© W. Ageeli et al., Published by EDP Sciences 2024

1 Introduction

The initial assessment of patients presenting with oral symptoms or diseases is typically the primary step in diagnosis and treatment planning within clinical practice. However, relying solely on visual examinations of dentoalveolar and craniofacial tissues has inherent limitations. While dental caries is often visually identified during clinical examinations, discerning the potential involvement of pulpal and peri-radicular tissues poses challenges (Abogazalah and Ando, 2017; Genc, 2018; Carvalho et al., 2020; Tinanoff, 2020). Notably, interproximal caries are more frequently detected on bitewing radiographs than through clinical observation (Abogazalah and Ando, 2017). In the realm of implant dentistry, a comprehensive radiographic evaluation using panoramic radiographs and cone-beam computed tomographic scans is crucial to correlate alveolar bone structures with vital anatomical features such as the maxillary sinus and inferior alveolar nerve (Genc, 2018). Additionally, radiographic assessments play a pivotal role in diagnosing periodontal and peri-implant osseous morphology and associated diseases (Javed, 2007; ALHarthi et al., 2018). The capacity of ionizing radiation (IR) to penetrate tissues and reveal non-visible images is significant in this context. However, it is imperative to exercise caution and implement safety measures during IR procedures, as uncontrolled exposure may potentially lead to adverse health effects (Ribeiro et al., 2008). Professionals must be cognizant of the criteria for accurate imaging while also considering a range of safety measures to mitigate the potential risks associated with dental and craniofacial radiography. Notably, IR has been reported to induce changes in DNA strands through the generation of free radicals, resulting in damage to living tissues (Santivasi and Xia, 2014; Wdowiak, 2019). According to some researchers, exposure to dental radiography has been linked to an increased incidence of cancer in the head and neck area, as well as other health consequences (Preston-Martin et al., 1988; Preston-Martin and White, 1990; Hwang et al., 2018). Dental radiography, while indispensable, necessitates adherence to radiation protection principles and guidelines to mitigate risks and ensure the safety of patients and dental healthcare providers.

Despite individual radiation doses in dental treatments appearing low, the cumulative exposure from repeated examinations raises concerns about potential adverse effects, including cancer (Sudhakar and Kumar, 2011).

The well-established harmful effects of ionizing radiation on biological tissues, causing direct cellular damage or generating free radicals leading to various forms of DNA damage, underscore the importance of understanding these biological risks (Ribeiro et al., 2008).

These risks are categorized as stochastic and non-stochastic, with non-stochastic effects triggered by a specific dose threshold and stochastic effects having no predictable threshold, particularly evident at lower doses (Asano et al., 2001; Vii, 2005; Little et al., 2009).

Each radiographic exposure during a patient’s examination must be clinically justified, ensuring a confirmed diagnostic benefit, as potential health risks from diagnostic X-rays have long been a focus of public health concerns (Lee and Ludlow, 2013).

Factors influencing radiation exposure levels in dental radiography include film speed, exposure parameters, technique, collimation, and the use of protective barriers (Okano and Sur, 2010). It is imperative for dental students and interns, especially those in their clinical years, to develop a comprehensive understanding of X-ray-related biological risks and protective strategies (junior residential physicians and house surgeons) (Sudhakar and Kumar, 2011).

Few studies have been conducted among students at JU regarding MRI safety and radiation protection (Abuhadi, 2019; Alyami et al., 2023, 2024). However, these studies have been conducted in different fields. To the best of our knowledge, there are no conducted studies examining the awareness and knowledge of dental students at JU. In light of these concerns surrounding radiographic exposure in dentistry, this study aims to assess the knowledge and practices of undergraduate dental students regarding the biological risks associated with dental X-rays. Additionally, the study seeks to compare knowledge, attitudes, and practices (KAP) between preclinical and clinical undergraduate students. The investigation aims to provide insights into the effectiveness of dental education in imparting crucial radiation safety awareness to future dental practitioners, promoting responsible use of radiographic procedures, and ensuring the safety of both patients and operators.

2 Materials and methods

2.1 Study design and population

A descriptive, cross-sectional survey was conducted among dental students enrolled in the dentistry program at Jazan University (JU) to evaluate awareness, knowledge, and practices concerning radiation protection. The inclusion criteria for participants in the study were dental students enrolled in the dentistry program at Jazan University (JU). All dentistry students were eligible to participate, resulting in a total of 82 participants out of 120 students in the college including 63 males (77%) and 19 females (23%). The level of study among the participants varied, as they were distributed across different academic years within the dentistry program at Jazan University. Demographic factors, such as gender and academic year, were analyzed to ascertain their potential influence on radiation protection awareness among dental students. To maintain confidentiality, the identity of participants was not disclosed, and all personal data were kept confidential.

