Infection Control in the Private Dental Sector in Riyadh

Transcription

1 Abdullah Al-Rabeah, DipFETP; Ashry Gad Mohamed, DrPH From the Saudi Field Epidemiology Training Program (Dr. Al-Rabeah), and the Department of Family and Community Medicine (Dr. Mohamed), College of Medicine, King Saud University, Riyadh, Saudi Arabia. Address reprint requests and correspondence to Dr. Mohamed: Department of Family and Community Medicine (34), College of Medicine & KKUH, P.O. Box 2925, Riyadh 11461, Saudi Arabia. Accepted for publication 28 October, Received 26 February Background: With the global rise in the number of people infected with hepatitis B and C and HIV viruses, cross infection has become of paramount concern to dental health care workers and their patients. The objective of this study was to assess the infection control practice in the private dental sector in Riyadh, Saudi Arabia. Subjects and Methods: The study was conducted through a cross-sectional survey of private dental practices in the city of Riyadh. A total sample size of 132 dental units was chosen using the proportional allocation method. Three hospitals, 45 clinics and 39 centers were selected randomly. A self-administered questionnaire was completed by dentists working in the selected settings. Results: Of the 206 questionnaires sent, 203 (98.5%) were completed. The mean age of the responding dentists was 36.8±6.7 years. A total of 139 dentists (68.5%) were general practitioners and 64 (31.5%) were specialists. A total of 129 (63.5%o) stated that they had been vaccinated against hepatitis B virus and 189 (93.1%) stated that they always took a medical history of each patient before treatment. All the studied dentists reported that they always used gloves for every patient during dental treatment, and 90.6% stated that they always wore a face mask during dental treatment. The primary source of infection control information for the studied dentists was from the colleges (78.3%). Only 37.9% of the dentists sterilized their handpieces by autoclaving, while the other 53.7% used disinfectant. About 56% disposed of used needles and sharp instruments in special safety containers. Multivariate logistic regression analysis revealed that working in clinics, age >40 years and knowledge of correct sterilization steps were independent promoting factors for adherence to infection control practice (OR=3.8, CI= ; OR- 10.2, CI= ; OR=5.6, CI= , respectively). Conclusion: The development of infection control manual for dental practices, in addition to a campaign of health education for dentists in the private sector, is recommended. Ann Saudi Med 2002;22(1-2): A Al-Rabeah, AG Mohamed, Infection Control in the Private Dental Sector in Riyadh. 2002; 22(1-2): Key Words: Infection control, private dental sector, dentists. Infection control, which is one of the most discussed topics in dentistry, has become such an integral part of the practice to the extent that dental health workers no longer question its necessity. 1 Dental care professionals are at an increased risk of cross infection while treating patients. This occupational potential for disease transmission becomes evident when one realizes that most human microbial pathogens have been isolated from oral secretion. 2,3 In addition, a majority of carriers of infectious diseases cannot be easily identified. 4,5 Dental health care workers are known to be at increased risk of hepatitis and human immunodeficiency virus (HIV) infections. 4,6 Numerous surveys and studies have shown that the incidence of hepatitis B developing after needlestick injuries from HbsAg patients is approximately 20% compared with an estimate of 0.4% following similar exposure to the AIDS vims. 7 With the presence of people who are infected with hepatitis B and C and the HIV viruses, cross infection has become a major concern both to the dentist and his patient. 2 There is evidence to suggest that many infected patients are unaware of their status because of long incubation periods and post-infection window period during which antibodies cannot be detected. 2,8 Many studies have shown that dental personnel have a five- to ten-fold chance of acquiring hepatitis B infection than the general population. 9 Al-Sohaibani et al. showed that the occupational risk of HBV infection to Saudi physicians is quite high, and recommended that vaccination against HBV be administered to all Saudi physicians with no previous exposure to HBV. 10 Infection control practices in developing countries have not been widely documented. 5 Most hospitals have no infection control programs due to the lack of awareness of the problem or absence of properly trained personnel. 11 Currently, there are no standard instructions or protocols on infection control practice in private dental clinics in Saudi Arabia. The objective of this study was to assess the infection control practice in this dental sector in Riyadh.

