ACHAIKI IATRIKI | 2021; 40(2):96–106
Original research article
Karolina Akinosoglou1, Panagiota Ntolou2, Vasilina Dimakopoulou3, George Moutousis4, Charalambos Gogos1
1Department of Internal Medicine and Infectious Diseases, University Hospital of Patras, Patras, Greece
2Medical School University of Patras, Patras, Greece
3Department of Internal Medicine, University of Patras, Patras, Greece
4Department of Oral and Maxillofacial Surgery, University Hospital of Patras, Patras, Greece
Received: 31 Oct 2020; Accepted: 25 Nov 2020
Corresponding author: Assist. Professor Karolina Akinosoglou, Specialist in Internal Medicine and Infectious Diseases, Dept of Internal Medicine and Infectious Diseases, University Hospital of Patras, 26500, Rio GR, Tel.: +30 6977 762897, E-mail: akin@upatras.gr
Key words: Infectious diseases, occupational exposure,dentists,HIV, access to care
Abstract
Background: A difficulty of patients with infectious diseases to access dental care is still identified worldwide. We aimed to explore dentists’ knowledge and attitude towards infectious diseases in Greece, where no data is currently available.
Methods: We performed a survey among dentists of a wide region of Southwestern Greece, via electronic distribution of anonymous questionnaires, within a period of three months.
Results: Of 199 questionnaires that were delivered to dentists, 60 (30%) were finally completed and returned. The majority of participants were males (53.3%) and below 45 years of age (65%). Almost all had studied dentistry in Greece (90%) and practiced dentistry in the private sector (96.7%). Most practised in large urban centres (78.3%), and treated between 5-10 patients in a typical working shift (75%), assisted by other personnel (61.7%). Knowledge upon ID was found to be poor; nonetheless, 56.7% showed confidence of appropriate action post occupational exposure. The majority (81.7%) treat any patient as potentially contagious, however, only 51.7% were willing to treat a patient with ID upon disclosure. Occupational exposure has been common (71.7%), without any major long-term physical or psychological consequences (95.5%) following immediate advice from an ID specialist (32.6%). No correlation was found between any socio-demographic characteristic and knowledge on ID or current practice, although, a trend towards reluctancy (r=-0.247) to treat patients with ID (p=0.05) was detected.
Conclusion: Although, dentists’ compliance with universal precaution measures is satisfactory, knowledge on infectious diseases is poor, potentially hampering access to care for these patients
Introduction
Dental care is not free from infectious disease transmission risk [1,2]. Cross-infection during dental practice can occur through infected blood, air droplets, saliva, and instruments contaminated with secretions between patients and healthcare workers [3]. Dental care providers have an ethical and legal obligation to treat patients suffering from infectious diseases [4], in line with respective dental association recommendations worldwide [5]. Nonetheless, recent observations in Europe [6,7], suggest lack of preparedness against infectious diseases [8] and persistent undetected discomfort of dental practitioners to treat patients with infectious disease, thus compromising their care [9-11].
Most reports concerning dentists’ knowledge and practice towards infectious diseases, patients originate from the era before 2000s, following which, immunization practices and therapeutic developments significantly changed our approach. At the same time, incidents of reported occupational exposure have been rare [12-14]. No respective data has ever been available in Greece as for dentist’s attitude and practice towards patients with infectious diseases. Moreover, infection-related occupational diseases are rarely reported among professionals in Greece, similar to other countries [15,16]. Our study set out to investigate dentists’ perspectives on infectious diseases and explore their knowledge and practices towards respective patients.
Methods
Study population and methodology
We performed a cross-sectional observational survey among dental practitioners-members of the largest Greek Dental Association of Southwestern Greece. To this purpose, an anonymous questionnaire was developed by a dentist, a hygienist, and 2 specialists in infectious diseases and was electronically distributed and reminded twice by phone and e-mail, within the respective dental association. It was previously approved by the respective bioethics research committee Π7Θ9/16-10-2018, and tested for validity by two independent users. The questionnaire was accompanied by an informative letter, describing the purpose of the research, the modalities to fill in the questionnaire and the anonymous procedure of the study. About 10-15 min were needed to fill in the questionnaire. A 3-month period was fixed for data collection, at the end of which the study was considered completed.
