Treating Patients with HIV and Heatitis B and C Infections: Croatian Dental Students Knowledge, Attitudes, and Risk Percetions Vlaho Brailo, D.M.D., Ph.D.; Ivica Pelivan, D.M.D., Ph.D.; Josi Škaričić; Marko Vuletić; Nikša Dulčić, D.M.D., Ph.D.; Gordana Cerjan-Letica, Ph.D. Abstract: Dentists and dental students can be exosed to the human immunodeficiency virus (HIV), heatitis B virus (HBV), and heatitis C virus (HCV) during routine work. The aims of this study were to assess a grou of dental students knowledge about HIV, HBV, and HCV infections; assess their attitudes and risk ercetions about the treatment of atients with HIV, HBV, and HCV; and identify factors their knowledge and willingness to treat these atients. An anonymous survey was administered to 534 redoctoral students at the School of Dental Medicine, University of Zagreb, Croatia. The resonse rate was 71.9 ercent. Students knowledge increased with each year of study. Senior students (in their third, fourth, and fifth years) had more rofessional attitudes and were significantly more ositive about dentists rofessional obligation to treat atients who are HIV-ositive than were junior students (in their first and second years; =0.0002). Senior students also exressed significantly more willingness to treat intravenous drug users and atients with heatitis (=0.016 and =0.033, resectively). Female students were significantly more convinced than male students that routine dental treatment carried a significant risk of HIV and heatitis infection (=0.025). These students knowledge negatively correlated with the lack of willingness to treat intravenous drug users and atients with heatitis, and they exressed their willingness to receive further theoretical and ractical education on this toic. Dr. Brailo is Assistant Professor, Deartment of Oral Medicine, School of Dental Medicine, University of Zagreb, Zagreb, Croatia; Dr. Pelivan is Senior Assistant, Deartment of Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia; Mr. Škaričić is a student, School of Dental Medicine, University of Zagreb, Zagreb, Croatia; Mr. Vuletić is a student, School of Dental Medicine, University of Zagreb, Zagreb, Croatia; Dr. Dulčić is Assistant Professor, Deartment of Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia; and Dr. Cerjan-Letica is Associated Professor, Deartment of Social Sciences, School of Dental Medicine, University of Zagreb, Zagreb, Croatia. Direct corresondence and requests for rerints to Dr. Ivica Pelivan, Deartment of Prosthodontics, School of Dental Medicine, University of Zagreb, Gunduliceva 5, HR-10000 Zagreb, Croatia; elivan@sfzg.hr. Keywords: dental students, HIV/AIDS, heatitis B and C, occuational exosures, clinical education, dental clinics, atient safety, Croatia Submitted for ublication 7/22/10; acceted 1/24/11 Dental treatment often includes direct contact with atients blood and saliva, so dentists and dental students can be exosed to athogenic microorganisms like human immunodeficiency virus (HIV), heatitis B virus (HBV), and heatitis C virus (HCV). Even though HIV and viral heatitis have different eidemiological characteristics, they can all be transmitted to the members of a dental team by rofessional exosure, most often by a needlestick injury. However, the risks of infection with HIV, HBV, and HCV after a single needlestick differ significantly: 0.3 ercent for HIV, 3 ercent for HCV, and 30 to 50 ercent for HBV. 1,2 Regarding HIV infection, Croatia is a country with a low level of HIV incidence, amounting to aroximately fifteen newly diagnosed cases a year over the last ten years. 3 As these figures may seem unrealistically low, it is imortant to note that only a very small roortion of the sexually active oulation in Croatia gets tested so the actual figures are robably higher. On the other hand, the estimated revalence of HCV infection in the general Croatian oulation is 1.6 ercent. 4 In the last few years, the average number of new cases of HBV infection in Croatia was aroximately 200 er year. 4 It is now estimated that every twelfth erson in Croatia suffers from either HBV or HCV. 3 Due to these high eidemiological values, it is very imortant to develo Croatian dental students awareness of this roblem. Previous research has found that Croatian dentists and dental students have insufficient knowledge about routes of transmission and the risks related to treating HIV atients. 5,6 In these studies, 48.8 ercent of dentists and 38.6 ercent of dental students believed that HIV could be transmitted by saliva, and 21.5 ercent of dentists and 39.6 ercent of dental students believed the risk of seroconversion after a single needlestick to be August 2011 Journal of Dental Education 1115
