Patients’ attitudes toward dentistry and AIDS

III V BEYOND INFECTION CONTROL

Patients’ attitudes toward dentistry and AIDS

B a rb ara G erb ert, P h D ; B ryan T . M a g u ir e , B S c; S h erry S p itz e r , P h D

lthough dentistry’s response to the AIDS epidemic has improved, some dentists are still refusing to . treat patients who have AIDS or who are HIVinfected.1^ Many dentists are not using recommended infection control procedures.5'8 The response of individual dentists to the epidemic has been reported and often criticized in the public and professional medical press, to the detriment of dentistry’s image.9-10 But uncertainty about patient reactions to infection control barrier techniques has impeded some dentists’ use of such techniques.11 Many dentists fear that if they treated people who have AIDS, other patients would seek care elsewhere.7 As dentists appear to be making some decisions about care based on assumptions about the public’s con­ cern, we wanted to ascertain patients’ actual attitudes about AIDS, HIV, and dentistry. Thus, we conducted a nationwide telephone survey of a random sampling of adult dental patients to assess levels of patient concern about AIDS and HIV infec­ tion in the dental office, beliefs about HIV transmission in the dental office, whether patients avoid practices in which they know patients with AIDS are treated or that the dentist has AIDS, and patients’ thoughts about dentists’ use of barrier techniques.

Perspective

A

M e th o d s

Two thousand civilian, noninstitutionalized adults (age 18 or older) were contacted in a nationwide random telephone survey between July 5 and August 19, 1988. A stratified, random-digit-dial procedure was used. 16-S ■ JA D A Supplem ent Novem ber 1989

Subjects were drawn from two frames: one consisting of those residing in the nine metropolitan areas with the highest prevalence of AIDS,12 and the other of those in the US outside the nine areas. The interview questionnaire contained 70 items concerning public perceptions of AIDS and health care. (Table 1 shows the items used in the study reported here). Because telephone interviews yield representative samples and valid data, they are a suitable method for nation­ wide surveys.13 To make a random choice of one respondent per household,14 callers asked to speak to a household mem­ ber older than age 18 who had most recently celebrated a birthday (the designated respondent). If the desig­ nated respondent was not available, up to 12 callback attempts were made at different times and on different days until the person was reached. The interview er inform ed the respondent about the sponsorship of the study and described how the sample was selected. Verbal informed consent was obtained and subjects were given a contact number to call if they had any questions about the survey. All interviews were conducted in English and were monitored by trained supervisors for consistent administration. The mean time for completing the interview was 16 minutes. Respondents were never identified by their full name and all data were treated as confidential. The response rate for completed interviews was 75%, calculated as the number of completed interviews divided by the number of completed interviews plus the number of English-speaking adults who refused or terminated the interview. Ninety-one percent of the designated respondents had received dental care in the past 5 years, so the denominator

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Table 1 ■ Items concerning patients’ attitudes and opinions about AIDS and dental care used for patient interview. 1. When it comes time for you to go to the dentist, how afraid are you of the visit—very afraid, somewhat afraid, or not at all afraid? 2. I’m going to read you a list of procedures in pairs of two, and for each, I would like you to tell me which you would prefer your dentist or hygienist to do when treating you, or whether you d o n ’t care one way or the other. a. wear gloves or not wear gloves b. wear a face mask or not wear a face mask c. wear protective glasses or goggles or not wear protective glasses or goggles 3. Have you ever thought about the risk of getting AIDS when visiting your dental office, or is this not something you have thought about? 4. How concerned are you about the possibility of getting AID S from visiting your dental office—very concerned, somewhat concerned, or not at all concerned? 5. How com fortable would you feel a. if you had a conversation with your dentist about AIDS b. if your dentist asked you questions about your sexual behavior c. if your dentist asked you questions about your use of intravenous drugs very com fortable, mostly comfortable, somewhat uncom­ fortable, or very uncom fortable. 6. If your dentist or hygienist had AIDS or the AIDS virus infection but was well enough to stay in practice, would you continue to see your dentist or hygienist, or do you think you would go to a different dental office?

