Observational / Cross sectional Study Critical AnalysisPresentation Transcript
Compliance of Saudi
dental students with
Dr. Priyanka Sharma
1st year Post Graduate
Dept. of Public Health
INFECTION: Invasion and multiplication of microorganisms in body tissues,
which may be clinically unapparent or result in local cellular injury due
competitive metabolism, toxins, intracellular replication or antigen antibody
The infection may remain localised, subclinical and temporary if the body's
defensive mechanisms are effective.
A local infection may persist and spread by extension to become an acute, subacute or chronic clinical infection or disease state.
A local infection may also become systemic when the microorganisms gain
access to the lymphatic or vascular system.
INFECTIOUS DISEASE : The pathological state resulting from the invasion of
the body by pathogenic microorganisms and their multiplication which
can lead to tissue damage and diseases.
INFECTIOUS DISEASES IN DENTISTRY
Infection control is the discipline concerned with preventing nosocomial
or healthcare-associated infection, a practical (rather than academic) subdiscipline of epidemiology.
Infection control and hospital epidemiology are akin to public
health practice, practiced within the confines of a particular health-care
delivery system rather than directed at society as a whole.
Concepts in dental infection control were developed in the 1960s (due to
Hepatitis-B viral infections).
Disease transfer to the dentist and dental staff during dental care is
considered an “occupational exposure” to a given pathogen, while disease
transfer from one patient to another in the dental clinics is considered
Decontamination & Spaulding’s
Infection control is today without doubt an integral part of contemporary
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
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
The compliance of DHCPs with these guidelines has been investigated
by a number of studies worldwide.
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.
There is little information regarding compliance with universal control
precautions in the Middle East in general and Saudi Arabia in particular.
AIM OF THIS STUDY
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
The questionnaire was developed after consulting with specialists from
each dental specialty at the teaching hospital and based on similar
questionnaires used in the past.
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.
The questionnaire included 18 questions that evaluated:
(1) demographic data (gender and academic
(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,
Data analysis included descriptive statistics and Pearson‟s chi-square
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.
Overall, 311 students (93.9%) responded to the survey.
The distribution of respondents by academic level
and gender is shown :
About 99% reported that they usually review the medical history of their
patients before commencing dental treatment and 80% were vaccinated
against hepatitis B.
Among the personal protective equipment, the highest compliance rates
were reported for wearing (100%) and changing (98.5%) gloves between
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.
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.
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 aerosols.
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.
A thorough medical history must be recorded and reviewed before
starting the dental treatment and updated at subsequent visits.
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 applied.
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
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 studies.
VACCINATION AGAINST HBV
Dental health-care professionals are at an increased risk of acquiring
hepatitis B infection and therefore must be vaccinated against it.
About 80% of the respondents received an HBV vaccination, thus falling
in the range reported by previous studies.
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
To overcome this negative aspect, it is recommended that students be
immunised during their preparatory study years before they start their
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 jackets.
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.
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 avoided.
All the study sample wore gloves and 98.5% changed them between
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% now.
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
In contrast, fewer applicants wore face shields (30%) and protective eye
Indeed, the routine use of the latter barriers is low among the dentists all
over the world.
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
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
Africa and 13.6% of Jordanian dentists and 29.8% of undergraduate Indian
STERILISATION & DISINFECTION OF PATIENTCARE ITEMS
Patient-care items are generally categorised into critical, semi-critical or
Critical items must be sterilised while disinfection and/or surface
protection is generally adequate for semicritical and non-critical items.
Of particular concern are dental handpieces which should be heatsterilised between patients despite the fact that they are classified
as semi-critical items.
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 documented.
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 laboratory.
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 and 18.1% by Al-Omari & Al-Dwairi.
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 bags.
In previous studies, 8–75% of dentists used puncture-resistant containers
compared with 91% of the respondents in this study.
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
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 the 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
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.
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.
Vancouver system of referencing.
SOURCE OF THE ARTICLE
International Dental Journal
It is an international, quarterly, peer reviewed and indexed journal.
Mesh Representation : Int Dent J.
Impact Factor : 1.04
Online ISSN : 1875-595X
Print ISSN : 0045-0421
Publisher : John Wiley & sons
Editor : Dr Stephen Hancocks
Year of publication : June 2013
Volume No : 63; Issue No : 2; Page nos. : 196-201
1) Ibrahim Ali Ahmad
2) Elaf Ali Rehan
3) Sharat Chandra Pani
The authors‟ institutional attachments have been stated .
Designation & Qualifications are not mentioned.
Ibrahim Ali Ahmad
Asst. Prof. of Endodontics
Restorative Dentistry Department, Riyadh Colleges of Dentistry and
Pharmacy, Saudi Arabia
Publication – 1
Area of interest – Infection control
Elaf Ali Rehan
Publication – 1
Area of interest – Infection control
Sharat Chandra Pani
PhD in Physics
Indira Gandhi Centre for Atomic Research
Publications – 83
Area of interest – Molecular dynamics, Quantum chemistry, Density
funtional theory, Material modelling, Structural property coefficeint.
CRITICAL APPRAISAL OF THE TITLE
Title is catchy (7 words).
It is meaningful.
It includes all the important variables intended to be measured.
It indicates topic and focus of the study.
Gives an idea about study population.
Does not give an idea about study design and study setting,
PROPOSED ALTERNATE TITLE
Compliance with Infection Control Guidelines
among students in a Saudi Arabian Dental School –
A Cross Sectional Study.
