The carbon footprint of dental practice: sources, measurement, and evidence for reduction

INTRODUCTION

Health care is responsible for roughly 5% of global greenhouse gas emissions, a share comparable to that of the food sector and larger than that of aviation.(1-3) A systematic review of health-care settings arrives at the same order of magnitude, between 4% and 5% of global emissions, and attributes them across the three scopes of the Greenhouse Gas Protocol, with the majority in the purchased goods and services that constitute scope 3.(4) Dentistry sits inside this footprint, yet the field cannot agree on how to describe its own contribution. One body of evidence presents dental care as almost negligible at the level of a single appointment: a life cycle analysis of one dental examination concluded that its environmental burden, compared with one person's annual impact, is minimal.(5) A second body of evidence points in the opposite direction, at the scale of a career of care and of an entire profession. Modeled lifetime oral healthcare for a patient with high disease experience was estimated at approximately 2,170 kg CO2e, against 285 kg CO2e for a person with very low disease experience,(6) and the air travel of only four global oral health meetings was estimated at about 47,000 metric tons of CO2e.(7) The same profession is thus described, in published work, both as a trivial emitter and as a material contributor to the climate crisis.

The contradiction matters because it changes what the profession does. If the footprint is trivial per unit, the rational response is to focus on clinical quality and leave emissions alone. If it is large in aggregate, the response is to redesign travel, procurement, and waste, which requires measurement and intervention data that dentistry largely lacks. The framing also has a moral dimension that the profession has begun to articulate: oral health professionals have an ethical responsibility to manage the environmental impact of the care they provide, and the World Dental Federation has tied good-quality oral healthcare explicitly to environmental sustainability.(8) National health systems have committed to net-zero targets that include dentistry, and the National Health Service in England has quantified and tracked its footprint in ways that name dental care as a component to be decarbonized.(9) Overviews directed at clinical teams now list carbon reduction alongside plastics, nitrous oxide, and antibiotics as domains for routine action.(10) The gap is not awareness but quantification: frameworks and toolkits describe what to change, while the evidence on how much each change saves is only beginning to accumulate. Dentists therefore need a defensible account of where the emissions of their practices come from and which changes actually reduce them, rather than a list of aspirational principles.

A review is timely because the measurement literature has grown rapidly and remains scattered. Most carbon accounting for dental care has appeared since 2020, in the form of process-based life cycle assessments of individual procedures, calculator-based audits of clinics and laboratories, and scoping reviews that map the field without reconciling its findings.(11,12) The health-care sector more broadly has consolidated methods for this task, and narrative reviews of the sector's climate role now exist for guidance.(13) What the dental literature still lacks is a synthesis that holds the per-unit and the aggregate estimates together, separates measurement from intervention, and identifies which reductions are supported by measured outcomes rather than by assumption. The methods needed to close that gap already exist elsewhere: health-care systems have established hybrid accounting that combines spending and activity data, and hospital-level reviews have demonstrated that service-level footprints can be produced routinely.(9,14) The objective of this review is to synthesize the published evidence on the size, main sources, and reduction strategies of the carbon footprint of dental practice between 2018 and 2025. It is guided by one question: how large is the footprint, which processes contribute most, and which strategies reduce it measurably without compromising care?

METHODS

DEVELOPMENT

Size and measurement of the footprint

The evidence that speaks most directly to the opening contradiction shows that both framings are correct, because they measure different things. Process-based life cycle assessments find small footprints for single episodes of care. A two-visit root canal treatment was estimated at 4.9 kg CO2e,(16) and a carbon audit of private clinics in Egypt placed an average patient visit at 4.3 kg CO2e.(17) These per-unit values are small in absolute terms and easy to dismiss. The aggregate values are not. The same Egyptian audit estimated an average clinic at 14,426.8 kg CO2e per year, and a companion study of dental laboratories estimated 20,820 kg CO2e per laboratory-year, equivalent to 2.9 kg CO2e per prosthesis or appliance.(17,18) Lifetime modeling in the United Kingdom reported between 285 and 2,170 kg CO2e per person depending on disease and treatment experience.(6) The gap between the per-unit and the aggregate scale is therefore not a disagreement about method but a difference in the functional unit chosen (Figure 1).

