| Abstract|| |
Objectives: The objectives of the study were to assess the knowledge, attitude, and behavior (KAB) of dentists toward blood-borne virus (BBV) diseases, associated hazards, and infection control guidelines and to determine factors which influence KAB of dentists toward above-mentioned variables.
Materials and Methods: This was a cross-sectional survey. Eighty-four dentists were provided a self-prepared, structured questionnaire. The dentists were of varying specialties and health-care sectors. Frequency distribution and Fisher's exact test were performed.
Results: Most of the dentists knew the common oral manifestations of acquired immunodeficiency syndrome, but none knew all. Many dentists were not aware of mode of transmission of hepatitis D virus (HDV) (n = 42), herpes simplex virus (n = 50), and herpes zoster virus (n = 47). Over half of the dentists (n = 43) did not know that hepatitis C virus vaccine does not exist. Many dentists (n = 63) knew that interferon is used for treating hepatitis B virus infection. Knowledge of HDV transmission and infection control officer availability in dentist's clinic were influenced by a number of continued dental education (CDE) hours and workplace of dentist. Most of the dentists were not aware of National Health Service guidelines for BBV-infected dentists practicing exposure-prone procedures (EPPs).
Conclusion: KAB of dentists was influenced by a number of CDE hours and workplace of dentist. We request the dental authorities to increase the number of infection control-based CDE hours, BBV educational campaign for dentists and to issue a guidelines for BBV-infected dentists practicing EPP.
Keywords: Blood-borne virus, hepatitis B virus, hepatitis C virus, HIV, infection control, knowledge
|How to cite this article:|
Ahsan SH, Alanazi KJ, Al-Qahtani ZH, Turkistani SA, Siblini MR, Al-Arabi M. A multicenter survey of factors influencing knowledge, attitude and behavior of dentists towards blood borne virus infected patients and associated infection control guidelines. J Educ Ethics Dent 2016;6:78-84
|How to cite this URL:|
Ahsan SH, Alanazi KJ, Al-Qahtani ZH, Turkistani SA, Siblini MR, Al-Arabi M. A multicenter survey of factors influencing knowledge, attitude and behavior of dentists towards blood borne virus infected patients and associated infection control guidelines. J Educ Ethics Dent [serial online] 2016 [cited 2020 Jun 1];6:78-84. Available from: http://www.jeed.in/text.asp?2016/6/2/78/223003
| Introduction|| |
Blood-borne viruses (BBVs) are heterogeneous group of viruses which share a unique characteristic of transmission between hosts through blood. A dentist is morally and professionally obliged to treat dental patients infected by BBV. Refusal to treat such patients can result in disciplinary action against the dentist in certain parts of the world. However, the practice of treating BBV-infected patients is not a norm. BBV-infected patients are usually denied treatment on the basis of their disease. 
The kingdom of Saudi Arabia (KSA) is not an exception in relevance to the prevalence of BBV. Hepatitis B surface antigen (HBsAg) positivity in the KSA has been shown to be around 8.3%. The overall number of HIV-positive Saudis by 2010 was reported to be 4019.  These studies did not incorporate the prevalence of BBV in foreign nationals residing in the KSA, which would further increase the overall prevalence of such diseases. As the number of such patients continues to increase, it is mandatory for dentists to enhance their knowledge regarding nature, associated hazards, and infection control guidelines of BBV diseases.  Inability to gain relevant knowledge will result in reluctance to treat BBV-infected patients, as shown by a study, in which dental students were reluctant in treating acquired immunodeficiency syndrome (AIDS) patients because of lack of confidence in managing such patients. 
In addition to knowledge, two other important traits of a dentist which influence the implementation of infection control guidelines and the treatment provided to BBV patients are attitude and behavior of a dentist. Attitude is defined as “a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor.” While behavior is defined as “internally coordinated responses (actions or inactions) of whole living organisms (individuals or groups) to internal and/or external stimuli.” It is pivotal to assess knowledge, attitude, and behavior (KAB) of dentists toward BBV-infected patients so that mandatory steps could be taken in the future to enhance the treatment quality of BBV-infected patients and the confidence of dentist in managing such patients.
