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J Dent Educ. 69(6): 693-698 2005
© 2005 American Dental Education Association
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International Perspectives in Dental Education

Compliance with Infection Control Programs in Private Dental Clinics in Jordan

Mohammad Ahmad Al-Omari, B.D.S., M.S.C., Ph.D., F.F.D.R.D.C.I.; Ziad Nawaf Al-Dwairi, B.D.S., Ph.D.

Key words: infection, private, programs, sterilization, Jordan

Submitted for publication 11/11/04; accepted 03/29/05


   Abstract
Top
 Abstract
Materials and Methods
 Results
 Discussion
 References
 
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. A pilot-tested questionnaire about infection control measures was distributed in March 2004 to 120 private practices. 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. 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.

The identification of human immunodeficiency virus (HIV) and the epidemiologic evidence of its transmission through inoculation with contaminated blood,1,2 in addition to early reports of hepatitis B virus (HBV) transmission to patients from surgeons and dentists,3 all raised concerns related to cross infection with HIV and HBV and other bloodborne pathogens. As a result, there was a need to develop infection control recommendations designed to reduce the risk of transmission of bloodborne diseases in health care facilities. These procedures were termed as universal standard precautions, which consider all blood and blood-contaminated fluids as potentially infectious.4,5 The issue of cross infection becomes an integral part of dental practice and a major concern to dentists and patients due to the increased risk of hepatitis and AIDS.6,7 Both viruses can be transmitted after needle-stick injuries and contact with body secretions8 and also because many infected patients are unaware of their status or not willing to disclose their disease status to health care workers.9,10 There have been several reports of HBV and HIV transmission to patients from surgeons despite the development of the universal precautions.11–13

To minimize the risk of cross infection in the dental office, specific recommendations have been issued by professional health agencies. These recommendations include routine use of barrier techniques (gloves, masks), heat sterilization of dental instruments, vaccination against HBV, and the universal precautions. Dentists’ compliance with these recommendations and infection control programs (ICP) has been recently studied in different parts of the world.7,14–18,20 These investigations indicate that there are gaps in some dentists’ knowledge regarding modes of transmission of infectious diseases, the risk of infection from needle stick injuries, and awareness that general measures that protect against HBV transmission are sufficient to protect against HIV. However, dentists working in hospitals and dental schools are more likely to adhere to ICP than private sector dentists because institutions usually have occupational health policies related to infection control.19

The role of the dental assistant is vital to the process of infection control; however, the adherence of this particular group to these guidelines is inadequate because they receive less formal training than provided for dentists.20 The compliance of dental assistants is not investigated in this study because most, if not all, dental assistants working in private clinics in Jordan are not certified in dental nursing or hygiene. Thus, any infection control training they receive is provided by the dentists who employ dental assistants.

The aim of this study was to assess the infection control compliance of general dental practitioners (GDPs) in North Jordan who own private dental clinics. This particular group of private dentists was selected because of lack of known standard infection control programs that are conducted by the Jordanian dental association and routinely practiced in private dental offices.


   Materials and Methods
Top
 Abstract
 Materials and Methods
Results
 Discussion
 References
 
A list of 120 privately owned dental clinics was obtained from the Jordanian dental association records. This represents the total number of clinics in Irbid, the second largest city in North Jordan. The majority of GDPs in North Jordan open their private clinics in this city.

Data was collected from the GDPs by a mailed questionnaire that we developed. The questionnaire was pilot-tested by distributing it to twenty dentists who provide patient care in a university-based hospital. Responses from the pilot-test were analyzed to assess the clarity and relevance of the questions, and modifications were made based on feedback from pilot-test participants. Each of the 120 GDPs received a personalized letter that explained the goal of the study and a stamped addressed return envelope. Follow-up included reminder post cards and two additional mailings of the questionnaire to non-respondents. The study was conducted between March and May 2004.

The questionnaire requested respondents to provide demographic data about age, gender, knowledge, and practice of infection control measures. Respondents were asked if they used each of the following infection control practices: wore and changed gloves and masks during and between patients; wore and changed masks; had been vaccinated against HBV; checked medical histories at the beginning of the treatment; disinfected impressions; used autoclaves for sterilization of handpieces; used sterilization wrappings; changed burs, handpieces, and extraction instruments between patients; used rubber dams; and used a sharps waste disposal system. Respondents were also asked this question: Do infection control measures place an additional financial burden on you?

Dentists were considered compliant if they adhere to the complete list of infection control procedures included in the questionnaire. This list is shown in Table 1Go.


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  		Table 1. Adherence to infection control procedures among dentists in private dental clinics in Irbid
 

   Results
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 Abstract
 Materials and Methods
 Results
Discussion
 References
 
One hundred and ten of the 120 questionnaires were returned by the practitioners for a response rate of 91.66 percent. Of the total respondents, seventy-four (67.3 percent) were males, and thirty-six (32.7 percent) were females, with a mean age of thirty-eight years (Table 2Go).


