SPECIAL ARTICLE
Compliance with infection control procedures among California orthodontists John Woo, ~ Robert Anderson, b.= Bryan Maguire, BSe, a.~ and Barbara Gerbert, PhD d.-
San Francisco, Calif. We conducted a survey of a random sample of California orthodontists and of general dentists to compare their infection control procedures. Questionnaires were returned by 124 orthodontists (56% response rate) and 126 general dentists (61% response rate). Eighteen questions were asked covering practice profile, perception of risk from hepatitis B virus (HBV) and human immunodeficiency virus (HIV), exposure to blood, barrier protection used, and sterilization and disinfection procedures. Gloves always were worn by 80% of the orthodontists sampled, 63% always wore glasses, and 59% changed gloves between patients. Orthodontists sterilized their instruments 66% of the time and pliers 49% of the time. Compared with general dentists, orthodontists' perception of risk, use of barrier protection, and sterilization and disinfection procedures were lower in all areas. Our data suggest that poorer performance may be because orthodontists: (1) perceive their younger population of patients at less risk for HBV and HIV; (2) treat 2.5 times as many patients, which increases the costs of infection control; (3) do not use invasive procedures; and (4) perceive that glove use decreases dexterity. Orthodontists should follow the American Dental Association/Council on Dental Therapeutics infection control guidelines for universal precautions. To meet these guidelines, orthodontists still need improvement in all aspects of their infection control procedures. (AMJ ORTHODDENTOFACORTHOP1992;102:68-75.)
I n recent years, the American Dental Association (ADA) has placed a great deal of emphasis on infection control in the dental office. ,-7 Both patients and dentists desire a high level of protection from pathogens which may be carried by blood and saliva, t These bodily fluids may carry high concentrations of potentially infective bacteria or viruses that can produce the common cold, herpes, tuberculosis, pneumonia, and hepatitis B (HBV). Also, blood is known to transmit human immunodeficiency virus (HIV), the causative ,agent of acquired immune deficiency syndrome (AIDS). t While there have been many studies documenti'ng general dentists' increasing levels of infection control in their practices, 3"s~6 there have been few studies documenting the infection control procedures of orthodontists, t72~ By using California general dentists as a comparison group, this survey focused on the in-
fection control procedures used by California orthodontists. METHODS
A complete list of California orthodontists was obtained from the Pacific Coast Society of Orthodontists. A questionnaire adapted from a previous study t9 was mailed to every third orthodontist on the list (n = 220). For the comparison group, a random sample of 500 California general dentists was obtained from the American Dental Association. An identical questionnaire was mailed to approximately every other dentist on this list (n = 206). The questionnaire asked 18 questions, covering information in six areas: practice profile, perception of risk from HBV and HIV, exposure to blood, barrier protection used, and sterilization and disinfection procedures employed (Table I). The t tests and chi-square statistics were used to compare the groups. Two separate mailings were sent to increase the response rate. RESULTS
=Orthodontic resident, Saint Louis University Medical Center. "Orthodontic resident, University of the Pacific. 'Formerly dental students, School of Dentistry, University of California, San Francisco. aDivision of Behavioral Sciences, Department of Dental Public Ilealth and Ilygiene, School of Dentistry. University of California, San Francisco.. . . . . 'Center of AIDS Prevention Studies, School of Dentisu3', University of California, San Francisco. 8/i/31587
68
Responses were received from 124 orthodontists (96 questionnaires were not returned) for an adjusted response rate of 56% and from 126 general dentists (80 questionnaires were not returned) for an adjusted response rate of 61%. Since some outlying responses drastically skewed the mean, the median score was found to be more representative of the average respon-
Volume 102 Number l
Special article
69
Table I. S u r v e y o f infection control procedures 1. ttow many patients do you see per week? 2. Your practice profile: a. % children b. % adolescents c. % adults 3. What percentage of your patients do you suspect carry the Hepatitis B virus? 4. What percentage of your patients do you suspect carry the AIDS virus? 5. How many times per week would you estimate that you experience a cut, puncture wound or needle stick? 6. ttow many times per week would you estimate that your chairside assistant experiences a cut, puncture wound or needle stick? 7. ttow many patients per week would you estimate that you or your chairside assistant sees blood in the mouth? or in an impression? 8. Which items are used with ALL patients with the doctor? chairside? laboratory assistant? a. mask b. gloves e. eyewear d. gown 9. Do you change gloves between patients? 10. If not, do you wash your gloves between patients? I I. Were you trained using gloves in dental school/residency? 12. Do you think that gloves decrease your dexterity? 13. Do you think that gloves lead to increased cuts or puncture wounds'? 14. What type of sterilization/disinfection procedures do you use for instruments? pliers? handpieces? a. soap/water b. alcohol c. steam autoclave d. dry heat oven e. chemical vapor f. chemical disinfection g. other 15. Do you have an environmental disinfection program? If yes, what type of disinfectant do you use? a. iodophors b. phenols c. bleach/chlorine d. other 16. If you use mechanical coverage please list. 17. Impressions are: a. disinfected and poured immed. b. poured immed w/o disinfecting c. disinfected then sent to lab d. sent to lab w/o disinfecting 18. Evaluate your current sterilization and disinfection procedures.
dent. T h e r e f o r e , in this study, the m e d i a n score (rather than the mean) is reported, unless otherwise noted.
