A Systematic Review to Evaluate Knowledge, Attitude, and Practice Regarding Biomedical Waste Management among Dental Teaching Institutions and Private Practitioners in Asian Countries.

OBJECTIVE: The objective of this study was to assess knowledge, attitude, and practices among dental teaching institutions and private practitioners in Asian countries.
MATERIALS AND METHODS: Systematic review of observational studies on BMW management was conducted. We searched the following electronic bibliographic databases: PubMed/MEDLINE and Google Scholar. Manual search was carried out for similar topics in the National Medical Library, New Delhi. In addition, the bibliographies were manually searched. There was no disagreement between the two reviewers. This review was reported and conducted in step with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies written in English and published until November 2019 were included. This review was registered in International Prospective Register of Systematic Reviews (PROSPERO registration number is CRD42019124900).
RESULTS: In this review, of 678 articles, 24 articles met inclusion criteria. Available scientific studies showed that knowledge regarding BMW management guidelines varied from 33% to 100% among dentists. Most of the studies reported that knowledge and practice regarding segregation of BMW was limited. Most of the study subjects were aware of hazardous effects of amalgam and had amalgam separator. Studies done in Chennai and Karnataka, approximately one-third dentists were not following BMW guidelines for sharp management and most of them were disposing of sharps in general waste bins.
CONCLUSION: On the basis of the current evidence and data extracted from the various databases, it can be concluded that knowledge regarding BMW management guidelines among dentists is inadequate and practice regarding the same is poor. Regular training sessions and Continuing Dental Education (CDE) on BMW management guidelines and updates need to be organized for improvement of knowledge and practice regarding BMW among dentists. Copyright:

INTRODUCTION

Dental colleges and clinics are those places that have existed since long time in various forms and are increasing more rapidly since the last decade. This increase in dental institutions resulted in a tremendous increase in biomedical waste (BMW) generated by these settings. BMW is defined as any waste, which is generated during the diagnosis, treatment, or immunization of human beings or animals or research activities pertaining to the production or testing of biological or health camps, including the categories mentioned in Schedule I appended to these rules.[1] Dental waste is a subset of hazardous BMW, which includes various materials such as soaked cotton, sharp needles, extracted teeth, and human tissue parts that are usually contaminated with body fluids such as blood and saliva.[2] Dental institutions also generate other types of waste such as mercury, silver, amalgam, and various chemical solvents.[3] Amalgam and its waste products need to be strictly regulated otherwise it may lead to environmental pollution as well as occupational hazards.[4] Waste generated in a dental teaching hospital is similar to that generated by other hospitals which include a large component of general waste and a smaller proportion of hazardous waste. According to study conducted in Bangalore, total quantity of waste generated was 0.161kg/dental clinic/day with 0.130kg and 0.026kg of infectious and recyclables waste, respectively.[5] Dentists are always at higher risk for getting infections from patients due to exposures to oral secretions that are potential reservoir for many human pathogens.

As per BMW management rules put forth by government, color coding should be followed while disposing waste generated in dental institutions. Health-care establishments are responsible for segregation, disinfection, and disposal of BMW in an eco-friendly manner.[1] Dentists are therefore expected to be aware of these waste management regulations, also they are expected to follow these regulations to ensure safe disposal of BMW for maintenance of safe and healthy working environment.

There is paucity of studies on BMW management among dental teaching institutions which produce a considerable amount of BMW. This systematic review is aiming to assess the status of BMW management among dentists of Indian as well as other Asian countries working in private clinics or dental teaching institutions. This will help us to understand the broad picture of waste management awareness and practices among dentists and recommend necessary steps to improve it.

Therefore, this review was planned on available literature for reporting knowledge, attitude, and practices (KAPs) among dental teaching institutions and dental practitioners in Asian countries.

MATERIALS AND METHODS

The protocol of this systematic review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO registration number is CRD42019124900.) (https://www.crd.york.ac.uk/PROSPERO/#recordID=124900).

ELIGIBILITY CRITERIA FOR THE STUDIES

This systematic review was carried out on KAP regarding BMW management among dental teaching institutions and private practitioners in Asian countries. The recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were followed to report this systematic review. The eligibility criteria were based on PICOS (population, intervention, comparator, outcomes, and study design) strategy.

