Compliance of Saudi dental students with infection control guidelines

Abstract

The aim of this study was to investigate compliance of dental students in a Saudi dental school with recommended infection control protocols. A pilot-tested questionnaire concerning various aspects of infection control practices was distributed to 330 dental students. The response rate was 93.9% (n = 311). About 99% of students recorded the medical history of their patients and 80% were vaccinated against hepatitis B. The highest compliance (100%) with recommended guidelines was reported for wearing gloves and use of a new saliva ejector for each patient. Over 90% of the respondents changed gloves between patients, wore face masks, changed hand instruments, burs and handpieces between patients, used a rubber dam in restorative procedures and discarded sharp objects in special containers. A lower usage rate was reported for changing face masks between patients (81%), disinfecting impression materials (87%) and dental prosthesis (74%) and wearing gowns (57%). Eye glasses and face shield were used by less than one-third of the sample. The majority of students were found to be in compliance with most of the investigated infection control measures. Nevertheless, further education is needed to improve some infection control measures including vaccination for Hepatitis B virus (HBV), wearing eye glasses, gowns and face shields and disinfecting impression materials and dental prostheses.

INTRODUCTION

Infection control is today without doubt an integral part of contemporary dental practice¹. 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 infections2., 3., 4..

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 (Table 1)2., 3., 4.. The compliance of DHCPs with these guidelines has been investigated by a number of studies worldwide1., 5., 6., 7., 8., 9., 10., 11., 12., 13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24.. 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 (Table 2).

Table 1.

Cross-infection control guidelines

Immunisation against infectious diseases (i.e. hepatitis B virus)

Use of personal protective equipment (PPE) including gloves, masks, protective eyewear, face shields and protective clothing such as gowns and jackets

Sterilisation and/or disinfection of patient-care items

Critical items are those that penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile tissue. Examples include: surgical instruments, periodontal scalers, scalpel blades and surgical dental burs

Semi-critical items are those that contact mucous membranes or non-intact skin; they will not penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile tissue. Examples include: dental mouth mirror, amalgam condenser, reusable dental impression trays and dental handpieces

Non-critical items are those that contact intact skin. Examples include: radiograph head/cone, blood pressure cuff, facebow and pulse oximeter

Environmental infection control of operating surfaces such as light handles, unit switches and drawer knobs

Safe disposal of waste materials

Table 2.

Compliance with recommended cross-infection measures reported by previously published studies

Reference	Country	Sample	Implementation of cross-infection measures (%)
			Medical history	HBV vaccination	Gloves	Facemask	Eye glass	Gowns/coats	Rubber dam	Change handpieces	Change burs	Change saliva ejector	Disinfection of impression
13	USA (California)	297 dentists			79.8	70.4
11
1986 survey	USA (Minnesota)	1609 dentists		49	33.1	28.5	65.9
1987 survey		794 dentists		61.9	85.9	53.9	87.9
23
1986 survey	USA (national survey)	3437 dentists		49	23	26	77	13
1988 survey		3648 dentists		59	76	47	82	20
10	UK (England and Wales)	1530 NHS dentists			68	30
22	New Zealand (national survey)	773 dentists			42	64.8	66.4
14	UK (north-western region)	917 dentists	93	93	75	38	62
9	UK (north-western region)	312 dentists			86		68			77
19	Kuwait	132 DHCPs	80		81	75	52.4
6	Saudi Arabia (Riyadh)	122 dentists		55	94	86	35	11		32			13
17	Canada (Ontario)	3623 GDPs		92.3	91.8	74.8	83.6
18	Canada (Ontario)	402 specialists		95.3	91.8	63.2	75.4
7	Saudi Arabia (national survey)	472 dentists			92.4	85.3	50.8			27.1	90.2		61
15	Ireland(national survey)	177 GDPs			92	68
24	South Africa (Durban)	68 dentists		90	97	82.4	52.9				40		53.7
1	Saudi Arabia (Riyadh)	203 dentists	93.1	63.5	100	90.6
12	Sudan (Khartoum)	150 dentists		52	92	50	14.7	61
5	Jordan (Irbid)	110 dentists	77.3	36.4	81.8	54.5			13.6	48.1	95.5	100	18.2
20	Jordan (Irbid)	37 DTS		95	100	43	32
21	India (Haryana)	207 dentists		62	78%	59	2	21					78
8	Jordan (Irbid)	279 dentists	25	72.6	73.7	69.5	43.8	75.9
16	India (Udaipur)	142 UGS	97.9	75.2	99.3	96.5			29.8	16.3	20.6	69.5	27

HBV, Hepatitis B virus; NHS dentists, dentists working in the National Health Service; DHCPs, dental health care providers; DTS, dental teaching staff; GDP, general dental practitioner; UGS, Undergraduate student.

There is little information regarding compliance with universal control precautions in the Middle East in general and Saudi Arabia in particular. Therefore, the aim of this study was 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, anonymous questionnaire. The questionnaire was developed after consulting with specialists from each dental specialty at the teaching hospital and based on similar questionnaires used in the past5., 21.. 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. Further details of the validation of the questionnaire are beyond the scope of this paper.

The questionnaire included 18 questions that evaluated: (1) demographic data (gender and academic level); (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. 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 (χ²) 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 level and gender is shown is Table 3.