very high. This indicates a need for further education of resent and future dental rofessionals. On the other hand, knowledge about HBV and HCV among dentists and dental students in Croatia, to the best of our knowledge, has not yet been assessed. The aim of this study was thus to 1) assess dental students knowledge about HIV, HBV, and HCV infection; 2) assess their attitudes toward and risk ercetion of atients with HIV/AIDS, HBV, and HCV; and 3) identify factors their knowledge and willingness to treat these atients. Methods The study was erformed at the School of Dental Medicine, University of Zagreb, by means of an anonymous questionnaire. The questionnaire was distributed to undergraduate dental students in all five years of study during their usual curricular activities. Imlementation of the study was aroved by the Ethics Committee of the School of Dental Medicine, University of Zagreb. Prior to enrollment in the study, its urose was exlained to the students, and informed consent was obtained from each. Table 1. Sociodemograhic characteristics of study articiants Variable Value Number (total number) 384 (534) Resonse rate 71.9% Gender, number (%) Male 113 (29.4%) Female 271 (70.6%) Age (mean±sd) 23±2 Year of study, number (%) First 61 (15.9%) Second 80 (20.8%) Third 61 (15.9%) Fourth 101 (26.3%) Fifth 81 (21.1%) High school education, number (%) General rogram 344 (89.6%) Medical rogram 40 (10.4%) Dental technicians 26 (6.8%) Nurses 12 (3.1%) Laboratory technicians 2 (0.5%) Parents rofession, number (%) Health care rofessional 173 (45.1%) Other 211 (54.9%) Note: For high school education, resondents were allowed to select all that alied. The questionnaire consisted of five arts. The first art asked questions about students sociodemograhic status: age, gender, high school education, year of study, and arents rofession. The second art of the questionnaire assessed students knowledge about HIV/AIDS, HBV, and HCV infection. The twenty-three questions had three ossible resonses: yes, no, and don t know. The third art of the questionnaire sought students ersonal attitudes towards atients with HIV/AIDS, HBV, and HCV, and the fourth art examined their ercetions, e.g., their awareness of risks treatment of these atients. Students attitudes and risk ercetion were assessed by a five-oint Likert scale that determined level of agreement with each statement (1=strongly disagree to 5=strongly agree). The fifth art of the questionnaire assessed the existing state and need for further education and consisted of seven yes or no questions. The data were organized into Microsoft Excel sreadsheets (Microsoft Excel, Microsoft Inc., USA) and statistically rocessed using SPSS 11.0 software (IBM Inc., USA). For the urose of statistical analysis, students were divided into junior (first and second) and senior (third, fourth, and fifth) years of study. This division was chosen due to the fact that in the third year students begin clinical ractice and become actively involved in matters of infection control, rofessional exosure, and ersonal rotection. between grous were assessed by the chi-square test, Student s t-test, and analysis of variance when alicable. Correlations between variables were exressed by the Searman s rank correlation coefficient. Values lower than 0.05 (<0.05) were considered statistically significant. Results Of the total of 534 students, questionnaires were comleted by 384, for a resonse rate of 71.9 ercent. Of the resondents, 271 (70.6 ercent) were women, and 113 (29.4 ercent) were men. The mean age was 23±2 years. The majority (89.6 ercent) were general rogram high school graduates. Twelve (3.1 ercent) graduated from medical high schools, twenty-six (6.8 ercent) from the school for dental technicians, and two students (0.5 ercent) from the school for laboratory technicians. Of the resondents, 173 (45.1 ercent) had at least one arent working as a health care rofessional. The articiants sociodemograhic data are summarized in Table 1. 1116 Journal of Dental Education Volume 75, Number 8
Knowledge The resonding students answers were first tabulated as the ercentage of correct answers and were further analyzed by demograhic arameters (gender, high school education, arents rofession, year of study) by means of the chi-square test (Table 2). Gender did not have a significant imact on their knowledge excet on the subject of HIV transmission routes in which female students had a significantly higher ercentage of correct answers (69.7 ercent vs. 58.4 ercent; =0.044) than their male colleagues. Male students gave significantly more correct answers to the question Should individuals with heatitis B or C infection receive dental treatment in hosital? (58.3 ercent vs. 53.1 ercent; =0.037). In terms of high school education, no significant differences in knowledge were observed excet in two cases. Students who had graduated from a general rogram high school showed a significantly higher