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 Table of Contents  
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 81-87

Knowledge, attitude, perception toward radiation hazards and protection among dental undergraduate students: A study


1 Department of Oral Medicine and Radiology, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India
2 Department of Dental Surgery, Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Ranchi, Jharkhand, India
3 Department of Dentistry, Anugrah Narayan Magadh Medical College and Hospital, Gaya, Bihar, India
4 Department of Oral and Maxillofacial Surgery, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India

Date of Web Publication13-Apr-2017

Correspondence Address:
Rahul Srivastava
783/4 W.1, Saket Nagar, Juhi.2, Kanpur - 208. 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_26_16

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  Abstract 


Aims and Objectives: To evaluate the knowledge, attitude, and perception (KAP) of dental students toward ionizing radiation, biological hazards, and appropriate radiographic protection methods. To assess the need for improving the knowledge/awareness toward radiation hazards and protection methods among the dental students and interns. Materials and Methods: A cross-sectional questionnaire study was conducted. A total of 174 dental students who had completed their 30 days posting in Department of Oral Medicine and Radiology were inducted for the study. All the students were subjected to structured 17 response questionnaire with multiple choices. Data collected were subjected to statistical analysis using the SPSS software package version 17. Pearson Chi-square test was done to evaluate the statistical significance. Results: The present study revealed 54.22% correct response from 3rd year followed by 57.78% from final years and 61.64% from interns. The overall correct response was 57.57%. Conclusion: The results from the present study revealed that the KAP level in regard to the biological hazardous effects of X-ray and protection was low to average among dental students. It is recommended that the syllabus of dental radiology should be expanded to provide clinical knowledge regarding radiation hazards and protection, so that students are well grounded with the principles of dental radiography.

Keywords: Hazard, knowledge, perception, protection, radiation


How to cite this article:
Srivastava R, Jyoti B, Jha P, Shukla A. Knowledge, attitude, perception toward radiation hazards and protection among dental undergraduate students: A study. J Int Oral Health 2017;9:81-7

How to cite this URL:
Srivastava R, Jyoti B, Jha P, Shukla A. Knowledge, attitude, perception toward radiation hazards and protection among dental undergraduate students: A study. J Int Oral Health [serial online] 2017 [cited 2019 Aug 24];9:81-7. Available from: http://www.jioh.org/text.asp?2017/9/2/81/202704




  Introduction Top


X-rays are electromagnetic radiations which have short wavelength and high frequency.[1] When these X-rays pass through matter, ionizing radiations produce negatively and positively charged particles, i.e., ions, these ions turn may cause injury to normal biological tissues. The consequences of ionization to the human cells:

  1. Creation of unstable atoms
  2. Production of free electrons
  3. Production of low-energy X-ray photons
  4. Creation of reactive free radicals capable of producing substances poisonous to the cell
  5. Creation of new biological molecules detrimental to the living cell
  6. Injury to the cell that may manifest itself as abnormal function or loss of function.[2]


When patients undergo X-ray examinations, millions of photons pass through their bodies, this may lead to damage to the DNA in the chromosomes, most DNA damage is repaired immediately, but rarely a portion of a chromosome may be permanently altered - a mutation.[3]

In general, more the radiation that strikes a cell, the greater the chances of causing an effect. If a significant number of cells are affected, the organism may be damaged or even die.[4]

Radiology is a diagnostic test, and in dentistry, this test almost always involves the use of ionizing radiation. Therefore, oral and maxillofacial radiology should be performed thoughtfully and responsibly, minimizing radiation dose, but maximizing diagnostic benefit.[5]

In addition, the film speed, collimation, technique, exposure factors, and protection barriers used determine the amount of radiation the patient and the operator would receive.[6]

Enabulele and Igbinedion assessed dental student's knowledge of dental radiation protection and practice as well as correlating their knowledge to practice on dental radiography. He concluded that there is 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.[7]

Arnout assessed and compared knowledge, attitude, and perceptions (KAPs) among Egyptian dental undergraduates, postgraduate, and interns toward biological hazards of dental X-ray and appropriate radiographic protection techniques. The KAP level regard the biological hazards effect of X-ray and different protection protocols were noted to be ranged from low to high in all groups. This outcome necessitates continual teaching to ensure maximum safety toward X-ray.[8]

Most of the undergraduates grossly underestimate the proper use of dental imaging tools, protective measures, and their associated radiation risks.

