Int Dent J. 2013 Aug; 63(4): 196–201.

PMCID: PMC9375015
Published online 2020 Nov 4. doi: 10.1111/idj.12030 PMID: 23879255

Compliance of Saudi dental students with infection control guidelines

Ibrahim Ali Ahmad,1,* Elaf Ali Rehan,1 and Sharat Chandra Pani2

Abstract

The aim of this study was to investigate compliance of dental students in a Saudi dental
school with recommended infection control protocols. A pilot-tested questionnaire
concerning various aspects of infection control practices was distributed to 330 dental
students. The response rate was 93.9% (n = 311). About 99% of students recorded the
medical history of their patients and 80% were vaccinated against hepatitis B. The highest
compliance (100%) with recommended guidelines was reported for wearing gloves and use
of a new saliva ejector for each patient. Over 90% of the respondents changed gloves between
patients, wore face masks, changed hand instruments, burs and handpieces between patients,
used a rubber dam in restorative procedures and discarded sharp objects in special
containers. A lower usage rate was reported for changing face masks between patients (81%),
disinfecting impression materials (87%) and dental prosthesis (74%) and wearing gowns
(57%). Eye glasses and face shield were used by less than one-third of the sample. The
majority of students were found to be in compliance with most of the investigated infection
control measures. Nevertheless, further education is needed to improve some infection
control measures including vaccination for Hepatitis B virus (HBV), wearing eye glasses,
gowns and face shields and disinfecting impression materials and dental prostheses.

Key words: Compliance, dental students, hepatitis B, infection control, Kingdom of Saudi
Arabia

INTRODUCTION

Infection control is today without doubt an integral part of contemporary dental practice1.
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 infections2., 3., 4..
:
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 themselves (Table 1)2., 3., 4.. The compliance of
DHCPs with these guidelines has been investigated by a number of studies worldwide1., 5.,
6., 7., 8., 9., 10., 11., 12., 13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24.. 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 (Table 2).

Table 1

Cross-infection control guidelines

Immunisation against infectious diseases (i.e. hepatitis B virus)

Use of personal protective equipment (PPE) including gloves, masks, protective eyewear, face
shields and protective clothing such as gowns and jackets

Sterilisation and/or disinfection of patient-care items

Critical items are those that penetrate soft tissue, contact bone, enter into or contact the
bloodstream or other normally sterile tissue. Examples include: surgical instruments, periodontal
scalers, scalpel blades and surgical dental burs

Semi-critical items are those that contact mucous membranes or non-intact skin; they will not
penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile
tissue. Examples include: dental mouth mirror, amalgam condenser, reusable dental impression
trays and dental handpieces

Non-critical items are those that contact intact skin. Examples include: radiograph head/cone,
blood pressure cuff, facebow and pulse oximeter

Environmental infection control of operating surfaces such as light handles, unit switches and
drawer knobs

Safe disposal of waste materials

:
 Table 2

Compliance with recommended cross-infection measures reported by previously published studies

Reference Country Sample Implementation of cross-infection measures (%)

Medical HBV Gloves Facemask Eye Gowns/coats

history vaccination glass

13 USA 297 79.8 70.4

(California) dentists

11

1986 USA 1609 49 33.1 28.5 65.9

survey (Minnesota) dentists

1987 794 61.9 85.9 53.9 87.9

survey dentists

23

1986 USA (national 3437 49 23 26 77

survey survey) dentists

1988 3648 59 76 47 82
survey dentists

10 UK (England 1530 68 30
and Wales) NHS
dentists

22 New Zealand 773 42 64.8 66.4

(national dentists
survey)

14 UK (north- 917 93 93 75 38 62
western region) dentists

9 UK (north- 312 86 68
western region) dentists

HBV, Hepatitis B virus; NHS dentists, dentists working in the National Health Service; DHCPs, dental
health care providers; DTS, dental teaching staff; GDP, general dental practitioner; UGS, Undergraduate
student.
:
There is little information regarding compliance with universal control precautions in the
Middle East in general and Saudi Arabia in particular. Therefore, the aim of this study was 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 questionnaire. The questionnaire was developed after consulting with specialists
from each dental specialty at the teaching hospital and based on similar questionnaires used
in the past5., 21.. 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. Further details of the
validation of the questionnaire are beyond the scope of this paper.

The questionnaire included 18 questions that evaluated: (1) demographic data (gender and
academic level); (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, IL, USA). Data analysis included descriptive statistics and
Pearson’s chi-square (χ2) 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.