Ethical approval for the study was obtained from the standing committee for scientific research on 3 January 2023 (reference number REC-44/06/467). All dentistry students met the inclusion criteria, and a total of 82 participants engaged with radiography were included in the study.

2.2 Method of the questionnaire

The questionnaire utilized in the survey was structured to assess various aspects of radiation protection awareness, including knowledge of deterministic and stochastic effects of ionizing radiation, familiarity with radiation protection guidelines, and adherence to safety practices during radiographic procedures. The questionnaire, inspired by a study (Sudhakar and Kumar, 2011), was constructed using Google Forms and comprised 16 items, including demographic inquiries. To facilitate participant responses, most questions were structured with close-ended options of ’yes’ or ’no’. The Google Form link to the questionnaire was distributed to a cohort of over 120 students officially enrolled in the full-time program at the Faculty of Dentistry at JU. This methodology aimed to ensure participant convenience, comprehensive data collection, and anonymity in responses.

2.3 Data analysis

In this study, data analysis was carried out using the Statistical Package for the Social Sciences (SPSS) v27. Both descriptive statistics, which encompassed percentages and means, and inferential statistics, such as Pearson chi-square tests and associated P-values, were utilized. Pearson chi-square correlation was employed to assess the connection between participants’ awareness levels and their demographic characteristics. Statistical significance was considered achieved when the P-value was less than 0.05. Qualitative data frequencies and percentages were employed to assess participants’ awareness and knowledge relative to other available data. Descriptive statistical analyses were executed using Microsoft Excel.

3 Results

3.1 Demographic characteristics

The demographic characteristics of the study participants revealed a predominant presence of males, constituting the majority with 77% (n = 63) of the total sample. Students’ distribution across academic years varied, with the fourth year being the most frequently reported (25%, n = 19), followed by the fifth year (19%, n = 15). Additionally, Different ages of participants were enrolled in this study, 39% were between the age of 21–23 yr, 31% were between the age of 18–20 yr, 24% were between the ages of 24 and 26 and 6% of the study participants were above the age of 26 yr, as depicted in Table 1.

Participants were surveyed on their knowledge of the adverse effects of dental X-rays and radiation safety concepts, including the ALARA principle and the use of collimators and filters. Their understanding of technical radiation protection, such as personal monitoring badges, lead aprons, lead barriers, and shielding in X-ray rooms, was also assessed. This section sets the stage for a detailed analysis of results and provides a comprehensive view of participants’ awareness of radiation in dental imaging.

3.2 Knowledge and awareness regarding radiation

Most of the respondents (91%) agreed that the dental x-ray is harmful. More than half of the respondents were aware of deterministic and stochastic effects and the usefulness of Collimators and filters in dental radiography (52% and 60%) respectively. The National Council of Radiation Protection and the International Commission of Radiation Protection were known to about 83% of the participants. Moreover, the majority of the students (90%) were aware of the ALARA principle. Nearly 90% of the participants were aware of particular situations such as pregnant women and children who are more vulnerable to the harmful effects of radiation. More than half of the students (63%) reported that they were aware of the personal monitoring badges and their function and role in radiation protection. Many of the participants (79%) were aware of the radiation protection instruments that could be used during radiation exposure and 79% of them were using a lead apron for patients. Also, 85% of the students were standing behind a lead barrier during exposure. In addition, the Person’s Chi-square test with Yates’ continuity correlation between the awareness level of deterministic and stochastic effects and academic year was 69% were aware of the radiation shielding in X-ray rooms. The respondent’s knowledge concerning the most important organ to protect during dental radiography was divided, but the majority (86%) reported the thyroid. In addition, 79% were aware that DNA is the critical target for radiation, and 73% were aware of the lethal whole-body dose of 3-5 Gy received; however, a notable percentage of respondents still showed gaps in understanding other critical aspects of radiation exposure and safety measures. Most of the participants (90%) were aware that extra-oral radiological techniques may deliver more radiation compared to intra-oral techniques.

The results of the statistical analysis for various questions related to radiation protection awareness and practices among participants, categorized by year classification, are presented in this section.

Data analysis was conducted using chi-square tests in SPSS. The data were categorized based on the students’ academic year specifically, before and after taking radiation protection modules and after their third year. Overall, the study provides valuable insights into the awareness and practices related to radiation protection among participants based on their year classification, with significant associations observed in certain aspects of knowledge. Significant statistical differences were observed in the awareness level of deterministic and stochastic effects among dental students in relation to academic year levels (χ² = 12.187, df = 2, p = <0.001). Furthermore, a statistically significant difference was detected regarding radiation shielding in X-ray rooms (χ² = 9.495, df = 2, p = <0.005). The overall awareness of these two factors is illustrated in Figure 1.

