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Attitudes toward HIV-infected individuals and infection control practices among a group of dentists in Mexico City—a 1999 update of the 1992 survey
Attitudes toward HIV-infected individuals and infection control practices among a group of dentists in Mexico City—a 1999 update of the 1992 survey Gerardo Maupomé, CD, MSc, DDPH RCS(E), PhDa S. Aída Borges-Yáñez, CD, MPH, DOb F. Javier Díez-de-Bonilla, CD, MASSb María Esther Irigoyen-Camacho, CD, MPH, DO Portland, Oregon, and Mexico City, Mexico Background: The teaching of infection control (IC) was introduced at dental schools in Mexico during the 1990s. A 1992 survey indicated that some dentists had limited access to current IC standards. Deficient knowledge of bloodborne pathogens may influence dentists’ attitudes about infected individuals and reduce compliance with IC recommendations. Objective: To update the 1992 appraisal of attitudes about persons infected with HIV or the hepatitis B virus (HBV) and IC knowledge and practices in a nonrepresentative sample of dentists in Mexico City. Method: One hundred eighty dentists were interviewed in 1999 (response rate, 84.1%) with the same methods used in 1992. Results: Seventy-nine percent of respondents perceived the risk of HIV infection as “considerable” to “very strong.” The risk of HBV infection was considered higher than that of HIV. Only 32% of respondents had not been immunized against HBV. Reported use of personal protective equipment remained high. Dry heat was the preferred method for sterilization in 1992, but by 1999 it had been displaced by steam under pressure. Reported preference for more effective disinfectants was also evident overall. Conclusions: We found certain improvements in IC knowledge and practices between 1992 and 1999, and the results suggest targets for educational and regulatory efforts that are needed to promote better adherence to current IC standards. (Am J Infect Control 2002;30:8-14)
In the United States1 and Canada,2,3 both consumer awareness and the collaboration of regulatory agencies, professional associations, and the academic establishment have influenced professional compliance with recommended infection control (IC) pracFrom the Health Services Research Program, Center for Health Researcha; Dental School, National University of Mexicob; and Department of Health Sciences, Metropolitan University—Xochimilcoc Reprint requests: Gerardo Maupomé, CD, MSc, DDPH RCS(E), PhD, Center for Health Research, 3800 N Interstate Ave, Portland, OR 972271110. Copyright © 2002 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2002/$35.00 + 0 17/46/117042 doi:10.1067/mic.2002.117042
8
tices. The introduction of IC practices in curricula at dental schools and in everyday clinical practice in Mexico has been a gradual process during the 1990s. Practicing dentists seem to have various degrees of access to current IC standards.4-6 Varying levels of knowledge on bloodborne pathogens, such as HIV and the hepatitis B virus (HBV), may influence attitudes about treating infected individuals and compliance with IC recommendations.1 A step to standardize guidelines was taken in 1994, when the Mexican National Standard (MNS) on Oral Health and Prevention was introduced (based on the 1993 IC recommendations by the US Centers for Disease Control and Prevention7). The MNS was modified and republished in 1995 and 1999.8 Ample consultation within the public and private
Maupomé et al
February 2002 9
Table 1. Opinions on the position of the profession on dental practice and HIV infection in 1992 and 1999 Very strong
Strong
Considerable
Medium
Weak
Null
10% 5%
3% 3%
8% 2%
Probably
Maybe
Difficult to accept
No
Dentists have a professional duty to treat HIV-infected patients 1992 83% 3% 1999 81% 6%
4% 8%
4% 2%
4% 2%
3% 1%
Dentists have a moral duty to treat HIV-infected patients 1992 88% 1% 1999 84% 6%
4% 5%
4% 3%
2% 1%
1% 1%
Every patient must be considered potentially HIV positive 1992 60% 3% 1999 76% 7%
13% 7%
7% 5%
8% 3%
10% 2%
How strong is your personal worry on the risk of being infected with HIV? 1992 33% 25% 21% 1999 40% 28% 22% Of course
Almost sure
As a dental clinician, fear of HIV infection has forced me to elude high-risk patients (such as homosexual men and people that need frequent blood transfusions) Extra answer option: I have never been in that situation (1999, 61%) 1992 2% 3% 1% 2% 5% 42% 1999 2% 2% 0% 5% 5% 26% Would you willingly work in the same environment as a person infected with HIV? 1992 41% 7% 14% 1999 49% 8% 18% Very strong
Strong
Do you have objections to treating HIV-infected patients? 1992 6% 4% 1999 1% 3%
sectors took place simultaneously with enactment of the MNS, but no concerted effort or program was explicitly followed for its implementation. Changes in dental education were left to the discretion of individual schools. We undertook a survey to assess dental practitioners’ attitudes toward persons with HIV or HBV and IC knowledge and practices in Mexico City in 1992.6 This report offers the result of an identical survey undertaken in 1999 and presents an update on the evolution of attitudes, knowledge, and practices.
MATERIALS AND METHODS The research methods have been described in detail elsewhere.6 Briefly, questionnaire items and response scales were obtained by content analysis of transcripts derived from focus groups, with dentists discussing issues affecting their practice. The questionnaire was administered to a systematic sample of dentists attending the largest dental prod-
14% 14%
8% 3%
16% 7%
Considerable
Medium
Weak
Null
12% 16%
11% 19%
5% 8%
61% 53%
ucts exhibition that takes place every year in Mexico City. The November 1992 exhibition drew more than 2000 attendees, and the November 1999 exhibition was attended by approximately 2500. Every tenth dentist entering the exhibition hall was approached on a one-on-one basis. Data were analyzed with the student t test, Pearson’s χ2 test, and Mann-Whitney U test (M-W U) (P < .05, level of significance).
