Coininiinily Dent Oral Epidemiol 1996: 24: 341 5Printed in Denmark . .ill rigtils reserved

Copyright © Munksgaard 1996

Conrniunify Dentistryand Oral Epidemiology

lSSS 0301-5661

Dangerousness and dentistry: anexplanation ot dentists' reactionsand responses to the treatment ofHIV-seropositive patients

Barry Gibson and Ruth FreemanDental Public Health Research Group, School otClinical Dentistry, Queens University of Belfast,N, Ireland

Gibson BJ, Freeman R: Dangerousness and dentistry: an explanation of dentist'sreaetions and responses to the treatment of HlV-scropositive patients. CommunityDent Oral Epidemiol 1996; 24: 341-5. © Munksgaard, 1996

Abstract - Factors which inlluence health professionals' willingness to treatseropositive patients have been explained in terms of tbe concept of dangerousness.Can this concept be used as a vehicle to explain dentists' responses? All dentistscurrently in practice in Northern Ireland (/? = 664) were invited to take part intbe study. A final valid response rate of 73.3'y!) was achieved. Attitudes and behav-ioural aspects of dental practice were examined in relation to whether they hador had not treated and HW seropositive patients. In addition correlation andfactor analyses were conducted. The results indicated that the concept of "dan-gerousness' provides a useful framework to explain dentists' attitudes and behav-iours with respect to the provision of dental care for this patient group.

Key words: HIV-positive, AIDS, dental healthcare, dangerousness

Barry Gibson, Dental Public Health ResearchGroup, c/o The Division ot Paediatric andPreventive Dentistry, School of Clinical Dentitry,Queen's University of Belfast, Belfast BT12 6BP,N, Ireland

Accepted for publication 18 August 1995

In 1989 the World Health Organisationstated that at least 5-10 million peopleworld-wide were infected with HW(Human Immunodeficency Virus) (1).By 1992 this figure had reached nearly13 million, with 4.7 being women and1.1 million being children (2). It is ex-pected that this figure will rise to over 2million by the year 2000 (3). In Britainthere are 8,529 reported cases of AIDS(4) with 21,101 people including chil-dren having been diagnosed as beingHFV-positivc. However, in Northern Ir-eland there have been only 54 cases ofAIDS witb 134 people having been firstdiagnosed HIV-seropositive in North-ern Ireland (5)

For health professionals their appre-ciation of tbe influence of AIDS andHIV for clinical interactions with pa-tients and staff altered with the chang-ing prevalence of the disease. Attitudesand thoughts relating to the contain-ment of tbe infection to so-called high

risk groups gave way to fears of an epi-demic spreading throughout entirepopulations (6-7). Containment of HIVwithin the clinical arena rellectcd wishesfor isolation of the virus wilhin "high-risk groups" as well as fears of general-ised spread throughout communities(8-9).

Dentists' responses were similar -containment of the virus was para-mount (10-13). Fears of self-contami-nation and concerns associated with thepublic image ofthe dental practice (14-15) became major determinants oftreatment policy. Such was tbe concernthat HIV seropositive patients would berefused dental treatment in the UK thatVirginia Bottomley (16) as Minister ofHealth stated tbat: - "Dental eare ofHIV-positive patients as with any otberpatient (must he) provided by generaldental practitioners. Any individualwbo has difficulty in obtaining dentaltrealment is advised to contact his fami-

ly health services authority". In supportthe General Dental Council (17) statedthat: - "It would be unethical for a den-tist to refuse to treat a patient solely onthe ground that the person was HIV-positive".

The response to HIV and AIDS wastherefore considered inappropriate (16-20). However how could such reactionsbe understood? Small (21) proposedthat a concept of 'dangerousness' couldexplain health professionals' concernsin treating HIV-seropositive patients.Small's (21) notion of dangerousness,attempts to explain health profession-als' attitudes and behaviours in termsof "ghcttoisation of the problem" andtbe need "to stop tbe spread ofthe virusto the rest ofthe (normal) community".Can dangerousness be of use as a vehi-cle to understanci dentists' propensityto treat HIV-seropositive patients?

The study reported here examines theappropriateness of dangerousness as a

342 GIBSON KT AL.

concept in the understanding of den-tists' responses and reactions to treatingHIV-set'opositive patients.

Material and method

Ttie .sampte - All 664 currently practic-ing dentistry in Northern Ireland wereinvited to take part in the study. A listof dentists was obtained frotn theNorthern Ireland Council for Postgrad-uate Medical Education, the CentralServices Agency and the four HealthBoards. Each dentist was sent a copy ofthe questionnaire with a letter of expla-nation and a stamped addressed returnenvelope. After two months, a secondtnail out was conducted for non-re-sponders. The first tnail out took placein November 1992 and the second inJanuary 1993.

