation and reporting, as well asthrough collaboration with NGOs and governments.

ISO Standards: A Roadmap for Solutions

A well-structured roadmap ofsolutions that meet both therequirements of business and thebroader needs of sustainabledevelopment can be found in the ISOlibrary of international standards. Theinternational standard ISO 26000—Social Responsibility—is the broadestone and represents an over-archingapproach to sustainability, since itenables organizations of all sizes toprogress in all three dimensions ofsustainable development of theenvironment, economy, and society.The benefits for the dental communityof integrating social responsibility into their business are mainly from:

Improved competitiveness, as it1.allows savings associated withincreased productivity andresource efficiency (lower energyand water use, decreased waste,and recovery of by-products)


Sustainability


Enhanced reputation, greater2.public trust and “social license”to operate Created innovative working3.environment Enhanced employee attraction,4.loyalty, participation, morale, and retention as it improveshealth and safetyReduced or prevented potential5.conflicts with consumers aboutproducts or services

The ISO Guide 82:2014, Guidelinesfor addressing sustainability instandards, for example, is thedocument intended to provide ISOTechnical Committees (TCs) andSubcommittees (SCs) with guidanceon how to incorporate sustainabilityinto the development and revision of ISO standards.

Promoting a sustainabledevelopment agenda is the bridgebetween environmental, economic,and social goals; betweengovernments, civil society, andbusiness; between science and policy;and between policy and action. Theoral health community needs toprovide a powerful forum for guidinga prompt and sustainable response. Toface this challenge, key partnershipsneed to be drawn among practitioners,dental industry, science, technology,and education for using ISO resourcesof sustainable development standards.A well-structured roadmap ofsolutions that meet both therequirements of business and thebroader needs of society, such as thesustainability process can be found inthe ISO international library ofstandards. Technical standards areindeed a map of solutions for differentareas, and can be implemented inseveral steps. ISO Central Secretariathas committed to sustainabilitythrough several Technical Committeesexperienced with developing

international standards as aframework for sustainabledevelopment, such as productmanufacture, energy conservation,environmental safety, managementsystems, carbon footprinting, waterfootprint, and social responsibility.

Call for Action

The quest for more meaningfulpractices towards sustainability in the world of oral care is going to be a journey. This call for action offersthe means for accomplishing it, but it needs to build up strength andcompetence in the different dentalsegments. Participants should bestakeholders, sensitive to the visionand interested to commit to thejourney. Included among these are:

Industry: dental equipment, dental•consumables, hygiene products,supply chainService: trade, transportation,•education (undergraduate, postgraduate, and continuingeducation), clinical practitioners,oral health insurance plans Science, technology and•innovation: research institutes,specialized mediaGovernment: public health,•regulators

This new paradigm requires amultilateral initiative for dental,education, and sports stakeholders toraise awareness of the importance oforal health to life quality, mobilizesocial power and increase the impactof oral health issues on governmentpolicies at the national level. The key proposed actions are:

Add the dimension of1.sustainability as a key argumentfor defending preventive-basedmodels for oral health care as itreduces the impact on naturalresources as well as the energy,water, and carbon footprintsAdd the dimension of2.sustainability in the global R, D,& I agenda, including both publicand private sectors, to developand commercialize replacementor new alternatives to hazardousdental materials that improve thatof current available alternativesmaterials alongside expandedpreventive approachesAdoption of environmentally3.sound lifecycle management fordental products


Sustainability

It is time to develop a working agenda that will position us

to effectively promote measures to improve oral health and

maintain patient safety in a timely and constructive manner.


Develop and implement a model4.for sustainable developmentplatforms for all dental segmentsEncourage all dental educational5.institutions to include asustainable dentistry dimensionin the curriculum, includingpreservation of natural resources,operational efficiency of energy,safe handling of hazardous inputs,effective waste management, andappropriate disposal of dentalmaterials and other unserviceableproductsImplement ISO 26.000 values to6.the dental clinical practiceDevelop policies and strategies to7.support effective and sustainable“green dentistry” initiativeswhich emphasize sustainabledevelopment and socialresponsible practices

The focus must be on treating theburden of oral disease in the safest,most efficient, and effective ways wecan, and with the least possibleenvironmental impact. How will wepractice across the globe in a way thatmakes us all proud?

It is time for people’s engagementand participation, not only as businesspeople but also as human beings. Weneed to change the way we think andwork. Dentists should collaborate withkey stakeholders to conserve earth’sresources without diminishing theimportance of promoting safe,effective and affordable oral healthcare for all. n

Resources

Bakker P. (2013). Accountants will save theworld. Harvard Business Review. Digitalarticle, March 5.

FDI. (2018). Sustainability in Dentistry. Policy Statement adopted by the FDI GeneralAssembly: August 2017, Madrid, Spain.International Dental Journal, 68 (1), 10-11.https://doi.org/10.1111/idj.12369

Fink, C., & Whelan, T. (2016). Thecomprehensive business case forsustainability. Harvard Business Review.Digital article, October 21.

ISO Guide 82:2014. Guidelines foraddressing sustainability in standards.

Sukhdev P, Stone S, & Nuttall N. (2010).Green economy developing countries successstories. St-Martin-Bellevue United NationEnvironment Programme UNEP.

Sustainability Science in a Global Landscape.A report conducted by Elsevier incollaboration with SciDev.Net.www.elsevier.com/research-intelligence/ resource-library/sustainability-2015

United Nations. Transforming our World: The2030 Agenda for Sustainable Development.Resolution adopted by the 80th GeneralAssembly, September 25, 2015.http://unctad.org/meetings/en/SessionalDocuments/ares70d1_en.pdf

World Commission on Environment andDevelopment (Brundtland Commission): Our Common Future. Oxford: OxfordUniversity Press. 1987. www.un-documents.net/our-common-future.pdf


Sustainability

This allows savings associated with increased productivity and resource efficiency;

enhanced reputation, greater public trust and “social license” to operate; created

innovative working environment; enhanced employee attraction, loyalty, participation,

morale, and retention as it improves health and safety; and reduced or prevented potential

conflicts with consumers about products or services.


Robert “Tito” Norris, DDS

Abstract

A sustainable dental practice is much morethan recycling and energy conservation. The physical, emotional, and professionalspirit of the dentist and the office team mustbe high for the duration. Nine dimensions ofthis full sense of dental office sustainabilityare identified: physical plant, physical andmental health, continuing professionalgrowth, positive work environment, long-term employee participation, communityservice, financial sustainability, and job satisfaction.

In the field of dentistry, sustainabilitycan mean various things to different

people. In this article I will exploresustainability as it relates to ninedifferent areas of our lives as dentists.

The Physical Plant

You cannot get through a single daywithout having an impact on the worldaround you. What you do makes adifference, and you have to decide whatdifference you want to make. —Jane Goodall

The aspect of sustainability thatprobably enjoys the highest “top ofmind” awareness is environmentalsensitivity in where and how wepractice dentistry. When designingand building or finishing out officespace, there are a number of factorswhich will contribute to energyconservation, environmentalstewardship, and an inviting,productive workplace. If you choose to embrace these tenets, then the U.S. Green Building Council’sCertification in Leadership in Energyand Environmental Design (LEEDCertification) can be pursued. A fewconsiderations include a viablerecycling program; high-efficiencyHVAC units; insulation value of walls,ceilings, and windows; natural lightingto all rooms; bicycle rack and shower;low-flow sinks and toilets; LEDlighting; low-VOC or zero-VOC paint;flooring of recycled materials; and asolar energy-generation array. Beingpaperless, and using digital scanningversus impressions are just two of

numerous other sustainable practiceswithin a dental office. My experiencein constructing a LEED-Certifiedoffice in 2010 was that going to thesemeasures increased construction costsby approximately 10%. However,energy savings and long-termincreased productivity in thisenhanced work environment hasrepaid this initial investment.