The dominant sources are more consistent. Travel, procurement, and energy explain most of the emissions in every study that decomposes them. In the Egyptian clinic audit, patient travel contributed 45.6% and staff travel 19.6%, together 65.2% of the footprint, followed by energy at 18% and procurement at 12.4%.(17) Energy ranked below travel in both audits, a reminder that the direct energy of the building is a smaller lever than the movement and manufacture that surround it. In the laboratory audit, staff travel contributed 43.6%, procurement 27.8%, and energy 25%.(18) The same ordering appears in life cycle analyses of a United Kingdom practice, which repeatedly identified travel as the largest contributor.(19,20) The pattern also matches health care at large, where purchased goods and services and patient travel dominate national footprints rather than the energy of care facilities themselves.(9) This convergence is the clearest quantitative finding of the literature: a dental practice's climate impact is driven less by the clinical procedure itself than by how people reach it and how its supplies are made and moved. The attribution across scopes explains why procurement looms large: the emissions embedded in purchased instruments, materials, and consumables sit in scope 3, outside the practice's direct control but inside its purchasing decisions.(2,9) Table 1 summarizes the principal estimates (Table 1).

Study (year)	Setting and scope	Method	Main estimate
Duane et al. (2020)(16)	United Kingdom; two-visit root canal treatment	Process-based LCA	4.9 kg CO2e per procedure
Elwan et al. (2025)(17)	Egypt; private dental clinic, 1 year	Carbon footprint calculator	14,426.8 kg CO2e per clinic-year; 4.3 kg CO2e per patient visit
Elwan et al. (2025)(18)	Egypt; private dental laboratory, 1 year	Carbon footprint calculator	20,820 kg CO2e per laboratory-year; 2.9 kg CO2e per prosthesis
Martin et al. (2024)(6)	United Kingdom; lifetime oral care to age 50	Modeled from peer-reviewed data	285 to 2,170 kg CO2e per person
Noodaeng et al. (2025)(21)	Thailand; implant-supported prosthesis	Comparative LCA	31.8 to 35.1 kg CO2e per unit
Lalloo et al. (2025)(7)	Global; air travel to four oral health meetings	Public attendance data and calculators	Approximately 47,000 t CO2e total

Note: CO2e = carbon dioxide equivalent. Values are reported as published by each study and use different functional units. Source: Elaborated from the primary studies cited in the review.

Method heterogeneity is the main obstacle to comparability. Studies differ in system boundaries, in whether travel is included, in the use of spend-based or activity-based accounting, and in the choice of functional unit.(22) A calculator built for general dental practice combines spend-based and activity-based accounting precisely because neither alone captures the full footprint.(22) Some analyses exclude patient travel, which the audit data show can be the single largest source, so exclusions change rankings as well as magnitudes. Reviews of hospital care pathways report the same difficulty and call for standardized functional units and transparent boundaries.(14) This heterogeneity means the field can currently rank sources within a study more reliably than it can compare magnitudes between studies, and it explains why published numbers for superficially similar units of care can differ by an order of magnitude.

Measurement tools are available and are the precondition for any of the reductions that follow. The carbon calculator developed for general dental practice translates a practice's activity and spend into a greenhouse gas estimate without requiring specialist software, which lowers the entry barrier to a baseline audit.(22) The Egyptian clinic and laboratory studies used the same calculator-based logic and demonstrated that a practice can obtain a decomposed estimate from routine administrative data on visits, staff, energy, water, procurement, and waste.(17,18) What is still missing is a common reporting standard: without an agreed functional unit and system boundary, two practices measuring the same activity will not produce comparable numbers, and benchmarking, which drives improvement in other areas of quality, cannot begin.

