Perspective of dental health-care professionals during the second wave of COVID-19 pandemic: A national online survey

INTRODUCTION

The entire mankind was cuffed by the unsung sickness due to tiny creatures landing as a pandemic, the slams of which were not easy for the world to deal with for ages. In the present scenario, one such crisis being experienced by the entire human race is Coronavirus Disease (COVID-19)/novel coronavirus/2019-nCoV/SARS-CoV-2. The World Health Organization (WHO) declared it as a global pandemic in March 2020.^[1] The first outbreak was in Wuhan city of China, and gradually spread to the entire world, which has taken nearly 5,531,069 (as of January 15, 2022) lives so far according to the WHO. Severely infected patients feel difficulty in breathing, chest pain, and cytokine storms, affecting the lungs and various other body parts finally leading to acute respiratory distress and death.^[2]

After two decades of infections such as SARS-CoV, Middle East respiratory syndrome CoV, and currently, with the SARS-CoV-2, frontline workers have been overburdened, experiencing alarming stress levels, depression, and psychological abnormalities. Dental professionals are among those who carry a higher risk of infection due to their direct exposure to droplets, saliva, and other body fluids including the production of aerosols during therapy which, in turn, carries the risk of virus transmission.^[3,4] In support of this, Liu et al.^[5] gave a possibility of isolation of the virus in salivary epithelial cells. Even, Barzon et al.^[6] published the presence of the virus even after 29 days of recovery. The reason salivary fluid is highly contagious is due to a greater number of angiotensin-converting enzyme-2 receptors in the salivary gland and it is highly impossible to avoid its contact during dental treatment. Moreover, nasal and throat swab tests that were being performed are not reliable to some extent. Thus, it caused a greater impact in the field of dentistry. In support of this, a recent study done by Shetty et al.,^[7] in 2020, concluded that long-term unknown stress has shown effects of morbidity and fatigue on dental healthcare professionals.

There was a drop in the count of cases by January 2021 but due to mutagenic nature of the virus, more powerful strains emerged (esp., Delta strain) leading to the rapid spread of infection and resulting in the second wave of pandemic. The government has not relaxed double mask protocols, social distancing, and lockdowns. All these were done to control the spread of the disease.^[8] Apart from this, mass vaccination programs have already been implemented by the governing bodies for the general population including frontline workers.^[9] The deteriorated situation has tremendously affected the citizens both physiologically and psychologically. One among them was dental healthcare professionals who are more prone to getting infected. The fear of transmitting it to their family has always been a hunted factor and financial disturbances were also unavoidable.^[10] This led to a tremendous change in their perspective levels regarding the COVID-19 second wave. As considerable numbers of studies were not performed, the present study aimed to evaluate the perspective levels of dental healthcare professionals in the second wave through an online-based questionnaire survey.

MATERIAL AND METHODS

Based on an initial pilot study on 25 dentists, the obtained Cronbach’s alpha value was 0.74 [Table 1]. For including maximum responses, convenient sampling (where dentists were contacted by the investigators themselves) and snowball sampling (further dentists were asked to forward the questionnaire to their contact dentists and this procedure goes on further) were used in the present study.

The present study was a nation-wide, open, randomized, qualitative, descriptive, and validated^[11] online cross-sectional questionnaire survey. The sample was gathered by sending the Google link (https://forms.gle/UfKxTuEwyZssZoKt9) to all dental professionals across India through electronic means and no specific time frame was allocated. This consists of two sections; the first section consists of demographic data while the second section consists of 15 questions [Figures 1 and 2] that were used to assess the perspective levels of dental professionals regarding the second wave of the COVID-19 pandemic.

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Figure 1:

Depicts the questions from 1 to 8.

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Figure 2:

Depicts the questions from 9 to 15.

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RESULTS

[Graph 1] depicts the percentages of respondents regarding the age groups (>30 years [166] 19.46% and ≤30 years [687] 80.54%), gender (males [251] [29.43%] and females [602] [70.57%]), education BDS (571) (66.94%) and MDS (282) (33.06%), specialty (Conservative dentistry and Endodontics [33] [11.71%], Oral and Maxillofacial surgery [22] [7.80%], Oral Medicine and Radiology [14] [4.96%], Oral Pathology [4.26%], [12] Orthodontics [29] [10.28%], Pediatric and Preventive Dentistry [16] [5.68%], Periodontics [138] [48.94%], Prosthodontics [12] [4.26%] and Public Health Dentistry [6] [2.13%]) and profession whether student/clinician, academician or both clinician and academician (Academics [30] [3.52%], both clinician Academics [120] [14.07%], Clinician [164] [19.23%], and Students [539] [63.19%]).

