Oral radiology is an essential component of dental diagnosis, yet the biological effects of ionizing radiation are well documented [1,2]. The ALARA principle requires exposures to be kept as low as reasonably achievable [3], and regulatory standards exist to reduce occupational and patient risk [4,5]. In the Indian private-clinic setting, however, radiation safety is not determined only by the dentist. Dental assistants often help position patients, expose radiographs, process films, and handle radiographic waste, meaning their knowledge and routine practice directly influence clinic safety [6-8].   Conventional film-based dental radiography also produces hazardous waste, including developer and fixer solutions, silver-containing effluent, lead foil packets, and contaminated ancillary materials [9,10]. Improper disposal can harm both the environment and human health [11,12]. Although modern digital systems reduce some of this burden, many clinics still use conventional techniques or mixed systems. Therefore, safe radiological practice includes not only dose reduction and shielding but also proper waste segregation, storage, and disposal [13,14].   Knowledge-attitude-practice (KAP) surveys are useful for identifying training gaps, unsafe habits, and system-level weaknesses in healthcare settings [15]. Available literature has focused mainly on dentists and students [16,17], whereas dental assistants in Indian private clinics remain under-studied despite their frequent operational role in radiography and waste handling. Wardha district was selected because of its active private dental practice network and feasibility for district-level survey coverage. The present study aimed to assess knowledge, attitude, and practice related to radiation safety and radiological waste management among dental assistants in private dental clinics in Wardha district.   Study objectives   To assess the knowledge of dental assistants regarding radiation safety measures and radiological waste management To assess their attitude toward radiation protection and safe radiological waste handling To assess their reported practice and explore associations with selected demographic variables

Study Design and Setting This cross-sectional questionnaire-based study was conducted over six months, from November 2019 to April 2020, among dental assistants working in private dental clinics in Wardha district.   Study Population Dental assistants were defined as individuals assisting dentists in patient-care tasks such as patient registration, maintenance of case records, disinfection and sterilization, assistance during radiographic and operative procedures, management of biomedical wastes, and manipulation of dental materials.   Inclusion and Exclusion Criteria Participants aged 19 years or older, with at least one year of clinic experience, and willing to provide informed consent were included. Individuals with less than one year of clinical experience and questionnaires with incomplete responses were excluded.   Data collection All private dental clinics in Wardha district were approached. A total of 142 assistants were contacted; 126 were eligible after excluding 5 assistants with less than one year of experience and 11 who declined participation. Eighteen incomplete questionnaires were excluded from final analysis, resulting in a study sample of 108 participants. This participant pathway has been summarized in the Results section for clarity.   Data Collection Tool Questionnaire: A closed-ended questionnaire was initially developed in English with 28 items after an extensive literature review [18,19]. Content validation was performed by seven subject experts from the dental faculty. Two non-essential questions with a content validity ratio of 0.42 were removed, yielding a final 26-item questionnaire. The final instrument was translated into Marathi by three bilingual translators and independently back-translated into English. A pilot assessment was carried out among 25 dental assistants to improve clarity and comprehensibility. Reliability was assessed by test-retest after 15 days, and internal consistency was evaluated using Cronbach's alpha. Participants completed the self-administered questionnaire after informed consent, and responses were collected the following day.   Definitions and Scoring The questionnaire included 10 knowledge items scored as 1 for correct and 0 for incorrect responses, 9 attitude items on a five-point Likert scale, and 6 practice items scored as 1 for correct practice and 0 for incorrect practice. For this dataset, participants scoring at or above the mean for each domain were categorized as having good knowledge, attitude, or practice, whereas those scoring below the mean were categorized as poor. Radiation safety and radiological waste management were assessed together because both are integral components of safe dental radiology.

