CONTINUING EDUCATION ARTICLE: Compliance with infection-control procedures among Illinois...

CONTINUING EDUCATION ARTICLE

Compliance with infection-control procedures amongIllinois orthodontists

Dale Davis, DDS,a and Ellen A. BeGole, PhDb

Chicago, Ill.

The authors of previous studies have reported an increasing percentage of orthodontists complyingwith infection-control procedures in their offices, yet compliance was found to be less than ideal. Inthis study we surveyed Illinois orthodontists to evaluate their compliance with the infection-controlguidelines established by the American Dental Association and the Centers for Disease Control andPrevention. This study is an addition to a small number of studies in the field of orthodontics oninfection-control procedures. The study population was taken from the World Directory ofOrthodontists, which contains 374 listings for the state of Illinois. Responses were received from140 orthodontists, for a response rate of 37%. Thirty-two percent of the responding orthodontistsstated that they always wear masks; 13% said they never do. Almost 97% of the orthodontists saidthey always wear gloves, and no orthodontist reported never wearing gloves. Nearly 64% of theorthodontists reported always using eyewear, and 34% said they wear gowns, whereas only 5% donot wear eye protection and 35% never wear gowns. With regard to instruments and pliers, most ofthe orthodontists reported using dry-heat ovens (72% and 80%, respectively), whereas nearly 58%said they use chemical disinfection to some extent on instruments and 39% said they use chemicaldisinfection on pliers. Only 51% of the orthodontists surveyed in our study reported using a steamautoclave to sterilize handpieces, whereas 27% said they use dry-heat ovens, 11% reported usingchemical vapor, and 37% said they use chemical disinfection. In conclusion, compliance withinfection control procedures among orthodontists has improved from recent studies but is still lessthan full compliance. (Am J Orthod Dentofacial Orthop 1998;113:647-54.)

In the recent past, awareness on the partof health-care professionals and the public hasincreased with regard to control of the cross-con-tamination of infective bacteria and viruses in thehealth-related fields. As a result, health-care profes-sionals have striven to achieve, and the public hasdemanded, a higher level of protection.

Buckthal et al.,1 in 1986, found that most orth-odontists were using cold disinfection (62%), mostfrequently glutaraldehyde or isopropyl alcohol.They concluded from their survey results that orth-odontists viewed disinfection as a reasonable alter-native to sterilization, whereas the American DentalAssociation, at the time, recommended heat or gassterilization of dental instruments. Cash,2,3 in 1988and 1990, found a dramatic increase in the percent-age of dentists using barrier protection. Glove usewas found to have increased from 50% in the earlierstudy to 89%, whereas mask and gown use hadincreased from 10% to 20%. In 1990, it was shown

that all orthodontists used some form of barrierprotection, whereas in 1988, 17% wore none. Only56% of the orthodontists believed the sterilization/disinfection procedures they were using at the timewere adequate. Woo et al.,4 in 1992, comparedcompliance of California orthodontists and generaldentists. They concluded that the orthodontists usedfewer infection-control procedures than dentists be-cause of the increased cost of barriers such as gloves,eyewear, masks, and gowns with a higher volume ofpatients.

In this study we surveyed Illinois orthodontistsso that we might evaluate their compliance with theinfection-control guidelines established by theAmerican Dental Association5 (ADA), the Centersfor Disease Control and Prevention6 (CDC), andthe Occupational Safety and Health Administra-tion7 (OSHA).

MATERIAL AND METHODS

We drew our study population from the World Direc-tory of Orthodontists,8 which contains 374 listings for thestate of Illinois. The specific issues to be investigated andthe information to be extracted from each question wereidentified. In general, questions were short, simple, andspecific. When possible, we asked closed questions, whichthe respondent answered by checking a box, filling in a

From the Department of Orthodontics, University of Illinois College ofDentistry, Chicago, Ill.aIn private practice, Midland, Mich.bAssociate Professor of Biostatistics.Reprint requests to: Ellen A. BeGole, PhD, Department of Orthodontics(m/c 841), 801 South Paulina St., Room 131, Chicago, IL 60612-7211.Copyright © 1998 by the American Association of Orthodontists.0889-5406/98/$5.00 1 0 8/1/85567

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blank, or circling a numbered response. To test thequestionnaire, we administered it to a small sample of thepopulation for which it was designed. This testing helpeddetect weaknesses and errors in the instrument anddetermine how the elements and concepts of the surveywere interpreted. Confidentiality was assured, and stepswere taken to ensure that the respondents could not beidentified by name. So that our results would be compa-rable to existing findings of the limited number of avail-able studies, we compiled frequency and percentage data.

