Practices of Infection Control Among Dental Care Providers: A Cross Sectional Study.

BACKGROUND: A wide range of microorganisms poses a threat to patients and dental care teams. Implementation of safety guidelines is thus essential to prevent infection in dental clinics. AIM: To investigate the level of infection-control practices among dental health-care providers in Jordan.
METHODS: A self-administered questionnaire was distributed to dental care providers from hospitals, academic institutions, and dental centres. The questionnaire covered sociodemographic variables, professional characteristics, and recommended guidelines of infection control.
RESULTS: A total of 190 questionnaires were obtained out of 500 distributed questionnnaires (response rate: 38%). Females accounted for 62.6% of the sample and 64.7% were dentists. The majority was vaccinated against hepatitis B (82.1%) and wash their hands as usual behavior before (66.3%) and after (83.2%) treatment. Approximately 87.9% wear gloves and 78.9% wear masks while performing dental procedures. Autoclave sterilization and puncture-resistant containers for sharp instruments were used by 90.5% and 88.4%, respectively. The majority (81.0%) had protocols for emergency treatment of needle stick or other sharps accidents. High volume evacuation was used in 28.6% of public hospitals compared to 19.4% in academic institutions (P<0.01). In addition, surface barriers for dental unit surfaces were used by 70.2% of private dental clinics, 50% of public hospitals, and 36.1% of academic institutions (P<0.001). Finally, compared to dentists, dental support staff showed low compliance with infection-control guidelines.
CONCLUSION: The overall practice of infection-control measures among the participants is very good. Educational programs and training strategies should be implemented to maximize and enhance the compliance of the dental care providers with infection-control guidelines.

Introduction

In dentistry, a wide range of microorganisms poses a threat to patients and dental care providers such as Mycobacterium tuberculosis, hepatitis viruses, staphylococci, streptococci, herpes simplex virus types, human immunodeficiency virus, mumps, influenza, rubella and others.1 In dental environment, pathogens can be transmitted through direct contact with infected blood, saliva, or other body fluids; or indirectly via contaminated instruments, materials and surfaces.2 In addition, pathogens can be transmitted through inhalation of airborne pathogens in splattered droplets or aerosols from saliva and respiratory fluid.2,3 The Infection-Control Practices for Dentistry was among the first guidelines for the prevention of infection by blood and body fluids of patients.1 According to these guidelines, all patients should be treated as potentially infectious in order to prevent disease transmission.1,4 Therefore, implementing infection-control precautions is the standard of care to protect both patients and dental care professionals and to ensure a safe working environment. Among such precautions are personal protective equipment (PPE), hand hygiene, waste management and sterilization.5

Preventing infection exposure in dental care settings can also be achieved efficiently by immunization.6 Therefore, many dental education institutions and dental care facilities have a comprehensive immunization policy for their students and dental care providers.7 However, most patients are not similarly protected, which may increase the risk of transmission of infectious diseases between patients.6 PPE such as gown, gloves, face mask and eye protection have been shown to be an effective means of preventing the transmission of pathogens.8,9 However, any failure to comply with implementing infection-control measures can harm both patients and heath-care teams.4,5

In Jordan, few studies have evaluated the level of infection control in dental practice. These studies were limited either to one institution,10 private dental clinics11 or to dental technicians in commercial dental laboratories.12 Therefore, the aim of this study was to evaluate the level of infection-control practices among dentists and dental care providers in the different dental sectors in Jordan. In addition, the study examined the association between socio-demographic and professional characteristics of the participants and their practice of infection-control measures.

Materials and Methods

Study Design and Instrumentation

This cross-sectional survey was conducted between January and April 2019. Institutional Review Board approval was granted by the Jordan University of Science and Technology (305–2018). The study involved a self-administered questionnaire that was distributed to a convenient sample of the dentists, and dental care providers from eight public hospitals (2 Military, 4 governmental and 2 University affiliated hospitals) and 30 public and private dental clinics from North Jordan and the capital city. The questionnaire was developed in English and was based on the Guidelines for Infection Control in Dental Health Care Settings of the US Centers for Disease Control and Prevention.13 The questionnaire was pilot tested on 20 participants to ensure its clarity and content validity. The questionnaire was divided into several sections. The first section collected personal sociodemographic variables (age, sex, specialty, and university degree). The second section collected information about the professional characteristics of participants. The last part was about the participants’ practice of vaccination, personal protective equipment, hand hygiene, waste management and sterilization. Data entry was reviewed by random audit of 10% of the entered information. The questionnaire is available upon request from the corresponding author.