Few studies of such nature have been conducted in the KSA. A study assessed the implementation of infection control protocol in private sector.  Another study assessed the awareness and attitude of dentists toward hepatitis B vaccination.  Recently, a study assessed the knowledge and attitude of male dental students toward AIDS patients. We took into consideration the finding of these studies and widened the scope of our study, by inclusion of dentists of varying specialties, from both government and private health-care sectors.
The objectives of this study were two folded: (1) To assess the KAB of dentists toward BBV diseases, associated hazards, infection control guidelines, and postexposure management and (2) To determine the effect of factors such as specialty, number of years of clinical experience, number of infection control-based continued dental education (CDE) hours, and health-care sectors, on the KAB of dentists toward above-mentioned variables.
| Materials and Methods|| |
This is a cross-sectional survey-based study. The Ethical Review Committee of Riyadh Colleges of Dentistry and Pharmacy (RCsDP) formally approved this study. It was conducted at four different sites in Riyadh (the capital city of the KSA). The name and type of sites are:
- Riyadh Colleges of Dentistry and Pharmacy (university-based dental hospital)
- King Saud Medical City (university-based dental hospital)
- Al Jazeera Hospital (private tertiary care hospital)
- Prince Sultan Military Medical City (government tertiary care hospital)
A two-stage convenience sampling method was utilized. The primary stage comprised of selection of study sites based on above-mentioned health-care sectors so that comparison could be made between dentists working in different health-care sectors. The second stage comprised of selection of subjects from each study site based on convenience.
The subjects of this study were dentists. They were categorized into “General Dental Practitioner,” “Endodontist,” “Restorative Dentist,” “Pedodontist,” “Prosthodontist,” “Periodontist,” “Orthodontist,” “SBARD” (known as Saudi Board Advanced Restorative Dentistry), and “Oral Maxillofacial Surgeon.” The dentists were categorized so that KAB toward BBV diseases could be compared between different specialties. The targeted sample size was 97, of which 13 declined because of limited time availability, whereas 84 responded positively by filling up the questionnaire.
A self-prepared, self-structured questionnaire comprising 26 questions was prepared in English language. The questionnaire was based on the following sections:
- Dentist's personal, professional, and practice characteristics
- Knowledge of oral lesions in AIDS
- Knowledge of viruses which are transmittable through blood
- Knowledge of risk of transmission on individual BBV exposure
- Knowledge of how to manage sharp injuries
- Knowledge of practice guidelines for dentists infected with BBVs (based on National Health Service [NHS] guidelines)
- Attitude toward BBV-infected patients
- Attitude and behavior toward prevention of BBV infection.
Name of the subjects was not asked to maintain confidentiality.
Frequency distribution and Fisher's exact test through SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp) were performed. Level of statistical significance was set at P < 0.05. Our justification of using Fisher's exact test, rather than Chi-squared test, was small expectation values and small sample size of our study.
| Results|| |
[Table 1] summarizes the frequency distribution of age, nationality, specialty, health-care sector, years of practice, and number of continued dental education hours of dentist.
|Table 1: Frequency distribution of dentist's personal, professional, and dental practice characteristics|
Click here to view
[Table 2] highlights the correlations between KAB of dentists and factors such as number of CDE hours, specialty, workplace of dentist, and number of BBV patients treated by dentist in career.
- Knowledge of dentist regarding HDV transmission through blood was shown to be statistically correlated with number of CDE hours and workplace of dentist
- Knowledge regarding non-availability of HCV immunization was significantly correlated with number of CDE hours and workplace of dentist
- Knowledge of dentist regarding follow-up of screening test was statistically correlated with specialty and workplace of dentist
- A statistically significant correlation was found between knowledge regarding hepatitis B virus (HBV)-infected dentist not allowed EPP and workplace of dentist
- Availability of infection control officer in the dentist's clinic was statistically correlated with number of CDE hours and workplace of dentist
- Statistically significant relationship was found between concern of dentist on treating BBV patients and number of years of practice, number of CDE hours, and number of BBV patients treated by the dentist in career.
|Table 2: Correlation of dentist's personal, professional, and dental practice characteristics with knowledge, attitude, and behavior of dentist (original)|
Click here to view
[Table 3] highlights the knowledge of dentist regarding oral lesions in AIDS, transmission of individual virus through blood, BBV immunization availability, BBV screening test on sharp injury, follow-up test after initial BBV screening test, drug for BBV therapy, and guidelines of BBV-infected dentists practicing exposure-prone procedures (EPPs).