RESULTS Of 214 dentists approached in the 1999 survey, a response rate of 84.1% was achieved. Of 180 respondents (46% women), 41% were 21 to 25 years old, 30% were 26 to 30 years old, and 29% were older than 30 years. Sex and age distributions in 1999 were similar to the 1992 distributions. Years in practice varied from 1 to 26 (4.4 SD 6.4); 83% of participants had only a dental degree, and 17% had a dental degree plus specialty or graduate degrees. The proportion of respondents with advanced
Maupomé et al
10 Vol. 30 No. 1
Table 2. Subjective estimates of risk of HIV and HBV contagion in the clinical setting in 1992 and 1999 Very strong
Strong
Considerable
Medium
In spite of the clinical precautions in the dental setting, the possibilities of contagion by HIV: From dentist to patient 1992 5% 9% 21% 11% 1999 13% 11% 29% 14%
Weak
Null
33% 15%
21% 18%
16% 8%
6% 3%
From patient to dentist 1992 1999
16% 27%
21% 23%
27% 30%
13% 9%
6% 9%
7% 18%
15% 23%
11% 10%
20% 18%
42% 20%
23% 16%
9% 10%
11% 6%
6% 1%
From patient to patient 1992 1999
The risk of a dentist getting HBV in clinical practice is 1992 1999
19% 43%
33% 24%
degrees was similar in 1992 and 1999, but the number of years in practice was higher among the 1992 respondents (5.8 SD 5.0; P = .021). Most 1999 respondents (83%) answered that they had no friends or relatives infected with HIV—a similar proportion to the 1992 survey (89%; χ2 = 2.8, df = 1, P = .09). Whereas most 1999 respondents (84%) had not knowingly treated HIV-infected patients, this proportion was significantly larger in the 1992 survey (91%; χ2 = 4.8, df = 1, P = .03). Most respondents acknowledged a professional (87%) or moral (90%) obligation to treat HIV-infected patients (Table 1), positions virtually identical to responses in 1992 (M-W U, P = .709 and P = .713, respectively). In both surveys, a minority (5% in 1992 and 3% in 1999) objected to treating HIV-infected individuals and felt no moral duty to treat them. Reasons given for not wanting to treat HIV-infected individuals included concerns with regard to the costs to implement current IC standards; fear that they could expose themselves and their families to HIV infection; and fear that they may lose staff or scare away other patients. With slight differences of emphasis, these same reasons were cited by the 1992 respondents. In general, attitudes toward HIV-infected persons were more positive in 1999 than in 1992, despite that personal worry about the risk of HIV infection and the perception of every patient being potentially HIV positive also increased (see Table 1; M-W U, P < .05). To compare the cohort effects of successive “generations” of dentists modifying their appraisals to 2 key perceptions of risk in the survey, the responses
of participants who were 21 to 25 years old in 1992 were compared (χ2 test) with responses of participants who were 26 to 30 in 1999; identical comparisons were made for the groups of 26 to 30, 31 to 35, and 36 to 40 years of age. Small numbers in the 40 and older group precluded analyses. We found that there were no changes in the responses of any cohort when asked about the strength of personal worry about the risk of being infected with HIV. However, such a cohort effect was evident when participants indicated how likely it was that every patient must be considered potentially HIV positive (χ2 = 26.5, df = 5, P < .01), suggesting that a shift had occurred within cohorts between 1992 and 1999. Respondents both in 1999 and in 1992 considered significantly higher the risk of being infected with HBV than with HIV (P < .01). Although a substantial proportion of respondents in 1992 had not been immunized against HBV (78%), in 1999 68% of respondents had already been immunized (43% of the overall 1999 respondents had had 3 or 4 doses of the immunization series). Even with following IC recommendations, 79% of the 1999 respondents perceived the risk of HIV infection to themselves as “considerable” or as “very strong” (Table 2), compared with 64% of respondents in 1992. The risk of patient-to-patient transmission was perceived by 49% of 1999 respondents as “null” or “weak,” whereas 51% considered this risk as “considerable” to “very strong.” In general, the likelihood of the various modalities of HIV
Maupomé et al
February 2002 11
Table 3. Opinions on perceived proficiency of knowledge on HIV infection in 1992 and 1999 Very strong
Strong
Considerable
Medium
Weak
How would you rate your level of knowledge on the HIV infection, with regard to the specific aspects of the following: The modes of infection 1992 17% 24% 40% 15% 3% 1999 35% 32% 26% 7% 1%
Null
0% 0%
The specific oral signs 1992 1999
14% 22%
21% 34%
33% 29%
24% 13%
6% 2%
2% 1%
15% 20%
25% 31%
34% 31%
19% 16%
5% 1%
2% 1%
The specific systemic signs 1992 1999
infection in the dental setting were perceived to be different overall in 1999 than in 1992 (see Table 2; M-W U, P < .001). As in 1992, results from the 1999 survey indicated that the hazard posed to dentists was considered higher than the risk to patients (see Table 2) (P < .01). The increased emphasis from 1992 to 1999 was even more marked with regard to the risk of HBV infection to the dentist (M-W U, P < .001) (see Table 2). As in 1992, most respondents rated their knowledge on HIV as “considerable” to “very strong” (Table 3), but a larger proportion of the respondents in 1999 considered their knowledge at these levels (M-W U, P < .010). HIV infection was perceived as a “considerable” to “very strong” occupational hazard by respondents who generally rated their knowledge on modes of infection as “medium” to “very strong” (χ2 = 112.0, df = 1, P < .01). As in 1992, most dentists in 1999 declared that they used gloves and facemasks and almost always changed them between patients (Table 4). Figures on infection barriers from the 1999 survey were as good as or better than figures from 1992. Although the users of dry-heat sterilization decreased in the 1999 survey compared with the 1992 survey, the proportion of respondents adopting sterilization with steam under pressure improved by almost the same extent between 1992 and 1999 (Table 5, χ2 tests). This positive trend toward more stringent customs in the dental environment was also evident when disinfectants were investigated (Table 6, χ2 tests). Benzalkonium chloride and household bleach had been the most widely used disinfectants in 1992. By 1999, glutaraldehyde together with bleach became the most widely used disinfectants. Benzalkonium chloride use showed a substantial
drop. Chlorhexidine and iodine compounds became more important overall.
