E-ISSN 2348-3407 DOI: 10.4103/2348-3407.135072

Original Research

Knowledge and practice adopted by dental practitioners and dental auxiliaries regarding biomedical waste management in Pune Musarrat Khatri, Rohit Agrawal1, Mamatha GS Reddy, Jay Khatri2, Neha S Kokil Departments of Oral Pathology and Microbiology and 1 Public Health Dentistry, D Y Patil University’s Dr. D Y Patil Dental College and Hospital, Pimpri, 2Private Practitioner, Pune, Maharashtra, India Access this article online Website: www.iadrsd.org Quick response code

Abstract Aim: The aim of this study was to assess knowledge and practice adopted by dental practitioners and auxiliaries regarding biomedical waste (BMW) disposal in Pune. Materials and Methods: A questionnaire study was conducted among 150 dentists, 36 nurses and 20 Class IV workers (total sample n = 206) from Pune city. A 12‑item questionnaire which was used to collect the data had questions related to BMW generation, segregation, disinfection and disposal. Results: Overall, 93.69% respondents were aware of BMW management system. Only 74.6% were registered at local governing body. Dentists who were not registered (25.3%) for BMW disposal system, disposed waste in dustbins. About 70.67% had permission from Maharashtra Pollution Control Board to generate waste. About 72% dentist practiced color‑coded waste disposal, whereas 69.4% nurses and 60% Class IV workers did not follow it. Nearly 52.9% responded that sharps should be disposed in white containers. More than 90% participants reported to have generated all types of dental waste. 52.9% of the respondents treated waste before disposing in red containers. Daily disposable of the waste at the collection center was practiced by 32.5% respondents. Conclusion: The results of this study showed that the knowledge and practice regarding waste disposal was poor. Proper training, continuing education programs, and short‑term courses about BMW management and infection control procedures are required to improve the knowledge of dentists and dental auxiliaries.

Key words: Biomedical waste, dental auxiliaries, dental waste, dentistry

Introduction Many advances with newer techniques have been introduced in health care sector.[1,2] Health care facilities, which include hospitals, medical colleges, dental colleges, and dental clinics are mainly concerned with providing good quality health care to the community.[3] Although it largely has its own benefits, the hazardous effects regarding medical waste cannot be ignored, where the treating doctors, paramedical staff and also society at large can be at risk.[1] Biomedical waste (BMW) contains pathogenic microorganisms, including viruses and bacteria. Some of these microorganisms are very dangerous and may be resistant to treatment with a high degree of pathogenicity. The hazards of BMW can range from tuberculosis, septicemia, tetanus and skin infections to more deadly diseases such as AIDS and hepatitis. One of the main causes for the spread of these infections is the improper disposal of waste in health care facilities.[4] Hospital employees get infected due to close contact with infected tissues, biological fluids, and infected materials of patients. Similarly, doctors, dentists, nurses, laborer staff, and technical staffs working in laboratories are usually at the verge of accidental infection.[5]

It is commonly seen that in many hospitals, nursing homes, health care centers, and dental care facilities dumping of waste is done in dustbins used for household garbage collection. BMW along with the household garbage is then taken away by the vehicles for final disposal. Most of the waste disposal sites are open for rag‑pickers who may get infected while collecting such infected items. The items picked up are often sold to the market for recycling. Recycled items also pose the risk of infection among those who use this items.[5] Dental waste comprises of three main categories: Infectious waste, noninfectious waste, and domestic‑type waste. Infectious waste contains materials and items contaminated with blood, saliva or other infectious fluid of the mouth, sharps and amalgam. Dental waste generated during various clinical procedures has the possibility to be discharged into the waste water system and the majority of dental solid waste is dumped into domestic disposal sites and landfills without any recycling and segregation processes. Since some of these wastes are perilous in nature, this type of practice is potentially risky to human health and the environment.[3] Therefore correct identification, segregation, collection, treatment and disposal of BMW is very important as it can

Correspondence to: Dr. Mamatha GS Reddy, Department of Oral Pathology and Microbiology, D Y Patil University’s Dr. D Y Patil Dental College and Hospital, Pimpri, Maharashtra, India. E‑mail: [email protected]

