volume 87 - number 2

March - April 2008
Pucker Up - The Effects of Sour Candy on Your Patients' Oral Health

Anatomical Variations of the Lingual Mandibular Canals and Foramina

Taken to Heart: The 2008 MDA President’s Interview

Can I Afford to Retire?

Heading Home

MDA News


Classified Ads

Cover Feature

The Green Dental Office

Introduction by Christopher E. Carroll, D.M.D.*


“We have become great because of the lavish use of our resources, and we have just reason to be proud of our growth…  But the time has come to inquire seriously what will happen when our forests are gone, when the coal, iron, the oil and the gas exhausted?  We must handle the water, the wood, the grasses so that we will hand them on to our children and our children’s children in better and not worse shape than we got them.”

Theodore Roosevelt at the Governors Conference on the Conservation of Natural Resources, May 1908

Northwest Dentistry thanks the following individuals and companies for their help in creating this article.

Carl Robertson, AIA
Sjoquist Architects, Inc.

Minneapolis, MN

Larry Karkela, President
Karkela Construction Inc.

St. Louis Park, MN

Bob Shaffer, AIA, CID
The Foundation Architects

Minneapolis, MN

Stuart Bailey, AIA
Miller Architects & Builders

St. Cloud, MN

Tom Olesak, President
Progressive Architecture

Saint Paul, MN

Andrew Christensen, President
Heritage Construction

Elk River, MN

Russ Karasch, President
Keystone Design Build, Inc.

Cold Spring, MN

Bill Krake, AIA
Welsh Construction

Minneapolis, MN

A hundred years later, Roosevelt looks pretty prescient to us. Of course there were other visionaries, and a quote from Black Elk, John Muir, or Izaak Walton would have suited the purpose just as well. Still, I don’t think that the environment was getting nearly as much attention then as it is garnering today — Academy Awards and Nobel Prizes, no less — and they certainly didn’t know anything about global warming.

It is difficult to watch the news or open a magazine or newspaper without seeing the environment dealt with in a serious, if not urgent, fashion. The above quote, for instance, was pulled from my latest “Smithsonian” magazine. “National Geographic” had a cover story on recycling, with another article on e-waste (computers, printers, etc.). The Minnesota DNR journal “Minnesota Conservation Volunteer” ran a piece on biofuels. “Newsweek” had an article on fuel cells and another on the revival of the electric car. Even my morning’s “Winona Daily News” offered a couple of items. Lake Superior is rebounding a little from record low levels since we had nice rain in October and nice snow in December. Noted polar explorer Will Steger and Gov. Pawlenty will be holding forums around the state to bring attention to what scientists predict global warming has in store for Minnesota’s forests. And much closer to home for our professional climate, the January 8 ADA web news warned us to brace for a public backlash because Norway is banning amalgam restorations purely on environmental grounds.

What all this means and will increasingly continue to mean for us is change. Whether for social, philosophical, economic, religious, or legal reasons, we are all altering our lifestyles and professional practices in ways intended to lessen our impact on the environment.

Since I’m an expert on only one dental practice, mine, and assuming that it is fairly representative of a typical Minnesota office, let us use it as an example of how environmental concerns have had an impact on what we have done. In our office we have:
• weather-stripped and increased insulation when we remodeled and used recyclable steel construction studs
• converted old T12 fluorescent fixtures to more efficient T-8 tubes with electronic ballasts
• installed programmable thermostats
• added reflective glass (low E) windows
• installed mini-fluorescent fixtures
• installed a central vacuum that uses no water and has an amalgam trap
• converted heating and cooling return-air vents from the ceiling return vents in the summer to the floor return vents during the winter
• installed three high-efficiency heating and ventilating units on the roof
• replaced the old 30-gallon hot water heater with an efficient ten-gallon one
• recycled where we can
• installed water-saving toilets, and
• I walk to work and drive a gas/electric hybrid

