Sustainability in Dentistry: Assessing knowledge, attitude, and practices of dental practitioners about green dentistry

Objective: Green dentistry is an emerging concept necessary to address the worsening climatic changes. It is essential to compile the existing literature on knowledge, attitude, and practice on green dentistry that can be accomplished by conducting a literature review. The objective of this literature review was to summarize and present the existing knowledge that dentists have regarding green dental practices, their attitude about this shift towards sustainability, and steps that they have taken in their personal practice to adhere towards an eco-friendlier dental approach. Methods: Three months of effective research and review development from March 2022 to June 2022. Design using keywords, a literature search was performed in PubMed, Google scholar and Web of Science databases. A total of 13 articles of 45, fulfilling the inclusion criteria were selected, of which two were excluded as these were not in English. Results: Dental practitioners have good knowledge about green dentistry and positive attitudes towards environment conservation, but implementation in their practice is not adequate. Most common themes of knowledge, attitude and practice assessment in green dentistry are amalgam management, radiographic management, infection control, waste management, water, and electricity management. Conclusion: The absence of adequate literature on eco-friendly practices in dentistry makes it difficult to validate the findings of most of these studies. Dental professionals are familiar with environmentally friendly dental practices and have a positive outlook on their role in environmental protection, but its application in practice is far from adequate.


INTRODUCTION
Sustainable Development Goals (SDGs) were presented in the United Nations (UN) in 2015, by encouraging all countries to adopt a set of 17 goals targeted to end poverty, protect the planet, and ensure prosperity for all.Sustainable development is becoming increasingly important due to environmental concerns. 1limate change is caused by human actions that produce greenhouse gases, leading to rising temperatures, heat waves, fires, droughts, and warming waters. 2 The healthcare sector is committed to providing safe and effective care. 3Health and dental care providers prioritize efficiency over sustainability, leading to the production of a lot of waste and carbon dioxide emissions. 4ental practices discard millions of sterilization pouches, chair barriers, and light handle covers annually.Gloves, masks, suction tips, saliva ejectors, needles, and paper as other disposables are difficult to breakdown. 5360 gallons of water waste each day, production of 4.8 million lead foils, 28 million liters of poisonous X-ray fixer, and 3.7 tons of mercury waste annually. 5Farahani and Suchak pioneered eco-friendly dentistry in 2007.His recommendations have been heavily used in subsequent studies. 5The World Federation of Dentistry (FDI) called for sustainable techniques in oral health care to safeguard service delivery and foster green economy. 6ince the idea of "green dentistry" is novel, only a few studies have explored dentists' knowledge, attitudes, and practices (KAP) in order to learn more about what they know, believe, and engage in. 7However, these studies are not unidirectional and cover various aspects of KAP of dentists with regards to sustainable dental practices.Compiling and analyzing existing KAP literature is essential to identify gaps and guide future research efforts.KAP questionnaires can be used to inform further research.Literature review was identified as the most effective method.This literature review aims to summarize the knowledge and attitudes of dentists regarding sustainable dental practices, their attitude towards this shift, and their steps to adhere to an eco-friendly dental approach.

METHODS
Literature search Design: Literature search and review development was conducted from March 2022 to June 2022 using PubMed, Google Scholar and Web of Science databases using keywords such as knowledge, attitude, practice, green dentistry, ecofriendly dentistry, and sustainable dentistry.Every individual search term was supplemented with relevant free text terms.When appropriate, the free text terms have been truncated in order to include alternative word endings.The database searches were complemented with manual review of the reference lists of relevant articles, which resulted in a few additional articles included in the study.
Studies exploring knowledge, attitude, and practices of dentists regarding green dentistry in English with free full text were included.Thirteen articles were selected, of which two non-English were excluded.A manual screening of references from final articles was performed to ensure inclusion of all articles.The eleven studies were all original research manuscripts, with one being a thesis dissertation.Fig. 1 shows the flowchart of the search strategy.Ethical approval: Not Applicable.