Population

Population of interest in the systematic review was the dental professionals of Asia (dental undergraduate students, dental postgraduate students, dental professors, and dental private practitioners).

Intervention/exposure(s)

There was no intervention in this analysis. However, the responses (numbers or proportion) in the form of yes or no to each question of KAP components were evaluated.

Comparator/control

Not applicable. There were two groups: one for “yes” component and other for “no” component of each KAP question.

Types of the study to be included

Cross-sectional observational KAP studies on BMW management among dental teaching institutions and private practitioners in Asian countries were included. Studies published until November 2019 were included in the study as mentioned in protocol.

Exclusion criteria for this review

The exclusion criteria of the study were research studies not conducted in Asia, reviews, articles that were not in English language, and protocols of published studies.

SEARCH STRATEGY

A systematic search was performed by three authors independently (PT, BK, and NP) using an electronic search as well as manual method. The electronic search was done with PubMed and Google scholar databases. Search strategy used the subject headings and keywords (medical waste disposal, BMW, dental waste, KAP, dentists, dental practitioners, Asia). Boolean operators such as “AND,” “OR” were used for making various combinations of keywords.

The bibliographies of relevant guidelines, reviews, and reports were also inspected to identify further relevant primary reports. A manual search was done from VSPM Dental college library, Nagpur and National Medical Library, New Delhi for gray literature. For studies with data missing or requiring clarification, corresponding authors were contacted. Online search for major conference’s proceedings was also conducted to identify unpublished literature.

SELECTION OF STUDIES

Two authors (PT and BK) individually searched the studies which were included in this review. Initially, exclusion of the studies was done based on titles and abstracts of retrieved studies which were inappropriate. Reference lists of previous reviews were searched for studies that were missed by the electronic search. Full-text articles were retrieved for studies that met inclusion criteria. STROBE checklist for observational study was applied for screening of retrieved articles.

COLLECTION AND EXTRACTION OF DATA

This review was done according to the guidelines set forth by PRISMA.[6] Three authors (PT, BK, and BA) were given the responsibility of extracting data from the studies. Prespecified data were extracted from each of the studies including the study design, sample size, knowledge, and practices regarding BMW management among the study subjects. Any kind of disagreement regarding article screening and extraction was sorted out by discussion with other authors (NP and UR).

CONTROL OF BIAS ASSESSMENT

RISK OF BIAS ASSESSMENT

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used for assessment of risk of bias. Risk of bias or quality assessment was done using four criteria: (1) Study type (2) outcome measures such as KAPs regarding BMW management (3) outcome used for reporting (4) completeness of the information on BMW management. The assessment of risk of bias was performed by rating each of the study criteria as “yes” (low risk of bias), “no” (high risk of bias), or “can’t say” (uncertainty over the potential for bias). The risk of bias assessment was conducted by one of the reviewers and also cross-checked by the other.

RESULTS

DESCRIPTION OF SELECTED STUDIES

The original search identified 744 studies and only 24 studies were potentially eligible for the systematic review after performing necessary exclusions [Figure 1]. The study population of 24 identified studies comprised of private and government dentists and only five studies consist paramedic staff in addition to dentists. Most of the studies (21) were conducted in India and remaining studies were conducted in Pakistan, Nepal, and Palestine. In this review, all the studies were of cross-sectional type and most of them used a semi-structured, validated interview schedule for collecting information from participants [Table 1].