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decrease health risks to people and prevent damage to the environment.[4] For safe and effective BMW management in India, the Ministry of Environment and Forests of the Government of India has issued the BMW  (management and handling) rules, which came into effect on from the month of July, 1998.[6,7] These rules are applicable to every hospital and nursing home, veterinary institution, animal house or slaughterhouse that generates BMW.[4,6] However, there has not been any clear‑cut guidelines for dental waste disposal. The health personnel involved in handling the BMW at a different point of time in health care facilities at dental hospitals and private dental clinics comprise of physicians, dentists, medical and dental students, nurses, laboratory technician and ward boy.[8] Thus the knowledge regarding BMW management among health care personnel including dental professionals and auxiliaries have a greater impact on maintaining good health and safe environment. Earlier studies conducted in India, conclude that most of the dentist’s and dental auxiliaries have poor knowledge of BMW disposal.[1,9‑12] Against this background, a study has undertaken to assess knowledge, and practice adopted by dental practitioners and auxiliaries from Pune regarding BMW disposal, which is vital for control of cross infection.

Materials and Methods A questionnaire study was conducted for 2  months in 2011 among dental practitioners, paramedical staff  (nurses) and Class  IV workers working in dental hospitals and private dental clinics of Pune to assess their knowledge and practice toward BMW management. With the help of Pune city map, four zones were selected and dental clinics located in those areas were identified. Further, telephonic call was made asking them to participate in the study. Only, those who consented to participate were recruited for the study. The study population included 206 participants of which 150 were dentist, 36 nurses and 20 were Class IV workers. A 12‑item questionnaire was designed keeping the study group in mind and questions were based on the information related to BMW generation, segregation, disinfection and disposal.

Results The results are summarized in five tables. Q1: Overall, 93.67% respondents were aware of the BMW management system. While, 98.67% dentists were aware, 25% nurses and 10% Class  IV workers were unaware about the BMW disposal system. Q2: Of the total number of dentist aware of BMW disposal management system, only 74.6% were registered at local governing body. Q3: Of the dentist who were not registered  (25.3%) for BMW disposal system, maximum that is,  (n  =  29) disposed waste in dustbins, also 44% (n = 16) nurses and 35% (n = 7) reported to have disposed waste in dustbin. Q4:  70.67% of the dentists had obtained a license to generate BMW from the Maharashtra Pollution board. Q5: Overall, 61.6% respondents followed color‑coding for waste disposal. 72% dentist practiced, whereas 69.4% nurses and 60% Class IV workers did not follow color‑coding for waste disposal respectively. Q6: Majority, 52.91% responded that sharps should be disposed in white containers. Dental practitioners (60.67%) were more knowledgeable than nurses (30.56%) and Class IV workers  (35%). Q7:  52.91% of the respondents treated waste before disposing in red containers. Q8: Daily disposal of the waste at the collection center was practiced by 32.5% respondents. Positive response was provided by 31.3%, 22.2%, and 45% of dentists, nurses and Class IV workers respectively [Table 1]. Though all types of waste was produced by the respondents, gloves, mouth masks, head caps, needles, syringes, cotton and gauge and LA bottles were produced extensively by more than 90% of the sample. Production of developer solution and fixer solution waste was relatively lesser [Table 2]. It was noted that masks  (50%), head caps  (42.72%), gloves  (42.23%), cotton and gauze  (38.35%) and other substances to a lesser extent were disposed in the yellow containers [Table 3]. It was observed that the red container was used to a lesser extent to dispose waste, that is, 15.05% LA bottles, 22.82% saline bottles, 15.05% lead foils, 13.11% X‑ray films, 13.59% fixer solution and 11.65% developer solution and other waste to a lesser extent [Table 4].

The investigator personally distributed the questionnaires and got them filled by cross checking through interview, thereby avoiding any ambiguity pertinent to questionnaire. In case the dentist was not available, two attempts were made to follow him up in order to complete the questionnaire.

Majorly, 40.78% respondents disposed needles, 30.58% disposed syringes, 35.44% disposed suture needles and 42.23% disposed blood pressure (BP) blade in white containers [Table 5].