DISCUSSION The sampling approach warrants some methodologic discussion. The mixture of systematic and convenience techniques to sampling our study population is not an ideal way of tackling the problem at hand, but there is no official roster of active, licensed dentists in the country.9 Data for the sample framework are mostly absent from this report because they do not exist: the Ministry of Education knew that until 1996, 67,616 dentists had registered their degrees. This one-time registration is the only mandatory licensure procedure that is required by law. The Mexican Dental Association has about 3000 members, and another association, the National College of Dental Surgeons, has roughly 1500. It is unfeasible to determine how many of the more than 60,000 dentists that registered once in their lifetime in the Ministry roster and do not appear to belong to a professional association have retired and how many are working and what type of practice involvement they have. The slightly larger proportion of men and of younger dentists we have found, however, are in line with the demographic composition of the profession in the city.9 Usually two thirds of the student body are women, but not all of them practice clinically or full time when they graduate.10,11 This repeated cross-sectional survey may not be representative of the current IC customs and attitudes about patients with HIV or HBV that prevail in the entire Mexican dental profession. This survey depicts a mosaic of opinions outlining the general directions with regard to attitudes, self-reported behavior patterns, and stated knowledge among a convenience sample of active dental clinicians interviewed in Mexico City.
Maupomé et al
12 Vol. 30 No. 1 Table 4. Reported use of infection barriers in the clinical setting in 1999 In your daily clinical practice, do you always use the following: Latex gloves Do you change them between patients? Face masks? Do you change them between patients? Protection glasses Do you wash them between patients? Clinical scrubs or coats
Yes
No
97% 96% 98% 76% 82% 48% 97%
3% 2% 2% 14% 10% 36% 3%
Sometimes 2% 10% 8% 16%
Table 5. Reported use of equipment in 1992 and 1999 What equipment do you use daily to treat instruments (you may choose as many as you want)? % in 1992 % in 1999 Dry heat oven Steam under pressure Quartz beads sterilizer Ultrasonic bath Ultraviolet light
Most participants declared that they felt they had professional and moral obligations to treat HIVinfected patients. A similar high level of declared willingness to treat HIV-infected persons was reported among separate samples of dentists in Mexico City.5,6 As we have suggested while discussing the results from the 1992 survey, such good disposition must be interpreted with caution since many dentists in Mexico City have not faced a decision to knowingly treat an HIV-infected person. There appears to be, however, a shift to increasingly more positive attitudes: in 1992, only half of the respondents would be willing to share their workplace with an HIV-infected person, and at least 20% said “no” or “difficult to accept” to this possibility. In 1999, three quarters of respondents said they would be willing to share their workplace with a person with HIV, and only 10% said “no” or “difficult to accept.” Although no statistically significant differences were found in the proportions of respondents having relatives or friends infected with HIV, by 1999 more dentists stated that they had knowingly treated patients infected with HIV, and more dentists indicated that they had no objection to treating them. It has been reported that improved IC compliance is associated with more tolerant attitudes toward patients with HIV.12 Interestingly, the positive perceptions with regard to the moral or professional obligations to treat patients infected with HIV did not change between 1992 and 1999 (under the current repeated cross-sectional research framework). The main reasons for not wanting to treat HIV-infected individuals appear to be consistent with previous reports.13,14 Dentists who believe they “don’t have
72 41 9 4 1
60 63 6 8 6
P value .007 .001 .120 .060 .120
the necessary facilities” or “don’t want to expose themselves” might unknowingly be treating HIVinfected persons, as well as patients infected with other bloodborne pathogens. Such shortcomings in the understanding of Universal Precautions was also observed by Irigoyen et al5 as almost two thirds of their respondents modified their clinical questionnaires in an attempt to detect “high-risk” patients. Participant dentists appear to be eager to implement IC measures but do not appear to fully trust their effectiveness: many perceived that even when following IC recommendations, HIV or HBV crossinfection in the dental office was likely (see Table 2). This feature stands in obvious contrast to findings among American dentists.12 The main difference in this regard is that respondents to our 1999 survey showed a more proactive position to meet these challenges, in particular HBV infection: in 1992, 22% of respondents had been immunized against HBV, and 3 times as many stated they had been immunized by 1999. Although we do not know whether this substantial improvement has benefited ancillary personnel in the dental offices, it is hoped that increased awareness among the profession may benefit dental office employees. Reported use of personal protective equipment was high in 1992 (see Table 4), was still adhered to at the same level or even higher in 1999, and compared quite favorably with the utilization levels published in surveys in the Untied States12 and Canada.2,3,15 Of all IC recommendations, dentists most frequently complied with the use of disposable gloves and facemasks. In contrast with the data collected by Irigoyen et al5 in 1995 and our own data from 1992,
Maupomé et al
February 2002 13
