Abstract

Infection control is essential in dentistry to ensure patient and practitioner safety. However, gaps often exist between theoretical knowledge and practical implementation. This study assessed the knowledge, attitudes, and practices of senior dentistry students regarding infection control methods, focusing on critical areas such as handling dental chairs, sterilization processes, use of personal protective equipment, and tool storage. A questionnaire was administered to 666 participants, comprising first- to fifth-year dental students and newly graduated dentists from various academic institutions in Iraq. Results revealed that while 61.1% of respondents demonstrated adequate theoretical knowledge of sterilization procedures, adherence to best practices was inconsistent. For instance, only 10.2% of participants consistently wore protective eyewear, and 18.2% left dropped instruments unattended during procedures. Disparities in responses were statistically significant (p > 0.05), highlighting knowledge gaps in the practical application of infection control protocols. This study's findings underscore the need for systematic interventions to bridge the gap between knowledge and practice, emphasizing the role of regular seminars, practical workshops, and curriculum revisions to reinforce infection control adherence. The study provides novel insights into the critical yet underexplored area of infection control practices among dentistry students in developing countries, highlighting institutional and behavioral factors influencing compliance. These findings have broad implications for improving infection control training programs and promoting safety standards in dental education and practice.

Highlights:

1. Assess dental students' infection control knowledge, attitudes, practices.
2. Questionnaire for preclinical and clinical students; 666 participants analyzed.
3. High knowledge, poor adherence; recommends annual seminars to improve compliance.

Keywords: dental students, infection prevention, and sterilization methods

Introduction

According to the World Health Organization, infection prevention and control (IPC) is a methodical strategy and workable remedy to stop infection-related harm to patients and healthcare professionals (1). Its foundations are in the social sciences, epidemiology, infectious disease science, and healthcare systems.

The dental team must come into direct touch with tissues and oral fluids, such as blood and saliva, as part of their work. Numerous bacteria and viruses, including mycobacterium tuberculosis, the hepatitis B and C viruses, the human immunodeficiency virus (HIV), the mumps, influenza, and rubella, can be found in these tissues and fluids (2). Since infections can spread from patient to patient, patient to dental team, or dental team to patient, the risk of infection transmission extends beyond patients to the entire dental team, including the dentist, assistants, nurses, laboratory technicians, and even janitors (3). It is well-known that treating every patient as potentially infectious to stop disease transmission is essential to infection control (IC) (4). Future dentists have only sometimes followed these guidelines, even at dentistry colleges (5).Dental education can be a significant component of a dentist's training program, assisting in adopting appropriate attitudes and understanding regarding infection control practices (6). This study aimed to examine dental students' knowledge, attitudes, and practices about various infection prevention strategies in Iraqi dental schools

Methods

This study used a questionnaire with ten questions about various aspects of infection control—including handling instruments before and after being placed in the sterilizer, serialization techniques, personal protective equipment, surface disinfection techniques, and instrument handling—. Dental students received the surveys and filled them out right away.

The following categories were present on the questionnaire form:

1. Gender

2. Academic year.

3. How do you store the clinical instrument equipment?

4. Actions made following the use of dental instruments.

5. Using the dental chair once therapy is complete.

6. Reaction scenario if instruments unintentionally fall to the ground.

7. If the spittoon is cleansed following a treatment.

8. If safety glasses are used while receiving therapy.

9. Understanding of how the sterilizer functions.

10. Donning a medical gown in a dental office is significant because it helps with infection control.

The statistical analyses of the study were performed using the SPSS 25.0 software produced by IBM Inc., located in Chicago, IL, USA. The descriptive metrics were presented in a tabular format, comprising frequency, percentage, and mean values. The statistical technique employed in this study was chi-square analysis, which was supplemented with Monte Carlo correction. This approach was utilized to investigate the associations between categorical variables. The One-Way Analysis of Variance (ANOVA) compares independent groups, whereas the Independent Sample T-test compares two independent groups. The frequency test was utilized to investigate the relationships between categorical variables. Throughout the investigation, a fixed level of significance of 5% was established to accommodate the potential occurrence of a type-I mistake. The assessment of statistical significance involved comparing the resultant p-value with a predetermined threshold of 0.05.

