Keywords
COVID-19 - pandemic - dental professionals - continuing education - awareness
Introduction
The novel coronavirus disease 2019 (COVID-19) is a newly discovered viral infection
that started in Wuhan, China in December 2019 and caused the outbreak of pneumonia
in the rest of the world.[1] The World Health Organization (WHO) declared a public health emergency of international
concern over this global outbreak on January 30, 2020.[1] On February 11, 2020, the WHO named the novel viral pneumonia as “coronavirus disease
(COVID-19).”[2] On March 11, 2020, the WHO declared it as a controllable pandemic disease.[3]
As per the WHO, till May 27, 2020, there were 5.49 million confirmed positive cases
worldwide with 0.349 million global death toll.[4] New cases are reported every day and are increasing in an exponential manner. It
has been spread in 217 countries, areas, and territories. Among these, four countries
including Turkey, India, Saudi Arabia, and Pakistan are in top 20 highly reported
countries. It is anticipated that COVID-19 is a disaster for developing nations not
only medically but also economically and psychologically. The data recording these
cases can be tracked on WHO Web site and many other platforms.[4]
Currently, there are four genera of coronaviruses: α-CoV, β-CoV, γ-CoV, and δ-CoV.[5]
[6] Latest COVID-19 has caused severe respiratory infection which leads to severe pneumonia
and eventually death in elderly population and immunocompromised individuals.[1] The typical clinical symptoms of the patients who suffer from the COVID-19 are fever,
cough, and myalgia or fatigue with abnormal chest CT scan, and less common symptoms
are sputum production, headache, hemoptysis, and diarrhea.[7]
[8]
The common transmission routes of COVID-19 include direct (cough, sneeze, and droplet
inhalation transmission) and contact (contact with oral, nasal, and eye mucous membranes)
transmissions.[9] Although common clinical manifestations of novel coronavirus infection do not include
eye symptoms, the analysis of conjunctival samples from confirmed and suspected cases
of 2019-nCoV or novel coronavirus suggested that eye exposure might provide an effective
way for the virus to enter the body.[10]
[11] Indirect spread of coronavirus has also been seen through the touch or close contact
of the contaminated surfaces.[1]
[11]
Health care professionals including dentists are performing their duties in close
contact with patients and they are at high risk of exposure to aerosol and droplets
splashing out of patients’ oral cavity.[12] Therefore, all dental health care professionals should follow the latest infection
control guidelines published by Disease Control and Prevention (CDC),[13] the American Dental Association (ADA),[14] and the WHO[4] to prevent the spread of COVID-infection. The main recommendations of these guidelines
are related to personal protective equipment and routes of transmission.[1]
[11] It is critical for the dental professional to have optimal knowledge of prevention
practices, that’s how they can play their role in disease prevention and control.[1]
[13]
[14] Therefore, the aim of the present study was to assess the knowledge, attitudes,
and clinical practices of dental professionals regarding the prevention and control
of COVID-19 disease during the pandemic.
Materials and Methods
The study population for this cross-sectional survey included dental professionals
(general dentists and dental specialists) from Pakistan working in private dental
practices, dental hospitals, and/or teaching institutions. A sample of 381 was calculated
assuming 95% confidence interval (CI), 5% margin of error, population size (N = 22,000), and 50% response distribution. A convenience sample of dentists who wanted
to voluntarily participate in the study was used. The study approval was obtained
from the Institutional Review Board of the Dow University of Health Sciences, Karachi,
Pakistan. The study was conducted as per the ethical guidelines of the Helsinki Declaration.[15]
Based on recent guidelines of ADA,[14] WHO,[4] CDC,[13] and recent published literature,[1]
[11]
[16] a questionnaire was developed and discussed among researchers (K.A., A.S.K., A.T.,
M.A.N.) to confirm its content validity. The content of each item in the questionnaire
was carefully reviewed and discussed so that the questionnaire accurately assesses
the aspect of COVID-19 research on dental professionals. The draft of the questionnaire
was pretested among 20 dental professionals to ensure its reliability and validity.
The pretested data were not included in the final results of the study. The final
questionnaire was then created/developed at www.google.com/forms for distribution among study participants.
The questionnaire was in English language and consisted of two sections. Section one
included questions regarding demographic data of study participants (age, gender,
designation, years in practice, workplace, income, etc.). Section two consisted of
series of multiple-choice questions related to the awareness, knowledge, and clinical
practices of dental professionals with respect to COVID-19 signs and symptoms, routes
of transmission, patient evaluation, treatment, and infection control protocol. In
addition to these, there were questions about preparedness, willingness to treat patients,
impacts of COVID-19, attendance of workshop/seminar on COVID-19, and willingness to
know more about the disease.