“Who does he think he’s fooling?” you might be asking yourselves. “That modest effort is hardly impressive.” I couldn’t agree with you more! For one thing, I only live three blocks from my office, and that dinky daily trek is hardly worth mentioning. “Let he without sin” you might be muttering, and you’d be right again. No one need fear having to dodge an environmentalist stone coming from my direction. Just to reassure you, take a look at another list: my transgressions.
• My office is as big as a tennis court yet only one dentist practices in it.
• I usually use conventional materials (carpet, paint, etc.) instead of recycled or more sustainable ones.
• I don’t sign up for my energy company’s summer energy savings program.
• Every workday we toss plastic bag after plastic bag of disposable products into our dumpster.
• I use no alternative energy sources (wind, solar, geothermal).
• My showers are too long and hot.
• We still have a mini-van.
• My T.V. is an energy hog plasma, and I have a gazillion electronic components wasting energy on standby.
• My office has too much and too much of the wrong kind of lighting.

This last one is my worst addiction. I love lighting. In my office I have sconces, chandeliers, parabolic reflectors, down-lights, up-lights, and table lamps. I’ve gone to the trouble of counting them for you. There are 26 four-foot fluorescent tubes, 36 fluorescent mini-tubes, one metal halide bulb, five low-voltage halogen bulbs (including patient lights), and a whopping 50 halogen bulbs. It has been reported that on a clear night my office can be seen from outer space.

Alas, I really should change out all of those incandescents, but I love the quality of that crisp halogen light. LED lighting is coming on rapidly. Maybe it will come along soon enough to save me before they take incandescent bulbs off the market (slated for 2016, I think).

So as you can see, I still have a lot of work to do. I imagine most of the rest of you do as well. We all have ample reasons to push forward and reduce our carbon footprints, and that is why this issue of Northwest Dentistry is entering into the environmental arena. We asked a number of Minnesota architects and contractors who have a strong environmental component in what they do to contribute their experience and expertise to create the following article. It is our intent to get you thinking both in the here and now and for the future. Dentists are leaders in so many areas. This should be a genuinely natural fit.

Square One, Day One
When addressing dental offices specifically, the green movement is relatively new, and its growth will be dependent upon a number of factors, including values and priorities relating to legal, professional, personal, and business and financial considerations. While thinking globally is now a given, we need to recognize that there will always be a financial consideration driving any decision, and that reality needs to be a clear focus as a project is planned. Contractor Larry Karkela stated, “It is my firm belief that most good changes are economically driven, and once the economics become more widely known, the green movement will accelerate rapidly.” As well as a means to possible business efficiencies, more dental practices will be using sustainability as a marketing direction. Thus, selecting architects and contractors with both the commitment and the experience in this philosophy is essential for success.

Levels of Action
“Green”, i.e., sustainable, design has many levels to consider. Design decisions should be focused on those aspects that will be most beneficial to the clinic and the environment. Green design should protect occupant health; improve productivity; be energy, water, and resource efficient; and minimize impact on the environment. It is always wise to add an LEED (Leadership in Environmental and Energy Design/U.S. Green Building Council) consultant to the architect/contractor team for any new project to explore all options before the final design. An LEED certified design will give a project of any size guidelines and goals, and focuses on five key construction areas: sustainable site development, water savings, energy efficiency, materials selection, and indoor environmental quality. While LEED certification comes with no tax breaks or such, it carries the weight of “I did it right”, and can be a positive community influence and practice builder. Dentists are leaders, and when they “talk up” a concept, people pay attention. That’s a contribution to green movement right there.

You Are – Where?
The first step in evaluating a green project is the building itself. The approach for an existing dental office will be completely different from that for creating a new one. Size and location of any existing office create limits on what can be done. For new, free-standing offices, the possibilities are wide open. One resource to consider is the Minnesota Energy Challenge, a self-guided energy audit available at mnenergychallenge.com. It will start you with a solid “you are here” and offer good, easy suggestions on how to improve.

Site Selection
Site selection is a high impact topic for both urban and rural areas. In rural areas, rather than building new on what was good arable land, renovating an old building, perhaps even a historic one, is very green. When looking for “location, location, location”, a landmark building can be value added. In the city, availability and crowding are issues that will have to be looked at in terms of environmental impact. But town or country, site selection always comes down to the needs of an individual practice.