Figure 1

PRISMA flow diagram

Table 1

Characteristics of studies included in systematic review

Authors	Year of publication	Study population	Sample size	Study area	Outcome measure	Results
Kishor et al.[7]	2000	Dentist	64	Delhi, India	Awareness and practice about biomedical waste management	Most of them were not aware of BMW management and 50% were practicing proper waste management method
Sudhir et al.[8]	2006	Dentists	302	Karnataka, India	Awareness and practices about dental waste management	73% were aware about categorization and color coding of waste, 55% did not have knowledge about hospital waste management policy, 18% were following improper practice for amalgam waste management.
Mumtaz et al.[9]	2008	Dentist	239	Islamabad and Rawalpindi, Pakistan	Knowledge and practices regarding amalgam waste management.	90% perceived amalgam as health risk, 46% considered it as environmental hazard and Only 6% used amalgam separator.
						Others (94%) disposed in trash, down the sink.
Al- Khatib et al.[10]	2008	Dentist	97	Palestine	Awareness regarding dental solid waste management	30% throw sharp in garbage 56% had special container for sharp needles. There was no guidelines for recycling
Sudhakar et al.[11]	2008	Private dental practitioner	432	Bangalore	awareness and practices of dental waste management	64% did not segregate BMW before disposal, 48% hand over waste directly to street garbage collector and 42% did not had knowledge about BMW waste segregation
Sood et al.[12]	2010	Dental students, faculty of dental college and private practitioner	100	Delhi, India	Knowledge, attitude and practices in disposal of BMW	60–75% participants had awareness about hazardous nature of BMW and its management regulation, 32% participants disposed waste into general garbage and 39% disposed amalgam in dustbin and 6% in drain.
Sushama et al.[13]	2010	Private dentist	96	Mangalore, India	Awareness, attitude and practice regarding dental solid waste management	98% were aware of waste management policy and 48% handed over waste to municipal garbage collector
Narang et al.[14]	2012	Dentists, auxiliary staffs	160	Punjab, India	Awareness and practices about dental waste management	100% dentists and 12% staffs aware about BMW management rules, 82% dentists and 12% staffs aware about hospital waste management policy and 52% dentists and 20% staff members dispose BMW properly
Singh et al.[15]	2012	Dentist in dental hospitals	800	India	Knowledge, attitude and practices for cross infection control procedure	71% use boiling water as sterilization medium and 69% disposed hazardous waste into municipality bins.
Sushma et al.[16]	2012	Dentists, auxiliaries and attenders	272	Karnataka, India	Knowledge about BMW management	54% dentists, 83% attenders and 38% auxiliaries had knowledge about segregation of BMW waste management
Bansal et al.[17]	2013	Private dental practitioner	100	Chandigarh	awareness and practices of dental waste management	14% were aware of categories of BMW waste and 26% disposed it wrongly
Sharma et al.[2]	2013	staffs of Jaipur Dental college	144	Jaipur, India	awareness regarding biomedical waste management policy and practices	36% nurses had poor knowledge regarding BMW disposal and Only 15% Class IV staff had good knowledge for it.
Khandelwal et al.[3]	2013	Dental practitioner	105	Indore, India	Knowledge, attitude and practice regarding dental solid waste management	42% dentists dumped BMW in corporation bin, 37% dumped in authorized waste collection site and Only 11% doctors believed that they have role in segregation and 23% practitioners disposed sharps with solid waste
Bala et al.[18]	2013	Medical personnel of dental college	116	Rohtak, India	awareness regarding BMW management	<30% doctors and no single student knew about BMW management legislation and 45% doctors knew about segregation
Singh et al.[19]	2014	Private dental practitioner	200	Uttar Pradesh, India	Awareness regarding dental waste management rules	64% dentists were not aware of different types of BMW and 41% disposed amalgams by throwing into common bins.
Arora et al.[20]	2014	Dentists	100	Chhattisgarh, India	KAP about dental waste management	48% had knowledge about waste management and only 8% used amalgam in the recommended manner
Bangenavar et al.[21]	2015	Dentist, auxiliary staff and attenders in dental clinic	158	Karnataka, India	KAP about dental waste management	29% dentists and 1% attenders identified different color coded bags and 48% clinics had needle destroyer, 71% dentists and 92% dental attainders responded that developer and fixer can be drained into the sewer
Rajeev Ranjan et al.[22]	2016	Dental students	500	Odisha, India	Awareness about BMW management	44% were not aware of BMW management. 61% were completely unaware regarding recycling and reusing of BMW.
Abhisek et al.[23]	2016	Private dentists	186	Karnataka, India	Knowledge and practices about dental waste management	86% had knowledge about waste management and 68% handed over BMW to biomedical waste management agency
Kesavan et al.[24]	2017	Dentist	250	Chennai, India	awareness regarding BMW management	28% were unaware about different types of color coding for BMW and 28% were unaware of BMW management policy
Singh et al.[25]	2018	Undergraduate dental students	434	Nepal	Awareness of biomedical waste management	92% students had positive attitude towards BMW management and only 50% of the students were aware of guidelines.
Kumar et al.[26]	2018	Dental students	109	Lucknow, India	KAP about dental waste management	43% had adequate knowledge about BMW management
Raghuvanshi et al.[27]	2018	Private dentist practitioner	614	India	Knowledge, attitude and practices in disposal of BMW	80% private practitioners were aware of BMW categories and >41% practitioners disposed BMW directly into sewer.
Jamkhande et al.[28]	2019	Dentist	200	Pune, India	KAP about dental waste management	95% were aware of dental waste management and 73%–81% practiced BMW management policy

In 24 quantitative studies, primary tool consists of structured questionnaire that consists questions regarding KAPs regarding BMW management.