Informative and comprehensive .
Gives a brief outline of the whole text.
Total words : 222
Compliance, dental students, hepatitis B, infection control, Kingdom
of Saudi Arabia
Keywords are appropriate - 1st article in pubmed
CRITICAL APPRAISAL OF INTRODUCTION
Meaningful and concise.
Built on existing literature..
Citations (24) are relevant and pertinent to study being reported.
The scientific background and rationale for the study have been
Objectives of the study are mentioned.
Hypothesis to be tested is NOT also stated.
Research Question : Is there presence of compliance of dental
students in a private school in Saudi Arabia with recommended crossinfection protocols?
Null Hypothesis: There is presence of compliance of dental students
in a private school in Saudi Arabia with recommended cross-infection
Alternative Hypothesis: There is absence of compliance of dental
students in a private school in Saudi Arabia with recommended cross-
CRITICAL APPRAISAL OF MATERIALS AND
Methodology represented is logical and meaningful .
Key elements of study design are mentioned .
Study population ,and data collection are clearly stated.
Basic explanation about the validation of the questionnaire is given.
The eligibility criteria ,the sources , methods of selection of
participants are NOT stated.
Sample size estimation is not done .
Power of the study is not mentioned.
All variables considered for and included in the analysis have been
All statistical methods used have been described .
Measurement of each variable have been described in detail .
P value has been stated .
Ethical clearance was obtained .
Duration of the study is not mentioned.
Informed consent from the participants?
Where it was done? College class/clinic/hostel?
Whether all the students were included?
What language is been preferred in the questionnaire?
CRITICAL APPRAISAL OF RESULTS
Characteristics of study participants has been mentioned.
All the outcome events have been reported.
Results are based on aims and objectives of the study.
Results are presented in table and text matter.
Results are logical and comprehensible.
Tables are numbered .
Data given in text matches with tables .
CRITICAL APPRAISAL OF DISCUSSION
Discussion is meaningful.
Key results has been summarized with reference to study objectives
Enough explanation of all significant results is mentioned.
Comparison has been done of current results with that of previous
Reason to select the sample population is discussed.
Limitations of the study has NOT been discussed .
“AS Exposure to disinfectants can cause defects in gloves”
AS = Aerosol (or) Arsenic (or) a printing mistake [As] X
NOT DISCUSSED ABOUT :
HIV Infection :
Whether the students have undergone HIV test ?
Do the students know to handle HIV patients?
Tuberculosis Patients :
Use of HEPA filters during the contact of infected patients?
influenza, measles, mumps, rubella, diphtheria, chicken pox and
Washing and care of the hands?
Before Sterilization / High level disinfection :
Thorough cleaning of instruments wearing heavy-duty gloves?
Prevention of contamination of radiographic equipments?
CRITICAL APPRAISAL OF CONCLUSION
Conclusion is meaningful and based on aims and objectives of the
Appropriate recommendations have been made .
Acknowledgement is mentioned
Conflict of interest – none.
CRITICAL APPRAISAL OF REFERENCES
References are given for all the citations in the text.
References are in Vancouver system of referencing.
All articles are NOT accessible online.
INFECTION CONTROL IN THE PRIVATE DENTAL
SECTOR IN RIYADH
Abdullah Al-Rabeah, Ashry Gad Mohamed.
Ann Saudi Med 2002;22(1-2):13-17.
AIM & OBJECTIVES: The objective of this study was to assess the infection
control practice in the private dental sector in Riyadh, Saudi Arabia.
MATERIALS & METHODS:
The study was conducted through a cross-sectional survey of private dental
practices inthe city of Riyadh. A total sample size of 132 dental units was
chosen using the proportional allocation method. Three hospitals, 45 clinics
and 39 centers were selected randomly. A self-administered questionnaire
was completed by dentists working in the selected settings.
Results: Of the 206 questionnaires sent, 203 (98.5%) were completed.
The mean age of the responding dentists was 36.8±6.7 years.
A total of 139 dentists (68.5%) were general practitioners and 64 (31.5%)
A total of 129 (63.5%) stated that they had been vaccinated against
hepatitis B virus and 189 (93.1%) stated that they always took a medical
history of each patient before treatment.
All the studied dentists reported that they always used gloves for every
patient during dental treatment, and 90.6% stated that they always wore a
face mask during dental treatment.
The primary source of infection control information for the studied dentists
was from the colleges (78.3%).
Only 37.9% of the dentists sterilized their handpieces by autoclaving, while
the other 53.7% used disinfectant.
About 56% disposed of used needles and sharp instruments in special
Multivariate logistic regression analysis revealed that working in clinics, age
>40 years and knowledge of correct sterilization steps were independent
promoting factors for adherence to infection control practice (OR=3.8, CI=1.212.1; OR=10.2, CI=1.61-64.8; OR=5.6, CI=1.04 -29.9, respectively).
Conclusion: The development of infection control manual for dental
practices, in addition to a campaign of
health education for dentists in the private sector, is recommended.
Compliance with Infection Control
Programs in Private Dental Clinics in
Mohammad Ahmad Al-Omari, Ziad Nawaf Al-Dwairi.
Journal of Dental Education ■ Volume 69, Number 6 :2005
AIM: The aim of this study was to assess the compliance of general dental
practitioners (GDPs) in the private sector in North Jordan with infection
MATERIALS & METHODS:
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
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
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.
Compliance of Saudi
dental students with