The preventive measures adopted during dental practice by the dentists in a low-income country to prevent the transmission of COVID-19: A questionnaire-based survey

INTRODUCTION

A novel coronavirus (SARS-Cov-2) caused severe pneumonia (COVID-19) explored in Wuhan city, Hubei province, China, and then spread rapidly to other provinces and countries.^[1] On June 17, 2020, 213 countries have reported cases of COVID-19.^[2,3] The World Health Organization declared the COVID-19 as a public health emergency of international concern.^[4] The most common and typical clinical symptoms of the patients with coronavirus disease were fatigue, fever (88.7%), and coughing (67.8%); however, nausea and diarrhea (5% and 3.8%, respectively) were uncommon. The radiological findings showed that 56.4% of the patients have ground-glass opacity, and 51.8% have bilateral patchy shadowing in CT chest. Laboratory findings showed that lymphocytes were present in 83.2% of the patients.^[5] The most common transmission route of coronavirus is direct contact with the coughing and sneezing patient’s droplet. Furthermore, it can also be transmitted from person to person by direct or indirect contact. The dental staff has the risk of coronavirus infection due to the specificity of their procedures such as face-to-face communication, direct contact with saliva, and micro-organism inhalation that may be remained in the air for a long time.^[6] Therefore, infection control and preventive measures should be very strict during dental diagnosis and treatment, especially that doctors get infected with COVID-19 more.^[7]

The aim of this study was to estimate the infection prevention and control (IPC) that may be adopted for both patients and dental team in the Syrian Arab Republic (SAR) dental clinics.

MATERIAL AND METHODS

A cross-sectional study was done using an online questionnaire. Ethical approval for this study was obtained from the Damascus University Ethical committee with the ID 2432020. The questionnaire was sent electronically to dental practitioners in (SAR) at a randomly selection, in March 2020 for 45 days. The study sample is composed of 1013 dentists who are 25 years old and above and have the willingness and desire to participate in this survey. STROBE statement for reporting cross-sectional studies was applied in this research.

The questionnaire consists of 20 questions to evaluate the infection control and preventive measures that may prevent the transmission of coronavirus disease (COVID-19) during dental treatment. The questionnaire was filled after an explanation about the study and its purposes.

The questionnaire had five sections. In the first section, the participants should fill the sex, age, and the specific specialization.

In the second section, the dentists were asked if the dental treatment was limited to only emergency cases or all usual treatments. They were also asked about the prevention methods that were used during dental treatment to all of the medical and administrative staff, such as (mask, surgical gown, cover head, cover shoes, face shield, and plastic eyeglasses).

In the third section, the dentists’ opinions about the roles of recording patients’ fever, cleaning patients’ hands with an alcohol-based hand rub, or with soap and water for 20 min in reducing disease spread were recorded. The dentists were also asked if they use eyeglasses, cover shoes, surgical gown, mouth wash, surgical suction, and rubber dam for patients during dental treatment.

In the fourth section, they were also asked questions related to their sterilization process of contaminated air, handpieces, dental chair, and waiting room.

Finally, in the fifth section, dentists were asked if they increase patients’ awareness of the preventive measures that should be taken in their daily life to reduce the transmission of COVID-19.

RESULTS

After 30 days, 1013 dentists out of 23800 dentists registered in Syria have responded to this survey.

In the first section, regarding demographic data, 61% of the participants were males, most of the respondents were specialist dentists with 53% prevalence. The highest frequency of age was between 25 and 35 years (73%) [Table 1].

In the second section, regarding the procedures followed in the dental clinic after the announcement of the virus spreading, 61% of the participants treated the emergent cases only. About 84% of them wear facial masks, while the prevalence was 34% for surgical gowns, 40% for the cover head, 7% for cover shoes, 41% for a face shield, and 12% for plastic eyeglasses. Only 46% of the participants force both the dental and administrative staff to follow the previous preventive methods [Table 2].

In the third section, the procedures taken before, during, and after the dental treatment were assessed. The majority of the participants (83%) schedule the appointments, so there is only one patient in the waiting room. However, 62% do not measure the patient’s fever before entering the dental clinic. Furthermore, 63% of the dentists sterilize the patients’ hands before and after the dental treatment, and 59% of the participants choose 70% ethyl alcohol as a disinfectant [Table 3].

About 44% of the dentists were aware that the use of the cover shoes for patients is very essential in reducing virus spreading. The minority of the respondents provide the patient with surgical gown and plastic glasses (22% and 17%, respectively).

Most of the respondents use dental mouthwashes before the initiation of the treatment (70%), including 0.12% chlorhexidine gluconate (47%), 0.2% povidone-iodine (14%), and hydrogen peroxide (9%) [Table 3].

