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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 266-272

Attitude, practices and experience of dental professionals during COVID-19 pandemic: A cross-sectional survey from Gujarat, India


1 Department of Dentistry, Pramukh Swami Medical College, Bhaikaka University, Anand, Gujarat, India
2 Department of Prosthodontics, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
3 Department of Public Health Dentistry, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India
4 Department of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India
5 Department of Prosthodontics, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Submission04-Apr-2021
Date of Acceptance14-Apr-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Aalap Sureshkumar Prajapati
Department of Dentistry, Pramukh Swami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_58_21

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  Abstract 


Introduction: Coronavirus disease (COVID-19) is a declared public health emergency of international concern. Occupational Safety and Health Administration (OSHA) classified health-care professionals and exposure risk to coronavirus (COVID-19), identifying dental professionals in the very high-risk group due to the specificity of dental procedures and instrumentations used. Guidelines from relevant authorities suggested providing only emergency and urgent dental treatment during the pandemic which has led majority of dental practice to stop, thus instilling anxiety in the dental professionals. A study to assess the attitude, practice and experience of dental professionals from Gujarat state during the COVID-19 pandemic was planned. Materials and Methods: An online questionnaire consisting of 32 questions using Google Form was distributed to 315 dental professionals. Data obtained were analysed using the Statistical Package for the Social Sciences 22.0. Descriptive statistical analysis was used to describe variables. Chi-square test was used to find a significant association between parameters, and P < 0.05 was considered statistically significant. Results: Overall, 194 dental professionals (104 general dentists and 90 specialists) filled the questionnaire. Nearly half of the participants (49.5%) said that personal protective equipment (PPE) is uncomfortable while performing dental procedures. The majority of them (86.6%) insisted on increasing the cost of dental treatments. Regarding new practices adapted during the pandemic, 53 dental professionals (27.3%) did not find teledentistry effective in resolving the patient's problem. Only 75 dental professionals (38.7%) followed all the screening criteria for patients. Fifty-nine participants (30.4%) got the COVID-19 test for patients requiring the aerosol-generating procedure. While 125 participants (64.4%) performed aerosol-generating procedures either in urgent/emergency cases or elective cases, only 115 (59.3%) used full PPE with an appropriate mask. One hundred and thirty-seven (70.6%) of them reported a decrease in income during the pandemic, while 74 (38.1%) suffered from anxiety and depression. Conclusion: Dental health-care providers are at the highest risk of contracting COVID-19. Thus, they should execute proposed precautionary measures more diligently. Regular training and screening of dental professionals should be undertaken by state regulatory bodies. Adapting and adhering to change in work protocols by dental professionals will ensure not only their safety but also their patients. The emergence of COVID-19 has been great learning for the field of dentistry, and the dental practice is going to change for the better.

Keywords: Attitude, COVID-19, dental practice, dentists, pandemics


How to cite this article:
Prajapati AS, Kulkarni PR, Shah HG, Shah DB, Sodani V, Doshi P. Attitude, practices and experience of dental professionals during COVID-19 pandemic: A cross-sectional survey from Gujarat, India. Adv Hum Biol 2021;11:266-72

How to cite this URL:
Prajapati AS, Kulkarni PR, Shah HG, Shah DB, Sodani V, Doshi P. Attitude, practices and experience of dental professionals during COVID-19 pandemic: A cross-sectional survey from Gujarat, India. Adv Hum Biol [serial online] 2021 [cited 2021 Oct 26];11:266-72. Available from: https://www.aihbonline.com/text.asp?2021/11/3/266/321973




  Introduction Top


Coronavirus-19 (CoV) disease, which originated in Wuhan province, China, was declared by the World Health Organization (WHO), an International Public Health Emergency on 30 January 2020. It was named COVID-19 by the WHO and Severe Acute Respiratory Syndrome-Coronavirus2 (SARS-CoV2) by the International Committee on the Taxonomy of Viruses.[1] CoV is zoonotic pathogens transferable from animals to humans and further transmitted from human to human through contact and/or direct route.[2] Specificity of dental procedures requiring close contact with patient's oral cavity and aerosolisation may lead to viral transmission to dentists, dental team and indirectly to other patients. Various guidelines were declared for providing dental treatments with new practice protocols. Regardless of such precise guidelines mandated for prevention, many dental professionals lack the minimum requirement of infection control due to low interest.[3] Furthermore, it was found that dental professionals lacked knowledge[4] about respiratory disease contagion compared to other health-care professionals,[5] despite more risks involved.[6] Apart from that, a significant limitation of clinical activities has brought a negative impact on the economy of the dental sector. Data by the Irish Dental Association mentioned about 75% of dental practitioners expecting a financial loss of over 70% during the COVID-19 outbreak. The same was indicated by the British Dental Association.[7],[8] This has brought psychological distress and fear of existing unprecedented situation in many dental professionals.[9],[10] To what extent this perception of fear is based, as well as clinical knowledge of dental professionals is unknown.

