Awareness of radiation protection among dental practitioners in UP and NCR region, India: A questionnaire-based study

Abhilash Panwar; Swati Gupta; Kamarthi Nagaraju; Sangeeta Malik; Sumit Goel; Abhinav Sharma

doi:10.4103/jomr.jomr_6_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 13-18

Awareness of radiation protection among dental practitioners in UP and NCR region, India: A questionnaire-based study

Abhilash Panwar, Swati Gupta, Kamarthi Nagaraju, Sangeeta Malik, Sumit Goel, Abhinav Sharma
Department of Oral Medicine and Radiology, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India

Date of Submission	07-Mar-2022
Date of Decision	30-Mar-2022
Date of Acceptance	07-Apr-2022
Date of Web Publication	21-Apr-2022

Correspondence Address:
Abhilash Panwar
Department of Oral Medicine and Radiology, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jomr.jomr_6_22

Abstract

Background: Biological effects of radiation include deterministic and stochastic effects. Dental colleges still follow radiation protection principles due to guidelines laid by the Dental Council of India and the Atomic Energy Regulatory Board, but private practitioners sometimes are negligent about the significance of radiation protection. The study focuses on the awareness of radiation protection among dental practitioners based on their knowledge, attitude, and application. Aim and Objectives: The aim and objectives of this study were to evaluate the level of awareness and attitude about radiation protection among dental practitioners in Uttar Pradesh and the NCR region, India. Materials and Methods: The survey was performed on dental practitioners from UP and NCR region, India. The survey comprised two sections: one section on basic information of the dentists and their working place, consisting of two questions. The second section consisted of 21 questions regarding patient and personnel protection methods and knowledge about radiation exposure. The questionnaire was disseminated through Google Forms. Results: Among 200 dentists, 84% use Radio visual graph (RVG) in their clinics. Ninety percent of the specialists attended the basic lecture on radiation exposure, nearly 50% of the dentists use digital receptors in pediatric patients, 86% of the specialists use their hands when adjusting the X-ray tube, 98.4% of the dentists know the related complications of radiation, 46.8% of the specialists explain the radiation measures to the patients, 76.2% of the dentists use lead barriers in their clinics, and 76.2% of the clinicians often get their X-ray machines serviced yearly. Conclusion: The current study shows the utmost need for further implementation of radiation protection. The majority of dentists are negligent in practicing radiation protection procedures properly. Emphasis on radiation safety and mandatory professional education is needed.

Keywords: The Atomic Energy Regulatory Board, awareness, dental practitioners, the International Commission on Radiological Protection, radiation protection

How to cite this article:
Panwar A, Gupta S, Nagaraju K, Malik S, Goel S, Sharma A. Awareness of radiation protection among dental practitioners in UP and NCR region, India: A questionnaire-based study. J Oral Maxillofac Radiol 2022;10:13-8

How to cite this URL:
Panwar A, Gupta S, Nagaraju K, Malik S, Goel S, Sharma A. Awareness of radiation protection among dental practitioners in UP and NCR region, India: A questionnaire-based study. J Oral Maxillofac Radiol [serial online] 2022 [cited 2023 Mar 28];10:13-8. Available from: https://www.joomr.org/text.asp?2022/10/1/13/343694

Introduction

From the time of its discovery, X-rays have played an essential role in the field of medical and dental sciences. Ranging from diagnostic to therapeutic applications, the use of X-rays is manifold. Probably, the most extensive application is in the field of dentistry, ranging from diagnosis of incipient caries and minuscule fractures to aiding in more complex procedures such as precision implant planning.^[1]

The International Commission on Radiological Protection (ICRP) is one of the essential organizations that are concerned with the protection against ionizing radiation. The Atomic Energy Regulatory Board (AERB) is the qualified authority in India that implements the safety provision by the Atomic Energy Act, 1962. It should be constantly monitored if the radiation protection comes foremost in the radiography.

The first protection recommendations were given by an American engineer Wolfman Fuchs. He stated that make the exposure as short as possible, do not stand within 12 inches (30 cm) of the X-ray tube, and coat the skin with Vaseline.^[2]

In 1915, the British Roentgen Society had put forth the resolutions to protect people from overexposure to X-rays in hospitals and formulated a dose range, in 1924, by the name of “tolerance.” They called this range to be safe after conducting a study on different personnel.^[2]

A dentist must be prepared to discuss intelligently the radiation exposure to the patients as the risk of X-ray exposure has increased the risk of cancer, birth defects, and cataracts. The principle of radiation protection is to minimize radiation exposure and provide benefits for the patient in the diagnosis.