The survey was conducted in April-May 2020 through an online questionnaire. The questionnaire
was circulated through social media outlets (WhatsApp, Facebook) and online submissions
through emails were received during this period. Participants could fill the questionnaire
only once to avoid duplication. Incomplete questionnaire feedback was not included
in the study and all received data were anonymous and confidential.
Variables Description
There were 22 variables regarding knowledge/awareness of dental professionals about
COVID-19. These variables broadly assessed infection prevention measures, patient
screening including COVID-19 signs and symptoms, and patient management. Five variables
such as being comfortable in treating patients, refusing patients diagnosed with COVID-19,
maintaining clinical protocols, attending seminars/workshops, and receiving more information,
were used to evaluate the attitudes/clinical practice of dentists.
The independent variables of the study included gender, place of work, monthly income,
job status, experience, qualifications obtained from the public or private institute,
comfortability in treating patients, refusing patients, following clinical protocols,
and willingness to receive more information. These variables were used to assess their
association with the attendance of workshop/seminar on COVID-19 (dependent variable).
Data Analysis
The data were analyzed using the Statistical Package for Social Sciences (SPSS) version
22 (IBM Corp.; Armonk, New York, United States). Descriptive statistics were used
to describe items included in the survey. Means and standard deviations were used
to describe the continuous variables and frequency and percentages were used to describe
the categorical data. The knowledge score of each participant was calculated by adding
the scores of 22 variables. Mann-Whitney U-test was performed to compare knowledge
score between different categories of participants (males vs. females, dentists vs.
specialists, etc.) Bivariate and multiple logistic regression analyses were performed
to evaluate the association of independent variables with the attendance of seminar/workshops.
The significance level was set at 5%.
Results
[Table 1] presents demographic information of the participants and comparison of their knowledge
score during the COVID-19 pandemic. Of 381 dental professionals, 343 returned completed
questionnaires and the response rate was 90% in the study. There were 47.2% of males
and 52.8% of females in the study. More than half the participants were specialists
(58.6%), had a monthly income of more than 1,000 U.S. dollars (55.4%), worked in the
private sector (60.3%), and had more than 10 years of experience (57.1%). The mean
knowledge score was 16.78 ± 2.25, and the minimum score was 6 and the maximum was
21. Mean knowledge score significantly differed between general dentists (16.55 ±
2.36) and dental specialists (17.15 ± 2.04) (p = 0.020), and those with up to 10 years of experience (16.58 ± 2.28) and those with
more than 10 years of experience (17.05 ± 2.2) (p = 0.026). The study found no significant difference in knowledge score with regards
to gender, monthly income, place of work, and qualifications obtained from private
and public institutions.
Table 1
Comparison of knowledge scores in different categories of participants
|
Variables
|
Frequency (%)
|
Knowledge score
mean (SD)
|
p-Value
|
|
Abbreviation: SD, standard deviation.
|
|
Gender
|
|
|
0.358
|
|
Male
|
162 (47.2)
|
16.79 ± 2.42
|
|
Female
|
181 (52.8)
|
16.77 ± 2.11
|
|
Monthly income
|
|
|
0.269
|
|
Up to 1,000 U.S. dollars
|
153 (44.6)
|
16.6 ± 2.47
|
|
More than 1,000 U.S. dollars
|
190 (55.4)
|
16.93 ± 2.06
|
|
Place of work
|
|
|
0.496
|
|
Government sector
|
136 (39.7)
|
16.74 ± 2.07
|
|
Private sector
|
207 (60.3)
|
16.81 ± 2.37
|
|
Qualification obtained
|
|
|
0.212
|
|
Government institution
|
212 (61.8)
|
16.94 ± 2.27
|
|
Private institution
|
131 (38.2)
|
16.67 ± 2.24
|
|
Job status
|
|
|
0.020
|
|
Dentist
|
142 (41.4)
|
16.55 ± 2.36
|
|
Dental Specialist
|
201 (58.6)
|
17.15 ± 2.04
|
|
Experience
|
|
|
0.026
|
|
Up to 10 y
|
196 (57.1)
|
16.58 ± 2.28
|
|
More than 10 y
|
147 (42.9)
|
17.05 ± 2.2
|
In response to a question about the action taken in the case of a patient with an
elevated temperature without respiratory symptoms, 38.4% of participants reported
sending the patient home and advising self-isolation. However, in the case of a patient
with an elevated temperature with respiratory symptoms, 60.8% of participants reported
to quarantine the patient and to report to the infection control department. Very
few participants reported performing the required elective treatment on a patient
with an elevated temperature and with or without respiratory symptoms ([Fig. 1]). The majority of participants (86.7%) reported to quarantine the patient and to
report to the infection control department in case of a confirmed COVID-19 case ([Fig. 2]).
