It is important that laws and regulations be followed to protect both patients and health care providers from contracting infectious diseases in dental offices. It also is important to examine procedures that are not required, how patients perceive them and if optional procedures need to be continued, regardless of patients’ desires. Many dental practices use plastic barriers in their operatories instead of disinfection alone. Yet do we have any idea how our patients perceive their use? Should patients’ desires have an impact when two different accepted approaches exist?

Does our professional dress influence the patients’ belief in our competence? There have been numerous studies of patients’ perceptions of health care providers’ clothing over the past two decades. Articles about physicians’ professional appearance generally have shown that adult patients prefer name tags^2,3 and white coats.^2–5 Another even has suggested that patients’ perceptions of a provider’s competence may be influenced by how the provider dresses.⁶ No articles have been published on the opinions of adult patients on clothing preferences in dentistry.

Several articles, however, have been published on patients’ attitudes toward dentists’ wearing gloves and masks. Bowden and colleagues⁷ found that 47 percent of patients preferred that dentists wear gloves and masks during treatment. There was, however, a large variation depending on whether the patients were being treated in a general dentistry practice or a specialty clinic. Gerbert and colleagues⁸ found that more than 70 percent of patients preferred that their dentists wear gloves, while 45 percent and 23 percent preferred that their dentists use masks and protective glasses, respectively. Grace and colleagues⁹ found that 87 percent of patients preferred that gloves be worn, 62 percent wanted masks to be worn, and 45 percent preferred that the dentist wear protective glasses. Humphris and colleagues’¹⁰ study had results similar to those found by Grace and colleagues⁹; 79 percent of patients preferred that dentists wear gloves and 66 percent preferred that dentists wear masks. Do patients still feel the same way today?

There have been no studies published on patients’ attitudes about the use of plastic barriers, patient safety glasses or head covers for dentists. We have observed that the use of plastic barriers, dentists’ head covers and patient safety glasses varies among dental practices, and, while the newest CDC guidelines¹¹ have very specific infection-control requirements, there has been little research published on how patients perceive them. If dentists are better informed about patients’ preferences, they may implement certain infection-control procedures that are not required by law but are preferred by patients.

Patients’ attitudes change over time, and the dental profession needs to monitor and be aware of these shifts. This may help generate greater customer satisfaction. We conducted this study to determine adult patients’ perceptions on specific issues related to infection control and clinical attire in both military and civilian dental settings.

	MATERIALS AND METHODS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We developed a questionnaire to obtain demographic information and data on patients’ attitudes about clinical attire and a variety of infection-control procedures. We used slightly different versions for military and civilian dental offices because of differences in the patient populations and available clothing options; for example, military personnel wear uniforms. We chose to survey both civilian dental offices so we could compare the attitudes of patients treated in a military environment with those of patients in a civilian community.

We conducted a trial survey of 20 adults to ensure that the questions were understandable. We obtained feedback and modified the questions as necessary.

The demographic information we collected in 1997 from the final questionnaire included the respondents’ sex, ages, highest education levels, family income levels, frequency of dental visits, reasons for dental visits over the past five years and military status, if applicable. Infection-control procedure questions were presented in a multiple-choice format, as is shown in the box ("Survey Questions"). The survey we used at military facilities included clothing choices specific to the uniformed services, each of which was indicated by an asterisk.

We gave each office 250 surveys, irrespective of the practice’s size, and asked for them to be returned by the office within 60 days. Only people 18 years of age or older were allowed to participate. The surveys were given to all eligible people by the receptionist before appointments and were placed in a sealed box by the respondents before they left the office.

We tabulated the data for each question and statistically analyzed it using the Pearson ² test with significance set at the .05 level. We performed analyses on three clinic pairs— Mil A and Mil B, Gen A and Gen B, and Perio and Ortho—as well as the entire data set. When significance was found, we reduced the table dimensions by combining or eliminating rows or columns and reapplying the statistics to the question until the nature of the differences were determined. The study was reviewed and approved by the Institutional Review Board of the Wright-Patterson Medical Center in Dayton, Ohio.

	RESULTS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We gave 1,500 surveys to the offices, and 1,081 (72 percent) were returned. The percentages of completed surveys by office are shown in the figure. The overall results of the survey are presented in Tables 1 through 3. The response percentages do not always add up to 100 percent in the tables; the differences represent the respondents who chose not to answer the questions.

View larger version (52K): [in this window] [in a new window]   Figure. Percentage of surveys completed.

Clinical attire and infection-control procedures. We found that 52 percent of respondents from the military practices preferred name tags (P = .001) compared with 23.6 percent from all other offices combined (Table 2). Significantly more respondents from the Ortho practice preferred name tags (33.6 percent, P = .001) than did those from the Perio office (23.4 percent).

We found no statistically significant correlations between the demographic data and responses to the infection-control questions.

A majority of respondents from all of the practices (68.9 percent) had no preference regarding the clothing worn by dentists. Very few respondents selected surgical scrub tops only, so we combined the data for all scrubs. We found that 37.7 percent of respondents in Mil A preferred scrub suits or scrub tops (P = .001), which was higher than percentages for any of the other groups.

A total of 43.4 percent of respondents said that dentists should wear safety glasses during dental examinations, while 46.5 percent responded negatively or that they did not care. Mil A was the only exception; 53.3 percent of respondents said they preferred that glasses be worn (P < .001). A total of 73.8 percent of respondents preferred that dentists wear masks during examinations. The Ortho office respondents indicated a significantly higher preference for this (P = .05) than did respondents from the other offices. The majority of respondents (56.1 percent) showed no preference as to whether dentists wore head covers when conducting examinations.

A majority of respondents (54.1 percent) preferred that dentists wear safety glasses when performing treatments such as restorations (Table 3). Significantly more respondents from Mil A (63.3 percent, P = .007) preferred this than did respondents from the other groups. The majority of respondents (77.4 percent) said they prefer that dentists wear masks during treatments; the Ortho office’s response rate was notably higher (87.6 percent, P = .003). The majority of respondents (51.1 percent) did not have a preference about dentists’ wearing head covers during treatment, except in military facilities, in which 38.5 percent of respondents said they wanted their dentists to wear them compared with 21.8 percent of respondents from civilian offices (P < .001).

Few respondents (19.1 percent) wanted to wear safety glasses when being examined by their dentists; in the military practices, however, 36.3 percent wanted to wear safety glasses (P = .001). A total of 30.6 percent of respondents said they wanted to wear safety glasses during treatment, except at military facilities, in which 53.4 percent of respondents said they wanted to wear safety glasses (P = .001). Eight hundred seven respondents (74.7 percent) had previous experience with plastic barriers. We noted statistically significant differences (P < .001) when we compared the Ortho group with the Mil B group (74.8 percent vs. 59.5 percent) and the Perio group with the Gen A and Gen B groups (64.9 percent vs. 82.7 percent). Sixty-three percent of respondents said the use of plastic barriers made them feel confident that effective infection-control procedures were being followed. We found no significant differences among offices. We also noted that 73.0 percent of respondents who had had previous experience with barriers said that barrier use made them confident, compared with 37.0 percent of respondents who did not have previous experience with barriers. A majority of respondents (52.3 percent) said they would be concerned if plastic barriers were not used to cover dental equipment. This increased to 61.0 percent for those who had had previous experience with barriers and decreased to 31.5 percent for those who did not have previous experience (P < .001).

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
This study showed that patients have very definite attitudes about infection-control procedures that dentists routinely follow in their offices. Yet we do not always take their opinions into account when instituting these practices. While the number of surveys completed in this study were fairly equal across offices, the number from Perio offices was low. This was due to the frequency of repeat visits inherent in a periodontal practice. The numbers, however, were statistically sufficient for this study.

Demographics. The respondent pool represented a diverse population relative to age, sex and education. The income level varied over a wide range; however, the pool did not include either the rich or very poor. Nearly all of the respondents were high-school graduates and most had some college education. None of the demographic data, however, influenced the questionnaire responses.

Name tag use. The majority of respondents overall said they did not care if dentists wore name tags, but it was noteworthy that respondents in the military group practices did care. This is in contrast with the medical literature that reports that patients prefer name tags.^2,3 It is important to note that Gjerdingen and colleagues’² 1987 study consisted of patients treated in hospital-based family practice residency programs, while Matsui and colleagues³ conducted their 1998 study using parents of children being treated in the pediatric emergency room at a children’s hospital. Both of these studies involved a large number of different providers practicing in the same facility. One might expect that the adults would be interacting with physicians they had never seen and would want them to wear name tags for identification purposes. One could assume that patients visiting private dental offices already know which dentists they are seeing and do not feel a name tag is necessary.

Clothing use. This study demonstrated that, overall, respondents did not have any preference about what clothing dentists wear. Respondents in the Mil A group, however, showed a significant preference for scrubs. This was not surprising, considering that scrubs are worn by all providers at this major medical facility, which likely influenced respondents’ attitudes. We did not note the preference for scrubs at any other facility, including Mil B.

This indifference among respondents about dentists’ clothing is directly opposed to what has been published in the medical literature. The medical literature has supported the concept that not only do patients prefer white coats,^2–5 but also they may question the competence of a physician based on his or her dress.⁵ This clearly does not carry over into dentistry, as 68.9 percent of our respondents had no preference. Have physicians continued their image by wearing white coats, while dentistry moved away from this practice many years ago?

This indifference among respondents about dentists’ clothing is directly opposed to what has been published in the medical literature.

Personal protective equipment use during examinations. The dental profession uses varying levels of protective equipment when performing dental examinations. Some dentists wear glasses, masks, head covers or combinations thereof. The CDC requires dentists to wear protective equipment only when splatter or aerosols are likely to be produced,¹¹ which may not be likely to occur during a dental examination, depending on the dentist’s procedures.

Our survey showed that a majority of respondents (73.8 percent) preferred that dentists wear masks during dental examinations. A total of 43.4 percent of respondents said they prefer that their dentists wear safety glasses when performing dental examinations. This is different from the data reported by Grace and colleagues,⁹ in which only 27 percent preferred that dentists wear glasses. This may be an effect of the passage of time and a new patient’s expectation. Head covers were not expected or preferred by respondents. In summary, many respondents expect dentists to wear safety glasses and masks when conducting dental examinations, although such gear is not required by regulations.

Personal protective equipment use during treatments. We noted a difference in respondents’ expectations of dentists’ wearing protective equipment when they provide treatment compared with when they conduct examinations. More respondents said they saw the need for dentists to wear glasses when providing treatment; this majority was even higher at Mil A and Mil B.

Mask use was preferred by respondents from all facilities; more than 70 percent of respondents said they preferred that dentists wear masks when conducting examinations and providing treatment, while Grace and colleagues⁹ reported in 1991 that patients did not care. The difference may have occurred because seven years passed between Grace and colleagues’ study and our study, and patients have had more experience with dentists wearing masks. Respondents from the Ortho office indicated a significantly higher preference, which might be expected by the patients’ parents’ desire to protect their children from communicable diseases.

We found that while respondents did not expect dentists to wear head covers, more respondents from the military practices preferred their use than did respondents from the other practices.

Patient safety glasses use. Respondents’ attitudes about their own protection when being examined or treated varied by office. Few at civilian dental practices said they preferred to wear safety glasses when being examined or treated (11 percent and 20 percent, respectively). This increased significantly for respondents at the military practices (36.2 percent and 53.4 percent, respectively). The two military facilities require patient safety glasses to be worn for all care. This may have affected respondents’ attitudes to the point that they now expect and prefer to wear safety glasses. Their use can protect patients’ eyes from being injured accidentally during care, as well as (if they are tinted) shield the light from their eyes. We feel that dentists should consider the use of safety glasses for patients in their practices, if they are not already using them.

Plastic barrier use. A total of 74.7 percent of respondents in this study had previous experience with plastic barrier use when receiving dental care. Most of these respondents preferred that barriers be used when receiving care. In fact, they said they felt uncomfortable and apprehensive when barriers were not used.

The majority of respondents said they would be concerned that infection-control procedures were not properly being followed if barriers were not used. This supports the concept that patients prefer barrier use and that plastic barriers use should be considered in all dental offices, as they can be an effective infection-control tool when properly used and increase efficiency and productivity.

Practice type comparison. Although we expected to find significant differences between general practices and military or specialty practices, we found no major variations except in the use of safety glasses for patients and dentists, and head covers and name tags for dentists, as noted earlier.

	CONCLUSIONS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Dental patients, whether treated in a military or civilian practice, had similar perceptions of the infection-control procedures we surveyed in this study. They showed no preferences regarding a dentist’s clothing or whether a dentist wore protective glasses or a head cover when performing examinations. Respondents said they preferred dentists who wore name tags in group practices, routinely wore masks and used protective glasses when providing treatment. Plastic barriers were preferred by respondents and made them feel confident that proper infection-control procedures were being followed in the dental office.

Overall, respondents had similar attitudes about clinical attire and safety and infection-control procedures, regardless of where they receive their care, with some minor differences. Their attitudes about patient safety glasses and plastic barriers were influenced in a large part by their previous experiences. The results question the concept that a dentist’s clothing makes a difference to the patient.

We hope this study will increase dentistry’s awareness of patients’ preferences and allow us to take another look at procedures not required by law but expected by patients, thereby increasing customer satisfaction. It not only is important for dentistry to institute effective infection-control practices, but it is important to educate the public on the benefits of those practices and why they should accept them.

View larger version (85K): [in this window] [in a new window]   Dr. Shulman is the commander, 48th Dental Squadron, RAF Lakenheath, England. When the study was conducted, he was the chair, Department of Pediatric Dentistry, 74th Dental Squadron, 74th Medical Group, Wright-Patterson Air Force Base, Ohio. Address reprint requests to Dr. Shulman at PSC 41, Box 206, APO AE 09464, e-mail "penguin1sp{at}aol.com".

View larger version (82K): [in this window] [in a new window]   Mr. Brehm is a bio-statistician, Clinical Research Laboratory, 81st Medical Support Squadron, 81st Medical Group, Keesler Air Force Base, Miss.