Abstract
Objectives: This study aimed to survey changes in practices of infection control (IC) procedures by dentists in Beijing between 2000 and 2010. Methods: Data were based on the feedback of 592 and 769 dentists surveyed in 2000 and 2010, respectively. Statistical analysis was conducted using Pearson’s chi-squared test. Results: Response rates of 95% (2000) and 94% (2010) were achieved. The percentages of dentists who had received training in IC were 62.96% (2000) and 76.21% (2010). Improvements in practices in 2010 over those in 2000 included increases in: the percentage of vaccination for hepatitis B virus from 32.66% to 68.14%; the routine use of gloves from 73.31% to 99.73%; the use of face shields or eyewear as protection against splatter during dental treatment from 13.94% to 95.45%; the use of protective gowns from 14.51% to 54.23%; the use of high-volume suction from 11.19% to 74.34%; routine changing of gloves between patients from 63.25% to 99.22%; pressured steam sterilisation of dental handpieces between patients from 41.24% to 96.10%, and the flushing of dental unit waterlines after each treatment from 42.01% to 73.49%. Conclusions: Although compliance with recommended IC practices by dentists in Beijing improved between 2000 and 2010, not all dentists are properly familiar with IC procedures. Education in IC in dental schools and in continuing training in hospitals, and mandatory regulations are needed to improve IC practices in dental health care settings.
Key words: Infection control, sterilisation, dentist, improvement, personal protective equipment, Beijing
INTRODUCTION
The incidence of infection with hepatitis B virus (HBV) in China is high and carriers of the hepatitis B surface antigen are reported to represent 9.75% of the total Chinese population. Among 400 HBV-infected patients, 42.5% were found to have a medical history of dental disease and 9.8% were confirmed to have been infected during dental treatment1. In addition, the numbers of people infected with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) in China have been increasing since 2006 and the incidences of these conditions have spread from high-risk groups to the general public2. Dental staff are at high risk for exposure to the blood and body fluids of HBV- or HIV-infected patients, but such patients may not be aware of their infection status and thus all dentists should follow standard precautionary procedures strictly. All blood and body fluids should be treated as potential infectious biohazards and required infection control (IC) procedures should be implemented during dental treatment processes3., 4..
However, there are few data on the compliance of Chinese dentists with necessary IC procedures. Therefore, we surveyed dentists in the Beijing area in 2000 about their practice of IC procedures. A questionnaire was designed to cover the procedures recommended by the American Dental Association in 19965. The results showed that the level of knowledge, attitudes and behaviours of dentists concerning IC rules were worrying. Since 2000, the Chinese health authorities have issued regulations concerning dental IC and enforced supervision in dental clinics. Various dental organisations and associations have provided IC training in different provinces. Beijing is the capital city of China and our concern referred to whether compliance with IC procedures had improved among Beijing dentists. We therefore conducted the survey again in 2010 and compared the results with those obtained in 2000. This study was approved by the ethical review board of Capital Medical University School of Stomatology and written consent was obtained from all participants.
METHODS
All data were based on feedback from dentists in response to the questionnaires administered in 2000 and 2010, respectively. The questionnaires were administered in the course of dental professional training sessions organised by dental authorities in Beijing. Participating dentists were drawn from various dental health care settings in Beijing, including clinics, institutes and hospitals.
The questionnaire consisted of 32 items, including questions on basic knowledge and procedures for dental IC. Such IC procedures can be sorted into five categories: HBV vaccination; basic personal protection; cleaning and disinfection of hands; personal protection against splatter during procedures, and the sterilisation of dental handpieces. The consistency of the data was confirmed, and responses were recorded and processed using SAS Version 9.1 (SAS Institute, Inc., Cary, NC, USA). The chi-squared test was employed in the statistical analyses to compare differences in the proportions of attitudes and behaviours among dentists in 2000 and 2010. This research was conducted in full accordance with the World Medical Association Declaration of Helsinki and all information obtained from participants was kept confidential.
RESULTS
A total of 592 responses were received in 2000, giving a response rate of 95%; 769 responses were received in 2010, for a response rate of 94%. Kappa values for consistency of the survey ranged from 0.65 to 1.00. Table 1 compares levels of understanding and implementation of IC procedures by Beijing dentists in 2000 and in 2010. The increases between 2000 and 2010 in the proportions of dentists practising the various procedures were statistically significant (P < 0.01).
Table 1.