AWARENESS REGARDING BIOMEDICAL WASTE MANAGEMENT GUIDELINE

Knowledge regarding BMW management guideline was highest (100%) in the study done by Narang et al.[14] among dentists of Punjab and lowest knowledge (33%) was seen in study done by Bala et al.[18] in Rohtak. Majority of studies reported that more than 50% dentists were aware about BMW policy set by government.[121314151623,24] In a study done by Mumtaz et al.[9] in Pakistan, 56.5% were having limited knowledge regarding amalgam waste management policy [Figure 2].

Figure 2

Knowledge and practice regarding BMW management

SEGREGATION OF BIOMEDICAL WASTE

Most of the studies reported that knowledge and practice regarding segregation of BMW was limited. Sood et al.[12] in their study done in Delhi reported that 100% dental practitioners were aware about segregation of waste but only 67% were practicing segregation in routine practice, whereas in a study done by Kesavan et al.[24] in Chennai 14.8% dentists were not aware about different categorization of BMW and 82.4% were not segregating BMW in practice. Singh et al.[19]in their study done among dentists of Uttar Pradesh found that 40.6% were not aware about different color coding of BMW and 86.2% were not segregating BMW as per rule in their clinics.

CATEGORIZING OF BIOMEDICAL WASTE AND DISPOSAL OF SHARP

Categorization of BMW and disposal in color-coded dustbin is utmost important part of BMW management rule but many studies reported that it is not followed up to the mark in private and government settings. A study done by Narang et al.[14] in Punjab reported that 85 % dentists were aware of BMW color coding but only 60% dentists were practicing it. Sushma et al.[13]in their study done among private dental practitioners of Karnataka reported that 45.8% dentists used different color-coded containers and only 43.8% used puncture-proof containers for disposal of sharps. Abhishek et al.[23] reported that of 186 private dentists of Karnataka 24.4% disposed sharps into general waste bins. A study done in Chennai by Kesavan et al.[24] found that 28% dentists were not aware of categorizing of waste, 24.4% dentists used needle destroyer, and only 16.4% dentists used color-coded bags for disposal of BMW. Similar finding was reported by Singh et al.[19] in which 40.6% dentists of 200 were not aware of color coding and 31.9% dentists disposed sharps into the common bin [Figure 2].

SEGREGATION AND DISPOSAL OF DENTAL AMALGAM

Use of dental amalgam is very common practice in dental setup. As it contains mercury, proper segregation and disposal is warranted to avoid hazardous effects of mercury on human health. Most of the study subjects were aware of hazardous effects of amalgam and had amalgam separator. Khatib et al.[10]reported that most of dentists did not follow proper segregation of dental waste and mercury-containing amalgam and generally used to dispose amalgam in general waste. In a study by Sood et al.,[12] 55% dentists used amalgam separator, whereas 81.2% dentists used amalgam separator in a study by Mumtaz et al.[9] Khandelwal et al.[3] reported that only 8% dentists used amalgam separator. Majority of the dentists (69%) were aware of mercury spill management as reported in a study by Abhishek et al.[23] in Karnataka whereas Bangennavar et al.[21] reported that only 29% dentists were aware of mercury spill management.

KNOWLEDGE, ATTITUDE, AND PRACTICE OF BIOMEDICAL WASTE MANAGEMENT AMONG AUXILIARY STAFF

Some studies reported knowledge and practices of auxiliary staff along with the dentists in their study. Majority of study findings showed that auxiliary staff had poor knowledge of BMW guidelines and practically also they were not following BMW guidelines strictly.[214,1821]

QUALITY ASSESSMENT

Across the six quality domains evaluated, majority of studies met four or more of the quality criteria. Two studies met all the quality criteria assessed. Twelve studies did not mention how they reached sample size and it was not based on prestudy considerations of statistical power. None of study described methods used to address potential bias. All studies gave a summary of results at the end [Table 2].

