Infection control practices among
Dental Practitioners of Lahore, Pakistan

Syed Akhtar Hussain Bokhari¹, Shamta Sufia², Ayyaz Ali Khan³

ABSTRACT

Objective: To observe adoption of infection control measures among dental practitioners.

Methodology: A cross-sectional study based on a convenient sampling technique was conducted. Dental Practitioners in each subdivision (towns) of the Lahore, Pakistan were approached through 15 dental hygiene students to fill a close ended structured questionnaire. Study was conducted during 1st March-15 March 2005. Chi square test was applied with a significance level of p <0.05.

Results: Four hundred dental practices were visited and response rate of 83.25% was obtained. 62.76% surgeries were found being run by un-qualified dental practitioners and 37.23% by qualified dentists. 94.35% qualified practitioners used gloves as compared to only 28.2% of the un-qualified practitioners and a high percentage of qualified practitioners used gloves for every patients compared to their un-qualified counter parts (85.48% and 14.35%) respectively. 97.5% qualified practitioners and 80.3% of the un-qualified dentists used face masks. 85.1% of un-qualified and 98.3% of the qualified dental practitioners used fresh set of instruments for each patient. Use of sterilization methods including disinfectants, autoclaving of instruments was higher in qualified practitioners. Infection control measures among qualified and non-qualified practitioners were statistically significant. (p= 0.000)

Conclusion: A poor level of infection control practice was observed in dental practices run by un-qualified practitioners. Majority of qualified dentists were observing infection control measures. There is need for further education and training for all the dental practitioners.

KEY WORDS: Dental practitioners, Infection control Measures.

Pak J Med Sci    January - March 2009    Vol. 25 No. 1    126-130

How to cite this article:

Bokhari SAH, Sufia S, Khan AA. Infection control practices among Dental Practitioners of Lahore, Pakistan. Pak J Med Sci 2009;25(1):126-130.

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1. Syed Akhtar Hussain Bokhari, BDS, MCPS
Assistant professor of Community Dentistry,
Margalla Institute of Health Sciences,
Gulraiz III,
Rawalpindi - Pakistan.
2. Shamta Sufia, BDS, MSc
Assistant professor of Community Dentistry,
FMH College of Medicine & Dentistry,
Shadman,
Lahore - Pakistan.
3. Ayyaz Ali Khan, BDS, MSc, PhD
Professor of Community Dentistry,
Riphah International University,
Islamabad - Pakistan.

Correspondence

Dr. Syed Akhtar Hussain Bokhari
22-Rewaz Garden,
Lahore – Pakistan.
E-mail: pdplhr@yahoo.com

* Received for Publication: July 29, 2008
* Revision Received: October 7, 2008
* Second Revision Received: November 3, 2008
* Final Revision Received: November 10, 2008

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INTRODUCTION

The public expectations from a health care facility are zero risk.1 Infection control is a dynamic and ever-changing subject and all dental staff should be kept aware of the most up-to-date procedures required to prevent the transmission of infection. Dental practitioners should understand why these procedures are necessary.2 Unless precautions are taken, there is a high possibility that patients and Dental Health Care Personnel (DHCP) will be exposed to blood-born and other potentially pathogenic infectious materials. By understanding principles of disease transmission and using infection control practices, dental personnel can prevent disease transmission.3 Adequate precautions for infection control should be in place for protection of both dental staff and patients. Sterilization, disinfection and barrier protection are universal precautions. Unique nature of most dental procedures, instrumentation, and patient-care settings call for specific strategies directed to the prevention of transmission of pathogens among dental personnel and their patients; "universal precautions", must be observed routinely in the care of all dental patients.4

Dentistry predominantly involves exposure to blood and other potentially infectious materials and involves high standard of infection control.5 Dental Practices in Pakistan have been identified as potential risk factor in transmission of infectious diseases especially Hepatitis B & C.6 Oral health care services are provided through dental surgeries both in public and private sector. There are also a substantial number of unqualified practitioners in the country.7 A previous study reports poor status of infection control measures among dental practitioners of Lahore.8 This study was conducted to collect information about the cross infection control and sterilization methods adopted by the qualified and un-qualified practitioners in the city of Lahore, Pakistan.

