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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 2  |  Page : 126-131

Knowledge and perspective of dental clinicians toward radiological waste management in dentistry


Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Submission15-May-2018
Date of Acceptance15-Jun-2018
Date of Web Publication16-Jul-2018

Correspondence Address:
Dr. Shaikh Firdous
Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_80_18

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   Abstract 


Introduction: Oral and maxillofacial radiology is the daily part and parcel of dental practice. It does contribute a major section to the biomedical waste generated in the dental clinic. Pollution can be controlled only if the clinicians are aware about appropriate waste collection and disposal methods. This study aims toward evaluating the knowledge of clinicians toward this issue. Materials and Methods: A survey was performed for a sample size of 100 dental clinicians. A multiple-choice response type of questionnaire was designed with close-ended questions with a maximum choice of four responses. Responses were evaluated to extract the results. Results: An overall analysis yields total correct results which have been reported to be <50%, almost 14 out of 20 questions. This represents constrain in knowledge of the clinicians. Conclusion: Lack of knowledge may lead to serious health and environmental hazards. A governing body needs to be set-up to provide guidelines and handle proper disposal of radiologic waste.

Keywords: Dental radiology waste, developer and fixer management, radiology waste management


How to cite this article:
Firdous S, Sodhi S, Farha SS. Knowledge and perspective of dental clinicians toward radiological waste management in dentistry. J Indian Acad Oral Med Radiol 2018;30:126-31

How to cite this URL:
Firdous S, Sodhi S, Farha SS. Knowledge and perspective of dental clinicians toward radiological waste management in dentistry. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2021 Dec 7];30:126-31. Available from: https://www.jiaomr.in/text.asp?2018/30/2/126/236738




   Introduction Top


Oral and maxillofacial radiology has been the most vital arena of dentistry since the discovery of X-rays and their medical application. Roentgen in 1895 revolutionized the practice of medicine for the practitioners of being able to diagnose and planning before prepping patient for any invasive procedure. In dentistry radiography goes hand-in-hand with diagnosis as well as prognosis. Conventional oral radiography has never gone out of practice and still plays a pivotal role in dentistry in the era of digitization.

The radiology setup at a dental clinic is always a must and requires a lot of armamentarium such as films and the X-ray machine along with the processing area and solutions for the conventional radiography and digital radiography requires the X-ray tube, sensors, software, and computer monitor.

The pros for digital radiography include good image quality, reduced patient exposure, and precision, whereas the cons for digital dental radiology include more cost of setup and expensive imaging modality for the patient compared to the conventional ones. Conventional radiography, on the contrary, is less expensive for sure but does increase patient's exposure, hence cannot be considered patient-friendly.

Everything that yields benefit generates discarded buildup. Waste should be taken care of as an important element in the dental offices. Biomedical waste is any kind of waste containing infectious (or potentially infectious) materials.[1] Healthcare wastes are defined as discarded materials from healthcare activities that have the potential of transmitting infectious agents to humans.[2]

Dental office is a source of generation of biomedical waste. During the radiographic processing in a dental office or clinic, residues are originated which must follow their proper handling and discarding, aiming to minimize the environmental impacts.[3] The dental clinicians generally have the basic biomedical waste management protocols to be studied during the curriculum. But practice what you preach is the mantra. Bringing those things in day-to-day implementation is utterly important.

Dental clinics generate following waste: biomedical waste, radiological waste, waste from the dental materials, general office waste, etc. Knowledge of waste segregation plays a key role to facilitate waste disposal. Not only the solid waste generated is a concern but also the effluents from processing are. Hazardous and nonhazardous wastes need to be separated in order to avoid pollution as well as risk to health of the staff, patients, and general public coming in contact with it.

Pollution has become issue of the hour that needs to be taken care of at the global level. Proper waste management will be the first step toward pollution control. For this the dentists need to know about its techniques and act accordingly. This study examines the knowledge and approach of dental clinicians toward radiological waste in dentistry. Keeping the area of concern concise helped to establish accurate results. The study has also enquired the clinicians about the need to establish a governing body with the help of experts in oral radiology to guide, manage, and help in proper management of radiological waste generated in a dental setup.