Table 2

Quality assessment of all studies included in the systematic review

Study	Does the study title and abstract indicate study design summary?	Does the methodology explain study setting, eligibility criteria, selection of participants?	Does the study describe any efforts to address potential sources of bias?	Does study explain how the sample size was arrived at?	Does the study explain all statistical methods?	Does the discussion summarize key results with reference to study objectives?
Mumtaz et al.[9]	Y	Y	N	Y	Y	Y
Singh et al.[25]	Y	Y	N	Y	Y	Y
Singh et al.[19]	Y	CS	N	N	Y	Y
Rajeev et al.[22]	Y	Y	N	N	Y	Y
Sood et al.[12]	Y	CS
	N	Y	N	Y
Raghuvanshi et al.[27]
Y	Y	N	N	Y	Y
Singh et al.[19]	Y	Y	N	N	Y	Y
Bansal et al.[17]
Y	Y	N	N	Y	Y
Sudhakar et al.[11]
Y	Y	Y	Y	Y	Y
Sharma et al.[2]	Y	Y	N	Y	Y	Y
Isaam et al.	Y	Y	N	N	Y	Y
Sushma et al.[13]	Y	Y	N	Y	Y	Y
Khandelwal et al.[3]	Y	N	N	Y	Y	Y
Bala et al.[18]	Y	Y	N	N	Y	Y
Kesavan et al.[24]	Y	Y	N	Y	Y	Y
Jamkhande et al.[28]	Y	Y	Y	Y	Y	Y
Bangenavar et al.[21]	Y	Y	N	N	Y	Y
Arora et al.[20]	Y	Y	N	N	Y	Y
Sudhir et al.[8]	Y	Y	N	N	Y	Y
Kumar et al.[26]	Y	CS	N	N	Y	Y
Sushma et al.	Y	Y	N	Y	Y	Y
Abhisek et al.[23]	Y	Y	N	Y	Y	Y
Narang R et al.[14]	Y	Y	N	N	Y	Y
Kumar et al.[29]	Y	Y	N	Y	Y	Y

Y = Yes, N = No, CS = Can’t say

DISCUSSION

We conducted this systematic review on assessment of awareness regarding BMW management rules among dentists because waste management is an important aspect not only for dentists but also for society. We analyzed all domains of BMW management in this review which is depicted in given results. We found that awareness level regarding BMW management among study participants was not up to the mark and there was significant variation in practices of BMW management which could be due to difference in sample size and different study settings [Figure 2]. It was also seen that dentists working in teaching institutions were more aware about BMW guidelines than dentists working in the private set up this may be due to timely training activities in teaching institutions. Most of participants were interested in attending training on BMW management guidelines on a timely manner.[318] Private practitioners were not disposing BMW as per guidelines in some places due to lack of authorized BMW recycler in their area or not aware of recycler in the vicinity.[22] Amalgam separator use was low among participants of studies conducted in Uttar Pradesh, Karnataka and Chhattisgarh.[3192021] In some studies, paramedical staffs were also included which showed that there was lacunae in awareness and practice of BMW management among these staff.[218,21]

Strength of this review is it included studies not only from India but also from other Asian countries. Private practitioners and dental teaching institutions were also included in this review. This review had some limitations like different countries and states had different rules and regulations regarding BMW management which might had affected study results. BMW rules keep changing over the period and studies included in this review were conducted in different time periods which might had effect on results.

CONCLUSION

The result of this review showed that awareness level of the study participants regarding BMW management was low and there was substantial variation in BMW management practices within different studies. Effective management of BMW is important for prevention of hazards related to it as well it is a social responsibility and not mare a legal necessity. Timely training and sensitization programs regarding BMW guidelines are warranted for dentists as well as auxiliary staff to bridge the gap. BMW rules need to be strictly implemented in all health institutions and proper monitoring by concerned authority is necessary for India and other Asian countries.

ACKNOWLEDGEMENT

Not applicable.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil.

CONFLICTS OF INTERESTS

There are no conflicts of interest.

AUTHORS CONTRIBUTIONS

Not applicable.

ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT

Not applicable.

PATIENT DECLARATION OF CONSENT

Not applicable.

DATA AVAILABILITY STATEMENT

Not applicable.