Only those participants, who gave informed consent, were included in the study. A  pilot study was undertaken on 15 dentists and it was pretested to ensure feasibility and interpretation of responses. The data were analyzed and descriptive statistics  (frequency and percentages) were computed.

Self‑reported awareness about the BMW management system among dentists  (98.67%) in the present study was good. However, 25% and 10% nurses and Class IV workers respectively were unaware about it. A study done in Kerala showed that 82.2% of study participants self‑reported knowledge was not adequate.[9] Dentists of New Delhi,[10] dental personnel, nurses

Discussion

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Table 1: Percent distribution of participants according to responses towards various questions related to BMW management Questions

n (%)

Response

Q1. Are you aware about BMW management system in dental clinics? Q2. Have you registered for BMW at your local governing body? Q3. If not where do you dispose the waste? Q4. Do you have license to generate BMW (registered under MPCB) Q5. Do you follow color‑coding system to dispose waste? Q6. Sharp waste is disposed in which of the following containers?

Yes No Yes No Dustbin Randomly Yes No Yes No Red Yellow White Other Yes No Yes No

Q7. Do you treat the waste before disposing to red container? Q8. Do you submit the waste to the collection center every day?

Dentist

Nurses

Class IV workers

Total

148 (98.67) 2.0 (1.33) 112 (74.66) 38 (25.33) 29 (76.3) 9 (23.68) 106 (70.67) 44 (29.33) 108 (72.0) 42 (28.0) 22 (14.7) 2 (1.33) 91 (60.7) 15 (10.0) 85 (56.67) 52 (34.67) 49 (32.7) 101 (67.3)

27 (75.0) 9 (25.0) ‑

18 (90.0) 2 (10.0) ‑

193 (93.69) 13 (6.31) ‑

15 (60.0) 10 (40) ‑

9 (75.0) 3 (25.0) ‑

53 (70.7) 22 (29.3) ‑

11 (30.6) 25 (69.4) 7 (19.44) 0 (0.0) 11 (30.6) 9 (25.0) 11 (30.56) 20 (55.56) 9 (25.0) 27 (75.0)

8 (40.0) 12 (60.0) 5 (25.0) 0 (0.0) 7 (35.0) 1 (5.0) 13 (65.0) 7 (35.0) 9 (45.0) 11 (55.0)

127 (61.6) 79 (38.4) 34 (16.5) 2 (0.97) 109 (52.9) 25 (12.1) 109 (52.91) 79 (38.35) 67 (32.5) 139 (67.5)

BMW: Biomedical waste, MPCB: Maharashtra pollution control board

Table 2: Different type of waste generated Dentist

Gloves Masks Head caps Needle Syringes Cotton and gauze Suture needles Blood pressure blade Suture thread Impression materials Dental casts Acrylic materials Metal crowns and bridge Silver amalgam LA bottles Saline bottles Lead foils X‑ray films Fixer solution Developer solution Other

Nurses

Class IV

Total

n

%

n

%

n

%

n

%

147 147 146 146 145 148 133 132 129 126 120 111 112

98 98 97.33 97.33 96.67 98.67 88.67 88 86 84 80 74 74.67

36 35 35 33 33 36 30 30 31 33 32 26 26

100 97.2 97.2 91.67 91.67 100 83.33 83.33 86.11 91.67 89 72.22 72.22

19 19 19 17 17 19 15 16 15 14 14 13 13

95 95 95 85 85 95 75 80 75 70 70 65 65

202 201 200 196 195 203 178 178 175 173 166 150 151

98.06 97.57 97.09 95.15 94.66 98.54 86.41 86.41 84.95 83.98 80.58 72.82 73.30

106 141 128 105 109 102 100 92

70.67 94 85.33 70 72.67 68 66.67 61.33

30 34 32 28 29 29 28 22

83.33 94.44 88.89 77.78 80.56 80.56 77.78 61.11

12 17 15 12 14 10 10 9

60 85 75 60 70 50 50 45

148 192 175 145 152 141 138 123

71.84 93.20 84.95 70.39 73.79 68.45 66.99 59.71

and other auxiliaries of Haryana[11] and Jaipur[12] were less knowledgeable about Bio Medical Waste Disposal compared with this study. Although the self‑reported awareness was high, as much as 25% dentists were not registered at local governing body. Those

