Improving Compliance to Infection Control in Dental Clinics


The focus of this literature review is to evaluate effective methods that increase healthcare workers’ compliance to IC protocols. The writer will resolve the question: what is the most efficient approach to increase health care workers’ compliance with infection control protocols? This review is divided into three sections. In the first section, the author will review literature about the importance of infection control practice in the sphere of dental medicine. The second section presents a review about the level of knowledge and attitudes of dental staff towards infection control in different nations. In addition, the writer will review prospective factors affecting knowledge and attitudes of dental health care workers towards infection control practices. The last critically analyses elements that influence compliance of infection control precautions and also reviews multiple interventions based on behavioural theories or single techniques focusing on one or two elements.

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To carry out the study, a literature review of published medical journals obtained from Medline, Science direct, Emerald and Google scholars were carried to identify general research on information control practices in dental facilities. The analysis mainly focused on research studies that examined the knowledge and attitudes of dental health care workers towards infection control protocols, and factors influencing compliance of infection control. The research included the following terms in the study, “infection control”, “cross-infection” in “dentistry”, “education”, “training”, “compliance”, “behaviour models” and “infection control programs”. The following inclusion criteria were used:

  1. Published between 1985 and 2013;
  2. English language;
  3. Focus specifically on activities that necessarily increase staff compliance with infection control.

Importance of infection control practice in dental medicine

Over the last few decades, infection control in the field of dental medicine has continued as a major subject of public interest. The emergence of HIV and reports of doctors infecting patients in the 1980s activated public debates around the safety of dentistry procedures (Olulola & Olaide 2003). Medical studies suggest that the cross infections pose threats to both dental practitioners and their patients. This section develops a critical analysis about the importance of infection control to dental staff and patients.

Dental Staff

Reviewed literature reveals that the dental team is considered with the highest risk of Hepatitis B (HBV) exposure among health care workers. Research studies carried out by Younai (2010) suggest that in olden times, the prevalence rate of HBV among dentists was 16-28 prior to institutions of mandatory vaccination for HCW. In addition, HBV transmissions from infected dentists to patients were rampant. Hepatitis C (HCV) infections also pose a threat to dental care. Longitudinal studies conducted by Krajden et al. (2010) revealed slightly higher prevalence rates of HCV carriers among dental health care workers compared to other healthcare workers. More studies suggest that the transmission rates of Hepatitis B & C Viruses in dental care are 3 to 10 times higher than that of other health care workers (Younai 2010). Even though the transmission rate of viral infections is significant, practitioners are also exposed blood borne infections through percutaneous injuries and airborne organisms (Kohn et al. 2003). Studies conducted by Cleveland et al. (2012) reported a 3 times increase in needle stick injuries in dentists between 1986 to 1995.


Poor infection control among dental practitioners jeopardizes the safety of patients by exposing them to infections. A national survey representative sample of 6444 dentists conducted in Canada revealed that 66.4% of the sample confirmed that compliance of dentists was inadequate in most infection control procedures. Only 5.6% of the sample practised excellent compliance displaying obvious evidence that dental patients were exposed to viral and blood associated infections. Findings also revealed that patent disparities existed on what was recommended and what had being practiced, which was considered a threat from the patients’ perspective (Jawdekar 2013).

Knowledge and Attitudes of Dental Staff towards Infection Control Procedures

Dental societies and government organization have devised several recommendations and guidelines that aim at regulating infections among practitioners and patients. In spite of this, recent studies demonstrate that infections are not contained properly in dental settings (Cheng et al. 2012; Gordon et al. 2001). Studies conducted by Cheng et al. (2012) reveal that most dental practitioners have inappropriate knowledge, practice and attitudes regarding proper measures of infection control.

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Levels of Practitioners’ Knowledge and Practice

Information about infectious diseases and the necessary infection control procedures is fundamental in all medical spheres and notably in the dental profession. Studies conducted by Khanghahi et al. (2012) showed that the dental sphere needed sufficient information about infection control. This was deduced from surveys conducted in United States, Italy, Nigeria, England and Iran (Khanghahi et al. 2012).

Additional information from three studies conducted in 1990s suggested that dentists were unable to observe significant signs and infections of HIV infection in the mouth (Gordon et al. 2001). Practitioners who had clues were unable to contain spread of infections because of erroneous beliefs on modes of transmission. For example, some practitioners believed that the saliva was the principal route of transmission of HIV. Thus, the lack of primary expertise in deducing HIV infections among dental patients probably precipitates the rate of infection between patients and practitioners. Information deficiency also explains why many dentists take extra precautions when treating HIV carrier patients despite the fact that it contradicts to the principal guideline of modern infection control, namely to treat all patients as potentially infectious (Gordon et al. 2001).