DISCUSSION

The contradiction that opened this review dissolves once the two scales are placed side by side. The literature is not divided about the size of dental care's footprint; it is divided about the unit in which that footprint is expressed. Studies that measure a single procedure report a few kilograms of CO2e, and studies that measure a practice, a laboratory, or a lifetime of care report hundreds to thousands of kilograms.(6,16,17) Both are true, and both are needed: the per-unit estimate tells a clinician what a single appointment costs the climate, while the aggregate estimate tells a profession what its annual and lifetime volume costs. The same reconciliation applies to the sources. Travel is the largest contributor in practice-level audits in Egypt and in life cycle analyses in the United Kingdom, which is why a per-visit footprint looks small in the operatory but large when the journey to and from the operatory is included.(17,20) That reconciliation, rather than a single headline number, is the main finding of this review. The synthesis earns this conclusion by holding per-unit life cycle assessments alongside practice-level audits and lifetime models, and by keeping intervention studies separate from descriptive ones so that the state of the evidence on reductions is explicit rather than implied.

The finding that travel, procurement, and energy dominate the footprint aligns with what is known about health care more broadly, and diverges from the clinical intuition that treatment itself is the main environmental act. Health-care carbon assessments consistently locate most emissions in supply chains and purchased goods and services, which is why procurement is the largest single scope in many national health systems.(1,2,9) Primary care reviews report the same pattern, with patient travel and consumables outweighing facility energy.(4 8 ) The dental-specific estimates are therefore not an anomaly but a local instance of a general rule: in a service that produces health rather than physical goods, the environmental weight sits in the movement of people and materials, not in the moment of care.

The divergences among studies are explained by the conditions of each setting rather than by conflicting findings. The Egyptian audits rank travel first because clinics there receive many patients over long distances and use calculator-based accounting that includes travel explicitly.(17) The United Kingdom life cycle analyses rank procurement and travel together because their boundaries include the supply chain of purchased goods.(19) The anaesthesia studies rank nitrous oxide first because they isolate the gas rather than the whole visit.(33) Each ranking is correct for its boundary, which is why the field's disagreements are mostly disagreements about what to count, and why a single standardized boundary would resolve more debates than any new estimate.

The review differs from earlier syntheses in one respect that has practical consequences. Scoping reviews published between 2021 and 2025 mapped the field and catalogued awareness, barriers, and best-practice checklists.(11,12,15) They established that the profession is aware of the problem and identified travel, procurement, and waste as priorities. What they could not do, because the studies did not yet exist, was say which changes measurably reduce emissions. The intervention evidence assembled here is thinner but points in a consistent direction: removing clinically unnecessary single-use plastics, substituting harvested rainwater, and avoiding travel through teledentistry all produced measured reductions in the studies that quantified them.(41,42,44) The next step for the field is to treat emission reduction as an outcome to be measured, not a virtue to be assumed.

Two cautions emerge from the comparisons of materials and equipment, and both matter for practice. The first is that reusability is not automatically lower-carbon. The disposable examination kit was worse than the reusable kit, and disposable sedation equipment was worse than reusable, but a reusable gown carried a higher human health burden than a disposable gown when its laundering was included.(25-27) The second is that digital fabrication is not automatically lower-carbon: fully digital implant workflows were not uniformly better than semi-digital ones, because the material block and its production burden could outweigh the savings from fewer steps.(21) These findings argue against checklist-style substitution and for life cycle assessment as the default arbiter when a practice chooses between options. They also explain a tension that surfaces in reviews of green dentistry: the field offers many candidate substitutions and few verified ones, which is why checklists proliferate while measured reductions remain scarce.(10,43)

Nitrous oxide and amalgam deserve emphasis because they are concentrated and policy-relevant. Nitrous oxide attaches a large climate impact to a small number of appointments, and the anaesthesia literature shows that wastage and leakage, not clinical necessity, drive much of the total.(27,33) Amalgam is being phased down under the Minamata Convention, but readiness is uneven across countries, and the substitutes bring their own material and packaging burdens that are only beginning to be quantified.(28,36,38) Both cases illustrate the same risk: an intervention that is environmentally rational at the level of policy can fail, or simply relocate the burden, at the level of the operatory if the substitute is not assessed. Prevention is the other policy lever the synthesis surfaces, because lower disease experience is associated with a markedly lower lifetime footprint, which makes disease prevention a sustainability strategy as well as a clinical one.(6,8)