Physical Sustainability

Health is hearty, health is harmony,health is happiness. —Amit Kalantri

Perhaps one of the least-consideredaspects of sustainability is our ownpersonal physical health. Dentistry is a physically taxing profession.Therefore, discovering and routinelyengaging in activities which counter-balance the physical strain thatdentistry puts on our bodies isparamount to maintaining one’s abilityto continue practicing dentistry as along career. Elements of a well-rounded health program includeregular low-impact cardio-vascularexercise such as cycling, swimming,hiking, rowing, or cross-countryskiing to maintain a healthy heart.Weight training helps build musclemass and strengthens our bones.Frequent and targeted stretching oryoga are equally important to lengthenand strengthen the numerous muscleswhich undergo tenuous isometric


Sustainability

Full Sustainability in Dentistry

Dr. Norris is a diplomate of the American Board ofOrthodontics who practices in San Antonio, Texas;[email protected]


contraction as a result of ourprofession. Regular therapeuticmassages can also alleviate muscularknots and tension. As doctors, weshould be well-versed in nutrition and moderation. We are in a uniqueposition to set an example of a healthy lifestyle to our team members,our colleagues, our patients, and our community.

Mental Health Sustainability

If you build it, they will come.—Ray Kinsella, Field of Dreams

One of the buzz words of mygeneration is “balance.” Lumberjacksknow that working hard is importantto get the job done. However, they also understand that taking rest andsharpening their saws is equallyimportant to success. As dentists, weare responsible for taking care of ourpatients, taking care of our team

members, and taking care of ourfamily members. This demands anincredible amount of energy anddedication, and the only way to be able to fulfill these responsibilities is to take care of ourselves first.

It is indeed possible to work oneself to death. So, in order to findbalance, taking regular breaks fromour practices to “sharpen the saw”makes sense. This is important time to replenish ourselves mentally byengaging in relaxing leisure activities,spending quality time with our lovedones, and setting plans and goals.Taking this time regularly andfrequently also contributes to thesustainability of relationships with ourloved ones. The frequency of thesevacations depends on a person’sindividual needs and comfort level.Some may find that a quarterly weekof holiday is sufficient; whereas, othersmay feel that a monthly retreat is more appropriate for their needs. One strategy is to plan out each year’svacations in advance, and thenschedule patients around those times.

Sustainability viaContinuing Education

Once you stop learning, you start dying.—Albert Einstein

Only through continuing educationare we able to keep up with technologyupgrades and changes. Attendinglocal, regional, and national meetingsallows us to stay on the forefront oftechnology, and allows us to offer ourpatients the most advanced techniques,materials, equipment, and procedures.Dentists do not have the luxury ofbeing static in their practice. If we are not moving forward, learning,growing, and improving, then we are actually moving backwards inrelationship to our profession.

One of the most powerful vehiclesfor staying abreast of changes in ourprofession is active participation in astudy club. Study clubs can be local ornational, loosely organized or highlystructured, online or face-to-face. One commonality they share is thatwe only get out of them what we putinto them. My experience is that inevery study club “sub-specialists”exist. Certain participants will haveparticular interests and areas ofexpertise that they are passionateabout and are willing to share.Consequently, all members of thestudy club then become highlyeducated in an aggregation of areas of dentistry including technology,marketing, management, and a widevariety of clinical skills and techniques.

Sustaining a Positive Work Environment

Life is short…Work where you arecontinuously accepted, respected,appreciated, encouraged, inspired,empowered, and valued. —Ty Howard

Developing and maintaining a teamculture founded on admiration,appreciation, and respect is one of themost challenging tasks that dentistsencounter. Setting about such a taskmust start with the hiring process. The adage “Hire for personality andtrain for skill” has served me well over the last 20 years, as I cannot trainan employee how to be charismatic,thoughtful, empathetic, or compas-sionate. These qualities must be deeplyembedded within long before theperson applies for a position in adental office. A question I’ve askedmyself when interviewing a potentialteam member is, “Could I ride in a car for eight hours with this person?”


Sustainability

When designing and

building or finishing out

office space, there are a

number of factors which

will contribute to energy

conservation, environmental

stewardship, and an inviting,

productive workplace.


In a nutshell, I’m looking for anattitude of gratitude.

Once a potential employee haspassed the screening process andworking interview, she or he mustagree to our three rules ofconversation in the office before aposition is offered. These three rulesare as follows:

Is my conversation true? •Is it kind? •Is it helpful? •As leaders, we are all painfully

aware that gossip and negative energydestroys teams. By committing tothese three tenets, employees aregiving their teammates permission to call them out on it immediately bysimply holding up three fingers, andagreeing to hold their teammatesaccountable for the three tenets bydoing the same.

Another idea for maintaining acohesive team is to have all teammembers read an inspirational ormotivational book each quarter. Thereare literally thousands of these booksavailable in multiple media. In ouroffice, team members are monetarilyrewarded for submitting a one-pagebook report describing how theybenefited from reading the book andwhat concepts from the book theywould like to see implemented. Anadditional tool for developing a rockstar team is regularly scheduled, off-site, team-building retreats. Theseevents can be coordinated by aprofessional who has experience inteam-building activities and who candesign exercises to engage employeesin areas such as trust, respect, andservice. An important lessonemployees can gain from these retreatsis an understanding and appreciationfor each other’s vital role in the office,and to encourage communication and synergy.

Sustaining Long-termEmployees

Once you have experienced excellence,you will never again be content withmediocrity. —Thomas Monson

In addition to having an overall workenvironment which is sustainable andhealthy, having a sustainable team ofhighly skilled professionals whoregard their positions as careers, andnot just jobs, is equally important.Investing in long-term employeesmeans developing loyalty by providingcontinuing education and trueownership in the business. It meansoffering them a comfortable livingwage with health-care benefits, aperformance-based bonus system, anda meaningful retirement plan. Ourbonus system has worked well for usfor many years. There are twocomponents to our system: (a)monthly office financial goals and (b)quarterly individual performancegoals. In each month of the quarter, ifthe office financial goal is met, then50% of the bonus is awarded to teammembers carte blanche. The other50% is held back until the end of thequarter after performance reviews.

Employees review themselves andgrade themselves out of a possiblescore of 100%, with particularattention given to improvementopportunities identified during theirlast quarterly review. Their manageralso reviews them, and these twoscores are averaged. If the resultantscore is 90%, for example, then as anindividual performance-based bonus,the employee receives 90% of theirshare of the monies that were heldback for that quarter. It is interestingto note that most of our officeemployees score themselves lowerthan their manager scores them.

Community Karma andCommunity Service

The best way to find yourself is to loseyourself in the service of others.—Mahatma Gandhi

One of the office activities our teammembers appreciate most is ourquarterly community service projects.We affectionately refer to this asBenevolent Marketing, although it isso much more than that. During anannual planning meeting, we choosefour charitable organizations per yearto which we will donate one day’swork as a team. Examples include thelocal food bank, homeless shelter,


Sustainability

Dentists do not have the luxury of being static in their

practice. If we are not moving forward, learning, growing,

and improving, then we are actually moving backwards in

relationship to our profession.


Habitat for Humanity, Rape CrisisCenter, and Wounded WarriorsCenter. During these “volun-teaming”days, we close the office andparticipate in work that particularcharity needs done. Participation is mandatory, and, therefore, employee hours are compensated. It is incredibly rewarding to serveothers less fortunate, and it is astartling reminder of just howfortunate we are to work indoors in the comfort of a temperature-controlled, pleasant-smellingenvironment. A good deal of team-building, communication,understanding, and forgivenessoccurs during these outings, and theteam inevitably returns from themwith a deeper appreciation for theircareers, for their life circumstances,and for each other. These communityengagement opportunities are greatmoments to share via social media,and this really helps build a strongercommunity karma.

Financial Sustainability

Customer satisfaction is worthless.Customer loyalty is priceless.—Jeffrey Gitomer

In order to sustain ourselves asdentists and business owners we haveto continually attract new patients to

our offices. Of course, the best referralcomes from fired-up, existing patientswho can’t contain their enthusiasmover how gently, warmly, skillfully, and professionally they were treated in your office by your entire team.This type of endorsement conveyswith it a significant element of trust, as long as we perform up to these expectations. In today’scompetitive climate, an onlinepresence is also critical, as this is theother major source of new patients. In addition to having an attractive,informative, easily navigable website,the quantity and quality of onlinereviews are extremely important. It is vital to train your team to askappropriately for these reviews. Here’s an example: “If you are happywith the service you received today,we’d be honored if you would shareyour experience with others byposting a review online.” Then make itsimple for them to do so by offeringthem a tasteful card with a link to yourreview page, or send them a follow-upe-mail or text message with the link.You will be amazed at the responsesyou will receive if you ask appropriatelyand make it easy for them.