A study conducted among dental nursing students in South Western Nigeria showed that 48.3% of sampled nurses believed that all HIV positive patients always looked sick and unhealthy (Azodo et al. 2007).This strongly showed the lack of appropriate information on blood borne infections related to dental practice. Subsequently, information about dental transmission blood borne infections, especially HIV, should be included in infection control procedures.

Factors affecting Knowledge and Practice

Reviews from different literatures established that knowledge among dental healthcare workers was shaped by infection control procedures that varied in different nations (Khanghahi et al. 2012; Terezhalmy 2009). However, most studies revealed that even despite the existed guidelines, most dental health care workers displayed information deficiency. In an African study published in 1994, dentists had poor information about basic infection control procedures (Olulola & Olaide 2003). A similar study in Iran established that the dental staff lacked adequate knowledge about infection control (Khanghahi et al. 2012). Similarly, a study in Egypt about infection control experience revealed that about one third (31) of surveyed dentists and few (44) dental nurses gave correct and complete answers about methods of infection transmission (Terezhalmy 2009). In addition, a study conducted in Turkey revealed that only 43% of the dentists surveyed understood and defined “cross-infection” correctly (Yüzbasioglun et al. 2009).

A number of associations between information of infection control and other variables exist in dentistry. A study conducted in Dutch linked practitioners who lacked sufficient information on infections to increased expression of fear in practice (Terezhalmy 2009). Reviewed literature suggests that the lack of high-risk patient contact could lead to poor infection control information in some clinical settings (Nobile et al. 2002). Similar studies also suggest that dentists working in cities would likely have the will power to treat high-risk patients. Perhaps, this trend results from city dentists’ gained knowledge and experiences with infected patients. Studies by McCarthy and colleagues found that dentists practicing in suburban areas were less likely to be prepared to treat infectious patients than those in villages (McCarthy, Koval, & MacDonald 1999). In addition, similar studies documented the association between health care workers and adherence to age and gender of practitioners, proficiency in oral surgery, and quantity of patients treated (Tada, Watanabe, & Senpuku 2014).

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Attitudes of dental health care workers also act as major affects to infection control practice in many clinics. Literature reviewed revealed that dental practitioners demonstrated a low observance with infection control procedures than dental students. The findings suggest that compliance with infection control, which was enforced in dental schools, did not extend into practical life. In addition, controversial research revealed that doctors were more compliant with infection control procedures than nurses were.

Nature of Practice in Different Countries

Dental health care workers’ perceptions and attitudes about infection control protocols differ depending on context and nation of residence. Literature reviewed about workers’ adherence with protective equipment revealed disparities. A study conducted in Turkey showed that 96.30% of dentists complied with the use of obstruction techniques, such as masks, gloves, and protective spectacles (Yüzbasioglun et al. 2009). A similar study conducted in Saudi Arabia showed that 100% of dentists used gloves and at the same time, 90% used masks (Al-Rabeah & Mohamed 2002). In Kuwait, research revealed that 90% of practicing dentists used gloves, 75% of them used masks and 52% of professionals used protective spectacles (Morris et al. 1996). In New Zealand, 42% dentists used gloves, 64.8% used masks and 66.4% used protective spectacles (Treasure & Treasure 1994). Canadian studies also revealed that in Ontario, 91.8% dentists used gloves, 74.8% used masks and 83.6% used protective spectacles (McCarthy & MacDonald 1997).

Similar studies about observing infection control methods using handpiece sterilization among patients recorded statistics that differed among nations surveyed. In Turkey, 80% dentists sterilized handpieces with disinfectants, while 17.8% sterilized handpieces with autoclave (Al-Rabeah & Mohamed 2002). In Kuwait, studies revealed that 94% sterilized handpieces with autoclave (Morris et al. 1996), and 30% of practicing dentists in Saudi Arabia sterilized handpieces with autoclave Al-Rabeah & Mohamed 2002).

The Role of Education in Improving Compliance to Infection Control Practices

In most cases, compliance rates are significantly less than a hundred percent for nearly all infection control guidelines. Factors that influence compliance rates are acquainted with distinctive levels of healthcare structures. Health care workers possibly hold on protocols due to the belief that some measures are effective. They also receive positive or negative feedback, or follow role models.

Empowering practitioners through education and Training

Most studies about improving compliance to infection control protocols identify education as an important element in the prevention and control of Healthcare Associated Infections (HCIA) (Cleveland et al. 2012; Yassi et al. 2007). Studies conducted by Cleveland et al. (2012) presumed that positive effects on the implementation on infection control guidelines were associated with education interventions. Cleveland and colleagues also proposed that effective educational interventions required at least six hours of learning time, and could include annual dental meetings, educational courses, and Continuous Dental Education programs about infection control.