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Graph 1:

Depicts the demographic data of the study respondents in percentages.

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In the present study, the age group variation (>30 and ≤30 years comparison) [strongly agree] has shown a significant difference (P = 0.004) for higher risk of exposure to deadly viruses such as COVID-19 and second wave was more worrying than first wave (P = 0.001). Values were statistically significant (P = 0.001) in age group variations (>30 and ≤30 years comparison) [agree] that vaccination could prevent people from getting infected. Significant (P = 0.001) agreement was also recorded regarding the vaccination drive that the population was hesitant to take and participate in the drive. A significant amount of the study population was vaccinated (P = 0.002) and has an idea of any best available vaccine (P = 0.001). The present study results also showed statistical significance (P = 0.001) regarding increased nervousness and anxiety levels in dentistry fields in age group variations (>30 and ≤30 years comparison) [Graph 2].

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Graph 2:

Depicts the association of age groups (≤30 and >30) with responses for each question regarding COVID-19. For Q6 instead of agree, strongly agree, disagree, and strongly disagree options – Yes, No, Registration done, and not interested were considered while for Q7,9, 12-14 options are Yes, No, May be, and None of the above; For Q10 – No, mild, moderate, and severe; For Q15 – No change, Little change, Moderately changed, and Severe change.

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Regarding the gender-wise comparisons, statistically significant results were recorded for vaccination which can prevent and save from getting infected (P = 0.001), despite the vaccination drive many people including health care professionals were hesitant to take vaccine (P = 0.001). Further, significance was also recorded that females were relatively vaccinated more in numbers (P = 0.001) and Covishield was reported as the type of vaccine that was received by a significant number in the study population (P = 0.006). Except for questions 4, 5 and 7 remaining questions were statistically insignificant when gender-wise distribution was compared [Graph 3].

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Graph 3:

Depicts the association of gender with responses for each question regarding COVID-19. For Q6 instead of agree, strongly agree, disagree, and strongly disagree options – Yes, No, Registration done, and Not interested were considered, while for Q7,9, 12-14 options are Yes, No, May be, and None of the above; For Q10- No, mild, moderate, and severe; For Q15 – No change, Little change, Moderately changed, and Severe change.

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When statistical comparisons were performed between BDS and MDS individuals, statistical significance was recorded for dental professionals who are at higher risk of exposure to deadly virus infections such as COVID-19 (P = 0.009). Significance was also recorded that the COVID-19 second wave was more worrying than the first wave (P = 0.007). Most dentists in the present study significantly agree that people were hesitant to get vaccinated including health care professionals (P = 0.001). A significantly higher number of the study population was vaccinated (P = 0.001) and all dentists significantly (P = 0.001) reported that any available vaccine at your place would be best. Anxiety and nervousness levels and significant values were recorded when BDS and MDS responses were compared (P = 0.001). A significantly higher number of dentists were interested to treat patients during the COVID-19 pandemic (P = 0.003) and there was a significant change in the level of personal hygiene when BDS and MDS individuals were compared (P = 0.001) [Graph 4].

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Graph 4:

Depicts the association of qualifications between BDS and MDS with responses for each question regarding COVID-19. For Q6 instead of agree, strongly agree, disagree, and strongly disagree options – Yes, No, Registration done, and Not interested were considered while for Q7,9, 12-14 options are Yes, No, May be, and None of the above; For Q10-No, mild, moderate, and severe; For Q15-No change, Little change, Moderately changed, and Severe change.

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Regarding comparisons between clinicians and students, statistical significance (P < 0.05) was obtained for dental professionals who were at high risk, the second wave was different and more worrying, rapid spread, vaccination can prevent disease, vaccination drives, best vaccine, lack of transparency, lifestyle affecting, change in hygiene, and family worrying, while remaining were non-significant (P > 0.05) [Table 2].

DISCUSSION

Dental professionals are at higher risk and stress of contracting infection due to their close approximation to the oral cavity as a part of time-consuming therapies.^[12] In the present study, younger age group, females/or clinicians (33%), and from clinical departments had given higher responses superior to the studies done by Hussein et al.,^[13] 2020 and Lugito et al.,^[14] 2020 and inferior to Shetty et al.,^[7] and Kamate et al.,^[15] 2020 which might be due to variation in the study sample size and apprehensive nature of females toward health care. Apart from this, higher occurrence of undiagnosed asymptomatic cases, aerosols generation, and saliva contact may lead to contraction of infection in dentists and supporting staff. Moreover, regarding the nerve-wracking circumstances (elections, sports events, and religious gatherings) during the second wave of COVID-19, 43–55% of dentists (overall, age/gender-wise, and educational qualification) agreed that it was a much worrisome and fearful condition which had shown greater impact on the spread of virus. Fear of isolation centers and social stigma led to an asymptomatic spread.^[16] The mortality rate has also increased within a shorter span, causing more fear in the population.