METHODOLOGY

Data about the distribution of dental practices in Lahore is not available. Lahore, the second biggest city of Pakistan is divided into six administrative towns as defined by City District Government (CDG). A convenient sampling technique was used to cover each locality of the towns. First 70 dental practices in each town irrespective of the fact whether the practice was owned or run by a qualified / non-qualified practitioner were visited. The owner / practitioner were explained the purpose of study and verbal consent was taken. Information about infection control and sterilization methods were collected through a close ended structured questionnaire designed by the authors. Fifteen trained dental hygiene students of Lahore medical & dental college filled the questionnaires and completed the survey in two weeks (1st March-15 March 2005).

The questionnaire was piloted on ten dental practitioners and dental hygiene students were trained to fill in the questionnaire; a reliability of 90% was achieved.

Following questions were asked in the questionnaire:

1. Practice owned by ———Qualified / Un-qualified practitioner;

2. Use of gloves ———All patients / selected patients /on demand / occasionally;

3. Use of Face mask ———All patients / selected patients /on demand / occasionally;

4. Method of sterilization————Boiling / autoclaving / chemicals / Dry Heat;

5. Use of Separate instruments for hepatitis patients———Yes / No;

6. Use of pouches for instruments————Yes / No;

7. Change instruments for each patient ————Yes / No

Data was categorized into qualified and un-qualified practitioners and their characteristics were compared using SPSS version 11.5 for Windows. Cross tabulation was done using Chi square test to find the associations between the different variables, and a probability level of p <0.05 was considered significant.

RESULTS

Four hundred dental practices of Lahore were approached by dental hygiene students to collect the required information. Fifty two practitioners refused to participate, 25 forms were rejected on the basis of incomplete information; 333 forms were found with complete information. A response rate of 83.25% was obtained.

Results of study on ownership of practice, use of gloves, use of face masks, sterilization methods, and on use of separate instruments for patients are presented in Table-I. 62.76% surgeries of Lahore were found being run by un-qualified dental practitioners and 37.24% were under the control of qualified dentists.

A significantly higher number of qualified practitioners used gloves while working on their patients (94.35%) compared to the un-qualified practitioners (28.2%) (p=0.000). Similarly a very high percentage of qualified practitioners used gloves for every patients compared to their un-qualified counter parts (85.48% and 14.35% respectively) (p= 0.000). Gloves were not worn for every patient by the both categories of practitioners in this study.

The use of face masks between qualified and un-qualified practitioners was also statistically significantly different (p= 0.000). 97.5% among qualified practitioners and 80.3% among the un-qualified practitioners were in the habit of wearing face masks. However 79.8% among qualified and 32.5% among the un-qualified dentists used a face mask for all patients during examination and treatment (p= 0.000).

The sterilization methods also differed significantly between the two categories of dental practitioners in this study (p= 0.000). 67.4% of the un-qualified practitioners were using boiling of instruments as sterilization method and 48.3% of the qualified practitioners reported this technique. Autoclaving was practiced by 12.9% and 5.7%, dry heat sterilizers by 9.6% and 5.7% of qualified and of un-qualified practitioners respectively. A chemical method of sterilization was practiced by 29% of qualified and 13.3% of un-qualified dentists.

Dental practitioners in the present study also differ in their practice of changing instruments for every patient. 85.1% of un-qualified and 98.3% of the qualified dental practitioners use fresh set of instruments for each patient. The results are different significantly for the two groups (p=0.000). Storage of instruments in pouches and having separate instruments for Hepatitis patients was significant among qualified and un-qualified practitioners (p= 0.000 and 0.003 respectively. Degree of freedom for Chi-Sq test in each application is noted as ‘1’.

DISCUSSION

In Lahore, the second largest city of Pakistan and capital of Punjab province, higher numbers of dental practices were found being owned and/or run by un-qualified (traditional practitioners) dental personnel. The standard of these dental settings were lower in respect of the dental personnel working there and the working environment that may be considered acceptable for the patients’ satisfaction. Standardization and quality control of private practices has never been on agenda of Government of Pakistan. Every Pakistani with little / no knowledge and training in medicine / dentistry can run a private clinic/hospital and play with lives of people.

There are 7046 dentists registered with the Pakistan Medical & Dental Council (PMDC) by Feb. 20079; a Dentist (qualified) to Population ratio in Pakistan becomes 1: 23000, if un-qualified are included then this ratio becomes 1:5000. Only 200 qualified dentists are working in the rural areas of Pakistan that make up 70% of the country population; 10 thus 30% population has access to the qualified dentists.