Fig. 1 Distribution of participants’ responses about the action taken in case of a patient
with an elevated temperature but with and without the recent onset of respiratory
symptoms.
Fig. 2 Distribution of participants’ responses about the actions taken in case of confirmed
COVID-19 patient. COVID-19, coronavirus disease 2019.
Regarding dental procedures, 91.2% of participants mentioned to only perform emergency
procedures, whereas 6.5% described not to perform any dental procedure during the
COVID-19 pandemic ([Fig. 3]). Financial impact (47.4%) was one of the most commonly reported impacts of the
COVID-19 pandemic on the dental practice followed by psychological (33.8%), social
(14.9%), and behavioral (3.9%) impacts ([Fig. 4]).
Fig. 3 Distribution of participants’ responses about dental procedures during the COVID-19
pandemic. COVID-19, coronavirus disease 2019.
Fig. 4 Distribution of participants’ responses about the major impacts of the COVID-19 pandemic
on dental practice. COVID-19, coronavirus disease 2019.
[Table 2] shows the attitudes of dentists during the COVID-19 pandemic. Only 15.5% of participants
were comfortable in treating patients during the COVID-19 pandemic. A workshop/seminar
on the COVID-19 pandemic was attended by 23% of the participants. Clinical protocols
to deal with the COVID-19 pandemic were available with 54.8% of the participants.
Table 2
Participants’ responses about clinical practice during the COVID-19 pandemic
|
Variables
|
Frequency (%)
|
|
Abbreviation: COVID-19, coronavirus disease 2019.
|
|
Comfortable in treating patients during the COVID-19 pandemic
|
|
|
Yes
|
53 (15.5)
|
|
No
|
290 (84.5)
|
|
Refuse treating a patient with COVID-19 positive diagnosis
|
|
|
Yes
|
188 (54.8)
|
|
No
|
155 (45.2)
|
|
Clinical protocols to deal with current COVID-19 pandemic
|
|
|
Yes
|
148 (43.1)
|
|
No
|
195 (56.9)
|
|
Attend a workshop/seminar on COVID-19 pandemic
|
|
|
Yes
|
79 (23.0)
|
|
No
|
264 (77.0)
|
|
Willing to receive information about COVID-19 pandemic
|
|
|
Yes
|
321 (93.6)
|
|
No
|
22 (6.4)
|
In [Table 3], bivariate and multivariate analyses of data show the relationship of different
factors with the attendance of workshop/seminar on COVID-19 pandemic. The bivariate
analysis shows that being comfortable in treating patients (odds ratio [OR] = 3.2,
95% CI = 1.73, 5.93) and having clinical protocols (OR = 2.07, 95% CI = 1.24, 3.44)
during the COVID-19 pandemic were significantly associated with increased odds of
attending workshop/seminar. On the other hand, significantly reduced odds of attending
workshop/seminar were associated with being a dentist (OR = 0.45, 95% CI = 0.27, 0.75)
and having a low monthly income (OR = 0.53, 95% CI = 0.31, 0.9). In multivariate analysis,
being comfortable in treating patients (OR = 3.31, 95% CI = 1.63, 6.73) and being
a dentist (OR = 0.49 95% CI = 0.27, 0.86) remained significant factors associated
with the attendance of workshop/seminar.
Table 3
Attendance of workshop: relationship with different factors
|
Variables
|
Unadjusted odds ratio
|
p-Values
|
Adjusted odds ratio
|
p-Value
|
|
Abbreviation: COVID-19, coronavirus disease 2019.