level (=0.009) of knowledge about HIV treatment (34.6 ercent vs. 17.5 ercent of correct answers) than those who graduated from medical schools. On the other hand, students who had graduated from medical schools gave a significantly higher number of correct answers on ost-exosure rohylaxis (67.5 ercent vs. 50 ercent; =0.003). Parents rofession (health care rofessionals vs. others) did not influence students knowledge excet in one case. Students with a arent who was a health care rofessional showed greater knowledge about the risk of rofessional acquisition of HCV than those whose arents were not health care rofessionals (37.6 ercent vs. 28.4 ercent of correct answers; =0.044). The number of correct answers increased with the year of study. First-year students gave the greatest number of correct answers to two out of twentythree questions, while fifth-year students gave the highest number of correct answers to twelve out of twenty-three questions. In sixteen of twenty-three questions, significant differences in the number of correct answers were observed between senior and junior students (Table 2). Personal knowledge was calculated as the number of correct answers er student. The average number of correct answers er student amounted to 17.49±2.35 (14.75±2.19 to 19.38±2.19) and increased with the year of study (Figure 1). Statistically significant differences (<0.05) in ersonal knowledge were determined between junior and senior students (16.28±2.43 vs. 19.29±2.22 correct answers) by ANOVA. The Tukey ost hoc test did not establish statistically significant differences in ersonal knowledge between those in their junior and senior years of study (>0.05). Gender, high school education, and arents rofession did not influence ersonal knowledge. Attitudes The students attitudes toward atients with HIV, HBV, and HCV were assessed on a five-oint Likert scale and comared according to gender, high school education, arents rofession, and year of study by means of the chi-square test (Table 3). Gender did not influence attitudes towards atients with HIV, HBV, and HCV. Students whose arents were not health care rofessionals exressed a significantly higher level of agreement with the statement If I found out that my longtime atient had HIV or heatitis, I would sto treating him comared to students with at least one arent who was a health care rofessional (=0.013). Senior students were significantly more ositive about a dentist s rofessional obligation to treat atients who are HIV-ositive than junior students (=0.0002). Senior students exressed significantly more willingness to treat intravenous drug users and atients with heatitis (=0.016 and =0.033, resectively) and less in agreement with the statement that atients with HIV, HBV, and HCV should receive dental treatment in secialized clinics (=0.025). Risk ercetion was also assessed on a fiveoint Likert scale and comared according to gender, high school education, arents rofession, and year of study (Table 4). Female students were significantly more convinced than males that routine dental treatment carried significant risk of HIV and heatitis infection and also significantly more suortive of the statement that all health care rofessionals should undergo routine HIV and heatitis testing on a yearly basis (=0.025 and =0.018, resectively). Students who had graduated from a general rogram high school showed more confidence than others in the rotection from HIV, HBV, and HCV during routine work rovided by common ersonal rotective equiment (gloves, mask, glasses; =0.043). Senior students were significantly more ositive than others that all atients should be considered otentially infectious and that standard disinfection and sterilization measures were effective for instruments used with atients with HIV, HBV, and HCV (=0.0002 and =0.005, resectively). Furthermore, August 2011 Journal of Dental Education 1117
Table 2. Students knowledge regarding HIV/AIDS, HBV, and HCV infection Question No N (%) Yes N (%) Don t know N (%) Correct answer N (%) associated with gender high school education associated with arents rofession (health care rofessionals vs. others) between junior and senior students 1 Can HIV/AIDS be transmitted from mother to child? 3 (0.8%) 377 (98.2%) 4 (1.0%) 377 (98.2%) 0.971 0.340 0.285 0.278 2 Can HIV be transmitted through air or water? 376 (97.9%) 7 (1.8%) 1 (0.3%) 376 (97.9%) 0.597 0.29 0.539 0.397 3 Can HIV be transmitted through social contact (shaking hands, kissing, sharing glasses, clothes, etc.)? 296 (77.1%) 72 (18.0%) 16 (4.2%) 296 (77.1%) 0.756 0.176 0.226 0.233 4 Can HIV be transmitted through saliva? 