Job Satisfaction

Do what you love and you will neverwork a day in your life. —Anonymous

Providing quality care is a majorelement in a dentist’s overall jobsatisfaction. Taking pride in your work leaves you with a sense ofaccomplishment and fulfillment of ajob well done. It also contributes to asustainable dental practice, as qualitywork is less likely to need replacementand repair in the future, thus resultingin happy patients who refer theirfamily and friends. Working with ateam of skilled professionals takes a lot of the burden off the dentist andbolsters the confidence that your teamis going to care for your patients as ifthey were family. Performing high-quality dentistry eventually results in community acclaim and peerrespect and admiration. This positivefeedback loop encourages us tocontinue to strive harder and holdourselves to an increasingly higherstandard of care in our work. n


Sustainability

Taking pride in your work leaves you with a

sense of accomplishment and fulfillment of a job

well done. It also contributes to a sustainable

dental practice, as quality work is less likely to

need replacement and repair in the future, thus

resulting in happy patients who refer their family

and friends.


Wilhelm Wang, MD

Abstract

Issues inherently associated with practice ofdentistry, whether they are sociallyinfluential, environmentally significant, orfinancially consequential, present both risksas well as opportunities to dental profes-sionals and dental service organizationsaround the world. Increasingly, variousnational public health authorities andregional dental professional associationshave recognized the importance for dentalprofessionals to address issues related tosustainability and pledged calls to actionswithin the dental industry. Development andsubsequent adoption of ASTM E3014–15,Standard Practice for Managing Sustainabilityin Dentistry, the first and single recognized,consensus-based national standard thatcomprehensively covers considerations for,and relevant issues pertinent to, managingsustainability in dentistry, marked aprominent milestone and offered a practicalmanagement framework for those who arepursuing sustained performance, whether it is in a single dentist’s own practice or it isfor a multi-facility dental service corporation.From establishing the context in whichdental service organizations (DSOs) mightchoose to operate to demonstration ofcontinual improvement, this article presentsa synopsis of the ASTM E3014 standard,discusses system-oriented thinking andapproach to managing risks andopportunities, as well as highlights keymanagement practice elements andrequisite operational controls in provision of dental care and services.

Sustainability is a big word and amouthful to say. But, as you will

soon see, it does come in all forms,sizes, and shapes. Specifically, whatdoes sustainability mean to you as aprofessional dental practitioner or as a head of an oral healthcare serviceorganization? It is all in the eyes of beholders.

From an academic perspective,“sustainability” has been welldiscussed, interpreted, and applied ina number of ways. As Merriam-Webster has it, sustainability is derivedfrom being “sustainable,” or, of,relating to, or being a method ofharvesting or using a resource so thatthe resource is not depleted orpermanently damaged.

Around the world, the most widelyaccepted definition derived from theUnited Nation World Commission on Environment and Development or the Brundtland Commission in1987: “Sustainable development isdevelopment that meets the needs of the present without compromisingthe ability of future generations tomeet their own needs.” As a directderivative of this understanding, awell-regarded institution such asUniversity of California, Berkeley hasdefined sustainability as “the ability tomeet the needs of the present whileliving within the carrying capacity ofsupporting ecosystems and withoutcompromising the ability of future

generations to meet their own needs.”U.S. Environmental Protection Agencydeclares that “to pursue sustainabilityis to create and maintain the conditionsunder which humans and nature canexist in productive harmony to supportpresent and future generations.”Finally, it is with interest to see thatsustainability has been defined to be“… maintaining or improving thequality of human life while livingwithin the carrying capacity ofsupporting eco-systems,”as per theAustralia Dental Association.

At the turn of the new millennium,executives from ten financial institutesgathered together to discuss howsustainability can pose as a risk and, at the same time, present as anopportunity for their investments and holdings. Their discussions led to the establishment of the EquatorsPrinciples (EPs) in 2003 which setforth a collection of voluntary codes of practices and a risk managementframework for assessing andevaluating sustainability-related risksin investment projects and decisions.


Sustainability

Attaining and Strengthening Sustainability in Your Dental Practice

A System-Oriented Thinking, Approach, and Realization

Dr. Wang practicesinternal medicine inStockton, California;[email protected]


Today, adopted by 92 EquatorPrinciple Financial Institutions in 37 countries around the globe, theEquator Principles are recognized asthe preeminent benchmark forrecognizing and managing environ-mental and social risks in theinvestment decision-making process.Fundamentally, the EPs are addressingissues related to environmental andsocial impacts “to ensure that theprojects we finance and advise on aredeveloped in a manner that is sociallyresponsible and reflects soundenvironmental managementpractices…” It is with great interest to note that an Inquiry Working Paperby United Nations EnvironmentProgramme (UNEP) in 2016challenged the inherent ability andeffectiveness of the Equator Principles,as well as other similar privatevoluntary mandates such as GlobalReporting Initiatives (GRI) or theCarbon Disclosure Project (CDP), to“create substantial changes with

respect to sustainability impacts ofbusinesses”; the same study, notwith-standing, indicated that the EquatorPrinciples do “hold the promise andpotential to contribute to social andenvironmental sustainability.”

After all, sustainability is in theeyes of (markedly different) beholders!The dental profession is certainlycommitted to promoting better oralhealth for all. That being said, what isit expected to know and do aboutsustainability? To understand howsustainability can affect the dentalindustry as an entity as well asindividual dental practices is to, first,look inward to examine what activitiesand associated impacts are involved in what is offered to patients; and,second, deliberately and systematicallyevaluate the risks and opportunitiesassociated with how our products and services are delivered.

What Exactly is System-Oriented Thinking?

Mr. Scott Adams, famed creator of the Dilbert comic strip, has a keen andaccurate take on system-orientedthinking when he recognized andpointed out that “…With a system,you are always scanning for anyopportunity.” So what is a system after all?

In management terms, a system is a set of interrelated or interactingelements. Simply put, a system is acollection of various functional andorganizational parts or process of anentity or an operation known aselements. For instance, an element of asystem may include an organization’sstructure, defined and delegated roles and responsibilities, the planningand operation activities, operationperformance evaluation andimprovement, or other managementprocesses. Incidentally, process isdefined as “a set of interrelated or

interacting activities that transformsinputs into outputs.” Consequently, a dental practice and operationsystems may generally be described as a set of interrelated or interactingdental practice activities and operationprocedures that transforms inputs into outputs.

When a dental professional isstarting up a private dental practice,not only does he or she need to haveproper levels of competency, requisitepermitting or licensing, and adequateinstrumentation and equipment, he orshe must also set up operatingprocedures governing how materialsand consumables are to be orderedand refilled, how are cleanliness of theclinic and sanitization of dental toolsto be assured, how biohazardouswastes are to be disposed of, whatinsurance must be secured (or riskshedged), and how are patient recordsto be maintained and services to beinvoiced. These are exactly some ofthe essential elements of a dentalpractice and operation system.Certainly, one may choose to outsourceor seek contracted services on many if not all of these associated activitiespertaining to a dental practiceoperation. Guess what? Outsourcingand contracting, as a category ofactivities, is very much an element of a dental practice and operationsystem and must, too, be managed.

Moreover, in order to operate your dental practice or serviceestablishment sustainably, the systemmust also consider, function, anddelivers what is consistent with theexpectations of pertinent interestedparties, including financial investorsand sponsors, with no or onlytransient and reversible adverse effectsto the environment while enhancing


Sustainability

Sustainable development

is development that meets

the needs of the present

without compromising the

ability of future generations

to meet their own needs.


the livelihood of the communities inwhich it operates. Contrary to manycurrent definitions within the dentalindustry, it is important to discern and recognize that managingsustainability in dentistry does notexclusively deal with environmentalissues. In certain situations, peopletake a restrictive view to define andqualify “eco-dentistry” or “green

dentistry” which often only focus on resource conservation.

