Socio-Economic Impact and Fear of Infection During COVID-19 PandemicAmong General Dentists - A Survey

Coronavirus disease 2019 (COVID-19) was first identified in Wuhan, Hubei Province, China, in December 2019.² Viruses that cause COVID-19, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), are abundant in nasopharyngeal and salivary secretions of patients infected with SARS-CoV-2, and is thought to spread primarily by respiratory droplets, aerosols and fomites. Recent evidence shows that normal breathing and talking can produce small droplets that are transported as aerosols, and that aerosolized SARS-CoV-2 particles remain suspended in the air for several hours. However, it is unclear to what extent aerosol dispersal contributes to the transmission of the virus.^3,4

The widespread outbreak of SARS-CoV-2 in many communities poses the risk that infected individuals who are presymptomatic or asymptomatic will transmit the virus to others. The unique nature of dental procedures, their proximity to the patient’s mouth and throat, contributes to the high risk that dental personnel are at and may transmit the virus to other patients or staff. Few dental procedures result in the formation of aerosols, increasing the risk of transmission of viruses to dental staff and patients through direct inhalation or direct contact with contaminated surfaces.^5,6

Fear, anxiety and rejection in social circles related to COVID-19 pandemic was evident among dentists, with most expressing fear of spread of infection. As health professionals were among the primary contacts with COVID-19 patients, public attitude towards them significantly shifted. Physicians faced several hurdles in their clinical practice.

Hence this study was planned to understand the anxiety and socio-economic impact of COVID-19 pandemic on dentists through an online survey using google questionnaires.

Materials and Methods

This survey was conducted among 255 dentists having a clinical practice. Ethical approval was obtained from the Institutional Review Board of Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore. Data were collected through an online google form. The questionnaire consisted of 15 questions with five questions each on knowledge, attitude, and practice and each question was provided with five response options.

The questionnaire assessed knowledge, attitude, and practice related to fear of infection and socio-economic impact of COVID-19 pandemic on dentists. The Google questionnaire was distributed among general dentists having clinical practices. The online google responses were collected and the results were tabulated accordingly.

Study sample

An anonymous questionnaire was distributed to approximately 255 dentists working in clinics and private practices. The questionnaires were sent through online forms.

The questionnaire consisted of three sections.

Section A: Knowledge regarding infections

Section B:Attitude towards fear of infection and socio­economics

Section C: Clinical practice

Statistical analysis

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013.

Armonk, NY: IBM Corporation was used to assess statistical analyses.

Descriptive statistics

Descriptive analysis was performed for all explanatory and outcome parameters using mean, and standard deviation for quantitative variables, and frequency and proportions for categorical variables.

Inferential statistics

The Chi-square test was used to compare responses to the questionnaire regarding the socio-economic impact and fear of infection across key socio-demographic variables.⁷ The significance level (P-value) was set at P <0.05.

Results

As per the data mentioned in Table 1, majority of the participants were in the age group of 20-30 years. The percentage of male dentists was 45.1%, female dentists were 54.9%. Among the participants, 49.4% had BDS degree, while 50.6% were MDS practitioners.

On comparing responses to the knowledge questions based on designation, 82.3% of MDS practitioners demonstrated greater knowledge about the COVID-19 pandemic, gained through seminars, CDE programs, and other scientific research, compared to 63.8% of BDS participants. The difference was statistically significant (P = 0.02). The economic crisis was also significantly higher among MDS (64.6%) and BDS (62.2%) practitioners with a P value of 0.43. About 40.2% of BDS participants used N-95 masks & surgical 3-Ply masks, while 32.3% of MDS participants used respirators and N-95 masks; the P value was 0.003. MDS participants (60.8%) were found to be more knowledgeable regarding operating room disinfectants compared to BDS participants (45.7%) and the P value was 0.006. Stress and anxiety were better managed by MDS participants (49.2%) compared to BDS participants (43.3%); P value was 0.73 (Table 2a).

When comparing responses to the attitude questions based on designation, fear of treating individuals affected by the COVID-19 virus was higher among BDS practitioners (47.2%) than among MDS practitioners (40.8%), with a P value of 0.47. On comparing BDS and MDS practitioners, 14.2% and 11.5% of their patients, respectively, were scared to visit the doctor. About 13.4% patients visiting the clinics of BDS participants and 13.1% patients visiting the clinics of MDS participants enquired regarding the safety measures followed in the clinical practice during the COVID-19 pandemic. Both BDS and MDS participants had significantly higher percentages and the P value was 0.84. However, BDS participants had a higher percentage value compared to MDS participants.

The observed attitudes regarding the increase in the cost of dental treatment were significant. Around 44.9% of the patients asked for concession in the dental treatment charges (P = 0.45). About 62.3% of MDS participants reported to have avoided public meetings compared to 55.9% of BDS participants and the P value was 0.32. Stress was slightly higher among MDS participants (43.1%) compared to BDS participants (33.1%) and the P value was 0.38 (Table 2b).

When responses to practice-based questions were compared based on the designation, it was reported that treatments with elevated aerosols were avoided in clinical practice during COVID-19 pandemic. Treatments such as scaling and flap surgeries were avoided by 39.2% of MDS and 30.7% of BDS participants to prevent frequent aerosol contact and as a safety measure during the COVID-19 pandemic (P = 0.68). Fear of spreading infection was significantly higher among MDS practitioners (75.4%) compared to BDS (59.8%) practitioners (P = 0.04). All safety protocols were better followed by MDS (69.2%) practitioners than BDS (60.6%) (P = 0.13). Reduction in clinical income was significantly higher among BDS compared to MDS practitioners (P = 0.26). Both the group of participants experienced wastage of stored dental materials during the COVID-19 pandemic (P = 0.72) (Table 2c).

Comparison of mean sum of total questionnaire responses based on study participants’ designation using the Mann-Whitney test was as follows: BDS- 18.35 ± 3.85 and MDS- 19.03 ± 4.12 (Table 3).

Discussion

The present study was conducted to determine the fear of infection & socio-economic impact of COVID-19 pandemic among dentists. Dentists fall into the highest risk category because their work generates droplets and aerosols which are considered the main route of transmission of viruses.⁸

The present cross-sectional study found that MDS practitioners had better knowledge, attitude and practice in treating patients during COVID-19 pandemic compared to BDS practitioners.

In the present study, 30.7% of BDS and 33.8% of MDS practitioners experienced fear of contracting COVID-19 infection and the P value was 0.47. About 60.6% of BDS and 69.2% of MDS practitioners followed the safety protocols in their clinical practice using UV-light protection, N-95 masks, face shields, fumigators, and air purifiers; the P value was 0.13. The anxiety levels were found higher among the BDS practitioners compared to MDS practitioners. Anas F Mahdeel, Sarhang S Gul et al., in 2020 reported high levels of anxiety among Iraqi dentists as a result of COVID-19 outbreak.9 The high levels of anxiety experienced by these Iraqi dentists were considered a natural human response during the pandemic situation, given the rising number of cases and mortality rates. Around 80% of the participants reported a fear of spread of infection during COVID-19 and anxiety levels were found higher among younger dentists and women. Awareness and adherence to precautionary protocols and infection control measures related to COVID-19 were high among these dentists (94%). Statistical significance was assessed based on age, qualification, and designation. Approximately 75% of the dentists experienced an economic impact, regardless of demographic variables, with their income decreased by approximately 50%.

In the present study, 60.6% of BDS and 69.2% of MDS practitioners were aware of the safety protocol for the prevention of spread of infection and implemented the same in their clinical practice. This is in accordance with the findings of the study conducted by Mariam Mohsen Aly and Marwa Aly Elchaghaby et al., in 2020 to assess fear of infection among Egyptian dentists practicing during COVID-19 pandemic and also to assess the dentists’ knowledge regarding guidelines to control the virus.10 They reported that among 216 dentists, 200 (92.6%) were afraid of contracting COVID-19, while 196 (90.7%) were afraid to treat patients with suspicious symptoms. Most participants were aware of the modes of virus spread during the COVID-19 pandemic. They were aware of current Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines for cross-infection control. In their study, they concluded that the COVID-19 pandemic had a significantly higher impact on dental personnel.