366 (95.3%) 16 (4.2%) 2 (0.5%) 366 (95.3%) 0.742 0.451 0.797 0.816 5 Major routes of HIV transmission are: 5a unrotected sex 0 384 (100%) 0 384 (100%) 5b blood transfusion 16 (4.2%) 366 (95.3%) 2 (0.5%) 366 (95.3%) 0.044* 0.334 0.292 0.557 5c intravenous drug use 3 (0.8%) 380 (99.0%) 1 (0.3%) 380 (99.0%) 0.431 0.791 0.106 0.419 5d occuational exosure 98 (25.5%) 255 (66.4%) 31 (8.1%) 255 (66.4%) 0.015* 0.543 0.353 0.0002* 6 Can HIV be comletely cured with antiretroviral theray? 351 (91.4%) 6 (1.6%) 27 (7.0%) 351 (91.4%) 0.900 0.097 0.293 0.031* 7 Nucleosides/non-nucleosides reverse transcritase inhibitors are the most widely available HIV medications. 13 (3.4%) 126 (32.8%) 245 (63.8%) 126 (32.8%) 0.765 0.009* 0.266 0.0001* 8 Can antiviral medications (Acyclovir, Amantadine) be used to treat HIV/AIDS? 107 (27.9%) 106 (27.6%) 171 (44.5%) 107 (27.9%) 0.611 0.351 0.162 0.0004* 9 Can atients with HIV/AIDS donate blood? 369 (96.1%) 2 (0.5%) 13 (3.4%) 369 (96.1%) 0.509 0.841 0.881 0.838 10 Is ost-exosure HIV rohylaxis recommended after a needlestick injury? 45 (11.7%) 199 (51.8%) 140 (36.5%) 199 (51.8%) 0.870 0.003* 0.545 0.0003* 1118 Journal of Dental Education Volume 75, Number 8
11 Are HIV and AIDS synonyms? 336 (87.5%) 44 (11.5%) 4 (1.0%) 336 (87.5%) 0.536 0.119 0.828 0.0001* 12 Can HIV infection develo into AIDS within a year? 98 (25.5%) 178 (46.4%) 108 (28.1%) 98 (25.5%) 0.230 0.892 0.404 0.042* 13 The risk of HIV infection after a needlestick is about 50-75%. 145 (37.8%) 88 (22.9%) 150 (39.1%) 145 (37.8%) 0.101 0.950 0.446 0.0002* 14 Heatitis B is mainly transmitted through sexual contact or blood. 38 (9.9%) 303 (78.9%) 43 (11.2%) 303 (78.9%) 0.408 0.602 0.928 0.0005* 15 In health care rofessionals, heatitis B can be transmitted through blood slashing into mucous membranes of the eye or mouth. 17 (4.4%) 309 (80.5%) 58 (15.1%) 309 (80.5%) 0.675 0.274 0.762 0.0006* 16 In health care rofessionals, heatitis B can be transmitted through mechanical skin injury. 26 (6.8%) 309 (80.5%) 49 (12.8%) 309 (80.5%) 0.980 0.262 0.897 0.0002* 17 Heatitis B virus and heatitis C virus-infections can result in chronic heatitis and liver cancer. 8 (2.1%) 336 (87.5%) 40 (10.4%) 336 (87.5%) 0.100 0.616 0.960 0.0001* 18 Is a heatitis C vaccine available? 251 (65.4%) 72 (18.8%) 61(15.9%) 251 (65.4%) 0.748 0.946 0.756 0.0001* 19 Should individuals with heatitis B or C infection receive dental treatment in hosital? 218 (56.8%) 104 (27.1%) 62 (16.1%) 218 (56.8%) 0.037* 0.634 0.715 0.088 20 Do health care rofessionals belong to the high-risk grou for heatitis virus infections? 15 (3.9%) 354 (92.2%) 15 (3.9%) 354 (92.2%) 0.921 0.783 0.075 0.007* 21 The risk of heatitis C infection after a needlestick is about 50-75%. 56 (14.6%) 125 (32.6%) 203 (52.9%) 56 (14.6%) 0.981 0.423 0.044* 0.001* 22 Vaccination against heatitis B is an efficient rotection against infection after an infected needlestick. 55 (14.3%) 252 (65.6%) 77 (20.1%) 252 (65.6%) 0.592 0.412 0.772 0.0002* 23 Are you familiar with the rocedure in case of a needlestick injury? 227 (59.1%) 133 (34.6%) 24 (6.3%) no correct answer 0.248 0.367 0.393 0.0001* *Significant difference (<0.05); these numbers are also in bold. Note: Percentages may not total 100% because of rounding. August 2011 Journal of Dental Education 1119
Figure 1. Students ersonal knowledge exressed as the number of correct answers er student (mean±sd) senior students were less willing to agree with the statement regarding routine yearly HIV and heatitis testing of health care rofessionals, as well as with the statement that dentists with HIV or heatitis should cease their occuational activity (=0.001 and =0.0003, resectively). Finally, senior students felt less confident in their cometence to treat HIV atients (=0.01). Students attitudes toward education on the treatment of atients with HIV, HBV, and HCV were assessed by seven questions with yes and no answers (Table 5). The great majority of the students (97.4 ercent) thought that theoretical education on the dental treatment of atients with HIV, HBV, and HCV should be obligatory in the curriculum, while 84.4 ercent suorted the idea of a searate course that would include theoretical and ractical knowledge about atients with HIV, HBV, and HCV. More than half of the resondents (51.8 ercent) stated that they had not dealt with roblems dental treatment of atients with HIV and heatitis during their education. Although 69.3 ercent of resondents thought that treating several atients with HIV and heatitis would influence their attitudes toward them, only 58.1 ercent exressed a willingness to treat these atients and acquire greater self-confidence. Nearly two-thirds (62.5 ercent) felt that they would be cometent enough to treat atients with HIV and heatitis after finishing their education. However, a significantly lower roortion of senior students gave an affirmative answer to this question than their junior colleagues (55.1 ercent vs. 75.2 ercent; =0.0002). Relationshi Among Factors Searman s rank correlation coefficient (r) was