Participants

The target population of the current study is approximately 5000 dental care providers who are responsible for applying the infection-control guidelines in the dental setting. To have a good representation of the target population, a total of five hundred subjects (10%) were invited to complete the questionnaire. One hundred and ninety participants agreed to complete the questionnaire by signing the consent form. Participation was voluntary and questionnaires were not identified by name or code to maintain anonymity and confidentiality. Access to data was restricted to the research team.

Data Analysis

Data analysis was conducted using the Statistical Package for Social Sciences (SPSS) software version 21.0 (SPSS®: Inc., Chicago, IL, USA). Frequencies and percentages were produced. Chi- square test was used to compare between subgroups. The level of significance was set at (P ≤0.05).

Results

Demographics and Work Characteristics of the Study Sample

The response rate was 38% (190 out of 500). Table 1 shows the demographic characteristics of the study participants. About two third (60.5%) of the sample were older than 30 years. Females accounted for 62.6% of respondents and approximately 52.6% held bachelor degrees. Two thirds of respondents were dentists while the remainder were members of the dental support staff. The mode of practice of the clinic showed that 52.6% worked in general dentistry and the remainder were from specialty practices. The majority of participants were from Northern Jordan (58.4%) and approximately one fifth (18.9%) were from academic institutions.

Table 1

Demographic and Work Characteristics (N=190)

Variable	N(%)
Age (Years)
<30	75(39.5)
30–39	63(33.2)
≥40	52(27.4)
Gender
Male	71(37.4)
Female	119(62.6)
Educational level
High school	12(6.3)
Diploma	41(21.6)
Bachelor	100(52.6)
Higher education	37(19.5)
Profession
Dentists	123(64.7)
Dental support staff	67(35.3)
Mode of practice of the clinic Speciality General practice	90(47.4)100(52.6)
Region of practice
Northern Jordan	111(58.4)
Capital city	79(41.6)
Practice type
Private clinics	84(44.2)
Academic institutions	36(18.9)
Public hospital/centres	70(36.8)

Practice of Infection Control Among Study Participants

Vaccination Against Hepatitis B

Results revealed that 82.1% of participants were vaccinated against hepatitis B. The distribution of the non-vaccinated fraction was 34.4% of dental support staff and 9.9% of dentists (χ2 = 19.15; P<0.0001). In addition, diploma/high school degree holders tended to be unvaccinated compared with participants holding other degrees (31.7% vs 39.6%, respectively, χ2 = 25.83; P<0.001). With respect to other demographic variables, there were no statistical significant differences regarding hepatitis B vaccination.

Hand Hygiene Practices

Table 2 summarizes the practice of hand hygiene, use of personal protective equipment, and sterilization and disinfection among participants. The majority of respondents reported practiced hand washing after treatment (83.2%) and prior to starting treatment (66.3%). About one-half (45.8%) reported usually washing hands before wearing gloves. With respect to materials used in handwashing, 49.5%, 32.1%, and 27.9% reported washing their hands using plain soap, hand sanitizer and antiseptic solutions, respectively.

Table 2

Infection-Control Practices in the Study Sample (N=190)