RESULTS

Overall, 311 students (93.9%) responded to the survey. The distribution of respondents by
academic level and gender is shown is Table 3.
:
 Table 3

Distribution of the respondents by academic level and gender

Level Male (%) Female (%) Total (%)

Fourth year 43 (27.4) 53 (34.1) 96 (30.8)

Fifth year 47 (30.1) 39 (25.2) 86 (27.7)

Sixth year 47 (30.1) 39 (25.2) 86 (27.7)

Interns 19 (12.2) 24 (15.5) 43 (13.8)

All sample 156 (50.2) 155 (49.8) 311 (100)

About 99% reported that they usually review the medical history of their patients before
commencing dental treatment and 80% were vaccinated against hepatitis B (Table 4).
:
 Table 4

Adherence to various infection control procedures among dental students according academic level and
gender

Procedure Response All Academic level (%) Gender (%)

sample 4th 5th 6th Intern P Male Female
(%)

Recording Yes 99 97 99 100 100 0.240 99 98

medical No 1 3 1 0 0 1 2
history

Hepatitis B Yes 80 88 79 71 83 0.047 76 83

vaccination No 20 12 21 29 17 24 17

Wear Always 100 100 100 100 100 100 100

gloves Sometimes 0 0 0 0 0 0 0

Never 0 0 0 0 0 0 0
Change Always 98.5 98 98 99 100 0.734 97 99
gloves Sometimes 1 1 2 1 0 3 0
Never 0.5 1 0 0 0 0 1

Wear face Always 98 100 96 98 95 0.265 97 98

mask Sometimes 1.7 0 4 1 5 2 2

Never 0.3 0 0 1 0 1 0
Change Always 81 89 82 71 83 0.095 82 80
face mask Sometimes 16.5 10 15 24 17 15 18

Never 2.5 1 2 5 0 3 2
Wear Always 28 24 39 23 24 0.234 30 26
eyeglasses Sometimes 63.5 69 54 67 64 61 66
Never 8.5 7 7 10 12 9 8

Wear face Always 30 23 42 27 24 0.116 35 24

shield Sometimes 54 58 47 56 57 50 59
Bold values indicate statistically significant difference.

Among the personal protective equipment, the highest compliance rates were reported for
wearing (100%) and changing (98.5%) gloves between patients. 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. Approximately 98% reported that they
changed handpieces 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.

DISCUSSION

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 aerosols2.,
3., 4.. 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.

Medical history

A thorough medical history must be recorded and reviewed before starting the dental
treatment and updated at subsequent visits3. 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 applied5.

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 measures2., 3., 4..

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
studies1., 5., 8., 14., 16., 19..
:
Vaccination against HBV

Dental health-care professionals are at an increased risk of acquiring hepatitis B infection

and therefore must be vaccinated against it25., 26.. About 80% of the respondents received
an HBV vaccination, thus falling in the range reported by previous studies5., 6., 8., 11., 12.,
16., 17., 18., 20., 21., 23., 24..

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
concern. To overcome this negative aspect, it is recommended that students be immunised
during their preparatory study years before they start their clinical work.

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 jackets4.

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. AS 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 avoided3., 4.. All the
study sample wore gloves and 98.5% changed them between patients. 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% now1., 20., 23..

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 26–
96.5% (Table 2). In contrast, fewer applicants wore face shields (30%) and protective eye
glasses (28%). Indeed, the routine use of the latter barriers is low among the dentists all over
the world (Table 2). 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 procedures27. 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 Africa24 and 13.6% of Jordanian dentists5 and 29.8% of undergraduate Indian
students16.

Sterilisation and disinfection of patient-care items

Patient-care items are generally categorised into critical, semi-critical or non-critical items (
Table 1). Critical items must be sterilised while disinfection and/or surface protection is
generally adequate for semi-critical and non-critical items. Of particular concern are dental
handpieces which should be heat-sterilised between patients despite the fact that they are
classified as semi-critical items3., 4..

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 documented6., 28.. 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 laboratory4. 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.24, and 18.1% by Al-Omari & Al-Dwairi5.
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 bags3. In previous studies, 8–75% of dentists
used puncture-resistant containers compared with 91% of the respondents in this study1., 5.,
8., 14., 16., 21..

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 difference. 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 this 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 Saudi Arabia. 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.

CONCLUSIONS

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.

Acknowledgements

The authors are grateful to the students who participated in this study.

Conflict of interest

None declared.

