HIV/AIDS: A Survey on Private Sector Oral Health Care
Individuals serve as an early indicator of the immunosuppressive condition. Oral lesions strongly associated with HIV infection include Pseudo membranous candidiasis, Erythematous or atrophic candidiasis, Hyperplastic or chronic candidiasis, Angular cheilitis, Herpetic Gingivostomatitis, Hairy Leukoplakia, Oral warts, Acute Necrotizing ulcerative gingivitis/periodontitis, Kaposi’s Sarcoma, Non Hodgkin’s Lymphoma and Oral Ulcers3,4,5.
WHO outlined some basic principles for developing a country-specific approach to capacity- building to control HIV/AIDS-related oral disease7,8. four areas were identified: (1) health promotion and health education, (2) patient care, (3) infection control, and (4) epidemiology and surveillance. WHO Oral Health Programme recommends encouraging oral health personnel and public health practitioners to make oral health status, an integral part of optimum case management and of surveillance activities of the diseases associated with HIV infection6. In India, dental care scenario is unique, at present there are more than 267 dental schools, producing approximately 19,000 dental graduates/year and almost 3000 specialists/
year6. Assessment of the knowledge levels of the Oral health care providers is considered important for treatment of oral manifestations of HIV/AIDS, as it would help in identifying the levels of competence, training needs and preferences of Oral health care providers.
METHODS & MATERIALS
Association for Rural and Urban Needy (ARUN) is a non-government organization established in 1995 with an objective of promoting the health awareness among the underserved people with an emphasis on HIV/AIDS across Andhra Pradesh. ARUN undertook this study on oral health care providers with the following objectives: (i) To assess the levels of knowledge of Oral Health care Providers on oral manifestations of HIV infection; (ii) To assess the knowledge of oral health care providers on HIV testing; (iii) To assess the expected outcome in terms of the level of competence that Dental Health care provider need; (iv) To assess the knowledge of oral health care providers on universal safety precautions.
The survey was carried out in the Dental colleges, private clinics and Trust hospitals located across four districts (Nalgonda, Medak, Nellore and Khammam) in the State of Andhra Pradesh.
DATA
A semi structured questionnaire was developed specially after consultations among trained investigators from ARUN. The self-administered
questionnaire attempted to capture both qualitative and quantitative data and was field tested by experienced investigators. The questionnaire was circulated to all the departments within dental college and in private hospitals. A total of 75 oral health care providers were chosen by convenience sampling to participate in the survey. The respondents asked to fill up the self administered questionnaire based on their observations and clinical experience. The questionnaire was based on ten different parameters capturing the information pertaining to objectives framed. In addition, secondary data was derived from the additional information collected from the medical records of the hospital with in the dental college. The data was entered on MS Excel and was analysed using SPSS version software.
RESULTS 1. Typical/Special cases:
Among the commonly treated typical or special cases in a dental hospital 33% of cases are Impaction cases, 31% are flap surgeries, 16% are Space infections, 15% are Trismus and 5% are of various carcinomas.
2. Universal safety precautions:
Procedure % adopting
Providing Glass tumblers to patients for rinsing mouth
during surgical procedures 61
Changing glass tumblers
after each procedure 10
Wearing Gloves 97
Changing Gloves after each procedure 45
Wore masks 98
Changed masks after each procedure 88
Used Drapes 94
Changed drapes after each procedure 62
Wearing of Aprons 100
Changed Aprons after each procedure 7
Used rubber dams 18
Changed rubber dams for each patient 8
Among oral health care providers surveyed, 61%
of dentists were using Glass tumblers for patients to rinse their mouths, while doing surgical procedures;
only 10% of oral health providers who are providing glass tumblers to patients are changing the tumblers after each procedure. About 98% of dentists wore gloves while performing surgeries and only 88% of them were changing the gloves after each surgery. 97%
of oral health care providers surveyed wore mouth masks while performing surgeries, but only 45% of them changed their mouth masks after each surgery.
All the dentists wore Aprons during treatment
procedures (Simple clinical examination and while performing surgeries) but where as mere 7% of them are changing their Aprons after finishing each treatment procedures. 94% of dentists are placing drapes on the patients while performing the treatment but whereas only 62% of them are changing drapes from patient to patient. 18% of dentists are using Rubber dams while carrying out treatment, but only 8% of them are changing the Rubber dams from patient to patient.
3. Risky surgical procedures
Among the surveyed dentists, 67% of dentists felt that various dental extraction procedures have maximum risk of occupational injuries and exposure to HIV infection, 28% of dentists felt, Flap surgeries have the maximum risk and 5% of dentists felt that Root Canal Therapy (RCT) have maximum amount of risk of occupational exposure.
4. HIV Oral Indicators
The percentage of oral health care providers who are aware of the oral manifestations of HIV/AIDS working within surveyed hospitals illustrated that, 20% of oral health care providers are of aware of Oral Candidiasis, 18% are aware of Angular Chelitis, 7%
are aware of Leukoplakia, 4% are aware of Shingles, 8% are aware of Herpetic Stomatitis, 1% are aware of Kaposi’s Sarcoma, 2% of them are aware of Non Hodgkin’s Lymphoma, 8% are aware of Acute Necrotizing Ulcerative Gingivitis/Linear Gingival Erythema, 8% are aware of Necrotizing Ulcerative Periodontitis, 14% are aware of Recurrent Aphthous Ulcers and 11% know about Xerostomia.