Variable	Response N(%)
	Always	Occasionally	Rarely/None
Hand hygiene
Washing hands before patient treatment	126(66.3)	45(23.7)	19(10.0)
Washing hands after patient treatment	158(83.2)	27(14.2)	5(2.6)
Washing hands before donning gloves	87(45.8)	65(34.2)	38(20.0)
Using hand sanitizer instead of washing	61(32.1)	84(44.2)	45(23.7)
Protective personal equipment
Wearing gloves while performing dental procedures	167(87.9)	17(8.9)	6(3.2)
Changing gloves between patients	170(89.5)	16(8.4)	4(2.1)
Using sterile surgical gloves for surgery	121(63.7)	36(18.9)	33(17.4)
Wearing protective eyewear	68(35.8)	62(32.6)	60(31.6)
Wearing mask	150(78.9)	20(10.5)	20(10.5)
Changing masks between patients	90(47.4)	62(32.6)	38(20.0)
Wearing disposable gowns for surgery	84(44.2)	46(24.2)	60(31.6)
Using high volume evacuation	69(36.3)	66(34.7)	55(28.9)
Using of single ampoules for local anaesthetic injections	156(82.1)	20(10.5)	14(7.4)
Asking your patient to do preoperative mouth rinses	75(39.5)	68(35.8)	47(24.7)
Disinfection and sterilization
Immersing used instruments in decontaminant solutions	131(68.9)	44(23.2)	15(7.9)
Sterilizing of hand pieces	141(74.2)	34(17.9)	15(7.9)
Sterilizing of burs	158(83.2)	25(13.2)	7(3.7)
Sterilizing of endodontic files	160(84.2)	21(11.1)	9(4.7)
Use of wrapping bags for instrument sterilization	149(78.4)	30(15.8)	11(5.8)
Use of surface barriers for dental unit surfaces	107(56.3)	45(23.7)	38(20.0)
Use of routine wiping for surface disinfection	142(74.7)	36(18.9)	12(6.3)
Chemical disinfection of impressions before sending to the laboratory	123(64.7)	31(16.3)	36(18.9)
Washing impressions with water before sending to the laboratory	144(75.8)	27(14.2)	19(10.0)

There was no statistically significant difference regarding practicing hand hygiene by demographic and work characteristics except in specific areas as shown by bi-variate analysis in Table 3. Females (26.1%) rarely washed their hands before wearing gloves compared with male (9.9%) subjects (χ2 =7.3; P=0.026). Dental support staff (19.4%) reported that they rarely wash their hands before starting patient care compared to only 4.9% of dentists (χ2 = 10.36; P=0.006). Participants with a diploma degree reported that they always wash their hands after patient treatment at a lower proportion compared with the others (χ2 value = 13.37; P=0.038). Approximately 41.0% of participants from specialty clinics reported that they always use hand sanitizer instead of washing hands compared with 24.0% of those in general practice clinics (χ2value = 12.17; P=0.002).

Table 3

Practice of Hand Hygiene and Use of PPE by Subgroups of the Study Sample

Demographic	Practice of Hand Hygiene and Use of PPE			χ2 value; Sig
	Rarely (N%)	Occasionally N(%)	Always N(%)
Washing hand before donning gloves
Gender				7.3; 0.026
Male	7(9.9)	27(38.0)	37(52.1)
Female	31(26.1)	38(31.9)	50(42.0)
Washing hands before starting treatment
Profession				10.63; 0.006
Dentist	6(4.9)	32(26.0)	85(69.1)
Support dental staff	13(19.4)	13(19.4)	41(61.2)
Washing hands after treatment
Educational level				13.37; 0.038
High school or less	0(0.0)	2(16.7)	10(83.3)
Diploma	3(7.3)	11(26.8)	27(65.9)
Bachelor	2(2.0)	9(9.0)	89(89.0)
Higher education	0(0.0)	5(13.5)	32(86.5)
Using hand sanitizer instead of hand washing
Mode of practice				12.17; 0.002
Specialty	25(27.8)	28(31.1)	37(41.1)
General practice	20(20.0)	56(56.0)	24(24.0)
Preprocedural mouth rinsing
Age (years)				10.7; 0.030
<30	22(29.3)	31(41.3)	22(29.3)
30–39	16(25.4)	24(38.1)	23(36.5)
≥40	9(17.3)	13(25.0)	30(57.7)
Using high volume evacuation
Practice type				30.23; <0.0001
Private	17(20.2)	25(29.8)	42(50.0)
Academic	6(16.7)	23(63.9)	7(19.4)
Public	32(45.7)	18(25.7)	20(28.6)

Using Personal Protective Equipment

The majority of participants reported an acceptable level of personal protective equipment use (Table 2). This includes constantly wearing gloves while performing dental procedures (87.9%), changing gloves between patients (89.5%), wearing sterile surgical gloves (63.7%) and masks (78.9%) while performing surgical dental operations, and using single ampoules for local anaesthetic injections (82.1%). Table 3 shows that approximately one-fourth of the study sample reported that they frequently use high volume evacuators, with significant differences between public hospitals (28.6%) and academic institutions (19.4%) (χ2=30.23; P<0.0001). In addition, about 40.0% of the sample employs preprocedural mouth rinsing. In this regard, participants aged 40 years and older employ preprocedural mouth rinsing more frequently than those participants in other age ranges (χ2=10.71, P=0.030).

