Knowledge and Applicational Arsenic Poisoning among Dental Students: A Survey

Arsenic pollution of groundwater has far-reaching implications, including consumption through the food chain, which manifests as social problems, health dangers, and socioeconomic breakdown, as well as sprawling with mobility and groundwater mining. Food crops grown with arsenic-affected water are marketed to other locations, including uncontaminated areas where residents may be exposed to arsenic via the contaminated food. This could result in the emergence of a new threat.


INTRODUCTION
Arsenic is one of the most hazardous metals that may be found in nature. The main source of human arsenic toxicity is natural geological contamination of drinking water, rather than mining, smelting, or agricultural sources (pesticides or fertilisers) [1]. Drinking water in many industrialised and developing countries is contaminated by arsenic [2,3]. Bangladesh, West Bengal and India, are the two worst-affected countries on the planet.
Groundwater arsenic concentrations exceeding the World Health Organization's maximum allowed level of 50 g/l are present in 42 districts in southern Bangladesh and nine nearby districts in West Bengal, exposing 79.9 million and 42.7 million people, respectively [4]. The cause of arsenic in each of these locations is geological, damaging aquifers that supply water to nearly one million tube wells [5,6]. The concentration of arsenic in some tube wells in West Bengal is as high as 3400 g/l [7].
Arsenic is a human carcinogen that has been linked to a number of negative health effects [8]. Raindrop pigmentation, hyperpigmentation, hyperkeratosis, squamous cell carcinoma, basal cell carcinoma, and Bowen's disease are all skin disorders caused by chronic arsenic exposure [9]. Toxic metals have a significant impact on dental health. Melanocytes in the oral mucosa's basal cell layer are comparable to those found in the skin [10]. After oral cavity lesions, oral cancer is the sixth most prevalent cancer worldwide, and it continues to be a significant health problem [11].
Arsenic pollution of groundwater has far-reaching implications, including consumption through the food chain, which manifests as social problems, health dangers, and socioeconomic breakdown, as well as sprawling with mobility and groundwater mining. Food crops grown with arsenic-affected water are marketed to other locations, including uncontaminated areas where residents may be exposed to arsenic via the contaminated food. This could result in the emergence of a new threat.
A number of counteractive actions, initiatives, and research projects have been launched and put into operation, primarily in West Bengal, to tackle the arsenic threat.
This survey based study is one such initiative to determine the level of knowledge and awareness of dental students about arsenic poisoning.

Study Setting
The Institutional Ethics Committee gave its clearance to the study [SDC/SIHEC/2020/ DIASDATA/0619-0320]. One reviewer, one assessor, and one guide were involved in the research.

Study Design
All students in years I, II, III, and IV BDS, as well as interns and post-graduates, were invited to participate in the study.

Sampling Technique
A non-probability consecutive sampling strategy was used in the investigation. All replies were evaluated and incorporated to reduce sample bias.

Data Collection and Tabulation
The poll was performed using Google Forms, an online platform. All data were included to reduce sampling bias. The data was taken from Google Forms and imported into Excel, where it was tabulated. The data was tallied and analysed.

RESULTS AND DISCUSSION
The survey involved 244 students, and the data were gathered and examined. 25% were 1st year students, 25% were 2nd year students, 25% were 3rd year students and 25% were 4th year students [ Fig. 1]. [ Fig. 2 Fig. 11] represents the knowledge of undergraduate students about the use of arsenic in dentistry. [ Fig. 12] represents the knowledge of undergraduate students about the common oral symptoms due to arsenic leakage into the oral cavity.

