Knowledge, attitudes, practices, and barriers regarding environmentally sustainable dentistry among dental faculty in the Delhi/National Capital Region of India

INTRODUCTION

Climate change caused by human activities is a pressing global concern, with the average global temperature already 1.1 degrees above the pre-industrialization level. To reduce greenhouse gas emissions and carbon footprint by 2030, transformative changes are required in every aspect of human activity.^[1] The contemporary oral healthcare delivery system is not environmentally sustainable. Three principal sources of carbon dioxide (CO₂) emissions in dentistry are (a) travelling to the clinic/hospital by dentists and patients, (b) biomedical waste generated during dental treatment, and (c) emissions due to the manufacturing of dental materials. In addition to these, the use of single-use plastics has increased in dental care delivery during the COVID-19 pandemic due to the high use of personal protective equipment. Therefore, to achieve sustainable dental care, we must aim at reducing CO₂ emissions and waste generation.^[2]

India, a country of 1.4 billion people, is battling with a high level of air, water, and soil pollution.^[3] With regard to dentistry, we have 292,738 registered dentists and 318 dental colleges with an annual intake of 27,868 fresh undergraduate students.^[4] These staggering numbers of dental colleges and practitioners contribute significantly high CO₂ emissions, emphasizing the need for sustainability in oral health practices. There have been very few studies and reviews published in the literature on the topic of environmentally sustainable dentistry (ESD).^[5-7] We found only one questionnaire survey conducted in the UK with the aim of assessing the general population’s attitude toward sustainable dentistry.^[8] From the Indian context, few studies have been published with a focus on assessing the knowledge, attitude, and practices of Green Dentistry among dental professionals.^[9,10]

Whether it is a dental college or a dental clinic, dentists oversee day-to-day affairs; hence, they must take the lead in bringing about changes in their workplace or organization so that sustainable oral healthcare is provided to their patients. Therefore, dental students as well as practitioners must be made aware of the means to practice ESD. The group best suitable for teaching the practices of ESD is the teachers involved in teaching future dentists in a dental school. Therefore, the present study aims to assess the current knowledge, attitudes, and practices of dental educators in India regarding the promotion of ESD.

MATERIALS AND METHODS

The present cross-sectional study was conducted following the principles of the Declaration of Helsinki and in accordance with local statutory requirements. An approval of the Institutional Ethical Committee (IEC) of Jamia Millia Islamia was taken before starting the study (letter no. FOD/IRRC/110/17022023/F). Written informed consent was obtained from all the participants. Participants were informed about the purpose of the study, their data protection rights, and the right to refuse participation in the study or to terminate the participation without reasoning or penalty.

We focused on including teaching staff working in dental institutions in Delhi and the National Capital Region (NCR) for this survey. A purposive snowball sampling method was employed to recruit participants for this survey. This sampling method limits the generalizability of the findings due to potential selection bias and lack of randomization. A pragmatic approach was used to guide data collection, which was halted when incoming responses became repetitive and unlikely to alter the study outcome.^[11]

The data collection tool was a questionnaire, which was developed by adopting questions from previous studies on this topic.^[9,10] A draft containing a combination of open- and closed-ended questions was prepared after reviewing the available literature. This draft was sent to five senior dental faculty members for their expert opinion. These experts were asked to rate each question to assess its suitability for the study (face and content validity). Based on the feedback received from the experts, necessary changes were made to the questionnaire.

The modified questionnaire was then pilot tested on ten dental educators to evaluate the clarity of the questions and to aid in the training and calibration of the examiners. The Cronbach’s alpha coefficient (a) value was found to be 0.84 for knowledge questions, signifying an acceptable level of reliability of the questionnaire. The final questionnaire was distributed to eligible faculty through both digital and printed formats, based on participants’ access and preference. Standardized instructions were provided to the participants, and data were collected. Anonymity was maintained to ensure unbiased responses. Incomplete responses were excluded from the analysis.

The data were analyzed using the Statistical Package for the Social Sciences version 21.0 (IBM Corp., Armonk, NY, USA). The reliability of the questionnaire was assessed using the Cronbach’s alpha test. Frequency distribution was used to display the overall data and subgroup characteristics. No inferential statistical test was performed, as the study design focused on descriptive analysis.

