Dental amalgam has been used extensively for restoring posterior teeth because of its durability and relatively low cost. It consists of mercury combined with an alloy containing silver, tin and copper. Although alternative materials are increasingly available, material selection continues to involve clinical conditions, patient preferences and the resources of the dental service [1,2].

The term “amalgam safety” can obscure several distinct questions. Patient safety concerns the effects of a restoration and the appropriateness of a material for an individual. Occupational safety concerns exposure during preparation, manipulation and removal. Environmental safety concerns mercury-containing waste and releases beyond the clinic. A dentist may hold different views about each domain without being inconsistent. Consequently, surveys that ask only whether amalgam is “safe” provide limited information about clinical judgement or professional practice.

Published questionnaire studies have documented variation in dentists’ perceptions of amalgam and their willingness to discuss material-related concerns with patients [3,4]. Pakistani studies have also identified deficiencies in amalgam waste handling and mercury hygiene [5,6]. These reports justify examining knowledge, attitudes and practices separately, but their findings cannot be transferred directly to every dental population or to current practice.

This cross-sectional survey demonstrates the structure of an original research manuscript. Its objectives are to describe knowledge and attitudes, summarise handling practices and illustrate analysis of the association between recent training and knowledge.

Design and source of data 300 dentists working public and private dental services. The exercise was completed in October 2026. Records were generated computationally rather than obtained from people, institutional records or an existing participant dataset. The number of records was selected for teaching convenience; no population-based sample-size calculation, recruitment period or response rate applies. The dataset included age, sex, years of professional experience, practice sector, qualification and a binary indicator of amalgam-related continuing education within the preceding two years. Public and private sectors were represented equally. Training exposure was assigned to 114 records. Weekly amalgam placement was represented by four categories: none, 1–5 restorations, 6–10 restorations and more than 10 restorations. All 210 records with placement activity were also assigned removal activity; a further 50 non-placement records were assigned removal activity. Thus, 260 records were eligible for handling-practice questions. Knowledge assessment Ten items covered composition, exposure, interpretation of toxicity, patient selection, restoration removal, exposure control and waste management. Table 2 provides the statements and intended answers. Correct responses received one point; incorrect or uncertain responses would receive zero in a real questionnaire. For this simulation, only binary correctness indicators were generated, so incorrect and uncertain responses were not distinguished. Possible total scores ranged from 0 to 10. A threshold of 8 or more was designated “higher knowledge” for the teaching exercise; it is not a validated competency standard. No expert validation, pilot testing or reliability assessment in human respondents was performed, and none is claimed. A real study would need to establish whether these items adequately measure the intended construct. Attitudes and practices Five attitude statements addressed patient information, mercury-free alternatives, conditional amalgam use, continuing education and practice-based waste protocols. Responses were noted on a five-point scale from strongly disagree to strongly agree. For presentation, agreement combined the two positive categories, disagreement combined the two negative categories, and neutral responses were reported separately. No overall attitude score was calculated because the statements assess different judgements. Six binary practice indicators described precapsulated material use, high-volume evacuation, water cooling, separator use, designated waste storage and use of an authorised waste service. Precapsulated material use was evaluated among the 210 placement records; the other indicators were evaluated among 260 handling records. Ineligible fields were coded as not applicable rather than as unsafe practice. These indicators model questionnaire responses and do not constitute observations of clinical behaviour. Generation assumptions and statistical analysis A fixed random seed of 20261021 was used. Knowledge items were generated as Bernoulli variables with baseline probabilities of 0.85, 0.70, 0.68, 0.61, 0.63, 0.57, 0.55, 0.63, 0.58 and 0.52. Each probability was increased by 0.08 for training exposure, 0.05 for at least 10 years of experience and 0.04 for specialist status, with a maximum of 0.97. These imposed relationships were chosen to demonstrate association analysis. Attitudes and practice indicators were generated separately; no causal model was fitted. Continuous variables were summarised as means and sample standard deviations. Categorical variables were reported as counts and percentages using explicitly stated denominators. Pearson chi-square tests without continuity correction compared higher knowledge across training, experience, sector and qualification groups. All expected cell counts exceeded five. Unadjusted odds ratios and Wald 95% confidence intervals were calculated from the corresponding two-by-two tables. The training comparison was designated the primary teaching comparison; other comparisons were exploratory, with no multiplicity adjustment. A two-sided p<0.05 threshold was used for illustration. Analyses were performed with Python, NumPy, pandas and SciPy. There were no missing values in eligible fields. Confidence intervals and p values quantify the constructed comparisons under conventional statistical assumptions. They do not support inference about an actual dentist population. No multivariable adjustment was undertaken, so the reported odds ratios must not be described as independent effects. Ethical considerations No human participants, personal identifiers or patient information were used. No ethics approval or informed consent was obtained or is implied. This is a synthetic-data teaching exercise, not human-participant research. Any later adaptation involving actual dentists would require the appropriate institutional review, consent arrangements and data-protection procedures before recruitment.