|
|
Gender
Male
Female
|
1.27 (0.77, 2.11)
|
0.343
|
1.07 (0.62, 1.86)
|
0.798
|
|
Monthly income
Up to 1,000 U.S. dollars (low income)
More than 1,000 U.S. dollars
|
0.53 (0.31, 0.9)
|
0.017
|
0.67 (0.36, 1.25)
|
0.212
|
|
Place of work
Government sector
Private sector
|
1.05 (0.63, 1.75)
|
0.859
|
1.08 (0.61, 1.92)
|
0.781
|
|
Qualification obtained
Government institution
Private institution
|
1.25 (0.75, 2.07)
|
0.391
|
1.09 (0.61, 1.94)
|
0.778
|
|
Current status
Dentist
Dental specialist
|
0.45 (0.27, 0.75)
|
0.002
|
0.49 (0.27, 0.86)
|
0.014
|
|
Experience
Up to 10 y
More than 10 y
|
0.66 (0.4, 1.1)
|
0.111
|
0.92 (0.51, 1.65)
|
0.783
|
|
Comfortable in treating patients during the COVID-19 pandemic
Yes
No
|
3.2 (1.73, 5.93)
|
<0.001
|
3.31 (1.63, 6.73)
|
0.001
|
|
Refuse treating a patient with COVID-19 positive diagnosis
Yes
No
|
0.75 (0.46, 1.25)
|
0.268
|
1.19 (0.66, 2.14)
|
0.554
|
|
Clinical protocols to deal with current COVID-19 pandemic
Yes
No
|
2.07 (1.24, 3.44)
|
0.005
|
1.61 (0.93, 2.79)
|
0.090
|
|
Willing to receive information about COVID-19 pandemic
Yes
No
|
0.62 (0.24, 1.58)
|
0.312
|
0.79 (0.29, 2.15)
|
0.640
|
Discussion
During the COVID-19 pandemic, all medical and dental professionals are confronting
with new challenges in offering optimal treatment to their patients.[17]
[18] By strict compliance to infection prevention and control policies, dental care providers
can play a vital role in the flattening of the COVID-19 epidemic curve and preventing
the complete failure of the health care system. Therefore, the present cross-sectional
study provided an insight into knowledge, attitude, and practices of dental professionals
during COVID-19 pandemic.
In the present study, dentists and dental specialists had optimal knowledge of modes
of COVID-19 disease transmission, signs and symptoms of the disease, and mandatory
preventive measures. Our findings were in accordance with a recently published study
where the majority (94.5 %) of the health care professionals exhibited adequate awareness
and knowledge regarding COVID-19.[19] In another cross-sectional study, Khader et al[20] reported similar results that Jordanian dentists had adequate knowledge related
to COVID-19 mode of transmission, symptoms, infection control, and prevention in dental
offices. On the other hand, a recent study by Sarfaraz et al indicated low knowledge
about disinfection protocol during COVID-19 pandemic among dental practitioners and
clinical post-graduate students globally.[21]
The mean knowledge score was significantly higher for dental specialists as compared
with general dentists in the present study. In addition, the years of practical experience
positively affected the knowledge score in our sample. In contrary to our findings,
Ahmed et al[19] observed no significant relationship (p > 0.05) between the health care providers’ knowledge and their education level. The
higher level of knowledge in specialists and experienced dental professionals is related
to their training in the specialist program and greater learning in dental practice
over years, respectively. The results of the present study exhibited no significant
difference in knowledge score with regards to gender. A previous study of health care
professionals in Pakistan reported no gender difference in their knowledge about COVID-19.[19]
In the present study, 38.4% of participants reported sending the patient home and
advising self-isolation if the patient had elevated temperature without respiratory
symptoms. However, 60.8% of participants agreed to quarantine the patient if he/she
had an elevated body temperature along with respiratory symptoms. Our observations
were in line with a recently published study in which 69.6% of the participants considered
that the best management strategy for suspected COVID-19 individuals was self-isolation
at home and seriously following social distancing measures.[20] In the present study, 55% of the participants refused to provide any type of dental
treatment to a patient with COVID-19 and only 15% were comfortable in providing dental
treatments during the pandemic. The attitudes of dentists in the present study were
similar to Jordanian dentists where the majority of participants (82.6%) preferred
to avoid treatment of a suspected COVID-19 patient even without signs and symptoms
of the disease.[20]
In this study, 91.2% of participants reported providing only emergency dental care
to their patients, whereas 6.5% preferred not to perform any dental procedure during
the COVID-19 pandemic. These results show strict compliance of the study participants
with CDC and ADA guidelines which recommended dentists to postpone all elective procedures
and focus on only emergency dental care to reduce COVID-19 infection transmission.[13]
[14] As it has been well-established that the main route for coronavirus transmission
is via saliva and aerosols, this increases the probability of dentists and dental
assistants from getting infected.[1]
[22] In the current situation, all elective dental procedures should be postponed until
the situation is under control.[1]
[22] The literature also indicates marked decline in the number of patients reporting
for emergency dental treatments during the COVID-19 pandemic.[22]
During the COVID-19 outbreak, dental health care professionals should take a comprehensive
medical history, history of recent travel, or contact and measurement of body temperature
for all patients presenting at dental offices as a routine procedure.[23] Based on recent guidelines, dentists should take comprehensive personal protective
measures and should avoid all the dental procedures that cause the production of droplets
or aerosols.[1]
[23] Four-handed dentistry, pretreatment mouthwash, and high-volume ejectors can significantly
reduce aerosols production.[11] The dentists should also encourage the testing of suspected cases of COVID-19 using
saliva specimen, an approach which is novel, noninvasive, and nondistressing for patients.[24] All dental practices and hospitals must follow comprehensive clinical protocols
to prevent disease transmission during this pandemic. However, in the present study,
only 54.8% of the participants reported that they had clinical protocols in their
practices to deal with the challenges of the current COVID-19 pandemic.