RESULTS
Articles on KAP of dental health care providers regarding green dentistry are summarized in Table-I.All studies used a self-administered questionnaire as their data collection tool, with responses ranging from 150 to 800.The respondents were mostly dentists, dental graduate and post graduate students, and dental assistants from regions including Thailand, Romania, India, Jordan, and Saudi Arabia.Knowledge of green dentistry: Six of eleven articles reported dental health care providers' knowledge or awareness of green dentistry, with Table-II providing a summary of studies.In 2013, two studies were conducted in Jordan and Thailand to assess the KAP of dentists regarding green dentistry using selfdeveloped questionnaires. 8,9Shatrat et al. in Jordan tested questionnaire on 30 volunteer participants for content validity, clarity, and format. 8Agrasuta V's study did pilot for clarity and ease of completion. 9Both studies reported no quantitative measures of internal validity or consistency and showing dentists are well-versed in sustainable dental practices.However, the design of the questionnaire, which forbade the use of parametric statistical tests, is one of the limitations of both studies that might have had an impact on the findings.Both studies expressed concern related to the lack of literature on eco-friendly dental practices, which also makes it difficult to validate the findings.
KAP of dentists in India and Saudi Arabia was assessed in 2015 and 2016.Zaharunnissa et al used a self-developed questionnaire to survey 150 dental practitioners.Pilot tested on thirty volunteers.The study found that dentists had adequate knowledge about sustainable dentistry, with "fully in place" being a proxy for high knowledge. 10Al Qarni et al in Saudi Arabia conducted an educational awareness intervention to increase awareness of eco-friendly dentistry. 11Using a self-administered questionnaire with internal consistency of 0.80-1.00.Unlike other studies by Shatrat et al  Three Indian studies were reported between 2017 and 2020 to assess dental practitioners' knowledge on sustainable dental practices.][14] They used self-administered questionnaires. 14Dental practitioners' knowledge of green dentistry was found to be high, while Shivangi et al reported otherwise. 12ccording to Pallavi et al the results cannot be regarded as having actual validity because the degrees of awareness in urban and rural areas of the country may differ.Attitudes about green dentistry: Seven of eleven studies reported positive dentists' attitudes towards green dentistry, with each study reporting on diverse themes as summarized in Table-III.Overall, dentists have a positive attitude towards adopting green dental practices to reduce environmental impact.Two studies reported negative attitudes towards green dental practices due to their perceived financial burden. 9,15Green dental practices: Eight studies assessed practices of dental health care providers on green dentistry using self-administered questionnaires with varying numbers of questions.The questionnaires focused on amalgam, radiographic, waste, water, and energy management.Shatrat et al and Agrasuta et al. reported green practices of dentists as being "fully implemented", "in the process", "not implemented" or "unsure". 8,9ther studies reported proportion of dentists following each practice.3][14][15][16] Majority reported Dentists of different ages, genders, post-graduates, and under-graduates have different practices. 9,10,12,14Nevertheless, many studies in terms of evaluating green practices were not free from biases.According to Zahrunnisa et al, the questionnaire could not address all eco-friendly dentistry practices because it only included a few in order to encourage compliance which makes it harder to support the findings. 10Similar to this, Al Qarni et al in Saudi Arabia focused on the role of dentists, but it might not have correctly represented the relevance of dental hygienists and assistants in the adoption of eco-friendly dentistry practices. 11][14][15][16] Majority using GIC and composites conserve water and electricity. 10,13,15,16Amalgam separators were least used with poorly established amalgam disposal practices. 8,10,13,15,16Majority of dentists have digitalized their radiographs and record keeping systems.Chemicals are often purchased in concentrated, bulk form from vendors.Reducing waste, using renewable energy, and using eco-friendly paint are important strategies for infection prevention in different regions.A summary of findings for practices is shown in Table-IV.