The current study revealed that 54.4% of dental professionals choose the option of a readily available type of vaccine to be taken during vaccination drive. These results are by Islam et al.,^[17] in 2021, who conducted an awareness study among residents in Delhi and reported that 72% study population were ready to take vaccines and more than 50% were ready to pay for the vaccines. Apart from this, 72% of the population stated that vaccination jabs should be given first to frontline workers. Thus, dental professionals being one of the frontline workers received their vaccination in the first sets and this was the main reason for higher percentages of vaccination. In support of this, Shacham et al.,^[18] in 2021, concluded that dentists have more awareness with a positive attitude toward vaccination than hygienists. Contrastingly, in the present study, 72–76% of dental professionals agreed that due to lack of transparency in the rationale of vaccines and their post-immunization effects, added fear even to educated people. Mucormycosis is a serious but rare fungal infection that is caused by a group of molds called micromycetes as per the Center for Disease Control and Prevention. Silva et al.,^[19] 2020, and Moorthy et al.,^[20] 2021, stated that this infection mainly affects those individuals who have compromised immune systems and those treated with steroids had a significantly increased risk for fungal infections like Mucormycosis. In the present study, 54–58% of dentists reported that COVID-19 treatment had effects on the immune system causing more vulnerability to infections like Mucormycosis (Black Fungus).

In the present study, 57–68% of dentists felt that their family members can get infected through them which is to Shetty et al.,^[7] 2020, Kamate et al.,^[15] 2020, and Lugito et al.,^[14] 2020, where they reported that dentists have higher fear of contraction of risk because reporting of patients to clinics would be disastrous, as individuals might be asymptomatic or pre-symptomatic.^[21] Moreover, dental treatments cause droplet transmission and aerosol production which might transfer the infection to various other sites and regions.^[22] The current study population has also shown a huge impact (nearly 93.2%) on academics and clinical practice, even then 42–55% of dentists were willing to treat patients and lend their helping hand. This is by a recent multi-national survey done by Abdelrahman et al.,^[10] 2021, shown that clinical practice was affected due to the closure of clinics mostly in private sectors compared to non-private sectors. The main reason behind this can be the lack of proper guidelines regarding dental treatment, the rapid spread of infection, and a greater number of positive cases.

The current study results also reported that there was a great change in the level of oral and general hygiene. In clinical practice, while dealing with dental emergency procedures, dental professionals make shorter appointments, usage of Personal Protective Equipment kits, proper mouth masks, and pre-procedural rinsing of the oral cavity using povidone-iodine or chlorhexidine gluconate or essential oil mouthwashes which would reduce the viral load and reduce that the spread of the disease has become a part of daily routine dental practice. In support of this, a study was done by Elzein et al.,^[23] 2021, concluded that povidone-iodine and chlorhexidine gluconate were effective as pre-procedural rinses against salivary SARS-CoV-2.

According to Marouf et al.,^[24] 2021, it was clearly stated that periodontitis was associated with a higher risk of ICU admission, assisted ventilation and death of COVID-19 patients. Oral diseases such as gingivitis, periodontitis, caries, abscess of the oral cavity, and poor oral hygiene will create an environment for COVID-19 to show a severe problem.^[25] This was even supported by the European Federation of Periodontology and a study done by Pitones-Rubio et al.,^[26] 2020, where it was concluded that periodontitis patients had a greater risk for COVID-19 infection contraction. Dental professionals should also participate in telephonic and video consultations so that patients will get proper guidance to brush their teeth, and reduce plaque and calculus which, further, reduces inflammation leading to good oral hygiene.^[25]

Limitations of the present study were multinational survey conductance, statistical comparisons were not performed for individual geographical areas, and greater younger people participated in the study. Lesser postgraduate and clinicians took part in the study.

CONCLUSION

Within the limitations of the present study, dental professionals have a positive perspective regarding the COVID-19 pandemic despite higher anxiety and stress levels which were seen particularly in females. Clinicians have better perception than students regarding the pandemic situation due to their regular clinical practice and up-to-date knowledge. Most dental professionals got vaccinated and had an idea regarding the type of vaccine to be taken. Apart from this, there is the responsibility of dental professionals to educate patients and the general population regarding this panic situation and to give assurance within their constraints to their patients. Further, future recommendations are necessary for doing more research on the fungal infections in COVID-19 patients which are mandatory to increase the robust surveillance of the high-risk hosts during this pandemic.