RESULTS

Of the 374 questionnaires mailed, responseswere received from 140 orthodontists, for a responserate of approximately 37%. The response was lowmainly because we did not conduct follow-up, in anattempt to protect the confidentiality of the respon-dents. Generally we found slightly better compliancewith infection control procedures than that reportedin previous studies. Percentage and frequency re-sponse data are presented in Table I for eachquestion on the survey.

Practice profile

The average responding orthodontist was prac-ticing in a suburban setting (61%), treating 188patients per week (range, 30 to 620), comprising30% children (,12 years), 50% adolescents (12 to18 years), and 20% adults (.18 years). The averagerespondent had spent 17.5 years in an orthodonticpractice (range, 1 to 40 years). Approximately 98%said they keep a medical history on each patient,whereas only 20% reported always reviewing themedical history. Still, only 7% said they alwaysupdate the medical history on subsequent visits,whereas 13% said they never did.

Approximately 32% of the orthodontists saidthey always wear a mask, whereas 13% said theynever do. Almost 97% of the orthodontists said theyalways wear gloves; no orthodontist reported neverwearing gloves. Nearly 64% of the orthodontists re-ported always using eyewear, and 34% always wearinga gown, whereas only 5% said they do not wear eyeprotection and 35% said they never wear a gown.Thirty percent of the chairside assistants were reportedto wear masks; 10% were reported not to. In our study,almost 93% of the chairside assistants were reportedto always wear gloves, whereas fewer than 1% neverdo. Approximately 44% of the chairside assistantswere reported to always use eyewear; only 7% werereported to never use it. Forty-four percent of thechairside assistants were reported to always wear agown; 24% were reported to never wear one.

Hand-washing practices

All of the orthodontists reported that hand-washing facilities are readily accessible to them, aswell as to their assistants, in the work area. Sixty-three percent of respondents said hands are alwayswashed immediately after removal of gloves; fewerthan 1% said they never wash their hands afterremoving their gloves. Of those who said they do notchange gloves between patients, 6% said they alwayswash their gloves; 3% said they never do.

Glove use

Only 18% of the responding orthodontists weretrained to use gloves in orthodontic school. Ninety-five percent of the orthodontists said they changegloves between patients; fewer than 1% said theynever do. Seventy-eight percent of the orthodontistsreported that gloves decrease dexterity to someextent, whereas 22% reported that this never occurs.Almost 77% of the respondents said they believegloves never lead to increased cuts on the hands,whereas 23% reported that gloves may lead to cuts.

Sterilization and disinfection practices

More than 61% of the orthodontists said theydisinfect work surfaces. Only 48% reported alwaysflushing their handpieces; 50% of these respondentssaid they do so after every patient. More than 15%of the respondents said they never flush handpieces,and 24% said they never flush their handpieces afterevery patient. Likewise, 42% said they flush air-water syringes always, but only 41% of these respon-dents reported “always” flushing syringes after everypatient. Sixty-five percent of orthodontists reportedalways disinfecting impressions, whereas 14% saidthey never do. Thirty-three percent reported alwaysusing iodophors, 25% phenols, 10% bleach/chlorine,and 15% alcohol. Fifty-one percent said they usesoap/water to sterilize instruments; 12% said theyalways use alcohol. Nearly 26% said they use asteam autoclave, 72% use dry-heat ovens, and only7% use chemical vapor always to sterilize instru-ments. Surprisingly, nearly 58% said they use chem-ical disinfection to some extent, and many reportednever using chemical sterilization on instruments.With regard to pliers, 50% said they always usesoap/water, whereas only 6% said they always usealcohol; 15%, 80%, and 6% reported always usingsteam, dry heat, and chemical vapor, respectively.As in previous studies, many orthodontists usedchemical disinfection to some extent on pliers(39%); 62% said they never use chemical steriliza-tion. Nearly half the orthodontists surveyed in our

American Journal of Orthodontics and Dentofacial OrthopedicsJune 1998

648 Davis and BeGole

Table I. Results of the questionnaire (percentage of subjectresponse is reported)