Result and Discussion

Result

The present study involved 676 participants, including newly graduated dentists and undergraduate students from various academic institutes in Iraq. The final analysis revealed that 20.7% (n=140) of the participants were newly graduated dentists, while 32.1% (n=217) were fifth-stage dental students. Additionally, 19.7% (n=133) of the participants were fourth-stage dental students. The remaining population was distributed among the dentistry college's first, second, and third stages, accounting for a total percentage of 27.5% (n=186), as depicted in Figure 1.

Figure 1.Distribution of participant according to the educational stage

Upon analyzing the collected responses, it was seen that there existed a notable disparity across all parts of the questionnaire, with a p-value > 0.05, as depicted in Table 1. When analyzing the responses to the initial question regarding the procedures undertaken after utilizing dental instruments, it was found that 43.2% (n=292) of participants advocated rinsing the tools with water and soap, followed by drying and placing them in the sterilization device. In contrast, 18.9% (n=128) of respondents preferred washing the instrument with water before placing it in the sterilization device. Additionally, 14.3% (n=97) of participants suggested rinsing the instrument with water, drying it, and placing it in the sterilizer. Conversely, 12.7% (n=86) of individuals proposed immediate instrument placement in the sterilization device after use. Lastly, 10.8% (n=73) of respondents indicated that the instrument should be rinsed with water and soap and placed in the sterilization device without drying, as depicted in Table 2.

About the management of the dental chair following treatment, a significant proportion of respondents (26.8%, n=181) indicated that they applied alcohol to the dental chair before vacating it. Additionally, 21.3% (n=144) reported using a surface disinfectant on the dental chair after treatment. Conversely, 21.7% (n=147) of participants left the dental chair without implementing specific measures. A smaller percentage of respondents (15.8%, n=107) preferred cleaning the dental chair with a damp cloth, while the remaining 14.3% (n=97) chose to utilize a Dettol solution for wiping the dental chair. These findings are visually represented in Table 3.

In the responses about managing a fallen instrument during dental procedures, a significant proportion of the study population, precisely 28.1% (n=190), indicated their preference for washing the instrument with water or disinfectant and placing it on the dental chair tray for reuse. Another notable portion of the study cohort, comprising 18.2% (n=123), suggested leaving the instrument on the ground until the completion of the treatment without making any contact with the fallen instrument during the procedure. Additionally, 17.5% (n=118) of the participants expressed their decision to promptly grip the instrument and dispose of it in the washing basin. In the study population, 103 individuals, representing 15.2% of the sample, opted to hold the instrument, spray it with alcohol, and place it back on the dental chair tray for reuse. Additionally, 88 participants, accounting for 13% of the sample, reported quickly picking up the instrument and placing it back for reuse. Conversely, 41 individuals, constituting 6.1% of the sample, chose to spray the instrument with alcohol and place it back on the tray without intending to use it again during treatment. Furthermore, only 13 participants, representing 1.9% of the sample, elected to hold the instrument, wash it with water and surface disinfectant, and place it back on the tray without intending to use it again during treatment, as depicted in Table 4.

Regarding the appropriate course of action for managing the dental unit spittoon following dental treatment, a significant proportion of the participants, namely 38.2% (n=258), preferred employing a specialized brush only to clean the spittoon with alcohol. In contrast, a subset of the research population comprising 19.4% (n=131) preferred cleaning the spittoon with soap and water, utilizing a specialized brush. Conversely, 12% (n=81) of participants advocated for just employing alcohol as a cleaning agent without the use of any other tools or solutions. Fifty-four individuals, accounting for 8% of the sample, reported that the spittoon is only cleaned using water. Only a tiny proportion of participants, specifically 4.9% (n=33), preferred using standard surface disinfectant and a specialized brush to clean the spittoon. Thirty-one survey participants, or 4.6% of the sample, reported that the spittoon is sanitized using other types of surface disinfectant, as indicated in Table 5.

Regarding the use of protective eyewear during medical procedures, 242 participants, accounting for 35.8% of the research cohort, reported that the operators utilize protective eyewear throughout treatment but only sometimes. Additionally, 117 individuals, representing 17.3% of the cohort, claimed that the protective eyewear is exclusively employed during special treatment. In contrast, a subset of the study population comprising 16.7% (n=113) said that they do not utilize protective eyewear due to the availability of medical eyeglasses, which they perceive as a suitable alternative. According to the study's findings, 12.9% (n=87) of the participants in the cohort reported that the protective eyewear was worn just during the start of the treatment and then removed by the operator. In the study group, a mere 10.2% (n=69) of participants consistently reported the utilization of protective eyewear. Conversely, a smaller proportion of participants, namely 7.1% (n=48), acknowledged that operators do not employ protective eyewear during treatment, as demonstrated in Table 6.