Practicing Disinfection and Sterilization

Table 2 reveals that immersing used instruments in decontamination solution, sterilizing hand pieces, burs and endodontic files were performed frequently by the majority of the study sample (68.9%, 74.2%, 83.2% and 84.2%, respectively). About 78.0% of participants reported that they use wrapping bags for instrument sterilization; while a slightly less proportion (74.7%) use routine wiping for the disinfection of surfaces in the dental care facility. Approximately, 56.0% of subjects reported that they use surface barriers for dental unit surfaces. Dental impressions were reported to be treated either by washing with water or chemical disinfection before sending to the laboratories by 76.0% and 64.7% of participants, respectively.

Table 4 presents practices of instrument sterilization and management of sharps waste. The majority of respondents (90.5%) reported that they use an autoclave to sterilize instruments in their dental clinics. Moreover, 72.6% of participants immerse the used instruments in decontamination solution after treatment. About one half of respondents (51.1%) reported that 1 week was the time since last maintenance of the sterilization devices. One week as a preferred time to use sterilized, wrapped packed instruments were reported by 72.1% of participants.

Table 4

Sterilization, and Management of Sharps Waste (N=190)

Variable	ResponseN(%)
Which of the following do you use to sterilize instruments in dental clinic
Autoclave	172(90.5)
Boiling	9(4.7)
Washing	6(3.2)
Disinfectant solution	3(1.6)
When do you immerse the used instruments in decontaminant solutions?
Before treatment	52(27.4)
After treatment	138(72.6)
Time since last maintenance of the sterilization devices
One week	97(51.1)
Four weeks	53(27.9)
Six weeks	20(10.5)
Twelve or more weeks	20(10.5)
Preferred time of use of sterilized, wrapped packed instruments
One week	137(72.1)
Four weeks	39(20.5)
Six weeks	8(4.2)
Twelve or more weeks	6(3.2)
Having an appropriate protocol for emergency treatment of needle stick or other sharp accidents?
Yes	153(80.5)
No	37(19.5)
Do you keep detailed records of these accidents?
Yes	123(64.7)
No	67(35.3)
Do you use puncture resistant container for sharp instruments?
Yes	168(88.4)
No	22(11.6)

Table 5 shows that the participants from academic institutions use wrapping bags for instrument sterilization (χ2=11.27; P=0.027), surface barriers for dental unit surfaces (χ2=21.76; P<0.0001), and wash impressions with water before sending to laboratories (χ2=19.61; P<0.001) in lower frequencies compared to public and private dental clinics.

Table 5

Sterilization, and Management of Sharp Wastes by Work Type

Practice	Work Type			χ2 value; Sig.
	PrivateN(%)	AcademicN(%)	PublicN(%)
Use wrapping bags for instrument sterilization				11.27; 0.027
Rarely	5(6.0)	4(11.1)	2(2.9)
Occasionally	10(11.9)	11(30.6)	9(12.9)
Always	69(82.1)	21(58.3)	59(84.3)
Use surface barriers				21.76; <0.001
Rarely	6(7.1)	10(27.8)	22(31.4)
Occasionally	19(22.6)	13(36.1)	13(18.6)
Always	59(70.2)	13(36.1)	35(50.0)
Washing impressions with water				19.61; 0.001
Rarely	2(2.4)	10(27.8)	7(10.0)
Occasionally	10(11.9)	5(13.9)	12(17.1)
Always	72(85.7)	21(58.3)	51(72.9)
Having protocol for emergency for needle stick/sharp accidents				7.36, 0.025
Yes	65(77.4)	25(69.4)	63(90.0)
No	19(22.6)	11(30.6)	7(10.0)
Using special container for sharp instruments				7.81; 0.020
Yes	73(86.9)	28(77.8)	67(95.7)
No	11(13.1)	8(22.2)	3(4.3)

Dealing with Sharp Instruments

Table 4 shows that approximately (81.0%) of participants reported that they have an appropriate protocol for emergency treatment of needle stick and other sharp accidents with significant differences between public hospitals (90%) and academic institutions (69.4%, χ2=7.36, P=0.025) (Table 5). About 65.0% reported that they maintain detailed records of such incidents. Furthermore, 88.4% of participants use puncture-resistant containers for sharp instruments with a significantly higher proportion of those who work in public hospitals (95.7%) compared to those who work in academic institutions (77.8%, χ2=7.81; P=0.020) (Table 5).