used for the assessment of the relationshi between ersonal knowledge and attitudes toward atients with HIV, HBV, and HCV, as well as the relationshi between ersonal knowledge and risk ercetion toward the treatment of the these atients (Table 6, only ositive correlations are shown). Personal knowledge ositively correlated with the attitude that dentists have a rofessional obligation to treat atients with HIV and the attitude that all atients should be considered otentially infectious (=0.0003 and =0.0002, resectively). Furthermore, ersonal knowledge ositively correlated with the attitude that standard rotective equiment (gloves, mask, glasses) rovides sufficient safety against infection (=0.023). Negative correlations between ersonal knowledge and the lack of willingness to treat atients with heatitis, as well as between ersonal knowledge and unwillingness to treat intravenous drug users, were observed 1120 Journal of Dental Education Volume 75, Number 8
Table 3. Students attitudes toward atients with HIV/AIDS, HBV, and HCV infection Statement Level of agreement with statement 1 2 3 4 5 gender high school education arents rofession (health care rofessionals vs. others) between senior and junior students Dentists have a rofessional obligation to treat atients who are HIV-ositive. 3.1% 6.5% 17.2% 37% 36.2% 0.844 0.521 0.475 0.0002* I would refer not to treat atients who are HIV-ositive. 13.8% 22.7% 35.7% 16.7% 11.2% 0.615 0.592 0.679 0.186 Patients who are HIV-ositive are themselves resonsible for their condition. 12.2% 32.3% 44.5% 6.8% 3.9% 0.088 0.164 0.847 0.306 Patients who are HIV-ositive should have a legal obligation to inform their dentists about their disease. 3.4% 1.3% 1.8% 7.8% 85.7% 0.572 0.798 0.361 0.089 Patients with HIV or heatitis should receive dental treatment in secialized clinics. 2.6% 12.0% 21.9% 34.1% 29.4% 0.265 0.369 0.486 0.025* Because of an increased risk of infection, I would refer not to treat atients with heatitis. 14.6% 43.5% 27.3% 10.4% 4.2% 0.359 0.408 0.418 0.033* Because of the risk of heatitis infection, I would refer not to treat intravenous drug users. 13.0% 40.1% 28.4% 12.8% 5.7% 0.165 0.602 0.982 0.016* If I found out that my longtime atient had HIV or heatitis, I would sto treating him. 26.6% 48.2% 18.2% 4.2% 2.9% 0.225 0.606 0.013* 0.433 If a atient informed me about having an infectious disease, I would sto treating him. 27.6% 50.3% 16.4% 2.1% 3.6% 0.501 0.009* 0.370 0.166 Dentists should have the oortunity to refuse to treat atients with HIV or heatitis. 6.0% 13.0% 27.9 35.2% 18.0 0.419 0.670 0.234 0.302 *Significant difference (<0.05); these numbers are also in bold. Note: Percentages may not total 100% because of rounding. August 2011 Journal of Dental Education 1121
Table 4. Students risk ercetion the treatment of atients with HIV, HBV, and HCV Statement Level of agreement with statement 1 2 3 4 5 gender high school education arents education (health care rofessionals vs. others) between senior and junior students All atients should be considered otentially infectious. 2.1% 3.1% 3.6% 29.7% 61.5% 0.343 0.189 0.871 0.0002* All health care rofessionals should go for mandatory HIV and heatitis testing once a year. 1.3% 2.3% 9.6% 33.1% 53.6% 0.018* 0.152 0.399 0.001* Standard rotective equiment (gloves, mask, glasses) rovides sufficient safety against infection. 3.6% 20.6% 31.0% 36.2% 8.6% 0.737 0.043* 0.962 0.055 I feel cometent enough to rovide dental care to atients with HIV/AIDS. 7.8% 26.0% 42.2% 19.3% 4.7% 0.444 0.188 0.848 0.010* I believe that routine dental treatment carries significant risk of HIV and heatitis infection. 1.0% 14.3% 27.9% 40.1% 16.7% 0.025* 0.092 0.408 0.075 In case of an infection at the work lace, I would artially accet resonsibility. 1.8% 7.8% 36.5% 46.4% 7.6% 0.364 0.233 0.189 0.960 Nowadays, there are 100% efficient methods of disinfection and sterilization of instruments used with atients with HIV, HBV, and HCV. 3.4% 17.4% 26.0% 37.2% 15.9% 0.376 0.781 0.148 0.005* Dentists having HIV or heatitis should cease their occuational activity. 10.4% 33.6% 32.0% 13.3% 10.7% 0.638 0.806 0.111 0.0003* *Significant difference (<0.05); these numbers are also in bold. Note: Percentages may not total 100% because of rounding. 1122 Journal of Dental Education Volume 75, Number 8