Aim

A study aiming to assess the attitude, practice and experience of dental professionals from Gujarat state during the COVID-19 pandemic was planned.

Objectives

  1. To identify deficiencies in attitude and dental practices, which in turn will help in addressing the prevention of disease spread
  2. To aid dental professionals promote safe dental practice protocols if the disease was to erupt as so-called multiple small waves sporadically
  3. To evaluate and address psychological concerns based on the experience of dental professionals.



  Materials and Methods Top


The current cross-sectional study was conducted after obtaining ethical approval from Institutional Ethical Committee (IEC/HMPCMCE/2020/Ex. 52/259/20).

Inclusion criteria

  1. Dental professionals who had at least a Bachelor of Dental Surgery degree
  2. Willing to give informed consent (implied in this study if they clicked 'next' to answer the questionnaire)
  3. Practising in Gujarat irrespective of their workplace (private or government sector or independent private clinic).


Exclusion criteria

  1. Undergraduate dental student
  2. Dental professional not practising in Gujarat
  3. If the participant fails to answer ≥1 question.


The sample size was calculated using:

N= Z2 p (1-p) / d2

where, Z level of confidence (at 95% = 1.96)

p - Expected prevalence (92%)

d - Precision (3%).

Thus, the total sample size for the research came out to be 314.

The study tool was drafted in simple English language. The preliminary draft was designed based on guidelines from regulatory bodies and expert's opinion, who also evaluated the face and content validity of the questionnaire. The study tool was an online questionnaire using Google Form, which was circulated to 315 dental professionals using WhatsApp (social media platform). The study duration was from 25 November 2020 to 18 December 2020, and a convenience sampling method was used. Upon clicking the link, the first page informed participants about the aim and objectives of the study and assured confidentiality of the data provided. It consisted of questions on demographic data (4), attitude (9), practice (13) and experience (6) of dental professionals, thus forming total 32 questions.

Microsoft Excel sheet was used to gather data. Descriptive Statistical analysis was used to describe the parameters of the questionnaire. Chi-square test was used to find a significant association between parameters, and P < 0.05 was considered statistically significant. IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA) software was used to perform calculations. The reliability statistics were done, and Cronbach's alpha was found to be 0.779. This study was conducted in compliance with the Helsinki 2013 declaration.


  Results Top


Overall, 194 dental professionals (104 general dentists and 90 specialists) filled the questionnaire giving a response rate of 61.78%. Male participants (n = 109, 56.2%) were more compared to female (n = 85, 43.8%). The majority of participants were having < 10 years of experience (n = 156, 80.4%). Fifty participants (25.8%) were associated with the private institute, 84 (43.3%) with government institute and 60 (30.9%) having independent private clinic [Table 1].
Table 1: Demographic data of dental professionals (n=194)

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One hundred and thirty-six participants (70%) followed the latest guidelines for providing dental care during the pandemic, while 139 (71.7%) believed that personal protective equipment (PPE) is effective in preventing virus transmission. However, nearly half (49.5%) said that PPE is uncomfortable while performing dental procedures. The majority of them (86.6%) insisted on increasing the cost of dental treatments [Table 2]. There was a statistically significant association (P < 0.03) between dental professionals with < 10 years of experience in favour of following the latest guidelines as well as an increase in treatment cost. Furthermore, there was a significant association (P < 0.01) between gender and attitude regarding reviving normal work at dental clinics, with more males in favour of starting work as was done previously and females waiting till the end of the alert phase.
Table 2: Attitude of dental professionals during pandemic (n=194)