Practice profile T h e a v e r a g e orthodontist treated 160 patients per w e e k (range: 0 to 620), consisting o f 2 1 % children (1 to 10 years), 5 2 % adolescents (i I to 18 years), and 2 7 % adults ( > 1 8 years). T h e a v e r a g e general dentist treated 60 patients per w e e k (range: 5 to 600), consisting o f 14% children, 16% adolescents, and 7 0 % adults.
Perception of risk of HBV and HIV Orthodontists p e r c e i v e d a smaller percentage o f their patients carrying H B V and H I V c o m p a r e d with
general dentists ( F i g s . 1 and 2). T h e average orthodontist suspected 1.0% o f the patients carried H B V (range: 0 to 20), whereas general dentists suspected 3 . 0 % o f their patients carried the virus (range: 0 to 100). T h e average orthodontist suspected that no patients carried the H I V virus (range: 0 to 2) c o m p a r e d with general dentists w h o suspected 1.0% (range: 0 to 100).
Exposure to blood Orthodontists and general dentists are exposed to b l o o d through cuts, puncture w o u n d s , and needle sticks. Orthodontists on the average reported one o f these exposures o n c e every 4 w e e k s c o m p a r e d with o n c e every 10 w e e k s for the general dentist. Taking
70
Woo el al.
Am. J. Orthod. Dentofac, Orthop. July 1992
50 .p..
GEN DOS
OJ
ORTHO. MEAN - 2.75 ORTHO. MEDIAN = 1.00 U}
.=
D D S . M E A N = 6.78
3o
DDS. MEDIAN = 3.00 ,CO
n,-
20
~5 ""
o;
10
10
% OF PATIENTS SUSPECTED OF CARRYING HBV Fig. 1. Perception of risk-HBV.
,oj
405011
[
ORTHO. MEAN = 0.41 ORTHO. MEDIAN = 0.00
0 0
.001-.099
GENDDS
1
2
3
4
5
% OF PATIENTS SUSPECTED OF CARRYING HIV Fig. 2. Perception of risk-HIV.
>5
DDS. MEAN = 2.91 DDS MEDIAN = 1.00
Volume 102 Number 1
Special article 71 100 o~
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9
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r
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Compliance with infection control procedures among California orthodontists John Woo, ~ Robert Anderson, b.= Bryan Maguire, BSe, a.~ and Barbara Gerbert, PhD d.-
San Francisco, Calif. We conducted a survey of a random sample of California orthodontists and of general dentists to compare their infection control procedures. Questionnaires were returned by 124 orthodontists (56% response rate) and 126 general dentists (61% response rate). Eighteen questions were asked covering practice profile, perception of risk from hepatitis B virus (HBV) and human immunodeficiency virus (HIV), exposure to blood, barrier protection used, and sterilization and disinfection procedures. Gloves always were worn by 80% of the orthodontists sampled, 63% always wore glasses, and 59% changed gloves between patients. Orthodontists sterilized their instruments 66% of the time and pliers 49% of the time. Compared with general dentists, orthodontists' perception of risk, use of barrier protection, and sterilization and disinfection procedures were lower in all areas. Our data suggest that poorer performance may be because orthodontists: (1) perceive their younger population of patients at less risk for HBV and HIV; (2) treat 2.5 times as many patients, which increases the costs of infection control; (3) do not use invasive procedures; and (4) perceive that glove use decreases dexterity. Orthodontists should follow the American Dental Association/Council on Dental Therapeutics infection control guidelines for universal precautions. To meet these guidelines, orthodontists still need improvement in all aspects of their infection control procedures. (AMJ ORTHODDENTOFACORTHOP1992;102:68-75.)
