Knowledge, attitude, and behaviour of Turkish dentists regarding contamination and prevention of Hepatitis B, Hepatitis C and HIV infection

Introduction: Dentists are at risk of Hepatitis B, Hepatitis C, and HIV infections in their professional practices. The purpose of this study was to determine the knowledge level, attitude, and behaviours of the Turkish dentists regarding contamination and prevention of Hepatitis B, Hepatitis C, and HIV infections. Methods: After receiving the required ethical and administrative approvals, a 33-item digital survey was applied within the context of the present study, and carried out amongst 58 dentists. Results: According to the results of this study, the knowledge level did not vary between different demographic features (p > 0.05). However, the dentists’ attitude and behaviours were different. Post-exposure attitude towards Hepatitis B, Hepatitis C, and HIV infection did not vary between different demographic features (p > 0.05). Female dentists who received education regarding infectious diseases more often got health check in case of injury (p < 0.05). Female dentists felt more concerned than male dentists when they were treating infected patients, and they were more often using protective barriers (p < 0,05). Dentists who were working at the university hospital and public hospital mostly had their Hepatitis B vaccinations more often than private clinics, also, dentists in university hospitals more often reported prefer to treat infected patients (p < 0.05). Dentists who did not receive any education have reported that dental treatment of infected patients should be performed in specialised clinics (p < 0.05). Conclusion: The Turkish dentists’ knowledge level, attitude, and behaviour were different. According to the findings of this study, efficacious education programs should be prepared for dentists to establish a positive attitude towards Hepatitis B, Hepatitis C, and HIV infected patients.


INTRODUCTION
The healthcare professionals are exposed to infectious agents as an inevitable result of their profession and work environment. 1 Therefore, in dentistry, bloodborne pathogens such as; hepatitis B virus, hepatitis C virus, and HIV may be transmitted through direct or indirect contact with blood, saliva, skin, and oral secretion, contaminated instrument, device and surfaces, stab wounds, and air-water spray. 2 The development of infection resulting from exposure to any contamination agent requires the presence of a pathogen with a sufficient amount and virulence, an appropriate route for transmission of this pathogen and a predisposing subject to infection. 3 The target of the infection control methods is to prevent the development of infection by breaking one or more links to infection chain. 3,4 All the dentists and dentistry students should apply universal standard precautions all patients regardless of estimated contamination status. 5,6 Vaccination, use of personal protective equipment such as sterile face masks, gloves and spectacles and post-exposure prophylaxis are crucial in preventing infection. [6][7][8][9] Oral health is an important part of general medical care in the hepatitis B virus, hepatitis C virus and HIV positive patients. 10 Dentists may be concerned and reluctant because of risk for contamination while treating hepatitis B virus, hepatitis C virus and HIV positive patients. 11 These concerns may be originating from the knowledge deficiency about these diseases in some dentists. 11,12 In our country, several studies have evaluated the awareness level and behaviours of the dentists about some contagious diseases, 13 exposure frequency to infection in dentists 14 and use of personal protective equipment. 15 However, there is no comprehensive study in the literature which analysed the exposure rate of the Turkish dentists to infection, their knowledge level about standard precaution and practices after exposure to hepatitis B virus, hepatitis C virus, HIV infections, and their attitudes and behaviours in an integrated approach.
The purpose of this study was to determine the knowledge level, attitude, and behaviours of the Turkish dentists regarding contamination and prevention of Hepatitis B, Hepatitis C, and HIV infections. This study hypothesised that the knowledge level, attitude, and behaviour of the dentists might vary depending on age, gender, professional status, and experience level.

METHODS
This study was a descriptive study to analyse the evaluation of the dentists who were representing healthcare service in health facilities regarding hepatitis B virus, hepatitis C virus and HIV infections. The study was conducted with the participation of 58 dentists throughout Turkey between July-August 2018 after receiving the required ethical and administrative approvals. A 33-item digital survey created using literature data [16][17][18][19] was applied. The dentists were requested to answer the survey questions individually and voluntarily.
The survey form was composed of the questions to analyze the demographic characteristics of the dentists (gender, age, province and medical facility where the dentist works, working tempo, academic degree, title, branch of the specialization), knowledge level, attitude and behavior about hepatitis B virus, hepatitis C virus and HIV infections.
