Knowledge, Attitude and Unwillingness to Treat with Herpes Labialis by Dental Health Care Practioners in Karachi, Sindh - A Cross-sectional Study

INTRODUCTION

Herpes labialis has been recognized as one of the most well-known and prevalent viral infections of the oral cavity in recent times. The condition is  caused by Herpes Simplex Virus-1 (HSV-1) and predominantly affects the upper and lower lips along with the gingiva and tongue manifesting in the form of ulcerative lesions.1 There has been an alarming increase in frequency of this disease reflected in the statistics provided by World Health Organization (WHO) which indicate that approximately 3.7 billion people under the age of 50 years suffer from HSV-1 infection worldwide.2 Oral herpetic infections are found in 57% to 80% of the population of the U.S while in the Asian region the prevalence was found to be higher affecting more than 75% of adults.³

Close proximity with infected patients or direct contact with their lesions and body fluids such as saliva have been identified as the major routes of transmission posing dentists at an increased risk of infection.4 Various reports5,6 have  highlighted the occurrence of conditions such as herpetic whitlow and herpetic keratitis in dental care providers as a consequence of treating patients with herpes labialis. The risk of viral spread can be reduced by adapting proper infection control practices. Although these protocols do not completely eliminate the chance of transmission making dental professionals unwilling to treat infected patients. HSV-1 has the tendency to shed during different stages of disease including the prodromal and clinical period. While it has been reported that most of the shedding occurs during the ulcerative phase, it may also occur even when individuals are asymptomatic.⁷ These findings in combination with the ability of the virus to penetrate through various dental materials such as acrylic monomer, solvent and latex gloves further illustrate increased exposure of dental practitioners to viral infections.⁸

It is extremely important that dental professionals should be equipped with adequate knowledge regarding treatment protocols for individuals presenting with active disease and methods of prevention. Moreover, the dental professionals should be aware that individuals suffering from disease may also experience depression and social anxiety which may worsen when they are refused treatment. This refusal to treatment may be considered unethical, creating discord between dentists and their patients.⁹

While a number of studies have been performed across the globe regarding the knowledge and attitude of undergraduate dental and hygienist students towards herpes labialis10,11, there is a dearth of evidence about the knowledge and practices of dental practitioners in Pakistan. In this study we aim to provide a comprehensive evaluation of awareness of dental house officers, resident doctors and faculty members about possible methods of transmission and prevention of viral infection along with their potential reasons for treatment refusal. 

METHODOLOGY

This cross-sectional analytical study was conducted at three different government dental colleges including Dow International Dental College (DIDC), Dow Dental College (DDC), and Dr. Ishrat-ul -Ebad Khan Institute of Oral Health Sciences (DIKIOHS). All three dental colleges are affiliated with Dow University of Health Sciences (DUHS). The study was conducted over a period of 8 months from June 2023 to January 2024. The study participants included dental professionals who perform routine dental procedures including house officers, resident doctors and faculty members. Undergraduates and paradental staff were excluded. Participants who did not provide consent were also not included. The study was approved by the Institutional Review  Board (IRB) of DUHS bearing IRB number: IRB 2894/DUHS/Approval/2023/91.

Sample size was calculated using OpenEpi Calculator version 3.0 with 95% confidence interval and 5% power using frequency of dentists with adequate knowledge regarding herpes labialis (85%) reported in a study by Kanjirath et al,12 The sample size was calculated to be 196. A total of 196 participants were selected in accordance with inclusion criteria and data was collected after obtaining verbal consent. A validated, self-administered questionnaire adopted in a study by Adodo et al.13 was utilized as a data collection tool.

The questionnaire consisted of 40 items covering several aspects of awareness and perception of dental professionals regarding herpes labialis along with possible reasons to refuse treatment. The responses were categorized as Yes, No and Don't know. Participation was voluntary and no incentives were offered to the respondents. Out of 196 questionnaires distributed, the number of completed questionnaires returned was noted to be 160 giving a response rate of 81.6%. 16 questionnaires were discarded due to improper filling and the final number of forms utilized for analysis was 144.