To assert sustainability, all of thefinancial outcomes, environmentalconsequences, and social responsi-bilities associated with dentaloperations will need to be equallytaken into consideration. Thus, a


Sustainability

How management view and translate sustainability into actionable agenda and performance metrics.

(Examples drawn from internal research and clientele learning)

Jabil Circuit, Inc.

Based in Saint Petersburg, Florida, Jabil is an electronicproduct solutions companyproviding comprehensive design,manufacturing, supply chain andproduct management services.Operating from more than 100facilities in 29 countries, Jabilemploys more than 180,000people and generates an annualrevenue of more than US $19billion in fiscal year 2017. At Jabil,sustainability means “connectingpeople, places, and partners toempower positive changes, with acommitment to improvingemployee safety and well-being,mitigating environmental impact,and positively impactingcommunities.” Specifically, Jabilmanagement has establishedobjectives and goals in fouraspects of its operations:• Mitigating environmental

impacts• Improving employee safety and

well-being• Positively impacting

communities• Reducing supply chain risk

www.jabil.com

The Weir Group, PLC

The Weir Group is a diversifiedengineering and manufacturingconglomerate with globalheadquarter based in Glasgow,UK, providing a wide range ofproducts, solutions, and servicesto the mineral, oil and gas, andpower industries. As of end of2017, Weir Group generates more than US $3.5 billion inannual revenues and employsapproximately 15,000 peopleoperating at 214 facilities in morethan 70 countries. Envisioningitself to be “the most admiredengineering business in our markets,” Weir Groupexecutives recognize thatsustainability is a multifaceteddiscipline and focus its sustain-ability efforts on six priority areaswith established high-levelperformance metricsunderpinning each area:• Health and safety• Product and technology• Environment• Community• People• Ethics www.global.weir/about-us

Wal-Mart Stores, Inc.

During its Net Impact Conferencein 2015, management at thehousehold-name retailer, Walmart, announced a new ten-year management vision to create “shared values” for itsbusiness and society, and placedsustainability on the sameorganizational platform withopportunity and community.Explicitly, management at Walmart established threeparticular goals addressing its sustainability issues:• Reduce energy intensity

and emissions• Eliminate wastes• Improving sustainability

in value chains

https://corporate.walmart.com/global-responsibility


sustainable dental practice oroperation deals with all pertinentissues laid out by people and partieswho have an earnest stake or intereston the dental practice and associatedactivities. This is a much larger matterthan just resource consumption orwaste generation. Whether one isstarting up a brand-new individualdental practice or establishing a dental service operation with multiplepoint-of-service dental clinics, system-oriented thinking calls forcomprehensive identifications ofissues pertaining to operation,beckons thorough evaluations ofassociated risks and opportunities,and delineates defined and disciplinedways of managing activities to ensure actions are getting deliveredproperly, goals are realized

progressively, and performance areimproved sustainably.

Commitment and Takingthe System ApproachManaging Sustainability in Dentistry

Development and adoption of ASTME3014–15, Standard Practice forManaging Sustainability in Dentistrymarked a prominent milestone andoffered a practical managementframework for dental professionalswho are pursuing sustainedperformance, whether it is for anindividual dentist’s own practice or forthe operation of a multi-facility dentalservice corporation. As stipulated inthe Significance and Use section of the standard, this standard “offers aconcerted approach to managing

social, economic, and environmentalaspects of dental practice; stipulatesminimum sustainability considerationsand requirements; and provides aframework for embedding sustainabledevelopment issue management intoday-to-day decision making anddental service activities.”

Aligned with benchmarkinginternational standard format, ASTME3014 defines who/what a DentalService Organization (DSO) is withinits scope of applicability and structuresstandard management practices inseven sections or clauses. Eachaddresses certain requisite elements of the subject system:

Understanding the context of1.dental service organizationsManagement system for2.sustainability in dentistry


Sustainability

FIGURE 1. Context of Dental Service Organization 5.1; Management System forSustainability in Dentistry 5.2

PlanLeadership & Committment 5.3

Roles, Responsibilities, Accountabilities, & Authorities 5.4

Planning 5.5Sustainablility Objectives 5.6

Demonstrated Sustainablilty in Dentistry

Inte

rnal

& E

xter

nal I

ssue

s 5.1

.1

Patie

nt N

eeds

& P

refe

renc

e &

Regu

lato

ry R

equi

rem

ents

5.1

.2

Intended Quality in Patient Care &

Sustained Organizational Perform

ance in D

ental Services 5.7.10

CheckPerformance Evaluation 5.7.7

Internal Audit 5.7.8

DoResources,

Competence,Communication,

Awareness,Documentation,

& Operations 5.7.1-5.7.6

ActManagement Review 5.7.9


Leadership and commitment3.Organizational roles,4.responsibilities, accountabilities,and authoritiesPlanning5.Sustainability in dentistry6.objectives and planning to achievethemSupport7.

Dental service operation•Performance evaluation•Internal audit•Review•Improvement•

First and foremost, it is profoundlyimperative that establishment of anymanagement system must be rooted ina well-defined context of organizationwith demonstrated leadership andcommitment. Experience has shownthat, otherwise, the resultantmanagement system would inevitablyfade into obscurity with no credibilityor standing. Context of a dentalservice organization is developed by(a) identifying and examining externaland internal issues pertaining to thepurpose and ability of the DSO toachieve intended outcomes; and (b)understating the needs andexpectations of its stakeholders.Collectively, developing the context(of an organization) is to cognizefundamentally what the DSO is andwhat does the DSO set out to deliverand accomplish.

A descriptive figure distinctlyoutlines the interrelationships ofvarious clauses and associatedmanagement system practices as theycorrespond to the four revolvingphases of a model management system—Plan-Do-Check-Act—is provided

in the Appendix of ASTM E3014-15and is reproduced here (Figure 1).

Having the context systematicallydemarcated and commitmentresolutely in place, the second mostcritical element of a well-structuredsystem managing sustainability in a DSO is to assess and develop actions to address pertinent risks andopportunities associated with itsactivities and operations. In particular,E3014-15 stipulates that “…Whendetermining the risks and oppor-tunities that need to be addressed, the dental service organization shallalso include considerations for risksassociated with organizationalintegrity, inclusivity, transparency, andstewardship as well as opportunitiesrelated to the practice of evidence-based dentistry.” This particularmanagement system requirement, for the very first time, genuinely andassertively brings about and boltstogether recognized benchmarkingsustainability management approachwith demonstrated state of science in dental practice.

Each of the subsequent clausesfurther delineates specific manage-ment practices and activities thatought to be taken or maintained.Consequently, requirements onmanagement review and improvement(Clauses 5.7.9 and 5.7.10) provideinput back to the planning activities.Finally, it is also noted with interestthat just nine specific managementactivities listed below where records,

also known as “documentedinformation,” are to be maintained:

Scope•Planning outcomes•Objectives•Competence•Certification, accreditation,•regulationDocumented information of external•origin as determined by DSOProcurement requirements, •criteria, and evaluation results ofperformance evaluationResults of management review•Nonconformities, actions taken,•and results of actions taken

As an integral part of the internalreview process, individual DSO shouldconsider periodically assessing anddetermining its ongoing operationalperformance along a sustainabledevelopment progression path. Auseful tool for this review, i.e., thesustainable development maturitymatrix first published in BS8900:2006,has also been suggested (Figure 2).Additional notations and guidance on use of the maturity model forperiodic assessment of sustainabilityperformance of a DSO are indicated


Sustainability

Contrary to many current definitions within the dental

industry, it is important to discern and recognize that

managing sustainability in dentistry does not exclusively

deal with environmental issues.