Table 6. Reported use of solutions in 1992 and 1999 Which of the following solutions do you use in your daily clinical practice (you may choose as many as you want)? % in 1992 % in 1999 Benzalkonium chloride Sodium hypochlorite Soap/household cleaning powders/liquids Glutaraldehyde Alcohols Phenolic compounds Iodophores Chlorhexidine Boiling water or steam
dry heat was no longer the prevailing sterilization method. Sterilization with steam under pressure has replaced it as the first choice for clinicians. Until recently in Mexico, as in other nations,16,17 the use of boiling water, ultraviolet light, and other forms of “sterilization” were associated with a lack of information regarding accepted sterilization techniques. Dry heat devices had serious design deficiencies. We may be witnessing a fundamental shift for the better in this regard, as well as in the utilization of more effective disinfectants. In our 1992 survey, we found that the use of benzalkonium chloride was widespread in the clinical environment. Results from the present survey indicate that by 1999, the dentists interviewed stated their preference for disinfectants with laboratory-tested activity against Mycobacterium tuberculosis. The use of other, more advanced quaternary ammonium compounds was not established. Although we did not investigate how appropriately disinfectants or equipment were actually used, it is encouraging to find that current IC measures, use of barriers, and adherence to Universal Precautions guidelines are improving. This state of affairs may or may not be a direct consequence of the MNS on Oral Health and Prevention introduced between 1994 and 1999 and the halo effect of its negotiation and implementation throughout the professional circles. From our findings, it is reasonable to speculate that at least 2 other factors could be involved in the improvements described in this report. First, the awareness of risk of HIV and HBV infections for everyone in the dental environment increased between our surveys in 1992 and 1999. Second, the dentists interviewed in 1992 and in 1999 stated that their proficiency of knowledge with regard to HIV had improved. These results prompt us to speculate that some mixture of continuing education efforts, improved legislation, heightened consumer demands, greater availability of equipment and supplies, and up-to-date IC
64 46 38 31 21 9 8 5 2
45 67 62 70 28 13 22 15 5
P value .001 .001 .001 .001 .090 .100 .001 .001 .090
customs within the dental training of the cohorts of dentists graduating more recently into the workforce are leading to better IC standards. It is not known whether this shift is related to the appearance of more favorable attitudes toward people with HIV or HBV or perhaps more simply reveals an increasing concern with regard to the occupational hazards of clinical practice. In other settings, younger clinicians have been found to be more receptive of patients with HIV,18,19 although this trend is not always observed.20 The specific combination of factors resulting in such improvements in this study was unclear. As recommended in the past,6 the assembly of a cadre of qualified IC professionals to promote, implement, and oversee IC standards and continuing education nationwide is desirable. Several opportunities for practical research are feasible in the future to determine the success of the MNS being adopted by the profession at large; for example, truly longitudinal evaluations of patterns of adherence to IC standards; quality control audits to determine not only that IC standards are reportedly used but also how appropriately they are adhered to; and qualitative research initiatives to determine professional and lay views of the importance of IC in the context of the various levels of access to dental care that prevail in the Mexican market.21 References 1. Gershon RRM, Curbow B, Kelen G, Celantano D, Lears K, Vlahov D. Correlates of attitudes concerning human immunodeficiency virus and acquired immunodeficiency syndrome among hospital workers. Am J Infect Control 1994;22:293-9. 2. McCarthy GM, MacDonald JK. Improved compliance with recommended infection control practices in the dental office between 1994 and 1995. Am J Infect Control 1998;26:24-8. 3. Gibson GB, Mathias RG, Epstein JB. Compliance to recommended infection control procedures: changes over six years among British Columbia dentists. J Can Dent Assoc 1995;61:526-32. 4. Maupomé-Carvantes G, Borges-Yáñez SA. [Attitudes and customs on infection control (HIV and hepatitis B) among dental students.] Salud Pública
Maupomé et al
14 Vol. 30 No. 1 Méx 1993;35:642-50. 5. Irigoyen M, Zepeda M, López-Cámara V. Factors associated with Mexico City dentists’ willingness to treat AIDS/HIV-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:169-74. 6. Maupomé G,Acosta-Gío AE, Borges-Yáñez SA, Díez-de-Bonilla FJ. Survey on attitudes toward HIV infected individuals and infection control practices among dentists in Mexico City. Am J Infect Control 2000;28:21-4. 7. Centers for Disease Control and Prevention. Recommended infection control practices for dentistry, 1993. MMWR Morb Mortal Wkly Rep 1993;41(RR-8):1-12. 8. Mexican National Standard. [Norma Oficial Mexicana NOM-013-SSA21994] To prevent and bring under control oral diseases. Published Jan 6, 1995, modified Jan 11, 1999. Diario Oficial de la Federación. México, Distrito Federal, Mexico. 9. Maupomé G, Borges A, Díez-de-Bonilla J. Knowledge and opinions about dental human health resources. Planning in Mexico. Int Dent J 1998;48:2431. 10. López-Cámara V, Lara-Flores N. [Dental practice in Mexico City. Analysis of mainstream practice]. Temas Universitarios No. 5. Departamento de Atención a la Salud, Universidad Autónoma Metropolitana Xochimilco. Mexico DF, Mexico. 1983. 11. López-Cámara V, Lara-Flores N. [Dental practice in Mexico City. Crisis and changes]. Departamento de Atención a la Salud, Universidad Autónoma Metropolitana Xochimilco, Mexico DF, Mexico. 1992. 12. Gershon RRM, Karkashian C, Vlahov D, Grimes M, Spannhake E. Correlates
13.