they tell you this only if you ask, or should they keep it strictly to themselves? 8. Do you think your dentist or hygienist currently treats anyone who has AIDS or the A ID S virus infection? 9. If your dentist or hygienist is treating someone with AID S or the AIDS virus infection, should they inform you about this, should they tell you this only if you ask,or should they keep it strictly to themselves? 10. If your dentist or hygienist were treating someone with AID S or the AIDS virus infection, would you continue to see your dentist or hygienist or do you think you would go to a different dental office? 11. Please tell me if you think that it is very likely, somewhat likely, somewhat unlikely, very unlikely or definitely not possible that a person will get A ID S or the A ID S virus infection being treated by a dentist who has the A ID S virus? If you don’t know how likely it is that a person will be infected, you may say so. 12. The last time you went to the dentist’s office did your dentist (not hygienist) a. wear gloves b. wear a face mask c. wear protective glasses or goggles covering the eyes 13. Have you ever talked to your dentist or hygienist about AIDS? 14. Who started the conversation . . . you or them? 15. Would you want to talk to your dentist or hygienist about AIDS, would you prefer not to discuss A ID S with them, or do you not care? 16. If you were to talk with your dentist or hygienist about AIDS, should they start the conversation, or would you rather start it yourself?

7. If your dentist or hygienist had AID S or the AIDS virus infection, should they inform you about this, should

for the proportions reported here was 1,825. Given the Results stratification design, the effective sample size, used to measure the statistical precision of the estimates, was 1,207.15 Thirty percent of the US public who use dental services Thus, the maximum 95% confidence interval (Cl) for had thought about the possibility of contracting HIV percentages is ± 2.82. This maximum value applies to the infection in the dental office. Of these, 63% expressed concern case of the estimated response being 50%. For other about this prospect (Fig 1). The groups most likely to have responses, the Cl is smaller as, for example, ± 1.69% for thought about the problem were those who visit a dentist estimated response of 90% or 10%. twice a year or more, those who were afraid of dental visits, To correct for known biases in the selection of respondents and those who lived in areas with a high AIDS prevalence that resulted from random digit dialing,15'16 responses were rate. weighted by the number of persons in the household and Sixty percent were unsure whether their dentist treated the inverse of the number of telephones in the household. HIV-infected patients (Fig 2). Respondents living in highAs there were some small discrepancies between the prevalence areas were more likely to think their dentist demographics of the respondents and current population treated someone infected with HIV (62% versus 47% in lowestimates, the data were also weighed by race, gender, and prevalence areas). Even if they believed their dentist was age. (Details of the weighing procedure are available from treating an HIV-infected patient, 56% said they would the authors.) continue to seek care from the same provider. JA D A Supplement Novem ber 1989 ■ 17-S

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Had not thought about AIDS in dentist’s office 70%

DOS 60

MD

*M 40 Thought about AIDS but not concerned

DDS MD

S o

* 20

11% Somewhat concerned 14%

Very concerned 5%

HIV-positive provider

HIV-positive patient

Fig 3 ■ Patients’ intention to switch providers if they knew their dentist or physician were HIV positive or their dentist or physician were treating som eone who was HIV positive.

Fig 1 ■ Level o f patients’ concern about contracting A ID S in the dental office.

Not sure 60%

500

____

400

' A

CM

« / / X

Does not / treat 18 %

High

□

Low

□

Don’t know

300

) Does treat 22%

F ig 2 ■ Patients’ beliefs about whether their dentist treats people with A ID S or HIV disease.

However, the reaction was more negative when respond­ ents were asked if they would continue with their dentist if the dentist was HIV-infected: about two-thirds said they would switch providers, 23% said they would continue with the HIV-infected dentist, and 12% were undecided. Patients were also more likely to change providers if the dentist was HIV-infected than if their physician was HIVinfected (Fig 3). This negative reaction to HIV-infected dentists seems associated with the patient’s perception of the likelihood of infection in the dental office. Most of the 242 patients who said they would continue to see the same dentist estimated that the likelihood of contracting HIV from a dentist who was infected was low or nonexistent (Fig 4). But half of the 804 patients who said they would seek treatment elsewhere if the dentist was HIV-infected believed that it was very or somewhat likely 18-S ■ JA D A Supplement November 1989

□

M c

O)

2

200

100

I I Continue

Switch

Don’t know

Fig 4 ■ Patient perception o f the likelihood o f getting A ID S from being treated by an HIV-positive dentist (high, low, don’t k n o w /n o t sure), grouped by their intention to continue seeing their own dentist if he or she were HIV positive.

that they could get AIDS from being treated by an infected dentist. Another indication of people’s negative views of HIVinfected dentists was the finding that 80% of patients wanted to be advised if the dentist were HIV-positive. As Table 2 shows, this desire to know the status of seropositive dentists

K1VA BEYOND INFECTION CONTROL \

Table 2 ■ Patients’ opinions on right to confidentiality of HIV-positive dentists and patients among the 1 ,2 0 7 respondents who reported they had a dentist. Yes, dentist should inform patient If your dentist had A ID S or the AIDS virus infection, should they inform you about this, should they tell you this only if you ask, or should they keep it strictly to themselves? 83.6% If your dentist is treating someone with AIDS or the AID S virus infection, should they inform you about this, should they tell you this only if you ask, or should they keep it strictly to themselves? 34.4%

