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Manuscript_74fea5f6b1b6320769be6829539141ba

ARTIFICIAL INTELLIGENCE for SUSTAINABLE ORAL HEALTHCARE

DUCRET Maxime1,2,3, MÖRCH Carl-Maria4, KARTEVA Teodora Georgina5, FISHER

Julian6, SCHWENDICKE Falk6

Affiliations
1 Institut de Biologie et Chimie des Protéines, Laboratoire de Biologie Tissulaire et
Ingénierie Thérapeutique, UMR 5305 CNRS, Université Lyon 1, 69367 Lyon, France
2 Faculté d’Odontologie, Université de Lyon, Université Lyon 1, 69372 Lyon, France
3 Hospices Civils de Lyon, Service de Consultations et de Traitements Dentaires,
69008 Lyon, France
4 FARI – AI for the Common Good Institute, Free University of Brussels, Brussels,
Belgium
5 Department of Operative Dentistry and Endodontics, Medical University, Plovdiv,
Bulgaria
6 Department of Oral Diagnostics, Digital Health and Health Services Research,
Charité – Universitätsmedizin, Berlin, Germany

Corresponding author: Dr Ducret Maxime, Université Claude Bernard Lyon 1,

Faculté d’odontologie, Service de Prothèses, 11 Rue Guillaume Paradin, 69008 Lyon

maxime.ducret@univ-lyon1.fr

Keywords: Ethics, Artificial intelligence, Sustainability, Sustainable development

goals, Oral healthcare

© 2022 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
ARTIFICIAL INTELLIGENCE for SUSTAINABLE ORAL HEALTH

Abstract

Objectives: Oral health is grounded in the United National (UN) 2030 Agenda for

Sustainable Developement and its 17 Goals (SDGs), in particular SDG 3 (Ensure

healthy lives and promote well-being for all at all ages). The World Health

Organization (WHO) Global strategy on oral health calls for prioritizing

environmentally sustainable and less invasive oral health care, and planetary health.

Artificial Intelligence (AI) has the potential to power the next generation of oral health

services and care, however its relationship with the broader UN or WHO concepts of

sustainability remains poorly defined and articulated. We review the double-edged

relationship between AI and Oral health, to suggest actions that promote a

sustainable deployment of AI for oral health.

Data: Concepts regarding AI, sustainability and sustainable development were

identified and defined. A review of several double-edged relationship between AI and

SDGs were exposed for the field of Oral Health following.

Sources: Medline and international declarations of the WHO, the UN and the World

Dental Federation’s (FDI) were screened.

Study selection: One the one hand, AI may reduce transportation, optimize care

delivery (SDG 3 “Good Health and Well-Being”, SDG 13 “Climate Action”), and

increase accessibility of services and reduce inequality (SDG 10 “Reduced

Inequalities”, SDG 4 “Quality Education”). On the other hand, the deployment,

implementation and maintenance of AI require significant resources (SDG 12

“Responsible Consumption and Production”), and costs for AI may aggravate

inequalities. Also, AI may be biased, reinforcing inequalities (SDG 10) and

discrimination (SDG 5), and may violate principles of security, privacy and

confidentiality of personal information (SDG 16).

Conclusions: Systematic assessment of the positive impact and adverse effects of

AI on sustainable oral health may help to foster the former and curb the latter based

on evidence.

Clinical significance: If sustainability imperatives are actively taken into

consideration, the community of oral health professionals could then employ AI for

improving effectiveness, efficiency, and safety of oral healthcare; strengthen oral

health surveillance; foster education and accessibility of care; ensure fairness,

transparency and governance of AI for oral health; develop legislation and

infrastructure to expand the use of digital health technologies including AI.

1. Introduction

Artificial Intelligence (AI) is “a computer-based process that aims at reproducing, at

least partly, human or animal intelligence and finds applications in a wide range of

fields (e.g., machine learning, natural language processing, and robotics)”[1]. Digital

transformation of health care, including the use of IA, can be disruptive and is

expected to significantly impact patient – professional relationships and interactions,

as well as the provision of care; AI could foster a better understanding of population

and individual health needs and disease over the life course through integrating,

synthesizing, comparing, and extrapolating a wide range of data points, allowing a

more precise, personalized, preventive, and participatory service and care [2].

AI is being applied across a range of fields of oral healthcare, e.g. image and speech

analysis and, more broadly, predictive oral healthcare [3]. For example, AI-based

software is already proposed for the detection of proximal caries from 2D bitewings

[4], prediction of periodontal clinical attachment level [5], smile design of patients

[6,7] and detection of temporomandibular joint osteoarthritis [8] from cone beam

computed tomography (CBCT). There are also a growing number of

applications using AI that are able to perform automatic segmentation of CBCT for

various applications such as patient specific modeling [9–14]. While there is

optimism about the positive impact that AI may have on improving oral healthcare, a

range of unanswered questions remain, for example around the quality of AI systems

(e.g., robustness or transparency of AI) [15,16], the regulation of (particularly

dynamic) AI [17], the health economic and societal effects of AI (e.g. cost-

effectiveness and fairness), and the associated ethical risks [18].