Practice Profile1. Practice setting (N 5 140):

Rural suburban urban12.2% 61.2% 26.6%

2. Practice profile: Mean SD Minimum MaximumChildren (,12 yr) 30.0% 15.0% 0% 75%Adolescents (12-18) 49.6% 16.7% 5% 90%Adults (.18 yr) 19.6% 11.8% 1% 95%

3. No. of patients seen per week?Mean SD Minimum Maximum187.8 91.7 30.0 620.0

4. No. of years spent in orthodontic practice?Mean SD Minimum Maximum17.5 9.7 1.0 40.0

5. Do you keep a medical history on each of your patients? (N 5 140)Yes No

97.9% 2.1%6. How often are medical histories reviewed? (N 5 138)

Always Frequently Occasionally Never20.3% 28.3% 46.4% 5.1%

7. How often are medical histories updated during subsequent visits?(N 5 138)


Barrier Protection1. Frequency of use by attending orthodontist?

Masks (N 5 140):Always Frequently Occasionally Never32.1% 19.3% 35.75 12.9%

Gloves (N 5 140):Always Frequently Occasionally Never96.4% 1.4% 2.1% 0.0%

Eyewear (N 5 140):Always Frequently Occasionally Never63.6% 16.4% 15.0% 5.0%

Gown/coat (N 5 140):Always Frequently Occasionally Never34.3% 7.1% 23.6% 35.0%

2. Frequency of use by chairside assistant?Masks (N 5 137):


Gloves (N 5 137):Always Frequently Occasionally Never92.7% 5.1% 1.5% 0.7%

Eyewear (N 5 137):Always Frequently Occasionally Never43.8% 29.2% 20.4% 6.6%

Gown/coat (N 5 136):Always Frequently Occasionally Never44.1% 15.4% 16.2% 24.3%

Handwashing practices1. Are handwashing facilities readily accessible to you in the work area?

(N 5 123)Yes No

100% 0%2. Are handwashing facilities readily accessible to employees in the

work area? (N 5 123)Yes No

100% 0%3. How often are hands washed immediately after removal of gloves?

(N 5 123)Always Frequently Occasionally Never N/A63.4% 23.6% 12.2% 0.8% 0.0%

4. If gloves are not changed between patients, how often are gloveswashed between patients? (N 5 109)

Always Frequently Occasionally Never N/A6.4% 0.0% 0.0% 2.8% 90.8%

Table I. Con’t

Glove use1. Were you trained to use gloves in orthodontic school? (N 5 122)

Yes No18.0% 82.0%

2. How often do you change gloves between patients? (N 5 121)Always Frequently Occasionally Never95.0% 3.3% 0.8% 0.8%

3. How often do gloves decrease your dexterity? (N 5 121)Always Frequently Occasionally Never10.7% 14.9% 52.1% 22.3%

4. How often do gloves lead to increased cuts on the hands? (N 5 121)Always Frequently Occasionally Never2.5% 3.3% 17.4% 76.9%

Sterilization and disinfection practices1. How often are impressions disinfected? (N 5 136)


2. How often do you disinfect work surfaces? (N 5 140)Always Frequently Occasionally Never61.4% 31.4% 6.4% 0.7%

3. How often are iodophors used? (N 5 135)Always Frequently Occasionally Never32.6% 23.7% 11.9% 31.9%

4. How often are phenols used? (N 5 131)Always Frequently Occasionally Never25.2% 29.0% 12.2% 33.6%

5. How often is bleach/chlorine used? (N 5 137)Always Frequently Occasionally Never10.2% 15.3% 24.1% 50.4%

6. How often is alcohol used? (N 5 139)Always Frequently Occaionally Never15.1% 19.4% 30.2% 35.3%

7. For the following pieces of dental equipment used in your practice,please indicate the frequency of procedures employed.Instrument Always Frequently Occasionally NeverSoap/water (N 5 132) 50.8% 12.9% 9.8% 26.5%Alcohol (N 5 125) 12.0% 5.6% 29.6% 52.8%Steam autoclave

(N 5 124)25.8% 6.5% 7.3% 60.5%

Dry-Heat Oven(N 5 123)

71.5% 10.6% 1.6% 16.3%

Chemical vapor(N 5 110)

7.3% 2.7% 1.8% 88.2%

Chemical disinfection(N 5 109)