14. 15.
16. 17.
18. 19. 20. 21.
of infection control practices in dentistry. Am J Infect Control 1998;26:2934. McCarthy GM, MacDonald JK. Gender differences in characteristics, infection control practices, knowledge and attitudes related to HIV among Ontario dentists. Community Dent Oral Epidemiol 1996;24:412-5. Grace EG, Cohen LA. Attitudes of Maryland dentists toward AIDS and hepatitis patients. Am J Dent 1993;6:32-4. McCarthy GM, Koval JJ, MacDonald JK. Compliance with recommended infection control procedures among Canadian dentists: results of a national survey. Am J Infect Control 1999;27:377-84. Treasure P, Treasure ET. Survey of infection control procedures in New Zealand dental practices. Int Dent J 1994;44:342-8. Trieger N, Schlesinger N, Kaufman E, Mann J. Israeli dentists: a survey of infection control practices and care of medically compromised patients. Special Care Dent 1993;13:117-21. Watt RG, Croucher R. Dentists’ perceptions of HIV/AIDS as an occupational hazard: a qualitative investigation. Int Dent J 1991;41:259-64. Sadowsky D, Kunzel C. Are you willing to treat AIDS patients? J Am Dent Assoc 1991;122:29-32. Kunzel C, Sadowsky D. Predicting dentists’ perceived occupational risk for HIV infection. Soc Sci Med 1993;36:1579-86. Maupomé G.“Who is filling what”: the contrast between the oral health situation and Human Health Resources in Mexico. Crit Pub Health 2000;10:153-66.
In the United States1 and Canada,2,3 both consumer awareness and the collaboration of regulatory agencies, professional associations, and the academic establishment have influenced professional compliance with recommended infection control (IC) pracFrom the Health Services Research Program, Center for Health Researcha; Dental School, National University of Mexicob; and Department of Health Sciences, Metropolitan University—Xochimilcoc Reprint requests: Gerardo Maupomé, CD, MSc, DDPH RCS(E), PhD, Center for Health Research, 3800 N Interstate Ave, Portland, OR 972271110. Copyright © 2002 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2002/$35.00 + 0 17/46/117042 doi:10.1067/mic.2002.117042
8
tices. The introduction of IC practices in curricula at dental schools and in everyday clinical practice in Mexico has been a gradual process during the 1990s. Practicing dentists seem to have various degrees of access to current IC standards.4-6 Varying levels of knowledge on bloodborne pathogens, such as HIV and the hepatitis B virus (HBV), may influence attitudes about treating infected individuals and compliance with IC recommendations.1 A step to standardize guidelines was taken in 1994, when the Mexican National Standard (MNS) on Oral Health and Prevention was introduced (based on the 1993 IC recommendations by the US Centers for Disease Control and Prevention7). The MNS was modified and republished in 1995 and 1999.8 Ample consultation within the public and private
Maupomé et al
February 2002 9
Table 1. Opinions on the position of the profession on dental practice and HIV infection in 1992 and 1999 Very strong
Strong
Considerable
Medium
Weak
Null
10% 5%
3% 3%
8% 2%
Probably
Maybe
Difficult to accept
No
Dentists have a professional duty to treat HIV-infected patients 1992 83% 3% 1999 81% 6%
4% 8%
4% 2%
4% 2%
3% 1%
Dentists have a moral duty to treat HIV-infected patients 1992 88% 1% 1999 84% 6%
4% 5%
4% 3%
2% 1%
1% 1%
Every patient must be considered potentially HIV positive 1992 60% 3% 1999 76% 7%
13% 7%
7% 5%
8% 3%
10% 2%
How strong is your personal worry on the risk of being infected with HIV? 1992 33% 25% 21% 1999 40% 28% 22% Of course
Almost sure
As a dental clinician, fear of HIV infection has forced me to elude high-risk patients (such as homosexual men and people that need frequent blood transfusions) Extra answer option: I have never been in that situation (1999, 61%) 1992 2% 3% 1% 2% 5% 42% 1999 2% 2% 0% 5% 5% 26% Would you willingly work in the same environment as a person infected with HIV? 1992 41% 7% 14% 1999 49% 8% 18% Very strong
Strong
Do you have objections to treating HIV-infected patients? 1992 6% 4% 1999 1% 3%
sectors took place simultaneously with enactment of the MNS, but no concerted effort or program was explicitly followed for its implementation. Changes in dental education were left to the discretion of individual schools. We undertook a survey to assess dental practitioners’ attitudes toward persons with HIV or HBV and IC knowledge and practices in Mexico City in 1992.6 This report offers the result of an identical survey undertaken in 1999 and presents an update on the evolution of attitudes, knowledge, and practices.
MATERIALS AND METHODS The research methods have been described in detail elsewhere.6 Briefly, questionnaire items and response scales were obtained by content analysis of transcripts derived from focus groups, with dentists discussing issues affecting their practice. The questionnaire was administered to a systematic sample of dentists attending the largest dental prod-
14% 14%
8% 3%
16% 7%
Considerable
Medium
Weak
Null
12% 16%
11% 19%
5% 8%
61% 53%
ucts exhibition that takes place every year in Mexico City. The November 1992 exhibition drew more than 2000 attendees, and the November 1999 exhibition was attended by approximately 2500. Every tenth dentist entering the exhibition hall was approached on a one-on-one basis. Data were analyzed with the student t test, Pearson’s χ2 test, and Mann-Whitney U test (M-W U) (P < .05, level of significance).