2 Subjects and Methods The study was conducted by the use of a cross-sectional survey. A list of 283 private dental units was obtained from the Riyadh General Directorate of Health Affairs of which a sample size of 132 units was chosen. Using the proportional allocation method, a random selection of nine units from three hospitals, 78 units from 39 centers, and 45 units from 45 clinics was made. A pre-structured self-administered questionnaire was distributed to all dentists working in the selected dental care units. The questionnaire required data on sociodemographic characteristics, knowledge and practice of infection control procedures in their units, e.g., sterilization, wearing of gloves, mask, use of rubber dam, vaccination against hepatitis B virus, method of storing instruments, and disposal methods of contaminated material. The completed questionnaires were reviewed for completeness and consistency. Epi-Info 6.04 was used to analyze the data. An outcome variable indicating compliance with infection control procedures was generated as binary variable (compliant and non-compliant). Compliance to different procedures was presented as percentages. Crude odds ratio (OR) and its 95% confidence interval (CI) was used to present the association of studied variables with compliance. Significant associates in bivariate analysis were treated in multivariate logistic regression model to remove the confounding effects and to yield the adjusted odds ratio and its 95% CI. Dentists were deemed to be compliant with infection control procedures if they carried out all of the following: always took medical history for each patient; have been vaccinated against HBV; always wore gloves; changed gloves after each patient; always wore facemask; changed mask after each patient or when it became moist; always wore coat; changed coat when dirty; always applied antibacterial mouthwash for patients before treatment; always used high-volume suction during any kind of dental treatment; changed extraction forceps, elevators, handpieces, saliva ejectors and burs after each patient; used autoclave, dry heat or chemicals to sterilize handpieces as appropriate; had special rigid containers to store used needle and scalpel blades; and stored the reprocessed instruments in the sterilization wrappers. Dentists were deemed to be non-compliant if they did not adhere to any of the above procedures. Results Of the 206 distributed questionnaires, 203 (98.5%) were completed by respondents, comprising 113 males (5 5.7%) and 90 females (44.3%). The mean age of the responding dentists was 36.8±6.7 years, and 62.6% belonged to the age group of years. The dentists were of different nationalities: 77 (37.9%) were from Syria, 74 (36.5%) from Egypt, 23 (11.3%) from other Arab countries, and the remaing 29 (14.3%) from non-arab countries. A total of 139 (68.5%) were general practitioners in dentistry while 64 (31.5%) were specialists. Over half of the dentists included in this study (123, 60.6%) were working in dental center clinics, and nearly all of them had worked in their respective countries after graduation before coming to Saudi Arabia. For approximately two-thirds of the studied dentists, their individual years of experience ranged from 6 to 15 years, with a mean of 13.2±6.1 years. Over 50% of the dentists examined 6 to 10 patients daily, while about 12.3% examined more than 15 patients daily, with a mean of 10.1±4.8 patients per day (Table 1).

3 Table 1. Socio-demographic and work experience of dentists in private dental sector in Riyadh Characteristic Number Percentage Age in years > Sex Male Female Nationality Egypt Syria Other Arabs Non-Arabs Marital status Married Single Qualification General practitioners Specialist Setting Clinic Center Hospital Daily load of patients < > Experience in years < > Table 2 shows that 93.1% of dentists asked about the medical history of patients before giving treatment, that 63.5%) had been vaccinated against hepatitis B, and 62% knew the correct sterilization methods. All the studied dentists wore new gloves and changed saliva ejector for each patient. Also, 98% changed the extraction forceps and elevator for each patient. Among the studied dentists, 56.2% used special containers for disposal of needles, syringes and extracted teeth.