Overall, the study findings suggest that the use of personal monitoring badges, lead aprons for patients, and standing behind lead barriers during exposure are consistent practices among participants, regardless of their year classification. These results underscore the importance of maintaining radiation safety measures in dental radiography, ensuring the protection of both operators and patients. The study found that, for most of the assessed radiation-related knowledge and awareness questions, there were no statistically significant differences based on participants’ year classification as summarized in Table 2. This study revealed several interesting findings related to radiation protection awareness and knowledge among participants. Gender was found to be a significant factor in certain aspects, such as awareness of NCRP and ICRP recommendations (χ² = 7.965, df = 1, p = 0.005), awareness of the ALARA principle (χ² = 9.821, df = 1, p = 0.002), the practice of standing behind a lead barrier (χ² = 11.445, df = 1, p < 0.001), and knowledge of radiographic techniques that deliver more radiation (χ² = 13.135, df = 1, p < 0.001) as summarized in Table 2.

Fig. 1 the charts showing the overall awareness based on the year level before and after taking the modules.

4 Discussion

The results of this study offer valuable insights into the awareness and knowledge of radiation protection principles among dental students. shedding light on areas of strength and opportunities for improvement within the field of dental radiography. In this comprehensive discussion, we will analyze and interpret the findings, considering their implications for patient safety, professional development, and future research endeavors. The effective dosage delivered to patients for each radiograph is low, but the collective dose is high due to the enormous number of radiographs performed. One of the prominent findings of this study is that the majority of dental students (91%) acknowledged that dental X-rays are harmful. Arnout’s study among Egyptian dental students reported an 88% awareness rate, while Shah et al. reported 75%, Arnout and Jafar’s study on Saudi students found 67%, Srivastava et al. reported 83.3% awareness rate in his study and Prabhat et al. reported a full 100% awareness in their participant group (Prabhat, 2011; Arnout, 2014a, 2014b; Shah, 2014; Srivastava, 2017). While these figures suggest a high level of general awareness about the harmful effects of dental X-rays among dental students, it is important to note that broader research, including studies by Shubayr et al. and Alomairy in Saudi Arabia, has indicated insufficient knowledge about the potential effects of ionizing radiation among healthcare professionals (Alomairy, 2024; Shubayr et al., 2024). However, the study further investigates specific aspects of radiation protection awareness and knowledge, shedding light on both areas of strength and potential improvement. In the context of deterministic and stochastic effects of radiation exposure, 52% of the participants reported awareness. This result indicates that slightly over half of the dental students have a fundamental understanding of the two primary categories of radiation effects. While this percentage may seem relatively low, it is consistent with findings from previous studies. For instance, a study by Arnout’s findings indicated only 34% demonstrated awareness of deterministic and stochastic effects; moreover, Arnout and Jafar’s research reported a 33% rate, which aligned with the results in our study. In contrast, Prabhat et al. presented more encouraging results with a noteworthy 84% rate (Prabhat, 2011; Arnout, 2014a, 2014b). This suggests that dental students, regardless of their geographic location, may have similar levels of awareness regarding these radiation effects. Approximately 83% of the participants were aware of the National Council on Radiation Protection (NCRP) and the International Commission on Radiological Protection (ICRP) recommendations. This result is encouraging, as it signifies that a significant proportion of dental students are informed about the guidelines set forth by these authoritative radiation protection organizations. A similar level of awareness rate of 94% was reported in a study conducted by Prabhat et al, further emphasizing the global reach of these organizations’ influence on radiation safety education (Prabhat, 2011). In contrast to our findings, Arnout’s study documented a 27% rate, Arnout and Jafar’s research reported 20%, and Shah et al. recorded a 56% rate (Arnout, 2014a, 2014b; Shah, 2014). The ALARA (As Low As Reasonably Achievable) principle, a fundamental concept in radiation safety, was recognized by 90% of the participants. This high level of awareness is encouraging, as it emphasizes the significance of minimizing radiation exposure for both patients and practitioners. In contrast, there were divergent findings in previous studies where dental students exhibited a lower awareness of the ALARA principle. Arnout and Jafar reported a 40% rate, and Srivastava et al. reported a rate of 34.4% (Arnout, 2014a, 2014b; Srivastava, 2017). The variations in results across different regions emphasize the global significance of incorporating ALARA principles into dental radiography education.

