Article Journal Club Discussion

Compliance of Saudi dental students with

infection control guidelines

Dr. Priyanka Sharma1st year Post Graduate Dept. of Public Health Dentistry

INFECTION: Invasion and multiplication of microorganisms in body tissues, which may be clinically unapparent or result in local cellular injury due competitive metabolism, toxins, intracellular replication or antigen antibody response.

The infection may remain localised, subclinical and temporary if the body's defensive mechanisms are effective.

A local infection may persist and spread by extension to become an acute, sub-acute or chronic clinical infection or disease state.

A local infection may also become systemic when the microorganisms gain access to the lymphatic or vascular system.

INFECTIOUS DISEASE : The pathological state resulting from the invasion of the body by pathogenic microorganisms and their multiplication which can lead to tissue damage and diseases.

PORTAL

ENTRY

MICROORGANISMS

INVASION

INFECTIOUS DISEASES IN DENTISTRY

INFECTION CONTROL Infection control is the discipline concerned with preventing

nosocomial or healthcare-associated infection, a practical (rather than academic) sub-discipline of epidemiology.

Infection control and hospital epidemiology are akin to public health practice, practiced within the confines of a particular health-care delivery system rather than directed at society as a whole.

Concepts in dental infection control were developed in the 1960s (due to Hepatitis-B viral infections).

Disease transfer to the dentist and dental staff during dental care is considered an “occupational exposure” to a given pathogen, while disease transfer from one patient to another in the dental clinics is considered “cross-infection”.

Decontamination & Spaulding’s Classification

Spaulding’s Classification

INTRODUCTION

Infection control is today without doubt an integral part of contemporary dental practice.

The repeated exposure of dental health-care professionals (DHCPs) to pathogenic microorganisms causing diseases such as the common cold, pneumonia, tuberculosis, hepatitis B and acquired immune deficiency syndrome places them at a greater risk of acquiring and spreading

Infections.

A number of cross-infection guidelines have been advocated by health and professional organisations to prevent or reduce the potential for disease transmission between DHCPs and the patients and between the patients themselves.

The compliance of DHCPs with these guidelines has been investigated by a number of studies worldwide.

The results of these reports showed variations in implementation of the recommended guidelines and a need to improve adherence to some aspects of infection control practices.

There is little information regarding compliance with universal control precautions in the Middle East in general and Saudi Arabia in particular.

AIM OF THIS STUDY

To investigate the compliance of dental students in a private school in Saudi Arabia with recommended cross-infection protocols.

MATERIALS AND METHODS

The study was conducted in full accordance with the World Medical Association Declaration of Helsinki and ethical clearance was obtained from the research centre of the institution.

The study sample included undergraduate students in their clinical years (fourth to sixth year) and dental interns.

The students were asked to complete a self-administered, anonymousquestionnaire.

The questionnaire was developed after consulting with specialists from each dental specialty at the teaching hospital and based on similar

questionnaires used in the past.

The initial questionnaire was then tested for reliability and reproducibility using Cronbach’s alpha.

The initial questionnaire had a Cronbach’s alpha of 0.86, with scores for items ranging from 0.79 to 0.91, suggesting good reliability.

The questionnaire included 18 questions that evaluated:

(1) demographic data (gender and academiclevel)

(2) Recording patient’s medical history and students’hepatitis B virus (HBV) vaccination status

(3) use of personal protective equipment

(4) Sterilisation and/or disinfection of patient-care items

(5) Disposal of sharp medical objects.

STATISTICAL ANALYSIS

The data were tabulated and analysed using the Statistical Package for Social Science (SPSS for Windows version 17.0; SPSS Inc, Chicago,

IL, USA).

Data analysis included descriptive statistics and Pearson’s chi-square test was used to assess differences in infection control practices

according to the gender and academic level of the respondents.

A probability value of < 0.05 was considered statistically significant.

RESULTS

Overall, 311 students (93.9%) responded to the survey.

The distribution of respondents by academic leveland gender is shown :

About 99% reported that they usually review the medical history of their patients before commencing dental treatment and 80% were vaccinated against hepatitis B.

Among the personal protective equipment, the highest compliance rates were reported for wearing (100%) and changing (98.5%) gloves between

patients.

Face mask ranked second: 98% of students reported that they wore it routinely and about 80% changed it between patients.

However, fewer subjects wore gowns (57%) while only one-third of the sample used the face shield and eye glasses on a routine basis.

Almost all the students (99%) changed hand instruments and burs between patients and all of them changed saliva ejectors between patients.

Routine disinfection of impressions and prostheses was undertaken by 87% and 74% of the respondents, respectively.

Finally, 99% of the study sample used a rubber dam and 91% discardedsharp objects in special containers.