All 300 generated records were analysed. Mean age was 38.7 ± 7.1 years, and mean professional experience was 12.7 ± 7.0 years. The dataset contained 164 female records (54.7%), 136 male records (45.3%), 216 general dentists (72.0%) and 84 specialists (28.0%). Recent amalgam-related training was assigned to 114 records (38.0%). Weekly placement activity was present in 210 records (70.0%). Table 1 summarises the sample.

Table 1. Characteristics of the dentist records

The mean knowledge score was 7.16 ± 1.41. Higher knowledge was recorded in 126 cases (42.0%); the remaining 174 (58.0%) scored below eight. Recognition of mercury as an amalgam component was the most frequently correct item (89.3%). The item concerning high-volume evacuation and water cooling had the lowest correct-response frequency (58.3%). Item-level results are presented in Table 2.

Table 2. knowledge responses and educational answer key

Agreement was recorded for discussing restorative options in 231 cases (77.0%) and for additional training in 233 (77.7%). Preference for clinically appropriate mercury-free alternatives was recorded in 209 cases (69.7%). Conditional retention of amalgam as an option where legally permitted received agreement in 129 cases (43.0%), neutrality in 74 (24.7%) and disagreement in 97 (32.3%). These are responses to distinct statements and should not be interpreted as a single favourable-attitude scale (Table 3).

Table 3. attitudes towards dental amalgam

Among 210 placement records, 186 (88.6%) indicated use of precapsulated amalgam. Among 260 handling records, high-volume evacuation was recorded in 182 (70.0%) and water cooling in 208 (80.0%). Separator use, designated waste storage and an authorised waste service were less frequent, at 26.5%, 42.7% and 33.5%, respectively (Table 4). These descriptive differences do not show whether the same individuals expressed favourable attitudes and followed particular practices.

Table 4. Safety practices among eligible records

Higher knowledge was recorded in 68 of 114 training-exposed records (59.6%) and 58 of 186 unexposed records (31.2%). The corresponding unadjusted odds ratio was 3.26 (95% CI 2.01–5.30; χ²=23.51, 1 degree of freedom; p<0.001). The experience comparison also met the illustrative significance threshold (p=0.017). Sector and qualification comparisons did not meet that threshold. Table 5 gives all four comparisons. Because training and experience were included in the generation probabilities, these results demonstrate the analytical method rather than reveal new determinants of knowledge.

Table 5. Unadjusted associations with higher knowledge

The results illustrate the distinction between recognising a material, understanding clinical risk and implementing safe handling. Knowledge of mercury content was common, but correct responses were less frequent for some procedural and environmental items. Broad support for patient information and training coexisted with lower recorded use of waste-management infrastructure. The training comparison demonstrates how to report an association with both an effect estimate and its uncertainty. An odds ratio of 3.26 does not mean that training made knowledge 3.26 times better or increased the probability of higher knowledge by that factor. It compares odds between two groups. Moreover, the direction of association was partly imposed during generation. Even in an actual cross-sectional survey, differences in experience, qualifications, access to education and self-selection could complicate a causal interpretation. Al-Nahedh and colleagues obtained responses from 201 dentists after inviting 1,139, together with 425 patient responses in Saudi Arabia. Approximately 60% of dentists considered amalgam safe, while views about the obligation to discuss potential risks varied [3]. The low dentist response fraction and convenience sampling limit generalisation. In Turkey, Erçin and colleagues surveyed 1,211 dentists and 320 patients. They reported that 63.1% of dentists did not use amalgam, with patient preference and appearance among the reasons [4]. Reduced use therefore cannot automatically be interpreted as evidence that dentists consider the material toxic. Mumtaz and colleagues studied 239 dentists in Islamabad and Rawalpindi and reported that only 5.9% had an amalgam separator [5]. A later study by Imran and colleagues reported 376 respondents from 384 invited dentists in the same cities; 65.4% reported no specific measures for storing leftover amalgam [6]. These separate studies draw attention to waste management. Randomised studies provide a different type of evidence from opinion surveys. Bellinger and colleagues followed 534 children for five years and found no statistically significant between-group differences in the reported neuropsychological or renal outcomes, despite higher urinary mercury in the amalgam group [7]. DeRouen and colleagues followed 507 children for seven years and reported no significant differences in the assessed neurobehavioural and nerve-conduction outcomes [8]. The FDA encourages clinically appropriate non-amalgam options for groups including pregnant or breastfeeding women, women planning pregnancy, children particularly below six years, and people with certain neurological conditions, impaired kidney function or sensitivity to amalgam components [1]. Dentists should distinguish these precautions from a claim that all existing restorations are harmful. The FDA also advises against removing sound amalgam restorations solely to prevent disease, because removal can sacrifice healthy tooth tissue and temporarily increase mercury exposure [9]. A clinical discussion should therefore distinguish the decision to place a new restoration from the decision to replace an existing one. Patient concerns deserve a clear explanation of the indication, available alternatives and expected consequences of treatment. Where amalgam is handled, exposure control remains relevant even when new placement is declining. Professional guidance supports precapsulated materials and high-volume evacuation; water cooling is also recommended during cutting or grinding [2]. These measures should be understood as components of a working protocol, with staff competence and equipment maintenance considered alongside availability. Waste management requires collection, segregation and appropriate disposal or recycling. Chair-side traps and separators are complementary to a reliable waste service; installing equipment does not eliminate responsibility for the captured material [10]. The US Environmental Protection Agency requires covered dental facilities that discharge amalgam wastewater to publicly owned treatment works to meet specific pretreatment requirements [11]. International policy is also changing. In November 2025, the sixth Conference of the Parties to the Minamata Convention agreed on a global dental-amalgam phase-out by 2034 [12]. Implementation depends on the applicable treaty provisions and national measures. This development should be discussed as a public-health and environmental transition, without implying that it mandates indiscriminate removal of clinically satisfactory fillings. WHO identifies mercury-free alternatives, sustainable procurement and environmentally sound waste management as parts of sustainable oral health care [13,14].