Table 3.

Distribution of the respondents by academic level and gender

Level	Male (%)	Female (%)	Total (%)
Fourth year	43 (27.4)	53 (34.1)	96 (30.8)
Fifth year	47 (30.1)	39 (25.2)	86 (27.7)
Sixth year	47 (30.1)	39 (25.2)	86 (27.7)
Interns	19 (12.2)	24 (15.5)	43 (13.8)
All sample	156 (50.2)	155 (49.8)	311 (100)

About 99% reported that they usually review the medical history of their patients before commencing dental treatment and 80% were vaccinated against hepatitis B (Table 4).

Table 4.

Adherence to various infection control procedures among dental students according academic level and gender

Procedure	Response	All sample (%)	Academic level (%)					Gender (%)
			4th	5th	6th	Intern	P	Male	Female	P
Recording medical history	Yes	99	97	99	100	100	0.240	99	98	0.311
	No	1	3	1	0	0		1	2
Hepatitis B vaccination	Yes	80	88	79	71	83	0.047	76	83	0.143
	No	20	12	21	29	17		24	17
Wear gloves	Always	100	100	100	100	100		100	100
	Sometimes	0	0	0	0	0		0	0
	Never	0	0	0	0	0		0	0
Change gloves	Always	98.5	98	98	99	100	0.734	97	99	0.082
	Sometimes	1	1	2	1	0		3	0
	Never	0.5	1	0	0	0		0	1
Wear face mask	Always	98	100	96	98	95	0.265	97	98	0.611
	Sometimes	1.7	0	4	1	5		2	2
	Never	0.3	0	0	1	0		1	0
Change face mask	Always	81	89	82	71	83	0.095	82	80	0.749
	Sometimes	16.5	10	15	24	17		15	18
	Never	2.5	1	2	5	0		3	2
Wear eyeglasses	Always	28	24	39	23	24	0.234	30	26	0.616
	Sometimes	63.5	69	54	67	64		61	66
	Never	8.5	7	7	10	12		9	8
Wear face shield	Always	30	23	42	27	24	0.116	35	24	0.132
	Sometimes	54	58	47	56	57		50	59
	Never	16	19	10	17	19		15	17
Wear gown	Always	59	60	60	59	55	0.617	59	59	0.752
	Sometimes	38	39	38	38	38		39	38
	Never	3	1	2	2	7		2	3
Change hand instruments	Yes	99	97	100	100	100	0.078	98	100	0.083
	No	1	3	0	0	0		2	0
Change handpieces	Yes	98	99	98	96	100	0.492	97	99	0.419
	No	2	1	2	4	0		3	1
Change burs	Yes	99	99	100	99	100	0.695	100	99	0.156
	No	1	1	0	1	0		0	1
Change saliva ejector	Yes	100	100	100	100	100		100	100
	No	0	0	0	0	0		0	0
Use rubber dam	Yes	99	99	100	98	99	0.526	99	99	0.990
	No	1	1	0	2	1		1	1
Disinfect impression	Yes	87	81	90	86	93	0.239	86	87	0.74
	No	13	19	10	14	7		14	13
Disinfect prosthesis	Yes	74	71	69	80	76	0.370	81	67	0.006
	No	26	29	31	20	24		19	33
Store sharps in special containers	Yes	91	94	85	93	95	0.106	91	91	0.868
	No	9	6	15	7	5		9	9

Bold values indicate statistically significant difference.

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. Approximately 98% reported that they changed handpieces 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% discarded sharp 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 aerosols2., 3., 4.. Adherence to various aspects of universally recommended guidelines 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 visits³. 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 applied⁵.

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 measures2., 3., 4..

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 studies1., 5., 8., 14., 16., 19..

Vaccination against HBV

Dental health-care professionals are at an increased risk of acquiring hepatitis B infection and therefore must be vaccinated against it25., 26.. About 80% of the respondents received an HBV vaccination, thus falling in the range reported by previous studies5., 6., 8., 11., 12., 16., 17., 18., 20., 21., 23., 24..

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 jackets⁴.

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. AS 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 avoided3., 4.. All the study sample wore gloves and 98.5% changed them between patients. This compliance with routine glove-wearing and -changing compares favourably with previously published studies which showed that the routine use of gloves increased from as low as 23% in late 1980s to 100% now1., 20., 23..

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% (Table 2). 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 (Table 2). 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 the regular use of a rubber dam, as this was shown to significantly reduce bacterial contamination of the atmosphere during restorative procedures²⁷. 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 Africa²⁴ and 13.6% of Jordanian dentists⁵ and 29.8% of undergraduate Indian students¹⁶.

Sterilisation and disinfection of patient-care items

Patient-care items are generally categorised into critical, semi-critical or non-critical items (Table 1). Critical items must be sterilised while disinfection and/or surface protection is generally adequate for semi-critical 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 items3., 4..

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 documented6., 28.. 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 laboratory⁴. 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.²⁴, and 18.1% by Al-Omari & Al-Dwairi⁵. 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 bags³. In previous studies, 8–75% of dentists used puncture-resistant containers compared with 91% of the respondents in this study1., 5., 8., 14., 16., 21..

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 this 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.

Acknowledgements

The authors are grateful to the students who participated in this study.

Conflict of interest

None declared.