Discussion

In dental practices, an infectious disease can be transmitted in many routes such as direct contact with blood, oral fluids and other body secretions. Also, indirect contact with contaminated instruments, operatory equipment and environmental surfaces is very possible.14 Therefore, it is essential to adhere to the universally recommended guidelines in order to prevent cross-infection among dental health-care providers and patients as well as between patients themselves. This comprehensive study aimed to assess the level of infection-control practices of dental health-care providers including vaccination, hand hygiene, use of PPE, sterilization and disinfection in public hospitals, private clinics, and academic institutions in Jordan. In addition, the current study examined the correlations between socio-demographic and professional characteristics of the participants and their practice of infection-control measures. In general, the study findings showed that the majority of the participants follow universal guidelines regarding vaccination against hepatitis B virus, using PPE, disinfection and sterilization, and dealing with sharp instruments. However, the self-reported infection-control practices did not reach optimal-desired levels.

Hepatitis B Virus is a well-recognized occupational risk in dental professionals, since it can be transmitted by exposure to blood and body fluids of an infected person.4 In this study, the majority of participants were vaccinated against hepatitis B (82.1%), this is higher than that was reported by previous studies from Jordan (36%)11 and Pakistan15 (71.6%), and less than the findings of a study from New Zealand16 (94.2%), Italy (85.7%)6 and Saudi Arabia17 (90.6%). The majority of hepatitis B non-vaccinated individuals was from dental support staff. Lower frequency of hepatitis B vaccinations in dental support staff may be explained by lack of formal training and more frequent on-the-job training by dentists, especially in Jordan’s private sectors.11

Good hand hygiene performed by dental practitioner is considered an effective method to prevent and control infection transmission in dental practice environment.4,18 This study showed that the majority of participants practice handwashing following patient treatment more than before starting treatment. Finding of this study is lower than a study conducted in Saudi Arabia that showed about 96.7% and 89.4% of the participants perform hand hygiene before and after contacting patients, respectively.17 However, in Pakistan, Ch et al15 reported that 79% of the participants wash their hands before and after treatment. The results of the current study showed that washing hands are affected by gender and academic degree. Males reported washing their hands before wearing gloves more than do females. In a study from Germany, it was reported that males conducted better hand hygiene than females after treatment, while females conduct correct hand hygiene more than males before treatment.18 However, some previous studies19–21 showed that females reported better hand hygiene practices than males. Dental support staff wash hands before treatment less frequently compared to dentists, and those with a diploma degree reported washing their hands after patient treatment less frequently than others in accordance with the conclusions of Mutters et al,18 who reported a lower compliance of dental assistants with infection-control procedures due to insufficient knowledge. The current findings showed dental care providers in specialty clinics use hand sanitizer for washing hands more than who work in general dental practice. In addition, participants who work in academic settings reported practicing handwashing less than those who work in private and public dental settings. The reason for such differences could be due to the pressure of work as a result of variations in the number of patient-care visits between the various settings.

Generating aerosols, droplets of water, saliva, blood, microorganisms, and other debris are very common during the performance of dental procedures. Therefore, disease transmission via travelling droplets and aerosol, which remain for a long time in the air, is a major concern in the dental environment. To minimize the susceptibility to airborne and blood born infections, dental care providers should adequately use PPE such as gloves, protective gowns, and face mask.1,4,18 The majority of respondents reported wearing gloves (87.9%) and masks (78.9%) frequently while performing dental procedures. The majority of participants (89.5%) reported changing gloves between patients, however only 47.4% of them reported changing masks. This finding is similar to that of other studies.1,15,22 However, the reported proportions of the current study are higher than the findings of a previous study in Jordan, where 81.8% of participants reported that they wear and change gloves and 54.5% wear masks.11 Whereas a study from a South African Province23 shows that only 52.2% and 65.25% of dental care providers reported wearing gloves and masks, respectively, while only 8.7% change gloves after each patient. The present findings also showed that wearing sterile surgical gloves, protective disposable surgical gown and use of high volume evacuation were reported to be less frequently practiced by participants. Yadav et al1 reported that 20% of the studied dentists use sterile surgical gloves, 10% use high volume evacuation, and 3.3% use protective gown. Using of high volume evacuation by the participants in private clinics is higher than that in public hospitals and academic institutions. This could be due to the fact that private clinics are usually more frequently inspected than public ones.