RESULTS Of 214 dentists approached in the 1999 survey, a response rate of 84.1% was achieved. Of 180 respondents (46% women), 41% were 21 to 25 years old, 30% were 26 to 30 years old, and 29% were older than 30 years. Sex and age distributions in 1999 were similar to the 1992 distributions. Years in practice varied from 1 to 26 (4.4 SD 6.4); 83% of participants had only a dental degree, and 17% had a dental degree plus specialty or graduate degrees. The proportion of respondents with advanced
Maupomé et al
10 Vol. 30 No. 1
Table 2. Subjective estimates of risk of HIV and HBV contagion in the clinical setting in 1992 and 1999 Very strong
Strong
Considerable
Medium
In spite of the clinical precautions in the dental setting, the possibilities of contagion by HIV: From dentist to patient 1992 5% 9% 21% 11% 1999 13% 11% 29% 14%
Weak
Null
33% 15%
21% 18%
16% 8%
6% 3%
From patient to dentist 1992 1999
16% 27%
21% 23%
27% 30%
13% 9%
6% 9%
7% 18%
15% 23%
11% 10%
20% 18%
42% 20%
23% 16%
9% 10%
11% 6%
6% 1%
From patient to patient 1992 1999
The risk of a dentist getting HBV in clinical practice is 1992 1999
19% 43%
33% 24%
degrees was similar in 1992 and 1999, but the number of years in practice was higher among the 1992 respondents (5.8 SD 5.0; P = .021). Most 1999 respondents (83%) answered that they had no friends or relatives infected with HIV—a similar proportion to the 1992 survey (89%; χ2 = 2.8, df = 1, P = .09). Whereas most 1999 respondents (84%) had not knowingly treated HIV-infected patients, this proportion was significantly larger in the 1992 survey (91%; χ2 = 4.8, df = 1, P = .03). Most respondents acknowledged a professional (87%) or moral (90%) obligation to treat HIV-infected patients (Table 1), positions virtually identical to responses in 1992 (M-W U, P = .709 and P = .713, respectively). In both surveys, a minority (5% in 1992 and 3% in 1999) objected to treating HIV-infected individuals and felt no moral duty to treat them. Reasons given for not wanting to treat HIV-infected individuals included concerns with regard to the costs to implement current IC standards; fear that they could expose themselves and their families to HIV infection; and fear that they may lose staff or scare away other patients. With slight differences of emphasis, these same reasons were cited by the 1992 respondents. In general, attitudes toward HIV-infected persons were more positive in 1999 than in 1992, despite that personal worry about the risk of HIV infection and the perception of every patient being potentially HIV positive also increased (see Table 1; M-W U, P < .05). To compare the cohort effects of successive “generations” of dentists modifying their appraisals to 2 key perceptions of risk in the survey, the responses
of participants who were 21 to 25 years old in 1992 were compared (χ2 test) with responses of participants who were 26 to 30 in 1999; identical comparisons were made for the groups of 26 to 30, 31 to 35, and 36 to 40 years of age. Small numbers in the 40 and older group precluded analyses. We found that there were no changes in the responses of any cohort when asked about the strength of personal worry about the risk of being infected with HIV. However, such a cohort effect was evident when participants indicated how likely it was that every patient must be considered potentially HIV positive (χ2 = 26.5, df = 5, P < .01), suggesting that a shift had occurred within cohorts between 1992 and 1999. Respondents both in 1999 and in 1992 considered significantly higher the risk of being infected with HBV than with HIV (P < .01). Although a substantial proportion of respondents in 1992 had not been immunized against HBV (78%), in 1999 68% of respondents had already been immunized (43% of the overall 1999 respondents had had 3 or 4 doses of the immunization series). Even with following IC recommendations, 79% of the 1999 respondents perceived the risk of HIV infection to themselves as “considerable” or as “very strong” (Table 2), compared with 64% of respondents in 1992. The risk of patient-to-patient transmission was perceived by 49% of 1999 respondents as “null” or “weak,” whereas 51% considered this risk as “considerable” to “very strong.” In general, the likelihood of the various modalities of HIV
Maupomé et al
February 2002 11
Table 3. Opinions on perceived proficiency of knowledge on HIV infection in 1992 and 1999 Very strong
Strong
Considerable
Medium
Weak
How would you rate your level of knowledge on the HIV infection, with regard to the specific aspects of the following: The modes of infection 1992 17% 24% 40% 15% 3% 1999 35% 32% 26% 7% 1%
Null
0% 0%
The specific oral signs 1992 1999
14% 22%
21% 34%
33% 29%
24% 13%
6% 2%
2% 1%
15% 20%
25% 31%
34% 31%
19% 16%
5% 1%
2% 1%
The specific systemic signs 1992 1999
infection in the dental setting were perceived to be different overall in 1999 than in 1992 (see Table 2; M-W U, P < .001). As in 1992, results from the 1999 survey indicated that the hazard posed to dentists was considered higher than the risk to patients (see Table 2) (P < .01). The increased emphasis from 1992 to 1999 was even more marked with regard to the risk of HBV infection to the dentist (M-W U, P < .001) (see Table 2). As in 1992, most respondents rated their knowledge on HIV as “considerable” to “very strong” (Table 3), but a larger proportion of the respondents in 1999 considered their knowledge at these levels (M-W U, P < .010). HIV infection was perceived as a “considerable” to “very strong” occupational hazard by respondents who generally rated their knowledge on modes of infection as “medium” to “very strong” (χ2 = 112.0, df = 1, P < .01). As in 1992, most dentists in 1999 declared that they used gloves and facemasks and almost always changed them between patients (Table 4). Figures on infection barriers from the 1999 survey were as good as or better than figures from 1992. Although the users of dry-heat sterilization decreased in the 1999 survey compared with the 1992 survey, the proportion of respondents adopting sterilization with steam under pressure improved by almost the same extent between 1992 and 1999 (Table 5, χ2 tests). This positive trend toward more stringent customs in the dental environment was also evident when disinfectants were investigated (Table 6, χ2 tests). Benzalkonium chloride and household bleach had been the most widely used disinfectants in 1992. By 1999, glutaraldehyde together with bleach became the most widely used disinfectants. Benzalkonium chloride use showed a substantial
drop. Chlorhexidine and iodine compounds became more important overall.