who had not registered were disposing waste more commonly in dustbins. A  study among Bangalore dentists in the year 2008 showed that nearly half of them were disposing waste in dust bins along with the domestic garbage.[13] The present study participants showed better awareness about BMW management as compared to dentists from Nairobi, Kenya where nearly half of them were unaware about guidelines for waste disposal.[14] In this study, the percentage of respondents using color‑coding for disposal of waste was similar to the ones who had registered and had the license for BMW disposal. 108 (72%) dentist and 19  (33.9%) dental auxiliaries, were following color‑coding system for the disposal of waste, whereas in a study done by Narang et  al., 68  (85%) dental surgeons and 44  (55%) dental auxiliaries, were using color‑coded bags for the waste disposal.[1] This study also showed that nearly all types of waste, that is, gloves, masks, head caps, needles, syringes, cotton and gauze, suture needles, BP blade, suture threads, impression materials, dental casts, acrylic materials, metal crowns and bridge, silver amalgam, LA bottles, saline bottles, lead foils, X‑ray films, fixer solution, developer solution and other types of waste were generated by most of the respondents. Although the dentists from Pune had a license and were registered, the actual practice of BMW disposal was poor. Only, less than half of the participating dentists were disposing gloves, cotton and gauze in the appropriate, that is, yellow container. Gloves and cotton are used extensively and is the

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Table 3: Frequency of waste disposal in yellow container

Gloves Masks Head caps Needle Syringes Cotton and gauze Suture needles B.P. blades Suture thread Impression materials Dental casts Acrylic materials Metal crowns and bridge Silver amalgam LA bottles Saline bottles Lead foils X‑ray films Fixer solution Developer solution Other

Dentist

Nurses

n

%

n

69 84 72 7 4 65 3 2 30 36 25 24 25

46 56 48 4.67 2.67 43.33 2 1.33 20 24 16.67 16 16.67

10 9 8 0 1 6 0 0 0 0 2 1 1

20 12 8 7 11 10 9 15

13.33 8 5.33 4.67 7.33 6.67 6 10

1 2.78 2 5.56 1 2.78 2 5.56 0 0 0 0 0 0 4 11.11

%

Class IV n

27.78 8 25 10 22.22 8 0 0 2.78 0 16.67 8 0 0 0 0 0 0 0 2 5.56 0 2.78 0 2.78 0 0 0 0 0 0 0 0 3

%

n

21 14 9 9 11 10 9 22

10.19 6.80 4.37 4.37 5.34 4.85 4.37 10.68

Table 4: Frequency of waste disposal in red container Dentist

Gloves Masks Head caps Needle Syringes Cotton and gauze Suture needles B.P. blades Suture thread Impression materials Dental casts Acrylic materials Metal crowns and bridge Silver amalgam LA bottles Saline bottles Lead foils X‑ray films Fixer solution Developer solution Other

Nurses

Class IV

Dentist

%

40 87 42.23 50 103 50.00 40 88 42.72 0 8 3.88 0 5 2.43 40 79 38.35 0 3 1.46 0 2 0.97 0 30 14.56 10 38 18.45 0 27 13.11 0 25 12.14 0 26 12.62 0 0 0 0 0 0 0 15

Table 5: Frequency of waste disposal in white container

Total

Total

n

%

n

%

n

%

n

%

48 27 28 18 36 10 15 14 10 11 19 14 18

32 18 18.67 12 24 6.67 10 9.33 6.67 7.33 12.67 9.33 12

0 1 1 0 1 5 2 2 4 5 1 2 1

0 2.78 2.78 0 2.78 13.89 5.56 5.56 11.11 13.89 2.78 5.56 2.78

1 0 0 2 7 0 2 1 0 1 3 2 2

5 0 0 10 35 0 10 5 0 5 15 10 10

49 28 29 20 44 15 19 17 14 17 23 18 21

23.79 13.59 14.08 9.71 21.36 7.28 9.22 8.25 6.80 8.25 11.17 8.74 10.19

26 29 40 29 27 25 23 16

17.33 19.33 26.67 19.33 18 16.67 15.33 10.67

2 2 2 2 0 2 1 0

5.56 5.56 5.56 5.56 0 5.56 2.78 0

0 0 5 0 0 1 0 3

0 0 25 0 0 5 0 15

28 31 47 31 27 28 24 19

13.59 15.05 22.82 15.05 13.11 13.59 11.65 9.22

most commonly produced waste. It is soaked in saliva and blood at times and is a potent source for cross infections and should be disposed correctly. Less than a quarter dentists