Statistical analysis was performed using SPSS 23.0 (SPSS Inc., Chicago, IL, USA). The analysis was performed using the Fisher test because the data were not normally distributed. Since some observations obtained for analysis were small (more than 20% of cells of 2 × 2 contingency tables had expected frequencies < 5), Fisher's exact test was needed. 20 Statistical significance was set at the p-value < 0.05.

RESULT
According to the results of the study, 39.7% of surveyed dentists were male, and 60.3% were female. 50.9% of dentists were 23-29 years old, 36.8% were 30-39 years old, 10.5% were 40-49 years old, and 1.8% were over than 50 years old. 51.7% of the dentists had 1-5 years experience, 22.4% had 6-10 years experience, 13.8% had 11-15 years experience, 12.1% had over than 15 years experience. According to the results of this study, 55% of the dentists were a general practitioner, 35% were PhD dentist, 7% were an assistant professor and 3% were professors. 55% of dentists had no specialisation in any branch of dentistry whereas 19% were specialized in prosthodontics, 10% periodontology, 4% pediatric dentistry, 4% orthodontics, 5% endodontics, 5% restorative dentistry, 3% oral and maxillofacial surgery and 2% oral radiology.
Of the participant dentists, 41% were working in a public hospital, 33% were in a university hospital, 21% in private hospitals and 5% in private clinics. 47% of the dentists have reported that they treated less than 10 patients daily, 16% treated 11-20 patients, 21% treated 21-30 patients, and 16% treated over than 30 patients. It was also reported that 86% of surveyed dentists received training about clinical infections whereas 14% did not receive any education.
Dentists' knowledge regarding contamination and prevention is presented in Table 1. Knowledge levels didn't vary between different demographic features also between individuals who received or not received any education (p > 0.05).
Dentists' attitude regarding contamination and prevention is presented in Table 2. Exposure times varied between age, experience, specialisation (p < 0.05); whereas there wasn't a difference between gender, working place and working tempo (p > 0.05). Dentists who were 30-39 years old, working for over 5 years and specialised in a branch have reported that they mostly got contact with infected blood and saliva. Exposure routes and post-exposure attitudes didn't vary between different demographic features (p > 0.05).
Participant dentists' behaviour regarding contamination and prevention of hepatitis B virus, hepatitis C virus and HIV infections are presented in Table 3. Dentists who received education about the infectious disease and were female more often got health check in case of injury (p < 0.05).  Dentists who were working at a university hospital and public hospital mostly had their Hepatitis B vaccinations more often than private clinics (p < 0.05). This is most probably because vaccination against hepatitis B is mandatory in public and university hospitals in Turkey. 21 Also, 22.2% of the dentists noted that they didn't know their anti-HBs titer values while some dentists reported that their titer values ranged between 96 and 1000. The frequencies of questioning medical history before dental treatment weren't varied between different demographic features (p > 0.05).
However, female dentists more often consider each patient as potentially infected than male dentists (p < 0.05). Participant dentists who have received education were more considering each patient as potentially infected than dentists who did not receive education (p < 0.05). Furthermore, female dentist more often reported that a blood test should be applied to each patient prior to the treatment (p < 0.05).
Participant dentists' attitude regarding infected patients is presented in Table 4. Female dentists felt more concerned than male dentists (p < 0.05). Dentists who work in university hospitals more often reported that they would prefer to treat infected patients (p < 0.05). Dentists who didn't receive an education have reported that dental treatment of infected patients should be performed in specialised clinics (p<0.05).
Participant dentists' attitude regarding infection control protocols is presented in Table  Table 5 Occasionally 0 Never 0 5. Male dentists more often consider that personal protective barriers can protect themselves from infectious agents (p < 0.05). On the other hand, female dentists more often used protective barriers (p< 0.05).

DISCUSSION
Dentists and auxiliary personnel carry a higher risk for contamination of numerous bacteria and viruses than normal populations. Therefore, knowledge level, attitude and behaviours of the dentists about prevention and protection from the pathogens which contaminated with infected blood and other body fluids become progressively important concerning achieving infection control. 7,13,22,23 The hypothesis of the study that knowledge level, attitudes and behaviours of the dentists may vary depending on age, gender, education, professional status and experience level was partially accepted. Knowledge levels of dentists weren't different (p>0.05). However, attitudes and behaviours varied between dentists. As a result of this study, dentists who received education about the infectious disease and were female more often got health check in case of injury (p< 0.05). Female dentists felt more concerned than male dentists when they were treating infected patients and they more often used protective barriers (p< 0.05). Dentists who were working at a university hospital and public hospital mostly had their Hepatitis B vaccinations more often than private clinics also dentists in university hospitals more often reported that they would prefer to treat infected patients (p<0.05). Dentists who didn't receive an education have reported that dental treatment of infected patients should be performed in specialised clinics (p< 0.05).