DISCUSSION The sampling approach warrants some methodologic discussion. The mixture of systematic and convenience techniques to sampling our study population is not an ideal way of tackling the problem at hand, but there is no official roster of active, licensed dentists in the country.9 Data for the sample framework are mostly absent from this report because they do not exist: the Ministry of Education knew that until 1996, 67,616 dentists had registered their degrees. This one-time registration is the only mandatory licensure procedure that is required by law. The Mexican Dental Association has about 3000 members, and another association, the National College of Dental Surgeons, has roughly 1500. It is unfeasible to determine how many of the more than 60,000 dentists that registered once in their lifetime in the Ministry roster and do not appear to belong to a professional association have retired and how many are working and what type of practice involvement they have. The slightly larger proportion of men and of younger dentists we have found, however, are in line with the demographic composition of the profession in the city.9 Usually two thirds of the student body are women, but not all of them practice clinically or full time when they graduate.10,11 This repeated cross-sectional survey may not be representative of the current IC customs and attitudes about patients with HIV or HBV that prevail in the entire Mexican dental profession. This survey depicts a mosaic of opinions outlining the general directions with regard to attitudes, self-reported behavior patterns, and stated knowledge among a convenience sample of active dental clinicians interviewed in Mexico City.
Maupomé et al
12 Vol. 30 No. 1 Table 4. Reported use of infection barriers in the clinical setting in 1999 In your daily clinical practice, do you always use the following: Latex gloves Do you change them between patients? Face masks? Do you change them between patients? Protection glasses Do you wash them between patients? Clinical scrubs or coats
Yes
No
97% 96% 98% 76% 82% 48% 97%
3% 2% 2% 14% 10% 36% 3%
Sometimes 2% 10% 8% 16%
Table 5. Reported use of equipment in 1992 and 1999 What equipment do you use daily to treat instruments (you may choose as many as you want)? % in 1992 % in 1999 Dry heat oven Steam under pressure Quartz beads sterilizer Ultrasonic bath Ultraviolet light
Most participants declared that they felt they had professional and moral obligations to treat HIVinfected patients. A similar high level of declared willingness to treat HIV-infected persons was reported among separate samples of dentists in Mexico City.5,6 As we have suggested while discussing the results from the 1992 survey, such good disposition must be interpreted with caution since many dentists in Mexico City have not faced a decision to knowingly treat an HIV-infected person. There appears to be, however, a shift to increasingly more positive attitudes: in 1992, only half of the respondents would be willing to share their workplace with an HIV-infected person, and at least 20% said “no” or “difficult to accept” to this possibility. In 1999, three quarters of respondents said they would be willing to share their workplace with a person with HIV, and only 10% said “no” or “difficult to accept.” Although no statistically significant differences were found in the proportions of respondents having relatives or friends infected with HIV, by 1999 more dentists stated that they had knowingly treated patients infected with HIV, and more dentists indicated that they had no objection to treating them. It has been reported that improved IC compliance is associated with more tolerant attitudes toward patients with HIV.12 Interestingly, the positive perceptions with regard to the moral or professional obligations to treat patients infected with HIV did not change between 1992 and 1999 (under the current repeated cross-sectional research framework). The main reasons for not wanting to treat HIV-infected individuals appear to be consistent with previous reports.13,14 Dentists who believe they “don’t have
72 41 9 4 1
60 63 6 8 6
P value .007 .001 .120 .060 .120
the necessary facilities” or “don’t want to expose themselves” might unknowingly be treating HIVinfected persons, as well as patients infected with other bloodborne pathogens. Such shortcomings in the understanding of Universal Precautions was also observed by Irigoyen et al5 as almost two thirds of their respondents modified their clinical questionnaires in an attempt to detect “high-risk” patients. Participant dentists appear to be eager to implement IC measures but do not appear to fully trust their effectiveness: many perceived that even when following IC recommendations, HIV or HBV crossinfection in the dental office was likely (see Table 2). This feature stands in obvious contrast to findings among American dentists.12 The main difference in this regard is that respondents to our 1999 survey showed a more proactive position to meet these challenges, in particular HBV infection: in 1992, 22% of respondents had been immunized against HBV, and 3 times as many stated they had been immunized by 1999. Although we do not know whether this substantial improvement has benefited ancillary personnel in the dental offices, it is hoped that increased awareness among the profession may benefit dental office employees. Reported use of personal protective equipment was high in 1992 (see Table 4), was still adhered to at the same level or even higher in 1999, and compared quite favorably with the utilization levels published in surveys in the Untied States12 and Canada.2,3,15 Of all IC recommendations, dentists most frequently complied with the use of disposable gloves and facemasks. In contrast with the data collected by Irigoyen et al5 in 1995 and our own data from 1992,
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February 2002 13
