Assessment of Adherence to Hygiene and Asepsis Protocols in the Dentofacial Orthopedics Department, Ibn Rochd University Hospital Center, Casablanca, Morocco

1. Orthodontics Department, University Hassan II, Faculty of Dentistry, Casablanca, Morocco.
2. Dento-facial Orthopedics Department, University Hassan II, Faculty of Dentistry, Casablanca, Morocco.
3. Private Dentist, Casablanca, Morocco.
4. Laboratory of Community Health Epidemiology and Biostatistics, Faculty of Dentistry of Casablanca, Casablanca, Morocco and Ouamima.

*Mail: [email protected]
ORCID ID: https://orcid.org/0000-0002-2954-5237

OPEN ACCESS

PUBLISHED 31 January 2025

CITATION Bouchghel, L., El Mabrak, A., et al., 2024. Assessment of Adherence to Hygiene and Asepsis Protocols in the Dentofacial Orthopedics Department, Ibn Rochd University Hospital Center, Casablanca, Morocco. Medical Research Archives, [online] 13(1). https://doi.org/10.18103/mra.v13i1.6153

COPYRIGHT: © 2025 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i1.6153

ISSN 2375-1924

ABSTRACT

Introduction: Dental practice is a focal point for cross-contamination, where dental surgeons and their assistants engage in daily activities posing infectious risks to both patients and themselves. Adhering to universal hygiene and asepsis recommendations is a professional, regulatory, and ethical obligation. This study aims to evaluate the attitudes and behaviors of practitioners in the orthodontics department of CCTD Casablanca, Morocco regarding hygiene and asepsis.

Methods: A quasi experimental study was conducted through passive observation of orthopedics practitioners at the dental consultation and treatment center (CCTD) at Ibn Rochd University Hospital Center (CHU) in Casablanca. Data were collected on evaluation sheets based on universal hygiene and asepsis recommendations. The study included an initial assessment period, a focus group training and a reassessment period. Data were analyzed using descriptive and analytical statistics via SPSS.

Results: The results align with international studies, showing that practitioners do not fully comply with regulations concerning work attire, hand hygiene, work surface disinfection, or waste management. Additionally, no statistically significant difference was observed before and after training (p≥0.01).

Discussion: The study assessed the adherence of practitioners in the dento-facial orthopedics service to hygiene and asepsis guidelines, emphasizing the need for continuous training and the use of guides to maintain proper standards. It found significant improvements in practices such as hand washing, attire changing, and mask usage post-training, although initial adherence was often lacking.

Conclusion: Despite some persistent challenges, the study highlights the importance of regular monitoring and training in enhancing infection control measures.

Keywords

• Hygiene
• Asepsis
• Dentofacial Orthopedics
• Infection Control
• Training

Introduction

Around 1847, Hungarian physician Ignaz Semmelweis made the first observation regarding the significance of infection prevention and control in healthcare settings. He proved that a patient died as a result of a doctor’s negligence in washing his hands before performing an examination. Dentistry only completely adopted the principles of infection control when the dangers of the Hepatitis B Virus (HBV) and the Human Immunodeficiency Virus (HIV) were identified in the 1970s and 1980s, respectively. According to Sanly et al., reducing person-to-person transmission requires constant and careful attention to infection control principles and practices.

Infection control is crucial not only for preventing cross-contamination and cross-infection but also for increasing the success rate of dental treatments. The significance of infection control is undeniable, especially with the rising prevalence of highly resistant organisms causing healthcare-associated infections (HAIs). In the USA, approximately 1.7 million HAIs occur each year, leading to nearly 100,000 deaths. HAIs have become a major cause of death, surpassing AIDS, breast cancer, and auto accidents combined. An estimated 5-10% of hospitalized patients in developed countries acquire HAIs, with even higher rates in underdeveloped countries. Most of these HAIs are preventable. Regardless of where dental care is provided, dental healthcare professionals are ethically and legally required to ensure the safety of both staff and patients.

