Title Page - include author details here only!

© 2016 The Authors. Published by the British Institute of Radiology

Title of the paper: Radiation awareness among dentists, radiographers and students
A shortened version of the title: Radiation awareness
Type of Manuscript: Research Article

Author names: Katarzyna Z. Furmaniak DMD1, Marzena A. Kołodziejska BS, RT1, Kazimierz T.
Szopiński MD, PhD, MS1.

FS
1. Department of Dental and Maxillofacial Radiology, Faculty of Medicine and
Dentistry, Medical University of Warsaw

O
O
R
P
D
E
T
C
E
R
R
O
C
N
U
 Abstract
1
2 Objectives. The aim of this study was to assess radiation awareness among dentists, radiographers,
3
4
dentistry students and radiography students from Medical University of Warsaw.
5
6 Methods. A questionnaire containing 13 multiple choice questions was administered to 200
7 dentists, 200 radiographers and 100 dentistry students and 100 radiography students. Participants
8 were asked about basic knowledge concerning dental radiological examinations.

FS
9
10
11
Results. In total, 301 questionnaires were returned (50.2%). Mean score of correct answers was
12 8.13 out of 13 for all responders; 8.36 for dentists, 8.11 for radiographers, 8.19 for dentistry
13

O
students, 7.46 for radiography students. Range of correct answers varied from 3 to 12. Differences
14
15 between four main groups were not statically significant. Dentists who had completed radiation
protection training had significantly higher number of correct answers in comparison with

O
16
17
18
untrained dentists. For radiographers, the level of education had no connection with the results.
Correlation between year of the study and results was not visible in dentistry students group.

R
19
20 Within the radiography students group, students in third year of the study had significantly higher
21
number of correct answers in comparison with first and second year.

P
22
23
24 Conclusions. Our survey shows that radiation awareness among dentists, radiographers and
25 students was inadequate, without significant differences in main groups. Dentists, who had
26
D
27 radiation protection training completed, had a better awareness, compared with dentists without
28 such training. Greater emphases should be put on dental radiology course in both dentistry and
E
29 radiography programs at the universities.
30
T

31
Key words. survey; dental radiography; medical staff; dentists; students
32
33
C

34
35
E

36
37
38
R

39
40
41
R

42
43
O

44
45
46
C

47
48
49
N

50
51
52
U

53
54
55
56
57
58
59
60
61
62
63
64
65
 Introduction
1
2 Many studies concerning radiation awareness among physicians of different specialties, interns,
3
4
radiographers and medical students have been performed. 1-5 However according to our
5 knowledge, no research has been conducted among healthcare professionals prescribing and
6 performing dental radiological examinations.
7
8 According to the report of the Polish Sanitary Inspectorate, in 2012 over half of about 15 000

FS
9
10 working X-ray devices were dental ones. 6 According to European Commission the number of dental
11 examinations constitute nearly one third of the radiological examinations in the European Union. 7
12
13 These data show that collective doses from dental radiography have significant share in average

O
14 annual dose from medical sources.
15
Average dose from intraoral radiography is lower or comparable with the daily background

O
16
17
18
radiation dose. 7,8,10 However every exposure to ionizing radiation entails the possibility of inducing
a stochastic effect (including leukemia and certain tumors). 9

R
19
20
21 Dentists should have adequate knowledge about radiation, as they prescribe the examinations.

P
22 They decide if the value of information provided by radiographs outweighs the possible negative
23
24 consequences for the patients’ health. Dentists as well as radiographers should be prepared to
25 inform patients about the possible hazards involved with the use of x rays.
26
D
27 Objectives
28
E
29 The aim of this study was to assess general radiological knowledge among health professionals
30
T

31 prescribing and performing dental radiological examinations, dentistry students and radiography
32 students from Medical University of Warsaw.
33
C

34 Material and methods

35
E

36 The questionnaire was administered to randomly selected 200 dentists and 200 radiographers
37
38 working in Mazovian Voivodeship and 100 dentistry students and 100 radiography students from
R

39 Medical University of Warsaw. As dental hygienists are not allowed to perform radiographs in
40
41 Poland, they were excluded from this study. 11 The authors were also excluded from the study. Data
R

42 were collected anonymously.