Age, gender, professional facility, professional experience and data of the daily treated patient's number which were obtained from this study were different from the previous studies conducted in Turkey. 13,15,24 It was thought to be because of the individuals participating in this study were different from other studies. While our study was conducted across the country, other studies were only conducted in specific populations.
In a study, among Canadian dentists, it was stated that 79.2% of dentists had education about infection control in the last 2 years. 17 In a study in Iran, 81.3% of dentists had a continuing education course in the last 2 years. 25 In a study among Tehran dentists, it was stated that %68.3 of them never attended to continuing education courses. 26 According to the results of this study, different from other studies, 86% of the dentists received training about clinical infections. It was thought that this difference was caused by the more frequent trainings about infection control in our country, especially in recent years.
In a study in Iran, it was stated that over 89% of dentists had chosen the correct answers about the transmission infections of HIV/AIDS, hepatitis B virus and hepatitis C virus. 18 According to the results of this study, 76% of dentists had chosen the correct answers about hepatitis B virus, hepatitis C virus and HIV infections. Aksoy et al. 13 have determined in their study that 61.5% of the dentists questioned the contagious diseases in Turkey. In the literature, it was reported that 90% of the German dentists obtain from their patients a risk factor history for hepatitis B and C, mostly by written means and mostly at the first visit. 7 According to the results of the study among Brazilian dentists, 83.1% of reported that they question the patient's history of hepatitis. 16 A study among dentists who works in private dental clinics in Jordan stated that 77% of dentists asked about the medical history of patients. 27 In a study in Pakistan, 95% of dentists were surveyed about past medical history from the patients. 28 According to data obtained from this study, similarly to Aksoy et al. 13 60% of the participant dentists reported that they were questioning the medical history of hepatitis B virus, hepatitis C virus and HIV.
All our study were aimed at measuring the level of knowledge, attitude and behaviour of the dentists about hepatitis B virus, hepatitis C virus and HIV. It was concluded that dentists had hesitations in treating infected patients. It is needed to increase the level of dentist's knowledge, attitude and behaviour regarding transmission routes and vaccination by appropriate training.
A study in India, it was stated that 93.5% of dentists agreed with the suggestion that all patients should be regarded as infectious and that precautions should be applied universally. 29 According to a study in Iran, 95% of dentists have reported that all patients should be considered potentially infectious. 18 In a study in Pakistan, dentists have reported that 98.5% of them agreed on the screening of patients for hepatitis B and C prior to any treatment. 28 According to the results of this study, different from Indian 29 , Iranian 18 and Pakistani 28 dentist, 75.9% of dentists agreed with that every patient should be considered as potentially infected. Additionally, in this study, 53.4% of dentists agreed with that blood-borne diseases should be screened in each patient by testing blood prior to dental treatments.
As a result of a study in Iran, it was stated that 92% of dentists were anxious about increasing transmission risk of HIV and hepatitis infections while treating them. 18 According to the results of a study in Poland, 64% of the dentists were moderately apprehensive of being infected with HIV, hepatitis B virus or hepatitis C virus as a result of performing their job. 19 In this study, 81% of dentists have reported that they were concerned about the risk for contamination of infection during treatment of the patients infected by hepatitis B virus, hepatitis C virus and HIV. Also, 72.4% of dentist stated that they would be concerned about the possibility of infections in the patients.
