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Knowledge and attitudes of dental
patients towards cross-infection control measures in dental practice
Adel A. Mousa,
Nadia M. Mahmoud, Azza M. Tag El-Din
ABSTRACT The
knowledge and attitudes of 460 dental patients attending outpatient
dental clinics in Alexandria, Tanta, and El-Mansoura universities were
studied. Every patient was interviewed individually using a
questionnaire concerning the routine use of protective gloves, masks and
spectacles. The results revealed that 90% of the patients expected
dentists to wear gloves, 73% expected them to wear face masks and 37% to
wear spectacles. Most patients believed that gloves were for the
patient's protection while face masks and spectacles were for the
dentist's protection. About 50% of patients believed that they could
contract infectious diseases during dental treatment; the more educated,
the greater the concern of infection. Tanta patients were more concerned
about cross infection than other patients.
Connaissances
et attitudes des patients des consultations dentaires en ce qui concerne
les mesures de lutte contre les infections croisées en pratique dentaire
RESUME Les
connaissances et les attitudes de 460 patients qui fréquentent les
services des consultations dentaires externes des universités
d'Alexandrie, de Tanta et de Mansoura ont été étudiées. Chaque patient a
été interviewé individuellement au moyen d'un questionnaire relatif à
l'utilisation systématique des gants, masques et lunettes de protection.
Les résultats ont montré que 90% des patients s'attendaient à ce que les
dentistes portent des gants, que 73% s'attendaient à ce qu'ils portent
un masque et 37% à ce qu'ils portent des lunettes. La majorité des
patients pensaient que les gants servaient à la protection du patient
alors que le masque et les lunettes étaient destinés à la protection du
dentiste. Environ 50% des patients croyaient qu'ils pouvaient contracter
des maladies infectieuses durant le traitement dentaire; plus le niveau
d'éducation est élevé, plus le souci relatif à l'infection est
important. Les patients de Tanta étaient davantage préoccupés par les
infections croisées que les autres patients.
Introduction
Cross infection
can be defined as the transmission of infectious agents between patients
and staff within a clinical environment. Transmission may result from
person to person contact or via contaminated objects. Transmission of
infection from one person to another requires a source of infection. The
infective agent is transmitted through blood, droplets of saliva and
instruments contaminated with blood, saliva and tissue debris. The route
of transmission may be inhalation or inoculation.
In dentistry, the
source of infection may be the patients suffering from infectious
diseases, those who are in the prodromal stage of certain infections,
and healthy carriers of pathogens. Carriers of pathogens who pose a
threat of disease transmission may be categorized as either convalescent
carriers or asymptomatic carriers. An asymptomatic carrier has no past
history of infection, as he/she may have unknowingly had a subclinical
infection, and thus such carriers cannot be easily identified.
Nevertheless, this individual may carry infective microbes in saliva and
blood. Hepatitis B is a classic example of a disease which may manifest
with or without symptoms. A convalescent carrier can be identified from
the past history of infection and can be easily diagnosed [1].
Transmission of
infection within a dental surgery may occur by direct contact of tissue
with secretions or blood, from droplets containing infectious agent, or
via contaminated sharps or instruments which have been improperly
sterilized. The major route of cross infection in dental surgery is via
infection through intact skin or mucosa due to accidents involving
sharps, or direct inoculation onto cuts and abrasions in the skin [1,2].
Viral diseases
such as hepatitis B, acquired immunodeficiency syndrome (AIDS), herpes
simplex and cytomegalovirus are important risks, not only for dentists
but also for their families, friends and other patients [3-5].
Wearing of gloves
by dental personnel has been advised as an essential element of
cross-infection control in dental surgery [6-8].
Dental surgery assistants, who are involved in the treatment of
patients, cleaning of instruments and surgery disinfection, should also
wear gloves, because their hands are considered to be a major source of
infection [9],
and potentially infected blood may be harboured beneath the fingernails
for up to five days [10].
It is difficult to remove contaminated material from the hands,
particularly from the subungual and nail fold areas, unless there is
meticulous mechanical cleansing. If such care were taken before
treatment of each patient, the risk of cross infection would be reduced,
but the operator would still be unprotected in the patient's mouth. It
is apparent, therefore, that the dentists' uncovered hands may be a
vector in cross infection or may themselves become infected [9].
It is the duty of practitioners to ensure that all members of the dental
team are adequately trained and suitably equipped to practise effective
cross-infection control, not only to optimize protection of all
personnel in the dental surgery, but also to prevent spread of infection
from one patient to another [8,11,12,13
]. The protection barrier works by protecting the dentist from the
patient or the patient from the dentist, or both from the surrounding
contaminated environment. These barriers include gloves, masks, eye
protectors, tray covers, covers of the working surfaces and light
handles [11-15].
The protective
mask is a source of contamination because it becomes impregnated with
microorganisms after 20 minutes. The same mask is sometimes worn by a
dentist working at the chair for a half or full day. It is reasonable to
conclude that a dentist who wears a mask for such a long period of time
when operating is more at risk from cross infection than a dentist who
operates unmasked [16].