Measures - The Survey of HIV Infec-tion and AIDS questionnaire (SHIA)used in this study was developed byMCCARTAN & SA.MARANAYAKL (22).

SHIA had been shown to be of use inthe assessment of dentists' knowledge,attitudes and behaviours with respect tothe treatment of HIV/AIDS patients(22).

SHIA is a 34 itetn categorically basedinventory which examines; - • Detiio-graptiie faetors - The dentist's gender,age and the nutnber of years in prac-tice. - • Ktwwtedge-related-questions -the knowledge-rehtted questions assessdentists' knowledge on the cotnmonoral tnanifestations of AIDS. Otherknowledge-related attitudinal questionsinclude knowledge of the risk of trans-mission of the virus during treatmentand ct'oss-inlection control procedures.* Attitudinal c/uestions - the attitudesare measured using a Likert Scale. Twoattitudes (1 and 3) are assessed on a Spoint scale Irotn 1 (definitely disagree)to 5 (delinitely agree). The other atti-tudes are assessed on a three point scalefrotn 1 (definitely disagree) to 3 (defi-nitely agree). • Behaviour ejuestions -the subject is first asked have they evertreated an HIV seropositive patient,then it assesses how subjects treat andcope with their concerns about cross-infection control. These questions in-clude the impletnentation of universalprecautions, cross-infection measuresused during 'HIV dental care and soforth.

Coding of the questiotinaires and sta-

tistiettl analysis - Once the question-naires had been returned the responseswere scored, coded and placed onto adata file using colutnn codes which werestatistically analysed using SPSS PC-I-.The data was subjected to statisticalanalysis using a Mann-Whitney U test,correlation analysis and factor analysis.

Results

A total of 664 questionnaires were sentto all dentists currently practicing den-tistry in Northern Ireland. In the ftrstmail-out a total of 407 questionnaireswere returned comprising 63.3% of thesample. A second mail-out increased thefinal valid response rate to 73.3'̂ !). Themajority of the respondents were lessthan 40 years old (65.2'^) and had beenin practice for less than 10 years (A5.A"Ai)and were tnale (70.9%). The majoritywere in general dental practice (76.2'Mi)and .self employed. Only 75 had evertreated an HIV-seropositive patient.

Attitudinal scores were compared be-tween those who had treated an HIV-seropositive patient with those who hadnot (HIV-seropositive treatment status).Those subjects who had treated HlV-sc-t'opositive patients had significantlyhigher scores for the attitude thatGDPs should treat HIV-positive pa-tients and that they had adequateknowledge of HIV. No other differencesin attitudinal score were dctnonstrated(Table 1).

The tnost cotntnon cross-infectioncontrol procedures the subjects statedthey would use if treating an HIV-sero-positive patient were double gloves(96"Ai), visor and mask (93"Ai). gowns(64%) and rubber dam isolation (54'y;i).Vv'heii clinical behaviours and interac-tions were compared between thosedentists who had and had not treated,an HIV-seropositive patient, those whohad treated, scored significantly higherfor stringent cross-infection controlprocedures and sending staff on semi-tiars to increase their knowledge aboutthe treatment of HlV-seroposilive pa-tients (Table 2)

The attitudinal and clinical behav-iour and interaction data were cotn-bined with the HIV-seropositive treat-ment status in a correlation analysis.This detnonstrated several significantrelationships. HIV-seropositive treat-ment status was significantly correlated

with the attitudes that GDPs shouldtreat HIV-positive patients (r = 0.32;P<0.()()\), that HIV/AIDS is a seriousthreat to public health (r=-0.30;P<0.001), that HIV seropositive dentistshould disclose status (r=0.13; ^=0.01)and that HIV positive dentist should bedistnisscd frotn all practice (r = 0.12; P=0.01). Three significant correlations ofHlV-scropositive treatment status withclinical behaviours and interactionswere demonstrated. These were withstritigent cross-infection control (r=0.08: P=0.03), coticerns of regularpractice patients with HIV practicetreatmetit policy (r=0.10; P=0.()2) andconcerns of regular practice patientswith practice cross infection controlpolicy (r=0.12; P=0.0\).