Radiation has become a part of modern living, reaching every sector of society. We are constantly exposed to naturally occurring ionizing radiation, i.e., background radiation, and also exposed to artificial sources, mostly through medical and dental procedures.

According to the report of the Polish Sanitary Inspectorate, in 2012, over 50% of about 15,000 working X-ray devices were dental ones. According to the European Commission, the number of dental examinations constitutes nearly one-third of the radiological examinations in the European Union, so it is the responsibility of the dentist to ensure that the patient avoids even the smallest unnecessary dose of radiation.^[3]

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 the doses are, some stochastic effects may result. The dental practice has its way of radiation exposure, and the practicing dentists differ from medical colleagues as they expose, process, and interpret the radiograph.

According to the book of Oral Radiology Principles and Interpretations, irradiation during the fetal period does not cause gross malformation.^[4] However, general retardation of growth may persist through life. There is also a bigger risk for childhood cancer after irradiation in utero. The current protection standards are based on three general principles: justification of a practice, optimization, and dose limitation.

The World Health Organization recommends continuous training and regular refresher courses and states that specific training in interventional radiology is required in addition to the basic training.^[5]

With this background, we performed a survey among dental practitioners to gain insight into the attitude of the UP and NCR region, India, toward radiation protection.

Aim and objectives

The aim and objectives are to evaluate the level of awareness and attitude about radiation protection among dental practitioners in Uttar Pradesh and the NCR region, India.

Inclusion criteria

Dentists running their private dental clinics and working in dental hospitals were included.

Exclusion criteria

Medical practitioners and dental students were excluded.

Materials and Methods

The survey was conducted with an online questionnaire that included dental practitioners from UP and NCR region, India [Annexure 1].

The questionnaire consisted of two sections: one section is on basic information about the dentists and their working place, consisting of two questions. The second section consisted of 21 questions regarding patient and personnel protection methods and knowledge about radiation exposure [Annexure 1].

The questionnaire was distributed through Google Forms. Dentists have explained the purpose of research, and they cooperated well for the same.

Results

Awareness of dental practitioners related to radiation protection was evaluated by assessing the responses of the dental practitioners, and from the questionnaire distributed, 200 out of 500 dentists responded and sent back their responses, which gave us a brief idea of radiation awareness protocols used by dental practitioners.

Ninety-four percent (188) of the dentists involve radiology in their practices and 7% (14) do not consider radiology in their practices. When dentists asked about the use of RVG in their clinics so, 84% (168) of them responded YES to that question and 15.1% (30) still use normal X-ray films for shooting an X-ray.

This questionnaire-based survey revealed the basic knowledge of radiology among dentists. Among 200 dentists, 90.4% (180) of the dentists have attended the basic lecture on radiation exposure, which proved that 90.5% (180) of the dentists know the full form of ALARA, and there was a 100% (200) positive response toward the knowledge about the awareness of the protection measures when operating the X-ray machine.

When asked about the protection barriers they use in their dental clinics, the question was asked in multiple-answer format [Table 1]; lead aprons were used by the most, i.e., 87.3% (174), followed by thyroid collars, i.e., 29.4% (58). Gonadal shields were used by the least, i.e., 9.5% (19) of the dentists, and very interestingly, instead of lead aprons, 20.6% (41) of the dentists used drape in their clinics as a protective barrier.

Table 1: Number and percentage of the dentists using the kind of protective barriers in their clinics while shooting X-rays

Click here to view

Among the pediatric patients, high-speed films are used to prevent exposure among children, and only 35.7% (71) of the dentists use E-films in their clinics. The majority of the dentists use digital image receptors.

About 4.8% (10) of the dentists were unaware of the position–distance rule and 95.2% (190) were familiar with it [Table 2]. It is contraindicated to use hands when adjusting the X-ray tube, but 86.5% (173) of the dentists were negligent to this protocol and used hands when adjusting the tube, whereas only a few dentists, i.e., 13.5% (27), were aware of this rule [Table 3].

Table 2: Are you aware of the position–distance rule while shooting X-rays?

Click here to view

Table 3: Do you use your hands while adjusting the X-ray tube?

Click here to view

One of the questionnaires in the survey which was regarding radiation exposure, the annual radiation exposure for the patients [Table 4], revealed that 73.9% (148) of the dentists had no idea about it.

Excessive exposure to X-rays leads to stochastic and deterministic effects of the cell and 98.4% (197) of the dentists were informed about the associated complications of X-rays and 89.7% (179) identified situations where it was beneficial to the patient from the diagnostic exposure. Patients who require radiological investigations before the final diagnosis and treatment should always be explained the radiation measures and limitations before exposing them to the X-rays, and 46.8% (94) of the dentists neglected the idea of explaining these measures to the patients [Table 5].