One central aspect which has until now received little attention in oral healthcare is

the association between AI and oral health, i.e. its contribution to promote
sustainable oral health care, but also to ensure the development of sustainable AI

solutions [1,19]. This situation is concerning in a context where oral healthcare is

occasionally deemed “currently unsustainable“ in terms of environmental impact

[20,21]. This explains the recent call for action to “embedding AI into current dental

curriculum for achieving environmental sustainability and good health in 2030” [22].

The aims of this narrative review were 1) to identify the existing document

approaching the concept of sustainable oral health, 2) to examine double-edged

relationship between sustainable oral health and AI, 3) to discuss how AI can AI can

contribute to a sustainable oral health

2. Materials and Methods

First, authors proceeded to an exploratory scientific literature screening using

several keywords (Sustainab*, “Oral Health”, Dentistry, “Dental medicine”, “Artificial

Intelligence”) on Medline to identify previous publications about AI and sustainable

oral health or dentistry. In accordance with a recent scoping review [1], no previous

study was found, and authors decided to perform a narrative review using a non-

systematic approach. Secondly, several concepts regarding sustainability and

sustainable development were identified and defined using literature and documents

collected from Medline and international declarations of the WHO, the UN and the

World Dental Federation’s (FDI). Thirdly, we emulated a methodology used in two

recent papers [23,24], where they systematically aimed at identifying facilitators and

inhibitors of their field (AI or Robotics) for each SDG (n=17) and their 169 targets.

This methodology was useful to examine the double-edged relationship between

sustainable oral health and AI. Lastly, authors discuss several key aspects where the

use of AI could promote sustainable oral health or suggest actions that could be

taken to reduce its adverse effects.

3. Results

3.1 Defining Sustainable Oral Health

The Brundtland Report, provided one of the first definitions of sustainable

development “a sustainable world must meet the needs of the present without

compromising the ability of future generations to meet their own needs” [25]. Others

have provided alternatives for example, the United Nations Educational, Scientific

and Cultural Organization (UNESCO) proposed: "Sustainability is often thought of as

a long-term goal (i.e. a more sustainable world), while sustainable development

refers to the many processes and pathways to achieve it" [26]. In 2015 the United

Nations adopted the 2030 Agenda for Sustainable Development which sets out 17

Sustainable Development Goals (SDGs) with 169 targets [27][28]. These concepts of

sustainability and 2030 Agenda with its 17 SDGs underpin the concept of equitable

and sustainable oral health for populations and individuals supported by policy,

strategies and programmes that are integrated and indivisible and balance the three

dimensions of sustainable development: the economic, social and environmental.

The 2021 World Health Organization (WHO) resolution on oral health and 2022

WHO global strategy on oral health are grounded in the 2030 Agenda for

Sustainable Development [29]. The concept and term sustainability are both

explicitly and implicitly referenced, and notes that Member States can “strengthen

oral health care system capacities by environmentally sustainable and less invasive

oral health care.” This signals that oral health policies, strategies, programmes and

plans should contribute to achieving the SDGs. Similarly, FDI’s World Dental

Federation’s Vision 2030 report [30] includes supporting approaches and targets to

deliver sustainable, health-needs-based, and people-centered oral healthcare.

Sustainability provides a common approach to operationalize, quantify, and

understand how healthcare interventions and digital health technologies might

contribute or hinder the achievement of sustainable oral health.

Grounding oral healthcare in 17 SDGS can encourage dental service providers and

dental practitioners to consider and adopt actions to promote a sustainable oral

healthcare. This includes taking into account issues such as the environmental

impacts (CO2e, air and water), the concept of “reduce, reuse, recycle and rethink“ or

even biomedical waste and plastic management, as well as the impact of oral health

services on planetary health [31]. This is well aligned with a recent call to action to

promote sustainable oral healthcare, where “manufacturers, consumers, health

professionals and policymakers should consider environmental sustainability as part

of a ‘triple bottom line’, alongside clinical efficacy and cost” [32].

