Abstract
Introduction
Environmental degradation from pollution, global warming, and industrialization, is alarming with dentistry significantly contributing through mercury and plastic toxicity from improper waste handling.
Aim
To evaluate the knowledge, attitude, and practice of Dental professionals towards “Green Dentistry” working in the public and private sectors of Karachi city.
Design
A cross-sectional survey.
Setting
Karachi, Pakistan (Online).
Materials and methods
An online questionnaire was conducted among dentists of Karachi, Pakistan, from January to June 2023 collecting participant’s demographic data and assessing knowledge, attitude, and practice of eco-friendly dentistry.
Results
With a 61% response rate, most respondents (48.5%) were General Dental Practitioners (GDPs). Dental consultants (DC) exhibited higher awareness of green dentistry (29%) with 50% of DCs favoring digital radiography as environmentally friendly (p < 0.05). Green dentistry practices were more prevalent among DCs with 42.8% (p < 0.05) eliminating amalgam usage, while more GDPs (72.2%, p < 0.05) adopted re-usable lab coats and patient drapes.
Discussion and conclusion
Awareness of “Green Dentistry” is generally lacking among participants. Both GDPs and DCs are inclined towards adopting environment-friendly dental practices. Education on energy conservation and materials is essential to reduce waste in the dental industry.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-025-07215-4.
Keywords: Eco-friendly dentistry, Green dentistry, Sustainable dentistry, Recycle
Introduction
While industrialization has significantly improved the quality of life, it has also contributed to deforestation, global warming, and pollution [1]. Dentistry, though essential for oral health, plays a role in environmental degradation through the mismanagement of mercury, plastics, and various biological or synthetic wastes [2]. These waste products include biological materials (e.g., extracted teeth, biopsy tissue), hazardous substances (e.g., mercury from amalgam), chemical agents (e.g., X-ray film developers, instrument lubricants) and disposable items (e.g., latex gloves, plastic suction tips [3, 4]. All these wastes collectively form a majority of dental wastes in the dental clinic setting [5]. The potential harm caused by improper handling of these materials is a growing concern, prompting environmentalists and policymakers to seek immediate sustainable solutions.
To mitigate the environmental impact of dental practices, the Eco Dentistry Association (EDA) has introduced the concept of “Green Dentistry” [6]. It is defined as “A high-tech approach that reduces the environmental impact of dental practices and encompasses a service model for dentistry that supports and maintains wellness” [2]. It aims to minimize waste and energy consumption, ultimately benefiting both the environmental and dental professions. This approach promotes the adoption of advanced technologies like digital radiography and intra-oral scanning, reducing the need for physical materials, thus averting waste production [7]. To facilitate this revolution in dentistry, the concept of “Four Rs” (Rethink, Reduce, Reuse, and Recycle) has previously been recommended [8]. ‘Rethinking’ is crucial to minimizing any unnecessary waste production, thereby averting further harm to the environment. ‘Reduce’ focuses on minimizing excess waste and reducing water consumption. ‘Re-use’ emphasizes the repeated use of products, including hand towels, biodegradable cups instead of plastic ones, and sterilizable instruments. ‘Recycling’ refers to converting used materials into reusable items, such as recycling paper cups and using rechargeable products.
Although green dentistry is gaining traction in developed countries, its adoption in South Asian countries like India [6, 9], and Thailand [10], remains limited. In Pakistan, there haven’t been any notable initiatives yet to promote the adoption of Green Dentistry, which can be owed to a lack of policy reinforcement and institutional preferences as highlighted elsewhere, despite attempts to introduce environmental friendly initiatives [11]. Therefore, this study aims to assess dentists’ knowledge, attitude and practice towards implementing environmentally friendly practices in a local setting, among dental consultants (dentists who have undergone recognized postgraduate specialty training of approximately 3 to 5 years following their primary dental qualification), post-graduate residents (dentists currently undergoing specialty training) and general dental practitioners. The findings are intended to inform strategies that can reduce material and energy waste through increased awareness and institutional support.
Materials and methods
This web-based, cross-sectional analytical survey was conducted across multiple centers and included dentists from both public and private sectors in Pakistan. The sample size was calculated using WHO software, based on the hypothesis that at least 280 dentists from Karachi would be aware of green dentistry. The calculation assumed a power of 90% to detect a 0.09 difference in green dentistry awareness [6], employing a two-sided test at a significance level of 0.05.