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  		Table 2. Age and gender distribution of dentists in private dental clinics in Irbid
 
Table 1Go shows that eighty-five dentists (77 percent) reported that they usually asked patients about their medical history at the beginning of the dental treatment and that 36 percent (40/110) were vaccinated against hepatitis B. Approximately 82 percent (90/110) wore and changed gloves during treatment and between patients; 54.5 percent (60/110) reported that they wore and changed masks during treatment and between patients.

Most of the dental practitioners (95.4 percent) reported that they changed extraction instruments and burs between patients. The remaining dentists (4.6 percent) thought that wiping these instruments with a disinfectant provided an adequate method of disinfection. All dental practitioners (100 percent) reported that they changed saliva ejectors between patients. Approximately 42 percent reported that they changed handpieces between patients; the remaining cleaned them with a disinfectant. About 63 percent (69/110) reported that they 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 to dental labs, 13.6 percent (15/110) used rubber dams in their dental clinics, and only 31.8 percent (35/110) had special containers for sharps disposal.

Table 3Go shows that only fifteen dentists (five males and ten females) were considered to be fully compliant with the inventory of infection control measures shown in Table 1Go, a compliance rate of 13.6 percent. The compliant dentists were mainly females and in the age group of twenty-five to thirty-four years. About 54.5 percent of dentists reported that applying the recommended ICP in their clinics would be an additional financial burden.


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  		Table 3. Compliance with infection control practices in private dental clinics in Irbid
 

   Discussion
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 Abstract
 Materials and Methods
 Results
 Discussion
References
 
Infection control forms an important part of practice for all health care professions and remains one of the most cost-beneficial medical interventions available.19 This is the first study conducted to assess the compliance of general dentists working in private clinics in Jordan with infection control procedures that are designed to reduce the risk of transmission of a variety of microorganisms to dental team and patients. We studied infection control in private clinics because they often lack hazard risk instructions or occupational health policies that are more commonly available in universities and hospitals.

The response rate to the questionnaire in this study (91.66 percent) was higher than or comparable to previous studies.19,20 This high rate is due to the importance of the issue of infection control in dental practice, as most general dentists who participated in this study pointed out verbally or as notes on the questionnaire. Inquiring about the medical history of all patients who seek dental treatment should be the first strategy before the start of the treatment. A thorough medical history can provide clues about what precautions, in addition to infection control procedures, are necessary because some patients may have medical problems that require premedications or laboratory investigations. In this study, about 77 percent of dentists asked about and updated the medical history of their patients although this is less than what has been reported in a previous study.21

Although the possibility of transmission of HBV from dental health care workers (DHCW) to patients is considered to be small, precise risks have not been quantified. Several reports indicated nine clusters in which patients were infected with HBV associated with treatment by an HBV-infected DHCW.22 However, transmission of HBV from dentists has not been reported since 1987, possibly reflecting such factors as incomplete reporting, increased adherence to universal precautions, or use of HBV vaccine. In the present study, only 36 percent reported to be vaccinated against HBV. This is a dramatically low percentage compared with other studies where vaccination rates were 63.5 percent in Saudi Arabia,20 88 percent in Scotland,23 and 92.3 percent in Canada.24 This low rate might be due to negligence or lack of awareness of the problem; absence of legislation in Jordan requiring HBV vaccination of clinical staff members in private clinics might also be a reason for the low compliance.

Despite the fact that all DHCW should wear gloves to prevent the transmission of infection to patients and to prevent the contact of the operator’s hand with blood and saliva, only 81.8 percent of dentists in this study reported that they wore and changed gloves. This is lower than what was reported by previous studies,7,20,24 but higher than reported by Treasure and Treasure.25 Difficulties in adjusting to the use of gloves, dermatological reactions related to glove use, and having a high percentage of non-risk patients were the main reasons reported by GDPs for not using gloves regularly. The wearing of protective gloves does not reduce the frequency of sharps injuries, but may confer some protection by virtue of their wiping action on the sharp object on penetration.26

In this study, 54.5 percent (60/110) wore and changed masks during treatment and between patients, in comparison to 75 percent in Kuwait,7 64.8 percent in New Zealand,25 74.8 percent in Canada,24 and 76 percent of the community GDPs and 29 percent of the private GDPs in Sweden.31 Some dentists who participated in the study commented that wearing masks is not as critical as wearing gloves in dental treatment.