The current study was done to evaluate the KAP of dental students toward radiation, its biological hazards, and ideal radiographic protection methods.


  Materials and Methods Top


This cross-sectional questionnaire-based study was conducted on 174 undergraduate dental students whose curriculum included Dental Radiology and who had completed their 30 days posting in the Department of Oral Medicine and Radiology of Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India. The study sample was taken from all 3rd year, final year, and interns who were satisfying the inclusion criteria of the study. Approval from the Ethical Committee of the Institute was obtained and informed consent was taken from the participants. A questionnaire was prepared for the evaluation of KAP among dental students and interns after PubMed/Medline search with studies which were closely related to KAP of dental students toward radiation safety and protection. We used a pretested questionnaire specially designed for the study.[8],[9],[10],[11] The questionnaire was divided into following two categories:

The first group of questionnaire consisted of questions to classify the participants into undergraduate students and interns and to classify the gender of participants. The second group of questionnaire consisted of questions for the assessment of KAP toward radiation hazards and radiation protection methods and guidelines.

The questionnaire with multiple choice (only one option to choose) was distributed to each and every participant and sheets were collected after specific time of 15 min.

Statistical analysis

The collected data were subjected to statistical analysis. The data were subsequently processed and analyzed using the SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. (SPSS Inc., Chicago). Pearson Chi-square test was done to evaluate the statistical significance. The correct response of participants on KAP toward radiation hazards and protection was graded into low (1%–50%), average (51%–75%), and good (>75%)


  Results Top


One hundred and seventy-four students were enrolled in the study out of which 60 students (males - 15, females - 45) were from 3rd year, 68 students (males - 30, females - 38) were from final year, and 46 students (males - 14, females - 32) were interns. When asked “Are you aware of the radiation hazard symbol?” total of 133 (76.4%) students gave correct response. Difference between the responses in all three groups was statistically significant (χ2 = 10.328 with P< 0.05) [Figure 1]. A total of 145 (83.3%) gave the correct answer to the question “Is dental X-ray harmful?” Difference between the responses in all three groups was statistically nonsignificant (χ2 = 5.723 with P> 0.05). When asked “Do X-ray beams reflect from room walls?” only 62 (35.6%) student's revealed correct response. Difference between the responses in all three groups was statistically highly significant (χ2 = 33.731 with P< 0.001) [Figure 2].
Figure 1: Response of the participants toward awareness of radiation hazard symbol. Difference between the responses in all three groups was statistically significant (χ2 = 10.328 withP < 0.05)

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Figure 2: Awareness of participants toward reflection of X-ray from room walls. Difference between the responses in all three groups was highly statistically significant (χ2 = 33.731 withP < 0.001)

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Are you aware of deterministic and stochastic effects? Difference between the responses in all three groups was statistically highly significant (χ2 = 33.237 with P< 0.001) [Figure 3]. Does dental radiograph absolutely contraindicated in pregnant patients? After evaluation of overall response among 174 students, 104 (59.8%) showed correct response. Difference between the responses in all three groups was statistically significant (χ2 = 11.882 with P< 0.05) [Figure 4].
Figure 3: Awareness of participants toward deterministic and stochastic effects. Difference between the responses in all three groups was statistically highly significant (χ2 = 33.237 withP < 0.001)

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Figure 4: Awareness on whether dental radiographs are absolute contraindication in pregnancy? Difference between the responses in all three groups was statistically significant (χ2 = 11.882 withP < 0.05)

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Are you aware of ALARA principle? After evaluation of overall response among 174 students, 65 (37.4%) gave correct response. Difference between the responses in all three groups was statistically highly significant (χ2 = 25.199 with P< 0.001) [Figure 5]. Are you aware of National Council on Radiation Protection (NCRP) and International Commission on Radiological Protection [ICRP] recommendations? After evaluation of overall response among 174 students, 67 (38.5%) gave correct response. Difference between the responses in all three groups was statistically nonsignificant (χ2 = 8.210 with P> 0.05). Are you aware of the usefulness of collimators and filters in dental radiography? After evaluation of overall response among 174 students, 145 (83.3%) showed correct response. Difference between the responses in all three groups was statistically significant (χ2 = 9.605 with P< 0.05) [Figure 6].
Figure 5: Awareness of participants about ALARA principle. Difference between the responses in all three groups was statistically highly significant (χ2 = 25.199 withP < 0.001)