RESULTS

The final questionnaire was sent to dental faculty members in successive rounds until no new patterns emerged in the responses. The invitations to participate in this survey were sent to 90 (n = 90), of which 74 (n = 74) completed the questionnaire. The majority of participants were females who held an MDS degree. Early-career professionals with less than a decade of teaching experience (44.6%) reflected a diverse mix of backgrounds and professional depth within the sample, as shown in Table 1.

The majority of participants were well-informed about ESD practices at their institutions. The primary purpose of assessing awareness of preventive dental treatments was to highlight their critical role in reducing the need for frequent dental visits, unlike curative treatments, thereby potentially lowering the overall carbon footprint. This was reflected in the finding that 81.1% (n = 60) of respondents reported being aware of regular preventive interventions, such as topical fluoride application and pit and fissure sealants, being provided at their institutions. Most participants, 77% (n = 57), reported that their institutions were equipped with energy-efficient appliances. Regarding digitalization, many respondents 71.6% (n = 53) confirmed that patient dental records were fully digitalized in their institutions, reflecting a strong integration of modern technology. Amalgam separators are essential for preventing mercury-containing particles from entering the drainage system during the removal of old amalgam restorations through suction. However, only 21.6% (n = 16) of participants reported the presence of an amalgam separator attached to dental chairs, highlighting a significant gap in environmentally responsible waste management practices in dental settings. When asked about life cycle assessment (LCA) of dental products, 13.5% (n = 10) of the participants stated that their college carried out such assessments. Most of the participants were unaware of what LCA is and why it is important.

The majority of respondents, 56.8% (n = 42), acknowledged that their colleges organized workshops or lectures on topics related to ESD. There was a slight divide in the frequency or emphasis placed on such initiatives. In contrast, only 39.5% (n = 29) of participants indicated that their colleges held formal staff meetings dedicated to sustainability-related issues, suggesting limited institutional prioritization of environmental concerns, as shown in Table 2.

The dental faculty emphasized both the practices and barriers surrounding the issue of ESD in their institutions. In terms of commuting, 55.4% (n = 41) of participants reported using personal vehicles to travel to their offices, with smaller groups 17.6% (n = 13) opting for public transport frequently, a practice strongly associated with daily carbon footprint in our life. More than half 52.7% (n = 39) of participants indicated that their institutions provide basic treatments in dental campus using mobile dental clinics or portable equipment, demonstrating a commitment to reaching underserved communities and reducing their commute to college/clinic for dental treatment by reducing carbon footprint. However, 18.9% (n = 14) reported that such initiatives were either limited or nonexistent, reflecting a barrier to broader access to such treatment. 56.8% (n = 42) of the participants acknowledge the use of single-use gowns, patient drapes, and plastic instruments in their colleges, which presents a challenge for reducing medical waste and adopting more sustainable alternatives.

On a more positive note, 64.8% (n = 46) of the participants reported that their colleges utilized energy-efficient appliances, such as LED lighting and motion sensors, highlighting a commitment toward energy conservation. Three-fourths, 75.7% (n = 56) of the participants stated that their colleges had made significant strides in reducing paper waste by transitioning to digital platforms for official work. Some participants still practice traditional methods of reducing paper waste, like double-sided printing or donating old magazines and books, which represent more limited strategies for reducing waste. Silver amalgam is still a widely restorative material, especially among undergraduate students, despite growing concerns about its environmental impact. While the majority of institutions disposed of amalgam waste responsibly, a few participants noted improper disposal methods in their institution, such as throwing it in regular trash or down the drain. Only 12.2% (n = 9) of participants reported that their institution had adopted digital X-ray imaging; a few still relied upon traditional X-ray films, contributing to hazardous waste generation [Table 3].

The most commonly reported barrier to sustainability was the time-consuming nature of public transport, reported by (n = 37) participants, followed by its limited availability (n = 20) and concerns about safety (n = 4), making transportation a significant challenge to adopting sustainable commuting options. Issues related to routine cleaning (n = 23) and accumulation of contaminants (n = 17) were the main concerns associated with the use of multiple-use gowns, drapes, and plastic instruments. The underutilization of preventive dental treatments, such as fluoride application and pit and fissure sealants only a few participants reported patient unwillingness, lack of materials, and lack of trained staff in contributing factors. In terms of digital sustainability, the cost of digitalization (n = 12) emerged as a key barrier to implementing fully digital dental records, while a smaller group of participants (n = 5) indicated a preference for paper-based systems, reflecting resistance to digital transitions.

Overall, the study highlights that reluctance to integrate preventive treatments into daily dental practice, cost-related concerns, and training gaps continue to pose challenges to achieving ESD, as shown in Graph 1.