Patient-care items should be categorized and sterilized or disinfected depending on the potential risk for infection associated with their use. The study findings revealed that the majority of participants always perform disinfection and sterilization. Sterilization of hand pieces is performed by 74.2% of the participants, which is higher than that reported in a study from Tanzania (54.2%)24 and lower than that in a study from New Zealand (99.5%).16 In addition, results showed that surface disinfection for routine wiping was reported by 74.7%, which is less than the findings that were reported in a study from Saudi Arabia (95.1%)17 and higher than that reported from India.1 Participants from academic institutions reported that they use surface barriers less than reported by public hospitals and private clinics. This could be due to the unavailability of the materials or budget restrictions. Furthermore, 65% of the participants reported disinfecting impressions. This percentage is less than the findings from Saudi Arabia (95.1%)17 and New Zealand (71.8%).16 Significantly higher proportions of those worked at public hospitals and private clinics reported that they wash impressions with water before sending to laboratories more than those who worked at academic institutions. In general, the safety practices with respect to sterilization procedures were more adequate in public and private sectors than academic institutions. More investigations are needed to uncover the reasons behind such observation. In addition, frequent inspection of academic dental centres by the government is recommended.

Participants who are 40 years old and greater were more eager to perform disinfection and sterilization periodically in comparison with those younger than 30 years old. Participants with bachelor degree or higher showed significantly better disinfection and sterilization practices than those without certification, and work in private dental clinics.11 Thus, more training on safety guidelines should be applied to dental care providers, especially young and less educated.

Using autoclave for instrument sterilization is the preferred method due to its safety, rapid and lethal effect of pressurized steam on all microorganisms.1 The majority of participants reported using autoclave sterilization of dental instruments. This is in accordance with other studies,15,25 and higher than what was reported in a previous study in Jordan by Al-Omari and Al-Dawiri 63%,11 whereas the findings of a study conducted by Banglani et al26 show that 76% of dental practitioners were using an autoclave.

Although performing maintenance and monitoring of autoclaves is very important to ensure perfect sterilization cycle,1 only half of the participants reported performing the last maintenance of the sterilization devices within a period of 1 week. Therefore, it is recommended to increase the training and education in autoclave biosafety measures and periodic maintenance.

Many dental instruments are sharp and can cause injuries when handled such as needle sticks. This type of accident can be a potential source of infections. Needle stick injuries and sharp accidents should be prevented by following the recommended measures including implementing an emergency protocol, maintaining detailed reports, and safely disposing of sharp objects.1,4 The majority of participants reported appropriate protocol for emergency treatment of needle stick and sharp accidents. However, approximately 65% reported that they keep detailed records of those accidents compared to 10% in India1 and in Germany 35% by dentists and dental assistants 42%, respectively.18 Using puncture-resistant containers for sharp instruments was reported by most of the participants (88.4%) which is higher than that was reported in a previous study in Jordan (31.8%)11 and less than that was reported in Saudi Arabia (99.2%).17 Although the overall practice in dealing with sharp objects among the study sample is good, it is recommended to optimize the performance of appropriate disposing protocols of sharp objects, compliance to the recommended guidelines during needle stick emergency, and maintaining detailed records of the accidents in the dental environment. Among the limitations of the current study is that the frequency of occupational infection and sharp injuries among examined population were not assessed. Therefore, future studies that include such measures are strongly recommended. Moreover, future similar studies should be conducted on a larger sample size.

Conclusion

The overall practice level of infection-control measures among dental care providers in Jordan is good. There is an improvement in the adherence of dental care providers to the universal guidelines of infection control compared to previous studies in Jordan. However, this level is not absolute as other studies have shown in various countries. Dental support staff showed less compliance with infection-control guidelines. Therefore, educational programs and training strategies should be implemented to maximize the compliance of dentists, as well as enhancing the compliance of dental support staff with infection-control guidelines. Academic curricula should emphasize on infection-control practice, by including comprehensive theoretical and practical courses of the most current infection-control measures. Also, dental support staff should be certified in order to practice dental assisting and dental hygiene. Finally, consistent infection-control compliance evaluations of various dental environments by well-trained persons/specialized committee is highly recommended.