The questionnaire (Annexure I) was developed after reviewing relevant literature [10, 12, 13]. The instrument was pre-tested on a pilot group of 30 participants to evaluate understanding by the participants and to identify and revise any ambiguous items that could cause confusion. Since no discrepancies were identified and the pretested participants met the same inclusion criteria as the main sample, their data were included in the final analysis in line with recommendations on incorporating pretest data when no changes are required in the final analysis [14].
To establish content validity, five subject experts reviewed the instrument. The Scale-level Content Validity Index (S-CVI) scores were 1.00 for knowledge, 0.96 for attitude, and 0.98 for practice, indicating strong expert agreement. Item-level CVI (I-CVI) values also showed excellent agreement, with scores approaching 1.0. Internal consistency of the tool was assessed using Cronbach’s α. The knowledge domain demonstrated excellent reliability (α = 0.83), while the attitude domain showed acceptable reliability (α = 0.73). The practice domain produced a Cronbach’s α of 0.58, indicating moderate reliability. The acceptable threshold for Cronbach’s α from 0.4 to 0.7 was based on established literature [15].
A total of 280 Questionnaires were distributed over a six-month period beginning January 1, 2023. The study protocol received exempt approval from the Ethical Review Committee of the Aga Khan University Hospital, Karachi (ERC no. 2023-8554-24444), as no interventions were undertaken, and participation was anonymous.
Eligible participants included general dental practitioners (GDPs), postgraduate residents (PGRs), and dental consultants (DCs). Dental undergraduates, non-practicing dentists, and participants with incomplete survey forms were excluded. The self-administered questionnaire was developed using Google Forms and distributed electronically to participants whose valid email addresses were available. The survey began with an informed consent statement outlining the study’s purpose and ensuring confidentiality, with permission to use collective responses for publication purposes.
Demographic information collected included age, gender, alma mater, education level and current academic position. The knowledge segment assessed the overall awareness of “Green Dentistry” concepts among dental professionals. The attitude section probed participants’ perspectives on the impact and practicality of adopting green practices within dental clinics. Meanwhile, the practice section focused on questions related to the four ‘Rs’ of eco-friendly dentistry. Data was analyzed using STATA 16.0. The frequencies and proportions of the descriptive variables were reported. Chi-square tests were used to examine associations, with a 95% confidence interval and statistical significance set at p < 0.05. Logistic regression was performed to explore associations between knowledge, attitude and practice of Green dentistry.
Results
A 61% response rate was obtained from 171 out of 280 participants. The sample included 103 females (60.2%) and 68 males (39.8%). The mean age of participants was 30.7 ± 7.4, reflecting a relatively young cohort. In terms of professional roles, general dental practitioners (GDPs) made up the largest group (n = 83/171; 48.5%), followed by postgraduate residents (PGRs) (n = 46/171; 26.9%) and dental consultants (DCs) (n = 42/171; 24.5%). Over half of the respondents (58.48%, n = 100) graduated from private institutions, while 41.5% (n = 71) attended public colleges. The distribution of dental specializations among the respondents is depicted in Fig. 1.
Fig. 1.
Distribution of dental specialities (n = 42) contribution among a sample of Pakistani dentists (N = 171)
Most participants (n = 111; 65%) lacked a clear understanding of green dentistry. This was consistent across all groups: 55% of DCs (n = 23), 66% of GDPs (n = 55) and 72% of PGRs (n = 33), with no significant group differences (p = 0.23). Similarly, familiarity with the “4Rs” of Green Dentistry was low and comparable among groups; 29% of DCs (n = 12), 27% of GDPs (n = 22), and 22% of PGRs (n = 10) with no significant difference (p = 0.74).
Half (50%) of DCs, 39% of GDPs and 37% of PGRs recognized “green dentistry” and “eco-friendly dentistry” as interchangeable terms (p = 0.38). Awareness of “Sustainable dentistry” was reported by 43% of DCs, 37% of GDPs and 22% of PGRs, with no significant difference between the groups (p = 0.086). Awareness of the 2015 United Nations (UN) sustainable development agenda was limited across all the groups: 31% of DCs, 19% of GDPs, and 11% of PGRs.
Most attitude-related responses towards Green Dentistry showed no significant differences between groups (Table 1 and 2) (p > 0.05), except perceptions regarding digital radiography’s ecological benefits (p = 0.003). A higher proportion of GDPs (n = 76;91.6%) and PGRs (n = 37;80.4%) supported this compared to DCs (n = 36; 85.7%).
Table 1.
