Knowledge, attitude and perception (KAP) of dental undergraduates and interns on radiographic protection- A questionnaire based cross-sectional study

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1 J.Adv Oral Research All Rights Res ORIGINAL RESEARCH Knowledge, attitude and perception (KAP) of dental undergraduates and interns on radiographic protection- A questionnaire based cross-sectional study MPVPrabhat* S Sudhakar B Praveen Kumar Ramaraju *M.D.S, Associate Professor, M.D.S, Asst Professor,Department of Oral Medicine & Radiology, St. Joseph Dental College & Hospital, Eluru, Andhra Pradesh, M.D.S, Professor and Head,Department of Oral Medicine & Radiology, PIDS, Gorakhpur, Uttar Pradesh,India. drsudhakaroralmed@gmail.com Abstract: Background: Radiation hazards are harmful and it becomes precarious when there is a professional negligence or ignorance. Objectives: To assess the knowledge, attitude and perception of the clinical year dental students and interns towards radiation protection protocols. Design: Institutional based study. Materials & Method: The study participants comprised of 234 dental undergraduates students and interns, whose curriculum includes dental radiology. The information was collected from each participant through structured questionnaires (18 in number) containing answers in the form of multiple choices. Statistical analysis: Pearson chi-square test and Fisher s exact test was done to evaluate the statistical significance. Results: Among 234 samples enrolled in the study 62 were interns and 172 were undergraduates (80 from third year and 92 from fourth year). Over all correct response was 77.3% and it was noted in descending order from Interns 90.62%, followed by fourth year (83.8%) and third year students (61%). Conclusion: The Knowledge, attitude and perception (KAP) level in regard to radiation protection protocol was noted to be higher with interns and the least with third years. This outcome necessitates incessant teaching to ensure maximum safety. Serial Listing: Print ISSN( ) Online-ISSN ( ) Formerly Known as Journal of Advanced Dental Research Bibliographic Listing: Indian National Medical Library, Index Copernicus, EBSCO Publishing Database, Proquest, Open J-Gate. Keywords: Radiology, Radioprotection, Radiation Safety, Radiation Guidelines, Radiation Protocol. Introduction: X-radiations are harmful to living tissues and it is sufficiently intense to cause cancer, leukemia and genetic damage. 1 Inspite of it, we do know that the benefits derived from the diagnostic application of x- rays in both medicine and dentistry are enormous. 2 Dental radiology is a rapidly evolving clinical speciality and recently, computed tomography and its variants 3D CT and ortho cubic super-high resolution CT(Ortho-CT) has been the technique of choice in diagnosis of various dental pathologies. 3-7 It is generally believed that the risk of radiation associated with dental radiography is not significantly greater than other everyday risks in life. 1 However, what is not known for certain is the degree of effect following diagnostic level of x-radiation. 2 The effects of x-rays on humans are the result of interactions at atomic levels. 8 These biological effects can be divided into two broad categories: Deterministic and stochastic effects. 9 Deterministic effects are those effects in which the severity of the response is proportional to the dose. These effects occur in all people when the dose is large enough. 10 Deterministic effects have a dose threshold below which response is not seen. By contrast, stochastic effects are those for which the probability of occurrence of the change, rather than its severity, is dose dependent. 9 The stochastic effects thus lay the patient s and the operating personals in a high risk zone as it does not have dose thresholds. 9 keeping this in mind, the dental radiograph should be prescribed only for a patient when the benefit of disease detection outweighs the risk of damage from x-radiation. 1 In addition, the amount of exposure a patient and the