43
O

44 The questionnaire was divided in two sections. The first one concerned surveyed person (e.g. year
45
of study, practice time, graduated university). The second one, containing 13 questions, assessed
46
knowledge regarding basic radiological and some legal issues. The questions were designed in the
C

47
48 form of affirmative sentences with “TRUE”, “FALSE” and “I DO NOT KNOW” answers. The questions
49
N

50 together with answers and the relevant reference sources are presented in Appendix.
51
52 The chosen metric of the level of knowledge was the number of correct answers. To compare the
U

53 average number of correct answers in groups (dentists, radiographers, etc.) and subgroups
54
55
(qualifications, year of study) univariate analysis of variance (ANOVA) was used, calculated with
56 IBM SPSS software version 22. The overall value for statistical significance was p<0.05.
57
58 Results
59
60
61
62
63
64
65
 A total number of 301 questionnaires (50.2 %) were returned from the 600 sent. Table 1 presents
1 the mean number of correct answers in the groups together with corresponding standard
2
3 deviations. Overall mean score of correct answers was 8.13 out of 13 (63%). Range of correct
4 answers varied from 3 to 12.
5
6 Differences between four main groups – dentists, radiographers, dentistry students and
7
8 radiography students – were not statically significant.

FS
9
10 Comparison between certain subgroups of particular groups revealed statistically significant
11 differences (Table 1). In the dentists group the number of correct answers was related with the
12
13 time of practice and the completion of radiation protection training (F=2.704; df=4; p<0.035;

O
14 eta2=0.107). Significant difference was observed only between dentists practicing 1-5 years and
15 more than 15 years. Dentists with radiation protection training completed had significantly higher

O
16
17 number of correct answers (F=4.979; df=1; p<0.028; eta2=0.051) in comparison with dentists
18 without such training.

R
19
20 In radiography students group the number of correct answers was related with the year of the
21
study (F=13.00; df 2; p<0.001; eta2=0.388). Third year students had significantly higher number of

P
22
23 correct answers in comparison with first and second year.
24
25 In radiographers group and dentistry students group differences between subgroups were not
26
D
27 statically significant.
28
E
29 Low-scoring questions
30
T

31 To explore how certain areas of radiological knowledge depend on the educational background and
32 experience, the per-question analysis of the results was performed. In 5 out of 13 questions less
33
C

34 than 50% of responders marked correct answers in at least one group. These questions together
35 with percentage of correct answers across all groups are presented in Figure 1.
E

36
37 In Question 4 the majority of dentists, dentistry students and radiography students mistakenly
38
claimed that one periapical radiation dose was absolutely safe and had no impact on health. Among
R

39
40 dentists who marked correct answer 81.5% had the radiation protection training completed.
41 Awareness of potentially harmful effects was the highest in radiographers’ group, where the
R

42
43 distribution of answers was not dependent on the level of education.
O

44
45 Question 7 concerning risks of inducing a fatal cancer from periapical radiograph was the most
46 confusing for all responders – there was highest percentage of “I do not know” answers (30.9%).
C

47
48 In Question 9 most of radiographers and radiography students found performing radiograph for
49
N

50 pregnant patient forbidden which was an incorrect answer. Dentists and dentistry students were
51 better at answering this question.
52
U

53 Approximately half of responders in each group falsely stated that the limit of radiographs for
54
55
patient per year is determined by law (Question 10).
56
57 Almost half of the dentists and radiography students could not correctly indicate that periapical
58 radiography can be performed on patient’s request (Question 11).
59
60
61
62
63
64
65
 Answers “TRUE” for both Question 4 and Question 6 (Appendix) were mutually exclusive. If
1 radiation was absolutely safe (Q4) then there would be no possibility of such harmful effects as
2
3 leukemia (Q6). It is interesting that there were 30 dentists (31.6%), 21 radiographers (23.6%), 33
4 dentistry students (45.2%) and 18 radiography students (93%), who marked answers in such
5
6 combination.
7
8 Discussion