Reverse attitude assessment of the included participants among a sample of Pakistani dentists (N = 171)
| Dental consultant | General Dental Practitioners | Postgraduate Residents | P -value | |
|---|---|---|---|---|
| n = 42 | n = 83 | n = 46 | ||
| n (%) | n (%) | n (%) | ||
| There is nothing a small sector dental practice can do for environmental issues | 0.068 | |||
| Strongly Agree | 1(2.38) | 3 (3.7) | 0 | |
| Agree | 6 (14.29) | 16 (19.75) | 7 (15.22) | |
| Neutral | 16 (38.1) | 15 (18.52) | 17 (36.96) | |
| Disagree | 10 (23.81) | 28 (34.57) | 19 (41.3) | |
| Strongly Disagree | 9 (21.43) | 19 (23.46) | 3 (6.52) | |
| It is difficult to change my current practice to be more ecological | 0.077 | |||
| Strongly Agree | 1(2.38) | 4 (4.82) | 2 (4.35) | |
| Agree | 6 (14.29) | 19 (22.89) | 15 (32.61) | |
| Neutral | 17 (40.48) | 32 (38.55) | 22 (47.83) | |
| Disagree | 13 (30.95) | 25 (30.12) | 7 (15.22) | |
| Strongly Disagree | 5 (11.9) | 3 (3.61) | 0 | |
| Creating a green dental clinic will increase the financial burden on management of the practice | 0.381 | |||
| Strongly Agree | 3 (7.14) | 4 (4.82) | 3 (6.52) | |
| Agree | 11 (26.19) | 32 (38.55) | 23 (50) | |
| Neutral | 17 (40.48) | 33 (39.76) | 14 (30.43) | |
| Disagree | 6 (14.29) | 11 (13.25) | 4 (8.7) | |
| Strongly Disagree | 5 (11.9) | 3 (3.61) | 2 (4.35) | |
| It is difficult to find eco-friendly products for the dental clinic | 0.397 | |||
| Strongly Agree | 2 (4.76) | 4 (4.82) | 3 (6.52) | |
| Agree | 12 (28.57) | 37 (44.58) | 22 (47.83) | |
| Neutral | 17 (40.48) | 23 (27.71) | 14 (30.43) | |
| Disagree | 7 (16.67) | 15 (18.07) | 7 (15.22) | |
| Strongly Disagree | 4 (9.52) | 4 (4.82) | 0 | |
| Recycling waste management is an extra burden on the work of our practice | 0.185 | |||
| Strongly Agree | 5 (11.9) | 3 (3.61) | 1 (2.17) | |
| Agree | 11 (26.19) | 33 (39.76) | 16 (34.78) | |
| Neutral | 14 (33.33) | 27 (32.53) | 20 (43.48) | |
| Disagree | 7 (16.67) | 16 (19.28) | 8 (17.39) | |
| Strongly Disagree | 5 (11.9) | 4 (4.82) | 1(2.17) | |
| Sterilized instruments are not as clean as disposable instruments | 0.193 | |||
| Strongly Agree | 1 (2.38) | 1(1.2) | 1 (2.17) | |
| Agree | 3 (7.14) | 15 (18.07) | 12 (26.09) | |
| Neutral | 9 (21.43) | 19 (22.89) | 11 (23.91) | |
| Disagree | 17 (40.48) | 34 (40.96) | 19 (41.3) | |
| Strongly Disagree | 12 (28.57) | 14 (16.87) | 3 (6.52) | |
| It is not necessary to control water conservation | 0.204 | |||
| Strongly Agree | 3 (7.14) | 5 (6.02) | 1 (2.17) | |
| Agree | 1 (2.38) | 10 (12.05) | 5 (10.87) | |
| Neutral | 8 (19.05) | 8 (9.64) | 9 (19.57) | |
| Disagree | 15 (35.71) | 30 (36.14) | 22 (47.83) | |
| Strongly Disagree | 15 (35.71) | 30 (36.14) | 9 (19.57) |
Significant p-values (≤ 0.05 denoted with “*”) are reported from Chi-square test
Table 2.