This review has limitations that follow from its design and from the state of the evidence. It is narrative and non-systematic, with selection performed by one reviewer against explicit criteria, so relevant studies may have been missed despite searches in three sources.(15) A systematic search with dual screening would strengthen confidence and should precede any attempt to pool effect sizes. The evidence is geographically concentrated in the United Kingdom and Egypt, with fewer studies from low- and middle-income settings, which limits generalizability to different travel, energy, and waste infrastructures; expanding measurement to those settings is a research priority.(38) The primary studies use heterogeneous methods and functional units, which prevents formal comparison of magnitudes across procedures.(14) Finally, most intervention evidence reports activity or waste outcomes rather than verified emission reductions, so the size of the achievable saving remains uncertain. Each of these limitations has a concrete remedy: protocol-based dual screening, standardized functional units and system boundaries, reporting emissions as a measured outcome, and replication in under-represented health systems.

The research agenda that follows from these gaps is concrete. Standardized functional units and system boundaries, agreed across the field, would make studies comparable and enable benchmarking. Intervention studies should report greenhouse gas emissions as a measured outcome, not only waste mass or activity counts, so that the size of achievable reductions becomes known. Measurement should extend beyond the United Kingdom and Egypt to low- and middle-income settings, where travel, energy, and waste infrastructures differ and where amalgam substitution is most constrained.(38) Finally, the environmental assessment of amalgam alternatives and digital workflows should be cradle-to-grave, so that burden shifting between material, energy, and waste streams is detected rather than assumed away.(21,28)

In practice, a dental team can act now on the findings that are already consistent. It can measure its footprint with an available calculator, target the two largest sources it controls indirectly, travel and procurement, remove single-use plastics that infection control does not require, manage nitrous oxide as a high-impact gas, and segregate waste.(22,39,41) None of these requires waiting for better data, and together they address the sources that the evidence identifies as dominant. What requires better data is the next layer of decisions: which restorative material, which fabrication pathway, and which reusable substitute are genuinely lower-carbon in a given setting, and those decisions should be guided by life cycle evidence rather than by the green credentials of a product label.

Framing sustainability as quality improvement rather than as sacrifice may be the most useful translation of this evidence. The changes with the strongest measured support, removing unnecessary plastics, capturing rainwater, and offering teledentistry where safe, are also operational simplifications that reduce cost or time.(41,42,44) The framing is not new: the World Dental Federation has argued that environmentally sustainable dentistry and good-quality oral healthcare are the same project, because prevention and minimal intervention reduce both disease and waste.(8) What this review adds is the ordering, that travel and procurement should be addressed first because the data place them first, and the caution that substitution decisions need life cycle evidence rather than intuition.

CONCLUSIONS

The carbon footprint of dental care is small at the level of a single procedure and large at the level of a practice, a laboratory, or a lifetime of care, and the difference is explained by volume, by the inclusion of patient and staff travel, and by procurement. Travel, procurement, and energy consistently outweigh the clinical procedure itself as sources of emissions. Single-use plastics dominate the waste stream, and reusable or digital alternatives reduce impact only when the substitute is assessed rather than assumed, because laundering and material production can offset the savings. Nitrous oxide and amalgam are concentrated, policy-relevant targets whose substitution must be managed with the same rigor as the burden they remove. Measurable reductions are achievable today through unnecessary-plastic removal, low-carbon procurement, rainwater harvesting, teledentistry, and waste segregation, while education alone changes awareness more than emissions. Standardizing measurement and reporting emissions as an outcome are the conditions required to move the field from demonstrated awareness to verified reduction.