Understanding and implementation of infection control procedures by Beijing dentists in 2000 and 2010
| Items | 2000 | 2010 | χ2 | P-value | ||
|---|---|---|---|---|---|---|
| Dentists (n = 592) | Dentists (n = 769) | |||||
| n | % | n | % | |||
| Received training | 373 | 62.96 | 583 | 75.81 | 26.24 | 0.000* |
| HBV vaccination | 193 | 32.66 | 524 | 68.14 | 169.48 | 0.000* |
| Use of basic personal protective equipment | ||||||
| Gloves | 434 | 73.31 | 767 | 99.73 | 225.22 | 0.000* |
| Masks | 551 | 93.05 | 751 | 97.66 | 16.96 | 0.000* |
| Hand hygiene | ||||||
| Wash hands pretreatment | 527 | 89.08 | 761 | 98.96 | 65.10 | 0.000* |
| Change gloves after every treatment | 347 | 63.25 | 763 | 99.22 | 366.66 | 0.000* |
| Wash hands after removing gloves | 427 | 72.07 | 747 | 97.14 | 176.54 | 0.000* |
| Protection against splatter during treatment | ||||||
| Wear eyewear or face shield | 83 | 13.94 | 734 | 95.45 | 924.35 | 0.000* |
| Wear gown | 86 | 14.51 | 417 | 54.23 | 226.26 | 0.000* |
| Use high-volume suction | 66 | 11.19 | 564 | 73.34 | 520.40 | 0.000* |
| Pressurised steam sterilisation of dental handpiece | 244 | 41.24 | 739 | 96.10 | 502.26 | 0.000* |
| Flush waterline after every treatment | 247 | 42.01 | 565 | 73.49 | 140.10 | 0.000* |
Chi-squared test, P < 0.01.
HBV, hepatitis B virus.
Table 2 shows the understanding and implementation by Beijing dentists of the five types of IC procedures. As the standardised rates show, the improvement from 2000 to 2010 was statistically significant (P < 0.05). However, in both 2000 and 2010, the rate of implementation of all IC measures combined decreased as the number of combined items increased. Even in 2010, the overall rate of implementation of all five types of IC measures was only 30.17%.
Table 2.
Understanding and implementation of five types of infection control procedures by Beijing dentists in 2000 and 2010
| Items | Coverage rate | χ2 | P-value | Standardised rate | 2010 : 2000 | ||
|---|---|---|---|---|---|---|---|
| 2000 | 2010 | 2000 | 2010 | ||||
| 1 Basic PPE | 52.60 | 97.53 | 394.10 | 0.000* | 53.62 | 97.50 | 1.82 |
| 2 Protection against splatter | 6.03 | 45.64 | 257.28 | 0.000* | 6.04 | 44.90 | 7.43 |
| 3 Hand hygiene | 43.05 | 95.84 | 471.25 | 0.000* | 41.25 | 95.80 | 2.32 |
| 4 HBV vaccination | 32.66 | 68.14 | 169.48 | 0.025 | 33.14 | 69.00 | 2.08 |
| 5 Sterilisation of dental handpiece | 41.24 | 96.10 | 502.26 | 0.000* | 46.51 | 95.90 | 2.06 |
| 1 + 2 | 4.86 | 44.86 | 268.09 | 0.000* | 4.97 | 44.10 | 8.87 |
| 1 + 2 + 3 | 3.35 | 43.43 | 278.86 | 0.000* | 3.51 | 42.60 | 12.14 |
| 1 + 2 + 3 + 4 | 1.51 | 30.95 | 195.02 | 0.000* | 1.59 | 30.90 | 19.43 |
| 1 + 2 + 3 + 4 + 5 | 1.17 | 30.17 | 194.14 | 0.000* | 1.32 | 30.20 | 22.88 |
Chi-squared test, P < 0.01.
1 Use of basic personal protective equipment (PPE) (gloves, masks).
2 Protection against splatter during treatment (use of eye protection, gowns, high-volume suction devices).
3 Hand hygiene (hand washing before treatment, changing gloves between treatments, hand washing after removing gloves).
4 Hepatitis B virus (HBV) vaccination.
5 Pressurised steam sterilisation of dental handpieces.
Table 3 shows attitudes and behaviours concerning IC measures among Beijing dentists in 2010. Of the 769 respondents, female dentists, dentists with fewer years of service and dentists with higher levels of education had much higher rates of HBV vaccination than male dentists, dentists with many years of service and dentists with lower levels of education (P < 0.05, P < 0.0001, P < 0.0001, respectively). Female dentists reported a higher rate of use of high-volume suction than male dentists (P < 0.05). Dentists with fewer years of service reported a higher rate of changing gloves between patients than did those with more years of service (P < 0.0001). Dentists with higher levels of education reported a higher rate of wearing gowns to protect against splatter than did those with lower levels of education (P < 0.01).