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Figure 6: Awareness of participants toward knowledge of the usefulness of collimators and filters. Difference between the responses in all three groups was statistically significant (χ2 = 9.605 withP < 0.05)

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Does digital radiography require less exposure than conventional? After evaluation of overall response among 174 students, 128 (73.6%) gave correct response. Difference between the responses in all three groups was statistically nonsignificant (χ2 = 9.274 with P> 0.05). Does the high speed film require a reduced exposure? After evaluation of overall response among 174 students, 109 (62.6%) showed correct response. Difference between the responses in all three groups was statistically highly significant (χ2 = 29.665 with P< 0.001) [Figure 7]. Do you prefer to hold the films during exposure? After evaluation of overall response among 174 students, 102 (58.6%) showed correct response. Difference between the responses in all three groups was statistically highly significant (χ2 = 67.498 with P< 0.001) [Figure 8]. Do you ask the patient to hold the film with their hand during exposure? After evaluation of overall response among 174 students, 125 (71.8%) showed correct response. Difference between the responses in all three groups was statistically significant (χ2 = 15.292 with P< 0.05) [Figure 9]. Should personal monitoring badges be worn by the operator? After evaluation of overall response among 174 students, 121 (69.5%) showed correct response. Difference between the responses in all three groups was statistically significant (χ2 = 19.933 with P< 0.05) [Figure 10].
Figure 7: Awareness of exposure requirements of high speed dental film. Difference between the responses in all three groups was statistically highly significant (χ2 = 29.665 withP < 0.001)

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Figure 8: Response of participants toward holding of film during exposure. Difference between the responses in all three groups was statistically highly significant (χ2 = 67.498 withP < 0.001)

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Figure 9: Response of participants toward asking the patient's to hold the film during exposure. Difference between the responses in all three groups was statistically significant (χ2 = 15.292 withP < 0.05)

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Figure 10: Awareness of participants toward personal monitoring badges (thermoluminescent dosimeter) worn by the operator. Difference between the responses in all three groups was statistically significant (χ2 = 19.933 withP < 0.05)

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Will you adhere to the radiation protection protocol in future? After evaluation of overall response among 174 students, 141 (81.0%) showed correct response. Difference between the responses in all three groups was statistically nonsignificant (χ2 = 1.391 with P> 0.05). What is the ideal distance an operator should stand while taking intraoral radiographic exposure? After evaluation of overall response among 174 students, 70 (40.2%) showed correct response. Difference between the responses in all three groups was statistically highly significant (χ2 = 36.694 with P< 0.001) [Table 1]. Do you use lead aprons on a regular basis? After evaluation of overall response among 174 students, 141 (81.0%) showed correct response. Difference between the responses in all three groups was statistically significant (χ2 = 28.027 with P< 0.05) [Table 2].
Table 1: Awareness of participants toward ideal position of the operator during intraoral dental exposure

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Table 2: Awareness of participants toward use of lead aprons

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When asked about the usage of lead aprons on a regular basis, if never/rarely/sometimes, why not? Among 60 students from 3rd year, 51.7% were not sure about the answer, 18.3% were following only position rule, 18.3% answered the nonavailability of lead apron, 8.3% answered common apron for all, and 3.3% answered due to weight they were not wearing the lead aprons. Out of 68 final year students, 26.5% were not sure about the answer, 26.5% were following only position rule, 35.3% answered the nonavailability of lead apron, 10.3% answered common apron for all, and 2.9% answered due to weight they were not wearing the lead aprons. Out of 46 final year students, 10.9% were not sure about the answer, 17.4% were following only position rule, 26.1% answered the nonavailability of lead apron, 10.9% answered common apron for all, and 34.8% answered due to weight they were not wearing the lead aprons. Difference between the responses in all three groups was statistically highly significant (χ2 = 30.568 with P< 0.001). Results of the present study revealed 54.22% correct response from 3rd year followed by 57.78% from final years and 61.64% from interns. The overall correct response was 57.57%. The correct response was noted in descending order from interns to 3rd year.