Positive attitude assessment of the included participants among a sample of Pakistani dentists (N = 171)
| Dental consultant | General Dental Practitioners | Postgraduate Residents | P -value | |
|---|---|---|---|---|
| n = 42 | n = 83 | n = 46 | ||
| n (%) | n (%) | n (%) | ||
| Green practice has many long-term benefits (e.g., reduced energy and water costs) | 0.439 | |||
| Strongly Agree | 11 (26.19) | 25 (30.12) | 6 (13.04) | |
| Agree | 19 (45.24) | 44 (53.01) | 28 (60.87) | |
| Neutral | 9 (21.43) | 8 (9.64) | 9 (19.57) | |
| Disagree | 2 (4.76) | 4 (4.82) | 2 (4.35) | |
| Strongly Disagree | 1 (2.38) | 2 (2.41) | 1 (2.17) | |
| Tooth colour-like materials are more environmentally friendly than amalgam | 0.615 | |||
| Strongly Agree | 17 (40.48) | 22 (26.83) | 9 (20) | |
| Agree | 18 (42.86) | 46 (56.1) | 28 (62.22) | |
| Neutral | 6 (14.29) | 12 (14.63) | 7 (15.56) | |
| Disagree | 0 | 1 (1.22) | 0 | |
| Strongly Disagree | 1 (2.38) | 1 (1.22) | 1 (2.22) | |
| Digital radiography is more ecological than conventional techniques | 0.003* | |||
| Strongly Agree | 21 (50) | 35 (42.17) | 7 (15.22) | |
| Agree | 15 (35.71) | 41 (49.4) | 30 (65.22) | |
| Neutral | 4 (9.52) | 4 (4.82) | 5 (10.87) | |
| Disagree | 0 | 1 (1.2) | 4 (8.7) | |
| Strongly Disagree | 2 (4.76) | 2 (2.41) | 0 | |
| Energy management is everyone’s responsibility | 0.652 | |||
| Strongly Agree | 14 (33.33) | 35 (42.17) | 14 (30.43) | |
| Agree | 21 (50) | 37 (44.58) | 26 (56.52) | |
| Neutral | 6 (14.29) | 8 (9.64) | 6 (13.04) | |
| Disagree | 0 | 2 (2.41) | 0 | |
| Strongly Disagree | 1(2.38) | 1(1.2) | 0 |
Significant p-values (≤ 0.05 denoted with “*”) are reported from Chi-square test
While not statistically significant, a higher proportion of GDPs (n = 69;83.13%), PGRs (n = 34; 74%) and DCs (n = 31; 71.4%) agreed on the long-term benefits of green practices, such as reduced utility costs (p = 0.439). Opinions regarding the availability of eco-friendly products were mixed across all groups, without statistical significance (p = 0.397).
Regarding practice assessment (Table 3), two significant differences were identified. First, the frequency of amalgam restoration use varied significantly (= 0.02), with 30.4% of PGRs(n = 14) using amalgam “sometimes” compared to 16.7% of DCs (n = 7) and 13.3% of GDPs (n = 11). Second, the use of re-usable lab coats and patient drapes differed significantly (p = 0.048); 72.3% of GDPs, 63.04% of PGRs utilized more reusable p items compared to only 50% of DCs. Additionally, there were no significant differences among groups in the use of digital dentistry technologies, such as digital impressions, digital patient charting, and CAD/CAM systems.
Table 3.
Practice assessment including four Rs of green dentistry of the included participants among a sample of Pakistani dentists (N = 171)
| Dental consultants | General Dental Practitioners (GDPs) | Postgraduate Residents | p -value | |
|---|---|---|---|---|
| n = 42 | n = 83 | n = 46 | ||
| n (%) | n (%) | n (%) | ||
| Rethink | ||||
| Lighting system used in your practice | 0.513 | |||
| LED lightbulbs with motion sensors | 24 (57.14) | 45 (54.22) | 24 (52.17) | |
| Compact fluorescent lamps (CFL) | 6 (14.29) | 7 (8.43) | 6 (13.04) | |
| Incandescent bulbs | 3 (7.14) | 15 (18.07) | 4 (8.7) | |
| Other | 9 (21.43) | 16 (19.28) | 12 (26.09) | |
| Should we go digital to eliminate photochemical waste? | 0.292 | |||
| Yes | 37 (88.1) | 79 (95.18) | 41 (89.13) | |
| No | 5 (11.9) | 4 (4.82) | 5 (10.87) | |
| Should Eco-friendly dentistry be universally recommended? | 0.761 | |||
| Yes | 38 (90.48) | 78 (93.98) | 43 (93.48) | |
| No | 4 (9.52) | 5 (6.02) | 3 (6.52) | |
| Reduce | ||||