Statistical analysis was performed using SPSS version 27.0. Frequency and percentages were obtained using descriptive statistics. Association of knowledge and attitudes of participants with professional status was evaluated using Chi-square test. A p-value of < 0.05 was considered as significant.

RESULTS

It was observed that among the 144 respondents, 104 (72.2%) were females. The predominant age group was 23-25 years as 88 (57.1%) people belonged to this category. Conversely, only 6 (3.9%) individuals were aged 32 or more. The study population comprised 93 (64.6%) and 31 (21.5%) house officers and residents respectively along with 20 (13.9%) dental faculty members. (Table 01)

A majority of 91 (97.8 %) house officers and 30 (96.8%) of resident doctors identified the virus as a causative agent for herpes labialis. All members of the dental faculty also expressed similar opinions regarding etiology of this condition. Several questions were asked to assess knowledge of participants regarding possible routes of transmission and it was observed that while 14 (45.1%) residents and 12 (60%) faculty members favored spread of virus through tears, only 22 (23.7%) house officers agreed with them. A significant association of professional status and awareness was noted. (p = 0.012).

It was noted that 85 (91.4%) of house officers acknowledged saliva as a potential pathway of disease

 spread. A large proportion, 30 (96.8%) residents and 16 (80%) were of the same opinion and a significant association between knowledge and professional experience was

 In addition to this, 78 (83.9%) house officers along with 27 (87%) residents believed that providing treatment to infected patients can put dentists at the risk of developing herpetic whitlow. More than half,13 (65%) dental faculty agreed with them and a statistically significant association opinion with professional expertise was noted. (p = 0.040). (Table 02).

 Important trends in participants' perceptions were observed regarding possible triggers that induce herpes labialis infections. It was detected that 58 (62.4%) house officers and 11 (55%) presumed fatigue as a trigger for disease. We were not able to uncover a significant relationship of opinion with different professional qualifications. (p = 0.531). Similar to this, no statistically significant association of knowledge with experience was identified concerning fever and stress as potential triggers. (p = 0.386) and (p = 0.240) respectively. (Table 03)

Regarding the attitude of study participants to treat herpes labials patients, it was noted that 48 (51.6%) house officers were keen to educate patients about their ailment. However, only 13 (42%) and 9 (45%) residents and dental faculty showed similar interest and a significant association was observed (p = 0.013).

 Only 19 (20.5%) house officers agreed to be comfortable in treating herpes labialis patients. Among residents and  dental faculty members,13 (42%) and 8 (40%) were willing to provide treatment and no substantial difference in attitudes was observed. (p = 0.215). Conversely, 7 (35%) dental faculty and 32 (34.4%) were apprehensive about provision of treatment. (p = 0.538) (Table 04).

 Dental professionals were also inquired about adequate measures for prevention of herpes labialis. Majority of study participants believed in the efficacy of these measures; frequent handwashing was supported by 78 (83.9%) and 23

 (74.2%) house officers and residents respectively. Avoidance of kissing and sharing crockery were also considered effective preventive measures by a large proportion of participants in each group. No significant association between opinions about preventive measures and professional status was observed.

 DISCUSSION

 One of the most fundamental responsibilities of a dentist is providing adequate oral health care. This provision of oral health puts clinicians at an increased risk of contracting various infectious diseases caused by microorganisms such as mycobacterium tuberculosis, Herpes simplex Virus 1 (HSV1), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and others.14 Herpes simplex is a highly contagious virus shed in saliva which can cause severe infections in exposed individuals, making its exposure a concern for dentists.15 It is extremely crucial for dental professionals to be well equipped with knowledge regarding possible routes of transmission of virus and its trigger factors enabling them to treat infected patients while adhering to strict prevention protocols.