Pearson’s chi-square test showed that HBV vaccination status was the only infection control procedure that differed significantly between the academic levels: more of the fourth year students and the dental interns received the vaccine compared with the final undergraduate years students (fifth and sixth years).

When evaluating the effect of gender, male respondents reported significantly more disinfection of dental prostheses.

DISCUSSION There are many possible routes for the transmission of infection within

dental procedures, including direct contact with blood, oral fluids and other secretions or indirect contact with contaminated instruments, operatory

equipment and environmental surfaces.

Infection may even occur as a result of contact with droplets, splatter, airborne contaminants and aerosols.

Adherence to various aspects of universally recommendedguidelines is therefore critical to prevent cross-infection between the health providers and patients, and indeed the patients themselves.

MEDICAL HISTORY A thorough medical history must be recorded and reviewed before

starting the dental treatment and updated at subsequent visits.

It may help in detection of infectious diseases and provides clues about what precautions are necessary for patients having medical problems that require pre-medications or modifications of treatment applied.

Given that the identification of infectious diseases through medical history, physical examination or laboratory tests may not always be possible, the Centre of Disease Control and Prevention (Atlanta, GA,USA) introduced the concept of ‘universal precautions’.

The concept states that each patient must be considered as ‘potentially infectious’ and all patients must be treated under the same infection control measures.

In this study, 99% of the respondents reported that they recorded the medical history of their patients before commencing dental treatment.

This rate is higher than that reported in earlier studies.

VACCINATION AGAINST HBV

Dental health-care professionals are at an increased risk of acquiring hepatitis B infection and therefore must be vaccinated against it.

About 80% of the respondents received an HBV vaccination, thus fallingin the range reported by previous studies.

The high response rate in this study may be attributed to the fact that colleges provide immunisation schedules for DHCP staff.

However, the fact that about 20% of the students were at risk of HBV infection because of a lack of immunisation was a serious cause for concern.

To overcome this negative aspect, it is recommended that students be immunised during their preparatory study years before they start their

clinical work.

PERSONAL PROTECTIVE EQUIPMENT The purpose of personal protective equipment (PPE) is to protect the

skin and mucous membrane of the eyes, nose and mouth of the DHCP from exposure to patients’ blood or fluids and in an oral health setting these would include gloves, mouth masks, face shields, protective eyewear and protective clothing such as gowns or jackets.

Gloves are perhaps the most commonly used PPE, preventing contamination of the DHCP’s hands while touching mucous membranes blood or saliva and at the same time preventing transmission of microorganisms from the hands of the DHCP to the patient.

A new pair of gloves must be worn for each patient and changed when punctured or torn.

Exposure to disinfectants can cause defects in gloves, diminishing their value as an effective barrier, repeated use of gloves after disinfection between patients should be avoided.

All the study sample wore gloves and 98.5% changed them between patients.

This compliance with routine glove-wearing and -changing comparesfavourably with previously published studies which showed that the routine use of gloves increased from as low as 23% in late 1980s to 100% now.

The second highest level of compliance was reported for wearing (98%) and changing (81%) face masks.

The current usage rate reported in the dental literature is in the range of 26–96.5%.

In contrast, fewer applicants wore face shields (30%) and protective eye glasses (28%).

Indeed, the routine use of the latter barriers is low among the dentists all over the world.

Efforts must be made to encourage the routine use of these measures among students, especially when air aerosols are expected to form (i.e. during scaling or cavity preparation).

In this context, additional protection may be achieved by theregular use of a rubber dam, as this was shown to significantlyreduce bacterial contamination of the atmosphere during restorative procedures.

Fortunately, 99% of the students in this study used a rubber dam for all restorative procedures, in comparison with 40% of the dentists in South Africa and 13.6% of Jordanian dentists and 29.8% of undergraduate Indian students.

STERILISATION & DISINFECTION OF PATIENT-CARE ITEMS

Patient-care items are generally categorised into critical, semi-critical or non-critical items.

Critical items must be sterilised while disinfection and/or surface protection is generally adequate for semicritical and non-critical items.

Of particular concern are dental handpieces which should be heat-sterilised between patients despite the fact that they are classified

as semi-critical items.

In the current study, almost all the respondents (99%) used sterilised kits of hand instruments and dental burs for each patient and 98% changed the

handpieces after each patient.

In contrast to a number of published studies, 100% of respondents changed saliva ejectors between patients, reflecting a high level of

compliance with recommended guidelines.

A risk of infection of laboratory technicians by saliva or blood-borne infections such as HBV has been documented.

Therefore, items such as impressions, casts, jaw relation records, prosthetic restorations and devices that have been in the patient’s mouth must be disinfected before they are sent to a dental laboratory.