Due to the complexity of dental procedures, including face-to-face communication with patients, frequent contact with saliva, blood and other body fluids, and handling of sharp instruments, a significant risk of infection transmission exists within dental settings. There are many routes of transmission of microorganisms in dental clinics. These include inhaling airborne microorganisms that can remain suspended in the air for long periods of time; direct contact with blood, oral fluids, or other patient materials; contact of the oral and nasal mucosa or conjunctiva with microorganisms, including aerosols and droplets produced by an infected person and traveled short distances by speaking or coughing; and indirect contact with contaminated instruments or surrounding surfaces. Thus, standard universal precautions are to assume that all patients are carriers of infectious agents. Dentists are also expected to follow all necessary precautions.

The most frequently transmitted infections in dental settings include tuberculosis, syphilis, herpes infections, hepatitis B (HBV), hepatitis C (HCV), and AIDS (HIV). The COVID-19 pandemic has had a profound impact on dental practices, necessitating the implementation of stringent infection control protocols to minimize nosocomial transmission. Dentists now play a critical role in preventing the spread of such infectious diseases by adhering to enhanced safety measures and adapting to new guidelines for patient care.

Infection prevention in dentistry is supported by organizations like the CDC (Centers for Disease Control and Prevention) and the ADA (American Dental Association), with key measures including vaccination, hand hygiene, protective clothing, and instrument sterilization. These measures are universally applied regardless of the patient’s serological status. The CDC further emphasizes the importance of equipment disinfection, waste disposal, and dental unit water treatment. At the Faculty of Dental Medicine in Casablanca, infection prevention is a central component of training, aiming to improve hygiene and asepsis practices among students and practitioners.

The primary objective of this study is to assess the attitudes and behaviors of practitioners in the Dentofacial Orthopedics Department regarding hygiene and asepsis during treatment. Additionally, the study aims to develop a procedural guide for hygiene and asepsis measures to be implemented in the department, with the goal of improving the conduct of hospital practitioners and enhancing the safety of care services.

Method

A quasi experimental study was conducted to assess the hygiene and asepsis practices in the Dentofacial Orthopedics Department at the Dental Consultation and Treatment Center (CCTD), Ibn Rochd University Hospital Center (CHU) in Casablanca, Morocco. The study included 9 residents and 2 dental specialists, while teachers, practitioners enrolled in the university diploma program for ODF, external interns, and students were excluded from the study.

An anonymous evaluation form based on international hygiene and asepsis recommendations was developed. It included six parts covering general information, individual hygiene, use of protection barriers, clinical gestures, equipment and surface disinfection, and waste management. The survey was conducted in two phases with a training session held between them. The first phase consisted of an initial evaluation of hygiene and asepsis practices, which was conducted over two weeks. After this, a two-week training session was held, focusing on professional attire, the use of protective barriers, aseptic procedures, and waste management. The second phase involved a re-evaluation of the practitioners’ practices after the training.

Data collected from the participants’ questionnaires were analyzed using SPSS software version 20. A p-value of less than 0.05 was considered significant. Approval for conducting the study was obtained from the Research Ethics Committee of Casablanca College of Dentistry. All participants were informed about the purpose of the study, and the questionnaires were completed anonymously to ensure the confidentiality of the information provided.

Results

The 11 female study participants responded back and filled the survey. Changes in work attire, hand hygiene, and the use of protective equipment are summarized in table I.

The findings reveal a notable reduction in aseptic faults and better hygiene management of frequently touched objects and dental equipment. Table II focuses on aseptic practices, including the management of waste and disinfection processes.