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Regarding new practices adapted during the pandemic, 53 dental professionals (27.3%) did not find teledentistry effective in resolving patient's problem. Only 75 dental professionals (38.7%) followed all the screening criteria (history of present illness, travel history, contactless temperature recording and providing mask and shoe cover/head cap to patients appointed for dental treatment). Fifty-nine participants (30.4%) practised getting COVID-19 test for patients requiring the aerosol-generating procedure. Statistically significant association (P < 0.001) was found between health sector and getting COVID-19 test, with dental professionals from government sector more in favor of the same. While 125 participants (64.4%) performed aerosol-generating procedures either in urgent/emergency cases or elective cases, only 115 (59.3%) used full PPE with appropriate mask [Table 3].
Table 3: Practices adapted by dental professionals during pandemic (n=194)

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Twenty-nine participants (14.9%) reported having symptoms of COVID-19, while 19 (9.8%) tested positive. One hundred dental professionals (51.5%) said they performed treatment understanding of such occupational risks related to the field. One hundred and thirty-seven (70.6%) of them reported a decrease in their income during the pandemic, while 74 (38.1%) suffered from anxiety and depression [Table 4]. No significant association (P > 0.05) was found between anxiety-depression and gender or health sector. Similarly, no association was found between income and years of experience or health sector.
Table 4: Experience of dental professionals during pandemic (n=194)

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  Discussion Top


Occupation safety and health administration (OSHA) in 2020 categorised dental professionals in very high-risk category.[11] This can be attributed to specificities of the branch, which are:

  1. Close contact with patient's oral cavity (35–40 cm approximately)
  2. Frequent exposure to oropharyngeal fluids and blood
  3. Armamentarium causing aerosolisation
  4. Time consuming and greater number of visits for dental treatment.


Further prolonged incubation period increases transmission during the asymptomatic phase of the disease. At the time of collecting data, there were no definitive treatment or vaccine approved for a human trial. Either way, it is mandated to continue taking the same precautions even after getting the vaccine. The only critical intervention available was early viral testing for disease confirmation and symptomatic relief excluding asymptomatic group of people which can act as carriers. Thus, preventive measures in the form of guidelines provided by the Ministry of Health and Family Welfare, Dental Council of India, Centers for Disease Control and Prevention (CDC) and WHO are of utmost importance. Right from deferring elective dental treatment to minimising aerosols produced while catering urgent/emergency dental care through triaging, pre-procedural mouth rinse with 1% hydrogen peroxide, single sitting procedure with rubber dam application, effective use of PPE, frequent disinfection to practising teledentistry and hydroxychloroquine (HCQ) prophylaxis was advocated.

The present study provides an insight into the attitude, practice and experience of dental professionals from Gujarat. Nearly 46.9% (n = 91) of participants believed reopening of dental clinics will not result in the spread of the virus. This is contrary to a study done by Indu et al.[12] and Ahmadi et al.[13] It may be the reason that 47.9% (n = 93) of dental professionals believe that clinics should start working normally. Male participants were more who reported it than females. There was a significant association between such attitude and financial reasons (P < 0.05). Nearly 70.6% (n = 137) of participants reported a decrease in their income during the pandemic. Response to decreasing in income was similar to results of Gambarini et al.,[14] Bakaeen et al.,[15] Ahmadi et al.,[13] and Rodrigues et al.[16] Nearly 70% (n=136) of participants said that there is an equal risk of COVID-19 transmission for the dental team as well as patients in dental clinics. The risk was perceived to be due to aerosols by 70% (n = 140). It is contrary to a study by Sezgin and Sirinoglu[17] and Aboalela et al.[18] where contributors said, close contact and/or indirect transmission carry maximum risk. The risk to dental team or patients and through aerosols, close contact and indirect transmission were perceived equal by participants of the study by Gambarini et al.[19]