Table 4: What should be the annual radiation exposure for the patients?

Click here to view

Table 5: Do you explain the radiation measures and their limitations to the patients before taking x-rays?

Click here to view

For safety updates and the availability of new equipment, supplies, and techniques that could further improve the diagnostic quality of radiographs, only 73% (146) of the dentists were informed and 27% (54) had no clue about the new technologies [Table 6].

Table 6: Do you remain informed about safety updates and the availability of new equipment, supplies, and techniques that could further improve the diagnostic quality of radiographs?

Click here to view

There are always extra precautions to be taken with pregnant women who come to the outpatient department for treatment. It is said in the literature that avoid X-ray exposure in pregnant females as much as you can and contact her previous dentists to gather information regarding X-rays to avoid further exposure. About 34.1% (68) of the dentists were heedless regarding which month is best suited for pregnant women for X-rays by giving the response that no radiographs are to be taken till the 3^rd trimester in pregnant females. The majority of the dentists, i.e., 64.3% (129), were concerned about it [Table 7].

Table 7: What approach will you use if pregnant female reports to your OPD?

Click here to view

The primary beam should never be directed at anyone, other than the patient itself. Walls should be made of 3” of concrete. It is said that 1 mm of lead will suffice to protect adjacent rooms. It is used because of its high-atomic number, density, and high linear attenuation coefficient. Based on the lead barriers used in the dental clinics, 76.2% (152) of the dentists use lead as a protective barrier in their clinics and 23.8% (48) were negligent about lead [Table 8].

Table 8: Do you use lead barriers in your clinic?

Click here to view

Periodic assessment of the performance of the X-ray machine is mandatory and safe for both the operator and the patient because it tells us about any leakage during the exposure. In this survey, 63.5% (127) of the dentists have responded YES to this question and 36.5% (73) do not assess it periodically [Table 9]. Among 127 dentists, only 38.3% (48) calibrate the X-ray machine yearly; otherwise, 61.4% (77) had no clue about the schedule of quality assurance procedures [Table 9]. When asked about the replacement of the processing solution, 61.3% (123) of the dentists replace it at the correct time, i.e., weekly, whereas 19.4% (39) are ignorant about it in their clinics.

Table 9: Do you periodically assess the performance of your X-ray machine? If the above answer is yes then, what is the duration of your assessment?

Click here to view

When asked about the duration of the X-ray machine, 61.9% (124) of the dentists had bought their machines in between 1 and 5 years. About 11.9% (24) of the dentists are using the same machines for more than 10 years and 76.2% (152) of the dentists get their machines serviced yearly. Only 23.8% (48) of the dentists had no idea about it [Table 10].

Table 10: How often do you get your X-ray machine serviced?

Click here to view

One should always measure the radiation exposure in their clinics, on this, 52.4% (105) of the dentists are unconcerned about measuring the exposure of X-rays in their clinics [Table 11] and 47.6% (95) are informed about this protocol and measured it using proper dosimeter, for example, thermoluminescent dosimeter (TLD) badges, a pocket dosimeter, and film badges [Table 11].

Table 11: Do you measure radiation exposure in your clinic? If the above answer is yes, how do you measure it?

Click here to view

Discussion

The effect of ionizing radiation on the living system is well known and definitive. Practitioners who regulate ionizing radiation must be familiar with the magnitude of radiation exposure confronted in dentistry, the possible risk that such exposure results in, and the methods used to reduce doses. This information provides the crucial background for explaining to concerned patients the benefits and possible hazards involved with the use of X-rays.

The present study was conducted to explore the various issues related to radiation protection in Indian dental practice assiduously and simultaneously in the dental practitioners. It assessed Indian dental practitioners' knowledge, attitudes, practices, perception about radiation hazards, and protection. To effectively control and prevent radiation-induced hazards, it is essential to understand the effects of ionizing radiation on the health of an individual. Various researchers have reported a lack of knowledge of dental practitioners toward radiation hazards and protection.

The thyroid gland is more susceptible to radiation exposure during dental radiographic examinations given in anatomic position, particularly in children. Protective thyroid collars and collimation substantially reduce radiation exposure to the thyroid.^[4] In our study, 87.3% of the specialists use lead aprons and 29.4% use thyroid collars. Similar studies were conducted in North Karnataka, India, by Javali and Dantu, where 41% of the clinicians wore lead aprons.^[6]

The National Council of Radiation Protection and American Dental Association concluded that leaded aprons are unnecessary because it is far more important in patient protection to emphasize reducing exposure of the primary beam to facial structures than to diminish the already very slight gonadal exposure.