Yes, but only if patient asks

4.5%

No, dentist should keep to self

6.7%

Not sure

5.3%

Table 3 ■ Patients’ opinions about discussing AIDS with dental health providers. Have talked to dentist or hygienist about A ID S W ould feel uncom fortable discussing AIDS with dentist W ould feel uncom fortable discussing IV drug use with dentist W ould feel uncom fortable discussing sexual behavior with dentist

55.1%

Of those who had talked about AIDS: Discussion initiated by patient

80.1%

O f those who had not talked about AIDS: W anted to talk to dentist/hygienist about A ID S Prefer not to talk to dentist/hygienist about AIDS Do not care about talking to dentist/hygienist about AIDS Of those who want to talk or who do not care about talking to dentist/hygienist about AIDS: D entist/hygienist should start discussion Patient should start discussion

25.4%

33.1%

7.1%

contrasts with the relative willingness to respect confiden­ tiality for dentists treating HIV-positive patients. The use of personal barriers by dentists has not gone unnoticed by patients (Fig 5). Patients in the high AIDS prevalence areas reported significantly greater use of gloves and masks by their dentists. In most cases these infectionpreventing barriers were what patients preferred (Fig 6). Those who reported that their dentists used the barriers during the last visit were significantly more likely to express a preference for their use. The majority (87%) of our nationwide sample said they would be comfortable talking with their dentist about AIDS. Yet, only 15% in the high prevalence areas and 11% in low prevalence areas (13% of the entire population) reported discussing the topic with their dentist. In most instances (80%), the conversations were initiated by the patient. Among those who had not yet spoken to their dentist about AIDS, 21% said they wanted to discuss AIDS and 30% said they did not want to talk about it. A plurality (49%) were ambivalent (Table 3). D isc u s sio n

Although some dentists have expressed concern that patients might be intimidated by the use of such personal barriers as gloves and masks, the results of this survey indicate a broad acceptance of these infection control measures. Most patients who preferred the use of barrier techniques also approved of them, particularly those already familiar with these measures. This finding agrees with the results of other

12.8% 13.2% 19.3%

20.8% 30.2% 49.1%

34.9% 34.9%

studies that showed patients responded positively to the use of gloves.11’17 Patients endorse the use of gloves more enthusiastically than they endorse masks and goggles. Perhaps this is because they perceive gloves as primarily for their benefit and masks and goggles as a means to protect the provider. This latter view was held by patients in our earlier study in California.18 Another positive finding is that most patients are willing to talk to their dentist about AIDS (although most had not done so). This suggests an expanded role for the profession in educating or counselling the public about AIDS. Patient education materials about AIDS and about dentistry’s response to the disease could be made available through brochures in the reception area. Patients’ attitudes toward barrier control techniques are encouraging as is the apparent public acceptance of the dentist’s role in educating patients about AIDS. But attitudes toward HIV-infected patients or dentists are less positive. Patients are concerned about contracting AIDS in the dental office. About a third said they would seek care elsewhere if they learned their dentists treated HIV-infected patients and two-thirds would change practices if their dentist was infected with the virus. These concerns are common even though there are no reports of HIV transmission from a dentist or any other health care provider to a patient or from one patient to another. Dentists must explain to their patients that there is no guarantee that HIV-infected patients will not enter their practice. Given the prevalence of the disease in the United States, it is not possible to screen all HIV-infected people and treat them in a separate facility. Just as dentists are encouraged to assume that every patient is potentially infectious, the public must realize that every dentist may JA D A Supplement Novem ber 1989 ■ 19-S

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Fig 5 ■ Patient reports about whether dentist was wearing personal barriers at the time o f their last visit. (Y = Yes, N = N o, N /S = N ot sure)