Structure of the questionnaire
The questionnaire was composed of three major sections, containing 35 multiple choice questions (Table 1). The aim of the first section was to investigate personal demographic and epidemiological data (i.e., gender; age; area where the professional activity is mainly performed; university degree in dentistry; years in practice; public or private practice). The second section was aimed at investigating the scientific knowledge of hygienists on infectious diseases and associated issues. For each knowledge question, a score of ‘‘1’’ was given for the correct answer and ‘‘0’’ for the incorrect or unknown answers. A total knowledge score was calculated, and it ranged from 0 to 7. Finally, the aim of the third section was to ascertain the precautions normally taken during the practice and the cleaning and ⁄ or sterilization procedure, to avoid the spread of infection between dental healthcare workers and patients and among patients, explore relative exposure experience, as well as, investigate the relationship between dental practitioners and infectious patients, to identify the presence of discriminatory behaviour and understand motives.
Statistical analysis
Differences between group proportions were assessed using chi-square test or Fisher’s exact test. Two-tailed tests of significance at the P < 0.05 level were used to determine statistical significance and Pearson test to explore correlations between knowledge score and socio-demographic parameters and attitudes. Statistical analysis was performed using SPSS (v.22).
Results
In total, 199 questionnaires were e-mailed, followed by respective reminders. Of the 199 questionnaires that were delivered to dentists 30% (60) of them were completed within the prefixed time period. It is important to note that all participants answered all questions as in Table 1, except for questions 25-29 where the denominator was respectively adjusted upon those that replied positively in question 24 (43).
The majority of participants were males (53.3%) and below 45 years of age (65%). Almost all had studied dentistry in Greece (90%) and practiced dentistry in the private sector (96.7%). A big proportion practiced in large urban centres (78.3%), and treated between 5-10 patient in a typical 6-hour working shift (75%), usually assisted by other personnel (61.7%).
Knowledge upon transmittable diseases remains poor to moderate as suggested by correct answers ranging from 0-75% per question. Only 1 dentist scored 4 correct answers (1.7%), 5 provided 3 correct answers (8.3%), while 53 scored 2 or less correct answers (90%) in questions examining knowledge on infectious diseases. Despite that, 56,7% shows confidence and supports good knowledge of appropriate action post occupational exposure.
Even though, 81.7% of practitioners treat any patient as potentially contagious and take necessary precautions in terms of protective and disinfection/decontamination measures, only 51.7% would be willing to treat a patient with communicable disease upon disclosure. Occupational exposure has been common in 71.7% of cases, half of which more than once, without any major long-term physical or psychological consequences (95.5%) following immediate advice from an infectious diseases’ specialist (32.6%). Despite exposure, only half modified their every practice or set a standard operating procedure in place, following incident. Immunization against HBV is almost universal among dentists (93.3%) who check for their serostatus (90%), however, yearly vaccination against influenza remains poor (56.7%), even though higher than average among other healthcare practitioners.
No correlation was found between any socio-demographic characteristic and knowledge on infectious diseases or current attitudes and practice, although a mild trend towards reluctancy (r=-0.247) to treat patients with communicable diseases despite good knowledge was observed (p=0.057).
Discussion
This has been the first study to explore dentists’ knowledge, attitude and practice towards infectious diseases in Greece. Our pilot survey highlights efficient protective and decontamination practices, that – do not justify by any means, but – seem to counter – balance poor knowledge of dental practitioners of infectious diseases and result in few, or no incidents of cross-infection, as per available national data. Nonetheless, reluctancy to treat this population remains high, and if occupational exposure takes place, validity of adopted individual practices is controversial. Our study represents a pilot survey and bears limitations further discussed, nonetheless, it significantly reflects dentists’ attitudes towards infectious diseases, in Greece; a population never examined before, while global data remain scarce and relatively old.