The financial impact (47.4%) was the most commonly reported impact of the COVID-19
pandemic on dental practice in our study. In private dental clinics, the provision
of dental care only for emergency dental procedures will reduce the income of the
clinics and contribute to financial stress.[11] Globally, private health care is not mostly supported by the government, and therefore,
it can cause a huge financial burden on dentists. This economic crisis has emphasized
the significance of social security as well as the financial education of the dental
team.
Psychological impacts in the form of fear and anxiety were quite prevalent in the
current pandemic, particularly when the number of infected individuals is increasing
every day and the mortality rate is rising exponentially.[25] Several reports have emerged about the infection and deaths of health care providers
from COIVD-19 infections.[26] Moreover, there is no vaccine or appropriate treatment available, which increases
stress and anxiety.[27] These reasons may account for 34% of participants in the present study reporting
the psychological impact of the COVID-19. Our results were in accordance with a recently
performed study, where many dentists had reported fear of getting infected from their
patients or coworkers during treatment procedures.[25] Psychological trauma, fear of getting infected, or infecting a relative or family
member had been reported among health care providers during previous similar outbreaks
of other infections such as severe acute respiratory syndrome (SARS).[28]
[29] Besides, health care providers carried the fear of being quarantined as a result
of suspected COVID-19 patients and how their family members would cope during this
stressful period.[25] This additional financial burden in terms of cost of treatment further enhances
one’s stress.[25] Therefore, psychological coping tools and strategies should be practiced among the
dental community to stay calm and perform their duties professionally.
A workshop/seminar on the COVID-19 pandemic was attended by 23% of the participants.
This was in accordance with a similar study amongst the health care professionals
where 24.4.% attended a professional scientific workshop/seminar related to COVID-19.[19] On the contrary, Shi et al[30] reported that 64.63% of health care professionals attended a training program on
COVID-19. In the present study, a positive relationship was observed between attending
workshops/seminars and being comfortable in treating patients and having clinical
protocols during the pandemic. Those who were comfortable in treating patients were
3.31 times more likely to attend the workshop than those who were not comfortable.
Similarly, dentists were 0.49 times less likely to attend the workshop/seminar than
specialists. Low attendance of workshops/seminars in our study can be related to the
lack of continuing education opportunities in the country. There is a substantial
need for online workshops, training, and seminars to significantly improve awareness,
attitude, and practices of dental health care providers as 93. 6% of our study participants
were willing to receive information about COVID-19.
The limitation of the present study was the use of self-reported data that was subjected
to under or overestimation of the responses by the study participants. Moreover, the
data were collected in 2 months, and currently pandemic is spreading rapidly in Pakistan
making dental health care providers more cautious regarding the COVID-19 disease transmission.
Therefore, knowledge, attitudes, and practices of dental professionals might change
with the emerging research and prospective treatment of COVID-19.
Conclusions
The study suggests that dentists and dental specialist participated in the study had
adequate knowledge related to COVID-19. However, only half of them had clinical protocols
in accordance with recent guidelines for their practices, and one-quarter attended
COVID-19- related continuing education activities. Dental practitioners reported had
huge financial and psychological impacts due to the COVID-19 pandemic.
Recommendations
-
Continued professional development programs should be available and mandatory for
all dental and other health care professionals to effectively prevent and control
disease transmission, and possibly to reduce the related morbidity and mortality.
-
General dentists and those dental professionals who are not comfortable in treating
patients should be the main target of these continuing professional development activities.
-
Financial as well as psychological support should be provided to all dental professionals
who are putting their lives at risk for the wellbeing of their patients.