A factor analysis was carried out toinvestigate the role of attitudes and be-haviours within a concept of danger-ousness. Forty-three per cent of thevariance in the attitudinal data was ex-plained by three dimensions, A (eigenvalue 2.91, variance 19.4%), B (eigenvalue 1.92, variatice 13.2%) and C(eigen value 1.62, variance lO.S'VI.).When the attitudinal data was corre-lated as a function of the ditnensions A,B and C then three groups of attitudeswere formed. Ditncnsion A was com-posed of four attitudes - HIV/AIDS isa serious threat to public health, HIV/AIDS should be notifiable disease, HIV-seropositive dentists should disclosetheir status and should be dismissedfrom all practice. Dimension B con-sisted of the two attitudes that GDPsshould treat HIV-positive patients andthat they had adequate knowledge ofHIV and dimension C was composed ofthe attitudes HIV/AIDS patientsshould be treated in hospital by special-ists and HIV-set'opositive dentistsshould disclose their status (Table 3).

When this was repeated for clinicalbehaviours and interaetions two dimen-sions A (eigen value 2.68, variance20.6'yii) and B (eigen value 1.86, vari-ance 14.3%) accounted for 35"A< of thevariance. Ditnension A consisted ofself-protection clinical behaviourswhereas ditncnsion B consisted of clin-ical interaction behaviours (Table 4).

Discussion

Health professionals, including dentistshave responded with various degrees of

Dentists' responses to HIV 343

c 1 Dil'lcicnccs in mean scores for attitudes between those dentists who have and have not treated HIV-seropositive patientsTabl

Attitudes

Dentists who have treated Dentists who have not treatedHI'V-seropositive patients HIV-seiopositivepaticnts

(// = 75) (H = 359)(rank mean) (rank mean)

A5 HIV a serious threatto public health 208.4 m 9 12780.0

(Mann-Whitney)

Z ' P

Al GDPs should treat HIVpositive patients

A2 Dental hospital specialistsshould treat HIV positivepatients

A3 Adequate knowledge of HIV

A4 HIV is transmitted inthe surgery

230.8

213.2

222.3

213.2

173.0

222.6

199.4

221.4

10125.0

13137.0

11727.0

13142.5

3.89

-0.81

2.41

-0.54

<O.OOI

>0.05

0.01

>0,05

-1.04 >0.05

A6 AIDS - a notifiable disease

A7 HIV-positive dentist shoulddisclose status

A8 HIV-positive dentist dismissalfrom all practice

240.7

221.8

213.8

216.9

216.6

218.2

12244.5

13144.0

13197.5

1.68

0.42

-0.29

>0.05

>0.05

>0.05

Table 2. Differences in mean scores for clinical behaviours and interactions lietween those dentists who haveseropositive patients

Clinieal behaviour andinteractions

Dentists who have ticatcdHIV-seropositive patients

(;, = 75)(rank mean)

Dentists who have not treatedHIV-seropositive patients

(/) = 359)(rank mean)

and have not treated HW-

(Mann-Whitncy)

Z

BI Stringent cross-infection eon-trol when treating all patients

B2 Double gloves worn whentreating HIV patient

B3 Mask/ visor worn when treat-ing HIV patients

B4 Boots/overshoes worn whentreating HIV patients

B5 Surgical gown when treatingHIV patients

B6 Surgical hat when treatingHW patients

B7 Rubber dam used when treat-ing HIV patients

11 Regular patients: concern withHIV practice treatment policy

12 Regular patients: concern wilhpractice ciossinfection controlpolicy

13 Training of staff in the treat-ment HIV dental patients

14 StalT attendance at seminarson HIV/ AIDS

224.5

213.0

219.9

220.2

214.9

220.1

233.8

216.3

215.5

223.6

225.4

201.0

217.2

215.8

199.2

216.8

199.3

212.9

220.2

222.1

219.8

193.2

122.30.0

13125.0

13132.5

12085.5

13266.0

12100.5

12088.5

13372.5

13311.5

13436.5

11524.0

2.01

-1.22

0.68

1.86

-0.15

1.58

1.54

-0.28

-0.51

0.30

2.3

0.04

>0.05

>0.05

>0.05

>0.05

>0.05

>0.05

>0.05

>0.05

>0.05

0.02

344 GIBSON ET AL.

Table 3. Factor analysis - dentists' altitudes as a function of the significant dimensions A, Band C

Attitudes

Al GDPs should treat HIV-patients

A2 Dental hospital specialists should treatHIV-patients

A3 Adequate knowledge of HIV

A4 HIV is transmitted in the surgery

A5 HIV a serious threat to public health

A6 AIDS - a notifiable disease

A7 HIV-positive dentist should disclose status

A8 HIV-positive dentist should be dismissalfrom all practice

DimensionA

0.06

0.10

-0.07

0.14

0.32**

0.42**

0.77***

0.62***

DimensionB

0.70***

0.14

0.40**

0.02

0.08

0.10

0.05

0.02

DimensionC

0.19

0.32**

0.18

0.05

-0.01

0.19

0.27*

0.07

Table 4 Factor analysis - dentists' clinical behaviours and interactions as a function of thesignilicant dimensions A and B

