Knowledge, Attitude and Practice about radiation safety among the undergraduates in Eastern province dental college.

BACKGROUND: Despite the fact that X-rays have a direct or indirect effect on tissues, imaging techniques have become an important part of modern dentistry, and dentists rely on them for diagnosis, treatment, and follow-up. This necessitates that dentists have adequate expertise and attitude in order to defend themselves and their patients. AIM: The present study was conducted to assess the knowledge, attitude, and practice of clinical side dental students and General Dental Practitioners (GDPs) regarding dental radiation protection safety protocol. STUDY
DESIGN: It is a prospective cross-section study among dental undergraduates and GDPs.
MATERIALS AND METHODS: One hundred and sixteen participants took part in this study and comprised 116 clinical side dental students and GDPs. Participants' data were gathered through a questionnaire that asked about their knowledge and practice of radiation biology, danger, and protection. Collected data subjected to statistical analysis using the SPSS 21. Pearson Chi-square test was done to evaluate the statistical significance. The P value fixed at ≤ 0.05 for significant.
RESULTS: From 116 participants, around 89.7%% of the participants believed that dental X-rays are harmful and 81% are having knowledge about annual radiation dose limit for a dentist, and overall, 56% of the participants were aware about the harmful effects of radiation exposure.
CONCLUSION: There is a need to expand the curriculum to provide better exposure to radiation protection and its practice so that these students on graduation will be well-grounded with the principle governing dental radiography. Copyright:

INTRODUCTION

Radiation is the transmission of energy through space and matter and it occurs in either in the form of particulate or nonparticulate, i.e. electromagnetic radiation (EMR). EMR is the movement of energy through space as a combination of electric and magnetic fields. Depending on their energy level the EMR grouped as ionizing and non-ionizing radiation and the ionizing radiations inducing various biological harmful effects.[12] However, EMR can be used safely in the medical and dental fields, and it has become an important field in diagnosis and treatment applications.

With the advent of new imaging methods, the field of radiology in dentistry has developed from rudimentary to tech-oriented.[3] Radiation's biological effects can be either deterministic or stochastic, with deterministic effects being dose-related while stochastic effects are not.[4] Although the radiation hazard posed by the dental radiographs is low, the accumulation of such low-level radiation in the human body over a long time can pose a threat to health.[56] This leads to both dentist and patients are at the risk of stochastic effects.

The international authorities such as the International Commission of Radiation Protection (ICRP) issues guidelines for restrictions on the amount of radiation received by both professionally exposed individuals and the public.[78] The ALARA principle (as low as reasonably achievable) sets limits on occupational and public exposures to ensure that no one is exposed to doses that are unacceptably high.[9] Some of the previous studies documented that there was insufficient knowledge among dental practitioners and dental students about understanding radiation and safety protocols.[1011]

The aim of the present study was to assess the knowledge, attitude, and practice about radiation techniques, biological effects, and safety protocols among 4th, 5th, and 6th year BDS students and General Dental Practitioners (GDPs).

MATERIALS AND METHODS

This study was conducted in the month of February 2020 in dental clinical complex in full compliance with the World Medical Association Declaration of Helsinki and informed consent was obtained from participants. The groups involved in this study were dental students attending clinical postings (102) and GDPs (18) who are working in the clinics with a total of 120 participants. Students not attending clinical postings (1st, 2nd, and 3rd year) and absentees were excluded from this study. After reviewing articles 15 multiple choice questions based on a questionnaire were prepared.[12131415] The questionnaire had three parts; the first part included demographic data as age, gender, and academic level, the second part had nine questions to evaluate the degree of knowledge and awareness of students and GDPs about radiation protection and the third part had six questions to evaluate their practice. Before starting the study, a pilot study was conducted with a group of 15 students in order to ensure the level of validity and degree of repeatability. The participants grouped according to their level of educational qualification (4th, 5th, 6th, and GDP) to determine whether the clinical experience years were more informed about radiation safety protocol. Prior to the survey participants have been given instructions on how to fill the questionnaire and they have been given 20 min to fill the forms. All statistical analyses were carried out using SPSS 24.0, (SPSS for Windows; SPSS Inc., Chicago, IL, USA). The association between awareness and practice about radiation protection among participants was carried through the Chi-square analysis and the statistical significance level was set at P ≤ 0.05.