  Discussion Top


Results from this study shows that out of 174, 133 (76.4%) students were aware of radiation hazard symbol whereas Shah et al. reported 83% and Prabhat et al. reported 89% in their subjects, 83.3% students knew that dental X-rays are harmful, Arnout reported 88% in Egyptian students, Shah et al. reported 75%, Arnout and Jafar on Saudi students reported 67%, and Prabhat et al. reported 100% in their set of students.[8],[9],[10],[11] In the response of a classic question three and four (Do X-ray beams reflect from room walls and awareness of deterministic and stochastic effects of X-rays?) asked by the participants, only 35.6% and 39.7% participants gave the correct response, Arnout reported 18% and 34%, respectively, Arnout and Jafar reported 33% on both questions which was similar to this study, whereas Prabhat et al. reported a promising 88% and 84%. These results were surprising as dental radiography is a crucial part of diagnosis and treatment in oral health and all participants are future dentists who will use the dental radiography in their routine dental practice. Only 59.8% participants answered that dental radiograph is not absolutely contraindicated in pregnant patients; similarly, Arnout reported 67%, Shah et al. reported 65%, Prabhat et al. reported 59%, whereas Arnout and Jafar reported a poor 20%, these results state that most of the dentists will lose the cases of pregnant women for dental treatment. However, the practitioners should take all possible precautions to minimize the risk, including use of lead apron and thyroid collar. Results obtained from the present study showed that 40.2% participants did not have sufficient knowledge regarding the diagnostic dental radiation risk and protection measures during pregnancy.

ALARA is an acronym for As Low As Reasonably Achievable and is not only a sound safety principle but is also a regulatory requirementfor all radiation safety programs.[12] Current recommendations of the NCRP and measurements relative to ionizing radiation are based on radiation protection principles that developed historically as information about radiation effects on human populations became available. Because the NCRP Charter states that the NCRP will cooperate with the ICRP, the basic principles and recommendations for radiation protection of the NCRP are closely coupled with those of the ICRP.[13] Results from the present study showed that only 37.4% participants knew about the ALARA principle; similarly, Arnout reported 33%, Arnout and Jafar reported 40%, Enabulele and Igbinedion on dental students reported a very low of 17.9%[7] whereas Shah et al. reported a high of 98.6% and Prabhat et al. reported 84%. NCRP and ICRP recommendations, Arnout reported 27%, Arnout and Jafar reported 20%, Shah et al. reported 56%, Prabhat et al. reported a high of 94%. These results were dreadful because radiological protection criteria are based on the ICRP and NCRP recommendations, which reflect the latest scientific knowledge about health effects of ionized radiation.

Response to the question asked regarding the knowledge of usefulness of collimators and filters, the awareness was showed by 83.3% participants, Arnout reported a low of 44%, Arnout and Jafar reported an accep[table 73]%, Enabulele and Igbinedion reported 50% whereas Prabhat et al. reported a high of 90%. About 73.6% participants had the awareness about the amount of exposure required for digital and conventional radiography. Arnout reported 86%, Shah et al. reported a promising 88%, Arnout and Jafar reported a low 40%, Prabhat et al. reported a good 75%. These were relatively good percentage. High-speed films are efficient in reducing radiation doses. Recent research indicates that F-speed films have a similar or higher contrast compared to Ektaspeed Plus Films and reduce patient exposure up to 20%. In this context, 62.6% participants were aware that high speed film requires less exposure. Arnout reported 66%, Shah et al. reported 87%, Arnout and Jafar reported 47%, Prabhat et al. reported a good 78%. To achieve optimum safety, the dentist must not hold the film in place for the patient during the procedure. Only 58.6% participants were aware about that they need not hold the films during exposure. Arnout reported a high 94%, Arnout and Jafar a low 46.7%, Prabhat et al. reported a high 97%. About 71.8% participants answered that they do not use to ask the patient to hold the film with their hand during exposure. Arnout reported astonishingly low 6.66%, Arnout and Jafar also a low 40% whereas Prabhat et al. reported an average 64%.

Personal radiation monitoring devices or dosimeters are badges that detect various forms of radiation a worker may be exposed to. Workers are required to wear the dosimeters for periods of up to 3 months. The accumulated dose from the various types of radiation is measured by the dosimetry service provider and reported to the employer.[14] In the present study, only 69.5% participants were aware that personal monitoring badges should be worn by operator. Arnout reported a high 78%, Shah et al. reported a low 29%, Arnout and Jafar reported an average 40%. About 81% participants were willing to adhere to radiation protection protocols in future. Arnout reported a high 82%, similarly Shah et al. reported a high 89%, and Prabhat et al. - 81% although Arnout and Jafar reported an average 53%.