- In the “knowledge of initial BBV screening test on exposure” section, 46.4% of the dentists stated that BBV screening test should always be requested after exposure, whereas, 39.3% stated that if the source of exposure claims that he or she is not infected, then BBV screening test is not required
- In the “knowledge of follow-up test after initial BBV screening test” section, 39.3% of the dentists stated that follow-up test is required after 1 year of initial BBV screening test, whereas 23.8% stated that follow-up test is required after 6 weeks of initial BBV screening test
- Nearly 38.1% of the dentists stated that, according to the NHS guidelines, dentists with “HbsAg positive >103, hepatitis B virus e antigen (HbeAg) negative” blood are not allowed to practice EPP, whereas 14/3% of the dentists stated that, according to the NHS guidelines, dentists with “HbsAg positive <103, HbeAg negative” blood are allowed to practice EPP.
| Discussion|| |
Dentist's personal, professional and practice characteristics
In our study, 62 subjects were Saudi national (n = 62). The most common age group was 20–30 years old (n = 38). General dental practitioners were the most common (n = 41), whereas the least common group was SBARD (n = 2). Twenty-eight subjects had 6–10 years of clinical experience, whereas twenty subjects had not obtained even a single CDE hour related to infection control protocol in their career [Table 1].
Statistically significant correlation was seen between a number of CDE hours and availability of infection control officer in subject's clinic (P = 0.003) [Table 2]. Almost 48.4% of subjects with 6–10 CDE credit hours had an infection control officer in their clinic. This indicates the importance of infection control-based CDE hours for dental practitioners. A statistically significant correlation was also shown between workplace and availability of infection control officer in subject's practice (P = 0.012) [Table 2]. Nearly 38.7% of subjects working in university-based hospital and 41.9% of subjects working in tertiary government hospital had an infection control officer at their clinic, in contrast to, subjects working in private tertiary care hospital (19.4%).
Knowledge of oral lesions in AIDS
Knowledge regarding oral manifestations of AIDS assists the clinician in screening undiagnosed HIV-infected patients. In a UK study conducted by Crossley, 96%, 87%, and 73% of the dentists stated that Kaposi sarcoma, oral candidiasis, and hairy leukoplakia are clinical manifestations of AIDS, respectively. While, in a Chinese study, 100%, 96.8%, and 98.9% of the dental students stated that Kaposi sarcoma, oral candidiasis, and hairy leukoplakia are clinical manifestations of AIDS, respectively. In our study, 72.6%, 78.6%, and 67.9% of the dentists stated that Kaposi sarcoma, oral candidiasis, and hairy leukoplakia are clinical manifestations of AIDS, respectively [Table 3]. It's pivotal for the dentist to be aware of the above-mentioned diseases, as they are strongly associated with AIDS.
Xerostomia is occasionally associated with AIDS. Fifteen percent of the dentists in the UK study and 14.7% in the Chinese study stated that xerostomia is a clinical manifestation of AIDS., On the contrary, 48.8% of the dentists in our study stated that xerostomia is associated with AIDS [Table 3]. We further assessed the knowledge of the dentists by inquiring about the association of certain oral diseases which are not normally associated with AIDS. Almost 42.9% of subjects wrongly stated that oral submucous fibrosis (OSF) is a clinical manifestation of AIDS [Table 3]. No statistically significant correlation was found between knowledge of OSF in AIDS and specialty of the subject (P = 0.826). However, there was a statistically significant correlation between OSF and years of practice of the dentist (P = 0.001) [Table 2]. Subjects with 1–5 years of practice comprised of 41.3% of those who stated that OSF is not a clinical manifestation of AIDS. Updated education and awareness of AIDS in recent years might be the reason behind better understanding of oral manifestations of AIDS among young dental graduates.