The amount of heat generated by equipment is always figured into a design mathematically. If constructing a new building, hire an engineer to do the heating and electrical calculations. If you hire just at the “design/build” level, they will most likely build to code and not fine tune beyond that. Surprisingly, even in Minnesota most larger office buildings don’t require any extra heating in the winter; the lights, computers et al are sufficient. The down side is that that same equation places very heavy loads on air conditioning in the summer. And “anecdotal evidence” tells us a lot of folks think most offices run too warm anyway.

Installing high-efficiency systems will have immediate results in reducing operating costs. Additional insulation allows systems to be reduced in size and will provide a more comfortable interior environment. Efficient lighting reduces heat loads, thereby reducing AC demand.

Electrical, Lighting, and Energy
When analyzing your project with a green approach, find out where your energy comes from: Is it a new facility or a re-use one? Then think ahead. Buying your energy from a wind co-op, for instance, will probably (at least currently) cost the same as other sources, but it is, again, a “right thing to do”. It is a vote, a step. Dental offices use a lot of power, so “self-generation” is a lot to ask, but consider solar panels. Do make sure to buy your energy locally. The further it travels on transmission lines, the more of it is lost. The “carbon footprint” each of us leaves applies to every category of materials and supplies, so start thinking in terms of sourcing. Dentists should ask their suppliers for efficient options in all categories.

A lot of good light is essential in a dental office, and a dentist can completely re-lamp any clinic. The quality and variety of energy-efficient light bulbs have vastly improved over the last 10 years. Virtually all new projects in the past five to seven years have incorporated energy-efficient fluorescent lighting. The latest systems incorporate LED lighting with automatic dimming capability to utilize sunlight more effectively and to maintain a relatively constant light level.

Addressing quality, especially for shade matching, the most natural light is best, and can be created with fluorescent lamp bulbs. The best option, however, is north facing windows and natural daylight. North means no direct sun at any time, just an even, direct light, as opposed to west, for example. Most dentists are well aware of color-correct lamps and ask for them. They are only needed in the operatories. And don’t forget classic architectural design: overhangs, windows shaded from the summer sun, deciduous vegetation.

Being green means being active in pursuit of environmentally sound options. Find an energy audit specialist. Xcel or any energy company will come out and audit, and that is an efficient place to start. They will tell you it is cheaper for them, especially as major providers, to give rebates for saving energy than to keep building new plants and using up non-replaceable resources. Anticipating demand is a huge part of their planning, and right now there is no good answer. Coal pollutes, nuclear energy comes with storage and toxicity issues, wind and solar power generation fluctuates too much to carry the baseload. We also have several new metropolitan areas in this state, and their issues will evolve.

“Phantom electricity loss” describes the electricity we use on a daily basis that we don’t see or typically think about, such as small transformers for electronics, instant-on devices like TVs, monitors, computers, surge-protected extension cords, and electronic phones, and it is something we will be hearing more and more about. For instance, while some computers do their back-up work at night, they don’t need the monitor on. These days almost anything may be on standby power. Rule of thumb: if it has a clock flashing or any red or green light on, it is using electricity.

Granted, it’s hard to unplug. But if you start to think this new way, you will find new ways. There are devices that calculate the amount of “phantom” electricity a home or business is using. Use a power strip. Some clinics have master switches in each operatory. While retrofitting for the latter is difficult, in a new clinic, ease of closing up at night is optimized. The more you look for things to do, the more you will see. And don’t run the T.V. in the waiting room if no one is there.

Construction Materials
Construction “materials and methods” have a substantial impact on the “greenness” of any office, new or existing. Some contractors now use trash dumpsters that are sorted to recycle up to 60% of the waste, sending much less to landfills. Ask about that; ask for that. Renewable resources such as cork or bamboo flooring and recycled materials from floor to ceiling are gaining popularity. Using green materials with recyclable waste creates both a stabilizing and sustainable cost and an environmental advantage. Low toxicity materials should be a priority.

Right now it appears we are moving toward more eco-friendly managed forestry. It is currently comparable to organic farming, but is already a big industry. Consider the choice between real wood and a petro-based product. Real is better for a lot of reasons, one of which is “sick building syndrome”. This is very complicated, even for the professionals, but they will do the research if you direct them to. A healthier working environment is very green: Medtronic has found air quality and lighting in a green building is improved and their employees are more content and productive. Employees in their older buildings are now asking to move to the green building.