have treated someone with HIV disease. This acceptance is not far off—only 18% of the respondents to our survey believe their dentist has not treated someone with HIV disease. A less common situation, but one that evokes a more extreme response, is the HIV-infected dentist. The Centers for Disease Control (CDC) report that there are 89 dentists nationwide who have AIDS (personnel communication; Meade M. AIDS program, CDC, August 22, 1988). We urgently need policies on the professional activities of dentists with HIV disease that are sensitive to public anxiety but which also reflect prudent assessment of the data regarding risk of transmission. Providers’ rights of confidentiality regarding their HIV status must also be safeguarded. The current policies19 of the American Medical Association regarding HIV-infected physicians provide a model for organized dentistry. Fears about AIDS were found equally among respon­ dents from areas of high and low prevalence of AIDS. In an earlier qualitative study,18we reported that dental patients in San Francisco did not distinguish between offices that they knew treated people with AIDS and other offices, which does not seem to be the case nationwide. The difference may be because of San Francisco’s unique experience of the epidemic20-21 or to methodologic artifact. If it is the former, perhaps as the epidemic spreads people will assume that their dentist is treating patients with AIDS and will begin to believe that it makes no difference as long as proper infection control procedures are followed.18 We do not expect a rapid improvement in the public’s attitudes regarding the association between AIDS and dentistry. Individual dentists can help by practicing proper infection control and assuring their patients that their office is safe. Dentists can also discuss AIDS with their patients, particularly if patients broach the subject. By modeling a calm, rational response, dentists may make an important 20-S ■ JA D A Supplement Novem ber 1989

Gloves

Mask

Protective glasses

Fig 6 ■ Proportion o f patients w ho prefer their dentist to wear personal barriers (P ), compared with those who prefer the dentist not to wear them (N ), and those who do not care (N C) whether the dentist wears them.

contribution to stemming the epidemic of fear that has accompanied the AIDS epidemic. This study was funded from the California University wide Task Force on AID S and by N IM H and N ID A Center grant no. MH42450. Dr. G erbert is assistant professor and chair; Mr. Maguire is staff research associate; and Dr. Spitzer was formerly a staff research associate with the division of behavioral sciences, School of Dentistry, and the Center for A ID S Prevention Studies, 707 Parnassus Ave, D1012, University of California at San Francisco, San Francisco, 94143-0754.

1. Hartley M. D ental discrimination? A ID S victim challenges treatm ent refusal. Dentist 1988;May-June:24. 2. Raber PE. AIDS: prevent its spread, treat its victims. Dentistry Today 1985;4:21-2. 3. Wolinsky H, Brune T. Dentists shun AIDS patients. Chicago Sun-Times 1987 July 19:14. 4. Williamson G. AIDS bias suit against dentists. San Francisco Chronicle 1988 Nov 30:A2. 5. Rowe T, Connolly GN. Infectious disease control practices of Massachusetts dentists. J Mass D ent Soc 1987;36:177-83. 6. Gerbert B, Badner V, M aguire B. AID S and dental practice. J Public Health Dent 1988;48:68-73. 7. Gerbert B. AIDS and infection control in dental practice. JA D A 1987;114:11-4. 8. M oretti R J, Ayer WA, Derefinko A. Attitudes and practices of dentists regarding HIV patients and infection control. J Academy General D ent (in press). 9. When doctors refuse to treat A ID S. New York Times 1987 August 8. 10. Page C. A deplorable effort to help dentists shun AIDS victims. Chicago Tribune 1988;June 15.

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11. Yoder KS. P atient’s attitudes toward the routine use of surgical gloves in a d e n ta l office. J In d ia n a D en t Assoc 1985;64:25-8. 12. Centers for Disease Control. AIDS W eekly S u rv e illa n ce R e p o rt— U nited States. 1988;May 23:3. 13. M arcus AC, Crane LA. Telephone surveys in public health research. Med Care 1986;24:97-112. 14. O ’R ouke D, Blair J. Im proving ra n d o m re sp o n d e n t selection in tele­ phone surveys. J M arketing Research 1983;20:428-32. 15. Frankel M. Sampling theory. In: Rossi PH, Wright JD , Anderson AB, eds. H andbook of survey research. New York: Academic Press, 1983. 16. Frey JH . Survey research by tele­ phone. Beverly Hills, CA: Sage Publica­ tions, 1983.

D

entists

can contribute to stemming the epidemic o f fear.

17. Bowden J R , Scully C, Bell C J, Levers H. Cross-infection control: attitudes o f patients tow ard the wearing of gloves and m asks by den tists in the U nited Kingdom in 1987. Oral Surg Oral Med Oral P athol 1989;67:45-8. 18. Gerbert B, M aguire B, Spitzer S, Henne J, Chamberlin K. Attitudes about AIDS. CD A J 1988;16:42-4. 19. Council on E thical and Judicial Affairs. Ethical issues involved in the growing A ID S crisis. JA M A 1988;259: 1360-1. 20. Scitovsky A, Cline M, Lee P. M ed­ ical care costs of patients with AIDS in San Francisco. JA M A 1986;256:3103-6. 21. Silverman M. A ID S care. The San Francisco m odel. J A m b u lato ry Care M anagem ent 1988;11:14-8.

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