| Use composite and/or GIC as an alternative to amalgam restorations. | 0.402 | |||
| Yes | 38 (90.48) | 80 (96.39) | 43 (93.48) | |
| No | 4 (9.52) | 3 (3.61) | 3 (6.52) | |
| Frequency of amalgam restorations performed in the clinic | 0.02* | |||
| Always | 0 (0) | 2 (2.41) | 0 (0) | |
| Often | 6 (14.29) | 11 (13.25) | 8 (17.39) | |
| Sometimes | 7 (16.67) | 11 (13.25) | 14 (30.43) | |
| Rarely | 11 (26.19) | 26 (31.33) | 19 (41.3) | |
| Never | 18 (42.86) | 33 (39.76) | 5 (10.87) | |
| Availability of an amalgamator in the clinic | 0.458 | |||
| Yes | 18 (42.86) | 34 (40.96) | 24 (52.17) | |
| No | 24 (57.14) | 49 (59.04) | 22 (47.83) | |
| Method of mercury disposal | 0.089 | |||
| In Sewerage system | 10 (23.81) | 9 (10.84) | 5 (10.87) | |
| In clinical waste bags or sharp containers | 22 (52.38) | 48 (57.83) | 20 (43.48) | |
| In waste destined for incineration | 8 (19.05) | 19 (22.89) | 19 (41.3) | |
| Recycle through Amalgam separator | 2 (4.76) | 7 (8.43) | 2 (4.35) | |
| Re-use | ||||
| Use reusable sterilization instruments (e.g., trays, film holders) instead of disposables | 0.706 | |||
| Yes | 35 (83.33) | 64 (77.11) | 37 (80.43) | |
| No | 7 (16.67) | 19 (22.89) | 9 (19.57) | |
| Use disposable plastic instead of reusable glass irrigation syringes | 0.512 | |||
| Yes | 35 (83.33) | 67 (80.72) | 34 (73.91) | |
| No | 7 (16.67) | 16 (19.28) | 12 (26.09) | |
| Use of disposable instead of rechargeable batteries in flashlights/digital cameras | 0.16 | |||
| Yes | 18 (42.86) | 26 (31.33) | 11 (23.91) | |
| No | 24 (57.14) | 57 (68.67) | 35 (76.09) | |
| Type of lab coats and patient drapes used in practice | 0.048* | |||
| Non-reusable | 21 (50) | 23 (27.71) | 17 (36.96) | |
| Reusable | 21 (50) | 60 (72.29) | 29 (63.04) | |
| Recycle | ||||
| Recycling of fixer and developer solutions | 0.289 | |||
| Yes | 9 (23.08) | 26 (36.62) | 12 (27.27) | |
| No | 30 (76.92) | 45 (63.38) | 32 (72.73) | |
| Availability of recycling bins in the clinic | 0.315 | |||
| Yes | 19 (45.24) | 38 (45.78) | 27 (58.7) | |
| No | 23 (54.76) | 45 (54.22) | 19 (41.3) | |
| Use of sharps disposal service that recycles materials | 0.417 | |||
| Yes | 16 (38.1) | 30 (36.14) | 22 (47.83) | |
| No | 26 (61.9) | 53 (63.86) | 24 (52.17) | |
| Frequency of discarding electronic items from clinical practice | 0.228 | |||
| Often | 3 (7.14) | 9 (10.84) | 4 (8.7) | |
| Sometimes | 12 (28.57) | 13 (15.66) | 13 (28.26) | |
| Rarely | 24 (57.14) | 42 (50.6) | 22 (47.83) | |
| Do not discard, we recycle | 3 (7.14) | 19 (22.89) | 7 (15.22) | |
Significant p-values (≤ 0.05 denoted with “*”) are reported from Chi-square test
Linear regression analysis revealed that having knowledge was significantly associated with higher attitude scores (β = 0.148, p = 0.006), with the 95% confidence interval [0.043, 0.253] indicating a robust positive relationship. In contrast, while a positive association was also observed between knowledge and practice scores (β = 1.08), this relationship did not reach statistical significance (p = 0.084; 95% CI: [−0.148, 2.308]).
Discussion
The integration of green dentistry practices is increasingly essential to promote sustainable dental care while minimizing the environmental footprint of dental procedures. Our results found that overall awareness of green dentistry among Pakistani dental professionals is limited, largely due to unfamiliarity with the United Nations’ 2015 Sustainable Development Agenda, which includes ‘sustainable healthcare practices’ [16]. Nevertheless, many participants expressed a strong interest in adopting eco-friendly dentistry, despite facing significant barriers such as financial constraints, particularly among young graduates.