Discussion

This study evaluates the compliance of practitioners in the dento-facial orthopedics service with hygiene and asepsis rules, based on universal recommendations. It highlights the lack of comprehensive studies on dentists’ adherence to infection control rules. Most existing studies focus on specific procedures using practitioner-filled questionnaires, which limit objectivity. Data was collected through passive observation to ensure objectivity. An anonymous, structured form with various criteria was used to reflect the reality of practitioners’ actions. The survey involved two phases of evaluation and re-evaluation, observing three patients per practitioner to assess all hygiene and asepsis practices.

The study evaluated the individual hygiene practices of practitioners in the dento-facial orthopedics service, highlighting that none of the practitioners wore the full professional attire (coat, pants, clogs) either before or after training, often resorting to just a coat and street shoes. The practice of changing attire at the end of shifts improved from 63.6% at initial evaluation to 100% upon re-evaluation. Hand washing, a crucial procedure in preventing disease transmission, showed notable changes. Initially, 81.8% of practitioners did not wash their hands before putting on gloves. Post-training, 36.4% of practitioners began washing their hands before glove use. Hand washing after glove removal increased from 36.4% to 72.7%. These findings are similar to those in a Jordanian study where 46% of practitioners consistently washed their hands before and after glove removal.

However, an Iranian study indicates that the dentofacial orthopedic service has the lowest adherence rates to hand hygiene guidelines (39%) and personal protective equipment guidelines (73.5%). This could be related to the non-invasive nature of the procedures performed within the service. Regarding poor hand hygiene, a recent meta-analysis conducted in Brazil in 2019 reported that adherence of dental students to hand hygiene guidelines was below 50%, which makes infection control a serious challenge. To solve this problem, they explained that continuous monitoring by the health inspectors and head nurses is imperative. Developing different strategies like hand hygiene campaigns are a method to encourage healthcare workers and improve their compliance.

The American Dental Association (ADA) recommends that dentists and dental assistants must always wear masks, protective eyewear, and gloves during clinical procedures to prevent cross-contamination. Failure to change gloves contributes to microorganism spread and increases cross-contamination risk due to glove permeability over time. In our study, all practitioners (100%) wore gloves for all clinical procedures, changed them after each patient or upon perforation, and disposed of them immediately after use, indicating a high awareness of hand-borne transmission risks. Similarly, Mutter et al evaluated several public clinics affiliated to dental schools, and reported that 100% of dental clinicians wore sterile gloves, and 85% of them changed their gloves between patients. Furthermore, in case of observing clear contamination, all dental clinicians replaced the contaminated items with new items.

Multiple infectious agents can be transmitted via airborne routes in dental practice, justifying the ADA’s recommendation for mask usage by both dentists and assistants. Additionally, side protective eyewear is crucial for conjunctival transmission protection, although OSHA (Occupational Safety and Health Administration) has not yet accepted regular eyeglasses as a substitute for protective eyewear. Masks must be changed between patients, after two hours of use, or when they become damp. Protective eyewear or face shields should be disinfected after each patient. Our study showed an increase in mask usage from 45.5% before training to 100% after training. Initially, 100% of practitioners did not change their masks between patients, but post-training, 9.1% began changing masks. Moreover, 90.9% of practitioners disposed of masks immediately after use before training, increasing to 100% post-training. Recent studies have shown an increase in the use of masks in dental practice. It should be noted that the COVID-19 pandemic and the emphasis placed on wearing a face mask and adherence to infection control protocols may be responsible for acquiring a full score in items related to wearing a face mask in all clinics. A different result might have been obtained if the assessment had been performed in a different period of time.

Our study found no use of protective eyewear or face shields among practitioners. Similarly, a study conducted in Saudi Arabia showed that prior to the COVID-19 pandemic, dental clinicians had a poorer performance by 1.4 times regarding the use of protective goggles compared with after the emergence of COVID-19 pandemic. The lack of eye protection among orthodontists may be due to the nature of their procedures, which typically do not involve blood splatter or aerosolization. However, some orthodontic interventions can unpredictably cause bleeding, justifying standard use of protective eyewear.