2 46 operator receives from dental radiographs depends on the film speed, collimation, technique, exposure factors and protecting barriers used. 1 This necessitates the operator to have thorough knowledge towards radiation hazards and its protection protocols. The operating personal mentioned here includes a qualified radiologist, radiology technician, interns (junior residential doctors/ house surgeons) and (clinical year dental) students. In the present study, the clinical year dental students belong to III rd and IV th year of BDS (Bachelor of Dental surgery) and the interns were one-year residential doctors. The study hypothesis was that these clinical years dental students and interns are more prone to radiation risks as their knowledge towards the radiation effects may be too little. A pubmed/medline search was carried out with studies related to knowledge, attitude and perceptions (KAP) of clinical year dental students and interns towards radiation safety and protection and the result found to be futile. Considering this, a questionnaire was prepared with an intention of evaluating the knowledge, attitude and perceptions (KAP) of clinical year dental students and interns towards radiation safety and protection. Materials and method: The study sample included 234 clinical undergraduates (third and final year dental students) and interns of St. Joseph Dental College and Hospital, Eluru, Andhra Pradesh, India. A questionnaire related to radiation protocol in the form of multiple choices was given to each participant and the response sheets were collected after 30 minutes. The questionnaire was a self-prepared, pilot-tested and it was specially designed for the study. Among the 18 questions; 16 were close-ended and 2 were leading questions. Prior to administration of the questionnaire the institutional ethical committee approval was obtained and the participants were informed about the importance of the study and included only on voluntary basis. The response from the participants were then computed into a Microsoft excel worksheet and evaluated with SPSS (Statistical package for social sciences, software Version 10.0; Chicago, IL, USA ). Pearson chi-square test and Fisher s exact test was done to evaluate the statistical significance. Results: Among 234 samples enrolled in the study 62 were interns and 172 were undergraduate students (80 from third year and 92 from fourth year) (Table 1). Classification of the participants based on gender showed a predominance of female participants (69.7%) with a higher percentage (74%) was noticed with interns. Over all evaluation of the response among the 234 participants showed 77.3% correct responses. The Interns response was accurate up to 90.62%, followed by fourth year students (83.8%) and third years (61%). A clear consensus was noticed among interns and fourth years to almost all questions except to question no. 17- Do you prefer to regularly use lead aprons?, where only 37% correct response was noted with fourth years as compared to 63% of interns (P<0.001) (Table 2). The response of the third year students, when compared with fourth year and interns showed significant difference in majority of questions except Dental X-rays are harmful? and Personal monitoring badges should be worn by the operator (Table 2). A totally different set of response was noticed to Will you ask the patient to hold the film with their hand during exposure ; Dental radiographs are absolutely contraindicated for pregnant patients and Do you prefer to regularly use lead aprons (Table 2). Discussion: Over the years, certain studies directed en route for the measurement of radiation exposure has shown increased occurrence of cancer, birth defects, cataracts and shortening of life span. 11 The above statement although being non-conclusive and may not hold well for diagnostic dental radiography it is still acceptable as it cannot be proved that there is no possibility of a hazard. 11 This situation has produced the concept of keeping radiation exposure As Low As Reasonably Achievable - The ALARA principle, which recognizes the possibility that no matter how small that dose is, some stochastic effect may result. 9,12 Stochastic effects as stated earlier, are those in which the probability of the occurrence of a change (harmful effects of radiation) does not depend on dose as seen with deterministic effects. Here the effects represent an all or none response i.e. a person even to a minimal radiation exposure either gets affected or does not get affected at all. Considering this, the goal of the radiation protection protocol should focus to prevent the occurrence of deterministic effects and to reduce the likelihood of stochastic effects by minimizing the exposure to patients and the office 9, 11, 12 personnel. The above objective can be achieved when the operating personnel empowers thorough knowledge and apply it in clinical situations. Keeping this in mind, in the present study, Undergraduate students (belonging to third and final year of bachelor of dental surgery) and interns (junior resident doctors/ House-surgeons) were selected as the participants as they have radiology syllabus in their curriculum. The