Table 6. Reported use of solutions in 1992 and 1999 Which of the following solutions do you use in your daily clinical practice (you may choose as many as you want)? % in 1992 % in 1999 Benzalkonium chloride Sodium hypochlorite Soap/household cleaning powders/liquids Glutaraldehyde Alcohols Phenolic compounds Iodophores Chlorhexidine Boiling water or steam
dry heat was no longer the prevailing sterilization method. Sterilization with steam under pressure has replaced it as the first choice for clinicians. Until recently in Mexico, as in other nations,16,17 the use of boiling water, ultraviolet light, and other forms of “sterilization” were associated with a lack of information regarding accepted sterilization techniques. Dry heat devices had serious design deficiencies. We may be witnessing a fundamental shift for the better in this regard, as well as in the utilization of more effective disinfectants. In our 1992 survey, we found that the use of benzalkonium chloride was widespread in the clinical environment. Results from the present survey indicate that by 1999, the dentists interviewed stated their preference for disinfectants with laboratory-tested activity against Mycobacterium tuberculosis. The use of other, more advanced quaternary ammonium compounds was not established. Although we did not investigate how appropriately disinfectants or equipment were actually used, it is encouraging to find that current IC measures, use of barriers, and adherence to Universal Precautions guidelines are improving. This state of affairs may or may not be a direct consequence of the MNS on Oral Health and Prevention introduced between 1994 and 1999 and the halo effect of its negotiation and implementation throughout the professional circles. From our findings, it is reasonable to speculate that at least 2 other factors could be involved in the improvements described in this report. First, the awareness of risk of HIV and HBV infections for everyone in the dental environment increased between our surveys in 1992 and 1999. Second, the dentists interviewed in 1992 and in 1999 stated that their proficiency of knowledge with regard to HIV had improved. These results prompt us to speculate that some mixture of continuing education efforts, improved legislation, heightened consumer demands, greater availability of equipment and supplies, and up-to-date IC
64 46 38 31 21 9 8 5 2
45 67 62 70 28 13 22 15 5
P value .001 .001 .001 .001 .090 .100 .001 .001 .090
customs within the dental training of the cohorts of dentists graduating more recently into the workforce are leading to better IC standards. It is not known whether this shift is related to the appearance of more favorable attitudes toward people with HIV or HBV or perhaps more simply reveals an increasing concern with regard to the occupational hazards of clinical practice. In other settings, younger clinicians have been found to be more receptive of patients with HIV,18,19 although this trend is not always observed.20 The specific combination of factors resulting in such improvements in this study was unclear. As recommended in the past,6 the assembly of a cadre of qualified IC professionals to promote, implement, and oversee IC standards and continuing education nationwide is desirable. Several opportunities for practical research are feasible in the future to determine the success of the MNS being adopted by the profession at large; for example, truly longitudinal evaluations of patterns of adherence to IC standards; quality control audits to determine not only that IC standards are reportedly used but also how appropriately they are adhered to; and qualitative research initiatives to determine professional and lay views of the importance of IC in the context of the various levels of access to dental care that prevail in the Mexican market.21 References 1. Gershon RRM, Curbow B, Kelen G, Celantano D, Lears K, Vlahov D. Correlates of attitudes concerning human immunodeficiency virus and acquired immunodeficiency syndrome among hospital workers. Am J Infect Control 1994;22:293-9. 2. McCarthy GM, MacDonald JK. Improved compliance with recommended infection control practices in the dental office between 1994 and 1995. Am J Infect Control 1998;26:24-8. 3. Gibson GB, Mathias RG, Epstein JB. Compliance to recommended infection control procedures: changes over six years among British Columbia dentists. J Can Dent Assoc 1995;61:526-32. 4. Maupomé-Carvantes G, Borges-Yáñez SA. [Attitudes and customs on infection control (HIV and hepatitis B) among dental students.] Salud Pública
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14 Vol. 30 No. 1 Méx 1993;35:642-50. 5. Irigoyen M, Zepeda M, López-Cámara V. Factors associated with Mexico City dentists’ willingness to treat AIDS/HIV-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:169-74. 6. Maupomé G,Acosta-Gío AE, Borges-Yáñez SA, Díez-de-Bonilla FJ. Survey on attitudes toward HIV infected individuals and infection control practices among dentists in Mexico City. Am J Infect Control 2000;28:21-4. 7. Centers for Disease Control and Prevention. Recommended infection control practices for dentistry, 1993. MMWR Morb Mortal Wkly Rep 1993;41(RR-8):1-12. 8. Mexican National Standard. [Norma Oficial Mexicana NOM-013-SSA21994] To prevent and bring under control oral diseases. Published Jan 6, 1995, modified Jan 11, 1999. Diario Oficial de la Federación. México, Distrito Federal, Mexico. 9. Maupomé G, Borges A, Díez-de-Bonilla J. Knowledge and opinions about dental human health resources. Planning in Mexico. Int Dent J 1998;48:2431. 10. López-Cámara V, Lara-Flores N. [Dental practice in Mexico City. Analysis of mainstream practice]. Temas Universitarios No. 5. Departamento de Atención a la Salud, Universidad Autónoma Metropolitana Xochimilco. Mexico DF, Mexico. 1983. 11. López-Cámara V, Lara-Flores N. [Dental practice in Mexico City. Crisis and changes]. Departamento de Atención a la Salud, Universidad Autónoma Metropolitana Xochimilco, Mexico DF, Mexico. 1992. 12. Gershon RRM, Karkashian C, Vlahov D, Grimes M, Spannhake E. Correlates
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