Principles PracticesStages of a Dental Organization’s Approach

to Sustainable Development

Increasing Maturity

Inclusivity Patient Consultingand Participation

Integrity Community Outreachand Services

Transparency Fair Pricing andBilling Transparency

Stewardship Energy Efficiency and Conservation

Addition Principle Additional Practice

in the E3014-15 standard (AppendixX.4). Maintenance of a sustainabledevelopment maturity matrix orequipment evaluation not only serve as internal measure for DSOmanagement, it also provides a source of documented informationwhen communicating sustainabilityperformance progress with external stakeholders.

Parting Thoughts

For those who are zealously andprogressively pursuing sustainabledental practices for the first time, astandard practice guidance outlining aroadmap and system methodologytoward managing sustainability indentistry has arrived. With a well-defined context of organization anddemonstrated leadership andcommitment, any dental professionalwill be able to methodically assess therisks and opportunities associated

with provision of dental services,prioritize actions for performanceimprovement, and more productivelyand sustainably contribute to thesociety. Application of E3014-15, in its entirety, provides a holisticapproach toward managingsustainability issues in dentistry andpractical steps in the realization ofattaining and continually strengtheningsustainability performance of a dental service organization. n


Sustainability

FIGURE 2. Sustainable Development Maturity Matrix


Sheila L. Margolis, PhD

Abstract

Every organization, including large and small businesses, can be characterized interms of its core culture. The central elementis purpose: not what the organization does,but why it does that (with the assumptionthat this is filling a need beyond theorganization itself). Organizations have a“personality” in the sense of a distinctivephilosophy that guides how they fulfill theirpurpose. Because organizations cannot do all things, they must choose some strategicand universal priorities for action. This coreculture is communicated to the world aroundthe organization through its practices and its projection, or efforts to control how it isperceived. Organizations that have a vaguecore culture or a core culture that does not fit the environment will not thrive.Organizations will also struggle when there is not a smooth fit among the elements of its core culture and the way it is realized in practices and projections.

What is valued at your dentalpractice? What is core to your

organization’s culture? For example, atAmazon, at the core of their culture isa focus on customer obsession.Amazon is built on an array ofcustomer-focused practices. Fromcustomer reviews, to selling third-party competitor products, to offeringa growing number of Amazon Primebenefits, Amazon ensures thatcustomer obsession is deeply embeddedin their culture and displayed in thecustomer experience. It is a value thatis core to their culture.

So for your dental practice, do youhave clearly defined values that guideyour practice? Is the image you projectto the public consistent with thesevalues? Likewise, is the patientexperience aligned with these values?And is the employee experienceconsistent with the values that youbelieve are core to your culture?

As it turns out, there’s a pattern insuccessful organizations; there areclearly defined core principles andvalues that are fundamental to eachorganization. These values are theorganization’s core culture: thepurpose, philosophy, and priorities.And in great organizations, employeesunderstand those principles andvalues, and they live by them each andevery day. They practice them inemployee-to-employee interactionsand in their interactions with patients.

Also, they project that image to thecommunity. Living your core culturebrings authenticity to your brand and harmony for those working inyour practice.

Look at Dental PracticeUsing the Five Ps

The Five Ps are purpose, philosophy,priorities, practices, and projections.The Five Ps is a system-wide, holisticway to think about your practice. You can use the Five Ps to understandculture, build alignment, and drivechange. The key to success is toconsistently practice and project the core culture principles and values that define you and that drive performance.

The Core Culture of Your Practice

To understand core culture andalignment, look deep inside yourorganization—at the central Three Ps:the organization’s core culture.

Purpose

At the center of core culture is theorganization’s purpose. Think ofpurpose as the why of your practice.It’s not what you do—like, forexample, in a university “to educate.”


Sustainability

Aligning Values and Business Strategy to AchieveOrganizational Change

Using the Five Ps to Embed Sustainability in Your Dental Practice

Dr. Margolis is President,Workplace Culture Institute,Atlanta, Georgia;www.SheilaMargolis.com


Instead, the purpose is why the work you do is important. For example,a university’s purpose might be “to prepare people for life” or “toempower people to make a differencein their own lives and the world.” Thepurpose is the foundation for yourpractice. It is your reason for being. It’swhy your organization exists.

Think of the purpose as the causethat defines one’s contribution tosociety. People seek meaning in theirlives through their work. Businessesexist to make a profit. They also existto make a difference. The purpose is ahuman focus. And when employeessee the purpose as challenging andmeaningful, work is more than a job.It’s a cause that makes a difference inpeople’s lives. The purpose definesyour gift to the world. It is what youbelieve in and why you’re in business.

For example, initially, you maydescribe the purpose of your practice assomething like “to provide dentistry.”But to define purpose, ask yourself,“Why is that work important?” If you think about it more deeply, interms of a why question and not awhat question, it might be expressedas “to promote health and well-being,”

“to foster health and self-esteem,” “to make a positive difference inpeople’s lives,” or something else.

Clarifying the purpose is the firststep in defining your organization’score culture. Everything you do must be aligned with the purpose. Are your daily activities working tocontribute to it?

Philosophy

Next, one layer outside of the purposeis the organization’s philosophy.Philosophy is a small set of principlesor values that guide how you and yourstaff distinctively do your work. Thephilosophy is how employees view the organization as being differentfrom other dental practices. And thephilosophy is enduring. There iscontinuity in the organization’scharacter. The philosophy describesthe values most important to thepractice in the past; it describes thevalues core to the organization today;and it would feel like a differentorganization if it was not important tothe practice in the future. Theorganization’s philosophy encompassesthe few principles or values thatemployees believe are fundamentaland distinctive over the years.

Philosophy is like the personality orcharacter of the organization. It istypically derived from the founder’spersonality, or the skills or ideals thatdrove the organization’s creation. Ifthe founder is the dentist, then thephilosophy describes what’s mostimportant to that individual. For

example, in one practice, there is aprime focus on delivering friendlycare. In that practice, there is aheightened concern that each patientfeels comfortable and enjoys his or herdental experience, or it might betechnical excellence, or even exploringinnovative technology.

In some practices, sustainability ispart of the philosophy of the dentalpractice. For dentists who truly valuesustainability, they use their dentalpractice as a way to model theirpersonal commitment not only to theeconomics of their practice, but also tothe social and environmental impactof their practice.

The purpose, plus the philosophy,are the organization’s identity. Identityis the essence of the practice. It is thewhy and the distinctive and enduringhow of the practice. Often the greatestchallenge of an organization is toconsistently maintain the discipline tobe that identity. And usually thechanges that an organization needs isto be better at being who you say youare. The organization’s identity is fairlystable. Rarely does an organizationchange its identity. Instead, the way anorganization drives change is throughits priorities.

Priorities

Now, one more layer outside ofphilosophy is the organization’spriorities. Priorities are part of core


Sustainability

Many organizations no longer exist because they had a flawed strategy.

As their industry made changes, these organizations did not. This lack of an

ability to change set them up for their demise.



Sustainability

Figure 1. The Five Ps.

Source: Margolis, S. (2010). Building a Culture of Distinction: Facilitator Guide forDefining Organizational Culture and Managing Change, Workplace Culture Institute.

Projections

ExternalPractices

InternalPractices

Strategic & Universal

Priorities

Philosophy

Purpose

culture—but not a part of organiza-tional identity. There are two types ofpriorities: strategic priorities anduniversal priorities. These are theadditional values that guide thepractice. They are the added values the organization must focus on andpay attention to now in order to becompetitive and to thrive in thecurrent business environment. Withthe ongoing changes in dentistry,dentists must be knowledgeable of thechanges and know where they mustmake adjustments in the way they runtheir practice. The purpose andphilosophy are relatively stable. Incontrast, priorities are the way tointroduce change in the culture.

Strategic priorities are yourstrategic values. They have an external,patient focus and align with industrychanges and the requirements to havea thriving practice. These prioritiesdescribe how you must perform inorder to achieve your business goals.Therefore, you must know yourstrategy and the changes in the dentalindustry in order to define yourstrategic priorities.

You must also have a smart strategyto guide your priorities. Otherwise,your strategic priorities will not leadyou to success. Many organizations nolonger exist because they had a flawedstrategy. As their industry madechanges, these organizations did not.This lack of an ability to change setthem up for their demise. Forexample, Borders did not have adigital, online focus—instead theyconcentrated on the growth of theirnetwork of stores and physical contentlike CDs and DVDs. They outsourcedtheir online sales operation toAmazon. It was like handing the keysover to a direct competitor.