REFERENCES

1. Al-Rabeah A, Mohamed AG. Infection control in the private dental sector in Riyadh. Ann Saudi Med.
2002;22:13–17. [PubMed] [Google Scholar]

2. The control of cross-infection in dentistry. Br Dent J. 1988;165:353–354. [PubMed] [Google Scholar]

3. Infection control recommendations for the dental office and the dental laboratory. ADA Council on Scientific
Affairs and ADA Council on Dental Practice. J Am Dent Assoc. 1996;127:672–680. [PubMed] [Google Scholar]

4. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings –2003.
MMWR Recomm Rep. 2003;52:1–61. [PubMed] [Google Scholar]
:
5. Al-Omari MA, Al-Dwairi ZN. Compliance with infection control programs in private dental clinics in Jordan. J
Dent Educ. 2005;69:693–698. [PubMed] [Google Scholar]

6. Al Bagieh NH. Cross-infection control practice of staff in a dental school. Odontostomatol Trop. 1997;20:25–
28. [Google Scholar]

7. Al Shammary AR. Infection control measures among dentists practicing in Saudi Arabia. Saudi Dent J.
2000;12:77–82. [Google Scholar]

8. AlNegrish A, Al Momani AS, Al Sharafat F. Compliance of Jordanian dentists with infection control strategies.
Int Dent J. 2008;58:231–236. [PubMed] [Google Scholar]

9. Bentley EM, Sarll DW. Improvements in cross-infection control in general dental practice. Br Dent J.
1995;179:19–21. [PubMed] [Google Scholar]

10. Burke FJ, Wilson NH, Wastell DG, et al. Glove use in clinical practice: a survey of 2000 dentists in England
and Wales. Br Dent J. 1991;171:128–132. [PubMed] [Google Scholar]

11. DiAngelis AJ, Martens LV, Little JW, et al. Infection control practices of Minnesota dentists: changes during 1
year. J Am Dent Assoc. 1989;118:299–303. [PubMed] [Google Scholar]

12. Elkarim IA, Abdulla ZA, Yahia NA, et al. Basic infection control procedures in dental practice in Khartoum–
Sudan. Int Dent J. 2004;54:413–417. [PubMed] [Google Scholar]

13. Gerbert B. AIDS and infection control in dental practice: dentists’ attitudes, knowledge, and behavior. J Am
Dent Assoc. 1987;114:311–314. [PubMed] [Google Scholar]

14. Hudson-Davies SC, Jones JH, Sarll DW. Cross-infection control in general dental practice: dentists’ behaviour
compared with their knowledge and opinions. Br Dent J. 1995;178:365–369. [PubMed] [Google Scholar]

15. Kearns HP, Burke FJ, Cheung SW. Cross-infection control in dental practice in the Republic of Ireland. Int
Dent J. 2001;51:17–22. [PubMed] [Google Scholar]

16. Kumar S, Sharma J, Duraiswamy P, et al. Infection control practices among undergraduate students from a
private dental school in India. Rev Odonto Ciênc. 2009;24:124–128. [Google Scholar]

17. McCarthy GM, MacDonald JK. The infection control practices of general dental practitioners. Infect Control
Hosp Epidemiol. 1997;18:699–703. [PubMed] [Google Scholar]

18. 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;85:47–54.
[PubMed] [Google Scholar]

19. Morris E, Hassan FS, Al Nafisi A, et al. Infection control Knowledge and Practices in Kuwait: a survey on oral
health care workers. Saudi Dent J. 1996;8:19–26. [Google Scholar]

20. Qudeimat MA, Farrah RY, Owais AI. Infection control knowledge and practices among dentists and dental
nurses at a Jordanian University Teaching Center. Am J Infect Control. 2006;34:218–222. [PubMed] [Google
Scholar]
:
21. Rai B, Anand S, Jain R. Infection control procedures employed during dental practice in Haryana (India). Int J
Epidemiol 2006 3. Available from: http://www.ispub.com/journal/the-internet-journal-of-epidemiology/volume-3-
number-2/infection-control/procedures/employed-during-dental-practice-in-haryana-
india.html=sthash.ELwkpudi.dpbs Accessed 07 July 2012

22. Treasure P, Treasure ET. Survey of infection control procedures in New Zealand dental practices. Int Dent J.
1994;44:342–348. [PubMed] [Google Scholar]

23. Verrusio AC, Neidle EA, Nash KD, et al. The dentist and infectious diseases: a national survey of attitudes and
behavior. J Am Dent Assoc. 1989;118:553–562. [PubMed] [Google Scholar]

24. Yengopal V, Naidoo S, Chikte UM. Infection control among dentists in private practice in Durban. SADJ.
2001;56:580–584. [PubMed] [Google Scholar]

25. Cottone JA. Hepatitis B virus infection in the dental profession. J Am Dent Assoc. 1985;110:617–621.
[PubMed] [Google Scholar]

26. Mosley JW, White E. Viral hepatitis as an occupational hazard of dentists. J Am Dent Assoc. 1975;90:992–
997. [PubMed] [Google Scholar]

27. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of
microorganisms during dental treatment. J Am Dent Assoc. 1989;119:141–144. [PubMed] [Google Scholar]

28. Georgescu CE, Skaug NF, Patrascu I. Cross infection in dentistry. Roum Biotechnol Lett. 2002;7:861–868.
[Google Scholar]
: