Masters Degrees (Dentistry)

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Effectiveness of selected surface disinfectants in the dental clinic – a report from a tertiary training facility in KwaZulu-Natal.
(2016) Deulkar, Swati Ahay.; Singh, Shenuka.; Govender, Thavendran.
Optimal infection control practice forms the cornerstone of quality oral health care delivery in any dental setting. There is very little published evidence on dental infection control practices in South Africa. In addition there is a paucity of evidence that specifically examined the efficacy of commonly used surface disinfectants in oral health clinical settings. The aim of this study was to determine the effectiveness of selected surface disinfectants on specific dental environmental surfaces in an identified public oral health training facility in KwaZulu-Natal. The objectives included the identification and classification of environmental areas that are at risk for cross-contamination in the dental clinic, and comparison of the microbial count at specified times of the day after the use of three surface disinfectants. This was a prevalence (cross-sectional), descriptive research study with a non-experimental design. Data collection included the application of three commonly used surface disinfectants (Chlorine®, Ethanol and Glutaraldehyde) on identified dental environmental surfaces in a public sector dental clinic facility in KwaZulu-Natal. The clinic consists of seventeen dental units that are numbered from one to seventeen. Systematic random sampling technique was used to select selected every second chair for the study (Dental Unit number: number: 1, 3, 5, 7, 9, 11, 13, 15, 17). The dental clinical environment was then divided into four zones: 1): the working area around the dental operator/assistant (chair, head rest, arm rest, foot rest, dental hand pieces, overhead light source, air water syringe tip, spittoon, suction hose, based of dental chair, dental stool, foot control, instrument counter and handle); 2): the area behind chair (wash basin, computer monitor, window, wall, table top, dust bin and taps): 3): the area away from chair (computer processing unit, telephone and floor); and 4): the reception area (patient chairs and reception table top). The swab samples were collected at specific time intervals (7am, 9am, 11am, and at 16.00) using a charcoal swab. Chlorine, Ethanol (70% in water) and Glutaraldehyde (2%) disinfectants were applied separately on the identified nine dental units by using a spray method. Use of the MALDE-TOF spectrometer enabled the mass spectra to be acquired and the bacteria to be identified. Out of the 312 samples taken, 262 (84%) were shown to be bacterial culture positive. More than seven microbial species were identified in which staphylococci, Bacillus species and fungi were present. The most contaminated areas in the dental environment were the area around the chair (86.5 %) and away from chair (92%). The results indicate that Chlorine® was not active against several bacteria because 92% samples had positive growth at the end of the day. Only 56 % of the samples using Ethanol were positive in the morning but the microbial growth increased to 96 % by the end of the day. The use of Glutaraldehyde indicated that 52% of samples were positive at 9 am but that 82% were found to be positive at the end of day. The bacterial survival rate was found to be less with the use of Glutaraldehyde. The study suggests that there was an association between frequency of cleaning, the type of disinfectants used and the microbial count on the specified dental environmental surfaces in the identified oral health facility. The findings therefore indicate that disinfection processes at the identified dental centre are inadequate, sub-optimal and could contribute to the infection chain. There is an urgent need to review the current infection control procedures and protocols, including a review of the type of surface disinfectants used. The frequency of disinfection (damp-dusting and housekeeping) must be reviewed, given the number of patients that are seen on a daily basis. It is also important that simple procedures such as awareness of hand hygiene practices are implemented and prioritized. There should also be dedicated infection control monitoring and evaluation processes.
Exploring oral antibiotic prescription patterns for the management of dental conditions at two public health institutions in Pietermaritzburg, KwaZulu-Natal.
(2020) Ramnarain, Prishana.; Singh, Shenuka.