In the section of the questionnaire about participants' understanding of the sterilization process, most respondents (61.1%, n=413) indicated that they knew about this process. Conversely, a smaller proportion (38.9%, n=263) reported a lack of knowledge regarding sterilization, as depicted in Table 7. During the survey, participants were questioned about the medical gown's significance. Out of the total sample size of 676 participants, 57.8% (n=391) acknowledged the importance of the medical gown. Conversely, 24.9% (n=168) believed that the medical gown has no impact on infection prevention and is unnecessary during dental procedures. Additionally, 17.3% (n=117) of the study cohort demonstrated a need for more knowledge regarding the medical gown, as depicted in Table 8.

Discussion

The COVID-19 pandemic has significantly raised the danger of infection. Healthcare workers are the group most at risk for infectious infections in the workplace in the medical area (7). Blood and saliva include a variety of germs that dentists are frequently exposed to. Consequently, compared to the general population, they have a higher incidence of some diseases (8). Dental undergraduate students occasionally disregard established infection control methods, even though they are standardized. More recently, an investigation was carried out by (9) to evaluate Mumbai dentistry undergraduate students' knowledge, attitudes, and practices surrounding infection prevention. Only 40% of final-year students, 40% of interns, and 42% of third-year students were specifically knowledgeable about infection control procedures. A correct attitude towards infection prevention was demonstrated by 24% of interns, 27% of final-year students, and 25% of third-year students. Finally, 41% of interns, 44% of final-year students, and 39% of third-year students were taught correct infection control practices.

Dentistry students typically put the infection control techniques they learned in dentistry school into practice. Our study looked into senior dentistry students at the Faculty of Dentistry's adherence to and use of a few fundamental infection control practices. During their third year as undergraduates, current dental school students hear lectures on infection management. Fourth- and fifth-year students are taught practice guidelines during their clinical training. Additionally, the university has created a standard infection control protocol, and clinical staff members monitor student adherence to the suggested protocol. The findings indicated that students most frequently store their devices in sterile pouches provided to all dental students at the clinics. The students are dedicated to following the established procedure of utilizing the faculty-provided sterilizers, such as the autoclave.

Equipment must be cleaned thoroughly to guarantee microbial inactivation because retaining organic or inorganic material could jeopardize later sterilization or disinfection procedures(10).

According to our findings, most students (43.2%) use soap and water to ensure the instruments are sufficiently cleaned after treatment, dry them off and then put them in the designated autoclave at the clinic for sterilization. These results are seen as encouraging and demonstrate a solid dedication to the most fundamental aspects of infection control practices. More limited IC instructions should be stressed, as 18.9% of students stated they washed used instruments with water before putting them in the sterilizer.

According to some research, thorough cleaning, which includes using plastic wraps and disinfectants, can increase the efficiency of infection control on the dental chair unit's surface (11).

According to our study, in 26.8% of students, effective infection control is achieved by spraying a disinfectant on the dental chair unit after removing the nylon wrap. Surprisingly, 21.7% of students removed the bandage and departed the treatment session without doing anything else. This is a concerning outcome that calls for further in-depth teaching of students on the significance of sprinkling disinfectant on all in-touch surfaces following treatment.

In cases where a dental item drops to the floor during a procedure, 18.2% of respondents said they leave it there until the procedure is over. If the fallen instrument, which is no longer sterilized, is placed back on the tray, this can prevent the sterilized instruments from becoming contaminated. On the other hand, the other students stated that they reacted by first grabbing the instrument and then doing something else (such as disinfecting, spraying with alcohol, etc.). This needs to be corrected and requires additional instruction and guidance at this level.