Gloves Masks Head caps Needle Syringes Cotton and gauze Suture needles B.P. blades Suture thread Impression materials Dental casts Acrylic materials Metal crowns and bridge Silver amalgam LA bottles Saline bottles Lead foils X‑ray films Fixer solution Developer solution Other

Nurses

Class IV

Total

n

%

n

%

n

%

n

%

2 2 3 72 54 2 58 72 20 5 5 2 7

1.33 1.33 2 48 36 1.33 38.67 48 13.33 3.33 3.33 1.33 4.67

0 0 0 7 7 1 9 9 2 0 1 1 1

0 0 0 19.44 19.44 2.78 25 25 5.56 0 2.78 2.78 2.78

0 0 0 5 2 0 6 6 1 0 0 0 0

0 0 0 25 10 0 30 30 5 0 0 0 0

2 2 3 84 63 3 73 87 23 5 6 3 8

0.97 0.97 1.46 40.78 30.58 1.46 35.44 42.23 11.17 2.43 2.91 1.46 3.88

3 6 5 0 2 0 0 7

2 4 3.33 0 1.33 0 0 4.67

1 2 2 0 0 0 2 0

2.78 5.56 5.56 0 0 0 5.56 0

0 1 1 0 0 0 0 0

0 5 5 0 0 0 0 0

4 9 8 0 2 0 2 7

1.94 4.37 3.88 0.00 0.97 0.00 0.97 3.40

were disposing impression material  (24%) and suture threads  (20%) into the yellow bin. The nonutilization of appropriate containers to dispose contaminated products was even worse among nurses and Class IV workers. Availability of color‑coded containers does not ensure proper disposal of waste. Similar result was reported by Narang et al.[1] The findings of both the studies indicate that the dentists and auxiliaries are not in touch with current evidence based knowledge with respect to BMW disposal and there is an urgent need to train and educate the dentists and auxiliaries through extensive training and re‑training educational programs on waste management. The use of red container was even worse. Only, 20-25% of the dentists were disposing materials, which have to be disposed in the red containers correctly. Saline bottles were most commonly being disposed in the red containers. About 32% of dentists were disposing gloves into the red containers. This may probably be due to the fact that a lot of dentists would be using reusable gloves, which is not recommended. A study among Nigerian dentists showed that 95% of the dentists would never re‑use gloves as there is high risk of disease like HIV in African countries.[15] Sharps are very dangerous category of wastes mainly due to two reasons. Firstly, mostly sharps are used to penetrate the tissues and are thus contaminated with blood. This makes the sharps very infectious. Secondly, it a major risk to the persons involved in waste management. Accidental injury with such infectious

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Khatri, et al.: Dentist and biomedical waste management