Although almost three-quarters of the dentists use high vacuum suctions such as surgical ejaculators, 73% do not use a dental rubber dam, and thus 77% of the latter allow the patient to spit in the spittoon [Table 3].

In the fourth section, concerning the contaminated air, half of the respondents improve ventilation of the dental clinic regularly (51%), while 8% decontaminate air through special sterilizers, 24% use the previous techniques both. However, 10% of the participants do not use any technique to refresh air, and 7% do not know if air decontamination reduces the risk of COVID-19 transmission. Moreover, the highest frequency of the respondents (68%) decontaminates all the equipment in the dental clinic and the waiting room frequently after each patient. Only a minority of dentists sterilize the dental handpieces in the autoclaves after each patient (15%), while others decontaminate them for 60 s before wiping with either a surface sterilizer (33%) or with alcohol (13%) [Table 4].

In addition, only 48% of the respondents throw the dental wastes away after completing the treatment of each patient [Table 4].

In the last section, most of the dentists (84%) educate their patients about the preventive measures to reduce the transmission of novel COVID-19. Moreover, over half of the participants make their patients aware of the necessity of washing their toothbrushes and avoid contacting them with other toothbrushes [Table 5].

DISCUSSION

The speed and the response of coronavirus disease around the word are depended on health-care systems, economies, and political ideologies.^[8] Thus, SAR is considered to have a high prevalence spreading of SARS-COVID-2 due to its classification as a low-income country because of the Syrian crisis.

Such surveys can be beneficial when preventive measures about infectious diseases are outlining.

The results of this study revealed that 61% of the participants treated the emergent cases only since the Syrian government imposed a partial quarantine, including the closure of schools, universities, and non-essential shops. Moreover, the ministry of health recommended dentists to treat the emergent cases only, based on the Centers for Disease Control and Prevention (CDC).^[9]

According to international and local awareness for the transmission ways of SARS-COVID-2, almost half of the respondents in this study imposed all the dental and administrative staff to follow strict preventive measures during dental treatment. Most of them used facial masks (84%) since it is considered as a usual procedure even before the pandemic, whereas the use of face shields, cover heads, cover shoes, and plastic eyeglasses was low, and this could be a result of its high cost under the economic sanctions.

About 83% of the participants schedule the appointments that are only one patient in the waiting room, and this was according to the WHO precautions to avoid crowded places and to maintain a physical distance at least 1 m.^[10] About 62% of the participants do not measure the patients’ fever before entering the dental clinic, despite it is considered as the most common symptom (88.7%); therefore, it is advisable for the dentists to know all of COVID-19 symptoms to take the required precautions when meeting such patients.^[5,6] Furthermore, 63% of the dentists sterilize the patients’ hands before and after the dental treatment. About 59% out of them choose 70% ethyl alcohol as a disinfectant, while 35% preferred washing hands with soap and water for 20 s. Both ways are considered an efficient option in killing viruses according to the WHO recommendations.^[10] This study was consisted of Hassenow et al. study, which was also conducted in Syrian Arab Republic.^[11]

More than half of the respondents were not aware to use cover shoes for the patients before entering the dental clinic; therefore, awareness of this point should be more highlighted since coronavirus can survive on the sole of the shoes for up to 5 days^[12] due to its ability to land on the ground surface by gravity or airflow effect.^[13]

The majority of the respondents use dental mouthwashes before the initiation of the treatment (70%), including 0.12% chlorhexidine gluconate (47%) due to its virucidal effect, while the prevalence of using 0.2% povidone-iodine was (14%), and 9% for hydrogen peroxide. Recently many researchers showed that the antiviral action for some antiseptic rinses, including chlorhexidine, may be limited since the lipid outer layer of coronavirus would probably be protected against such agents.^[14]

Although almost three quarters of the dentists use high vacuum suctions such as surgical ejaculators due to its highly role in reducing respiratory droplets and this would minimize the virus counts in aerosol and surfaces, therefore decreasing prevalence rate in the dental clinic, 73% do not use dental rubber dam, and this might be according to the application time taken.

Even 15% of dentists sterilize the dental handpieces in the autoclaves after each patient, and this might be due to prolonged time. Yet 33% decontaminate them for 60 seconds before wiping with a surface sterilizer and thus might be due to easiness.

After the end of the treatment, half of the respondents improve ventilation of the dental clinic regularly (51%) and thus ensure air movement in clean-to-less-clean flow direction according to CDC consideration.^[9]

Finally, most of the dentists (84%) educate their patients by informing them about the transmission routes and preventive measures of COVID-19. The percentage may become highly if the concerned authorities and government make all of the medical staff, including dentists, as a part of the awareness campaign.

CONCLUSION

Based on these results, the Syrians dentist’s practitioners should take more strict measures and awareness before and after dental practice to avoid pandemic outbreaks, and the health system collapses that may be a hard fact, especially in low-income countries such as SAR.