   Materials and Methods Top


A survey was performed for a sample size of 100 dental clinicians. A multiple-choice response type of questionnaire was designed with close-ended questions with a maximum choice of four responses [Figure 1]. A printed copy of this structured questionnaire of 20 questions was produced before dental clinicians for recording their response. Electronic format of this questionnaire was also prepared to collect responses from dental clinicians. Ninety responses were collected in person from the dentists and 10 were received in electronic format. Attempting all questions was mandatory for each responder. Only one option was to be marked and no change in response was allowed once submitted. Owning the specific device/material presently was not a compulsion so as to answer the questions as this study also intends to evaluate knowledge of the practitioners. The data have been collected on the terms to maintain the anonymity of all the responders. The questionnaires were collected, compiled, and then taken under consideration for evaluation of responses. Data collected were then stored in e-format in Excel sheet. Statistical analysis was performed using the Microsoft Office Excel version 2007 using specialized tools for statistics.
Figure 1: Structured Questionnaire of 20 questions with a maximum choice of 4 answers designed for collection of responses of the survey

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Inclusion criteria

  1. Dentists practicing oral radiology either owning a setup or in collaboration with other clinicians
  2. Clinicians with an experience of dental practice at their own setup but not practicing presently
  3. Interns presently working at a dental setup.


Exclusion criteria

  1. Dentists with no experience in clinical practice
  2. Dental students
  3. Dental institutes.



   Results Top


This study was aimed toward evaluation of the knowledge and perspective toward management of radiological waste and the objectives of evaluation of responses and comparing them with the expected correct responses was done to check the knowledge gap.

An overall analysis yields total correct results which have been reported to be <50%, almost 14 out of 20 questions [Figure 2]. This represents constrain in knowledge of the clinicians, which was represented in [Figure 2]. Total responses were evaluated for all the participants on percentage basis depicted in the bar chart in [Figure 3]. Stock chart has also been depicted for the responses per question in [Figure 4]. Mean of the responses in [Figure 5]. Individual questions were also evaluated to study the results. Almost 40% of clinicians practice only conventional radiology and 28% practice digital radiography along with 32% practicing both. Regardless of the method of practice, the respondents answered all the questions in the questionnaire as for evaluating their outlook. 46% dentists collect lead foils and dispose it to local waste collection body, whereas 20% dispose along with regular waste at clinic and 12% gives away the foils with patient's X-ray packet and the remaining 22% believe in recycling. Only 48% responders firmly believed that X-ray films are a hazardous waste, while 36% were not sure. 56% dentists collect the X-ray films separately to be disposed to local waste collection bodies, where only a 23% population gives it for silver recycling. 69% clinicians go with the response supporting the fact that used developer is hazardous and only a 31% of responders support the correct option that used fixer solution is hazardous. The results for method of disposal of developer suggested that 38% clinicians dispose the solution offsite, considering it as a hazardous waste, whereas 32 and 17% dispose in sewage and soil, respectively. Only 13% store and do not dispose the used developer. Similarly, the results of disposal of used fixer solution are represented in [Figure 6]. 56% of responders supporting the option say that it is not okay to mix used developer and fixer solutions, but 10% still believed there was no harm doing so. 34% clinicians had no knowledge about this concept. 18% of dentists mix these two solutions at their setup and just 68% could mention a firmly negative response for this. 62% people owned a X-ray developer system and 8% do not use it. 16% people use chromium-based cleaners for it over the environmentally safe labeled ones, which is used by 39% of the clinicians. 37% of dentists had no knowledge regarding the cleaning systems. 78% consider the chromium-based cleaners as a hazardous waste. 72% dentists support the fact that digital radiography does not create waste which is not true as it does create electronic waste, waste from the sensors and other devices as well as a small amount of biodegradable waste (paper). 44% practitioners only among the included dentists give prints for RVG images for each patient; 40% use regular quality of paper; 15% use high-quality paper; 27% even share the thought of using recycled paper for RVG prints; 24% believe that digital radiography generates hazardous waste; 72% dentists get the electronic waste repaired, replaced, or recycled, whereas 8% dispose it off and 20% give it back to the manufacturer. 76% dentists use lead aprons and only 41% dispose it for recycle. 87% responses were received for a need to setup an organizing authority to manage radiological waste in dentistry. Evaluation of expected versus observed answers is also done [Figure 7]. Chi-square test was also performed for two arrays, i.e. of the observed values against the expected correct answers considering the degree of freedom as 3(k − 1, 4 – 1=3) at 5% level of significance, which was observed to be 0.05 (P ≤ 0.05), and hence the results were considered statistically significant establishing evidence for knowledge gap in dental clinicians regarding radiological waste management.
Figure 2: The percentage of expected response received from the respondersforeach question. Only seven questions received more than 50% of replies as expected out of 20 questions. Fourteen questions are interpreted as that of the response received, as expected is more than or equal to 30%