In the current study, 87% of the respondents disinfected impressions before sending them to dental laboratories compared with the 53.7% reported by Yengopal et al and 18.1% by Al-Omari & Al-Dwairi.

However, only 74% of the study sample disinfected dental prostheses before insertion into their patients’ mouths.

Additional education is required to promote routine disinfection of impressions and prostheses.

DISPOSAL OF WASTE MATERIALS

Waste materials must be handled carefully and discarded to minimise human contact. Disposable materials such as gloves, masks, wipes, paper drapes and surface covers that are contaminated with blood or body fluids should be discarded in sturdy, impervious plastic bags.

Sharp items, such as needles and scalpel blades, should be placed into puncture-resistant containers before disposal in plastic bags.

In previous studies, 8–75% of dentists used puncture-resistant containers compared with 91% of the respondents in this study.

It has been previously noted that students tend to be more meticulous in following infection control protocols than practising dentists and the results of this study confirm that finding.

Why do more dental students than practising dentists comply with infection control protocols? Three reasons may account for the

difference.

First, during their study the students are willing to learn and practise the different aspects of their future career.

Second, cost/fee considerations, which have been shown to be a barrier for routine implementation of cross-infection protocols, are usually

not applicable in a dental school setting.

Third, implementation of these measures is mandatory in the academic institution and forms part of the student’s evaluation.

This cohort of students may be surveyed again in their future practices to see if their compliance rate has been maintained.

The findings of this study must be seen as the practices in a single school and cannot be considered as being representative of students across Saudi Arabia.

However, the findings could serve as a template for the planning and implementation of future interventions, including a national survey of schools and practitioners across the country.

Further research would be needed to correlate observational data and correlate those findings with the responses on the questionnaires.

CONCLUSIONS

Dental students have an increased awareness of the implementation of effective cross-infection control measures.

However, further improvement is needed in a number of areas such as vaccination against HBV, the wearing of eye glasses, face shields and gowns, and disinfection of dental prostheses before insertion

into the patients’ mouths.

These areas may be addressed by short-term courses and continuing education programmes, particularly those involving practical component.

REFERENCES

28 References

Vancouver system of referencing.

CRITICAL APPRAISAL

SOURCE OF THE ARTICLE

International Dental Journal

It is an international, quarterly, peer reviewed and indexed journal.

Mesh Representation : Int Dent J.

Impact Factor : 1.04

Online ISSN : 1875-595X

Print ISSN : 0045-0421

Publisher : John Wiley & sons

Editor : Dr Stephen Hancocks

Year of publication : June 2013

Volume No : 63; Issue No : 2; Page nos. : 196-201

DOI: 10.1111/idj.12030

AUTHORS

1) Ibrahim Ali Ahmad

2) Elaf Ali Rehan

3) Sharat Chandra Pani

The authors’ institutional attachments have been stated .

Designation & Qualifications are not mentioned.

AUTHOR DETAILSIbrahim Ali Ahmad

Asst. Prof. of Endodontics

Restorative Dentistry Department, Riyadh Colleges of Dentistry and Pharmacy, Saudi Arabia

Publication – 1

Area of interest – Infection control

Elaf Ali Rehan

Publication – 1

Area of interest – Infection control

Sharat Chandra Pani

PhD in Physics

Indira Gandhi Centre for Atomic Research

Publications – 83

Area of interest – Molecular dynamics, Quantum chemistry, Density funtional theory, Material modelling, Structural property coefficeint.

CRITICAL APPRAISAL OF THE TITLE

Title is catchy (7 words).

It is meaningful.

It includes all the important variables intended to be measured.

It indicates topic and focus of the study.

Gives an idea about study population.

Does not give an idea about study design and study setting,

PROPOSED ALTERNATE TITLE

Compliance with Infection Control Guidelines among

students in a Saudi Arabian Dental School – A Cross

Sectional Study.

(14 words)

Unstructured .

Informative and comprehensive .

Gives a brief outline of the whole text.

Total words : 222

KEYWORDS

Compliance, dental students, hepatitis B, infection control, Kingdom

of Saudi Arabia

Keywords are appropriate - 1st article in pubmed

ABSTRACT

Meaningful and concise.

Built on existing literature..

Logically presented.

Citations (24) are relevant and pertinent to study being reported.

The scientific background and rationale for the study have been

stated.

Objectives of the study are mentioned.

Hypothesis to be tested is NOT also stated.

CRITICAL APPRAISAL OF INTRODUCTION

Research Question : Is there presence of compliance of dental

students in a private school in Saudi Arabia with recommended

cross-infection protocols?

Null Hypothesis: There is presence of compliance of dental

students in a private school in Saudi Arabia with recommended

cross-infection protocols.

Alternative Hypothesis: There is absence of compliance of dental

students in a private school in Saudi Arabia with recommended

cross-infection protocols.