. This pie chart depicts respondents Knowledge about the Cause/Source of Arsenic
Poisoning, blue denotes the source is from release of contaminants from factories into the atmosphere, red denotes the source is from Drinking of arsenic contaminated tubewell water, yellow denotes the source is from use of arsenic containing products and green denotes none of the above mentioned options. 56.4% of the respondents said it was caused due to Drinking of arsenic contaminated tubewell water, 20.7% of the respondents said it was caused due to use of arsenic containing products, 14.9% of the respondents said it was caused due to release of contaminants from factories into the atmosphere and 7.9% of the respondents said it was none of the above options 19.2% said stomach cancer is an arsenic related disease, 12.5% said stroke is an arsenic related disease and 7.9 said arthritis is an arsenic related disease year whereas 59% of the study population said they had an idea for less than one year. For the question What is the source of arsenic poisoning 56.4% of the study population said it was due to drinking of arsenic contaminated tubewell water, 20.7% of the study population said it was due to use of arsenic containing products, 14.9% of the study population said it was due to release of contaminants from factories into the atmosphere and 7.9% of the study population said it was none of the other option. Arsenic (As) is released into the soil and groundwater as a result of the weathering of rocks and minerals, which is followed by leaching and runoff. Anthropogenic sources can also release it into soil and groundwater [12]. For the question what are the early symptoms of arsenic poisoning, 65.1% of the study population said it was darkening of skin on palms, 15.1% of the population said it was due to skin rash, 10.1% of the study population said it was itching, and about 9.7% of the study population it was loss of appetite. The skin, lungs, liver, and blood systems are the most common chronic symptoms. Prof. K. C. Saha of the School of Tropical Medicine, Calcutta, discovered this in West Bengal and Bangladesh patients of Khulna in December 1984 [13][14][15]. The cutaneous alterations are distinct but not unique. An initial erythematous flush progresses to melanosis, hyperkeratosis, and desquamation over time.
The skin pigmentation is spotty [16] and has been described as "raindrops on a sandy road" in lyrical terms. The hyperkeratosis is often punctate and affects the distal extremities. There is also a generalised desquamation of the palms and soles. For the question What are the more visible symptoms of arsenic ?72.1% of the study population said it was cardiovascular disorder, 15.4% of the study population it was weight loss, 6.3% of the study population said it was itching and 6.3% of the study population said it was a coma. Several epidemiological studies have suggested that chronic inhalation of arsenic trioxide increases the risk of death from cardiovascular disease in humans [17][18][19].
Inhaling inorganic arsenic over an extended period of time can harm blood vessels and the heart. In children who drank water containing about 0.6 mg/l arsenic, [20] documented multiple incidences of myocardial infarction and arterial thickening. For the question, what are the diseases caused because of arsenic?60.4% of the study population said it caused bladder cancer, 19.2% of the study population said it caused stomach cancer, 12.5% of the study population said it caused stroke and about 7.9% of the study population said it caused arthritis. Presently, epidemiological investigations of communities exposed to high levels of inorganic As have found substantial links and doseresponse connections between As in drinking water and bladder cancer, as well as probable links with kidney cancer [21]. These studies usually focus on locations of high exposure, with As levels in drinking water ranging from 150 to over 1000 ug/L. The extent to which health impacts may develop at lower levels of exposure (150 g/L) is unknown, with many studies failing to show the harm that may be expected based on findings from high levels of exposure [22]. For the question: How long does it take to develop visible symptoms due to arsenic poisoning?, 71.7% of the study population said it would be visible in 2-10 years, 11.8% of the study population said it would be visible in 15-18 years, 10.5% of the study population said it would be visible in 15-30 years, 5.9% of the study population said it would be visible in 1-2 years. The onset is gradual, with symptoms like abdominal pain, diarrhoea, and a sore throat [23]. For the question how long it takes to develop cancer post exposure to chronic arsenic poisoning, 74.4% of the study population said it will take about 5-20 years, 11.5% of the population said it will take about 6-8 years, 9.4% of the study population said it will take about 30-50 years and 4.7% of the study population said it will take about 2-4 years. Arsenic-related Bowen's disease can appear 10 years after exposure to arsenic, but other types of skin cancer can take 20 or 30 years to manifest [24]. For the question How can arsenic be removed from the water?, 26.4% of the study population said it can be removed by arsenic treatment plant, 8.7% of the study population said it can be removed by filters, 5.6% of the study population said it can be removed by the use of tablets, 59.3% of the study population said it can be removed by all of the up mentioned methods. So far, arsenic removal experiments have yielded positive results. The removal of arsenic from drinking water was discovered to be possible by running the water through wood-charcoal at a controlled flow rate, treating the water with calcium oxide, using the sedimentation process, and repeatedly removing the top surface layer having high levels of arsenic. These approaches could be used to remove arsenic from drinking water in a cost-effective and straightforward manner [25]. For the question respondents knowledge about the use of arsenic in dentistry is mainly for? 65.7% of the study population said it is for the use as a root canal treatment component. 8.7% of the study population said it is used as a component of implant, 12% of the study population said it is used as a component of anesthetic, whereas 13.6% of the study population said it was none of the above options. For the Dental pastes containing arsenic trioxide, an arsenic-based chemical, have been used to eliminate injured nerves in the dental pulp (the inside of the tooth). Analyses of data from laboratory and population research show that the arsenic contained in these dental goods may represent a danger of genotoxic effects, which could increase the risk of cancer, according to an assessment of the benefits and risks of these dental products. Furthermore, arsenic is suspected to have spilled into the areas around the teeth in a small number of cases, causing sections of the tissue, including bone, to die [26].
For the question what are the common oral symptoms due to arsenic leakage into oral cavity, 9% of the study population said it caused necrosis of oral tissue, and osteomyelitis, and 7.8% of the study population said it caused oroantral fistula, 74.2% of the study population that all the above mentioned symptoms are oral symptoms of arsenic poisoning [8].

CONCLUSION
The survey helped the students to understand the causes, symptoms and ways to prevent arsenic poisoning. They also were exposed to knowledge about use of arsenic in dentistry and the various oral symptoms that can be manifested. It was evident that students did have a well rounded understanding about arsenic poisoning.

CONSENT
As per international standard or university standard, Participants' written consent has been collected and preserved by the author(s).