Clinieal behaviour and interactions

BI Stringent cross-infection control when treating alldental patients

B2 Double gloves worn when treating HIV dentalpatients

B3 Mask/ visor worn when treating HIV dental patients

B4 Boots/ overshoes worn when treating HIV dentalpatients

B5 Surgical gown when treating HIV dental patients

B6 Surgical hat when treating HIV dental patients

B7 Rubber dam used when treating HIV dental patients

II Regular patients: concern with HIV practicetreatment policy

12 Regular patients: concern with practice cross-infec-tion control policy

13 Training of staff in the treatment HIV dental pa-tients

14 Staff attendance at seminars on HIV/ AIDS

DimensionA

0.10

0.65***

0.63***

0.68***

0.60***

0.61***

0.61***

0.02

0.05

-0.10

0.09

DimensionB

-0.24*

-0.32**

-0.39**

0.18

0.15

0.11

-0.43***

0.55***

0.44***

0.39**

0,43***

* = P<0,05:** = 0.05>P<0.01:*** =

concern to HIV and AIDS. There arethose who wish to contain the virus tobigb risk groups [6-9] while others, tak-ing a more realistic view equate healthcare treatment for this group as theywould any other. The question remains,therefore, why should this particular in-fection provoke such a diversity of reac-tion - compared with for instance Hep-atitis B? Small (21) has postulated thatsuch reactions and responses as fears of

contamination and the wish to ''{i;het-toise) the problem" are but retlectionsof dangerousness. Wbile this concepthas been applied to those working with-in the health care professions it has notbeen directly related to those workingin the dental profession. The aim of thisstudy is to examine the appropriatenessof this concept as vehicle to the under-standing of dentists' various reaetionsto HIV-seropositive patients.

ln Northern Ireland where the preva-lence of HIV and AIDS remains low,relatively few ofthe dentists (75 of 644)sampled had treated a known HlV-sero-positivc patient. However those dentistswho had treated a known HIV-seroposi-tive patient, they manifested not onlydifferent attitudes but also differentclinical behaviours and interactionscompared with the others. For instancein their agreement that lllV-seroposi-tive patients should be treated in prac-tice. Furthermore their confidence intheir scientific knowledge refiected a re-ality which in turn inlluenccd their clin-ical behaviours and interactions. Thesedentists were aware that cross-infectioncontrol regimes needed to be morestringent and that members of the den-tal team should be knowledgeableabout the treatment of HlV-scropositivepatients.

However when the correlation anal-ysis was conducted for the whole sam-ple it seemed that various attitudesand behaviours were working in oppo-sition. For instance the attitude thatHIV-seropositive patients should betreated in practice seemed to eonfiictwith the attitudes that HIV-seroposi-tive dentists should disclose theirstatus and be dismissed from all prac-tice. Tbis seemed to suggest tbatalthough in reality dentists knew thatthe likelihood of transmission of HIVduring treatment was low, and henceHlV-scropositive patients should betreated in practice, fears and concernsfor their livelihoods still existed. Thiswas refiected in their elinical bebav-iours and interactions. For instancedentists who felt able to treat HIV-se-ropositive patients would have morestringent cross infection control proce-dures and have specific practice po-licies to contain patient and staff anxi-eties as well as the virus itself.

This dichotomy of response to theprovision of dental care is supported bythe findings of the factor analysis.Three attitudinal dimensions illustratedthe wish for ghettoisation (dimensionC), containment (dimension A) and theinfluence of treatment realities andknowledge (dimension B). Similarly thebehavioural data reflected the wish forself-protection and hence containment(dimension A) on the one hand and theawareness (dimension B) that the use ofthese self-protection procedures re-

Dentists' responses to HIV 345

duced clinical interaction with patientson the other hand.

How can such diversity in attitudeand behaviour be understood. Thefindings presented here would suggestthat Small's (21) concept of dangerous-ness provides an appropriate structureby which dentists' reactions and re-sponses may be explained. As withother health professionals, dentists bavea tendency to "(ghettoise) the problem"and contain tbe virus to "stop (/7.s)spread to tbe rest of tbe (normal) com-munity".

Nevertheless, those dentists who hadgreater elinical experience and knowl-edge of treating HIV-seropositive pa-tients had different attitudes, clinicalbehaviours and interaetions comparedwith the others. While acknowledgingthe limitations of the KAB model ofeducation (23) the results of this studywould suggest that a means by whichdangerousness may be reduced is byproviding dentists with the opportunityto gain greater elinieal experience,awareness and knowledge in the treat-ment of this particular patient group.

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