I n recent years, the American Dental Association (ADA) has placed a great deal of emphasis on infection control in the dental office. ,-7 Both patients and dentists desire a high level of protection from pathogens which may be carried by blood and saliva, t These bodily fluids may carry high concentrations of potentially infective bacteria or viruses that can produce the common cold, herpes, tuberculosis, pneumonia, and hepatitis B (HBV). Also, blood is known to transmit human immunodeficiency virus (HIV), the causative ,agent of acquired immune deficiency syndrome (AIDS). t While there have been many studies documenti'ng general dentists' increasing levels of infection control in their practices, 3"s~6 there have been few studies documenting the infection control procedures of orthodontists, t72~ By using California general dentists as a comparison group, this survey focused on the in-
fection control procedures used by California orthodontists. METHODS
A complete list of California orthodontists was obtained from the Pacific Coast Society of Orthodontists. A questionnaire adapted from a previous study t9 was mailed to every third orthodontist on the list (n = 220). For the comparison group, a random sample of 500 California general dentists was obtained from the American Dental Association. An identical questionnaire was mailed to approximately every other dentist on this list (n = 206). The questionnaire asked 18 questions, covering information in six areas: practice profile, perception of risk from HBV and HIV, exposure to blood, barrier protection used, and sterilization and disinfection procedures employed (Table I). The t tests and chi-square statistics were used to compare the groups. Two separate mailings were sent to increase the response rate. RESULTS
=Orthodontic resident, Saint Louis University Medical Center. "Orthodontic resident, University of the Pacific. 'Formerly dental students, School of Dentistry, University of California, San Francisco. aDivision of Behavioral Sciences, Department of Dental Public Ilealth and Ilygiene, School of Dentistry. University of California, San Francisco.. . . . . 'Center of AIDS Prevention Studies, School of Dentisu3', University of California, San Francisco. 8/i/31587
68
Responses were received from 124 orthodontists (96 questionnaires were not returned) for an adjusted response rate of 56% and from 126 general dentists (80 questionnaires were not returned) for an adjusted response rate of 61%. Since some outlying responses drastically skewed the mean, the median score was found to be more representative of the average respon-
Volume 102 Number l
Special article
69
Table I. S u r v e y o f infection control procedures 1. ttow many patients do you see per week? 2. Your practice profile: a. % children b. % adolescents c. % adults 3. What percentage of your patients do you suspect carry the Hepatitis B virus? 4. What percentage of your patients do you suspect carry the AIDS virus? 5. How many times per week would you estimate that you experience a cut, puncture wound or needle stick? 6. ttow many times per week would you estimate that your chairside assistant experiences a cut, puncture wound or needle stick? 7. ttow many patients per week would you estimate that you or your chairside assistant sees blood in the mouth? or in an impression? 8. Which items are used with ALL patients with the doctor? chairside? laboratory assistant? a. mask b. gloves e. eyewear d. gown 9. Do you change gloves between patients? 10. If not, do you wash your gloves between patients? I I. Were you trained using gloves in dental school/residency? 12. Do you think that gloves decrease your dexterity? 13. Do you think that gloves lead to increased cuts or puncture wounds'? 14. What type of sterilization/disinfection procedures do you use for instruments? pliers? handpieces? a. soap/water b. alcohol c. steam autoclave d. dry heat oven e. chemical vapor f. chemical disinfection g. other 15. Do you have an environmental disinfection program? If yes, what type of disinfectant do you use? a. iodophors b. phenols c. bleach/chlorine d. other 16. If you use mechanical coverage please list. 17. Impressions are: a. disinfected and poured immed. b. poured immed w/o disinfecting c. disinfected then sent to lab d. sent to lab w/o disinfecting 18. Evaluate your current sterilization and disinfection procedures.
dent. T h e r e f o r e , in this study, the m e d i a n score (rather than the mean) is reported, unless otherwise noted.
Practice profile T h e a v e r a g e orthodontist treated 160 patients per w e e k (range: 0 to 620), consisting o f 2 1 % children (1 to 10 years), 5 2 % adolescents (i I to 18 years), and 2 7 % adults ( > 1 8 years). T h e a v e r a g e general dentist treated 60 patients per w e e k (range: 5 to 600), consisting o f 14% children, 16% adolescents, and 7 0 % adults.
Perception of risk of HBV and HIV Orthodontists p e r c e i v e d a smaller percentage o f their patients carrying H B V and H I V c o m p a r e d with
general dentists ( F i g s . 1 and 2). T h e average orthodontist suspected 1.0% o f the patients carried H B V (range: 0 to 20), whereas general dentists suspected 3 . 0 % o f their patients carried the virus (range: 0 to 100). T h e average orthodontist suspected that no patients carried the H I V virus (range: 0 to 2) c o m p a r e d with general dentists w h o suspected 1.0% (range: 0 to 100).
Exposure to blood Orthodontists and general dentists are exposed to b l o o d through cuts, puncture w o u n d s , and needle sticks. Orthodontists on the average reported one o f these exposures o n c e every 4 w e e k s c o m p a r e d with o n c e every 10 w e e k s for the general dentist. Taking
70
Woo el al.
Am. J. Orthod. Dentofac, Orthop. July 1992
50 .p..
GEN DOS
OJ
ORTHO. MEAN - 2.75 ORTHO. MEDIAN = 1.00 U}
.=
D D S . M E A N = 6.78
3o
DDS. MEDIAN = 3.00 ,CO
n,-
20
~5 ""
o;
10
10
% OF PATIENTS SUSPECTED OF CARRYING HBV Fig. 1. Perception of risk-HBV.
,oj
405011
[
ORTHO. MEAN = 0.41 ORTHO. MEDIAN = 0.00
0 0
.001-.099
GENDDS
1
2
3
4
5
% OF PATIENTS SUSPECTED OF CARRYING HIV Fig. 2. Perception of risk-HIV.
>5
DDS. MEAN = 2.91 DDS MEDIAN = 1.00
Volume 102 Number 1
Special article 71 100 o~
o~ p,,,
,
o r
9
8O
r
I,LI