All dentists changed saliva ejectors, and almost 96 percent changed burs and extraction instruments between patients. Although these precautions should be standard procedure for dentists, there were still about 4 percent of dentists, primarily older practitioners, who thought that cleaning burs and instruments with a disinfectant before providing dental treatment for other patients was satisfactory. This finding demonstrates the lack of awareness about cross infection, particularly among dentists who graduated from dental school many years ago.

Recently, there have been several reports about the transmission of infection as a result of inadequate sterilization of handpieces.27,28 In our study, only 41.8 percent of dentists sterilized handpieces in contrast to other studies that found higher rates of sterilization.7,20,29 Many survey respondents who did not sterilize thought that sterilization by autoclaving could damage the handpieces. This agrees with the findings of a previous study.30 Surface disinfection by wiping or soaking in liquid germicides is not an acceptable method of reprocessing handpieces, as this method does not address internal contamination as retraction valves in dental unit water lines may cause aspiration of patient material back into the handpiece and water lines. Therefore, anti-retraction valves have been installed in new units that need a routine maintenance to ensure effectiveness.33

The use of autoclaves is increasing, but compliance with this ICP guidelines still remains low. For example, 50 percent of UK dental practitioners reported that they do not regularly autoclave instruments between patients.32 In our study, about 63 percent of dentists reported that they use autoclaves for sterilization; the remaining 37 percent used a combination of methods, including boiling, dry heat, and chemicals to perform sterilization. About 47 percent of the sample population claimed to use plastic bags to wrap sterilized instruments, while 53 percent reported that they left the autoclave open to cool the instruments before storing them.

If the recommended IC practices are used, the risk of occupationally acquired infection with bloodborne pathogens is limited to sharp injuries, which can be minimized if puncture-proof containers for sharps disposal are used. Only 31.8 percent of the Jordanian GDPs participating in this study maintained special containers for sharps disposal in contrast to 56.2 percent of Saudi dentists.20

The general recommendation is that dental work, such as impressions, casts, dentures, and wax registration records, should be disinfected at the clinic prior to being sent to the laboratory. Contamination of the laboratory could occur if cross-infection control is neglected. Indeed, occupational infection of dental laboratory technicians with HBV has been reported.34 The results of this study revealed that as low as 18 percent of dentists used disinfectants for impressions before sending to dental laboratories. This is in contrast to 53.7 percent reported by Yengopal et al.36

The use of the rubber dam, in addition to improving safety and saliva control, significantly reduces bacterial contamination of the atmosphere during restorative procedures, particularly in the vicinity of the operator and dental assistant.35 The results of this study revealed that only 13.6 percent used rubber dams in their restorative procedures, compared to 40 percent among private dentists in Durban.36

In this study, 13.6 percent of dentists were found to be fully compliant with the complete list of infection control procedures, with more young females being compliant than males. This is consistent with other reported studies.19,30,31 The higher rate of compliance among younger dentists might be due to the fact that they are recent graduates from dental schools that have infection control programs. More than half (54.5 percent) of the responding GDPs reported that applying the recommended ICP in their clinics would place an additional financial burden on them, in agreement with the results of McCarthy and MacDonald.19

Although this study investigated a limited range of items on infection control and has focused on barrier methods, HBV vaccination, and sterilization, more research is needed to provide comprehensive data on compliance with all recommended infection control programs by general dentists and specialists. In addition, new methodological techniques need to be introduced for the assessment of compliance of the dental team with ICPs. Inclusion of a greater observational element within the study design may help to reduce the socially desirable responses resulting from the questionnaire currently available.20

In conclusion, the results of this study suggest that there is a great need to provide formal and obligatory infection control courses and guidelines for private dentists by the Jordanian Ministry of Health and the Jordanian Dental Association in addition to disseminating standard infection control manuals that incorporate all published updated recommendations.

Finally, these results lend support to the concept of mandatory continuing education that includes a specific component on infection control. With today’s increasing concerns about the transmission of bloodborne pathogens and the rise in drug-resistant microorganisms, compliance with recommended infection control must improve side by side with legal requirements. A health and safety committee should visit dental practices to assess standards of infection control and be empowered to prohibit patient care by dentists who are not compliant.


   Footnotes
 
Dr. Al-Omari is Associate Professor and Dr. Al-Dwairi is Assistant Professor—both in the Department of Restorative Dentistry, Jordan University of Science and Technology. Direct correspondence and requests for reprints to Dr. Ziad Nawaf Al-Dwairi, Department of Restorative Dentistry, Jordan University of Science and Technology, P.O. Box 3030, Irbid-Jordan; 0096227201000 phone; 0096227095115 fax; ziadd{at}just.edu.jo.


   REFERENCES
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Z. N. Al-Dwairi
Infection Control Procedures in Commercial Dental Laboratories in Jordan
J Dent Educ., September 1, 2007; 71(9): 1223 - 1227.
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