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Figure 3: The bar chart contains detailed data of the complete questionnaire and depicts the percentage for each option of every particular question. The significance of this chart is to evaluate the option-wise response against the correct expected response as well as the other replies received individually can be compared.

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Figure 4: Stock chart diagram highlighting the majority data so as to make it noticeable, to which response was received in a large percentage per question.

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Figure 5: Line diagram showing the percentage mean for individual options of the questionnaire.

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Figure 6: The percentage distribution of dental clinicians' method of disposal of used fixer solution. Still 35% clinicians dispose the solution in sewage and 18% in soil. But the total percentage of dental clinicians practicing silver recovery which is 41% is overruled by the remaining 59%, who lack the appropriate approach.

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Figure 7: Comparative bar chart showing the values for observed correct responses against the expected value for correct responses. Sixteen questions out of 20 show percentage correct response equal to or more than the expected range.

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   Discussion Top


Dental offices that house and operate standard radiography equipment must process the X-ray films using photochemical-fixer, developer, and equipment cleaner. Each of these chemical solutions is unique and requires special handling and disposal procedures.[4] Basically, the technique performed to obtain radiographic images involves exposure of radiographic films to X-rays, followed by their conventional processing, including image developing, washing, fixing, final washing, and drying.[3] The effluents coming from radiographic processing comprise solutions with high concentrations of silver and other chemical substances highly toxic to the environmental health.[5] Although individual dentists generate only small amounts of environmentally hazardous wastes, the accumulated waste produced by their profession may have a significant environmental impact which, in turn, may pose risk to human health.[6] Dental radiographic procedures generate certain waste substances with potential challenge to the environment. Examples of such waste materials include spent X-ray processing solutions, processor system cleaners, lead foil, lead aprons, lead shields, and used X-ray films.[7] There are a number of hazardous dental wastes that, when disposed of improperly, could cause harm to the environment. Examples include chemical solutions, lead foil film backing, mercury, scrap dental amalgam, fluorescent tubes, and batteries.[8] Basic knowledge regarding waste collection, segregation, and disposal could possibly change the approach of dentists toward it. In India, dentists pay no attention to waste management because they have no knowledge regarding waste management program.[9] Lead foil is used in intraoral films to protect them from backscatter and secondary irradiation. The lead content of this foil is between 69 and 85%.[10] No safe level of exposure to lead was found out, lead being toxic even in low doses. Lead poisoning in adults can affect the peripheral and central nervous systems, kidneys, blood pressure, and the reproductive systems. Children are more sensitive to lead than adults, as their exposure is increased by their hand-to-mouth activity, their gut absorbing lead more readily than an adult. The developing central nervous system (CNS) is more vulnerable to toxicants than a mature CNS.[11],[12] The lead foil from film packets has to be collected and returned back to the manufacturer for recycling. The only expense would be for postage. It appears that there is lack of awareness among the dentists on this service offered by manufacturers, as the companies report that only about 5% of the sold products are returned. Even lead aprons and lead shields should not be thrown into the regular garbage, yet returned to the manufacturer.[7] Undeveloped film contains a high level of silver and must be treated as a hazardous waste.[13] Typically, the used developer is not a hazardous waste, because of its low silver content (usually below the regulatory level of 5 mg/l silver) and lack of other constituents or characteristics that would make it dangerous.