CRITICAL APPRAISAL OF MATERIALS AND METHODS

Methodology represented is logical and meaningful .

Key elements of study design are mentioned .

Study population ,and data collection are clearly stated.

Basic explanation about the validation of the questionnaire is given.

The eligibility criteria ,the sources , methods of selection of

participants are NOT stated.

Sample size estimation is not done .

Power of the study is not mentioned.

All variables considered for and included in the analysis have been

defined.

All statistical methods used have been described .

Measurement of each variable have been described in detail .

P value has been stated .

Ethical clearance was obtained .

Duration of the study is not mentioned.

Informed consent from the participants?

Where it was done? College class/clinic/hostel?

Whether all the students were included?

What language is been preferred in the questionnaire?

CRITICAL APPRAISAL OF RESULTS

Characteristics of study participants has been mentioned.

All the outcome events have been reported.

Results are based on aims and objectives of the study.

Results are presented in table and text matter.

Results are logical and comprehensible.

Tables are numbered .

Data given in text matches with tables .

CRITICAL APPRAISAL OF DISCUSSION

Discussion is meaningful.

Key results has been summarized with reference to study objectives

Enough explanation of all significant results is mentioned.

Comparison has been done of current results with that of previous

literature.

Reason to select the sample population is discussed.

Limitations of the study has NOT been discussed .

“AS Exposure to disinfectants can cause defects in gloves”

AS = Aerosol (or) Arsenic (or) a printing mistake [As] X

NOT DISCUSSED ABOUT :

HIV Infection :

Whether the students have undergone HIV test ?Do the students know to handle HIV patients?

Tuberculosis Patients :

Use of HEPA filters during the contact of infected patients?

Other Vaccines?

Vaccines against influenza, measles, mumps, rubella, diphtheria, chicken pox and tetanus.

PPE:

Washing and care of the hands?

Before Sterilization / High level disinfection :

Thorough cleaning of instruments wearing heavy-duty gloves?

Prevention of contamination of radiographic equipments?

CRITICAL APPRAISAL OF CONCLUSION

Conclusion is meaningful and based on aims and objectives of the study .

Appropriate recommendations have been made .

Acknowledgement is mentioned

Conflict of interest – none.

CRITICAL APPRAISAL OF REFERENCES

28 references.

References are given for all the citations in the text.

References are in Vancouver system of referencing.

All articles are NOT accessible online.

CROSS REFERENCES

INFECTION CONTROL IN THE PRIVATE DENTAL SECTOR IN RIYADH

Abdullah Al-Rabeah, Ashry Gad Mohamed.

Ann Saudi Med 2002;22(1-2):13-17.

AIM & OBJECTIVES: The objective of this study was to assess the infection

control practice in the private dental sector in Riyadh, Saudi Arabia.

MATERIALS & METHODS:

The study was conducted through a cross-sectional survey of private dental

practices inthe 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%) 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=1.2-12.1; OR=10.2, CI=1.61-64.8; OR=5.6, CI=1.04 -29.9,

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.

Compliance with Infection Control Programs in Private Dental Clinics in

JordanMohammad Ahmad Al-Omari, Ziad Nawaf Al-Dwairi.

Journal of Dental Education ■ Volume 69, Number 6 :2005

AIM: The aim of this study was to assess the compliance of general dental

practitioners (GDPs) in the private sector in North Jordan with infection

control measures.

MATERIALS & METHODS:

A pilot-tested questionnaire about infection control measures was

distributed in March 2004 to 120 private practices.

RESULTS:

The response rate was 91.66 percent.

About 77 percent of dentists usually ask their patients about medical

history, 36 percent were vaccinated against hepatitis B, 81.8 percent

wear and change gloves during treatment and between patients, and

54.5 percent wear and change masks during treatment and between

patients.

Most dental practitioners (95.4 percent) reported that they changed

extraction instruments and burs between patients.

All dental practitioners reported that they changed saliva ejectors

between patients, but only 41.8 percent changed handpieces between

patients.

Approximately 63 percent (69/110) used autoclaves for sterilization,

47.3 percent (52/110) used plastic bags to wrap sterilized instruments,

and

only 18 percent (20/110) disinfected impressions before sending them to

dental labs

Fourteen percent used rubber dams in their clinics, and only 31.8

percent had special containers for sharps disposal. Based on these

responses, approximately 14 percent of general dentists in this sample

were considered to be compliant with an inventory of recommended

infection control measures.

CONCLUSIONS:

In Jordan, there is a great need to provide formal and obligatory infection

control courses and guidelines for private dentists by

the Ministry of Health and the dental association in addition to distribution of

standard infection control manuals that incorporate

current infection control recommendations.

.

Compliance of Saudi dental students with infection controlguidelines