More studies proposing the importance of empowering practitioners through offering education and training programs suggested that education and trainings were key factors in improving compliance (Rosenthal et al. 2005). To demonstrate this, Rosenthal and colleagues developed a program that focused on educating health care workers on hand hygiene. The program received positive performance feedback, and lowered infection rates (Yassi et al. 2007). Similarly, Yassi et al. (2007) suggested that improvements in teaching and controlled programs could improve consistency with hand disinfection procedures. To achieve long-lasting results on compliance rates, a number of educational methods could be used to educate practitioners about effective infection control practices (Yassi et al. 2007). According to Cleveland et al. (2012), dental settings could make use of internet-based education, continuous education meetings and other instructive educational interventions to support the implementation of infection control practices.

Using Non-educational factors

A number of investigators suggest that there is a lack of robust evidence of the efficacy of education in improving practice and reducing rates of infection, particularly in the long-term. They also suggest that while education may increase knowledge, this does not necessarily equate to an improvement in practice (Mateo and Kirchoff, 2009; Earl et al., 2001, Cohen et al., 2002). Among many studies that consider education as a key role in enhancing infection control compliance, it appears problematic to isolate education as the only intervention (Mateo and Kirchoff, 2009). In addition, while the work in a purely educational setting could identify the effects of education on facets, such as information and skills, in practice settings, there are multiple variables, which could affect both practice and outcomes. Some outcomes include infection, workload, skill mix, staff risk perception, time pressures and facilities available for staff to use (Earl et al., 2001, Cohen et al., 2002). As a result, adjusting to all these factors could be a difficult undertaking (Ward n.d.).

Using education and non-educational methods

While research has suggested that education plays a significant role in improving infection control practice through increasing knowledge, it is also suggested that increased knowledge does not necessarily improve practice. Important factors, such as institutional environmental constraints and interdependence of personal features, should be addressed in infection control educational interventions. Other factors like lack of written guidelines, appropriate facilities, resource promotion, compliance environment, administrative leadership, sanctions, rewards, and support should be taken into account when developing interventions to improve IC practices.

Further, more research should be developed to investigate long-term impacts of education, infection control education, the link between knowledge, practice and infection control education in healthcare settings. In addition, no research about specific dental departments within the literature was reviewed, which raised questions about the perceived value of infection control education in this setting.

Using Behavioural Intervention programs to Develop Infection Control Compliance

Studies on infection control compliance found that no existing intervention has consistently shown the capacity to enhance or uphold compliance with respect to infection control practices among health care workers. Researchers like Seto et al. (1995) concentrated on the value of applying the behavioural sciences in research involving staff compliance with infection control practices. This section provides a brief critique of several behavioural theories and their relationship with infection control practices.

So far, most of the literature reviewed insinuates that success rates are low and slow in single-programmed interventions that lack behavioural philosophies. In contrast, duplicated interventions established on behavioural theories succeed more than single or promotional programs that focus on one or two factors (GopalRao et al., 2002; Larson et al., 1997; Pittet, 2001).

Biomedical Theories

Biomedical theories explain the present-day approaches that explain how psychological, biological and social factors relate to human sickness. This model is commonly used in sociology, psychiatry, health psychology, and clinical social work to deal with attitudes and beliefs concerning medical and psychosocial patterns. The theory is based on the foundation that peoples’ characters help them interpret and solve problems. In medical settings, components of this model identify with psychological and social causes related to illnesses and health problems. Social components identify the impacts of social factors, such as technology and culture on health, while psychological components identify impacts of intellectual and attitude elements on health.

Biomedical theories can be equated to social cognition theories that explain active relationship between functions of the body and those of the brain signifying that there exist direct interactions between the human mind, body, and other intermediate factors. Within medical settings, patients are signified to obedient recipients who receive instructions in spite of whatever procedures being used (Creedon 2006).

To illustrate the functions of this model in complying with clinical guidelines, a medical investigator, Nishimura, carried out a survey that was aimed at testing the compliance of healthcare workers’ and visitors’ to specific hand washing guidelines. Guidelines compelling all those who entered and left the ICU facility to wash their hands was displayed on the entrance door. Observations revealed that throughout the period that the notice was on the door, a number of employees complied with the guidelines, and washed their hands. Investigators also observed that of those who abided by the terms of the guidelines, 71% were ICU employees, 74 % were non-ICU employees, and 94 % were visitors. Interestingly, as soon as the notice was removed, contrasting observations were recorded. Majority of people entering the ICU did not wash their hands (Creedon 2006). This suggests that behaviour changes occurred on a short-term basis, but in case of infection control compliance, there was a need to implement interventions that had a long-term impact

Communicative Approach and Learning Theories

Psychologists have developed learning theories that mainly focus on behaviours needed for compliance. These theories present theoretical contexts that explain the absorption, dispensation and retention of information throughout the learning process. The theories are mainly concerned with motivations and signals that bring forth behaviour-like rewards to reinforce actions. So far, no investigators have developed studies to prove that effective use of direct reinforcement to change health workers’ attitudes (Creedon 2006). A survey conducted by Seto et al. (1995) revealed that for people to comply with guidelines, their attitudes had to be similar to suggested actions. In addition, more studies supposed that influential people within underlying social constructs like opinion leaders could be used to exert influence on others and affect compliance rates (Myers and Robertson 1972). This concept was used to explain that people in different spheres of life could influence acquisition of information.