6. Reason for the Referral:
The survey results illustrated 37% of the dentists are not referring the patients for HIV testing. Among the dentists who are referring (63%) for HIV testing, only 32% are referring based on clinical diagnosis of oral manifestations of HIV/AIDS, 23% of them are referring as a precautionary measure, 8% of them are referring after assessing their attitude and behaviour.
7. Place of Referral for HIV testing None of the dentists are referring the patients to HIV testing centres [Integrated Counselling and testing Centres (ICTC)] run by the local government agency.
67% of them are referring to private health care facilities for HIV testing.
8. Sterilization
The analysis of the data on the practices of the sterilization of the used instruments followed by Oral Health care providers illustrated, 56% of them are not sterilizing the hand pieces after each use, 61% of them are disinfecting the impressions before sending to the laboratory, 53% of them are not using sterilization wrappings, 85% of them are not using the sterilized rubber dams, 25% of them are not sterilizing the burs after each use, only 1% of them are not using the disposable syringes and 13% of them are not changing the saliva ejectors after every use and 94% of dentists are unaware of Post Exposure Prophylactic drugs (PEP).
Details % of Oral
health care providers Not sterilizing instruments 56
% using sterilized wrappings
for impressions 61
Disinfecting wrappings 53
Not using sterilised
of rubber dams 85
% using disposable syringes 99 Not using sterilised burs 25 5. Referral for HIV Testing
The percent of patients having any one of the oral manifestations of HIV/AIDS being referred to HIV testing by the oral health care providers from the Out Patient Department in various health care settings are 16.3% from Dental Colleges and Hospitals, 1.2% from Private Clinics and 9.2% from Trust hospitals.
Graph 1: Incidence of HIV oral indicator
Graph 2: Referrals made from various health care settings for HIV testing
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DISCUSSION
HIV-related oral conditions occur in a large proportion of patients suffering with HIV/AIDS, oral manifestations may suggest possible HIV infection, although they are not diagnostic of infection. Dental expertise is necessary for proper dental management of complications in HIV/AIDS.
In this study practice of wearing gloves during performing surgical procedures as well as routine clinical examination to preventthe transmission of infection to patients and to prevent thecontact of the health care worker with blood and saliva,is reported to be 97% which is overwhelming but only 45% of dentists who are using gloves have reported that they changed gloves for each patient. This is higher than what was reportedby previous studies13. Though wearing of protectivegloves does not protect from the injuries caused during handling of the sharp equipment, butmay confer some protection by virtue of their wiping action on the sharp object on penetration14.
In this study, 88 percent of dentists wore and changed masksduring treatment in between each treatment procedure, in comparison to 54.5% in Jordan9 75%in Kuwait15, 64.8% in New Zealand, 13 74.8% in Canada. 12. It is observed that 87% of dentists are changing saliva ejectors, 75%of dentists changed burs and extraction instruments between patients. There have been reports of previous studies about the transmissionof infection as a result of inadequate sterilization of handpieces16, 17.
Only 44% of dentists sterilized hand piecesin contrast to other studies that found higher rates of sterilization15, 10.The reason for not sterilizing the instruments was false impression regarding autoclaving as it would cause damage to the equipments. This agrees withthe findings of a previous study18. Contaminationof the laboratory could occur if cross-infection control isneglected. Indeed, occupational infection of dental laboratorytechnicians with HBV has been reported19. The results of thisstudy revealed that as low as 39% of dentists used disinfectantsfor impressions before sending to dental laboratories. Thisis in comparison to 18% in Jordan9 and 53.7% reported by study done in durban20.The use of rubber dam, in addition to improving safety andsaliva control, significantly reduces bacterial contaminationof the atmosphere during restorative procedures, particularlyin the vicinity of the operator and dental assistant21. Theresults of this study revealed that only 15% of the oral health care providers participated in survey used rubberdams in their restorative procedures, compared to 13.6% among the
private providers in Jordon9 and 40%among private dentists in Durban20.
CONCLUSION
Form the data generated through this study illustrated a considerable amount of oral health care providers are (i) Unaware of the national program on HIV/AIDS; (ii) Have very low levels of knowledge on Clinical manifestation of HIV and their importance.
(iii) Have less understanding on Universal safety precautions that can avoid the occupational exposure;
(iv) Low level of the knowledge on HIV testing procedures purpose and place of referral; (v) Have low levels of knowledge on Infection control and Waste management; (vi) Low level of understanding on Post Exposure Prophylaxis (PEP).
ACKNOWLEDGEMENTS
We at ARUN express our sincere gratitude to management, administrative staff, and teaching staff of private dental colleges, private dental hospitals and Trust hospitals. We take immense pleasure in thanking many people who have given their time and talent to its implementation. We are grateful to our colleagues involved in this program for planning, discussing the details and generalities in developing strategies for smooth implementation of the program time to time.
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