Knowledge of viruses which are transmittable through blood
On assessing knowledge about viruses which spread through blood, 42 (50%) subjects stated that hepatitis D virus (HDV) does not spread through blood [Table 3]. There was no statistically significant correlation between knowledge of transmission of HDV through blood and specialty of subject (P = 0.866). While, a statistically significant relationship was found between knowledge of HDV transmission through blood and number of CDE hours (P = 0.021), in addition to the workplace of the dentist (P = 0.010) [Table 2]. Dentists working in government tertiary care hospital (34.3%) and university-based hospital (40%) comprised of a majority of the subjects who stated that HDV transmits through blood. Subjects with 1–5 CDE hours comprised of 64.3% of those who stated that HDV does not transmit through blood; unlike, subjects with 6-10 CDE hours who comprised of only 21.4% of this group. Meanwhile, 50 (59.5%) subjects stated that herpes simplex (HSV) and 47 (56%) subjects stated that herpes zoster virus (HZV) infection spreads through blood, respectively.
Knowledge of how to manage sharp injuries
According to the updated Centers for Disease Control and Prevention recommendations for the management of HBV-infected health-care providers and students, currently seven therapeutic agents are approved by the Food and Drug Administration for the treatment of chronic HBV infection including two formulations of interferon (interferon alpha and pegylated interferon). We assessed the knowledge of the dentists by inquiring about the medication utilized for the management of HBV infection. Sixty-three (75%) subjects rightly stated that interferon is used for the management of HBV infection [Table 3].
We also asked our subjects about availability of vaccine for BBV infections. Seventy-one (84.5%) of the subjects stated that there is a vaccine for HBV infection, whereas 42 (51.2%) and 34 (40.5%) subjects wrongly stated that there is a vaccine for HCV infection and HIV infection [Table 3].
Knowledge of practice guidelines for dentists infected with blood-borne viruses
The participants of this study were inquired about the NHS Dental Practice Guidelines On Dentists Infected with BBVs. Thirty-two (38.1%) subjects rightly stated that, according to NHS guidelines, a dentist with “HBsAg viral load of >103 genome/ml but HBeAg-negative blood” is not allowed to practice EPP. Similarly, six (7.1%) subjects rightly stated that dentist with “HBeAg-positive blood” is not allowed to practice EPP. Twenty-six (31.0%) subjects were not sure about the correct answer. In relevance to knowledge regarding “HBV-infected dentist allowed to do EPP,” 12 (14.3%) subjects rightly stated that a dentist with “HBsAg viral load of <103 genome/ml and HBeAg-negative blood” is allowed to do EPP but on annual checkup [Table 3]. Twenty-eight (33.3%) subjects were not sure about the correct answer. While, in relevance to knowledge regarding “HCV-infected dentist not allowed to do EPP,” only two subjects rightly stated that dentist with “HCV RNA-positive blood” is not allowed to practice EPP.
Attitude toward blood-borne virus-infected patients
In this study, 47 (56%) subjects treated 1–5 BBV patients, 5 (6%) subjects treated 6–10 BBV patients, whereas only 17 (20.2%) subjects treated >10 BBV patients in their career. In comparison, only 46% subjects in the UK-based study treated HIV patient in their career. Almost 29.6% of respondents in the UK-based study did not have any hesitation in treating HIV patients. In our study, 44 (52.5%) participants were not concerned at all about treating BBV patients. Among them, majority (72.7%) comprised of those who treated only 1–5 BBV patients in their career. In the UK study, 36% respondents stated personal risk as the reason behind their hesitation in treating AIDS patients. Surprisingly, in this study, only 29% of the subjects were concerned about personal risk on treating BBV patients. Among them, 36.4% comprised of those who treated only 1–5 BBV patients in their career, whereas 31.8% comprised of those who treated >0 BBV patient in their career [Figure 1]. As shown above, a statistically significant correlation was found between “concern of treating BBV patients” with “number of BBV patients treated in subject's career” (P = 0.027) [Table 2].