FS
9
10 Based on results we conclude that radiation awareness among dentists and radiographers was
11 insufficient. The mean percentage of correct answers was 64% for dentists and 62% for
12
13 radiographers. Only 46 of dentists (48%) and 40 of radiographers (45%) marked more than 8 correct

O
14 answers. We set the high expectations for the responders’ results, as the questions were simple
15 and assessed more general rather than academic knowledge. None of the questions concerned

O
16
17 precise numerical data and only few of them could be recognized as theoretical and irrelevant in
18 every day practice.

R
19
20 Data show that completion of radiation protection training increased dentists’ radiological
21
knowledge – similarly like in other study. 4 For radiographers, the level of education had no

P
22
23 connection with the number of correct answers. The cross group comparison tells that dentists
24 achieved better result than radiographers, but the difference was not statistically significant. Our
25
results are contrary to Ramanathan et al results, who found significant knowledge deficiency
26
D
27 among radiographers compared to other radiology department staff.1 Our responders’ knowledge
28 was similar regardless of time of the practice (significant difference was only between two
E
29 subgroups of dentists group).
30
T

31
32 We expected students to perform better, as they are more up to date with knowledge, but only
33 36% of dentistry students and 18% of radiography students marked more than 8 correct answers.
C

34
35
Radiography students achieved worse results. It may be because most of this group were first and
second year students (first year radiography students were after general radiography course and
E

36
37 had not started dental radiology course at the time they were being questioned). For some
38
R

39 questions (questions no: 2, 3, 9, and 13) the group-level distributions shows similarities for students
40 and their future counterparts – that may be explained by differences in curriculum with regards to
41
R

profession.
42
43
The majority of responders falsely claimed that one periapical radiation dose was absolutely safe
O

44
45 and had no impact on health. Disregard of radiation risk may lead to excessive number of
46 unnecessarily prescribed or repeated periapical radiographs. On the other hand, most of
C

47
responders overestimate risk of radiological examination of pregnant patients. The possible
48
49 negative consequences of this include abandoning radiological diagnostics for pregnant patients
N

50 even when the benefits outweigh the risk. Other much less likely but possible consequence is denial
51 of performing prescribed examinations for pregnant patient by radiographers.
52
U

53
54 Our study has the following limitations: (1) the chosen metric does not distinguish between
55 incorrect and “I DO NOT KNOW” answers - both were scored as 0 points, (2) the order of questions
56
might have had influence on answers, (3) responding group was small, (4) direct comparison
57
58 between our results and results from past studies is impossible (in other studies responders were
59 mostly asked to identify doses and radiation risk from examinations, while our study had
60
61
62
63
64
65
 comprehensive questions), (5) responders might have searched for answers in sources like books or
1 the internet, (6) some questions (no: 1-3, 4,6) were in some way related with each other.
2
3
4
The results indicate the need for improvement in dental radiology training at the universities. Also
5 Dentist Final Examination (Lekarsko Dentystyczny Egzamin Końcowy- LDEK), which is obligatory to
6 pass before starting dental practice, should include more questions from dental radiology field,
7
8 especially radiation safety topics.

FS
9
10 Conclusions
11
12 Our survey shows that radiation awareness among dentists and radiographers as well as students
13

O
was inadequate, without significant differences between main groups. Dentists, who had radiation
14
15 protection training completed, had a greater awareness, compared with dentists without such
training. Greater emphases should be put on dental radiology course in both dentistry and

O
16
17
18
radiography programs at the universities.