While the majority of participants demonstrated positive attitudes toward sustainable tools like eco-friendly materials and digital radiography, actual implementation remained low. This gap between awareness and practice reflects a broader issue: being informed about sustainable practices does not necessarily translate into their adoption, particularly in developing countries where economic constraints, limited exposure, and difficulties in rural application create significant barriers [17]. These findings are consistent with prior research by Agrasuta et al. [10] and Al Qarni et al. [18], where participants were unfamiliar with the terms “Green Dentistry” or “eco-friendly dentistry” being interchangeable, despite showing interest in sustainable practices. Conversely, studies by Al Shatrat et al. [19] and Pallavi et al. [6] reported higher awareness among their cohorts.
Financial barriers and doubts about the practicality of green initiatives were primary reasons for hesitancy, particularly among post-graduate residents (PGRs), general dental practitioners (GDPs) and dental consultants (DCs). These concerns echo those highlighted by Agrasuta et al. [10] and Kallakuri et al. [20], reinforcing the need for cost-effective, context-appropriate green solutions. Such barriers are especially relevant in low and middle-income countries like Pakistan and India. A recent survey in western India [21] also, revealed implementation to be costly and difficult, despite higher motivation and awareness.
Participants favored tooth-colored restorative materials over amalgam, influenced by the 2013 Minamata Treaty, endorsed and supported by the FDI [22, 23] which aims to phase down mercury use. Despite this awareness, improper amalgam disposal was still reported, posing a serious environmental risk, particularly in developing nations where recycling mercury through amalgam separators is underutilized [24]. The discrepancy likely stems from weak regulatory enforcement and limited recycling infrastructure. Implementing directives similar to the European Union’s ‘Waste Framework Directive’ which mandates appropriate waste management practices among member states, to protect human health and prevent environmental harm [25], could provide a valuable model for policy development in Pakistan.
Digital dentistry practices, particularly digital radiography, were positively received across all participant groups. These findings are consistent with Verma et al. [12], who emphasized the ecological advantages of digital over conventional radiography. Similarly, more than half of the participants (n = 24 DCs, n = 45 GDPs and n = 24 of PGRs) from our survey reported using LED bulbs with motion sensors, aligning with Verma et al. [12] and showing a sign of growing energy consciousness. However, regional inconsistencies were noted. For example, Al-Shatrat et al. [19], found high awareness was high, but low implementation, suggesting that even when knowledge is strong, adoption may be limited by deficiencies in local infrastructure or policy rather than by individual willingness.
Sustainable preferences extended to reusable lab coats, patient drapes, sterilizable instruments, and rechargeable batteries, especially among GDPs and PGRs, supporting prior findings by Verma et al. [12]. Yet, the continued reliance on disposable plastic syringes across all groups (n = 35 DCs, n = 67 GDPs and n = 34 PGRs), likely due to perceived convenience or hygiene concerns, despite their environmental impact, underscores the tension between hygiene concerns and sustainability [20, 26]. This tension mirrors broader regional hesitancy to change established clinical routines.
Our findings also revealed deficiencies in recycling practices. Very few clinics recycle fixer and developer solutions, even though these substances contain hazardous silver. While GDPs exhibited the highest recycling rate, DCs lagged significantly. Similar shortcomings were reported by Pallavi, Al Shatrat and others [6, 19, 27]. Moreover, adoption of sharp disposal services was particularly low among PGRs, indicating the need for improved waste management education and infrastructure.
Lastly, we inquired about digital impressions, digital patient charting facilities, and CAD/CAM adoption. Most participants supported the digitization of patient records, recognizing its role in reducing paper use. The use of CAD/CAM systems showed the highest adoption among DCs, aligning with studies indicating that digital dentistry tools reduce both emissions and material wastage [28–30]. These findings indicate a trend towards future adoption rather than current use.
To date, to the best of our knowledge, this is among the first studies exploring green dentistry awareness, attitudes and practices within Pakistan’s dental community. However, several limitations should be noted. Although a moderate response rate was obtained, the possibility of non-response bias cannot be ignored. The sample was geographically limited, potentially affecting generalizability, which can be overcome with a multi-center study with a larger sample size. The moderate internal consistency for practice-related items likely reflects the heterogeneous nature of green dentistry behaviors such as waste reduction, energy conservation and digital adoption, which do not appear to be strongly intercorrelated. As observed by Striener [31], Cronbach’s α varies with sample characteristics and item diversity, while Tavakol and Dennick [32] highlight that multidimensional constructs can underestimate reliability. Therefore, the moderate α in this study should be seen as an expected outcome of measuring complex practices rather than a methodological weakness. The lower coefficient for practice items likely reflects the heterogeneous nature of the questions, which covered a range of behaviors and contextual factors, as well as the relatively low variability in participant responses. Additionally, as a cross-sectional study, it captures a snapshot in time without assessing changes over time or causality. Focus was primarily on identifying issues rather than proposing solutions. Further research, especially in rural areas, is needed to enhance understanding and provide generalized data. Despite these challenges, this survey provides crucial foundational insights into green dentistry practices among dental professionals nationwide.