13.8% 19.3% 24.8% 42.2%

Chemical sterilization(N 5 115)

14.8% 20.0% 21.7% 43.5%

Pliers Always Frequently Occasionally NeverSoap/water

(N 5 119)49.6% 8.4% 10.9% 31.1%

Alcohol (N 5 111) 6.3% 6.3% 18.0% 69.4%Steam autoclave

(N 5 111)15.3% 2.7% 6.3% 75.7%

Dry-heat oven(N 5 123)

79.7% 4.1% 1.6% 14.6%


5.6% 2.8% 1.9% 89.8%

Chemical distinfection(N 5 113)

12.4% 10.6% 15.9% 61.1%

Chemical sterilization(N 5 110)

9.1% 9.1% 20.0% 61.8%

Handpieces: Always Frequenctly Occasionally NeverSoap/water

(N 5 109)22.0% 6.4% 3.7% 67.9%

Alcohol (N 5 112) 21.4% 10.7% 8.9% 58.9%Steam autoclave

(N 5 114)48.2% 2.6% 0.0% 49.1%

American Journal of Orthodontics and Dentofacial OrthopedicsVolume 113, No. 6

Davis and BeGole 649

study reported always using a steam autoclave tosterilize handpieces, whereas 22% and 21% re-ported always using soap/water and alcohol, respec-tively. Almost 17% said they always use dry-heat

ovens, whereas only 8% always use chemical vapor.Sixty-three percent said they never use chemicaldisinfection.

HIV and hepatitis B preventive practices

A great majority of the orthodontists (91%)reported that they have been immunized against thehepatitis B virus (HBV), and 98% said they offertheir staff immunization for HBV. Fifty-five percentof respondents indicated that they suspect none oftheir patients of carrying the AIDS virus; 40% saidthey suspect some and 5% said they suspect all.More than 66% said they suspect that some of theirpatients carry HBV, whereas 5% said they suspectall and 28% suspect none. Seventy-four percentreported treating patients as though they were in-fectious for HIV or HBV. Only a small percentage(6%) never used universal precautions. Approxi-mately 79% reported always discarding sharps in apuncture-resistant, labeled, leakproof container,and more than 88% said they have sharps containersclose to the area in which these instruments areused. Nearly 70% of the orthodontists and 66% ofthe chairside assistants reported sustaining cuts orpuncture wounds at least occasionally. Chairsideassistants were reported to see blood in the mouth(99%), in impressions (96%), and on instruments/pliers (98%) at least occasionally. Yet, when anexposure incident occurs, only 45% of the staffmembers are always referred for a medical evalua-tion, and 18% never are.

The materials used to cover surfaces were plastic(72%) and paper (42%); 11% reported using nosurface coverage. A very small percentage (,1%)stated that they cleaned surfaces only and used nocovering, or used foil.

DISCUSSIONPractice profile

Fig. 1 shows a comparison of our findings re-garding the number of patients treated per weekcompared with those of Cash3 in 1990 and Woo etal.4 in 1992. Fig. 2 shows percentages of children,adolescents, and adults for the three studies. Thepractice profile in terms of numbers of patientstreated per week and the proportions of children,adolescents, and adults have remained relativelyconstant over these three studies.

Hand-washing practices

Woo et al.4 found that 93% of the orthodontistswho did not change gloves noted that they washedtheir gloves between patients. We found that only

Table I. Con’t

Dry-heat oven(N 5 109)

16.5% 1.8% 8.3% 73.4%


7.6% 0.0% 2.9% 89.5%

Chemical disinfection(N 5 112)

18.7% 7.1% 11.6% 62.5%

HIV and HBV Preventive Practices1. Are you immunized against HBV? (N 5 128)

Yes No90.6% 9.4%

2. Do you offer your staff immunization against HBV? (N 5 127)Yes No

98.4% 1.6%3. How many of your patients do you suspect of carrying the AIDS

virus? (N 5 138)All Most Some None

5.1% 0.0% 39.9% 55.1%4. How many of your patients do you suspect carry HBV? (N 5 137)