It is crucial to clean the spittoon after a dental procedure to prevent infection from blood and saliva residue from spreading to janitors or even students who may use the chair later. According to the study, 38.2% of students said they would instead use a special brush to wipe the spittoon only with alcohol. Only 8% of people clean their spittoons with water, which is insufficient to provide a satisfactory level of sterilization. The remaining students reported using other disinfection techniques, and, unexpectedly, roughly 12% of them recommended using alcohol as the only cleaning agent and avoiding using any other instruments or supplies. These results show that faculty students must adhere to a single, established cleaning routine.

Contamination of the eye with human fluids such as blood and saliva usually poses several bacterial and viral dangers to the dental team and students. Thus, wearing protective spectacles is crucial during clinical practice, particularly during treatments that expose dentists to infectious droplets or aerosols. In our study, 35.8% of the research cohort reported that the operators utilize protective eyewear throughout treatment. Conversely, a smaller % of participants, namely 7.1%, acknowledged that operators do not employ protective eyewear during treatment.

Autoclave sterilization is the chosen approach because of the safety, rapidity, and fatal action of pressurized steam on all bacteria (12). The sterilizer's functioning mechanism should be widespread among dentistry students, as it is most often taught in their academic courses (13). However, this study found that approximately 38.9% of pupils needed to be made aware of the sterilizer's functioning mechanism. This could be because some students deem it irrelevant because they do not directly use the sterilizer and instead present the instruments to the staff in charge of such responsibilities.

Wearing disposable gowns, scrubs, or other personal protective equipment is a barrier to preventing the spread of pathogens between dental healthcare providers and their patients (14). Studies have demonstrated that pathogen-containing aerosol and spatter can contaminate clinical wear, primarily the chest and forearms, and stay there for several days (15). Most dental students in our research believed wearing a disposable gown during treatment was crucial. This significance is heightened during procedures (such as maxillofacial surgery and teeth extractions) that generate more significant blood aerosol volumes and increase spatter exposure.

Despite the considerable sample size and high response rate of the current survey, numerous potential limitations should be considered. One disadvantage is that the replies were subjective (i.e., based on students' self-report) rather than supplied under supervision in a clinical setting. Therefore, the results may only partially reflect students' knowledge and professional practice. Furthermore, this amount of questions cannot reveal the respondents' factual knowledge and practice. Nonetheless, the number of questions was minimal to improve the response rate, which worked well. Reinforcement or increased emphasis in the dentistry curriculum. Considering these limitations, this study provides valuable information about Iraqi dentistry students' knowledge, perspectives, and infection control practices. Such data should aid in identifying parts of the dentistry curriculum that require reinforcing or higher emphasis. In the section of the questionnaire about participants' understanding of the sterilization process, most respondents (61.1%, n=413) indicated that they knew about this process.

Conversely, a smaller proportion (38.9%, n=263) reported a lack of knowledge regarding sterilization, as depicted in Table 7. During the survey, participants were questioned about the medical gown's significance. Out of the total sample size of 676 participants, 57.8% (n=391) acknowledged the importance of the medical gown. Conversely, 24.9% (n=168) believed that the medical gown has no impact on infection prevention and is unnecessary during dental procedures. Additionally, 17.3% (n=117) of the study cohort demonstrated a need for more knowledge regarding the medical gown, as depicted in Table 8

Conclusion

Based on the findings of the current study analysis and investigation, the following conclusions can be drawn:

Dental students demonstrated a high degree of understanding and a favorable attitude towards infection management. Still, the learned material needs to be implemented in day-to-day activities. Improving adherence to infection control recommendations is still challenging, even with dental schools implementing all infection control methods. Refresh and upgrade students' knowledge of universal infection control methods through seminars or lectures every academic year and maintaining.

Precautions, proper Personal protective equipment (PPE), and infection control protocols should be followed appropriately when treating any patient, as dentists and dental students are more prone to infection than any other profession.

Even though surface infection and handpiece or bur sterilization are essential infection control techniques in dental settings, earlier research did not consider these activities. These practices have been addressed in the current investigation. Because those two practices are typically performed by dental nursing or dental assistants, dental students may need to pay more attention to them.

It is recommended to strengthen the supervision of dentistry students on excellent practices so that they adhere to using Personal protective equipment as part of standard clinical practice. Furthermore, vaccines, particularly Hepatitis B vaccination, should be made mandatory for students before admission to any dentistry school. It is recommended that continuous educational programs and training workshops on infection control measures and precautions be organized for dentistry students.

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