Introduction: Oral antibiotics are typically prescribed for the management of dental conditions such as acute odontogenic and non-odontogenic infections, and as prophylaxis for patients such as those with infective endocarditis or placement of joint prosthesis. While these measures are intended to limit the spread of possible infection that could occur as a result of oral surgical procedures, very little is known about antibiotic prescription practices and trends for dental purposes, specifically in the public sector in KwaZulu-Natal. Study Aim and Objectives: The aim of this study was to determine patterns of oral antibiotic prescription for the management of dental conditions at public health facilities in the Pietermaritzburg complex so as to create practitioner awareness of the need for the judicious use of antibiotics. The study objectives were to determine patterns of oral antibiotic prescription for dental patients at the identified public health institutions; understand dental and medical practitioners‘ knowledge, attitudes and practices related to antibiotic prescription for dental conditions; and ascertain public health pharmacists‘ perspectives on these patterns of oral antibiotic prescription. Method: This study was divided into 3 phases and a combination of quantitative and qualitative data was collected. The research sites comprised two purposively selected public sector hospitals located in the Pietermaritzburg complex of UMgungundlovu district (Institution A and B respectively). In Phase 1, data collection comprised a retrospective clinical record review to determine oral antibiotic prescription patterns for dental purposes (n=720) at the two identified research sites during the period March 2012- July 2018. For Phase 2, a cross sectional study design was used. Purposive sampling was used to select the study sample comprising medical and dental practitioners (Group 1, n=123) and pharmacists (Group 2, n=25). A separate self-administered questionnaire was developed for each group. The questionnaires comprised open and closed ended questions that were designed to assess the identified health care workers‘ knowledge, attitudes and practices related to oral antibiotic prescriptions or dispensing for dental use; perceptions of therapeutic duplication of antibiotics, availability of laboratory information and recommendations for the improvement of oral antibiotic prescriptions. A Likert scale format was used to elicit responses such as 1 (Strongly agree), 2 (Agree), 3 (Not sure), 4 (Disagree), 5 (Strongly Disagree). For Phase 3, the qualitative data was derived from focus group discussions held with purposively selected health care practitioners at each institution (Institutions A and B). The study sample included health care practitioners (medical and dental practitioners) and pharmacists, involved in prescribing or dispensing oral antibiotics for dental purposes. Two focus-group discussions (FGDs) comprising six people per group at each research site, were set up. The quantitative data was analyzed using the Statistical Package for Social Sciences software (SPSS Version 25 R). Univariate descriptive statistics such as frequency and mean distribution and inferential techniques such as Pearson‘s Chi-Square test were conducted to determine a possible relationship between the independent and dependent variables. A p-value of 0.05 was established as being significant. The internal consistency of the questionnaire, according to the Cronbach alpha score, was 0.68. Validity of the questionnaire was maintained. The qualitative data (obtained from the focus group discussions) were analyzed using thematic analysis. All emergent themes were further analyzed to gain a better understanding of participants‘ perspectives related to oral antibiotic prescriptions for dental conditions. Credibility, conformability, transferability and dependability of the collected data were maintained to enhance rigor and trustworthiness in the qualitative component of the study. Results: The results of the retrospective chart review indicated that dental abscesses (n=479; 66%) were the most common dental condition for which oral antibiotic therapy was prescribed. There were inconsistencies in the pattern of oral antibiotic prescription for dental conditions between the two public health care institutions. At Institution A, antibiotic therapy was prescribed for dental conditions such as trismus (n=13; 6%), soft palate swelling (n=9; 4%), fibrous epulis (n=6; 3%) and acute herpes (n=2; 1%). Interestingly, oral antibiotics were not prescribed at Institution B for the same dental conditions. Antibiotic therapy was prescribed for eruption pain (n=4; 1%) and in cases where patients did not bring their inhaler for asthma treatment (pump) (n=3; 1%) at Institution B. For the self-administered questionnaire, the response rate for Group 1 (medical and dental practitioners was 77.5% (n=93). The response rate for Group 2 (pharmacists) was 92% (n=23). The majority of participants in this study (n=72, 77.4%) indicated awareness of an Antibiotic Stewardship Programme in their respective institutions yet 42 participants (45%) were not sure on whether the programme was active. More than half of the study participants (n=60, 64.5%) indicated referring to the Standard Treatment Guidelines „some times‟ when prescribing antibiotics. The majority of participants (n=72, 77.4%) indicated that they would prescribe antibiotics for orofacial swellings. Almost 33 participants (35.4%) stated that they would prescribe antibiotics for irreversible pulpitis. Almost 31 participants (88.9%) from Institution A and 40 (75%) from Institution B indicated prescription of antibiotics for pericoronitis. Similarly, 27 participants (76.9%) Institution A and 14 (72.1%) from Institution B would prescribe antibiotics for periodontitis. The majority of participants (n=80, 86%) agreed that there was need to improve antibiotic prescription processes. With regards to the prescription of oral antibiotics as prophylaxis for the prevention of infections such as infective endocarditis, the following responses were obtained. Almost 13% of respondents from Institution A reported prescribing PEN VK 250mg daily followed by Penicillins, Augmentin, Benzyl Penicillin, Clindamycin and Kefazol while 23% of respondents from Institution B indicated prescribing Amoxicillin 2g stat dose one hour before a dental procedure followed by Pen VK, Penicillin, Clindamycin, Benzyl Penicillin oral and intravenous, Benzatime Penicillin, Penicillin G and Vancomycin. More than two thirds of study participants in Group 2 (n=18; 78%) perceived a correlation between the dental condition and the antibiotic prescribed thereof. Participants (n=17; 73.9%) also believed that oral antibiotics were sometimes prescribed without any clinical indication. The following themes emerged from qualitative data analysis (focus group discussions): inconsistencies in antibiotic coverage for dental-related clinical management between the two sites. There was no consensus among research participants on the need for diagnosis laboratory testing to improve antibiotics prescription. However, all participants agreed that there is a need to improve antibiotic prescription in their various hospitals. Discussion: Overall the results of the study indicated inconsistencies in antibiotic prescriptions for dental conditions. This suggests that over and under prescribing may be occurring in the identified clinical settings. The most common dental infection in this study, requiring antibiotic therapy was dental abscesses (66%). While the recommended treatment of choice for the management of periapical abscess, periodontitis abscess and localized dentoalveolar abscess is incision and drainage (Kuriyama et al. 2005), Lalloo et al. suggested that practitioners might be following some personal or ad-hoc criteria in selecting when to prescribe antibiotics or not (Lalloo et al. 2017). Peric et al. also reported that antibiotics were prescribed as a precaution because of ‗uncertainty concerning the diagnosis, patient‘s expectations, unavailability of dental services and in short- term cases where there is insufficient time for doing any treatment‘ (Peric et al. 2015:111). Participants in this study also prescribed antibiotics for the treatment of alveolitis (dry socket) (15%). This finding is supported by a previous study done in England, Kuwait and Turkey where almost half of the study population (dentists) reported that they would prescribe antibiotics for dry socket treatment (Dar-odeh et al. 2010). Antibiotics were also prescribed for systemic conditions (10%) in this study. This finding is consistent with previous reviews that concluded patients with low immunity may be at higher risk of infection (Sidana et al. 2017). Interestingly, a pattern of antibiotic prescription emerged based on the clinical site where the respondent was located. According to Standard Treatment Guidelines 2018, the prescribed regimen should be as follows: Amoxil, oral, 2g one hour before the procedure. Respondents from Institution B appeared to adhere to the Standard Treatment Guidelines. This difference in prescription pattern for the same health condition, which was dependent on the clinical site, was an interesting observation. Additionally, only 65% of respondents referred to the Standard Treatment Guidelines. In contrast, a previous study reported that only 45% of practitioners adhered to the Standard Treatment Guidelines and Essential Medicines List in Primary Health Care settings in South Africa (Gasson 2018). In a recent South African study, it was also reported that dentists were aware of the treatment guidelines but few followed the recommendations for antibiotic prophylaxis (Mthethwa et al. 2018). More research is thus required to further understand these differences across clinical settings. On the other hand 78% of pharmacists perceived a correlation between the dental condition and the antibiotic prescribed for the dental condition. This is a significant finding as a previous study has shown that when the treatment guidelines are adhered to, the resistant micro-organisms reduce in numbers (Ntsekhe et al. 2011). Gutierrez et al. therefore, highlight the need for professional agreement and consensus building with regards to the conditions for antibiotic prescriptions (Gutierrez et al. 2006). Such efforts are also needed in a South African context to facilitate practitioner consensus building and ensure consistency in antibiotic prescription. Antimicrobial Stewardship and infection and prevention control teams could provide opportunities to augment prescribing practices and streamline this process (South African National Department of Health 2015). Additionally, there is need for continuing professional development so as to better equip health practitioners with updated knowledge on antibiotic prescription for dental conditions (Rocha-Periera, Lafferty, Nathwani 2015; Lee et al. 2015). Conclusion: The results indicated that health care practitioners reported inconsistent knowledge, attitudes and practices related to antibiotic prescription patterns. The study showed that there was inconsistency in antibiotic therapy prescription for dental conditions at the two public health institutions. There is a need for consensus building among health professionals and better guidance for antibiotic prescription in the management of dental conditions.
Exploring oral health care for patients undergoing cancer therapy of the head and neck region: a case study in the eThekwini District, KwaZulu-Natal.
(2017) Bauluck-Nujoo, Bibi Saleenna.; Singh, Shenuka.
Oral health care is paramount for patients with head and neck cancer. There is currently no published evidence to ascertain these patients’ access to oral health care. The extent to which oral health planning in the province takes into account the specific oral health needs of patients with head and neck cancer is not known so far. Aim: The aim of this study was to assess the perceptions and oral health practices of patients undergoing therapy for cancer of the head and neck region, in the Ethekwini District, KwaZuluNatal, so as to inform oral health planning of the needs for this population. Method: This was a cross-sectional, descriptive and exploratory study using both quantitative and qualitative data to determine the perceptions and oral health practices of patients with head and neck cancer. The study population for the quantitative component of the study, consisted of purposively selected patients with head and neck cancer (n=235) from a public tertiary central referral hospital in the Ethekwini District, KwaZulu-Natal (KZN). Data collection included the use of two previously validated questionnaires that was combined, namely, The EORTC QLQC30 and the EORTC QLQ- H&N35. These combined questionnaires included both single and multiple item scales to assess self-reported treatment side effects and oral health–related symptoms (Aaronson et al., 1993). There were eleven single item questions (such as mouth opening, dry mouth, sticky saliva, teeth problems, feeling ill, cough, pain killers, nutritional supplements, use of feeding tube, weight loss/gain) and seven multiple item questions on pain, swallowing, sexuality, social contact, social eating, speech and senses (Aaronson et al., 1993; Sherman et al., 2000; López-Jornet et al., 2012). The quantitative data collected was captured in Microsoft excel spreadsheet and imported onto Statistical Package for Social Sciences software (SPSS) version 24 for analysis. The demographic details for the participants were calculated using descriptive statistics (mean, frequency, percentages, standard deviation). Pearson Chi-Square test was used to assess possible relationships between the independent and dependent variables. The p-value was set to less than 5% (p< 0.05) to be significant. For the qualitative component of the study, structured interviews were conducted with twelve voluntary patients (n=12) undergoing cancer therapy for the head and neck region. The purpose of the interview was to gain a better understanding of oral health-related challenges and opportunities facing these patients. The interview schedule comprised demographic questions related to the date of diagnosis, duration and type of treatment and past and present habits. Other questions included participant’s knowledge of oral health care in relation to one’s overall well-being, oral health self-care practices, perceived barriers and opportunities to access oral health care, and familial support. Another semi-structured interview was conducted with the Ethekwini oral health district coordinator using purposive sampling technique. The interview schedule comprised questions related to oral health strategies in place to support patients with head and neck cancer and the extent to which oral health care is covered in district health policy and planning for these patients. Other questions included the existent institutional support for oral health promotion activities such as risk factor intervention programmes or strategies to improve oral health awareness. Data analysis of the qualitative data incuded content analysis using a thematic process by following the steps described by Braun and Clarke (2006). The audio-recorded interviews were first transcribed verbatim and a data clean-up process was applied (Braun and Clarke, 2006; Theron, 2015). The narrative from each interview transcript was then coded and analysed based on the conventional thematic content analysis approach (Braun and Clarke, 2006; Theron, 2015). A code guide was developed to guide and support the coding process. Open nodes were generated in the open coding phase (Pateman et al., 2015). This form of coding thus allowed for inductive reasoning of the emergent themes (Theron, 2015). Results: The results from the quantitative component of the study indicated that head and neck cancer was most common among participants in the 61-70 (n=86; 36.6%) age group. Oral cavity cancer was most common type of cancer reported (n=91; 38.7%), followed by laryngeal cancer (n= 53; 22.6%). Males (n=50; 21.3%) were more affected by oral cavity cancer as compared to females (n=41; 17.4%). With regards to employment, 14.5% (n=34) of participants were employed, while 46.4% (n=109) were unemployed because of cancer and 39.1% (n=92) were unemployed due to other reasons (old age, housewife). With respect to treatment, 20.4% of participants (n=48) were on radiotherapy, 28.5% (n=67) on chemotherapy and 9.8% (n=23) were on concurrent chemoradiotherapy, while 17.4% of participants (n=41) had already undergone surgery. Only 8.5% of participants (n=20) were recently diagnosed with cancer of the head and neck while 23.4% (n=55) were on follow up programme. There were noted differences in