4 Table 2. Adherence to infection control procedures among dentists in private dental sector in Riyadh Procedure Number Percentage Asking about medical history of patients Vaccination for hepatitis B Gloves Wearing Changing after each patient Face mask Wearing Changing daily Coat Wearing Changing when dirty Use of high volume suction Changing instruments Extraction forceps Elevators Hand-pieces Saliva ejectors Burs Use of autoclave for sterilization of handpieces Use of special container for disposal of sharp objects Storage of sterilized instruments packed in plastic bag Knowledge of correct sterilization steps Factor Table 3. The studied variables and compliance to infection control practices in private dental sector in Riyadh Compliant (%) Non-compliant (%) OR 95% Setting* Clinic 10 (14.9) 57 (85.1) Other 7 (5.1) 129 (94.9) Age in years* 40 6 (3.8) 154 (96.3) >40 11 (25.6) 32 (74.4) Gender Male 13 (11.5) 100 (88.5) Female 4 (4.4) 86 (95.6) Nationality* Arab 11 (6.3) 163 (93.7) Non-Arab 6 (20.7) 23 (79.3) Degree General practitioner 10 (7.2) 129 (92.8) Specialist 7 (10.9) 57(89.1) Daily load of work 10 patients 9 (6.4) 131 (93.6) >10 patients 8 (12.7) 55 (87.3) Source of knowledge College 15 (9.4) 144 (90.6) Other 2 (4.2) 42 (95.5) Experience* 15 years 6 (4.2) 136 (95.8) >15 years 11 (18) 50 (82) *P<0.05.

5 Table 3 shows that 17 dentists (8.4%) were adherent to the complete list of infection control practices. Crude analysis shows that dentists working in clinics were significantly more compliant (14.9%) than those working in hospitals or centers (OR-2.23, CI= ). Dentists aged 40 years or under, those of Arabic descent, and those with experience up to 15 years (3.8%, 6.3% and 4.2%, respectively) were significantly less compliant than those aged over 40 years (25.6%), were non-arab (20.7%), and those with more than 15 years experience, (OR=0.11, CI= ; OR=0.26, CI= ; and OR=0.2, CI= , respectively). Multivariate logistic regression analysis (Table 4) shows that working in clinics, age over 40 years, and knowledge of the correct sterilization procedures were independent promoting factors for adherence to infection control practice (OR=3.8, CI= ; OR=10.2, CI= ; and OR=5.6, CI= , respectively). Discussion A variety of bacterial, viral, fungal, and protozoan microbes present hazards to the dental team and patients. They may be exposed to these microbes through direct contact with a patient's tissues such as blood, skin, and other secretions, or by indirect contact like injuries caused by sharp contaminated instruments, or by droplet infection from aerosols and spatter. 12 There are two reasons why dental health care workers must wear operating gloves: 1) to prevent transmission of infection from the operator's hands to the patients; and 2) to prevent contact of blood and saliva with the operator's hands. 13 The present study showed that all the dentists wore gloves and 90% wore facemasks. In 1991, a study by Al Ruhaimi showed that between 2%-4% of dental professionals in Saudi Arabia never wore gloves when treating patients. 14 Another study by Morris et al. showed that about 90% of dentists in Kuwait wore gloves, 75% wore masks and 52% wore eyeglasses. 6 From New Zealand, Treasure et al. showed in their study that 42% of dentists wore gloves, 64.8% wore masks and 66.4% wore eye protection. 15 In 1994, McCarthy et al. showed that 91.8% of dentists in Ontario, Canada, always wore gloves, 74.8%) always wore masks and 83.6% always wore eye protection. 16 Prospective studies have estimated the risk of infection from hepatitis B and hepatitis C virus infection in health care workers to be 6%-30% and 10%, respectively, after needlestick exposure. 17 The prevalence of hepatitis B antigen carriers in Saudi Arabia is estimated to be 8.3% for the entire population. 18 This means that dentists and their assistants in Saudi Arabia are at a high risk of exposure to hepatitis B antigen. Therefore, there should be 100% hepatitis B vaccination coverage of all dentists and dental workers, rather than the 63.5% found in this study. Similar to the present study, a survey completed in government primary health care (PHC) dental clinics on vaccination against hepatitis B found that only 70% of dentists had been vaccinated. 19 The study by McCarthy et al. showed that 92.3% of dentists in Ontario, Canada, had received HBV vaccine, 16 while Gore et al. showed that 88% of dentists in Scotland had completed a course of hepatitis B vaccination. 20 Regulations in Saudi Arabia require vaccination against hepatitis B for dentists working in hospital dental clinics only. 19 These regulations need to be extended to cover private dental centers and clinics. The vaccine is cheap and readily available, and universal vaccination of the dentists is possible at minimal extra cost. 19 Table 4 Results of multivariate logistic regression analysis of factors associated with compliance to infection control practice in private dental sector. Riyadh Factor Odds ratio 95% confidence interval Working in clinic* Age above 40 years* Male Experience >15 years Knowledge of sterilization steps* *P<0.05. Many authors have emphasized the hazard of cross infection by the use of dental instruments. 21,22 Morris et al. showed that 94% of dentists in Kuwait used autoclave to sterilize handpieces. 6 In 1997, Kurdy and Fontaine showed that 30% of dentists in PHCs in Saudi Arabia had sterilized handpieces with autoclave, and 90% of them autoclaved their instruments at the end the day. 19 The present study showed that only 37.9% of the studied dentists used autoclave for sterilizing handpieces. The most common reason for not sterilizing handpieces is the fear of damage to the equipment. 22 The advantage of packaging cleaned instruments in an appropriate wrapping material before sterilization is the protection of the processed instruments from environmental contamination. 23