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. On application, this rule not only takes advantage of the inverse square law of reduce X-ray exposure to the operator but also take the advantage of the fact that in this position, the patient's head absorbs most scattered radiation.[15] The percentage of awareness for this question was low, only 40.2% participants were know about the correct position and distance rule. Arnout reported an average 65%, Arnout and Jafar an average 53%, Enabulele and Igbinedion an average 41% whereas both Prabhat et al. and Shah et al. reported a high 87%. Lead has been found to be the best shield for the protection against diagnostic X-rays. A well-chosen lead apron can reduce the effective dose by 75%–90%.[16],[17] 32.8% participants showed the awareness regarding the use of lead apron on regular basis. Rest of the participants have various opinions regarding the avoidance of use of lead apron on regular basis such as unavailability of lead apron, weight, and common apron for all. Arnout reported a low 13%, Shah et al. reported a low 31%, Arnout and Jafar a low 33%, Enabulele and Igbinedion an average 66%, Prabhat et al. an average 46%. Praveen et al. conducted a survey in Bengaluru, among practicing dentists; he concluded that the radiation protection awareness among practicing dentists was very low and the necessary measures taken to reduce the exposure were not adequate.[18]

Enabulele and Igbinedion assessed the knowledge of dental radiation protection and practice on dental radiography and he found that most (75.6%) of the students thought they did not have adequate knowledge on radiation protection.[7] Mubeen et al. conducted a study to assess the knowledge, hazards, misconceptions, and misunderstanding among medical students regarding equipment using ionizing and nonionizing radiation. Author concluded that majority of medical students in both years have limited knowledge about various aspects of radiation sources, the risk involved, and its protection.[19] The current study revealed that the participants had basic knowledge and awareness that radiations due to dental radiography are harmful and radiation protection methods are mandatory. The knowledge and understanding of the basic physics of radiation was also variable across the groups. The awareness toward radiation protection protocols revealed a decreasing trend from interns to 4th and 3rd year students. This study was first of its kind in Kanpur and only few similar studies were available for comparison from other cities, the results fit well with our hypothesis that the KAP of undergraduates and interns toward radiation protection is limited. However, further studies with larger sample size are required to validate our hypothesis. Moreover, the current study is a single institutional-based one, hence a cross-sectional study comprising similar samples utilizing multiple institutional participants are required for authentication.


  Conclusion Top


Medical X-rays are the single largest source of manmade radiation exposure. Dental radiography is one of the most valuable tools used in modern dental health care. This study revealed that overall KAP level among dental students in respect to the biological hazardous effect of X-ray and protection was low to average. This calls for more theoretical along with practical training of the undergraduate dental students for safety protocols and ethical practice in the field of radiation and protection. This will lead to substantial increase the knowledge for strictly adhering to the principles of dental radiography.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Haring JI, Lind LJ. Radiation protection. Textbook of Dental Radiography Principles and Techniques. Ch. 5. Philadelphia: W.B. Saunders Company; 1996. p. 64-79.  Back to cited text no. 6
    
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Enabulele JE, Igbinedion BO. An assessment of dental students' knowledge of radiation protection and practice. J Educ Ethics Dent 2013;3:54-9.  Back to cited text no. 7
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8.
Arnout E. Knowledge, attitude and perception among Egyptian dental undergraduates, postgraduate and interns regard biological hazards and radiologic protection techniques: A questionnaire based cross-sectional study. Life Sci J2014;11:9-16.  Back to cited text no. 8
    
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Shah HG, Patel S, Patel K, Patel V, Sodani V, Savant S. Knowledge and practices of interns, graduates and post-graduates of Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat regarding radiographic protection. Int J Res Health Sci 2014;2:787-91.  Back to cited text no. 9
    
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Prabhat MP, Sudhakar S, Kumar BP, Ramaraju K. Knowledge, attitude and perception (KAP) of dental undergraduates and interns on radiographic protection – A questionnaire based cross-sectional study. J Adv Oral Res 2011;2:45-50.  Back to cited text no. 10
    
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Arnout EA, Jafar A. Awareness of biological hazards and radiation protection techniques of dental imaging – A questionnaire based cross-sectional study among Saudi dental students. J Dent Health Oral Disord Ther 2014;1:8.  Back to cited text no. 11
    
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    Figures

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    Tables

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