References

1. 1 Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett. 2019;14(6):064004. doi: 10.1088/1748-9326/ab19e1
2. 2 Karliner J, Slotterback S, Boyd R, Ashby B, Steele K, Wang J. Health care’s climate footprint: the health sector contribution and opportunities for action. European Journal of Public Health. 2020;30(Supplement_5):ckaa165.843. doi: 10.1093/eurpub/ckaa165.843
3. 3 Lenzen M, Malik A, Li M, Fry J, Weisz H, Pichler PP, et al. The environmental footprint of health care: a global assessment. The Lancet Planetary Health. 2020;4(7):e271-e279. doi: 10.1016/s2542-5196(20)30121-2
4. 4 Rodríguez‐Jiménez L, Romero‐Martín M, Spruell T, Steley Z, Gómez‐Salgado J. The carbon footprint of healthcare settings: A systematic review. Journal of Advanced Nursing. 2023;79(8):2830-2844. doi: 10.1111/jan.15671
5. 5 Borglin L, Pekarski S, Saget S, Duane B. The life cycle analysis of a dental examination: Quantifying the environmental burden of an examination in a hypothetical dental practice. Comm Dent Oral Epid. 2021;49(6):581-593. doi: 10.1111/cdoe.12630
6. 6 Martin N, Hunter A, Constantine Z, Mulligan S. The environmental consequences of oral healthcare provision by the dental team. Journal of Dentistry. 2024;142:104842. doi: 10.1016/j.jdent.2024.104842
7. 7 Lalloo R, Elango P, Nicolau B. The air travel carbon footprint of four recent global oral health meetings – Should we fly less?. Journal of Dentistry. 2025;158:105795. doi: 10.1016/j.jdent.2025.105795
8. 8 Martin N, Mulligan S. Environmental Sustainability Through Good-Quality Oral Healthcare. International Dental Journal. 2022;72(1):26-30. doi: 10.1016/j.identj.2021.06.005
9. 9 Tennison I, Roschnik S, Ashby B, Boyd R, Hamilton I, Oreszczyn T, et al. Health care's response to climate change: a carbon footprint assessment of the NHS in England. The Lancet Planetary Health. 2021;5(2):e84-e92. doi: 10.1016/s2542-5196(20)30271-0
10. 10 Hackley DM, Luca J. Sustainability in Dentistry: An Overview for Oral Healthcare Team Members. Journal of the California Dental Association. 2024;52(1):2422150. doi: 10.1080/19424396.2024.2422150
11. 11 Chalotra R, Shenoy R, Dasson Bajaj P, Rao A, Pai M, Jodalli P, et al. A scoping review exploring carbon emissions in dentistry—a step towards sustainability. BMC Oral Health. 2025;25(1):1674. doi: 10.1186/s12903-025-06952-w
12. 12 Martin N, Sheppard M, Gorasia G, Arora P, Cooper M, Mulligan S. Drivers, opportunities and best practice for sustainability in dentistry: A scoping review. Journal of Dentistry. 2021;112:103737. doi: 10.1016/j.jdent.2021.103737
13. 13 Or Z, Seppänen AV. The role of the health sector in tackling climate change: A narrative review. Health Policy. 2024;143:105053. doi: 10.1016/j.healthpol.2024.105053
14. 14 Kouwenberg LHJA, Cohen ES, Hehenkamp WJK, Snijder LE, Kampman JM, Küçükkeles B, et al. The Carbon Footprint of Hospital Services and Care Pathways: A State-of-the-Science Review. Environ Health Perspect. 2024;132(12):126002. doi: 10.1289/ehp14754
15. 15 Di Spirito F, Giordano F, Di Palo MP, De Benedetto G, Aulisio L, Boccia G. Sustainable Dental and Periodontal Practice: A Narrative Review on the 4R-Framework—Reduce, Reuse, Rethink, Recycle—And Waste Management Rationalization. Dentistry Journal. 2025;13(9):392. doi: 10.3390/dj13090392
16. 16 Duane B, Borglin L, Pekarski S, Saget S, Duncan HF. Environmental sustainability in endodontics. A life cycle assessment (LCA) of a root canal treatment procedure. BMC Oral Health. 2020;20(1):348. doi: 10.1186/s12903-020-01337-7