6 All sharp instruments used in dental clinics should be safely disposed of. It is a well-defined hospital policy that such instruments should be disposed of in safe containers, and that these containers should be puncture proof. 24,25 The study by Kurdy and Fontaine showed that 72% of dental clinics in PHC centers had containers for disposable needles and sharp instruments. 19 In the present study, about 56.2% of studied dentists had special containers for sharp objects. There is evidence that high-volume suction plays an important role in minimizing contamination of the treatment room by micro-particle aerosols that contain significant microbiological load. 2,26,27 Saliva alone has bacteria of about 150 million/ml. The present study revealed that only 49.8% of the studied dentists used the highvolume suction. This study shows that the overall compliance with infection control procedures was only 8.4% among dental practitioners in the private dental sector in Riyadh. A higher rate of compliance in some private clinics shown by this study may be attributed to repeated visits of officers from dental licensing offices to these clinics. In our study, dentists aged more than 40 years were more compliant than those in the younger age group. This may be due to more experience and knowledge acquired. Experience means more exposure to sources of knowledge and perhaps familiarity with previous infections in colleagues. Morris et al. in Kuwait showed that respondents with 10 or more years of experience were significantly more knowledgeable than the student dentistss. As well, McCarthy and MacDonald showed that dentists over 40 years of age were more likely to use recommended infection control procedures than those who were under 40 years. 16 All the data in the study were self reported, and it is pertinent to be cautious in interpreting and generalizing the findings. The observation that very few respondents have followed the full requirements of infection control practice developed by American Dental Association (ADA) and Centers for Disease Control and Prevention (CDC), however, is significant. Recommendations The Ministry of Health has to provide formal infection control courses for the dental profession, with mandatory attendance for continued licensing. Infection control manuals for dental practice have to be developed. All published guidelines and recommendations on infection control in dental practice should be incorporated into a standard dental infection control manual. Dentists and dental assistants must be vaccinated against hepatitis B. Continuous supervision of the private dental sector is encouraged to evaluate and check the facilities for sterilization and disinfection, as well as adherence to standard procedures. Acknowledgements The authors would like to thank Dr. Nasser Al Bagieh, Vice-Dean, Dr. Khalid Al Wassan, General Director of Dental Clinics, and Mr. Jameel Al-Asmar, the Central Sterilization and Supply Division Supervisor of the Ministry of Health, Riyadh. Our deep appreciation also goes to the Medical License personnel (Dental department) in the office of Riyadh Health Affairs. References 1. Runnells RR. An overview of infection control in dental practice. J Prosthet Dent 1988;59: Samaranayake L. Rules of infection control. Int Dent J 1993;43: Cottone JA, Terezhalmy GT, Molinari JA. Practical infection control in dentistry. 2nd edition. Baltimore: Williams and Witkins, Martin MV. New concepts in cross infection control in dentistry. Postgrad Dent 1990: Cohen AS, Jacobsen EL, Begole EA. National survey of endodontists and selected patient samples: infectious diseases and attitudes toward infection control. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83: Morris E, Hassan FS, Al Nafisi A, Sugathan TN. Infection control knowledge and practices in Kuwait: a survey on oral health care workers. Saudi Dent J 1996;8: Wood PR. Cross infection control in dentistry: a practical illustrated guide. London: Wolfe Publishing Ltd., Klein RS, Phelan JA, Freeman K, Schable C, Friedland GH, Trieger N, et al. Low occupational risk of human immunodeficiency virus infection among dental professionals. New Engl J Med 1988;318: Miller CH. Infection control. Dent Clin North Am 1996;40:

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