A smart strategy must guide yourstrategic priorities. And when yourpractice has a change in its business

strategy, you must also reevaluate yourpriorities. This may require eliminatingpriorities that are no longer a strategicfocus and embedding new priorities so your culture can align with thechange. Making changes in prioritiesis a key way to shape culture and bringneeded change.

For example, in the 2009 recession,many organizations had as theirpriority to reduce costs. Therefore,cost control was a strategic priority


adopted at that time. But years later,other issues have risen in importance.

More and more, organizations arechoosing sustainability as a strategicpriority. Sustainability is notnecessarily a part of the identity ofthese dental practices; it is neither thepurpose nor the philosophy. Instead,for many, it has become a focus due toan increased awareness of the need fora triple bottom line approach—notfocusing just on financial, but also onthe environmental and social impactof their practices.

Everyone in the practice mustunderstand the industry challengesand how the practice is going toachieve its goals within the context ofthe business environment. Life is notstable. The ability to embed changewithin an organization is key tosurviving and thriving. Priorities giveorganizations that flexibility to evolvewith the times, while simultaneouslysustaining the dental practice’sdistinctive and enduring identity.

The second type of priority isuniversal. Universal priorities are thevalues that drive employeeengagement. They are called universalpriorities because they promote anenriching and motivating workplacethat stimulates exceptional efforts andcontributes to heightened employeeloyalty. These are values thatorganizations today are seeking to

infuse in their cultures in their efforts to have happy, productive,engaged employees.

The six universal priorities are fit,trust, caring, communication, achieve-ment, and ownership. Having thesevalues promotes an engaged staff.

Fit: Employees should be a fit with•the core culture of the practice anda fit with their jobs. Trust: To thrive, employees must•trust their leaders. Caring: A workplace must be •caring and supportive. Communication: Information •must be shared—in healthyorganizations, information flowsfreely in all directions. Achievement: Employees must feel•like they are growing, developing,and achieving. Ownership: When employees feel•like an owner—having a feeling of reasonable control and flexibilityin their work and participating indecision-making that impactsthem—they are more engaged. In an ideal world, these values

would not be differentiators. Butorganizations do not uniformly livethese values; therefore, the presence of these values enhances thecompetitiveness of the organization,and the absence of these values detersan organization from achieving itspotential. Organizations should assesstheir strengths and weaknesses inthese values and highlight, in theircore culture, the values to focus onand improve. These values—theuniversal priorities to focus on andpay attention to—may change overtime. Universal priorities are a way tointroduce internal changes with yourstaff in order to have a thrivingworkplace where employees put forth

the energy and effort to help thepractice succeed.

Alignment of Practices and Projections with theCore Culture

Once you have defined the coreculture—your practice’s purpose,philosophy and priorities, you must audit your practices andprojections to find opportunities to increase alignment.

Think of alignment as the way to embed change in your culture. The aim is to more consistentlypractice the core culture principlesand values. So, for instance, ifsustainability is a new priority, thenyou must assess current practices andprojections to determine if they arealigned with sustainability. Wherethere is insufficient alignment, theorganization must make changes.

Organizations should always seekbetter ways to practice the core cultureprinciples and values that drive success.All interactions must be laced with thecore culture principles and values. Byauditing your practices and projections,you can find ways to improvealignment and make positive change.

Align Practices with the Core Culture

Practices can be internal or external.Internal practices are employee-to-employee practices such as how theorganization is structured; how work is designed; the systems andprocesses for doing work and makingdecisions; recruitment and selectionpractices; training and development;performance management; internalcommunications; and technology.


Sustainability


The aim is to ensure all internalpractices are aligned with yourpurpose, philosophy, and priorities.

External practices are the patientsand the markets you serve, yourproducts and services for your patients,and your suppliers, vendors, andbusiness partners. All external practicesmust also be aligned with yourpurpose, philosophy, and priorities.

Some examples of sustainablepractices that might be introduced to enhance alignment with the priorityof sustainability include energyconservation practices, waterconservation practices, eliminatingproducts with toxins, limiting oreliminating mercury waste, and usingbiodegradable products. Dentists

concerned about sustainability see theimportance of having the best indoorair quality for their patients and staff.And they consistently look for ways to recycle everything they possiblycan, including moving from paper todigital. They may offer patients paperbags instead of plastic and givetoothbrushes that can be recycled.

Align Projections with the Core Culture

Projections embody the organization’simage that it displays to the publicthrough things like the organization’sname, logo, symbols, location andlook of its offices, image of its dentists,dress/uniforms of the staff, marketing,public relations, advertising, andcommunity activities. Theseprojections must be aligned with thepurpose, philosophy, and priorities.

There are many ways to align the priority of sustainability withprojections. For some who practicesustainable dentistry, they project that image through public educationand community service projects. Some locate their practice where it will offer easy accessibility to publictransportation. The facility for thepractice is also a way to achievealignment with sustainability. Dentalpractices can achieve LEEDcertification when their facilities meetsustainable guidelines in theirconstruction. Alignment of the coreculture with projections ensures thecommunity is aware of the values thatare core to the practice’s culture.

Alignment Plan and Metricsto Monitor Change

Once you have audited opportunitiesfor change, you can create andimplement an alignment plan. Thisplan will guide you and your organiza-tion in better practicing and projectingthe core culture principles and values.The goal is to achieve better alignmenteach day. Use metrics to monitor how well you are delivering on yourpurpose, living your distinctivephilosophy, and practicing yourpriorities. Be sure everyone workseach day to more effectively live theprinciples of your core culture thatdrive performance.

In the words of Jeff Bezos aboutcustomer obsession: “Customer focus is deeply ingrained in all thenooks and crannies of our culture.”Bezos wants employees to embed that customer focus in everythingAmazon does.

Use the Five Ps to guide you. Know the purpose, philosophy, andpriorities of your practice and live by those principles and values eachday. Use your unique culture to drive change and ensure yourorganization’s success. n


Sustainability

Some examples of

sustainable practices

that might be

introduced to enhance

alignment with the

priority of sustainability

include energy

conservation practices,

water conservation

practices, eliminating

products with toxins,

limiting or eliminating

mercury waste, and

using biodegradable

products.


David W. Chambers, EdM, MBA,

PhD, FACD

Abstract

An organization’s communications with itsmembers can be read as partially reflectingthe identity of those members. Four issues of the ADA News from each of the years 1975, 1985, 1995, 2005, and 2015 werecoded for content. Information from theassociation and news about developmentsaffecting the context of practice remained a constant feature through the periodanalyzed. Commercial advertisements andsales promotions to member dentistsincreased dramatically at the same time that letters from members and personalstories about dentists were less commonlyfeatured. These changes parallel the steadydecline in ADA membership during this same period. Several hypotheses mayexplain this relationship.

The world is a looking-glass, and gives back to every man the refection of his face.—William Makepeace Thackeray,Vanity Fair

Membership in the AmericanDental Association has declined

steadily over the past half century. As shown in Figure 1, in the middle ofthe past century more than nine in tenactive dentists were ADA members.Although there is some sign that therate of decline is abating, the rate ofloss has been about 0.6% each yearover the past half century.

Even though the direction andregularity of this trend is clear, it mustcertainly reflect a variety of causes.Similar trends have been noted overthe time period in many organizations.Among the health professions, medi-cine and dentistry show comparablelosses, while nursing, veterinarymedicine, and others have been lessimpacted. Generally, civic andfraternal organizations such as theMasons and the League of WomenVoters have seen heavy losses, whileprofessions such as engineers,accountants, lawyers, and architectshave remained steady (Putnam, 2000).

The general decline in “joining”was examined by Chambers (2004). It is almost certain that, in the case of dentistry, there are both generalsocietal causes and changes in whatdentists value. It is not the purpose ofthis study to identify the causes andgive them their relative weights.