17. 17 Elwan AH, Tantawi ME, Fouda AM. Carbon footprint of private dental clinics in Egypt: a cross-sectional study. BMC Oral Health. 2025;25(1):93. doi: 10.1186/s12903-024-05413-0
18. 18 Elwan AH, Fouda AM. Carbon footprint of private dental laboratories in Egypt: A cross-sectional study. BDJ Open. 2025;11(1):40. doi: 10.1038/s41405-025-00316-w
19. 19 Duane B, Steinbach I. What is the environmental footprint of a dental practice? A life cycle analysis (Part 1). Br Dent J. 2024. doi: 10.1038/s41415-023-6710-z
20. 20 Duane B, Stancliffe R, Miller FA, Sherman J, Pasdeki-Clewer E. Sustainability in Dentistry: A Multifaceted Approach Needed. J Dent Res. 2020;99(9):998-1003. doi: 10.1177/0022034520919391
21. 21 Noodaeng S, Petchmedyai P, Janthasen A, Ponthip A, Neamhom T, Patthanaissaranukool W. Comparative carbon footprint analysis of semi-digital and fully digital implant-supported prosthesis fabrication processes. Environmental Challenges. 2025;20:101294. doi: 10.1016/j.envc.2025.101294
22. 22 Duane B, Steinbach I, Mackenzie L. A carbon calculator: the development of a user-friendly greenhouse gas measuring tool for general dental practice (Part 2). Br Dent J. 2024;236(1):57-61. doi: 10.1038/s41415-023-6626-7
23. 23 Martin N, Mulligan S, Fuzesi P, Hatton PV. Quantification of single use plastics waste generated in clinical dental practice and hospital settings. Journal of Dentistry. 2022;118:103948. doi: 10.1016/j.jdent.2022.103948
24. 24 Ivanović T, Meisel HJ, Som C, Nowack B. Material flow analysis of single-use plastics in healthcare: A case study of a surgical hospital in Germany. Resources, Conservation and Recycling. 2022;185:106425. doi: 10.1016/j.resconrec.2022.106425
25. 25 Almutairi W, Saget S, Mc Donnell J, Tarnowski A, Johnstone M, Duane B. The planetary health effects of COVID-19 in dental care: a life cycle assessment approach. Br Dent J. 2022;233(4):309-316. doi: 10.1038/s41415-022-4906-2
26. 26 Byrne D, Saget S, Davidson A, Haneef H, Abdeldaim T, Almudahkah A, et al. Comparing the environmental impact of reusable and disposable dental examination kits: a life cycle assessment approach. Br Dent J. 2022;233(4):317-325. doi: 10.1038/s41415-022-4912-4
27. 27 Fennell-Wells A, Duane B, Ashley P, Morgan E. The environmental impact of nitrous oxide inhalation sedation appointments and equipment used in dentistry. Eur Arch Paediatr Dent. 2024;25(3):393-408. doi: 10.1007/s40368-024-00895-6
28. 28 Smith L, Ali M, Agrissais M, Mulligan S, Koh L, Martin N. A comparative life cycle assessment of dental restorative materials. Dental Materials. 2023;39(1):13-24. doi: 10.1016/j.dental.2022.11.007
29. 29 Da Tan TY, Duane B, Hussein A, Samsonova A, Sizun G, Shakerdi L, et al. Environmental sustainability of post-orthodontic dental retainers: a comparative life-cycle assessment of Hawley and Essix retainers. European Journal of Orthodontics. 2024;46(2):cjae012. doi: 10.1093/ejo/cjae012
30. 30 Abed R, Ashley P, Duane B, Crotty J, Lyne A. An environmental impact study of inter‐dental cleaning aids. J Clinic Periodontology. 2023;50(1):2-10. doi: 10.1111/jcpe.13727
31. 31 Shinkai RSA, Biazevic MGH, Michel-Crosato E, de Campos TT. Environmental sustainability related to dental materials and procedures in prosthodontics: A critical review. The Journal of Prosthetic Dentistry. 2025;133(6):1466-1473. doi: 10.1016/j.prosdent.2023.05.024
32. 32 Al-Salih ZA, Ibrahem ET. Sustainable Practices in Dental Prosthesis: A Green Dentistry Perspective. Al-Wataniya J Med Sci. 2025;1(1):1-8. doi: 10.66564/ajms.2025.10001