|Figure 1: Correlation between concern of treating blood-borne virus patient and number of blood-borne virus patient treated by subject in career (original)|
Click here to view
Attitude and behavior toward prevention of blood-borne virus infection
Eighty (95.2%) subjects in our study stated that dental cubicles should be disinfected before and after every patient, but 47 (56%) subjects wrongly stated that universal precautions are only required for known BBV patients. Thirty-five (42.2%) subjects said that they use conventional glass syringes, whereas 44 (53%) subjects said that they use safety syringes and only four (4.8%) stated that they used disposable plastic syringes to anesthetize their patients. None of the subjects in our study could name the type of safety syringe they use in their practice. Twenty-two (26.2%) subjects stated that they use a conventional two-handed scoop to recap syringes, whereas sixty (71.4%) subjects stated they use one-handed scoop to recap syringes. Finally, 78 (93%) subjects in our study agreed that more resources are required in the KSA for infection control of BBV diseases.
| Conclusion|| |
- The number of infection control-based CDE hours influenced the KAB of dentists toward BBV diseases. Currently, only a handful of infection control-based workshops is being provided by the Saudi Council of Health Specialties (SCFHS), annually. We request the SCFHS to increase the number of such workshops
- The dentists working in university-based hospitals and government tertiary care hospitals had better knowledge regarding BBV infections and the associated guidelines. In addition to that dentists working in these places had infection control officers in their practice as well
- Most of the dentists had knowledge regarding commonly occurring oral manifestations of AIDS, but none knew all. Many lacked knowledge regarding mode of transmission of HDV, HSV, and HZV infections
- Most of the dentists were not aware of the NHS guidelines for BBV-infected dentists practicing EPP. We request the SCFHS to issue a guideline, similar to the NHS guidelines, pertaining to criteria for BBV-infected dentists to practice EPP in the KSA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Canadian Dental Association. Statement on the ethical and legal considerations of treating patients with infectious diseases. J Can Dent Assoc 1988;54:385.
McCarthy GM, Koval JJ, and MacDonald JK. Factors associated with refusal to treat HIV-infected patients: the results of a national survey of dentists in Canada. Am J Public Health 1999;89:541-5.
McCarthy GM, Koval JJ, MacDonald JK. Factors associated with refusal to treat HIV-infected patients: The results of a national survey of dentists in Canada. Am J Public Health 1999;89:541-5.
Alsamghan AS. Knowledge and attitude of male dental students toward HIV/AIDS in King Khalid University, Saudi Arabia. Int J Public Health Epidemiol 2012;1:001-8.
Alothman AF, Muhajer K, Balkhy H. Prevalence of HIV-infection in Saudi Arabia. BMC Proc 2011;5:252.
Darling M, Arendorf T, Samaranayake LP. Oral care of HIV-infected patients: The knowledge and attitudes of South African dentists. J Dent Assoc S Afr 1992;47:399-402.
Eagly AH, Chaiken S. The Psychology of Attitudes. Orlando florida: Harcourt Brace Jovanovich College Publisher; 1993.
Levitis DA, Lidicker WZ, Freund G. Behavioural biologists don't agree on what constitutes behaviour. Anim Behav 2009;78:103-10.
Al-Rabeah A, Moamed AG. Infection control in the private dental sector in Riyadh. Ann Saudi Med 2002;22:13-7.
Paul T, Maktabi A, Almas K, Saeed S. Hepatitis B awareness and attitudes amongst dental health care workers in Riyadh, Saudi Arabia. Odontostomatol Trop 1999;22:9-12.
National Health Service. National Health Service Circular issued by the Scottish Office Health Department as Health Department Letter (HDL); 2000. p. 3. Available from: http://www.sehd.scot.nhs.uk/mels/HDL2000_03.html
. [Last accessed on 2017 Nov 24].
Crossley ML. An investigation of dentists' knowledge, attitudes and practices towards HIV+ and patients with other blood-borne viruses in South Cheshire, UK. Br Dent J 2004;196:749-54.
Li R, Dong W, He W, Liu Y. Chinese dental students' knowledge and attitudes toward HIV/AIDS. Journal of Dental Sciences 2016;11:72-8. Available from: http://dx.doi.org/10.1016/j.jds.2015.09.001
. [Last accessed on 2015 Dec 11].
Jacobson JM, Greenspan JS, Spritzler J, Ketter N, Fahey JL, Jackson JB, et al.
Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group. N Engl J Med 1997;336:1487-93.
Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students. Morb Mortal Wkly Rep 2012;61:1-12.
Dr. Syed Hammad Ahsan
Riyadh Colleges of Dentistry and Pharmacy, Riyadh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]