R
19
20 Acknowledgements
21

P
22 The authors would like to thank Agnieszka Czusz at the John Paul II Catholic University of Lublin
23 (KUL), for her assistance with the statistical interpretation of the obtained data.
24
25
26 References
D
27
28
E
1. Ramanathan S, Ryan J. Radiation awareness among radiology residents, technologists, fellows and
29
30 staff: where do we stand? Insights Imaging 2014; 6(1):133-139.
T

31
32 2. Lee RKL, Chu WCW, Graham CA, Rainer TH, Ahuja AT. Knowledge of radiation exposure in common
33 radiological investigations: a comparison between radiologists and non-radiologists. Emerg Med J
C

34
35
2012; 29(4):306-308.
E

36
37 3. Zhou GZ, Wong DD, Nguyen LK, Mendelson RM. Student and intern awareness of ionising radiation
38 exposure from common diagnostic imaging procedures. J Med Imaging Radiat Oncol. 2010;
R

39
40
54(1):17-23.
41
R

42 4. Soye JA, Paterson A. A survey of awareness of radiation dose among health professionals in
43 Northern Ireland. Br J Radiol. 2008; 81(969):725-729.
O

44
45
46
5. Arslanoǧlu A, Bilgin S, Kubali Z, Ceyhan MN, Ilhan MN, Maral I. Doctors’ and intern doctors'
knowledge about patients' ionizing radiation exposure doses during common radiological
C

47
48 examinations. Diagnostic Interv Radiol. 2007; 13(2):53-55.
49
N

50 6. Skrzynski W. [Yesterday, today and tomorrow of Polish Radiology]. Inżynier i Fiz Med. 2013;
51
52 2(4):207-209. Polish.
U

53
54 7. European Commission. Radiation Protection. European Guidelines on Radiation Protection in Dental
55 Radiology. Issue N° 136. 2004.
56
57
58 8. Whaites E. Dose units and dosimetry. In: Whaites E. Essentials of Dental Radiography and
59 Radiology. Edinburgh: Churchill Livingstone Elsevier; 2007, pp 25-28.
60
61
62
63
64
65
 9. Whaites E. The biological effects and risks associated with X-rayse. In: Whaites E. Essentials of
1 Dental Radiography and Radiology. Edinburgh: Churchill Livingstone Elsevier, 2007 pp 29-33.
2
3
4 10. [Regulation of the Council Ministers of 18 January 2005 on Ionizing Radiation Dose Limits (Dz.U.
5 2005 nr 20 poz. 168)]. Polish.
6
7 11. [Proclamation of the Minister of Health of 26 April 2013 on announcing single text of the Regulation
8

FS
9 of the Minister of Health on conditions for safe use of ionizing radiation for all types of medical
10 exposure. (Dz. U. 2013 poz. 1015)]. Polish.
11
12 12. [Proclamation of the Marshal of the Polish Parliament of 17 September 2014 on on Announcing
13

O
14
Single Text of the Act - Atomic Law (Dz. U. 2014 poz. 1512)]. Polish.
15
13. White SC, Pharoah MJ. Radiation Safety and Protection. In: White SC, Pharoah MJ. Oral Radiology

O
16
17 Principles and Interpretation. St. Louis, Mo.: Mosby/Elsevier; 2009 pp 32-43.
18

R
19
20
14. Whaites E. Radiation protection and legislation. In: Whaites E. Essentials of Dental Radiography and
21 Radiology. Edinburgh: Churchill Livingstone Elsevier; 2007 pp 69-81.

P
22
23 15. Whaites E. The production, properties and interactions of x-rays. In: Whaites E. Essentials of Dental
24
25
Radiography and Radiology. Edinburgh: Churchill Livingstone Elsevier, 2007, pp 15-24.
26
D
27
28
E
29
30
T

31
32
33
C

34
35
E

36
37
38
R

39
40
41
R

42
43
O

44
45
46
C

47
48
49
N

50
51
52
U

53
54
55
56
57
58
59
60
61
62
63
64
65
 Tables and Figures:
1
2
3
1. Table 1. The mean number of correct answers in the groups, means ± SD. Additionally pairs
4 of subgroups with statistically significant differences are presented.
5 2. Figure 1. Low-scoring questions together with percentage of correct answers (less than 50%
6 correct answers in any of the groups).
7
8

FS
9
10
11
12
13

O
14
15

O
16
17
18

R
19
20
21

P
22
23
24
25
26
D
27
28
E
29
30
T

31
32
33
C

34
35
E

36
37
38
R

39
40
41
R

42
43
O

44
45
46
C

47
48
49
N

50
51
52
U

53
54
55
56
57
58
59
60
61
62
63
64
65
Table 1

Table 1. The mean number of correct answers in the groups, means ± SD. Additionally pairs of subgroups with
statistically significant differences are presented.