33. 33 Lehmann F, Schulz CM, Leicht D, Brady S, Fuhrmann A, Prütting J, et al. Persistent use of nitrous oxide for anaesthesia in European hospitals despite its harmfulness to the climate – how emission taxation can achieve the coupling of cost-effectiveness and climate protection: observational study. BMC Health Serv Res. 2023;23(1):1392. doi: 10.1186/s12913-023-10307-y
34. 34 Narayanan H, Raistrick C, Tom Pierce JM, Shelton C. Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study. British Journal of Anaesthesia. 2022;129(2):231-243. doi: 10.1016/j.bja.2022.04.022
35. 35 Karydi K, Kirkland J. Nitrous oxide mitigation at Horton General Hospital. BJA Open. 2023;6:100182. doi: 10.1016/j.bjao.2023.100182
36. 36 Kisumbi BK, Osiro OA, Gathece LW, Maina SW. Dental Amalgam Phase‐Down—Status, Alternatives, Strategies and Preparedness for Implementation: A Review. International Journal of Dentistry. 2025;2025(1):6688410. doi: 10.1155/ijod/6688410
37. 37 Makanjuola JO, Umesi DC, Ndukwe AN, Enone LL, Sotunde OA, Omo JO, et al. Managing the phase‐down of amalgam amongst Nigerian dental professionals and students: A national survey. Eur J Dental Education. 2020;24(4):666-678. doi: 10.1111/eje.12554
38. 38 Kisumbi BK, Gathece LW, Osiro OA, Maina SW. Knowledge on the Minamata Convention on mercury and dental amalgam phase down, availability, and selection of mercury-free restorative materials among dentists in Kenya: a cross-sectional study. Pan Afr Med J. 2025;52:1-1. doi: 10.11604/pamj.2025.52.1.44453
39. 39 Fisal AA, Rohani MM, Nor NAM, Hamzah TNNT. Reductions in clinical waste and environmental emissions through recycling and waste segregation in a dental school: a cross-sectional study. Br Dent J. 2025. doi: 10.1038/s41415-025-8913-y
40. 40 Hashemizadeh A, Lyne A, Liddicott M. Reducing single-use plastics in dental practice: a quality improvement project. Br Dent J. 2024;237(6):483-486. doi: 10.1038/s41415-024-7836-3
41. 41 Suresh P, Crotty J, Tesanovic S, Alaweed O, Doyle S, Kiandee M, et al. A life cycle analysis of the environmental impact of procurement, waste and water in the dental practice. Br Dent J. 2024;236(7):545-551. doi: 10.1038/s41415-024-7239-5
42. 42 Martin N, Smith L, Mulligan S. Sustainable oral healthcare and the environment: mitigation strategies. Dent Update. 2021;48(7):524-531. doi: 10.12968/denu.2021.48.7.524
43. 43 Danesh DO, Luca J, Kalady SE, Townsend JA, Hammersmith KJ, Meyer BD. The impact of teledentistry on travel distance and carbon emissions at a children’s hospital. The Journal of the American Dental Association. 2025;156(2):144-150. doi: 10.1016/j.adaj.2024.11.007
44. 44 Hassan EH, Lotfy N, Abdou MH, Fetohy EM, Hussein MF. Effectiveness of an environmental educational program on intern dentists’ knowledge and practices regarding eco-friendly green dentistry: a quasi-experimental study. BMC Med Educ. 2025;25(1):32. doi: 10.1186/s12909-024-06523-7
45. 45 Thakar S, Kinariwala N, 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(Suppl 2):S1287-S1290. doi: 10.4103/jpbs.jpbs_116_23
46. 46 Mary AV, Kesavan R, T H, S.B B. Green Dentistry: Assessing Carbon Footprint Awareness and Practices Among Dental Professionals. Int J Pharm Sci Rev Res. 2025;85(2). doi: 10.47583/ijpsrr.2025.v85i02.011
47. 47 Martin N, Sheppard M, Gorasia G, Arora P, Cooper M, Mulligan S. Awareness and barriers to sustainability in dentistry: A scoping review. Journal of Dentistry. 2021;112:103735. doi: 10.1016/j.jdent.2021.103735
48. 48 Walsh SJ, O’Leary A, Bergin C, Lee S, Varley Á, Lynch M. Primary healthcare’s carbon footprint and sustainable strategies to mitigate its contribution: a scoping review. BMC Health Serv Res. 2024;24(1):1630. doi: 10.1186/s12913-024-12068-8