RESULTS

Out of 120 students and GDPs, 2GDPs and 2 year four students were absent and they were excluded from the study. From 116 students and GDPs, 16 (14%) were GDPs, 22 (19%) were year 4, 56 (48%) were year 5, and 22 (19%) were year 6 students [Figure 1 and Table 1]. The age of participated students and GDPs ranged from 21 to 29 years and the mean age was 24.73 years [Table 2]. There was no significant statistical difference between the answers obtained from the four groups. Around 89.7%% of the participants believed that dental X-rays are harmful and remaining 10.3% of the participants feeling that the dental X-rays are not harmful (P = 0.03). There was a significant difference statistically (P = 0.03) among the participants with respect to the awareness of the repair of cells injured by radiation. The participants showed a significant difference (P = 0.05) with their response to choose the correct option regarding the position distance rule [Table 3]. Surprisingly, most of the participants (81%) are having knowledge about annual radiation dose limit for a dentist, and overall, 56% of the participants were aware about the harmful effects of radiation exposure. Regarding ALARA principle 70.7% responded positively and accepted they have to consider it before recommending radiographs. There is no significant difference among them (P = 0.12) for the question, whether digital radiography has less harmful effects compared to conventional radiography. Considering one of advantage of digital radiography over the conventional techniques most of them (58.6%) accepted that the digital radiographs give less radiation dose than the conventional radiographs and one more interesting finding is the knowledge level increases with year of experience. In practice, most of the participants are following the proper guidelines. For the usage of thyroid collar, 83.6% of the participants accepted that they are using thyroid collar and similarly 69.8% accepted that they are using lead aprons for the protection of the patients. About 77.6% of them accepted that they are using film holders to hold the sensors [Table 4].

Figure 1

Participants details

Table 1

Demographic data

	GDP	Year 4	Year 5	Year 6	Total
Participated	16	22	56	22	116
Absent	2	2	-	-	4

GDP: General dental practitioner

Table 2

Age distribution

	Mean age (years)
GDP	27.8
Year 4	21.3
Year 5	22.4
Year 6	23.8
-	24.73

GDP: General dental practitioner

Table 3

Response of the participants for the questionnaire (knowledge based)

Question number	Questions	GDP		Year 4		Year 5		Year 6		P
		Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)
1	Do you think average periapical radiation is comparable to daily background radiation?	11 (68.8)	5 (31.2)	13 (59.1)	9 (40.9)	31 (55.4)	25 (44.6)	13 (59.1)	9 (40.9)	0.51
2	Do you think dental radiograph is not completely safe and has impact on health?	15 (93.6)	1 (6.4)	19 (86.4)	3 (13.6)	49 (87.5)	7 (12.5)	21 (95.5)	1 (4.5)	0.03
3	Do all types of radiation exposure can do harmful effect on health?	14 (87.5)	2 (12.5)	18 (81.8)	4 (18.2)	37 (66.1)	19 (33.9)	17 (77.3)	5 (22.7)	0.18
4	Does dental radiograph absolutely contraindicated in pregnant patients?	4 (25)	12 (75)	4 (18.2)	18 (81.8)	20 (35.7)	36 (64.3)	3 (13.6)	19 (18.4)	0.46
5	Do you think that the cells, once injured by radiation cannot be repaired?	5 (31.2)	11 (68.8)	16 (72.7)	6 (27.5)	22 (39.3)	34 (60.7)	15 (68.2)	7 (31.8)	0.03
6	Does 20 mSv is the annual radiation dose limit for a dentist?	14 (87.5)	2 (12.5)	16 (72.7)	6 (27.7)	46 (82.1)	10 (17.9)	18 (88.8)	4 (18.2)	0.19
7	Does operator should stand away at least 3 m from the patient?	16 (100)	-	14 (63.6)	8 (36.4)	43 (76.8)	13 (23.2)	18 (82.8)	4 (18.2)	0.05
8	While prescribing radiographs every dentist should follow ALARA principle	13 (81.3)	3 (18.7)	14 (63.6)	8 (36.4)	42 (44.6)	14 (55.4)	13 (59.1)	9 (41.9)	0.12
9	Digital radiography has less harmful effects compared to conventional radiography	11 (68.2)	5 (32.8)	9 (41.9)	13 (59.1)	34 (60.7)	32 (39.3)	14 (63.6)	8 (36.4)	0.40