To enhance the adoption of sustainable dental practices, several strategies could be considered. Policy-level incentives, such as subsidies for eco-friendly materials and technologies, could alleviate financial barriers. Dental institutions and regulatory bodies might implement mandatory training on green dentistry and introduce sustainability metrics into accreditation systems. These suggestions are based on the fact that improving practices may require additional interventions beyond knowledge alone. Creating public-private partnerships to support infrastructure development, like amalgam recycling and digital integration, as these would also facilitate long-term change.
Conclusions
The findings of this study indicate a growing interest among dental professionals in adapting environmentally responsible practices. However, a critical gap persists in both knowledge and implementation of sustainable approaches within Pakistan’s dental community. Although some eco-friendly measures are in place, broader adoption remains limited due to financial, infrastructural and educational barriers. To bridge this gap, targeted awareness campaigns and the inclusion of sustainability principles in dental education are essential. Strengthening institutional support and offering policy-level incentives can further facilitate the transition toward more sustainable clinical practices.
Supplementary Information
Supplementary Material 2. Validity of questionnaire
Acknowledgements
None.
Clinical trial number
Not applicable.
Authors’ contributions
A) Conceptualization: MSB, SRK. B) Methodology: MSB, SRK. C) Investigation: MSB, SRK. D) Resources: MSB, SRK. E) Writing – Original draft: MSB. F) Writing – Review and editing: SRK, MRK, MTA. G) Visualization: MSB, SRK. H) Supervision: MTA. I) Project administration: MTA. J) Data Analysis – Farah Jabeen.
Funding
This project was self-funded.
Data availability
The data that have been used is confidential.
Declarations
Ethical approval and consent to participate
Ethics approval and consent to participate: This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study has been approved by the Ethics Committee of Aga Khan University Hospital (ERC# 2021-6073-17729), and informed consent was obtained from each participant.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.G BK. Green dentistry; ecofriendly dentistry: beneficial for patients. Beneficial Environ. 2012;4(2):72–4. [Google Scholar]
- 2.Gotur SPWV, Malik S, Yadav A. Eco-friendly Dentistry-Need of the hour. J Ind Assoc Pub Health. 2012;18(2):891–3. [Google Scholar]
- 3.Mensudar RKA, Amudha D. Biomedical waste management-Green dentistry. Biomed Pharmacol J. 2015;4(1):201–5. [Google Scholar]
- 4.Rules SA. Ministry of environment and forests notification. New Delhi, India 2009.
- 5.Rathakrishnan M, Priyadarhini A. Green dentistry: the future. J Int Clin Dent Res Organ. 2017;9(2):59. [Google Scholar]
- 6.Pallavi CMJ, Joybell CC, Sekhar KP. Assessment of knowledge, attitude, and implementation of green dentistry among dental practitioners in Chennai. J Oral Res Rev. 2020;12(1):6–10. [Google Scholar]
- 7.Rastogi V, Sharma R, Yadav L, Satpute P, Sharma V. Green dentistry, a metamorphosis towards an eco-friendly dentistry: a short communication. J Clin Diagn Res. 2014;8(7):ZM01-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Pockrass F, Pockrass I. The four r’s of Eco-friendly dentistry. J Am Dent Hyg Assoc. 2008;22(8):18–21. [Google Scholar]
- 9.Parakh AMJ, Sahasrabuddhe R, Sotaa B, Balhara S, Fernandes G. Evaluation of the knowledge & attitude of dental practitioners on green dentistry in navi Mumbai–A cross sectional study. J Dent Med Sci. 2020;19:34–42. [Google Scholar]
- 10.Agrasuta V, Nelson A. The adoption of green dentistry among dentists in Thailand. Thailand: Ministry of public health; 2013. [Google Scholar]
- 11.Khan SU, Manzoor Z, Rajaguru G, Syed SH. Sustainable development in pakistan: vulnerabilities and opportunities. Sustainable development: Asia-Pacific perspectives. Cambridge University Press. 2022. p. 339–58.