Dental films are commercially accessible in speed groups D and E as defined by the International Organization for Standardization.^[4] E-films are more sensitive to radiation (faster) and should be used. In the current study, only 35.7% (71) of the dentists use E-films in their clinics. The majority of the dentists use digital image receptors, and 14.2% (28) of the dentists are uninformed about the correct film for shooting the X-rays.

All practitioners should check their state's regulations for use of ionizing radiation regarding operator position during X-ray exposures. Strict adherence to what has been termed the position-and-distance rule is required: the operator should stand at least 6 feet (2 m) from the patient, at an angle of 90°–135° to the central ray of the X-ray beam. When enforced, this rule not only takes an advantage of the inverse square law to lessen the X-ray exposure to the operator but also takes an advantage of the fact that in this position, the patient's head absorbs most scatter radiation.^[4] Harleen B et al. stated in their study that 34.7% of the clinicians maintained a safe distance of at least 6 feet. In the same study, <5% of the clinicians use rectangular collimators and 2.8% do nothing to avoid direct exposure.^[7]

Neither the operator nor the patient should hold the radiographic tube during the exposure. Suspension arms should be adequately maintained to prevent housing movement and drift, but in the current study, majority of the dentists hold the X-ray tube with their hands.

According to the data from the 2007 recommendations of the ICRP, the average human exposure to ionizing radiation should be 1 mSv annually, but in the current study, the majority of the dentists are unaware of the annual radiation exposure.^[4]

Informed consent should be obtained from patients before radiography by national requirements. There is an increasing insistence on the need to gather informed consent for all forms of medical and dental practice and not purely for high-risk procedures such as interventional radiology or irreversible treatments such as tooth extraction. Informed consent is mandatory in some nation states. In the current study, the majority of the dentists explain all the radiation measures to the patients, but still, some dentists lack this in practice.

The study conducted in North Karnataka on attitude and awareness about radiation protection among dental surgeons by Javali and Dantu stated that approximately 51% of the dentists had no experience explaining radiation risk/benefits to patients.^[6]

It is advisable to delay nonurgent radiographs during the delicate period of 10–17 weeks of gestation (8 to 15 weeks after conception). The first 3 months of pregnancy are the most active regarding the development of the fetus. Due to this reason, many expecting mothers may choose to postpone dental X-rays until after this sensitive time has passed. Most medical professionals will suggest that any dental work should at least be postponed until the second trimester. There is unquestionably less risk to the baby. By the third trimester, it may be difficult for the patient to lie on their back for a long period. This is why the second trimester is the safest for having simple procedures or cleanings.^[4]

Operators of radiographic equipment should use barrier protection when desirable, and barriers should contain a leaded glass window to facilitate the operator to view the patient during exposure. In our recent study, the majority of the specialists use lead barriers in their clinics, but only 23% of the dentists are unfamiliar with such barriers in their clinics. Kaur et al. stated in their study that 60.9% of the dental practitioners have separate radiographic rooms.^[8]

There should be a proper schedule for radiographic quality assurance procedures. Daily replenishing of the processing solution is required, and proper temperature checking should be done. Processing solutions should be replaced every week. In the current study, 19.4% of the dentists are negligent about replacing their processing solutions, but the majority of the specialists are informed and applied them in their practices.

According to the American Academy of the Oral and Maxillofacial Radiology, calibration of dental X-ray machines should be done yearly, but our study shows that specialists are not much informed about quality assurance procedures. In the study conducted by Javali and Dantu, 60% of their clinicians got their X-ray machines calibrated periodically.^[6] Harleen B et al. stated in their study that 39.7% of the Indian dentists perform a checkup of their X-ray machines only if required, whereas 21.9% reported no checkup.^[7]

The best way to ensure that personnel are following office safety rules is with personnel monitoring devices. These devices provide a means to measure if the operator is procuring any occupational exposure. With proper use of TLD badges, pocket dosimeters, film badges, etc., we can measure our radiation exposure in our clinics. From this study, we got to know that dentists in UP and NCR region, India, do not measure radiation exposure in their clinics, and among those who measure, TLD badges are used the most.

A study conducted by Kaur et al. stated that 18.2% of the private dental practitioners in Lucknow used badges for monitoring radiation exposure.^[8]

Conclusion

The current study focused on the awareness of radiation protection among dental practitioners based on their knowledge, attitude, and application in practice. We concluded that specialists know radiology as a majority of the dentists know the basic concepts that are asked in the questionnaire.

Talking about attitude and practice, many of the dentists lack these two. More application of radiation protocols is needed by the dentists, so that they can make a safe environment for the patients coming to their clinics and for themselves as well.