This report looks, instead, at howchanges in one organization’s—the American Dental Association—self-image (as expressed in apublication intended to communicatewith its members) interacts withmembership rate.

Arguably, the ADA News reflectsthe interests of the association’smembers. To the extent this is true, itshould be possible to “read” what theassociation believes its members arelike or what they value by studying thecontent of the publication. If bothmembership and content in the ADANews changed in a systematic fashionduring the past 40 years, a prima faciecase can be made that some dentistsmay be leaving the association becauseit no longer reflects their values.

Materials and Methods

The ADA News began publicationtwice a month in 1975 as a means of providing members with timelyinformation regarding associationactivities and events of importance to practice. Originally two-tone and12 pages in size, it became full-color,four-column grid, 11 x 14, and variedin length from 12 to 32 pages insubsequent years.

The ADA library provided digitalcopies of 20 back issues of the ADANews for examination. These consistedof two issues from March and twofrom August in each of the years 1975,1985, 1995, 2005, and 2015.


Gies Ethics Project

Gies Ethics Project

The ADA News and ADA Membership

Dr. Chambers is Editor ofthe College. This report ispart of the empirical study ofethics in the professionrequested by the Regents ofthe College and known asthe ACD Gies Ethics Project.Photo by Dr. Herb Borsuk


FIGURE 1. Fifty-year membership trend in theAmerican Dental Association showing members as a percentage of active dentists.

differences were found, the average ofthe two values was used.

Results

Consistency of the coding wasacceptable, with correlation betweenthe first and second coding resultsacross all categories and issues of r = 0.936.

The overall percentage of ADANews content is shown in Table 1.Advertising and sales to membersaccounted for more than half of thematerial, and the proportion rosesteadily over the years. Internal andexternal news was constant at about


Gies Ethics Project

The content of these issues wasmeasured in terms of percent spacedevoted to eight different contentcategories. Space per item wasmeasured using a ruler, with text andphotographs being given equal weight.Because the number of pages differedacross issues, space per category wasconverted to percentages within eachissue.

Coding categories were determinedby an iterative process. Elevenpotential categories were identified byreview of 2016 and 2017 issues (notincluded in the study). Approximatelysix months later, four 2017 issues ofthe ADA News were reviewed andeach item was placed in the categorydemonstrating the best fit. When itwas uncertain how to categorize anitem, that prompted crafting tightercategory definitions, consolidations,and eventually the elimination of three potential categories.

The categories retained for use areshown in Table 1. Banners, statementsof ownership, and similar material were not coded. The selection ofMarch and August issues was partiallydetermined by a desire to avoid heavyemphasis on the ADA annual meetingor campaign material relative toofficer election. Approximately fourpages of such coverage were found inthe 20 issues examined, but they wereexcluded from coding.

The author performed all thecoding. The content of the 20 issueswas recorded twice, separated byapproximate two months. Where

A balance between

harvesting what is at hand

and searching for better

future alternatives is essential

to the survival of any group.

Sources: Putnam RD. Bowling alone: The collapse and revival of American community. New York:Simon & Schuster, 2000 and American Dental Association. National recruitment and retention reportfor active licenses dentists: End of year 2015. Chicago: The Association, 2016.


a quarter of the content. Focus onmember opinions and accomplishmentsrepresented about 15% of content, butthe proportion declined over the years.

Table 2 shows the correlationsbetween yearly ADA membership and percentage of ADA News content.There are two coefficients in each casebecause a pronounced curvilinearrelationship was observed. This wasdue to the fact that the effects ofchanged content balance on decliningmembership appears to have stabilized.

Declining association membershipis strongly paired with an increasingcommercial orientation in ADA Newscontent, as shown the two panels inFigure 2. This is apparent in moreadvertising space paid for by outsidevendors and in the association’s appealsto sell services to its own members.

Association membership waspositively correlated with two factors,both related to member participation.Opportunity to express personalopinions in the form of letters wassignificantly associated with highmembership numbers. To a lesser, but still statistically significant, extent, recognition of the personalaccomplishments, typically unrelatedto dental practice, in the form of“shout-outs” was also positivelyrelated to ADA membership, asgraphed in Figure 3.

An attempt was made to furthercharacterize the content of lettersappearing in the ADA News byanalyzing the apparent motivation ofthe letters. “Defender” letters werethose judged to praise the ADA orcriticize other organizations relative tothe practice of dentistry. “Builder”letters were those that questionedpositions or actions taken by theassociation or praised otherorganizations for actions thought toadvance oral health. “Defender”


Gies Ethics Project

Table 1. Coding categories for content in the ADA News.

Name % Definition

Advertisements 47 Promotion of products or services paid for bycommercial suppliers. Announcements ofmeetings sponsored by other dentalprofessional groups were not include in thiscategory, but in the “Other News” category.

ADA News 15 Association activities, announcements,information about officers and staff, statisticson practice patterns of dentists. Policypositions of the association accompanied bydescriptions of activity advocating thesepositions was coded as “Lobbying.”

Shout-outs 8 Personal recognitions for individual dentists ororganizations, announcements of new deans,or significant honors from groups other thanthe ADA, stories of unusual personalaccomplishments.

Other News 8 Information such as federal policy, scientificbreakthroughs, public health concerns,coming from sources other than the ADA butrelevant to individual practice.

Letters 7 Opinion from ADA members regarding issuesof the day. Letters were further sorted into fourcategories: those that praised the ADA, thosethat raised challenges to its practices, thosethat praised other organizations, and those thatchallenged the actions or positions of others.

Internal 7 Announcement of services, materials,Marketing information, or other member benefits for

which members (and others) would be chargeda fee. Buyer guides and affinity cards (forwhich the association receives a commission)were so categorized. Announcements of theannual meeting or other conferencessponsored by the ADA were not coded, in thisor any other category.

Lobbying 6 Announcements of ADA lobbying positions,political stances and their reasons in oppositionto positions taken by government, otherprofessional organizations, or commercialorganizations, such as benefits programs.

Awards 2 Announcements of winners of awardssponsored by the ADA or requests fornominations for such awards.


FIGURE 2. Changes in commercial content in ADA News and association membership.

FIGURE 3. Association between featuring individual members and membership rate on association membership.

letters, constituted 55% of thosepublished while the remaining 45%were more challenging. The graph in Figure 4 shows an associationbetween the attitude of letters in the ADA News and associationmembership. During times of highmembership, challenging letterspredominated; as membershipdeclined, more “patriotic” letters cameto predominate. Not only do the slopes for the two relationshipscross each other, they are significantlydifferent at p < 0.05, suggesting that astrong membership base is associated


Gies Ethics Project

Table 2. Correlation between ADA membership as apercentage of active dentists across the years 1975 to 2015and percentage of content in ADA News by category.

Category Linear r-value Best curve r-value

Advertisements – 0.818*** – 0.875***Association news 0.341 0.355Shout-outs 0.450* 0.513*Other news 0.408 0.418Letters 0.894*** 0.905***Internal marketing – 0.508* – 0.521*Lobbying – 0.069 – 0.228Awards – 0.379 – 0.383

NB: * = p < 0.05, *** = p < 0.001

Membership and Advertising Space Membership vs Internal Marketing

Membership and Letters Membership and Shout-outs


with open discussion of the strengths and weaknesses of an organizationrelative to its context, while a weakermembership is more defensive in its opinions.

Discussion

The official publication of anorganization can be read as projectingthe image those in leadership positionsor staff wish to communicateregarding who its members are andwhat they value. It is clear that theimage of members of the AmericanDental Association, as reflected in itstwice-month newsletter to itsmembers, has changed over the past40 years. At the same time the strengthof the association, or its claim torepresent the entire profession, hasalso changed.

The function of the ADA News withrespect to conveying news outside theorganization about matters that affectthe membership and informationfrom within the organization has

remained relatively constant over theperiod of 1975 through 2015. Thecommercial emphasis of the newsletter(advertisements and offers of servicesfrom the ADA in exchange of fees paidby members) has increased from aquarter of the content to two-thirds. At the same time the content thatfeatures the opinions and personalstories of members has decreased fromone-third to 10%. Both of thesechanges are significantly associatedwith declining membership in the association.