It remains a firm fact that there is no more basic cause and effect than the market directing what is produced. That is where the consumer can make the most positive impact.

Water consumption inside a practice is not a major item, although there is much that can be addressed. Water-saving faucets and appliances, including washing machines, should be considered. Clinic water does have to be very high quality, and that issue should be specifically addressed. As for water heating, a lot of people don’t see Minnesota as a good place for reliance on solar panels. Not true. Very few snowstorms, even here, can block a 45 degree solar panel. It will still have several hundred degrees of temperature in the middle of winter. The sun is strong enough. Solar water heating augments a system. You will use perhaps half the energy you otherwise would to heat your water. You can also go to a waterless hand sanitizer; you can do away with sinks – and a lot of plumbing - in the operatories. You simply have to evaluate your own willingness to look at the options and then prioritize.

As for the exterior, with a freestanding building, the landscaping on the site can manage the water issues. Native vegetation is already adapted to water management, and along with mulch and compost can reduce pesticide use as well. Use roof-collected runoff for any additional watering needed. Rain gardens reduce pollutants in the storm water stream and help control the amount of storm water flowing off a property. Savings of 40% inside and 70% outside can be achieved by selection of fixtures, vegetation, rainwater collection, and irrigation recycling.

And Goats on the Roof
Green roofs act not only as insulation but as water quality control for runoff. They are relatively new in the public awareness, and there are more raised eyebrows than consciousnesses about this option. The greatest drawback to their progress in the trade is initial cost. Even though green architects and builders emphasize the “life-cost” of an adaptation, most green adaptations do come with a greater front-end cost. Green roofs are viable. They do need to be maintained; they need a watering system, and plants can and do die. Architects say these issues are very manageable. Installers most often put a maintenance service into what is usually an annual contract. The practical side here is a genuinely serious one. In sites both urban and rural, water quality is a big and growing issue. It is being very regulated, and there is no flexibility in it. For instance, a one-acre site may require a pond to manage runoff from roof and parking lot. Replace the pond with a green roof, and you can have more building. Bottom line: Be aware of what you need from a site. Currently zoning requirements for parking drives most sites, so plan for greater function from your space.

Maintenance, Monitoring, and Upgrading
Green building can be challenging, and sometimes the intuitive answer is incorrect. Example: Adding insulation in the roof can take twice as long to pay back as investing in a window upgrade. The rule of thumb here is that maintenance and monitoring will be relatively low for passive components such as insulation and windows. For active ones such as AC, heating, and lighting, it will be essential to have a qualified service person conduct periodic tests and inspections, especially with high efficiency systems.

The technology to manage all these options is here, and it is growing rapidly, but it is operating at different levels of user capability. The good news is that there is probably someone in the practice who will love to get into all this.

The Practical Practice Builder
Developer/owners of larger multi-tenant buildings are recognizing the marketing benefits of green in their new properties, according to the Minnesota Commercial Association of Realtors (MNCAR), and that will rapidly drive the design of new multi-tenant buildings to green.

Some energy use statistics presented at the MNCAR seminar for a typical multi-tenant office building are useful in making decisions about investing in green.

1. Lighting: 36%
2. Heating: 5%
3. Cooling: 19%
4. Fans: 8%
5. Pumps: 3%
6. Receptacles (phantom): 29%

These numbers are for standard office use, and a clinic will probably differ. In new building construction, the owner has control over all of the above. However, as a tenant in a multi-tenant building, one has diminished control (if any) over heating and cooling system design.

In selecting dental and data processing equipment for a practice, energy consumption should rank after performance.

For those of you building, green construction can increase the cost of a building of 50,000sf or larger by 1.5-4%, and payback time can range from four to seven years. For those who are going to be tenants, remember you are being marketed to, and there will be a lot of opportunity to make exaggerated claims as the green movement becomes more prevalent.

Any aspect of a dental practice can serve as a practice builder as the green philosophy expands. For instance, while there would be no difference in the basic design of an office from place to place in our state, a dentist in the southern part could put a windmill on his or her property. It is a good investment, and it makes a strong statement. Dentists as a group have the wherewithal to make these changes a reality more than the general population does. They can appear symbolic, but practically speaking, seeing is believing.