Table 5. Students attitudes toward education on the treatment of atients with HIV, HBV, and HCV Question Answer No Yes gender high school education arents education (health care rofessionals vs. others) between senior and junior students Do you think that after finishing your university education you will be cometent enough to treat atients with HIV or heatitis? 37.2% 62.5% 0.243 0.002* 0.660 0.0002* Do you think that treating several atients with HIV and heatitis would influence your attitudes toward them? 30.7% 69.3% 0.581 0.916 0.852 0.445 During your study, are you willing to treat atients with HIV and heatitis and acquire greater self-confidence in this way? 41.4% 58.1% 0.761 0.465 0.360 0.892 Should your assistant/nurse be educated for treatment of atients with HIV and heatitis? 2.6% 97.4% 0.457 0.315 0.336 0.655 Should theoretical education about dental treatment of atients with HIV and heatitis during your study be obligatory? 2.1% 97.9% 0.197 0.845 0.776 0.963 Should there be a searate course that would comrise theoretical and ractical knowledge about atients with HIV and heatitis? 15.6% 84.4% 0.099 0.135 0.402 0.554 Have you been dealing with the roblems dental treatment of atients with HIV and heatitis during your education? 51.8% 48.2% 0.566 0.671 0.453 0.0003* *Significant difference (<0.05); these numbers are also in bold. Note: Percentages may not total 100% because of rounding. August 2011 Journal of Dental Education 1123
Table 6. Relationshi between students knowledge and attitudes toward atients with HIV, HBV, and HCV Statement Searman s rank correlation coefficient (r) Dentists have a rofessional obligation to treat atients who are HIV-ositive. 0.219 0.0003* All atients should be considered otentially infectious. 0.241 0.0002* Standard rotective equiment (gloves, mask, glasses) rovides sufficient safety against infection. Because of an increased risk of infection, I would refer not to treat atients with heatitis. Because of the risk of heatitis infection, I would refer not to treat intravenous drug users. 0.116 0.023* -0.143 0.005* -0.123 0.016* Dentists having HIV or heatitis should cease their occuational activity. -0.225 0.0001* If I found out that my longtime atient had HIV or heatitis, I would sto treating him. -0.119 0.02* *Significant difference (<0.05); these numbers are also in bold. (=0.005 and =0.016). A negative correlation was also found between ersonal knowledge and the attitude that dentists with HIV or heatitis should cease their occuational activities (=0.0001). Finally, a negative correlation was observed between ersonal knowledge and the statement If I found out that my longtime atient had HIV or heatitis, I would sto treating him (=0.02). Discussion The results of this study show that Croatian dental students knowledge regarding HIV and viral heatitis increased during the course of study. Indeed, the number of correct answers increased with each year of study. First-year students gave the greatest number of correct answers to two out of twenty-five questions, while fifth-year students gave the highest number of correct answers to twelve out of twentyfive questions. This clearly shows that, with advances through years of education, students total knowledge of these subjects increases. This fact can be associated with an increasing number of courses that focus more on the care of medically comromised atients. The rogress is esecially evident in the examle that no first-year student correctly answered the question Is ost-exosure HIV rohylaxis recommended? while 70.4 ercent of fifth-year students gave the correct answer. A considerable advance in the knowledge of the ossibility of HIV transmission through saliva was observed, with 95.3 ercent knowing that HIV was not transmitted through saliva, as oosed to research from 1999, in which 38.6 ercent of students at the Zagreb School of Dental Medicine thought saliva was one of the ossible ways of HIV transmission. 6 However, certain gas in their knowledge were also found. Almost one-fifth of the resondents (18 ercent) thought HIV could be transmitted through social contact (shaking hands, kissing, sharing glasses, clothes, etc.). This is consistent with results reorted by Suh-Woan et al., 7 in which 17.6 ercent of Taiwanese dental students thought there was a considerable risk of HIV transmission by kissing. Furthermore, our students largely overestimated the risk of HIV and HCV infection after occuational exosure and rovided the correct answer to the question The risk of HIV/HCV infection after an occuational exosure is about 50-75 ercent in 37.8 and 14.6 ercent of cases, resectively. These results are similar to those from the study in Taiwan, 7 in which 18 ercent and 39.9 ercent, resectively, of the students resonded correctly to a question about the transmission rates of HIV and HCV. Seacat and Inglehart 8 reorted that 44.4 ercent of dental students in their study gave the correct answer to a question about the risk of HIV infection after a needlestick injury. Students in our study with at least one arent who is a health care rofessional gave a significantly higher number of correct answers to the question about HCV transmission rates (18 ercent vs. 10.4 ercent; <0.05). This difference can be exlained 1124 Journal of Dental Education Volume 75, Number 8