In a study among Persian dentists, it was stated that %73 of dentists, would prefer not to treat HIV-positive patients. 18 In a study among Saudi dental professionals, it was stated that 89.8% of the surveyed dentists were unwilling to provide dental care for hepatitis B virusinfected patients. 30 According to the results of a study among Jordanian clinicians, 45% of the dental practitioners were willing to provide care to a person infected with the hepatitis B virus. 31 In a study among Tehran dentists, it was stated that 55.6% of dentists were willing to treat a patient with hepatitis B virus, unconditionally or with conditions. 25 In a study in Poland, it was stated that 25% of the dentists have refused to perform specific procedures in patients with known infections. 19 According to the results of a study in Palestine, %68 of dentists declined dental appointment requests from HIV positive patients whereas, 32% of the dentists refused appointments with hepatitis B virus-infected patients. 32 In this study, it was reported that, if it's possible, 66.7% of dentist would prefer not to treat the patients infected by hepatitis B virus, hepatitis C virus and HIV. However, 91.4% of dentists have reported that they would prefer to treat patients infected by hepatitis B virus, hepatitis C virus and HIV if the protective precautions were taken.
According to the results of a study in Iran, 70% of dentists have reported that patients with HIV or hepatitis should receive dental treatment in specialised clinics. 18 In the present study, 55.2% of dentists have reported that dental treatment of patients infected by hepatitis B virus, hepatitis C virus and HIV should be performed in the specialised clinics.
According to a study in Iran, 52% of dentists have reported that infection control principles are adequate for the prevention of transmission of HIV and hepatitis. 18  Bulut et al. 15 had reported in their study that 39.6% of the Turkish dentists used gloves, face masks, spectacles, patient scrubs and dentist scrubs when they were treating patients. In the literature, it was stated that 54% of German dentists always wore protective gloves, 58% wore protective eyeglasses, 50% always wore face mask. 7 96.3% of Brazilian dentists used mask, 97.8% used gloves, 50.4% used protective glasses. 35 98% of Italian dentists used gloves, 95% used masks, and 94% used protective eyewear. 34 82.3% of Canadian dentists wore the face mask, 82.1% always wore protective eyewear/face shield, %94.6 always use gloves. 17 In this study, similarly to Bulut et al., 15 39% of the surveyed dentists always used protective spectacles. Also, 95% of dentists used sterile face masks/ gloves during dental treatments.
Kandemir et al. 24 have stated that 69% of the dentists experienced percutaneous injury within the recent one year. 35.9% of dentist were exposed to at least 1 needlestick injury during the past 3 months in Egypt. 36 In Jordan, 66.5% of dentists had needle-stick injury within the preceding 12 months, and 77.9% of them did not report the injury. 37 In a study, 54.8% of Brazilian dentists had one accident, 23.8% had two accidents, 11.9% had three and 9.5% had four or more accidents and 31.1% of them have reported the injury in the preceding year. 35 A study in Italy stated that 73% of dentists had needle stick and other injuries in the last 5 years. 34 In a study, German dentists stated that 61.7% of dentists had at least one needle stick injury in their professional life. 38 In a study, 60.4% of Polish dentists had needle puncture injury, %54.7 got contact through splashing on conjunctiva within 12 months preceding the survey. 19 In the present study, similar to Kandemir et al. 24 69% of dentists got contact with patients' infected blood and saliva. 50% of dentists got injured by contaminated sharp objects, 27.3% injured by the contaminated injector, 22.7% got mucosal contact with contaminated blood and saliva. 44.8% of them got injured by sharp objects 1-5 times within the recent one year. Also, 27.6% of them have experienced contamination of infected material to eyes etc. 1-5 times within the recent one year.
In a study, it was reported that 41.3% of dentists in Canada applied a post-exposure protocol for needlesticks/cuts injuries. 17 According to another study among dentists from different regions of Canadia, 36% to 70% of dentists had a post-exposure protocol. 39 According to results of a study in Jordan, 77.9% of dentists who had needlestick injury did not report the injury. 37 31.1% of Brasilian dentists have reported their injuries in the preceding year. 3 According to the results of a study among Italian dentists, 29.7% of them claimed to have written protocols to follow in case of accident. 34 In this study, 63.6% of dentists have reported the injury and consulted the infectious diseases department after the exposure. Furthermore, 74.1% of dentists have reported that they washed their wound site with soap and water and applied the antiseptic solution in the case of injury by sharp objects.

CONCLUSION
Dentists frequently face a risk for contagious diseases such as hepatitis B virus, hepatitis C virus and HIV during dental treatments; but their knowledge levels, attitudes and behaviours regarding these infections are different. Efficacious training programs should be prepared for dentists to increase knowledge levels, establish positive attitudes and behaviours regarding hepatitis B, hepatitis C and HIV infected patients and to upgrade all of them to a standard level.