In a survey
conducted by Maguire et al. [17],
they found that 69% of patients expected their dentist to wear gloves
routinely, 47% expected them to use masks and 25% expected them to use
protective eye wear. Few patients object to the use of these barriers.
Only 4% preferred that gloves not be used, while 10% and 13% preferred
masks and eye protectors, respectively, not be used.
Porter et al.,
surveyed the attitudes of dental patients in the United Kingdom and Hong
Kong towards cross-infection control [18].
Almost all patients expected the dentists to wear protective gloves, but
only 73% expected dental staff to wear protective face masks and 40% to
wear spectacles. Most patients were aware that such measures were for
the benefit of both staff and patients. Over 50% of patients believed
that they could contract human immunodeficiency virus (HIV) from an
HIV-infected dentist.
A questionnaire
survey was conducted among 301 dental hospital and general practice
patients in the Glasgow region to assess their perception and awareness
of cross-infection preventive methods used in dentistry. Sixty percent
(60%) of the respondents expected dentists to wear gloves routinely, and
a large majority thought that the gloves were for the dentist's own
protection. Most respondents did not mind the dentist wearing either
gloves or masks during treatment. One-third was ignorant about
sterilization methods used in dentistry [19].
Bowden et al. reported that most patients believed that gloves and masks
should be worn routinely [20].
They found that patients receiving care in a dental hospital were more
concerned than patients in general practice about cross-infection
control.
The aim of this
work was:
• to study and
analyse the knowledge and attitudes of dental patients towards
cross-infection control measures in dental practice;
• to study
factors influencing knowledge and attitudes of dental patients towards
cross infection.
Subjects and
methods
A random sample
of 460 individuals (210 males, 250 females) was selected from people
attending the outpatient dental clinics of Alexandria, Tanta and El-Mansoura
universities. The sample comprised 150 patients from Alexandria, 160
from Tanta and 150 from El-Mansoura. Their ages ranged from 19 to
60 years. The sample members were interviewed in the waiting place on an
individual basis using a questionnaire (see Box 1). The questionnaire
contained a series of questions regarding attitudes towards
cross-infection control measures in dental practice and the perceived
risk of cross infection during dental treatment. The education and
occupation of different individuals were classified into high, medium
and low levels according to the sum of education and occupation scores.
The data were collected and statistically analysed using chi-square (c2)
and Z tests.
Results
Tanta patients
attend dental clinics more regularly than those in Alexandria and El-Mansoura
(Table 1). The difference was statistically significant between
Alexandria and Tanta patients (c2 = 16.189). Some answers
from Alexandria and El-Mansoura patients were excluded from the data.
There was no significant difference by sex (c2 = 0.72).
Table 1 also indicates that the level of education and occupation is
associated with the degree of regular attendance of patients. The higher
the level of education and occupation the more regular the attendance of
patients at dental clinics. There was a statistically significant
difference between high and low level (c2 = 14.95).
Most patients
(89.5%) agreed that dentists should routinely wear protective gloves and
72.4% agreed that dentists should routinely wear face masks. However,
only 36.8% believed that dentists should wear spectacles. There was a
significant difference between high and low levels of profession and
education regarding wearing face masks (c2 = 14.346). There
were significant differences between high and both low and medium levels
of profession and education regarding wearing spectacles (c2
= 13.148 and c2 = 13.431 respectively)
(Table 2). With regard to patients'
attitudes towards wearing gloves
(Figure 1), there was a significant
difference between Tanta and El-Mansoura patients (c2 =
13.879). There were also significant differences between Alexandria and
Tanta patients regarding wearing spectacles (c2 = 10.86).
There was a significant difference between males and females regarding
wearing gloves (c2 = 11.995)
(Figure 2).
The use of
gloves, face masks and spectacles was considered to be important in
preventing the three routes of transmission (dentist to patient, patient
to dentist, patient to patient) by 49.0%, 55.2% and 51.6% of all
respondents, respectively
(Table 3). Only 10.8% believed that dentists wore gloves for
their own protection. On the other hand, 19.7% and 21.6% believed that
dentists used face masks and spectacles for their own protection. There
were significant differences between the route of infection transmission
perceived by respondents regarding the use of gloves (c2 = 22.279)
and face masks (c2 = 18.272). There was no significant
difference regarding wearing of spectacles.
The results
indicate that 60.5% of respondents believed that dentists should use new
gloves for every patient, while 29.1% and 27.8% believed that dentists
should change or wash face masks or spectacles if visibly contaminated
(Table 4). There were significant
differences between the perceived reasons for changing gloves, masks and
spectacles and the respondents' location (c2 = 33.666, c2
= 65.319 and c2 = 74.064 respectively).
There was no
significant difference between patients' concern regarding the risk of
cross infection and sex (c2 = 1.49), but the level of
education and occupation significantly affected patient concern about
the risk of cross infection (c2 = 22.391)
(Table 5). In addition, there was a
significant difference between patient concern about cross infection in
different places (c2 = 17.564).