Poor or blurry knowledge of infectious diseases by dentists is a common observation in many studies and various settings [17-25]. In our study, only 10% reached 43% (3 points) of maximum knowledge score. Knowledge was not associated with age, neither years in practice as one would expect and observed in other studies [26]. Nonetheless, most dentists (56.7%) confidently replied, that are well aware of procedures to be followed post-exposure, similar to other studies, where false perception of adequacy of scientific knowledge appears disproportionate to findings following direct questions [27]. These observations can be worrying, since any further educational effort can be hampered, and underlying discomfort or even malpractice go undetected. Encouragingly, respective findings of poor knowledge in Croatia and Romania did highlight the need and wish on behalf of dental practitioners to acquire more in-depth education on infectious diseases [28,29]
In our study, we found no correlation between dentist knowledge and behaviour towards infectious diseases. Previous studies in both the UK [30,31] and US [32-34] have also examined dentists’ knowledge, attitudes and behaviours in order to assess which factors may be influential in affecting dentists’ willingness to treat patients with infectious disease like HIV/AIDS. The proportion of dentists that would treat a patient with HIV, HBV or HCV without hesitation ranges from 20-50% similar to our findings [31]. It seems, that even though, admittance of right to equal dental care for these patients does exist, most dentists are reluctant to be involved themselves to it and refer patients to someone else [35,36]. It has been suggested that dentists’ behaviour towards patients with infectious diseases is inversely related to their current knowledge [5,9,37,38] in terms of willingness to treat, but also sense of ethical responsibility [31]. Age, type and years of practice, as well as, type of procedure to be performed, have also been reported to be implicated in the decision to treat this population [26,27,31,39,40], however, this was not detected in our study.
Compliance with protective and good hygiene measures in this study was high, similar or even higher to previous reports [31,41]. Interestingly however, previous authors have reported the belief that, protective measures may not be adequate in all cases [42] and infectious patients should be treated in a specially adapted dental office (64.2%) [26,43]. Only one study did not find changes in the behaviour of dentists, despite their awareness that the patient was infected [44], in line with the notion that, every patient should be treated as potentially infected [23,26]. The majority (71%) complied with washing hands and other infection control measures, [23] showing improvement to previously described practices [45-47]. Immunization against HBV among dentists was high according to international guidelines and other reports in other countries [46,48-52], although in developing regions only 39.3% completed all three doses [53]. Even though, the majority checks for their serostatus in our survey, use of repeated performance remains controversial following initial seroconversion [54].
Occupational exposure has been common in 71.7% of cases, a percentage significantly higher than reports from South Wales (56%) [55], Netherlands (32%) [52], Italy (>40%) [56] or Jordan; in these studies the authors further looked into accidents among dental staff (27%) and nurses (35%) [46]. In our study, dentists did ask for advice from an expert following an incident at a percentage of 32.6%, in accordance to a retrospective report in Netherlands [52]. Worryingly though, no change in every day practice was noticed following accidental exposure, while even though our survey was not designed to detect for incident reporting, it appears that occupational exposure in dental settings can go undetected [57].
Limitations
Our study bears significant limitations including a convenience sample, a low response rate and a fixed time during which it was carried out, in the context of a pilot survey that can be further improved, for safer conclusions to be drawn. Electronic distribution, may limit responses to professionals of younger age and urban centres that are familiar with worldwide web, whereas personal on site contact could further enhance response and overcome such obstacles [58]. Our study also came from a specific geographical part of Greece, hence, results cannot be extrapolated to other areas that different socio-demographic conditions may apply, even though, our centre remains a reference centre of infectious diseases for Southwestern Greece.
Conclusion
Following this pilot survey, the design of a larger nationwide study to capture knowledge and attitudes of dentists towards infectious diseases is pivotal. A careful description and a full understanding of the numerous delicate interpersonal problems arising between dentists and patients with infectious diseases are both essential to avoid discrimination and offer patients the best possible dental health care.
Acknowledgements
The authors would like to thank members of Dental Association of Achaia.
Conflict of interest disclosure
None to declare.
Declaration of funding sources
None to declare.
Author contributions
All authors have made substantial contributions to conception and design of the study and have given final approval of the version to be published. PN and GM have been involved in data collection. KA, VD and CG have been involved in data interpretation and data analysis. KA drafted the manuscript, and CG critically corrected it.
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