Our study has many majorities of dental specialists who are practicing in their clinics, but still the practice regarding radiation protection lack in some clinics. The study suggests that practicing dentists need to be persuaded and reassured to conform to the rules of protection from X-rays. The AERB recommendations should reach out through the dentists' platform (e.g., IDA) and radiography equipment installing companies to the dental practitioner. Practitioners should be aware of the possible hazards involved with the use of X-rays and should strive hard to implement the various protective measures into practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Annexure 1: Questionnaire form on radiation protection for Dental practitioners

SECTION-1

Q.1: Do you involve radiology in your practices?

Q.2: Do you use RVG in your practices?

SECTION-2

Q.3: Have you ever attended a basic lecture on radiation exposure?

Q.4: Full form of ALARA?

As low as reasonably accountable
As low as reasonably achievable
As low as recommended allowance
As low as radiation averse

Q.5: Are you aware of the protection measures while using an X-ray machine?

Q.6: What kind of protection barriers do you use in your dental clinic while shooting x rays?

Thyroid collars
Gonadal shields
Lead aprons
Drape

Q.7: What kind of films do you use while taking X-rays in pediatric patients?

E-films
Medium speed film
Low-speed film
A film
Digital image receptor

Q.8: Are you aware of the position–distance rule while shooting X-rays?

Q.9: Do you use your hands while adjusting the X-ray tube?

Q.10: What should be the annual radiation exposure for the patients?

2 mSv
5mSv
1mSv
10mSv
Unaware

Q.11: Are you aware of the complications associated with radiations?

Q.12: Do you explain the radiation measures and their limitations to the patients before taking x rays?

Q.13: Do you remain informed about safety updates and the availability of new equipment, supplies, and techniques that could further improve the diagnostic quality of radiographs?

Q.14: What approach will you use if pregnant female reports to your OPD?

Take a new x-ray
Contact her previous dentist to bring her radiographs to avoid further radiation exposure
No radiographs to be taken till 3^rd trimester in pregnant females

Q.15: Do you identify situations where it is a benefit to a patient from the diagnostic exposure?

Q.16: Do you use lead barriers in your clinic?

Q.17: Do you periodically assess the performance of your X-ray machine?

Q.18: If the above answer is yes then, what is the duration of your assessment?

Yearly
Monthly
Weekly
Quarterly

Q.19: How old is your X-ray machine?

1-5 years
6-10 years
More than 10 years

Q.20: How often do you get your X-ray machine serviced?

Yearly
Weekly
Monthly
Daily

Q.21: Do you measure radiation exposure in your clinic?

Q.22: If the above answer is yes then, how do you measure it?

Using TLD badge
Using pocket dosimeter
Using film badge

Q.23: How often do you replace the processing solution in your clinic?

Yearly
Weekly
Daily
Negligent

References

1.	Aravind BS, Joy ET, Kiran MS, Sherubin JE, Sajesh S, Manchil PR. Attitude and awareness of general dental practitioners toward radiation hazards and safety. J Pharm Bioallied Sci 2016;8:S53-8.
2.	Joseph BB, George S. The road to radiation safety and ALARA: A review. IP Int J Maxillofac Imaging 2021;6:89-92.
3.	Furmaniak KZ, Kołodziejska MA, Szopiński KT. Radiation awareness among dentists, radiographers and students. Dentomaxillofac Radiol 2016;45:20160097.
4.	White SC, Pharoah MJ. White and Pharoah's Oral Radiology: Principles and Interpretation. 7^th ed. Riverport Lane St. Louis, Missouri: Elsevier Health Sciences 2014. p. 29-39.
5.	Shabani F, Hasanzadeh H, Emadi A, Mirmohammadkhani M, Bitarafan-Rajabi A, Abedelahi A, et al. Radiation protection knowledge, attitude, and practice (KAP) in interventional radiology. Oman Med J 2018;33:141-7.
6.	Javali R, Dantu R. Attitude and awareness about radiation protection among dental surgeons in North Karnataka: A questionnaire study. J Indian Acad Oral Med Radiol 2018;30:116. [Full text]
7.	Harleen B, Mishra N, Kaur P, Sharma S, Muthunagai R, Shraddha S. Awareness and attitude towards radiation protection and safety among dental community of North India. J Res Adv Dent 2018;9:32-42.
8.	Kaur A, Mishra N, Deepak U, Shiva Kumar GC, Singh P. Awareness of radiation protection measures of dental imaging among private dental practitioners in Lucknow city – A Questionnaire Survey. IP Int J Maxillofac Imaging 2016;1:1-5.