 The results of our study indicate that more than 90% dentists possessed sound knowledge regarding potential routes of transmission of virus. This result is quite encouraging in contrast to a study conducted in Nigeria assessing the knowledge of health care providers concerning herpes labialis infection. The study concluded that only 44.2% of dentists had sufficient information about etiology, transmission route and prevention of this infection.13 The findings of our study are supported by two studies performed in Egypt and Pakistan which report adequate knowledge among health care providers pertaining to spread of viral infections and appropriate infection control measures.16,17

 A significant difference was observed in responses between house officers, resident doctors and dental faculty (p-value 0.019) highlighting that professional experience may have an impact on level of knowledge. Bansal et al18 in their study evaluated awareness of herpes labialis among dental interns. It was reported that knowledge of most participants was unsatisfactory. In another study by Rao et al19 conducted in Rawalpindi, it was reported that senior practitioners exhibited less awareness regarding infection control procedures in comparison to dental students. HSV-1 exhibits the tendency to remain dormant in nerves for a prolonged period of time as observed by Gopinath et al.1 However, the virus can be re-activated in response to certain triggers including stress, exposure to sunlight and changes in immune system.20 Sufficient information regarding triggers and transmission potential of infectious agents is  compulsory for adoption of necessary preventive protocols in dentistry.

 Our study indicates that the majority of the respondents were well-informed about potential triggers that can precipitate recurrence of infection and the preventive measures that need to be taken in order to reduce spread. The study by Azodo et al13 also emphasizes that lack of knowledge regarding HSV-1 and other viral infections results in failure to adopt optimal protective measures by the dentist, consequently they have an increased risk of developing herpetic whitlow and herpetic keratitis.

 A number of measures can be advocated for prevention of herpes labialis such as minimizing contact with infected individuals and exposure to saliva.21 Our study revealed variations in the implementation of preventive measures among dentists. While house officers adhered to recommended protocols and favored frequent handwashing along with avoiding kissing, residents and faculty doctors were supportive of not sharing utensils and disclosing presence of a cold sore. Standardizing and reinforcing adherence to evidence-based guidelines, including the use of personal protective equipment and sterilization procedures is imperative to minimize the risk of transmission within dental settings.22

 There are certain dilemmas associated with treatment of herpes labialis infected patients among dental professionals. Some dentists may be reluctant to provide treatment which can impact patient care, treatment decisions, and the overall dynamics within a dental practice. We observed that most of the participants in our study would prefer to defer treatment of infected patients and might be concerned for their protection.

 Similar attitudes have been seen in context to other infectious diseases such as HIV and HBV. Nair et al9 in their qualitative study revealed that there is discrimination against HIV infected individuals making health care providers reluctant to provide treatment. Conversely, 54.9% health care providers in Saudi Arabia were unwilling to treat HIV positive patients due to perceived high risk of exposure.23 Addressing these attitudes through targeted educational initiatives and awareness campaigns is crucial for creating a supportive and nonjudgmental environment for both patients and practitioners.

 The findings of this study have direct implications for patient care. Improvement in knowledge, attitudes and practices of dental professionals regarding herpes labialis can lead to enhanced patient outcomes, reduced transmission risks, and a more empathetic approach to those affected by the infection. It is important to acknowledge limitations of the study such as small sample size along with potential biases in self-reported data and cross-cultural variations.

CONCLUSION

 Adequate knowledge regarding herpes labialis is indispensable for adoption of accurate preventive measures. Majority of dental professionals had sufficient knowledge and practiced appropriate infection control protocols. Some dentists were reluctant to treat infected patients which necessitates the need to provide continuous education within the dental community for improving patient care and minimizing the impact of herpes labialis infections in dental settings.

 ACKNOWLEDGMENTS

We would like to acknowledge the staff of dental colleges for helping us in data collection.

 DISCLOSURE

 None

CONFLICT OF INTEREST

 None declared

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