- 12.Verma SH, Thakur RU, Maran SA, Kale AN, Sagar KR, Mishra SA. Knowledge, attitude and practice of green dentistry among dental professionals of Bhopal city: a cross-sectional survey. J Clin Diagn Res. 2020;14(4).
- 13.Alshamrani A, Knowledge FA. Attitude and practice of green dentistry among dental professionals in Saudi arabia: A Cross-sectional study. J Dent Sci Res Reviews Rep. 2024;166:2–6. [Google Scholar]
- 14.MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31(2):180–91. [DOI] [PubMed] [Google Scholar]
- 15.Taber K. The use of Cronbach’s AlphaWhen developing and reporting research instruments in science education. Res Sci Edu. 2018;48(6):1273–96. [Google Scholar]
- 16.Huang YKCY. Oral health: the first step to sustainable development goal 3. J Formos Med Assoc. 2022;121(7):1348–50. [DOI] [PubMed] [Google Scholar]
- 17.Nagpal ASG. Daunting for developing countries. Br Dent J. 2019;227(3):175. [DOI] [PubMed] [Google Scholar]
- 18.Al-Qarni MASN, Alamri MA, Alshaikh YA. Awareness of eco-friendly dentistry among dental faculty and students of King Khalid University, Saudi Arabia. J Clin Diagn Res. 2016;10(10):75–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Al Shatrat SMSD, Darby ML, Jeng HA. Jordanian dentists’ knowledge and implementation of eco-friendly dental office strategies. Int Dent J. 2013;63(3):161–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kallakuri PKB, Rao VN, Nirupama YS, Velamala A, Ushakiran T. Assessment of attitude and implementation of eco-friendly dental office strategies among dental practitioners in a city practice area of South Indian state. Int J Sci Res. 2019;8(2):27–31. [Google Scholar]
- 21.Thakar SKN, Pandya D, Parekh NH, Patel NK, Patel A. Awareness and constraints towards the implementation of green dentistry amongst dental students and private practitioners of West India. J Pharm Bioallied Sci. 2023;15:S1287-90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Fisher J, Varenne B, Narvaez D, Vickers C. The Minamata Convention and the phase down of dental amalgam. Bull World Health Organ. 2018;96(6):436–38. 10.2471/BLT.17.203141. [DOI] [PMC free article] [PubMed]
- 23.Lynch CD, Wilson NH. Managing the phase-down of amalgam: part II. Implications for practising arrangements and lessons from Norway. Br Dent J. 2013;215(4):159–62. 10.1038/sj.bdj.2013.788. [DOI] [PubMed]
- 24.Zia NDJ, John J, Panezai J. Sustainability in dentistry: assessing knowledge, attitude, and practices of dental practitioners about green dentistry. Pak J Med Sci. 2024;40(1):233–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Mukherjee AB, Zevenhoven R, Brodersen J, Hylander LD, Bhattacharya P. Mercury in waste in the European Union: sources, disposal methods and risks. Resour Conserv Recycl. 2004;42(2):155–82. [Google Scholar]
- 26.Duane BSR, Miller FA, Sherman J, Pasdeki-Clewer E. Sustainability in dentistry: a multifaceted approach needed. J Dent Res. 2020;99(9):998–1003. [DOI] [PubMed] [Google Scholar]
- 27.Zaharunnissa MSA, Yalamalli M, Shetty P, Divya S. Attitude and practice towards eco-friendly dentistry among dental practitioners in North Bangalore. J Arch Dent Med Res. 2017;3:14–20. [Google Scholar]
- 28.DeMello MCCR, McMillan J, McMillan R, Henry K, Bommhardt C. Going… going… going…gone green. Making your dental practice environmentally friendly. J Mass Dent Soc. 2010;59(2):29–32. [PubMed] [Google Scholar]
- 29.Mulimani P. Green dentistry: the art and science of sustainable practice. Br Dent J. 2017;222(12):954–61. [DOI] [PubMed] [Google Scholar]
- 30.Digital Dentistry ZK. Transformation of oral health and dental education with technology. Eur J Dent. 2023;17(4):943–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.DL. Starting at the beginning: an introduction to coefficient alpha and internal consistency. J Pers Assess. 2003;80(1):99–103. [DOI] [PubMed] [Google Scholar]
- 32.Tavakol MDR. Making sense of cronbach’s alpha. Int J Med Educ. 2011;27(2):53–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Material 2. Validity of questionnaire
Data Availability Statement
The data that have been used is confidential.