The study also explored variations in radiation protection awareness and knowledge among participants based on their year classification. Statistically significant differences were observed in the awareness levels of deterministic and stochastic effects and radiation shielding in X-ray rooms between students at different academic stages. These differences suggest that as dental students progress through their academic years, their understanding of certain radiation protection concepts may evolve. suggesting that the curriculum effectively enhances understanding of these critical concepts over time.

The observed correlation between the year in which the dental imaging module takes place in the third year and the increased knowledge of participants highlights the importance of initial education about radiation protection. Specifically, participants in later classification years may have had more exposure to radiation protection concepts due to the increased practical experience during clinical practice modules, as they have already completed the protection modules. Conversely, participants in earlier classification years may have had limited exposure to such educational interventions, resulting in lower awareness levels as shown previously in Figure 1.

4.1 Implications for dental radiography education

The findings of this study have significant implications for dental radiography education. The observed high level of awareness among dental students regarding the harmful nature of dental X-rays is promising. However, the study reveals variations in awareness levels of specific radiation protection principles, such as deterministic and stochastic effects, among participants in different academic years. Our analysis suggests that these variations may indeed be linked to both the year of introduction of the dental imaging learning module and the practical modules which included practicing in hospitals. Specifically, participants in later classification years may have had more exposure to radiation protection concepts due to increased practical experience during internships. Conversely, participants in earlier classification years may have had limited exposure to such educational interventions, resulting in lower awareness levels. These observations are supported by the statistically significant associations found in our data analysis, indicating differences in awareness levels across academic years for certain aspects of radiation protection knowledge. Additionally, the study emphasizes the importance of reinforcing the ALARA principle, which was recognized by 90% of participants, indicating a positive trend in minimizing radiation exposure.

4.2 Limitations

While the study provides valuable insights into the awareness and knowledge of radiation protection principles among dental students, several limitations should be acknowledged. The research was conducted at a specific institution, limiting the generalizability of the findings to a broader population. Additionally, the study relies on self-reported data, which may introduce response bias. The cross-sectional nature of the research design limits the ability to establish causal relationships or assess changes in awareness over time. Future research could explore the long-term retention of radiation safety knowledge among dental practitioners and assess the effectiveness of different educational approaches in enhancing awareness and practices. We acknowledge that the absence of items on the justification and relevance of dental imaging examination prescriptions is a significant limitation of our study. The control of the repetition and accumulation of small doses is indeed a critical aspect of radioprotection in dental imaging, and medical students need to be aware of their responsibility in this regard. Future research should include items that assess students’ understanding of the justification and relevance of dental imaging examination prescriptions to provide a more comprehensive assessment of their knowledge and awareness in this area.

Despite these limitations, this study contributes valuable insights into the radiation protection awareness and knowledge of dental students. Future research in this area should aim to address these limitations by employing larger and more diverse samples and investigating the effectiveness of different educational interventions in enhancing radiation safety knowledge and practices among dental students.

5 Conclusion

This study sheds light on the awareness and knowledge of radiation protection principles among dental students, providing a comprehensive understanding of the strengths and areas for improvement within the field of dental radiography. The high acknowledgment of the harmful nature of dental X-rays is encouraging, yet the variations in awareness of specific radiation protection concepts among participants in different academic years and genders underscore the need for tailored educational approaches.

Funding

This research did not receive any specific funding.

Conflicts of interest

The authors declare no conflict of interest.

Data availability statement

The Data availability statement The data that support the findings of this study are available from the corresponding author, W. Ageeli, upon reasonable request.

Author contribution statement

WA, TR, and NM were a major contributor to the conception of the study and the literature search for related studies. WA, EA, AA, AS, and AG collated the results, conducted the literature search, and drafted the manuscript. WA, NM, TR, EA, AA, AS, and AG were involved in the planning of the study, conducted the statistical analysis, and reviewed the manuscript for important intellectual content. All the authors were involved in the approval of the final manuscript to be published.

Ethics approval

The study received ethical approval from the Standing Committee for Scientific Research at Jazan University, with the reference number REC-44/06/467.

Informed consent

Written informed consent was obtained from all participants.

Clinical relevance statement

Dental radiographs are a valuable and required tool for diagnosing and treating oral disorders such as caries, periodontal disease, and oral pathology (White & Pharoah, 2014). Despite the perceived low individual radiation doses, the cumulative exposure from repeated examinations raises concerns about potential adverse effects, emphasizing the need for stringent radiation safety precautions. This study delves into the knowledge and practices of undergraduate dental students, aiming to assess their awareness of biological risks associated with dental X-rays. Understanding these risks is crucial for ensuring responsible use of radiographic procedures, and safeguarding both patients and operators.

References

All Tables

All Figures

	Fig. 1 the charts showing the overall awareness based on the year level before and after taking the modules.
In the text