ALARA: As low as reasonably achievable, GDP: General dental practitioner

Table 4

Response of the participants for the questionnaire (attitude and practice based)

Question number	Questions	GDP		Year 4		Year 5		Year 6		P
		Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)
1	While taking radiographs do you use thyroid collar?	15 (93.8)	1 (6.2)	17 (77.3)	5 (22.7)	49 (87.5)	7 (12.5)	16 (72.7)	6 (27.3)	0.22
2	Do you use lead aprons on a regular basis?	11 (68.8)	5 (31.2)	14 (63.6)	8 (36.4)	41 (73.2)	15 (26.8)	15 (68.2)	7 (31.8)	0.78
3	Do you prefer to hold the films during exposure?	6 (37.5)	10 (62.5)	5 (22.7)	17 (77.3)	9 (16.1)	47 (83.9)	3 (13.6)	19 (86.4)	0.93
4	Do you adjust exposure time depends on the patient and required tooth?	13 (81.2)	3 (18.8)	15 (68.2)	7 (31.8)	43 (76.8)	13 (33.2)	16 (72.7)	6 (27.3)	0.27
5	Do you use plastic barrier to cover the sensor?	12 (75)	4 (25)	16 (72.7)	6 (27.3)	38 (67.9)	18 (32.1)	17 (77.3)	5 (22.7)	0.23
6	Do you follow disinfection protocol after each patient?	16 (100)	-	19 (86.4)	3 (13.6)	48 (85.7)	8 (14.3)	22 (100)	-	0.36

GDP: General dental practitioner

DISCUSSION

Knowledge and training acquired during college days are very crucial for a dentist because knowledge imparted during student life shapes their attitude. To follow proper radiation protection protocols, the dental practitioners should have sufficient knowledge about radiation hazards and its protection.[16]

Around 89.7%% of the participants in our study believed that dental X-rays are harmful (P = 0.03). Whereas Srivastava et al., 83.3%, Rathi Rela reported 56%, Swapna et al., reported 59%, Almohaimede et al., reported 60.8%, and Basheer et al., reported 63.5% of their participants were knew that dental X-rays are harmful to health.[1517181920] Our results show that the range of knowledge better than the previous studies. Even though the dental radiation dose is minimal, its better to avoid taking radiographs in the first trimester of pregnancy. According to ADA taking dental radiographs during pregnancy is not absolutely contraindicated but if radiographic investigation is mandatory, it can be carried out with proper safety measures. Our study reveals that 73.3% of the participants felt that during the pregnancy period taking dental radiographs is not absolutely contraindicated. This expresses that they are aware about the safety measurements to be carry out during the pregnancy.