All Most Some None5.1% 0.7% 66.4% 27.7%

5. How often are patients treated as though they are infectious forHIV, HBV, or other bloodborne pathogens? (N 5 135)


6. How often are sharps discarded in a puncture-resistant, labeled,leakproof container? (N 5 137)


7. How often are sharps containers close to the area in which thesharps have been used? (N 5 136)


8. How often do you sustain cuts or puncture wounds? (N 5 138)Always Frequently Occasionally Never0.0% 2.2% 69.6% 28.3%

9. How often does your chairside assistant sustain cuts or puncturewounds? (N 5 135)


10. How often does your chairside assistant see blood in the mouth?(N 5 136)


11. How often does your chairside assistant see blood in an impression?(N 5 136)


12. How often does your chairside assistant see blood on instruments/pliers? (N 5 136)


13. When an exposure incident occurs, how often is staff referred formedical evaluation? (N 5 123)


What materials are used to cover surface?Plastic Paper Foil Nothing

(surfacescleaned)

Nothing

72.1% 41.8% 0.01% 0.07% 10.7%

It was possible to select more than one answer.



6% of those who said they do not change gloveswashed their gloves between patients, a wide dis-crepancy. In a study by Bagg et al.9 the practice ofwashing gloves was shown not to be totally effective.After five washes, the gloves were shown to becontaminated.

Barrier protection

Figs. 3 and 4 present findings for the threestudies regarding use of gloves, eyewear, masks, and

gowns by orthodontists and assistants, respectively.Glove use by orthodontists has increased substan-tially since the 1992 study by Woo et al.,4 whereasthe use of eyewear has remained level. However,Woo et al.4 found less glove and mask/gown usethan did Cash in an earlier study.3 Glove use byassistants has remained constant. The use of eye-wear has increased since the time of the study byCash,3 and mask/gown use was found to be substan-tially more common in our study.

Fig. 1. Average number of patients treated per week ineach of three studies.

Fig. 2. Distribution of children, adolescents, and adultsin the average orthodontic practice.

Fig. 3. Use of barrier protection by orthodontists asreflected in the three studies

Fig. 4. Use of barrier protection by assistants as re-flected in the three studies



Glove use

Fig. 5 depicts glove use in the three studies. Asubstantially increased percentage of orthodontistssaid they change gloves between patients in our laterstudy. Also, our respondents said dexterity is lessoften decreased and fewer cuts are sustained as aresult of glove use. Woo et al.4 found that, of the

orthodontists trained to wear gloves, 35% believedthat gloves decreased their dexterity, whereas 77%of the orthodontists who were not trained withgloves believed that gloves decreased their dexterity.They further stated that if orthodontists used glovesin their training program, they were much morelikely to use gloves in practice.

Sterilization and disinfection practices

Summary data for disinfection of impressions,instruments, pliers, and handpieces are shown inFig. 6. A far greater percentage of orthodontists inour study said they disinfect impressions comparedwith the respondents in the studies by Cash3 andWoo et al.4 In the 1974 Woo study,4 78% reportedusing no disinfectant on an impression, whereas inour study only 14% never disinfect—a considerableimprovement over the earlier findings. The percent-ages of orthodontists using cold disinfection oninstruments and pliers were decreased substantiallyfrom the earlier figures reported by Cash3 and Wooet al.4; Woo et al.4 showed a considerable increaseover Cash3 and our studies for cold disinfection ofhandpieces.

With regard to disinfection of work surfaces, thepercentage using such disinfection in the study byWoo et al.4 is markedly increased over the figuredetected in our later study, as shown in Fig. 7. Theuse of iodophors and bleach was decreased, whereasthe use of phenols and alcohol was increased.

Results are shown in Figs. 8 through 10 for heatsterilization of instruments, pliers, and handpieces,

Fig. 5. Glove use in the three studies. Trained refers tothe percentage trained to use gloves in orthodonticschool; change refers to whether the respondentchanges gloves between patients; dexterity refers todecreased dexterity as a result of glove wear; and cutsrefers to the percentage reporting increased numbers ofcuts on the hands as a result of glove wear.

Fig. 7. Percentages of orthodontists disinfecting worksurfaces, and the agents used.