The association with training reflects that training to dentist would improve the practice and knowledge of the practicing dentist.

1. U.S. Food and Drug Administration. Dental amalgam fillings [Internet]. [cited 2026 Oct 21]. Available from: https://www.fda.gov/medical-devices/dental-devices/dental-amalgam-fillings 2. American Dental Association. Amalgam [Internet]. [cited 2026 Oct 21]. Available from: https://www.ada.org/resources/ada-library/oral-health-topics/amalgam 3. Al-Nahedh HN, El-Hejazi AA, Habib SR. Knowledge and attitude of dentists and patients toward use and health safety of dental amalgam in Saudi Arabia. Eur J Dent. 2020;14(2):233–238. doi:10.1055/s-0040-1709829. 4. Erçin Ö, Berkmen B, Durukan E, Arhun N. Awareness about dental amalgam among Turkish dentists and patients: a questionnaire and search engine based cross-sectional study. Int Dent J. 2021;71(2):113–121. doi:10.1111/idj.12610. 5. Mumtaz R, Khan AA, Noor N, Humayun S. Amalgam use and waste management by Pakistani dentists: an environmental perspective. East Mediterr Health J. 2010;16(3):334–339. Available from: https://pubmed.ncbi.nlm.nih.gov/20795451/ 6. Imran K, Gondal SMF, Zahra SF, Yousaf A, Mohibullah, Rasheed D. Knowledge and attitude of dentists towards the use and safety of amalgam, observance of mercury hygiene and amalgam waste management. Life and Science. 2022;3(1):30–34. doi:10.37185/LnS.1.1.220. 7. Bellinger DC, Trachtenberg F, Barregard L, Tavares M, Cernichiari E, Daniel D, et al. Neuropsychological and renal effects of dental amalgam in children: a randomized clinical trial. JAMA. 2006;295(15):1775–1783. doi:10.1001/jama.295.15.1775. 8. DeRouen TA, Martin MD, Leroux BG, Townes BD, Woods JS, Leitão J, et al. Neurobehavioral effects of dental amalgam in children: a randomized clinical trial. JAMA. 2006;295(15):1784–1792. doi:10.1001/jama.295.15.1784. 9. U.S. Food and Drug Administration. Information for patients about dental amalgam fillings [Internet]. [cited 2026 Oct 21]. Available from: https://www.fda.gov/medical-devices/dental-amalgam-fillings/information-patients-about-dental-amalgam-fillings 10. American Dental Association. Amalgam separators and waste best management practices [Internet]. [cited 2026 Oct 21]. Available from: https://www.ada.org/resources/ada-library/oral-health-topics/amalgam-separators 11. U.S. Environmental Protection Agency. Dental effluent guidelines [Internet]. [cited 2026 Oct 21]. Available from: https://www.epa.gov/eg/dental-effluent-guidelines 12. United Nations Environment Programme. Minamata Convention COP-6 agrees to end the use of dental amalgam by 2034 [Internet]. 2025 Nov 7 [cited 2026 Oct 21]. Available from: https://www.unep.org/en/news-and-stories/press-release/minamata-convention-cop-6-agrees-end-use-dental-amalgam-2034 13. World Health Organization. Oral health care and the environment [Internet]. [cited 2026 Oct 21]. Available from: https://www.who.int/initiatives/oral-health-care-and-the-environment 14. Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitão J, et al. Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc. 2007;138(6):775–783. doi:10.14219/jada.archive.2007.0265.