While catering, dental treatment guidelines were followed more by dental professionals with <10 years of experience. This can be due to the ease of accessibility to social media compared to the older age group. Majority of them practiced pre-procedural mouth rinse (n = 157, 80%), disinfection of dental impressions (n = 179, 92.3%) and clinic (n = 187, 96.4%). Only half of them (n = 95, 49%) used rubber dam, while one-third of participants took HCQ prophylaxis (n = 54, 27.8%). Only 38.7% (n = 75) followed guidelines for patient triaging such as taking travel history, measuring temperature with an infrared thermometer and providing mask, head cap/shoe cover to patients. This could be alarming as refraining from such basic measures could lead to the spreading of disease. It can be because of participant's negligence or their misconception that asking patients for extra precautionary measures would create a sense of panic in them.[3] Although 33% of dental professionals (n = 64) started practising teledentistry, the majority of them reported that it was somewhat or not at all effective in resolving patient's problem. It is due to major dental clinics do not have proper network infrastructure and trained workforce for practising teledentistry. The same result was found in a study done by Ahmadi et al.[13] However, a study by Sarate et al.[20] and Arora et al.[21] reported that 61% and 46.3% of participants, respectively, consider teledentistry efficient. When asked if they have treated/examined high-risk patient (with fever, myalgia and positive travel history), 21.6% (n = 42) of participants agreed. Nearly 44.3% (n = 86) of dental professionals reported the availability of all consumable items during the pandemic. That was possible as their supplies were continuously available at dental depots, though at a higher rate. The practice trend of getting the COVID-19 test was found more in dental professionals from the government sector. It can be due to the fact that, during the time of study, majority of COVID testing centres were government hospitals. More than half of the contributors to the study by Ahmadi et al.[13] and Gambarini et al.[14] were in favour of getting COVID-19 testing for patients requiring dental procedures. Nearly 29.9% (n = 58) of dental professionals did all dental procedures irrespective of the pandemic stage, while 60.3% (n = 117) provided dental treatment in urgent and/or emergency cases only. It can be due to the fact that, when data were collected, the second wave of COVID-19 was in decline, and dental Professionals were comfortable with new norms of dental practice. The result is contrary to a study by Sezgin and Sirinoglu,[17] Ahmadi et al.,[13] and Srivastava et al.[22] where participants were unwilling to provide routine dental treatment with proper PPE and performed only emergency procedures. Although 71.7% (n = 139) of dental professionals believed that PPE is effective in preventing virus transmission, only 59.3% (n=115) used a full set of PPE with N95 mask. As per CDC guidelines on infection control protocols for delivery of non-emergent services, universal precautions should be taken irrespective of pandemic status.[23] Use of PPE with N95 is of utmost importance during any dental procedure.[24] Perception of protection against aerosols with the 3-ply mask is a common misconception. The 3-ply mask does not provide adequate filtration against aerosols measuring <3 μm.[25],[26] The size of SARS-CoV-2 being smaller than that the 3-ply mask is unlikely to effectively filter the virus. Furthermore, it loosely fits between itself and the surface of the face. Even the results by Gambhir et al.,[27] Bakaeen et al.,[15] and Srivastava et al.[22] reported participants being unaware regarding the appropriate use of PPE during dental procedures. An interesting fact found in the study was that half of the contributors (n = 96, 49.5%) reported that comfort and dexterity are not maintained with PPE. It can be the reason, along with the perception of nearly one-third of participants of this study, regarding PPE ineffectiveness for not complying with appropriate PPE use as mandated by guidelines. Majority of dentists in a study by Rodrigues et al.[16] also said that PPE use did not guarantee them protection against the virus. Thirty-eight percent (n = 74) suffered from anxiety and depression. It can be because the field of dentistry is facing a new reality, new guidance of patient screening, new work protocol, restricting the dental practice, which altogether might have impacted financial outcome during a pandemic. The same result was derived in a study by Indu et al.[12] and Ahmadi et al.[13] The majority of them said that a change in work protocol ensured more safety for themselves as well as patients.


  Conclusion Top


The difference in opinion regarding dental practice and lack of preparedness during COVID-19 was observed between participants. Infection control guidelines in dentistry were last updated during human immunodeficiency virus epidemic.[28] In this context, a common standard dental treatment protocol is recommended. Further to educate dental professionals, various Continuous Dental Education programmes and training can be undertaken by state regulatory bodies from time to time. It is also the responsibility of state council to address the issue of decreasing income of dental professionals and propose standardised charges for dental treatments. Ultimately, it is upon individual dental professional how much to adhere to newer protocols which definitely ensures safety for them and their patients. Despite our best efforts, there are few limitations of the study. First, a low response rate can be due to a short period of time for data collection. Second, the cross-sectional nature of the study which proves only association and not a cause-effect relationship. Due to the employed sampling method and method of collecting data, self-selection bias and age bias could have occurred, which prevents the ability to generalise the results. Further study involving remote regions of Gujarat with a larger sample size can be done, which could achieve more comprehensive results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 1], [Table 2], [Table 3], [Table 4]



 

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