In the present study, 30.7% of BDS and 39.2% of MDS practitioners avoided aerosol-generating procedures like scaling and flap surgeries, while 24.4% of BDS and 21.5% of MDS practitioners avoided only scaling procedures to prevent the spread of infection through droplets (P value = 0.68). In this study, 16.5% of BDS practitioners and 32.3% of MDS practitioners used N-95 (3M) masks as well as respirators (P value = 0.003). This is in accordance with the findings of Iraj Kinariwala, Lakshman Perera Samaranayake et al.11 They addressed the fear among Indian dentists regarding professional practice during COVID-19 pandemic. Around 1200 questionnaires were sent as online forms randomly to the dentists practicing across India. A majority of dentists (57.8%) reported requiring COVID-19 test results for all patients prior to performing aerosol-generating procedures, while two-fifths (40.0%) conducted the test only for symptomatic patients. Adherence to standard infection control measures, including droplet prevention, were followed for the prevention of SARS-CoV-2 transmission in the operating rooms in this study. Aerosol-generating procedures were kept to a minimum, following the guidelines issued by professional associations. Although a nationwide lockdown was imposed in India, up to two-fifths of respondents (22.8%) provided emergency care during the lockdown period.¹¹

About 60.6% of BDS and 69.2% of MDS practitioners used UV- light protection, N-95 masks, face shields, fumigators, and air purifiers. This is similar to the findings of a nationwide cross-sectional study conducted by Ramsha Kamran, Kiran Saba et al.,on the impact of COVID-19 among Pakistani dentists in 2021.12 A total of 313 dentists from all the regions of Pakistan participated and submitted the online forms. Most dentists were aware of CDC guidelines. However, 75% of dentists had a fear of infection, 88% of them were anxious during treatment, 68% of the dentists avoided aerosolized procedures and only 28% used dental rubber dam isolation. About 38.5% of dentists in Baluchistan used N95 masks without rubber dam isolation. Initiating awareness programs to overcome the fear of infection and training personnel in infection control was essential to reduce the spread of viruses.

In the present study, infection control was efficiently managed by MDS practitioners compared to BDS practitioners; the P value was 0.13. About 45.7% of BDS practitioners and 60.8% of MDS practitioners used hydrogen peroxide, sodium hypochlorite, ETO (Ethylene oxide) gas, formaldehyde to disinfect the operatory. This concurs with the finding of Alessandra Amato, Mario Caggiano et al., who conducted a study in 2021 with an intention to provide practical advice to dentists based on recent literature that will be useful in reducing the risk of spread of infection in their clinical practice.8 Due to the pathophysiologic characteristics of COVID-19 and the high transmissibility of SARS-CoV-2, dentists, and dental workers are at increased risk of infection. Efficient disinfection procedures in conjunction with the proper usage of PPE can significantly reduce the likelihood of SARS-CoV-2 transmission in the dental office. Maintaining social distancing, following proper behavioral protocols, ensuring adequate air exchange in all dental office/clinic spaces, and adhering to instrument sterilization and surface disinfection procedures can help reduce the risk of SARS-CoV-2 transmission.

The present study found that MDS practitioners demonstrated greater knowledge, attitude, and practice regarding the management of COVID-19 compared to BDS practitioners. However, all practitioners possessed adequate knowledge about the COVID-19 pandemic. Most practitioners adhered to all safety protocols when treating infected patients during the COVID-19 pandemic. In this study, a majority of MDS practitioners demonstrated greater knowledge regarding operating room disinfection compared to BDS practitioners. Despite experiencing fear, anxiety, and economic challenges, MDS practitioners were more effective in managing patient care than their BDS counterparts.

Conclusion

Thus it can be concluded that MDS practitioners demonstrated better knowledge, attitude and practice in handling COVID-19 situation compared to BDS practitioners. However, the fear of spread of infection among family members was significantly higher among MDS practitioners compared to their BDS counterparts.

A significant decline in clinical income was observed in both MDS and BDS practitioners. Despite the challenges faced during clinical practice, MDS practitioners in the present study implemented appropriate infection control measures to prevent the spread of infection during COVID-19 pandemic.

Financial support and sponsorship

Nil

Conflicts of Interest

There are no conflicts of interest