DISCUSSION
Green dentistry seeks to promote sustainability in dental practice.Farahani and Suchak pioneered ecofriendly dentistry in 2007. 3Their green model of ecofriendly alternatives to conventional dental practices replaced harmful current dental practices with green practices. 3Since then, numerous studies have explored the environmental footprint of dental practices.
The review found that the lack of literature on ecofriendly practices in dentistry made it difficult to validate the findings of most of these studies.This led to the absence of a uniform instrument, which is pervasive throughout literature and is identified as a common barrier.The six green dentistry model themes-amalgam management, radiography management, infection control management, procurement management, energy and water conservation-were shared by all of them.Despite common themes, each study had developed their own tool.Overall, most studies reported high dentists' knowledge of green dental practices, but their practices were not adequate.Amalgam management: Regarding the first theme, amalgam management, its usage is contentious because of mercury, a bio-accumulating substance. 17Mercury is known to have negative effects on human health. 18,19mproper disposal of amalgam in regular trash is hazardous.Unused amalgam particles should be collected and recycled, and pre-capsulated amalgam should be used.Amalgam separators should be installed in suction and vacuum lines. 3,4,20All studies examined the environmental effects of amalgam and mercury, and asked questions about dentists' knowledge and practice.Respondents in Jordan, Thailand, Saudi Arabia, and India were aware of amalgam hazards. 8,9,11,12,14,15Dentists in Jordan, Thailand, and India used alternative filling materials to replace amalgam.However, the use of amalgam separators was low due to dentists disposing the amalgam in garbage and the lack of proper disposal practices with few using amalgam separators.Amalgam is a popular restorative material due to its affordability, longevity, and ease of use among Indian dentists. 21,22adiography management: Conventional radiographs use x-ray fixer, developer and dental film, which contain hazardous chemicals and should not be disposed of in regular trash. 8,23Dental practitioners must be aware of hazardous components and proper disposal of conventional x-rays.Green dentistry recommends digital radiographic techniques to minimize harmful chemical, paper, and plastic waste. 24]12 Infection control management: Only 20% medical waste is considered infectious and requires special disposal, while 3% from a dental practice requires management with protocol. 25[12][13][14]16,26,27 Sterilizing instruments, film holding devices and trays, are the most common green infection control practices.Amandeep et al reported 91% dentists use steam sterilization for disinfection, while other studies reported low implementation. 16Enzyme-based cleaners are biodegradable and free of harsh chemicals, making them ideal for green practices. 4,24,28Practices of using enzyme-based cleaners and reusable items are low, with more inclination towards disposable items 4,24,28 .Eco-friendly dental recommendations include paper recycling, electronic records, water and electricity conservation. 3,24Technology and awareness of recycling programs are essential for successful use of electronic records.Dentists in Jordan and Thailand recycle and use e-records.In contrast paper waste management was not well practiced in India, as reported by Praneetha et al and Pallavi et al. 12,15 The convergence of views regarding many facets of green dentistry is one of the review's main conclusions.The majority have a positive attitude towards environmental protection.This can be used to increase dental practitioner's engagement in sustainable practices by creating awareness.However, affordability, adaptation, and availability of green dental products are linked to negative attitudes.Green dental products are expensive and limited, making it difficult to adopt sustainable practices. 29Additionally, altering conventional dental practices necessitates a gradual transformation in thinking and behaviour. 30This study reviews the literature on dentists' KAP with regard to clinical green dental practices.It highlights the need for more stringent research on the subject and create a standardized tool to assess KAP before developing interventions to improve it.

Limitations:
The study scope is limited to only original KAP studies.

CONCLUSION
The practice of dentistry has a significant environmental impact due to its use of raw materials, water, and electricity.The studies identified in this paper provide a heightened level of knowledge, attitude and practices and serves as a rigorous review of literature pertaining to studies done globally for exploring dentists' KAP regarding green dental practices.Although dental professionals are aware of eco-friendly practices and have a positive attitude, their practice is far from acceptable.The greatest barrier to the implementation of sustainability in all studies is discernment that exists within the profession that do not consider or prioritize sustainable practices.These are particularly pervasive in developing countries, where the greatest barriers are a lack of economic feasibility and a poor knowledge-base on the subject.The lack of literature on eco-friendly practices in dentistry makes it difficult to validate the findings of the majority of these studies.This has led to the absence of a uniform instrument, which is ubiquitous throughout literature and is identified as a common barrier.There is a notable dearth of quality research that encourages and makes it possible to provide environmentally sustainable oral health care.Emerging research should attempt to develop a standardized tool comprising common aspects of green dentistry, to measure KAP of dentists, prior to planning interventions for improvement.

8 ,
Table-I: Summary of final articles included in the review.

Table -
II: Summary of studies assessing knowledge of dentists regarding green dentistry.

Table -
11I: Summary studies assessing attitudes regarding green dental practices of dentists.Agrasuta V et al9, and Zahrunnisa et al10, this study did not report final knowledge levels by means of continuous or categorical score.Instead, proportions of dentists responding correctly to each answer were reported with results showing improved knowledge of eco-friendly dental practices in post-intervention test.11

Table -
IV: Summary studies assessing green dental practices of dentists.