Table 3.
Attitudes and behaviour concerning infection control measures among Beijing dentists in 2010
| HBV vaccinated | Wash hands before each patient | Wear gloves | Change gloves after each treatment | Wash hands after each treatment | Wear face mask | Wear face shield or eye protection† | Wear gown† | Use heavy suction device† | |
|---|---|---|---|---|---|---|---|---|---|
| Gender | |||||||||
| Male | 62.13 | 85.77 | 98.18 | 97.44 | 83.03 | 98.53 | 75.28 | 28.89 | 39.71 |
| Female | 73.73 | 87.03 | 98.33 | 98.54 | 82.11 | 96.86 | 80.79 | 28.30 | 41.60 |
| P-value | 0.0009* | 0.3002 | 0.4072 | 0.4478 | 0.7760 | 0.3762 | 0.1874 | 0.9418 | 0.0120* |
| Time in practice, years | |||||||||
| 1–5 | 78.33 | 80.49 | 98.54 | 98.53 | 75.86 | 96.10 | 80.98 | 26.96 | 41.67 |
| 6–10 | 76.27 | 84.27 | 99.44 | 99.44 | 82.49 | 96.63 | 78.09 | 29.38 | 42.13 |
| 11–19 | 69.88 | 88.69 | 98.81 | 99.40 | 82.63 | 98.80 | 83.93 | 30.72 | 35.12 |
| 20–29 | 57.02 | 91.80 | 98.37 | 99.19 | 86.89 | 100 | 77.05 | 26.83 | 45.08 |
| ≥ 30 | 45.57 | 91.25 | 93.75 | 90.00 | 87.18 | 97.47 | 65.82 | 25.32 | 41.56 |
| P-value | < 0.0001* | 0.0327* | 0.0317* | < 0.0001* | 0.2326 | 0.0361* | 0.1253 | 0.9597 | 0.5590 |
| Education | |||||||||
| Technical secondary school | 47.17 | 90.91 | 94.55 | 100 | 90.91 | 98.15 | 69.81 | 11.54 | 41.51 |
| Junior college | 62.14 | 87.94 | 98.23 | 96.44 | 86.02 | 97.86 | 77.58 | 25.18 | 40.21 |
| Regular college | 73.48 | 84.81 | 99.05 | 99.37 | 80.25 | 97.47 | 80.38 | 31.95 | 42.36 |
| Master postgraduate | 85.92 | 78.87 | 97.22 | 98.61 | 69.01 | 94.37 | 87.50 | 29.17 | 31.94 |
| Doctor postgraduate | 85.71 | 92.86 | 100 | 100 | 85.71 | 100 | 78.57 | 64.29 | 57.14 |
| P-value | < 0.0001* | 0.3188 | 0.3883 | 0.2768 | 0.0088* | 0.6186 | 0.1956 | 0.0032* | 0.1978 |
Chi-squared test, P < 0.05.
Measures employed to protect against splatter during dental treatment.
DISCUSSION
Dental practitioners are at high risk for infection by blood-borne pathogens because they are continually exposed to blood and to saliva with blood, and may even suffer needle punctures. Some reports indicate that dentists have a higher chance of being infected by HBV than non-dental professionals. It is commonly considered that HBV is the most remarkable potential threat to dental staff, but, fortunately, HBV vaccination is available and accessible. Vaccination against HBV can obviously reduce infection rates and is effective in 95% of cases6., 7.. However, the rate of vaccination among the Beijing dentists surveyed in this study was not high. Although the vaccination rate of dentists in the Beijing area increased from 32.66% in 2000 to 68.14% in 2010, it remains lower than reported rates of 88% in Scotland, 92.3% in Canada, 74% in Berlin and 72.6% in Jordan8., 9., 10., 11.. Moreover, the vaccination rate derived from responses to our questionnaire may be higher than the actual rate derived from available serological evidence. Thus, fewer than 67% of Beijing dentists are really protected by the HBV vaccine. The reasons why dentists are unwilling to receive vaccinations include: concern over the safety of the vaccine; unavailability of the vaccine; inconvenience of receiving vaccination, and lack of awareness of the seriousness of HBV disease10. In Beijing dentists, vaccination rates are associated with the following factors: sex; length of time in practice, and educational level. Vaccination rates of > 70% were found among female dentists, dentists who had practised for < 19 years and dentists who had completed at least undergraduate education. Improving rates of HBV vaccination and further protecting the safety of dentists will require legal action to enforce dental employers and employees to, respectively, provide and receive HBV vaccination. Meanwhile, ongoing training should be developed to help dentists improve their understanding of infectious diseases and protective measures against them.