by health care rofessionals being better informed about the risks of HCV transmission. However, the total ercentage of correct answers was very low (14.6 ercent), indicating a need for more thorough education of students regarding transmission risks after occuational exosure. Personal knowledge, assessed by the number of correct answers er student, also increased during the course of study. A significant difference in ersonal knowledge was observed between senior and junior students (19.12±2.26 vs. 15.03±2.49 correct answers er student). This finding may be exlained by the fact that, in the third year, students comlete their reclinical courses and begin with clinical ractice. At the beginning of clinical rounds in each deartment, students are introduced to infection control rocedures and the roer use of ersonal rotection equiment. The risks of rofessional infection with HIV, HBV, and HCV are discussed. Furthermore, the third-year curriculum includes a course on infectious diseases, which may also contribute to students knowledge about HIV, HBV, and HCV. Social factors (gender, high school education, and arents rofession) did not influence ersonal knowledge. The resonding students attitudes toward atients with HIV, HBV, and HCV also seemed to change during the course of the study. Senior students had more rofessional attitudes and were less willing to agree with the statement that atients with HIV, HBV, and HCV should receive dental treatment in secialized clinics. Furthermore, senior students were more willing to treat intravenous drug users and atients with heatitis. The attitude that dentists have a rofessional obligation to treat HIV atients was significantly more suorted by senior students. Risk ercetions about the treatment of atients with HIV, HBV, and HCV is an imortant factor in education; therefore, the emhasis across the course of study should be on develoing awareness of real risks of infection transmission during dental treatment. This is esecially emhasized by the fact that more than half (56.8 ercent) of the students in our study agreed or strongly agreed that there was a high risk of HIV and heatitis infection in everyday atient treatment. Female resondents exressed significantly higher agreement with this statement: 61.3 ercent agreed or strongly agreed with the statement as oosed to 46 ercent of male students. This could be exlained by the fact that female students exress greater fear of rofessional injury than male students and reort more occuational exosures. 9,10 It is also necessary to imrove how well students are informed about ersonal rotection, since less than half of those in our study (44.8 ercent) believed that measures of ersonal rotection rovided sufficient security against infection. Gender, high school education, and arents rofession seemed not to influence attitudes and risk ercetion. Even though some minor differences existed, these were more ronounced in the junior years. It seems that the imact of social factors fades during education and new knowledge strongly influences attitudes and risk ercetion. The need for further education and training on this toic has been emhasized by the fact that the great majority (84.4 ercent) of resonding students thought that there should exist a searate course that would cover theoretical and ractical knowledge about atients with HIV, HBV, and HCV, as well as by the finding that the majority of the students (58.1 ercent) were willing to treat these atients in order to increase their self-confidence. Forty-nine to 81.1 ercent of the resondents in revious studies were reorted to be willing to treat atients with heatitis and/or HIV. 7,11-15 The imortance of treating atients with HIV, HBV, and HCV has been emhasized by Kuthy et al., 16 who reorted that students willingness to treat these atients increased with clinical exerience. Even though the majority of the students (62.5 ercent) in our study felt that after graduation they would be cometent to treat atients with HIV, HBV, and HCV, it is imortant to emhasize that senior students gave significantly fewer affirmative answers to this question than junior students (55.1 ercent vs. 75.2 ercent). This is worrisome because it is exected that senior students should have greater knowledge and self-confidence toward the treatment of these atients. Solomon et al. 17 reorted that 80 ercent of final-year dental students in their study considered themselves cometent to rovide dental treatment to atients with HIV/AIDS. This additionally emhasizes the need for theoretical and ractical education of dental students on this toic. Our study found a ositive correlation between students ersonal knowledge and the attitude that all atients should be considered otentially infectious and that standard rotective equiment (gloves, mask, glasses) rovides sufficient security against infection. This leads to the conclusion that students with better knowledge are more willing to treat atients with HIV, HBV, and HCV, being also aware that standard rotection rovides sufficient security from infection. Furthermore, a negative correlation was established between ersonal knowledge and the lack of willingness to treat heatitis atients and intravenous August 2011 Journal of Dental Education 1125