The study included 108 dental assistants, with the majority aged 18–30 years (50.9%) and a slightly higher proportion of females (53.7%) as shown in Table 1. The overall mean scores for knowledge, attitude, and practice were 3.91±2.91, 30.56±4.40, and 2.06±0.73 respectively. Females demonstrated significantly higher knowledge and attitude scores compared to males (p = 0.047), whereas no significant difference was observed in practice scores; additionally, no statistically significant differences were found across age, education, or work experience groups (Table 2). When categorized, good knowledge was observed in 54.6% of participants, good attitude in 47.2%, while only 28.7% demonstrated good practice, with poor practice being significantly higher (71.3%, p<0.001) as depicted in Table 3. Furthermore, a significant positive correlation was observed between knowledge and attitude (r = 0.607), knowledge and practice (r = 0.567), and attitude and practice (r = 0.396), indicating interdependence among these domains (Table 4).   Table 1: Demographic Characteristics of Study Participants Variable n (Percentage) Age (in years) 18-30 55 (50.9%) 31-40 36 (33.3%) 41-50 16 (14.8%) 51-60 1 (0.9%) Gender Male 50 (46.3%) Female 58 (53.7%) Religion Hindu 81 (75%) Muslim 12 (11.1%) Christian 5 (4.6%) Buddhist 5 (4.6%) Jain 5 (4.6%) Marital status Unmarried 12 (11.1%) Married 96 (88.9%) Education Less than 10th grade passed 15 (13.9%) 10th grade passed 38 (35.2%) 12th grade passed 40 (37%) Graduate 15 (13.9%) Work experience in years 1-5 35 (32.4%) 6-10 27 (25%) 11-15 20 (18.5%) 16-20 16 (14.8%) 21-25 5 (4.6%) 26-30 5 (4.6%) Total 108 (100%)   Table 2: Comparison of Mean Knowledge, Attitude and Practice Scores Based on Various Demographic Variables Variable category Knowledge scores Attitude scores Practice scores Mean±SD p value Mean±SD p value Mean±SD p value Gender (Unpaired t test) Male 3.32±2.86 0.047* 29.74±4.70 0.047* 2.08±0.60 0.844 NS Female 4.43±2.87 31.27±4.04 2.05±0.84 Age in years (One way ANOVA) 18-30 3.88±3.23 0.499 NS 30.18±4.67 0.736 NS 2.07±0.79 0.631 NS 31-40 3.67±2.48 30.91±4.73 2.05±0.64 41-50 4.21±2.65 30.84±2.94 2.00±0.74 51-60 8.00±0.00 34.00±0.00 3.00±0.00 Education (One way ANOVA) Less than 10th grade passed 4.06±3.26 0.577 NS 31.53±4.01 0.072 NS 2.00±0.84 0.838 NS 10th grade passed 4.73±2.34 29.68±4.58 2.02±0.67 12th grade passed 3.5±2.74 30.15±4.41 2.15±0.73 Graduate 3.95±3.13 32.93±3.63 2.00±0.84 Work experience in years (One way ANOVA) 1-5 3.34±3.15 0.313 NS 28.88±4.95 0.069 NS 2.08±0.78 0.949 NS 6-10 3.74±2.95 31.33±3.33 2.00±0.67 11-15 4.75±2.40 32.60±4.03 2.10±0.78 16-20 3.62±2.87 30.56±4.85 2.12±0.61 21-25 4.40±3.28 31.60±2.19 2.20±0.83 26-30 6.0±1.87 30.20±4.49 1.80±1.09 Overall mean 3.91±2.91 30.56±4.40 2.06±0.73 NS: Not significant, *Statistically significant   Table 3: Overall Comparison of Knowledge, Attitude, and Practice Levels Based on Scoring Domain Level p value Good Poor Knowledge 59 (54.6%) 49 (45.4%) 0.336 NS Attitude 51 (47.2%) 57(52.8%) 0.564 NS Practice 31 (28.70%) 77 (71.30%) 0.000* NS: Not significant, *Statistically significant   Table 4: Correlation between Knowledge, Attitude and Practice Scores Parameters Mean Knowledge Mean attitude Mean Practice Mean Knowledge 1 0.607* 0.567* Mean attitude - 1 0.396* Mean Practice - - 1 *Correlation significant at 0.01 level (2 tailed)

This study highlights an important public-health finding: the major deficiency among surveyed dental assistants was poor practice rather than knowledge alone. This distinction is important because safe dental radiology depends not only on awareness of radiation hazards, but also on consistent real-world adherence to shielding, distance, exposure control, and safe waste disposal [20-24]. In many private clinics, practice is likely shaped by clinic systems, availability of protective equipment, supervision, and disposal pathways as much as by individual knowledge.   Conventional oral and maxillofacial imaging generates waste such as spent developer and fixer, silver-bearing effluent, used radiographic films, lead foil packets, and other contaminated materials [25-29]. These wastes require specific handling and disposal protocols to avoid occupational and environmental harm. The findings of this study suggest that although some assistants may understand these hazards in principle, safe waste-management behavior remains inconsistent in routine practice. This has implications not only for worker safety but also for environmental protection.   Available literature on radiation safety and radiological waste management has focused predominantly on dentists, students, or general healthcare workers. Data on dental assistants in Indian private clinics remain limited. The present study therefore provides useful baseline information from Wardha district. However, the findings should be interpreted carefully because this was a self-reported survey, the sample was restricted to one district, and some subgroup analyses were limited by small cell sizes.   Females showed significantly better knowledge and attitude scores than males in the present sample. This observation should be interpreted cautiously, because the study was not designed to determine the underlying reasons for sex-based differences and several subgroup comparisons were statistically underpowered. More importantly, the study demonstrated that practice remained poor in the majority of participants regardless of subgroup, indicating that training alone may not be sufficient unless clinic systems support compliance.   The principal strength of this study is that it addresses an under-studied but operationally important workforce in private dental clinics and achieved a good response rate. Its limitations include self-reporting bias, possible social desirability bias, the district-specific setting, the use of mean-based cut-offs, and the absence of direct observation of clinic facilities or waste-disposal systems [30]. Future studies should incorporate observational audits, clinic-level variables, and pre-post evaluation of structured training programs.   Based on the present findings, competency-based certificate courses for dental assistants should specifically include ALARA principles, shielding, distance rules, exposure minimization, personal protection, radiological waste segregation, silver-containing fixer disposal, lead foil handling, and documentation of safe disposal practices. Periodic continuing dental education and clinic-level monitoring are also required so that good attitude can translate into actual practice.

The most important finding of this survey was poor practice, with 71.3% of participants showing inadequate adherence to radiation safety measures and radiological waste management protocols. Knowledge and attitude alone were insufficient to ensure safe behavior. Private clinic owners, local dental bodies, and regulators should therefore implement minimum standards for assistant training, protective equipment, supervision, and environmentally safe disposal of radiological waste. Multidistrict studies with observational audits are recommended to guide broader policy development.   Ethics Approval and Consent to Participate Ethical clearance was obtained from the Institutional Ethical Committee (Reference number: DMIMS(DU)/IEC/Dec-2019/8598). Written informed consent was obtained from all participants. Responses were collected confidentially and analyzed in aggregated form.   Data Availability The data supporting the findings of this study are available from the corresponding author on reasonable request.