waste may be more frequent if the wastes are not disposed in appropriate containers. Less than half the dentists and less than quarter nurses and Class IV were disposing sharps in the white containers. Similar results were also reported from a study among Jordan dentists where only 31.8% were disposing sharp waste appropriately in special containers.[16] A better practice was seen in dentists from Sudan where nearly half of them were disposing sharps in appropriate containers.[17] About 61% dentists, 30.6% nurses and 35% Class IV workers had the correct knowledge about disposal of sharps in the white containers. Significant others, that is, 15% dentists, 20% nurses and 25% Class IV workers thought that sharps are to be disposed in the red containers. Disposal of sharps in red containers can be a major risk as these wastes are chemically treated and reused at times. A  study among Turkish dentists found poor knowledge about control of cross infection.[18] The difference existed between self‑reported knowledge and practice of the dentists’ regarding disposal of waste in different color‑coded bags. On one hand, majority of dentists reported that they were aware of BMW disposal system and about the color‑coding followed for waste disposal, but actually on the other hand, they were not practicing waste disposal in the appropriate color‑coded bags. It is always lacunae in the questionnaire studies that participants tend to give socially desirable answers. Around 57% dentists, 30.5% nurses and 65% Class IV workers said that they treat waste of red containers before disposal. The percentage of Class IV respondents was high in this case as they are the ones who are assigned the duty to ensure proper disposal of wastes. Collection of waste on a day‑to‑day basis was poor because only 32.5% study participants were doing it. The maximum storage period for BMW according to the national guidelines is 48 h.[9] Timely disposal of waste is an important aspect and efforts are to be made to ensure wastes are disposed regularly. This study was undertaken in 2011, based on bio‑medical waste  (management and handling) rules, 1998.[6] However, the Ministry of Environment and Forests; Government of India has modified the rules in 2011 and made amendments under the Environment Protection Act, 1986.[19] Several new provisions have been added to the existing rules including the scope of application of these rules exclusively to BMW alone and no other wastes such as radioactive, hazardous chemicals, municipal solid wastes etc.; the necessity of every occupier/operator irrespective of the number of patients being serviced to obtain an authorization; reduction in the number of categories of waste from 10 to 8 and color‑coding was also changed.[19] We have discussed and compared the results of the respondents based on BMW (management and handling) rules,

1998 because after completion of the study the new modified version has been released.[6] Waste disposal is more of a social responsibility than a legal obligation. The present scenario of knowledge about waste disposal is not adequate and the practice of proper waste disposal is even poorer. The role of dentists starts from reduction in the quantity of waste disposed. All efforts should be directed towards appropriate and cost effective waste management.[20] Since there are no standardized guidelines for the dental BMW disposal, the authors have referred to the modified rules[19] for BMW management, and proposed a Table 6 for disposing the dental waste in the appropriate color‑coded bags which the dentist and the dental auxiliary can use.

Conclusion Protected and effective execution of waste management rules is not only a legal necessity but also a social liability. Lack of knowledge, motivation and cost factor are some of the hurdles faced in proper waste management. The results of this study showed that the knowledge and practice regarding waste disposal was poor. Presence of the legislation, governing health care waste disposal is not sufficient alone for smooth compliance of waste disposal rules among dental personnel. Proper training, continuing education programs and short‑term courses about BMW management and infection control procedures are required to improve the knowledge of dentists and dental auxiliaries. Waste management control committee should be formed for monitoring and evaluation of waste disposal procedure at local level.

Table 6: Proposed table for dental BMW disposal in the color‑coded bags Color‑coding/type of container

Waste category

Yellow bag (nonchlorinated plastic bag)

Teeth, excised tissues, biopsy specimen, material contaminated with blood/saliva (cotton, gauze, dressing), impression material (compound, alginate, shellac), waste from laboratory cultures, soiled dental casts (disinfected), discarded medicine, expired dental materials Sharp wastes (needles, syringes, blades, endodontic reamers, files, broken glass, etc.) Plastic (suction tips, tubing, celluloid strips, radiographic films), metal (crowns, orthodontic bands and brackets, matrix bands), glass bottles, lead foils, gloves Chemicals used in disinfection

Red bag (nonchlorinated plastic bags) Puncture proof container for sharps

Blue (nonchlorinated plastic bag) Black bag (nonchlorinated Municipal waste plastic bag) BMW: Biomedical waste

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Khatri, et al.: Dentist and biomedical waste management

Acknowledgments This study was funded by Indian Council of Medical Research

11.

under short‑term studentship project‑2011. Student reference ID No. 2011‑01012.

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How to cite this article: Khatri M, Agrawal R, Reddy MG, Khatri J, Kokil NS. Knowledge and practice adopted by dental practitioners and dental auxiliaries regarding biomedical waste management in Pune. J Dent Res Sci Develop 2014;1:34-9. Source of Support: This study was funded by Indian Council of Medical Research (ICMR) under Short Term Studentship (STS) project-2011. Student Reference ID No - 2011-01012 Conflict of Interest: No conflict of interest.

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