[14] Dental hospitals working with individual septic disposal systems should not pour this material into the drain because developer solutions are composed of aromatic phenolic compounds and amino acid salts whose chemical oxygen demand is high, and the products of its reactions can harm the septic system. They should contact an industrial wastewater disposal company for disposal of these wastes.[3] The fixer that dental offices use to develop X-ray is a hazardous material that should not be simply rinsed down the drain. Spent fixer solution contains approximately 4000 mg of silver/l.[15] Silver from the used fixer is a valuable resource that should be recycled. There are two basic management options for this: onsite treatment and disposal or offsite treatment and disposal. Whichever the treatment, silver is easily and economically recyclable, recycling remaining the preferred method.[14],[15] Onsite recovery of silver from the fixer involves either metallic replacement or electroplating methods. It can be transported to silver reclaiming facility or to the manufacturers or distributors of fixer solutions. Some of them apply the “take back” policy for solutions purchased from them. When storing the fixer for offsite treatment or disposal, remember to collect and store the fixer in a closed plastic container. Label the container “Used fixer” along with the date when it was first added to the container.[16] Many cleaners used for automatic processors contain chromium, which is a hazardous waste when discarded. As an alternative, it is easier and cheaper to use a system cleaner that does not contain chromium.[14] Dentistry is a part of healthcare services, and dental waste management is a category that needs to be organized.[6] Although dental centers are considered as a minor source of healthcare waste, but they generate a certain amount of hazardous waste. Dental offices produce a variety of wastes such as domestictype, infectious, toxic, and chemical and pharmaceutical wastes. Each fraction would require a specific approach for collection, treatment, and disposal.[6],[17] Educational pictures and posters in the dental office may be useful as guidance for the dental staff [Figure 8] and [Figure 9].
Figure 8: Encourage your dental assistants and staff to reduce wastage as well as promote proper collection of radiological waste generated using guiding symbols, motivational images for waste managing staff for recycle or disposal to collectors later. Image Source: Internet.

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Figure 9: Discarded lead foils should be most appropriately considered for recycle. Image source: Internet.

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   Conclusion Top


Dental radiology is practiced by almost all practicing clinicians for diagnosis, treatment planning, and patient education as well as maintenance of patient records. This versatile arena also is one of the reasons for production of hazardous type of biomedical waste that requires to be handled carefully. Lack of knowledge may lead to serious health hazards to both the clinician and the people coming in contact with it. Digitization has led to minimizing the waste created from conventional means but still the wisdom of disposal methods is found to be less than expected. An organization if founded can help clinicians to learn and employ appropriate methods of disposal and thereby reduce the risk of pollution. Even the clinicians need to take initiative to enquire and acquaint themselves with correct knowledge and change the perspective.

Acknowledgement

With great pleasure, I wish to express my deep sense of gratitude to Prof. Dr. Lata Kale, H.O.D, Dept of OMR, CSMSS Dental College, Aurangabad for her useful guidance and encouragement through the entire process of study. I would like to extend my sincere thanks to Mr. Yusuf Talib, Dept of Biotechnology, Maulana Azad College, Aurangabad. for his valuable support in statistical issues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Thacker SB, Hoffman DA, Smith J, Steinberg K, Zack M. Effect of low level body burdens of lead on the mental development of children: Limitations of meta-analysis in a review of longitudinal data. Arch Environ Health 1992;47:336-46.  Back to cited text no. 12
    
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Hedge V, Kulkarni RD, Ajantha GS. Biomedical waste management. J Oral Maxillofac Pathol 2007;11:5-9.  Back to cited text no. 13
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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