The use of personal protective equipment (PPE) is a basic protective measure. Dental professionals should always be cautious about the risk of disease infection and should use such items habitually.
In the course of administering dental treatment, dentists can be exposed to colonisation in the oral cavity and respiratory tract and blood-borne pathogens, such as cytomegalovirus, herpes simplex virus (types 1 and 2), mycobacteria, staphylococci, streptococci, HBV, hepatitis C virus (HCV) and HIV, among others. These microorganisms can be transmitted to dentists via multiple channels, including: direct exposure to patients’ saliva, blood, oral secretions, injured skin and mucosal membranes; puncture by sharp implements; inhalation of aerosols, and exposure to splashes12., 13., 14.. Therefore, dentists should take multiple measures to protect themselves15. Gloves and masks are basic items of PPE. In 2010, the use of gloves and masks was reported by 99.73% and 97.66% of respondents, respectively, and 97.53% reported using both. These percentages show improvement over the respective rates of 73.37%, 93.05% and 52.60% reported in 2000 and are comparable with rates of use of gloves and masks in Italy (98% and 95%, respectively)14.
During treatment in which splatter may occur, reported rates of use of face shields or eyewear, gowns and heavy suction devices were 95.45%, 54.23% and 73.34%, respectively, in 2010; the rate of implementation of all three was 45.64%. The rate of gown use is lower than the 61% rate reported in Sudan16 and the use of all three types of protective equipment is lower than the 95.6% reported by Turkish dentists17. Splashes occur often in the course of dental treatment and can lead to the formation of droplets that may carry saliva, blood and particles infected with various viruses, such as HIV and HBV. These particles not only cause indoor air pollution, but may also be inhaled, causing potential harm to the body18. Wearing a mask, face shield or eye protection can effectively reduce the chance of inhalation and exposure to pollution. In addition, the use of a high-volume suction device can reduce the spread of splatters. The use of a rubber dam and the practice of having the patient rinse out his or her mouth with an antimicrobial solution before treatment can greatly reduce the chance of pollution and contamination19., 20.. However, in Beijing, such procedures are not prevalent. This may be related to the fact that four-handed treatment is not usual in Beijing hospitals and clinics and thus dental assistants are unable to provide dentists with timely aid at the dental chair. In this context, dentists consider that performing such procedures themselves is a waste of time. In addition, certain items of equipment, such as rubber dams, are not available in many dental health care settings.
In 2010, reported prevalences of hand washing before treatment, changing gloves between treatments, and hand washing after the removal of gloves were 98.96%, 99.22% and 97.14%, respectively, and the rate of implementation of all three practices was 95.84%. These figures represent some improvement on the rates of 89.08%, 63.25%, 72.07% and 43.05%, respectively, reported in 2000, and are comparable with the 99% rate of changing gloves between treatments reported in Italy in 200414. The rates reported in 2010 are derived from data that include rates of 12.91% and 15.90%, respectively, for sometimes but not always washing hands before and after treatment. Overall, > 70% of dentists reported washing their hands before seeing patients. This is higher than the 68% rate reported in Italy14. Reasons why some dentists failed to clean their hands before and after treatment included: the perception that they did not need to wash their hands because they had worn gloves; lack of time for washing because of high numbers of patients, and the inconvenience of putting gloves onto wet hands after washing. However, dentists’ hands are likely to be exposed to saliva and blood, and gloves can be damaged during an operation, thereby allowing possible cross-contamination. Evidence proves that it is vital to wash the hands after every treatment. For hands without obvious visible stains, dentists can choose to use an antiseptic hand rub for 1–2 min rather than washing their hands in running water, which may not only save time, but may also reduce the costs of water, soap and paper towels. Furthermore, using an alcohol-based hand rub makes it easier to put gloves onto consequently dry hands21.
Dental handpieces are the most frequently used type of device in dental practice. In the 1990s, the sterilisation of dental handpieces by autoclave was recommended by the international community, but was not required by the Chinese authorities. At that time, in China, dental handpieces were to be disinfected on the outer surface only. The most likely reason for this refers to concern about the damage that might be caused by heat-based sterilisation.
The frequent use of dental handpieces and their complex structure lead to serious contamination both outside and inside the device. Dental handpieces without an anti-suction device can reintroduce contaminants into the tubes of the handpiece and below the dental unit waterline (DUWL). Consequently, the use of a contaminated dental handpiece in different patients enables cross-contamination22. Studies have shown that dental handpieces that have been intentionally contaminated with duck HBV (DHBV) can induce the DHBV infection of ducks, even if the liquid flushed from these handpieces shows a negative result on an enzyme-linked immunosorbent assay (ELISA) for the surface antigen of HBV (HBsAg). This suggests that non-sterilised dental handpieces can transmit HBV even when test results are negative23.
