A national study of oral health care delivery system was conducted in Saudi Arabia. The methodology was based on the International Collaborative Study of Oral Health Outcomes (ICS-II). A part of that study was to survey the dental practitioners for their knowledge, attitudes and practices. A 128-item questionnaire was administered to dentists practicing in multiple countrywide locations (5 provinces) and the number of respondents totaled 481. Results showed that 92% used a new pair of gloves for each patient; 85.32% wore face masks; for all procedures; 50.84% used eyewear or glasses for all procedures; 98.32% used a sterilized disposable needle for each patient 27.14% sterilized with autoclave handpieces after each patient; 90.2% sterilized hand instruments in the autoclave after each use; and 89.3% reported enhanced implementation of infection control procedures since they learned about AIDS. Approximately 26.3% disagreed and 8.5% strongly disagreed that they had adequate infection control training to treat AIDS patients. Over 37.3% strongly agreed and 30.3% agreed that they felt unsafe treating AIDS patients. It is concluded that Saudi Arabia, a rapidly modernizing middle-income nation, is making excellent progress in implementing barrier techniques in the dental care delivery system. In view of worldwide Al DS epidemic, it is vital that adequate infection control continues and greater efforts made in this area with more information provided to dentists about AIDS.

In dentistry, there is a major effort to re-evaluate methods of maintaining sterilization in the dental environment. The upsurge of new diseases such as AIDS and the recrudescence of diseases such as tuberculosis, hepatitis B, C, and D and other maladies have made it essential that strict sterilization be maintained. A survey¹ carried out in Canada on participants who attended the 1991 continuing education course on 'HIV and Infection Control in 1990s' indicated that the number of dentists who routinely adopt barrier protection techniques, e.g. use of gloves, was on the increase. Furthermore, 80% of the dentists were prepared to treat AIDS patients, a figure much higher than 60% reported for US dentists in 1991.² In spite of this favorable response, most of the dentists had some reservations with regard to treating AIDS patients. Among the reservations expressed were personal safety, staff resistance, stigma attached to dentists known to be treating AIDS patients and non-disclosure of HIV status by infected individuals.
Although most dentists now accept the routine adoption of barrier protection techniques and routine autoclaving of instruments as effective infection control measures, a survey carried out in California³ showed that only 59% of orthodontists changed gloves between patients.
Furthermore, the orthodontists sterilized their instruments 66% of the time and pliers 49% of the time. Compared with general dentists, orthodontists' perception of risk, use of barrier protection and sterilization and disaffection procedures was lower in all the areas of California surveyed. The improved infection control measures in dental practices in the United States have been attributed to at least three factors: continuing education courses on infection control, American Dental Association (ADA) education materials and the fear of contracting AIDS.⁴ Although the last factor had been particularly heightened by a report of a dentist who became HIV positive apparently from his professional practice, a survey by Klein et al⁵ indicated that dental professionals have a low occupational risk for HIV infection. Because continuing education for dentists has played and continues to play such an important role in the attitude of dentists to infection control measures, it is important to identify the educational needs of dental practitioners. One way of achieving this is to survey dentists' opinion on the subject. As a result of educational efforts in North America, the infection control practices were greatly improved.^{4, 77} used gloves and other barrier techniques for all patients in 1988 than in 1986.^{8 4} it was found that more general dentists used autoclaves for sterilization in 1988 than in 1986 (80% vs. 67%). Nevertheless, a third of the general dentists did not monitor their sterilization process. Of the 67% who did, only 21 % used biological monitors, in contrast to 11 % in 1986. Furthermore, only about half of the dentists had autoclavable handpieces in 1988. To identify the lapses, if any, in the infection control measures adopted in Saudi Arabia,⁹-¹⁰ there is a need for a survey of the infection control practices in the country and this was one of the aims of this study. The objective of this study was therefore to assess the knowledge, attitudes and infection control practices of dentists in five (5) provinces in Saudi Arabia For example, a greater number of dentists In another survey,