the self-reported severity and extent of oral complications in relation to the participants’ perceived oral health status. Xerostomia was found to be more common with increasing age. Pain in the jaw was experienced by 46.8% of participants while the majority of participants (n=125; 53.2%) did not report any pain in the jaw. Among those who perceived intra-oral discomfort, 13.8% females (n=13) and 7.8% males (n=11) experienced severe intraoral related pain and discomfort. More female participants (n=7; 7.4%) in the age group of 41- 60 reported severe difficulty in swallowing liquids than males of the same age group. Male participants who perceived severe difficulty to swallow liquids were all in the age group of 51- 70 years. Among those (n=100; 42.6%) who perceived difficulty to swallow pureed food, slightly more females (n=13; 13.8%) perceived severe difficulty in swallowing pureed foods than males (n=17; 12.1%, p=0.034). Most of the participants (n=148; 63.0%) had difficulty in swallowing solid foods. Similarly, the majority of participants experienced problems with their teeth (n=162; 69.0%) and reported xerostomia (n=159; 67.7%). A higher proportion of females (n=27; 28.7%) reported severe trismus as compared to male participants (n=33; 23.4%). Sticky saliva (increased viscosity in salivary flow) was reported by 34.0% (n=32) females and 29.8% males (n=42). Dysgeusia (altered sense of taste) was also reported by the majority of participants (n=131; 55.7%), among whom 22.3% females (n=21) reported severe dysgeusia as compared to 19.1% males (n=27). The majority of participants (n=138; 58.7%) perceived difficulty to eat, with 35.1% females among them (n=33) reporting of severe problem in eating as compared to 23.4% males (n=33). With reference to the qualitative data, six themes emanated from both interviews namely, knowledge and practices in oral health care, barriers in accessing oral health care, support for oral health care (includes both familial and institutional support), perceived opportunities to access oral health care, perceived precautions for outdoor activity and identified shortcomings in oral health service delivery at district level. Participants generally agreed that oral health was important for their overall well-being, with the exception of one participant. The reported oral hygiene practices included toothbrushing, mouthwash and dental floss. With reference to the perceived barriers, a lack of dental services in some areas of the province which consequently led to the need to travel long distances to access the nearest dental facility, was reiterated by some participants. The co-existence of other diseases in addition to cancer was perceived by one participant as being challenging to seek oral health services. The time taken by hospital staff to diagnose dental pathology was also seen as a barrier to access oral health care. Additionally, the fact that medical personnel fell short of informing patients about oral complications arising with chemotherapy was perceived as a shortcoming. Financial instability and failure of the local dental clinic to provide basic oral health care were reported to hamper access to oral health care. With regards to support, most participants reported that they had support, whether financially or morally from their families, with the exception of one participant who did not get any form of familial support. One interviewee reported that support was obtained through prayer. Participants also indicated the need to use protective clothing, hats and sunscreen. As for professional support, the oral health district coordinator reported that there was no specific support for oral health promotion activities from a policy perspective for head and neck cancer patients. However, he narrated that the pathway of referral patterns to oral and maxillofacial surgeons, ENT or oncology in cases of suspected malignancies was a form of oral health-related support for patients. Furthermore, he indicated that the district has many dental facilities with good infrastructure to offer services, such as oral prophylactic treatment and prosthetic services. Some of the opportunities perceived by head and neck cancer participants for improving oral health self-care practice included access to a dental hygienist, comprehensive explanation of the benefits and complications of cancer therapy, and clear referral patterns for further oral health management. Among the shortcomings identified to deliver oral health services at the district level was the absence of a specific oral health policy formulated for head and neck cancer patients and risk factor intervention programs. Conclusion: The results indicate that patients with cancer of the head and neck region reported limited access to professional oral health care. Oral health promotion services in the district, should take into account the specific needs for patients with cancer of the head and neck cancer region. There is an urgent need to prioritise oral health care for this vulnerable population in district oral health planning efforts.
Voluntary counselling and testing for HIV in the dental clinical setting: knowledge, attitudes, perceptions and practices of oral health care workers in the eThekwini District, Durban, South Africa.
(2018) Balwanth, Sonam.; Singh, Shenuka.
Abstract available in pdf.

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