Since 2000, Chinese researchers have carried out a set of studies to investigate the feasibility of using the autoclaves popular in China to sterilise the dental handpieces that are widely used in Chinese dentistry. These studies have shown that the autoclaves on the market are effective in sterilising dental handpieces and the shorter the time required for the sterilisation process, the less damage is caused to the mechanical properties of the handpiece; thus sterilisation by autoclave will not cause obvious damage to dental handpieces that impedes their clinical use24., 25.. Based on these studies, the autoclave has since become widely used in China. In 2005, the Chinese Ministry of Health announced the Standard of Practices for Disinfecting Dental Clinic Instruments, which requires dentists to sterilise dental handpieces, preferably using an autoclave. The Beijing Municipal Centre for Quality Control Improvement in Dental Health Care and the Beijing Municipal Institute of Health Regulation have provided multiple training sessions and yearly screening of dental handpieces after sterilisation. Autoclave use increased from 41.24% in 2000 to 96.10% in 2010 (P < 0.001), and 100% of devices sampled after sterilisation have been shown to be aseptic.
To reduce the contamination of tubing caused by the backflow of dental handpieces, the use of dental handpieces and dental units with anti-backflow devices is suggested. In addition, the DUWL should be flushed for ≥ 30 s, which, although it cannot fully remove the biofilm inside the tubing and sterilise the tubing, can reduce the number of microorganisms in the liquid and improve the quality of the output water26. The percentage of dentists who implement a policy of flushing the waterline after every patient has increased from 42.01% in 2000 to 73.49% in 2010; however, almost 30% of dentists still do not perform this procedure. Dental unit waterlines can cause serious water contamination. The human pathogens reported so far include Pseudomonas spp., Legionella spp. and non-binding Mycobacterium spp., among others. Until now, very few reports have found a correlation between incidences of infection by these bacteria and water contamination caused by infected DUWLs, but this does not mean that the water in the DUWL is safe because these infections are not easily identified until a patient is hospitalised. Dental professionals have been reported to show an increased incidence of nasal bacteria, especially of Legionella spp., which may cause inflammation, fever and shock, which suggests that DUWLs are the source of infection. Endotoxin in DUWLs can induce respiratory symptoms and the severity of asthma is directly related to endotoxin concentration. In addition, endotoxin can stimulate the gum tissue to release various proinflammatory cytokines, which can hinder the normal oral healing process27., 28.. Therefore, medical institutions should choose to use a water management system in dental facilities or should regularly disinfect the water lines manually. Dentists should be required to flush water lines after every treatment for ≥ 30 s, no matter which type of dental unit they use. In addition, external sterile water should be used during sterile surgeries29., 30..
The results obtained in the current survey indicate that significant improvements in IC practices occurred between 2000 and 2010. However, the survey data may not accurately reflect the real situation because some dentists may erroneously consider that they implement the practices they are supposed to, but may actually overlook or simplify some steps of IC.
Of the dentists surveyed in 2010, 76.21% had undergone training in IC and 98.31% believed it was necessary to receive training in self-protection and dental IC. These findings did not differ between participants with different levels of education, length of time in practice, or of different genders. Currently, training courses in IC are not available in dental schools in China and the knowledge-based curriculum in Chinese dental education requires further improvement to close the gap between Chinese dental education and that delivered in the USA, the UK and Japan31., 32., 33., 34.. Chinese dentists may receive training in IC just before they enter clinical practice and in the course of continuing professional education, but the knowledge delivered in this way is not comparable in extent and depth with that delivered in dental school. Moreover, not all clinics provide such pre-practice training and some dentists are reluctant to undertake such learning because they are not required by legislation to do so. To ensure the safety of dental professionals and patients, courses in IC must be integrated into the dental school curriculum in order to ensure that all dentists, including those who enter private practice in the future, are properly trained. Currently, dental clinics should provide pre-practice training, dental associations should provide continuing training, and medical authorities at all levels should strengthen regulatory requirements and monitoring systems in order to ensure the proper implementation of IC practices in dental health care settings.
Acknowledgements
We gratefully acknowledge Yan-Bin Guo, Beijing YouAn Hospital, Capital Medical University, Beijing, for conducting a survey investigating the relationship between dental medical treatment and the incidence of hepatitis B infection. This study was supported by a grant from the Beijing Municipal Science and Technology Commission.
Conflicts of interest
None declared.
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