The Best Thing Right Now
What can people do now? A lot. Relamp; put in programmable thermostats or occupancy sensors for light switches. It all adds up. Don’t overlook the simple things. That old refrigerator in the break room is very energy hungry. A new energy-star frig would pay for itself in a few years and pay it forward for even more.

For an existing practice in a leased building, energy consumption vs. cost increment evaluation of any new dental equipment, computers, and fixture purchases will be beneficial. If the lessee is responsible for all heating and cooling costs, be sure to have programmable thermostats properly set to save energy during non-business hours, and set temps near the most economical end of the comfort range otherwise.

The intangible is that any of these actions spark ideas, even if it’s a kid who walks into a bathroom, the light comes on for him, and he says, “Cool.” You never know who is watching, and what imagination will be ignited.

Granted, it is the contractor’s job to get a client into a building for the best price and in the best time, and it is really competitive out there. Time is money, but time is essential. Look at lead times. If you don’t give the contractor time to order the right materials, things are going to get compromised. Dental offices are very time sensitive, and it can be a big concern to relocate a practice. Be flexible, and understand that necessity. Build the time into the planning. Be honest with contractors up front about your values and priorities.

What Haven’t We Thought Of?
Among the most often overlooked elements in planning a green project is flexibility in dollar efficiencies. For instance, three partners in an LLC putting up their own building will find cost per square foot much lower than doing three individual sites. Such things as combined parking and site setback for efficient land use are where green and practice management meet.

Planning and staging – both are essential. Work with the designer. Plan for things later that you feel you can’t afford now. You may have a slab on grade now, but put the plastic tubing in and hook it up to a boiler or boiler/solar panel later.

Urban areas see sustainability more directly because of the closeness of people, buildings, vehicles, and the barrage of information about the “movement”. Rural areas may consider green design an urban concept, and the awareness may be vague at first. While we still need to get past the mindset against sustainable practices as everything from “hippie” or “goofy” to “elitist”, cost is always the biggest roadblock. Payback is still five to ten years on average before any profit from an adaptation is shown. The frustrations for all parties come with the rising costs during the entire process, often resulting in cost (i.e., quality) cutting measures no one wants to make. That’s where the solar panels or heat exchangers or green roofs just disappear. But if you don’t do it when you’re building, odds are against it happening later. Architect Carl Robertson told us, “My first warning to any dentist is always this: Whatever you’re thinking, it’s going to cost more than you think, it’s going to take longer than you think it will, and it’s going to be a bigger headache than you think it’s going to be. But when you’re done, you’ll be glad you did it. You won’t want to do it again soon, but you’ll be glad you did it.”

The Commitment
So here’s what we know:
1. Sustainability shouldn’t be considered a trend, it should be a way of life.
2. It is always wise to be a good steward of our resources, both energy and material.
3. Employing materials and systems to save energy and to minimize waste is good.
4. Thinking green will advance an enlightened professional’s personal and professional understanding of how things work.
5. The dentist benefits from lower operating costs and has the option of putting that saving to use in other good avenues.
6. Green choices have longevity, are the right thing to do, and they are never going to get less costly.

Do your homework; make good decisions. And don’t forget to switch off the light when you’re done.


*Dr. Carroll is a pediatric dentist in private practice in Winona, Minnesota.

Children’s Dental Services Project
Children’s Dental Services expanded the building it owns in Minneapolis, Minnesota to serve more low income children and families. Children’s Dental Services plays a critical role in providing essential, basic oral health care to more than 12,000 Minneapolis children each year.

In keeping with Children’s Dental Services’ mission of health and wellness, the building expansion plans included many innovative features to protect health and the environment, including storm water rain gardens, Energy Star appliances, high efficiency heating and air conditioning, high efficiency lighting, natural lighting, no-VOC (volatile organic compounds) paint, photo-voltaic solar panels, hot water solar panels, a reflective roof, natural building materials, recycled materials, recyclable materials, and double the required thicknesses of roof and wall insulation.

Copyright 2008. Minnesota Dental Association

<newsletter home>

Northwest Dentistry - Journal of the Minnesota Dental Association - contact us