Fig. 6. Disinfection of impressions, instruments, pliers,and handpieces.



respectively. Use of the autoclave and, especially,the dryclave for instruments and pliers in this studyis increased over the findings of Cash.3 For hand-pieces, use of all three methods is increased over theearlier study’s findings, especially the autoclave.Woo et al.4 found that orthodontists were divided onsterilization or disinfection of pliers (each 49%),whereas our figure for chemical disinfection was lowat 12%. Woo et al.4 found that 76% of orthodontistsdisinfected handpieces. In recent years, the trendtoward less use of disinfection and increased steril-ization of handpieces is evident. Overall, cold ster-ilization has decreased for instruments, pliers, andhandpieces, whereas use of the autoclave has in-creased for all three. Use of the chemiclave remainsabout the same for instruments and pliers, with asmall increase for handpieces, whereas the dryclaveshowed a dramatic increase for instruments andpliers, and a more modest increase for handpieces.

HIV and HBV preventive practices

Fig. 11 shows the percentages of orthodontists inthe three studies with no suspected HBV and HIVcarrier patient. Our results are similar to those ofWoo et al.,4 but Cash3 differs markedly in hisreported percentages, which are substantiallyhigher. Cash3 reported that orthodontists experi-enced an average of 65 wounds per year and thatblood was observed in the mouth an average of 15times per week and in impressions five times perweek by the chairside assistant. Woo et al.4 showedthat orthodontists and their assistants saw blood in

patients’ mouths an average of 10 times per week(8% of all patients) and in impressions an average ofthree times per week. In our study, blood was seenin the mouth and in impressions occasionally bymost assistants.

CONCLUSION

We found that substantially increased use of steriliza-tion versus disinfection methods has become evident inthe last 10 years, revealing a trend toward increasedobservance of universal precautions. Compliance has in-

Fig. 8. Percentages of orthodontists using heat steril-ization of instruments.

Fig. 9. Percentages of orthodontists using heat steril-ization of pliers.

Fig. 10. Percentages of orthodontists using heat ster-ilization of handpieces.



creased even since the most recent study by Woo et al.4 Apossible bias exists in that orthodontists who follow theguidelines are possibly more willing to return the com-

pleted questionnaire. Nevertheless our study shows thatorthodontists in the state of Illinois still need improve-ment in their use of barrier protection and in sterilizationof instruments, pliers, and handpieces. Compliance withthe ADA and CDC guidelines is the only way to ensure asafe environment for orthodontist, their patients, andtheir assistants.

REFERENCES

1. Buckthal J, Mayhew M, Kusy R, Crawford J. Survey of sterilization and disinfectionprocedures. J Clin Orthod 1986;20:759-65.

2. Cash R. Sterilization and disinfection procedures: a survey of Georgia Orthodon-tists. J Clin Orthod 1988;22:22-8.

3. Cash R. Trends in sterilization and disinfection procedures in orthodontic offices.Am J Orthod Dentofacial Orthop 1990;98:292-9.

4. Woo J, Anderson R, Maguire B, Gerbert B. Compliance with infection controlprocedures among California orthodontists. Am J Orthod Dentofacial Orthop1992;10:268-75.

5. Centers for Disease Control. Recommended infection control practices for den-tistry. MMWR Morbid Mortal Wkly Rep 1986;35:237-42.

6. Council on Dental Materials, Instruments, and Equipment, Council on DentalPractice, and Council on Dental Therapeutics. Infection control recommendationsfor the dental office and the dental laboratory. J Am Dent Assoc 1988;116:241-8.

7. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part1910.1030, Occupational Exposure to Bloodborne Pathogens: Final Rule. Fed Reg1991;59:64004-182.

8. Orthodontic Directory of the World, 36th ed. 1992:80-94. Nashville, TN: Orthodon-tics Directory of the World.

9. Bagg J, Jenkins S, Barker G: A laboratory assessment of the antimicrobialeffectiveness of glove washing and re-use in dental practice. J Hosp Infect 1990;15:73-81.

AAO MEETING CALENDAR

1998 — Dallas, Texas, May 16 to 20, Dallas Convention Center1999 — San Diego, Calif., May 15 to 19, San Diego Convention Center2000 — Chicago, Ill., April 29 to May 3, McCormick Place Convention Center

(5th IOC and 2nd Meeting of WFO)2001 — Toronto, Ontario, Canada, May 5 to 9, Toronto Convention Center2002 — Baltimore, Md., April 20 to 24, Baltimore Convention Center2003 — Hawaiian Islands, May 2 to 9, Hawaii Convention Center2004 — Orlando, Fla., May 1 to 5, Orlando Convention Center

Fig. 11. Percentages of orthodontists with no sus-pected HBV or HIV carriers.



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