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Graph 1:

Barriers to sustainability amongst participants in dental college practices.

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DISCUSSION

This study provides insights into the current status of environmentally sustainable practices in dental education institutions in the Delhi/NCR region. While there is a growing awareness of ESD, actual implementation across institutions remains inconsistent. The current scenario reflects a transitional phase, marked by increasing awareness among faculty members about sustainable practices, hindered by inconsistent implementation across institutions. Notable progress was observed in the adaptation of preventive treatment strategies, energy-efficient technologies, and digital record-keeping systems. These practices are increasingly aligned with global efforts to embed sustainability in healthcare education and operations.^[12,13] The move toward digitalization has been highlighted in earlier studies as a pivotal step in reducing environmental footprints in clinical and administrative settings.^[14]

Despite the infrastructural and economic advantages of the Delhi/NCR region, including its national capital status and the presence of both government and private dental institutions, our study highlights that the adoption of sustainable practices in dental colleges remains limited and inconsistent.^[15,16] Significant knowledge gaps persist, such as the poor knowledge and use of amalgam separators and the application of LCA tools essential for understanding and minimizing environmental impacts. Although educational institutes report some engagement through workshops and sustainability-related meetings, the frequency and depth of these initiatives vary widely.^[16] Moreover, there remains a disconnect between awareness and implementation, with certain areas such as the management of single-use materials or promotion of sustainable commuting lagging despite institutional awareness.

The barriers identified in this study underscore the urgent need for structured, targeted interventions to promote sustainability in dental education and practices. High reliance on private transportation among faculty continues to undermine efforts to reduce emissions, mirroring challenges documented in other urban healthcare settings where public transport infrastructure is insufficient.^[9] In our findings, the time-consuming nature and limited availability of public transport emerged as a major limitation to sustainable issues, similarly noted in urban Indian contexts.^[17] Outreach models like mobile dental clinics, though beneficial, show inconsistent uptake in rural areas, exacerbating inequalities in sustainable service delivery.^[18] The issue of clinical waste, particularly the use of non-biodegradable, single-use materials, complicates the sustainability goal, as highlighted in existing literature.^[19] The handling and disposal of silver amalgam demand focused attention, as many faculty members lack adequate training, despite adherence to disposal protocols. These observations resonate with findings from Kaur et al.,^[14] who emphasized the need for clearer guidelines and educational reinforcement in this area. There is a growing need to explore partnerships with manufacturers to develop and implement biodegradable alternatives.

The limited use of preventive dental treatments such as fluoride application and pit and fissure sealants seems to be linked to material shortages, lack of trained personnel, and patient-related factors. This underscores the need for institutional support in strengthening preventive care delivery and workforce training.^[20] In terms of digital sustainability, cost emerged as a significant constraint, along with a continued reliance on paper-based systems, indicating resistance to digital transformation.^[6] These barriers mirror broader trends in digital health adoption challenges across low- and middle-income countries, where financial and technical limitations remain prevalent (World Health Organization, 2021).^[21] Overall, addressing these challenges will require a multi-pronged approach, including investment in infrastructure, integration of sustainability into dental curricula, and policy-level support to facilitate environmentally responsible and technologically progressive dental practice.

A key strength of this study is its focus on dental faculty as the drivers of change in promoting environmental sustainability, an angle often overlooked in existing research. It is important not just to understand what faculty know, but how they act and what holds them back. The inclusion of both government and private institutions ensures a broader view of current practices. Our study effectively bridges gaps with everyday academic and clinical realities, making it a timely and grounded contribution to sustainable healthcare education.

As with most questionnaire surveys, our study suffers from self-reported bias. This study reflects what faculty members believe or observe, but those views may be shaped by the overall environment and routines of their institutions. It does not explore how factors such as management support, teamwork, or decision-making power affect ESD.

CONCLUSION

Addressing multifaceted challenges faced by dental faculty in implementing ESD in their institutions requires a coordinated and sustained approach, structured educational interventions for both faculty and public, infrastructure investment for digital systems, and policy support for sustainable practices are essential. Future studies should focus on assessing the impact of incentives and regulatory frameworks, such as funding for digitalization and rewards for implementing preventive care, to drive institutional change. The findings of this study strongly reinforce the call for immediate, system-level action to ensure that environmental sustainability becomes an integral and non-negotiable component of dental education and practice.