3 47 Table 1: Classification of the participants based on academic year and gender Academic Year Gender Male Female Total III year students IV year students Interns Table 2: Table showing the Questions given to the participant and their responses group wise Questions Response III yrs IV yrs Interns 1. Dental X-rays are harmful? Yes 100% 100% 100% No 0% 0% 0% 2.X-rays can be reflected from the walls of the room 3.Are you aware of NCRP/ ICRP recommendations 4. Are you aware of the radiation hazard symbol 5.Are you aware of usefulness collimators and filters in dental radiography 6. Are you aware of deterministic effects, stochastic effects and ALARA principle 7. Does digital radiography requires less exposure than conventional? Yes 5% 4.3% 4.8% No 77.5% 95.7% 92% Don t know 17.5% 0% 3.2% Yes 85% 96.7% 100% No 15% 3.3% 0% Yes 68.8% 97.8% 100% No 31.2% 2.2% 0% Yes 72.5% 97.8% 98.4% No 27.5% 2.2% 1. 6% Yes 60% 94.6% 96.8% No 40% 5.4% 3.2% Yes 31.2% 95.7% 98.4% No 2.5% 1% 0% Don t know 66.3% 3.3% 1. 6% 8. High speed films reduces exposure Yes 48.7% 90.2% 93.6% No 3.8% 0% 3.2% Don t know 47.5% 9.8% 3.2% 9. Do you prefer to hold the films in Yes 6.3% 0% 1. 6% your hand during exposure No 93.7% 100% 98.4% 10. Will you ask the patient to hold the Yes 93.7% 12% 3.2% film with their hand during exposure No 6.3% 88% 96.8% 11.Dental radiographs are absolutely contraindicated for pregnant patients 12. Personal monitoring badges should b worn by the operator 13. Will you adhere to radiation protection protocol at the time of your future private clinical practice Yes 63.7% 18.5% 6.4% No 6.3% 78.2% 92% Don t know 30% 3.3% 1.6% Above the lead 12.5% 18.5% 32.2% apron Below the lead 56.3% 70.7% 63% apron Doesn t matter 3.7% 6.5% 4.8% Don t know 27.5% 4.3% 0% Yes 86.2% 70.7% 87.1% No 1.3% 5.4% 3.2% Don t know 12.5% 23.9% 9.7% 14. If no/ don t know why Depends on 3.8% 16.3% 6.5 space availability Because of financial reasons 6.3% 7.6% 3.2% Private clinical setup has 1.3% 1.1% 0% less radiation exposure hence it does not require stringent protection measures Others 2.5% 4.3% 3.2%

4 During radiographic exposure the Yes 37.5% 12% 6.5% dental x-ray tube should be focused through open space No 13.8% 86.9% 87% Doesn t matter/ Don t know 48.8% 1.1% 6.5% 16.The ideal distance an operator 4 feet and % 2.2% 9.7% should stand (position distance rule) 4 feet and % 1.1% 1.6% while dental radiographic exposure is 6 feet and % 95.6% 83.9% 6 feet and % 1.1% 9.7% 17. Do you prefer to regularly use lea Yes 37.5% 37% 63% aprons No 43.7% 50% 4.8% Rarely 18.8% 13% 27.3% 18. If no/rarely why Non- availability of apron 1.3% 7.6% 11.3% Due to weight of the apron 11.3% 15.2% 21% Common apron for all 1.3% 10.9% 14.5% Will follow Position distance rule 7.5%) 62% 43.5% NCRP- National council on radiation protection and measurement ICRP- International commission on radiological questionnaire given was prepared as close-ended on most occasions in order to obtain accurate response in relevance to knowledge, whereas wherever the attitude and perception evaluation was required a leading question was given. Evaluation of the results of the current study showed that all the participants were aware of the fact that X-rays used in diagnostic dental radiology are harmful and certain levels of precautions should be taken while in use. Among all the groups evaluated, a subtle variation was noted in regard to the knowledge and understanding of the basic physics of radiation in an ascending order from third year, final year to interns. A classic example is that, when the participants were questioned about the type of intraoral film placement method they follow (question-10: Will you ask the patient to hold the film with their hand during exposure) over 93% of the third years preferred to follow the conventional film holding method (asking the patient/guardian to hold the film with their hands), whereas majority of the fourth years and interns claimed that they utilize film holding devices. This contrasting aspect can be attributed to less clinical experience of the third year students (Table 2). Over 80% of the participants claimed that they will adhere to radiation protection protocol at the time of their future private clinical practice. The remaining 19% reasoned space availability, financial constraints and personal interest (may) prevail above protocol adherence. From the current study, it is arguable that the participants were aware of the radiation protection protocols and it is more so with the interns, followed by the fourth and third year students. Although this study is first of its kind and no similar studies were available for comparison, the results fits well with our hypotheses that the KAP of undergraduates and interns towards radiation protection can be limited and this can be applicable to this community as a whole. However, further studies with a larger sample size are required to validate our hypotheses. Moreover the current study is a single institutional based one, hence a cross-sectional study comprising of similar samples utilizing multiple institutional participants are required for authentication. In the current study design, a week after completion of the study all the participants were recalled and a reassurance programme was conducted regarding strict adherence of radiation protection protocol. The programme included a lecture on basics of radiation physics, radiation biology and protection and clinical demonstration on usage of radiation protection barriers. A special emphasis was made on personal monitoring as well the operating environment as per NCRP (National council on radiation protection and measurements) and ICRP (international commission on radiological protection) guidelines. Each participant was individually recalled, counselled and stressed to adhere to the basic guidelines while advising dental radiograph. Further, the participants were provided with a monograph containing NCRP and ICRP guidelines with the details of their websites. 13 Conclusion: From the response obtained through our study, it is obvious that the participations were aware that thekap level in regard to radiation protection