3.2 Examine the double-edged relationship between sustainable oral health

and AI

While the benefits of AI are widely discussed, there is a double-edged relationship

between AI and achieving sustainable oral health. For example, AI may reduce

transportation efforts (of patients, but also professionals) and thus optimize care

delivery (e.g. via more self-diagnostics and management, better triaging and referral,

or supported tele-servicing) (SDG 3 “Good Health and Well-Being”, SDG 13 “Climate

Action”). However, the deployment, implementation and running operations of AI

systems as well as the training requirements need to develop AI devices are

considerable, which will call upon and use significant resources (SDG 12

“Responsible Consumption and Production”). Similarly, AI theoretically promises to

increase accessibility of services for all, contributing to reducing inequalities (SDG 10

“Reduced Inequalities”) and ensure equitable quality education (SDG 4 “Quality

Education”). However, many AI technologies may remain costly and unaffordable to

most individuals, especially in developing countries, aggravating inequalities. Also,

there are increasing efforts to access a wide range of data to train and test AI

systems, while there are plenty of examples showing that despite these efforts,

training datasets remain prone to selection bias, introducing problems of fairness

and the risk to reinforce inequalities (SDG 10) and discrimination (SDG 5 “Gender

equality”). Moreover, efforts to access data may conflict with the principles of

security, privacy and confidentiality of personal information (SDG 16 “Peace, Justice

and Strong institutions”). Overall, it remains unclear if AI as a digital tool will truly

“help achieve the 2030 Sustainable Development Agenda” [33].

4. Discussion

The ethical duality of technologies has long been documented [34], and AI is no

exception, notably in relation to sustainability; it can both foster and worsen it [23,35].

Action by a broad range of actors should be engaged in understanding and acting

upon positive impact and adverse effects of AI on sustainable oral health (Figure 1).

We identify several key aspects where usage of AI should promote sustainable oral

health, or actions could be taken to reduce its adverse effects:

1. Better oral care and integrated services: AI technologies will allow health

systems to gather and leverage the full potential of oral health data to improve

decision making that facilitates more precise, personalized, preventive – and

hence sustainable - oral healthcare. Moreover, digital technologies and

specifically AI may need to involve patients as active participants, for example

as both data donors and recipients. An increased participation of patients in

the care process will also mean a shift away from the current “on-off”

(episodic) assessment and management of oral health towards a more

 continuous and lifelong care. Involving patients and establishing multisectoral

partnerships (health professionals, schools, communities) will allow a better

identification of the determinants of oral health which may currently not be

accessible for providers and provider-focused interventions. AI-supported

tools may help to promote sustainable healthy habits and lifestyles every day

and to address risk factors that oral conditions share with other non-

communicable diseases.

2. Strengthened oral health surveillance for better policy decisions and more

effective advocacy: AI-supported oral health surveillance systems can help

guide and inform the development, implementation and monitoring of oral

health policies, and to ensure that services are better aligned with the

evolving oral health needs of vulnerable communities and the general

population. Comprehensive and systematic knowledge on oral health needs

and services as well as on effective interventions to improve oral and

systemic health will help to strengthen oral health advocacy.

3. Education and access: AI may foster quality control and improve diagnostics,

decision making and treatment conduct, especially for less experienced oral

health professionals, which is relevant when considering the limited

specialized oral health workforce pools worldwide. AI-support may also allow

to widen healthcare professionals’ competency profiles and support an

evidence-based approach to the development, deployment, and retention of

the oral health workforce. Digital technologies including AI-supported self-

care, decision and triaging support or tele-diagnostics may help to reduce

inequalities in service consumption and health by increasing the accessibility

of healthcare [33].
 4. Standards and transparency: Standards and normative actions are needed to

ensure fairness, transparency, governance and human oversight of AI for oral

health. Focus points are the generalizability and fairness of the training and

test datasets, the proven explainability of any AI and its accordance with

medical reasoning, as well as transparency towards any data sources and

data usage in accordance with local data security legislation. To provide

reliable and comparable accuracy estimates of AI, benchmarking against

standard datasets is needed. Pushing for open data and open code can

improve the quality of AI but also curb unnecessary repetitive efforts when

developing AI solutions, thereby improving sustainability. Developers and

users of AI should appraise the ecological impact of training, deploying and

running AI systems, and developers should regularly report this impact.

Online calculators can estimate the carbon footprint of training AI models [36].

5. Establish and/or reinforce governance legislation and infrastructure for digital

health: This should include principles for the ethical use of artificial

intelligence, and agreements on global appropriate use of oral health data and

technologies, and also on concepts such as oral health data as a global public

good.

5. Conclusion

The oral health professional community is called to action to actively employ AI to

foster more integrated, sustainable oral health to strengthen oral health surveillance

and advocacy, to support oral health workforce development and increase the

accessibility of services, to ensure standards and transparency of oral health AI, and

develop legislation and infrastructure to expand the use of digital health technologies

including AI.
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Figure

Figure 1: Positive impact and adverse effects of Artificial Intelligence (AI) on

sustainable oral health. SDG 3 “Good Health and Well-Being”, SDG 4 “Quality

Education”, SDG 5 “Gender equality”, SDG 9 “Industry, Innovation and

Infrastructures”, SDG 10 “Reduced Inequalities”, SDG 12 “Responsible

Consumption and Production”, SDG 13 “Climate Action”, SDG 16 “Peace,

Justice and Strong institutions”.