Group Subgroup Number Percentage Number of correct

answers
Dentists 95 32% 8.36 ± 1.76
Time of practice:
 32 9.13 ± 1.93 a

FS
1-5 years
 More than 15 years 23 7.78 ± 1.57 a
Radiation protection training:
 Without training 33 7.82 ± 1.81 b

O
 With training 62 8.65 ± 1.67 b
Radiographers 89 30% 8.11 ± 1.67

O
Dentistry students 73 24% 8.19 ± 1.46
Radiography students 44 15% 7.46 ± 1.58

R
Year of study:
 6.27 ± 0.38 c

P
I year 11
 II year 18 7.33 ± 0.3 d
 III year 15 8.8 ± 0.32 c, d
a, b, c, d
D
pairs of results differing significantly, p<0.05 vs. control by ANOVA
E
T
C
E
R
R
O
C
N
U
Figure 1 Question 4. Radiation dose associated with one periapical radio-
graph is absolutely safe and has no impact on health.

50.56%
28.42% 23.29% 22.73%

Dentists Dentistry Radiographers Radiography

students students

FS
Question 7. Statistically,one of a thousand people, who have had
one periapical examination performed, will die due to cancer
induced by radiation.

O
66.32% 64.04% 68.18%
49.32%

O
R
Dentists Dentistry Radiographers Radiography

P
students students

Question 9. Performing radiological examination to pregnant

female patient is forbidden.
D
E
54.74%
45.21%
T
16.85% 11.36%
C

Dentists Dentistry Radiographers Radiography

students students
E

Question 10. Number of radiographs prescribed to patient in one

R

year is not limited by law.

R

47.37% 52.81%
45.45%
O

34.25%
C

Dentists Dentistry Radiographers Radiography

N

students students

Question 11. To perform periapical radiograph patient has to have

U

prescription from dentist.

79.45% 75.28%
51.58%
45.45%

Dentists Dentistry Radiographers Radiography

students students
Appendix

Appendix

Questions along with correct answers and the relevant reference sources.

1. Background radiation comes from (among others) radioactive isotopes in the TRUE 8
Earth's crust, cosmic radiation emitted by the Sun, radioactive elements
contained in materials used for buildings’ construction.

FS
2. Ionizing radiation used in radiological diagnosis has similar properties to natural TRUE 8
background radiation.

3. The average dose from periapical radiography is lower or comparable with daily TRUE 7,8,10

O
background radiation dose.

O
4. Radiation dose associated with one periapical radiograph is absolutely safe and FALSE 9
has no impact on health.

R
5. Risk involved with radiation should be lower than benefits from diagnostic TRUE 12

P
information.

6. Every radiation exposure brings possibility of occurrence of the harmful effects, TRUE 9
e.g. leukemia
D
7. Statistically, one of a thousand people, who have had one periapical FALSE 7
E
examination performed, will die due to cancer induced by radiation.
T

8. Children and fetuses are more vulnerable to radiation. TRUE 7,9

C

9. Performing radiological examination in pregnant women is forbidden. FALSE 7,11

E

10. Number of radiographs prescribed to patient in one year is not limited by law. TRUE 10,13,14
R

11. A patient must have a prescription form a dentist to have a periapical FALSE 11
radiograph performed.
R

12. A patient must have a prescription form a dentist to have an orthopantomogram TRUE 11
O

performed.

13. In all X-ray devices there is a radioactive stone which emits X-rays. FALSE 15
C
N
U