In our study, the wearing of jewelry during clinical procedures decreased from 72.7% at the initial evaluation to 27.3% after training. This aligns with an Australian study where 35.3% of participants did not wear any accessories. Studies indicate that removing jewelry can significantly reduce bacterial colonies, supporting the recommendation to remove jewelry during care. The handling of materials outside the work field showed that 72.1% of practitioners used contaminated gloves before and after training. This unchanged behavior may be due to the lack of chairside assistance, complicating patient management and aseptic practices. All practitioners shared bonding materials and curing lights before and after training due to limited availability compared to the number of functioning chairs. Disinfection of bonding materials increased from 36.4% to 63.6% and curing lights from 45.5% to 63.6%. Regular disinfection of the treatment area (unit, spittoon, suction, surfaces) is crucial. The evaluation showed that regular chair disinfection after each patient increased from 27.3% before training to 63.6% after. Additionally, 90.9% of practitioners did not rinse the water system, but this improved to 36.4% post-training. Biofilm in dental unit water lines can transmit pathogens. Whereas, an Iranian study indicates that the dentofacial orthopedic service has the highest adherence rates to disinfection guidelines (80.7%).

Regarding waste management, universal infection control guidelines state that used needles and sharps should be placed in puncture-resistant containers. All practitioners disposed of single-use items and sorted waste into specific containers. This aligns with an Indian study on biomedical waste management, where all sharp objects were placed in specific containers. Similarly, a German report showed 100% compliance with special containers for each waste type.

This study reveals that the practitioners in the dental-facial orthopedics service initially do not fully adhere to basic hygiene and asepsis measures but training positively impacted their attitudes, similar to findings from international studies. Moreover, the enhancement of hygiene and aseptic attitudes among practitioners following focus groups reiterating these measures highlights the importance of continuous training and the provision of guides and reminder sheets on appropriate standards within the service.

Conclusion

The prevention of infection transmission during medical care is rooted in professional obligations that are regulatory, ethical, and deontological in nature, applying to all healthcare professionals. Dental surgeons face specific challenges due to their exposure to blood and biological products, and the use of complex instruments in naturally septic environments, necessitating strict adherence to regulations regarding infection risk prevention. The increasing concerns over pathogen transmission, such as hepatitis viruses and HIV, coupled with the rise in drug-resistant microorganisms, make the adherence to hygiene and asepsis guidelines indispensable for protecting both healthcare teams and patients. To further improve the quality of infection risk prevention practices among all professionals at the Casablanca Center for Dental Consultation and Treatments (CCTD), evaluating the compliance with hygiene and asepsis standards among the medical and paramedical staff of all services would be prudent.

Conflict of Interest:

None.

Funding Statement:

None.

Acknowledgements:

None.

References:

1. Hamad FS. Infection control in dentistry: a review. Journal of Advanced Medical and Dental Sciences Research. 2023;11(4):111-117.
2. Whitworth CL, Palmer N. Decontamination in primary care dentistry. Journal of Infection Prevention. 2010;11(6):200-204. doi:10.1177/1757177410385368
3. Sunley K, Gallagher R, Reidy P, Dunn H. Essential practice for infection prevention and control: RCN guidance for nursing staff. British Journal of Healthcare Assistants. 2017;11(12):586-593. doi:10.12968/bjha.2017.11.12.586
4. Essentials of Preclinical Conservative Dentistry 2/e – Harpreet Singh – Google Livres. Accessed December 17, 2024. https://books.google.co.ma/books/about/Essentials_of_Preclinical_Conservative_D.html?id=gkbrDwAAQBAJ&redir_esc=y
5. DePaola LG, Grant LE, eds. Infection Control in the Dental Office: A Global Perspective. Springer International Publishing; 2020. doi:10.1007/978-3-030-30085-2
6. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. International journal of oral science. 2020;12(1):1-6.
7. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020;104(3):246-251. doi:10.1016/j.jhin.2020.01.022
8. Airborne spread of infectious agents in the indoor environment – PubMed. Accessed December 17, 2024. https://pubmed.ncbi.nlm.nih.gov/27590694/
9. Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. The American journal of medicine. 1997;102(5):9-15.
10. Togami E, Griffith B, Mahran M, et al. The World Health Organization’s public health intelligence activities during the COVID-19 pandemic response, December 2019 to December 2021. Eurosurveillance. 2022;27(49). doi:10.2807/1560-7917.ES.2022.27.49.2200142
11. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings-2003. MMWR Recomm Rep. 2003;52(17):1-61.
12. Rutala WA, Weber DJ. Guideline for disinfection and sterilization in healthcare facilities, 2008. update: May 2019. Published online 2019. Accessed November 27, 2024. https://stacks.cdc.gov/view/cdc/134910
13. Graman PS, Hall CB. Epidemiology and control of nosocomial viral infections. Infectious disease clinics of North America. 1989;3(4):815-842.
14. ALNegrish A, Al Momani AS, Sharafat FA. Compliance of Jordanian dentists with infection control strategies. International Dental Journal. 2008; 58(5):231-236. doi:10.1111/j.1875-595X.2008.tb00193.x
15. Keshvad MA, Vatandoust MT, Tahmasebi E, et al. The Investigation of Clinical Guidelines and Standards on Infection Control in Specialized Dental Departments. Open Access Macedonian Journal of Medical Sciences. 2022;10(D):465-470. doi:10.3889/oamjms.2022.10981
16. Resende KKM, Neves LF, de Rezende Costa Nagib L, Martins LJO, Costa CRR. Educator and Student Hand Hygiene Adherence in Dental Schools: A Systematic Review and Meta-Analysis. J Dent Educ. 2019;83(5):575-584. doi:10.21815/JDE.019.060
17. Association AD. Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc. 1996;127:672-680.
18. Mutters NT, Hägele U, Hagenfeld D, Hellwig E, Frank U. Compliance with infection control practices in a university hospital dental clinic. GMS Hyg Infect Control. 2014;9(3):Doc18. doi:10.3205/dgkh000238
19. Mary Govoni MBA. Safety Documentation in Dental Practices: OSHA and CDC. Accessed November 27, 2024. https://www.hufriedygroup.com/sites/default/files/2020-01/Safety%20Documentation%20in%20Dental%20Practices%20Mary%20Govoni%20Dentistry%20IQ%20Oct%202019.pdf
20. Meisha DE. Comparison of Compliance with Infection Control Practices Among Dental Students in Saudi Arabia Before and During the COVID-19 Pandemic. Risk Manag Healthc Policy. 2021;14:3625-3633. doi:10.2147/RMHP.S318031
21. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res. 2020;99(5):481-487. doi:10.1177/0022034520914246
22. The implications of healthcare professionals wearing jewelry on patient care biosafety: observational insights and experimental approaches | Scientific Reports. Accessed December 17, 2024. https://www.nature.com/articles/s41598-024-69711-x
23. Kanayama Katsuse A, Takishima M, Nagano M, et al. Cross-contamination of bacteria-colonized pierced earring holes and fingers in nurses is a potential source of health care-associated infections. Am J Infect Control. 2019;47(1):78-81. doi:10.1016/j.ajic.2018.06.006
24. Singh BP, Khan SA, Agrawal N, Siddharth R, Kumar L. Current biomedical waste management practices and cross-infection control procedures of dentists in India. International dental journal. 2012;62(3):111-116.
25. Yashfika Abdul Bari SMW. Infection Control Measures in Pakistani Dental Practices During COVID-19 Outbreak. Laravel. Accessed December 18, 2024. https://www.jpda.com.pk/infection-control-measures-in-pakistani-dental-practices-during-covid-19-outbreak
26. Lee M. OSAP Executive Director’s Report. Journal of Dental Infection Control and Safety. 2021;3.