This study is the 3rd one in Pakistan to give results for a comparison of studies on infection control in dental practices in Lahore. Another study from Lahore in 1998 on use of infection control measures reported use of gloves by 60% (our study 94%), use of face-masks by 76% (our study 97%) of qualified dentists. 62% used autoclave, 46% dry heat and 36% chemical sterilization methods.5 The findings of our study shows an improvement in adoption of infection control measures by the qualified dentists. Results of our study correspond to other studies that report a high proportion of qualified practitioners using gloves (always, 91.8%; sometimes, 7.8%), masks (always, 74.8%; sometimes, 21.1%),11 using gloves and changing gloves after each patient.12 In Durban, 89% dentists have autoclaves, 97% reported routine use of gloves and masks13 Al-Omari and AlDwairi14 reports 81.8% wear and change gloves during treatment, 54.4% wear and change masks, and 95% change extraction instruments and burs between patients. The management of dental instruments can be considered efficient as long as they are sterilized in an autoclave (97%) and undergo periodic sterilization efficacy tests (76%).15

Infection control procedures e.g. use of gloves etc was observed negligible among traditional practitioners; that indicates lack of awareness, training and potential source of transmissible diseases. Disparity of infection control measures among qualified and un-qualified dental practitioners observed in this study calls for an attention of the stake holder of health to take necessary measures to control dissemination of infectious diseases through the dental practices. Further education is required in infection and sterilization, in particular the use of chemical sterilization/autoclaves. Provision of Guideline for Infection Control in Dental Health-Care Settings is an important update of current infection control practices that will help the dental profession to be better prepared to reduce the transmission of infectious disease(s) in the foreseeable future.16

CONCLUSION

Infection control / sterilization measures are rather poor in dental settings run by un-qualified (traditional) practitioners. There is need for creation of awareness and continuous education about the prevention of cross-infections and use of self protection methods. There is also need for a legislation regarding the standard and quality of dental practice.

ACKNOWLEDGEMENT

Authors would like to thank dental hygiene students (batch 2004-5 and 2005-6) of Lahore Medical & Dental College (LMDC), Lahore for their cooperation in the conduction of the study.

REFERENCES

1. Situation analysis of sterilization guidelines for invasive devices/instruments used in medical surgical & dental interventions. Govt. of Pakistan, Ministry of Health 2007; oms9000/MOH/OSP06-SA/STER

2. Update on infection control. South Afr Dental J 1999;54(12):641-3.

3. Kohn WG, Harte JA, Malvitz DM, Collins AS, Cleveland JL, Eklund KJ. Guidelines for infection control in dental health care settings. J Am Dent Assoc 2003;135(1):33-47.

4. Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry. MWMR 1993;42 (No. RR-8).

5. Puttaiah R, Bedi R, Almas K. A survey of infection control practices among general dental practitioners in Lahore, Pakistan. J Pak Den Assoc 2001;10(2):71-6.

6. Sadiq F, Khan NR, Mahmood S, Khan AA. Prevalence of Hepatitis –B Antigen among Dental Practitioners in Lahore. Int Dent J 1997;47(6):329-33.

7. Oral health in Pakistan: A situation analysis. www.fdiworldental.org/public_health/assets/database/pakistan/pakistan_nohp.pdf

8. Khan AA. Cross Infection control methods in dental practice: A pilot survey of Lahore Pakistan. JOPDAK 1997; 8(1):33-7. www.pmdc.org.pk/stat.htm

9. Khan AA. Oral health services in developing countries: a case for primary health care approach. Guest Editorial. Develop Denti 2004;256-60.

10. McCarthy GM, MacDonald JK. The infection control practices of general dental practitioners. Infect Control Hosp Epidemiol 1997;18(10):699-70.

11. McCarthy GM, MacDonald JK. A comparison of infection control practices of different groups of oral specialists and general dental practitioners. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85(1):47-54.

12. Yengopal V, Naidoo S, Chikte UM. Infection control among dentists in private practice in Durban. South Afr Dental J 2001;56(12):580-4.

13. Al-Omari MA and Al-Dwairi ZN. Compliance with infection control programs in private dental clinics in Jordan. J Dent Educ 2005;69(6):693-8.

14. Fabiani L, Mosca G, Giuliani AR. Hygiene in dental practices. Eur J Paediatr Dent 2006;7(2):93-7.

15. DePaola LG. Infection control and dental practice: Frequently asked questions. Compend Contin Educ Dent 2004;25(1 Suppl):38-42.

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