Tables 1-7 show the different results of the study in the following categories: from the five provinces-Central (Cent), Eastern (East), Southern (South), Northern (North) and Western (West).
Demographics
The distribution of dentists in the sample by nationality were as follows: Saudis 11.02%, Egyptian 41.74%, other Arabs 22.67%, USA/European 8.9%, Indian/Pakistani 10.81% and others 4.87% (Table 1).The distribution of dentists by the country where they obtained their basic dental training is: Saudi Arabia 10.08%, Egypt 51.89%, USA/Europe 9.82%and others28.2% (Table2).
Barrier Techniques
The results showed that 92.44% of respondents used plastic or rubber gloves for each patient. There was no significant relationship between years of experience and the tendency to use gloves between patients (Table 5A, 5B). Approximately 85.32% of respondents used a facemask for all procedures and there was little change in this based on years of experience (Table 5A,5B).
On the question of using protective eye wear, 50.84% of respondents used eye protection for all procedures.   There   was   a   slightly   higher percentage of those with experience between 0-5 years using eye protection (Table 3, 4, 5A,5B).
Sterilization
The type of sterilization technique used in the clinics were examined in reference to the country of basic dental training (Table 6c). Findings indicated that 100% (the highest %) of USA/Europe-trained dentists used sterile disposable needles for each patient, while 97.5% (the lowest %) of Saudi Arabian-trained followed this procedure. Those who disinfected the working surface after each patient ranged from 61.54% (Saudi Arabian-trained) to 97.44% (USA/Europe-trained) (P<.05). The widest range response was on sterilization using autoclave or dry heat for handpieces after each patient for this Saudi Arabian trained was 17.50% and USA/Europe was 48.72% (P<.05). The lowest percentage who used sterilization or dry heat of hand instruments after each patient was 87.96% (others) and the highest percentage was 100% (USA/Europe) (Table 6C). When years of experience were related to sterilization technique used, the only procedure which showed statistically significant relationship was disinfecting the working surfaces after each patient. The greater the experience, the more likely that this procedure would be carried out (Table 6B). When the five regions, were compared, the barrier techniques of using gloves between all patients and using facemasks for all procedures, showed no significant difference of usages (Table 5A). There was a significant difference among the five regions with respect to use of protective eyewear for all procedures (P<.01) (Table 5A, 5B). Over 98% of respondents used sterile disposable needles for each patient (Table 6A).

In an era when we are experiencing an increased awareness of communicable infectious diseases such as tuberculosis and hepatitis and in which stories regarding the fear of the spread of the HIV virus receive almost nightly news coverage; all health care professionals are taking extra precautions when providing care to the patients. The concern of occupational transmission of infectious diseases from patient to health care worker always remains as the main issue in the dental clinic infection control policy.¹² The mean number of dentists using plastic or rubber gloves for each patient of 92.44% reflects the high standards of barrier techniques common in Saudi Arabia. Being a middle-income developing country, the Saudi Arabian government has invested considerable resources into quality health care. Dentistry has benefited from this policy. The same trend exists for face mask use (84.32%). However, a declining trend for use of protective eyewear (50.84%) indicates that more educational efforts are needed for practitioners on this precaution (Table 5A). Differences between regions for some procedures indicate that specific programs should be organized by regions to disseminate more information. The goal should be 100% use of these barrier techniques.
Sterilization technique results indicate that over 98.32% of Saudi Arabian dentists use sterile disposable needles for each patient. This reflects an overall strong policy implementation not using re-usable needles. The 77% who disinfect working surfaces after each patient indicate that the 19% who do not should be educated to begin this precaution. An area of serious concern is the need to increase the number of practitioners in using the autoclave to sterlize their handpieces and instruments between patients. This has become the new international standard and organized dentistry in Saudi Arabia should stress this policy with stria implementation. This procedure along with others requires greater investment of capital resources for implementation. However, in view of great risk of cross-infection to patients in the dental office, it is necessary to do this. Over 90% of respondents' autoclave their instruments between patients, but the 10% who do not must be educated to comply. The 30% who autoclave their handpieces between patients are following the new standard, however, there is a need for intensive education in this area for dentists, dental administrators and for the authorities of health budgets. (Table 6A). In an Ohio study,¹³ 80% of dentists reported sterilization of handpieces between patients, 69% of the dental clinics changed infection control protocols  to   include   heat   sterilization   of handpieces between patients while 24% reported disinfection between patients. In those regions where resources are not present to implement these techniques, special efforts should be made to increase supply budgets to meet the needs of these practitioners. The presence of endemic hepatitis B and C in the country is a great risk to greater infection in the dental environment without these procedures. The international increase of AIDS also makes the establishment of nationwide strict sterilization and barrier guidelines necessary. There is perhaps no other issue in health care which surpasses the importance of sterilization and infection control.

This study was supported by King Abdulaziz City for Science and Technology with Grant No. AR11 -86.