In a study in Hong Kong, Seto and his colleagues investigated how nurses complied with urinary catheter guidelines. The researchers divided the respondents into two groups and randomly distributed study objects among the groups. Group A was composed of only opinion leaders. Statistics revealed that group A had 60% while group B had 69%. These figures decreased to group A 42% and group B 62% after the intervention (Creedon 2006). As a result, behavioural and communication theories are based in the foundation that role models and leadership support reported levels of compliance (Larson & Kretzer 1995)

Reason Action Theories

Reason action theories are founded on the notion of behaviour objective across calculation of manners and behaviours. Research studies by Ajzen and Fishbein (1980) suggest that people who believe that behaviours command positive results have productive attitudes. In addition, such people have the plan to carry out the behaviour (Ajzen and Fishbein, 1980).

To contextualize this theory, Seto and his colleagues examined rates of compliance with needle recapping guidelines among nurses. Respondents were divided into three distinct groups. Afterwards, Seto and his colleagues divided the groups into those who intended to discontinue recapping, and those who did not intend. Then, they introduced guidelines to stop needle recapping through passive and active educational models. Observations revealed that the changes in the plan to discontinue needle recapping were most marked among respondents who used passive techniques and no significant change was shown among respondents who used active techniques. Passive techniques included posters and pamphlets while active techniques included in-service lectures (Creedon 2006). From the study, there is a clear indication that acquisition of information through reasoned actions could be effective in modelling behavioural change programs.

The PRECEDE health education theoretic model

It is important to define the acronym PRECEDE before we link its use to medical research. In this context, personal factors and environmental features influence health behaviours; hence, the acronym is used to stand for two definite parts – educational diagnosis and ecological diagnosis (Gielen et al. 2008; Freire and Runyan 2006). In educational diagnosis, PRECEDE stands for Predisposing, Reinforcing & Enabling, Constructs in Educational Diagnosis & Evaluation. In environmental/ecological diagnosis, PRECEDE stands for Policy, Regulatory, & Organizational Constructs in Educational & Environmental Development.

Medical studies suggest that this model is cost-benefit and can facilitate health evaluators and planners to device health programs and scrutinize circumstances (Creedon, 2006, Larson et al., 1997). The model has a functional characteristic that helps it to evaluate people’s health needs and implement health programs (Goldrick and Larson, 1992). The model mainly operates on the attainment of outcomes rather than contributions.

The PRECEDE health education theoretic model has been used successfully in health education programs. A theoretical study was conducted to examine healthcare workers’ compliance with hand hygiene guidelines in an ICU facility before and after implementation of a multifaceted hand hygiene program (Creedon 2006). Observations revealed that health care workers complied with the guidelines, but after the guidelines were removed from the facility, handwashing was not observed.

On the other hand, different studies suggest that behaviours have less effect on compliance, and recommend planned interventions that focus on the organizations’ environment and culture (Yassi et al. 2007; Seto et al. 1995). According to the research, better safety compliance could be associated with healthy organizational culture that promoted safety. This would encourage healthcare organizations to increase emphasis on measures that promote healthy and safe workplace cultures in healthcare facilities (Hooper and Charney 2005; Yassi and Hancock 2005). The study of the behavioural sciences in infection control is still in its infancy. However, rich information is accumulated in psychological research and could be applied in infection control (Seto et al. 1995).


In conclusion, there is a lack of sufficient data about the adoption of effective strategies to improve compliance with infection control protocols. From the literature reviewed, it would appear problematic to isolate education as the only intervention to compliance and infection, as controversial hypothesis still exists about its value. While the research suggests that education increases knowledge, literature shows that increased knowledge does not necessarily improve practice. Therefore, there is no clear evidence that education alone can sustain positive effects on compliance with infection control precautions. Additionally, contemporary findings suggest that behavioural interventions could enhance compliance.

As a result, investigators should develop research that gives significant reasons about the failure of education in addressing infection control protocols. There is also a need for more comprehensive education programs that link theory with practice. Finally, government organizations and healthcare facilities should evaluate impacts of various components of interventional programs to promote optimal infection control practices.


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