Discussion
Today there is
considerable awareness in the dental profession of the possibility for
cross infection occurring in the dental clinic. This awareness has been
heightened by the advent of HIV, hepatitis B virus and other infectious
diseases [14].
In the present
study, 90% of respondents overall expected dentists to wear protective
gloves. This highly positive result is in agreement with most previous
studies of United States and United Kingdom patients, Yorden 87% [20],
Burke et al. 84% [21],
Gerbert et al. 76% [22],
Bowden et al. 70% [23],
Maguire et al. 69% [17],
and Samaranayake and McDonald 60% [19].
It appears that a high proportion of respondents consider that
glove-wearing by the dentist is an essential part of cross-infection
control, indicating a high degree of awareness of such matters. It is
the currently accepted norm that to reduce cross-infection risks gloves
should be worn for all aspects of routine dentistry except when a
no-touch technique is used [24].
Nearly sixty per
cent (60%) of all respondents expected dentist to wear new gloves when
treating each patient. Alexandria and El-Mansoura patients had lower
expectations than Tanta patients. Such view is in accordance with those
of many investigators; Porter et al. 79% [18],
Samranayake and McDonald 43% [19]
and Bowden et al. 86% [23].
Others have concluded that it is for the dentist to use his professional
judgement in such matters [25].
The perceived reasons for the objections to washing the gloves included
the danger of cross infection and the lack of belief in the efficacy of
washing gloves. In this respect, the Dental Health and Science Committee
of the British Dental Association have recommended that gloves be
changed if a puncture is suspected and if there is blood contamination.
The only safe approach is to assume that any patient is a carrier of a
blood-borne disease [26].
It is noteworthy that the American Dental Association has not
approved the reuse of gloves in clinical practice [14].
Seventy-two per
cent (72%) of the respondents expected dentists to wear face masks
routinely. This response is similar to that reported by Porter et al.,
73% [18]
but lower than that of Bowden et al., 56% [23].
However, only 26% believed that the face masks should be changed between
patients, contrary to current professional opinion which advises face
masks to be regularly changed, particularly to minimize airborne
transmission of infection such as tuberculosis, and to minimize the
inhalation of air constantly polluted with mercury and aerosols.
Interestingly, Alexandria and Tanta patients are more likely to expect
the dentist to wear face masks routinely than El-Mansoura patients.
Only 37% of all
respondents expected the dentist to wear protective spectacles
routinely. The result is similar to that reported by Porter et al. who
reported 37% for Hong Kong patients and 44% for British patients [18].
This low response may reflect patients' lack of knowledge about the risk
of infection transmission from dentist to patient via lachrymal
secretions and/or lack of awareness of the potential spread of infection
via debris from the patients mouth to the eyes of dental staff and vice
versa.
In the present
study, 26% and 22% of all patients believed that the dentist should use
a new face mask and spectacles for every patient. This finding agrees
with the results of other studies [22,23].
Patients endorse the use of gloves more enthusiastically than the use of
masks and spectacles, perhaps because they perceive gloves as primarily
for their benefit but masks and spectacles as a means of protecting the
dentist. Forty-nine percent (49%) of respondents were aware that the
wearing of gloves is for the benefit of both patient and dentist. This
finding is lower than Porter et al., 83% [18],
and Burke et al. 88%, [21].
In contrast, investigations of Scottish dental patients and United
Kingdom patients indicated that only 27% and 31% respectively of the
patients believed that the wearing of gloves was a means of minimizing
transmission of infection between staff and patients [19,22].
The three routes
of infection transmission in the dental practice are very important;
about 49% of the patients were aware of this, but only about 4% believed
that the most important reason for wearing gloves was to protect
patients from the dentist.
In agreement with
Bowden et al. [22]
there is a significant difference between sex regarding cross-infection
control measures (use of gloves, c2 = 11.99). This may be
because males in general are less concerned with hygiene in relation to
dentistry than females.
The majority of
patients (52%) are concerned about contracting infections during dental
treatment and this is in agreement with Porter et al. [18].
In contrast, the study of Gerbert et al. showed that 30% of the public
in the USA who use dental services had thought about the possibility of
contracting HIV [22].
In general,
Alexandria and Tanta patients have similar attitudes regarding
cross-infection protection and the likelihood of infection transmission
in dental practice. However, Alexandria patients are more positively
influenced by the routine use of masks and spectacles and more concerned
about the possible transmission of infection during dental treatment
than El-Mansoura patients
(Table 2).
The results
presented indicate the opinions of Egyptian dental patients in certain
areas. Whether such opinions would be widely held on a nationwide basis
remains to be determined by conducting similar surveys in other parts of
Egypt.
Conclusions
and recommendations
Conclusions
The present
results give encouragement to the effort for improving the standards of
cross-infection control in dental care. The majority of patients in this
study now accept, or even insist on, the dentist wearing gloves.
Recommendations
The media must
draw the public's attention to the transmission in the dental clinic of
infectious diseases such as influenza, common cold, tuberculosis,
hepatitis B and AIDS. This will encourage patients to become more
concerned about the safety of dental care. Patients in rural areas need
more information about infection-control measures in dental clinics from
the television or radio.
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