5 49 protocol was noted to be higher with interns and the least with third years. The principle of radiation protection is to do those things that will minimize exposure of patient and dental professional and still provide benefits for the patients from use of diagnostic radiography. Although the level of awareness were speckled (more with interns, followed by final and third years) it is arguable that more they get exposed to clinical situation more is the awareness. Similar studies with reassurance programme at regular intervals should be carried out at institutional and national level for strict adherence of regulation protocol. References: 1. Haring JI, Lind LJ. Chapter 5: Radiation protection in Textbook of Dental Radiography Principles and Techniques. W.B. Saunders Company P Bushong SC. Chapter 30: Fundamental principles of radiobiology in Radiologic science for technologists: Physics, Biology and Protection, fifth edition. Mosby, St. Louis. P Langlais RP, Langland OE, Nortje CJ. Chapter 1: Decision making in Dental Radiology in Diagnostic Imaging of the Jaws. Williams & Wilkins P Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed tomographic apparatus for dental use. DentomaxillofacRadiol 1998; 28: Chan HJ, Woods M, Stella D. Three dimensional computed craniofacial tomography (3D - CT): potential uses and limitations. AustOrthod J 2007; 23: Terakado M et al. Diagnostic imaging with newly developed ortho cubic super high resolution computed tomography (Ortho - CT). Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2000: 89; Honda K et al. Ortho cubic super high resolution computed tomography: A new radiographic technique with application to the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2001; 91: Barr JH, Stephens RG. Radiological health, In Dental radiology, Pertinent basic Concepts and their Applications in Clinical Practice. Philadelphia, WB Saunders, 1980; White SC, Pharoah MJ. Chapter 2: Radiation biology in Oral Radiology Principles and Interpretation, Fifth edition. Mosby, St. Louis P Frommer HH. Biological effects of Radiation, In Radiology for Dental Auxillaries, 6 th edition St. Louis, Mosby year book, 1996; Karjodkar FR. Chapter 6: Protection from radiation in Textbook of Dental and Maxillofacial Radiology, First edition. Jaypee brothers, New Delhi. P World Health Organisation, Geneva. Efficacy and radiation safety in interventional radiology. Chapter 2: Radiation safety. A.I.T.B.S. Publishers & Distributors (Regd.) Delhi 51. First edition 2002: P Indrajit IK. Few useful websites on radiation and radiation safety. Indian J Radiol Imaging 2010; 20 (1); Source of Support: Nil Conflict of Interest: No Conflict of Interest Received: April 2011 Accepted: Aug 2011

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ISSN (Print) Original Research Article

ISSN (Print) Original Research Article Scholars Journal of Dental Sciences (SJDS) Sch. J. Dent. Sci., 2017; 4(11):491-495 Scholars Academic and Scientific Publisher (An International Publisher for Academic and Scientific Resources) www.saspublisher.com