Previously conducted studies by Srivastava et al., 59.8%, Rathi Rela 64%, Swapna et al., 58%, and Bahseer et al., 63.2%, of their revealed that their participants were aware of consideration to taken during patient's trimester of pregnancy.[15171820] According to Srivastava et al., 59.8% of his study participants had proper knowledge annual recommended occupational radiation dose limit for operators.[15] In our study revealed that approximately 81% of the participants were having awareness about it. The biological effects of ionizing radiation differ depending on the dose of radiation and the body's reaction to it. When assessing the dangers of radiation's biological effects, the beneficial aspects of it should be considered. About 85% of those who took part in our study were mindful of the dangers of radiation. A study conducted by Srivastava et al., showed that 39.7%, Almohaimede et al., 64.4%, and Basheer et al., 51.5% of their participants are having sufficient knowledge about biological effects of radiation.[151920] Since 1977, the International Commission on Radiological Protection ICRP) started implementing the risk/benefit concept. It has suggested dentists should follow the principle of “ALARA” to reduce the radiation exposure. Results from this present study showed that 70.7% of the participants knew about the ALARA principle and similarly, Srivastava et al., in his study reported 37.4%., Rathi Rela reported 63%, Almohaimede et al., reported 68.1%, and Basheer et al., reported 61.8%, of their participants, knew about the ALARA principle.[15171920] About 73.6% of participants in our study agreed that digital radiography needs less exposure than conventional. Studies of conducted by Srivastava et al., and Almohaimede et al. have reported that 73.6% and 79.9% of their participants had knowledge about digital radiography needs less exposure than conventional.[1519] However in contrast to these results, Rathi Rela reported that only 19% of the participants had knowledge about this.[17] Film holders not only help radiographers to position the film but also help patients to avoid unnecessary exposure to their fingers. Regarding positioning the films intraorally, about 77.6% of participants of our study answered that they do not ask the patient to hold the film during the exposure. Its almost similar to Srivastava et al., 71.8% and Basheer et al., 72.6%.[1520] While operating dental X-ray machine the operator should stand at least 6 feet from the patient at the angle of 90° to 135° to the central ray of X-ray beam to avoid exposure from the scattered radiation. This is a basic safety principle, every dentist should be aware of it. In our study, 78.4% of participants were knew about the correct position and distance rule. Rathi Rela reported 77% of participants had knowledge about position distance rule which almost similar to our study.[17]

However other studies made by Srivastava et al., 40.2% and Sultan et al., 64.5% were less than our results.[1521] Lead is having a tendency of observing radiation. Because of this, it has been used to protect the operator and the patient in my form such as lead aprons, thyroid colors, and lead shield according to the previous studies properly selected lead apron reduces the effective radiation dose by 75%–90%.[22] In our study, 83.6% of participants accepted that they use thyroid color regularly and previously study done by Almohaimede et al., mentioned that only 75.7% of its participants used it.[19] Srivastava et al., mentioned that 32.8% of his study participants were had knowledge about the usage of lead apron.[15] However in contrast to these results Rahid Rela 97% and Almohaimede et al., showed 75.7% of the participants were using lead apron.[1719] In our study only 69.8% of them accepted that they are using lead apron on regular basis. This shows that awareness related to the usage of lead apron is not even among the students and they have to be closely monitored and trained. The current study revealed that overall the participants are having good basic knowledge and awareness about radiations and need of protection but its not evenly distributed among them. At the same time across the groups,the knowledge about radiation physics, usage of X-ray films, and protection from X rays were varied

This study was first of its kind in the Eastern province and only few similar studies were available for comparison from other cities. Within the limitations of the study, it can be concluded that the knowledge of radiation hazards and protective measures from dental X-ray radiation among dental undergraduate students in Eastern province's dental college of Saudi Arabia was quite fair. However, the radiation protection measures need to be emphasized. This reveals that need of more theoretical as well as practical training of the undergraduate dental students. This will lead to substantial increase the knowledge for strictly adhering to the principles of dental radiography. Since this present study was based on only one institution for generalization purposes a study based on multiple institutions with large number of samples needed.

CONCLUSION

Even though the current study revealed that overall, the participants are having good basic knowledge and awareness about radiation and protection, the knowledge and understanding about radiation varies across the groups. Based on this we conclude that the dental students need more training about radiation protection and practice so that these students on graduation will be well grounded with the principle of governing dental radiography, its justification, quality control practice, and the correct practice of the ALARA concept.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.