These are correlations, so it isimpossible to say in a definitivefashion that a shift away from thepersonal voice and participation ofmembers to a commercial orientation“caused” a decline in membership.Both trends could reflect generalchanges in society. Another plausibleinterpretation is that increasedcommercialism, especially a greateremphasis on drawing money frommembers to support the organization,represents an effort to compensate fordeclining membership revenues. Theassociation’s 2015-2019 strategic planincludes the following objectives:“Objective 2: Achieve a net increase

of 4,000 active licensed members bythe end of 2019” and “5.2: Increasemember utilization of existingproducts and services and pursue newmarkets.” These goals may competeagainst each other. To the extent thatthe ADA emphasizes benefits overparticipation, it will be in competitionwith an increasing number of othergroups, including those withcommercial expertise and substantialresources, who provide specializedservices for dentists. Those dentistswho prioritize patient care andprofessional relationships overcommercial success may identify less with the image of dentistryincreasingly portrayed in ADA News.

There is an alternative explanationfor the observed association betweencommercial and non-personalcharacterization of the imageprojected by the ADA News anddeclining membership. At RobertPutnam (2000) and William Sullivan(2005) have argued, organizations are drifting toward increasing“professionalization.” As these authors


Gies Ethics Project

FIGURE 4. Association between ADA membership and letters classified as thosedefending the status quo and those challenging the profession to make improvements.


use the term, it should not be mistaken for the exercise ofprofessional standards of integrity andservice among the members, but theuse of lawyers, advertising executives,fund-raisers, lobbyists, consultants,event planners, web designers,research firms, and the like—bothwithin the organization and especiallyon a contract basis—to replacevolunteer members in leadershippositions. Such changes can becomeself-perpetuating when they consumeincreasing resources. Putnamdescribes this as “checkbookparticipation,” the practice of payingnon-colleagues to run an organizationon behalf of the members. Thisexplanation has the advantage ofaccounting for both the increasedcommercialization of the ADA Newsand the decreased voice given tomembers in terms of printing theiropinions and featuring their personalaccomplishments. Although notformally measured in this study, theabsence of information from theHouse of Delegates and reports fromcommittees and councils, includingactions of the trustees in thenewsletter, is notable.

The opportunity for member voicein the form of letters has declined inthe ADA News in recent years; thebalance has also shifted toward adominance of ADA-positive messages.Healthy organizations need both thosewho praise what is essential and thosewho ask how we can do better. Agroup that lives off its successes orpublicizes past accomplishmentsrather than making new ones possibleis unwisely investing in the future ofits young members (Fisher, 2009). An organization that fails to balanceits attention between hunting and

harvesting is doomed (Blum &Merkle, 2010). Bill Bishop’s The BigSort (2008) is a cautionary tale of howan imbalance of the “defenders” overthe “builders” leads to fragmentationrather than strength.

These results should also beconsidered in the context of whetherthe ADA represents the entire dentalprofession or the entire oral healthprofession. Membership numbers may not be the best indicator. In the1930s and ’40s, the American Collegeof Dentists challenged the thenprevailing model of dental journalism(American College of Dentists, 1932)as being dominated by commercialinterests and failing to serve the entireprofession. As a result of the efforts ofthe college, the S.S. White Company,which published the leading journal in the field, Dental Cosmos, assignedownership of their publication to theADA. The ADA agreed in exchange topublish a brief, periodic notification ofscientific advances to be sent free ofcharge to all dentists (Chambers,2012). The current JADA contains ahigher percentage of advertisementsthan did Dental Cosmos, and apublication for the entire professionnever materialized.

The ADA News is one of fourcommunication platforms used by theassociation. The others include theJournal of the American DentalAssociation that is devoted todisseminating scientific informationabout the materials, procedures, andpatient characteristics that affectclinical care; a website that focuses on expressing policy, services, andmaintaining membership functions;and a rich range of in-personopportunities at meetings and viaservice on committees. As an exampleof “professionalization” of theseplatforms, JADA is now published “onbehalf of ” the ADA by Elsevier, Inc.

These other forms of communicationshould be studied as has been begunwith the ADA News in an effort tounderstand how communicationshapes the identity of the professionand how changes in communicationcan best be used to strengthen it. n

References

American College of Dentists (1932). Thestatus of dental journalism in the UnitedStates: Report of the Commission onJournalism of the American College ofDentists, 1928-1932. New York, The College.

American Dental Association (2016). Nationalrecruitment and retention report for activelicenses dentists: End of year 2015. Chicago:The Association.

Bishop B. (2008). The big sort: Why theclustering of like-minded America is tearingus apart. Mariner Books: New York.

Blum, C., & Merkle D. (eds) (2010). Swarmintelligence: Introduction and applications.Berlin: Springer-Verlag.

Chambers, D. W. (2004). Joining. Journal of the American College of Dentists, 71 (1),31-35.

Chambers D. W. (2012). The 1932 report ofthe American College of Dentists Commissionon Journalism: Commercialism in dentaljournals. Journal of the History of Dentistry,60 (1), 2-17.

Fisher L. (2009). The perfect swarm: Thescience of complexity in everyday life. NewYork: Basic Books.

Putnam R. D. (2000). Bowling alone: Thecollapse and revival of American community.New York: Simon & Schuster.

Sullivan, W. M. (2005). Work and integrity:The crisis and promise of professionalism inAmerica. San Francisco: Jossey-Bass.


Gies Ethics Project



Manuscript Submission

Manuscripts for potentialpublication in the Journal

of the American College of Dentistsshould be sent as attachments via e-mail to the editor, Dr. David W.Chambers, at [email protected] transmittal message should affirmthat the manuscript or substantialportions of it or prior analyses of thedata upon which it is based have notbeen previously published and that the manuscript is not currently under review by any other journal.

Authors are strongly urged to review several recent volumes of JACD. These can be found on theACD website under “publications.” In conducting this review, authorsshould pay particular attention to the type of paper we focus on. Forexample, we normally do not publishclinical case reports or articles thatdescribe dental techniques. Thecommunication policy of the Collegeis to “identify and place before theFellows, the profession, and otherparties of interest those issues that affect dentistry and oral health.

The goal is to stimulate this communityto remain informed, inquire actively, and participate in the formation ofpublic policy and personal leadership to advance the purpose and objectives of the College.”

There is no style sheet for the Journalof the American College of Dentists.Authors are expected to be familiarwith previously published materialand to model the style of formerpublications as nearly as possible.

A “desk review” is normallyprovided within one week of receivinga manuscript to determine whether it suits the general content and qualitycriteria for publication. Papers thathold potential are often sent directlyfor peer review. Usually there are sixanonymous reviewers, representingsubject matter experts, boards of theCollege, and typical readers. In certaincases, a manuscript will be returned to the authors with suggestions forimprovements and directions aboutconformity with the style of workpublished in this journal. The peer-review process typically takes four to five weeks.

Authors whose submissions are peer-reviewed receive feedback from this process. A copy of the guidelinesused by reviewers is found on theACD website under “How to Review a Manuscript for the Journal of theAmerican College of Dentists.”

An annual report of the peer reviewprocess for JACD is printed in thefourth issue of each volume. Typically,this journal accepts about a quarter of the manuscripts reviewed and theconsistency of the reviewers is in the phi = .60 to .80 range.

Letters from readers concerning any material appearing in thisjournal are welcome at [email protected]. They should be no longerthan 500 words and will not beconsidered after other letters havealready been published on the sametopic. [The editor reserves the right torefer submitted letters to the editorial board for review.] Where a letter to theeditor refers specifically to authors ofpreviously-published material or otherspecific individuals, they are given anopportunity to reply.

This journal has a regular sectiondevoted to papers in ethical aspects ofdentistry. Manuscripts with this focusmay be sent directly to Dr. BrucePeltier, the editor of the Issues inDental Ethics section of JACD, [email protected]. If it is not clearwhether a manuscript best fits thecriteria of Issues in Dental Ethics, itshould be sent to Dr. Chambers at the e-mail address given above and a determination will be made.

Submitting Manuscripts for Potential Publication in JACD


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