drug users. Students with oorer knowledge referred not to treat atients with heatitis and intravenous drug users significantly more because of an increased risk of infection. All the aforementioned correlations lead to the conclusion that knowledge lays an imortant role in forming attitudes toward atients with HIV, HBV, and HCV. By imroving knowledge of risks, ercentages, and means of transmission, dental students may become more ready to treat these atients and less inclined to hold discriminatory attitudes. Conclusions The results of this study rovide insight into a toic that finds many eole still holding numerous unfounded negative attitudes toward atients with HIV, HBV, and HCV. Based on the results of our study, the following conclusions can be drawn about this grou of students: The level of their knowledge of infectious diseases and routes of their transmission increases with each year of study. The senior students showed a more ositive aroach and less inclination toward forming discriminating attitudes toward atients with HIV, HBV, and HCV, in comarison with junior students. The level of ersonal knowledge lays a very imortant role in forming these students attitudes and risk ercetion regarding atients with HIV, HBV, and HCV. Social factors such as gender, high school education, and arents rofession have minimal imact on these students knowledge, attitude formation, and risk ercetion. These future dentists show willingness and a need for further theoretical and ractical education on the dental treatment of atients with HIV, HBV, and HCV. REFERENCES 1. Scully C, Greensan JS. Human immunodeficiency virus (HIV) transmission in dentistry. J Dent Res 2006;85(9):794 800. 2. Tarantola A, Abiteboul D, Rachline A. Infection risks following accidental exosure to blood or body fluids in health care workers: a review of athogens transmitted in ublished cases. Am J Infect Control 2006;34(6):367 75. 3. Eidemiology service of Croatian institute for ublic health Zagreb. At: www.hzjz.hr/eidemiologija. Accessed: Aril 26, 2010. 4. Lakošeljac D, Rukavina T. Eidemiology of heatitis C viral infection. Medicina 2007;43:112 17. 5. Vucicevic-Boras V, Cekic-Arambasin A, Alajbeg I, Biocina-Lukenda D, Blazic-Potocki Z, Ognjenovic M. Dentists knowledge of HIV infection. Acta Stomatol Croat 2001;35(1):9 13. 6. Vucicevic-Boras V, Cekic-Arambasin A, Alajbeg I, Biocina-Lukenda D. Fifth-year dental students knowledge of HIV infection. Acta Stomatol Croat 1999;33(4):401 5. 7. Suh-Woan HU, Hsiang-Ru L, Pao-Hsin L. Comaring dental students knowledge of and attitudes toward heatitis B virus-, heatitis C virus-, and HIV-infected atients in Taiwan. AIDS Patient Care STDS 2004;18(10):587 93. 8. Seacat JP, Inglehart MR. Education about treating atients with HIV infections/aids: the student ersective. J Dent Educ 2003;67(6):630 40. 9. Wood AJ, Nadershahi NA, Fredekind RE, Cuny EJ, Chambers DW. Student occuational exosure incidence: ercetion versus reality. J Dent Educ 2006;70(10):1081 8. 10. Younai FS, Murhy DC, Kotelchuck D. Occuational exosures to blood in a dental teaching environment: results of a ten-year surveillance study. J Dent Educ 2001;65(5):436-48. 11. Cohen LA, Romberg E, Grace EG, Barnes DM. Attitudes of advanced dental education students toward individuals with AIDS. J Dent Educ 2005;69(8):896 900. 12. Sadeghi M, Hakimi H. Iranian dental students knowledge of and attitudes towards HIV/AIDS atients. J Dent Educ 2009;73(6):740 5. 13. Azodo CC, Ehigiator O, Oboro HO, Ehizele AO, Umoh A, Ezeja EB, et al. Nigerian dental students willingness to treat HIV-ositive atients. J Dent Educ 2010;74(4):446 52. 14. Kuthy RA, McQuistan MR, Rinker KJ, Heller KE, Qian F. Students comfort level in treating vulnerable oulations and future willingness to treat: results rior to extramural articiation. J Dent Educ 2005;69(12):1307 14. 15. Rankin KV, Jones DL, Rees TD. Attitudes of dental ractitioners and dental students towards AIDS atients and infection control. Am J Dent 1993;6:22 6. 16. Kuthy RA, Heller KE, Riniker KJ, McQuistan MR, Qian F. Students oinions about treating vulnerable oulations immediately after comleting community-based clinical exeriences. J Dent Educ 2007;71(5):646 54. 17. Solomon ES, Gray CF, Gerbert B. Issues in the dental care management of atients with bloodborne infectious diseases: an oinion survey of dental school seniors. J Dent Educ 1991;55(9):594 7. 1126 Journal of Dental Education Volume 75, Number 8