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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 137-144

Emergency preparedness of oral health professionals during COVID-19 pandemic: A knowledge, attitude, and practices study


1 Department of Oral and Maxillofacial Surgery, Sudha Rustagi Dental College, Faridabad, Haryana, India
2 Department of Pedodontics, Dr HSJIDS, Panjab University, Chandigarh, India
3 Department of Oral Maxillofacial Surgery, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
4 Department of Prosthodontics, Himachal Dental College, Sundernagar, Himachal Pradesh, India
5 Sub-Investigator, Community Dentistry and Oral Disease Prevention, Eastman Institute of Oral Health, Rochester, New York, USA
6 Astt Professor of Clinical Dentistry, University of Rochester Medical Center, School of Medicine and Dentistry, New York, USA

Date of Submission07-Jun-2020
Date of Decision16-Jul-2020
Date of Acceptance01-Aug-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Pankaj Bansal
Professor, Department of Oral and Maxillofacial Surgery, Sudha Rustagi Dental College, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_88_20

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  Abstract 


Background: Coronavirus disease 2019 (COVID-19) is an emerging respiratory disease caused by a novel coronavirus and was first reported in Wuhan, China. Affecting almost 207 countries, COVID-19 was declared a pandemic on March 11, 2020.[1] Considering social distancing as first-line measure of reducing the transmission of disease, nationwide lockdown in India was announced. Health-care professionals and first responders are considered to be high-risk groups for the transmission of the virus. As oral health professionals form, a significant risk group for infection and need to take all transmission-based precautions to prevent the transmission of the disease. Keeping that in view, various advisories were also issued to provide interim guidance to the dental practitioners during this pandemic. This study was designed to have an insight into problems and deficiencies faced by the dental fraternity in the practical application of their knowledge in today's changing scenario. Objectives: The aim of this study was to assess the knowledge, attitude, and practices of dentists across North India during the COVID-19 pandemic. Materials and Methods: Dental practitioners across North India were requested to take part in the online survey. Survey forms were sent in the form of Google document. Four hundred and ten survey questionnaires were sent to dental practitioners in the northern Indian region. Three hundred and thirty responses were received with response rate equivalent to 80.4%. Statistics were applied to analyze the responses. Conclusion: Dentists across North India are well informed and aware of the changing scenarios during COVID-19 Pandemic. They seemed to be optimistic and trying to keep themselves abreast of the latest guidelines and providing emergency dental care in the best possible way with an intent to serve their community.

Keywords: COVID-19, dental practitioner, knowledge, attitude, and practices survey


How to cite this article:
Bansal P, Agnihotri A, Gupta A, Singh G, Kaur A, Arora R, Singh S. Emergency preparedness of oral health professionals during COVID-19 pandemic: A knowledge, attitude, and practices study. Indian J Dent Sci 2020;12:137-44

How to cite this URL:
Bansal P, Agnihotri A, Gupta A, Singh G, Kaur A, Arora R, Singh S. Emergency preparedness of oral health professionals during COVID-19 pandemic: A knowledge, attitude, and practices study. Indian J Dent Sci [serial online] 2020 [cited 2020 Sep 19];12:137-44. Available from: http://www.ijds.in/text.asp?2020/12/3/137/292280




  Introduction Top


In early December 2019, pneumonia cases of unknown origin emerged in Wuhan, China.[1] This outbreak caused by coronavirus was stated as a public health emergency of international concern by the WHO on January 30, 2020.[2] Corona viruses are a group of viruses that primarily infect the upper respiratory and gastrointestinal tract of birds and mammals.[1] Infected hosts exhibit different clinical courses, ranging from asymptomatic to severe symptoms in their respiratory, digestive, and genitals organs.[3],[4] Due to its rapid spread across the globe, novel coronavirus disease (COVID-19) outbreak was declared a pandemic on March 11, 2020[1] and on March 24, a nationwide lockdown was announced in India for 21 days to control the spread of the disease.[5] This unprecedented spread and very little information on novel coronavirus response of the World Health Authorities were left much to be desired. Confusions, misinformation, and opinions without much scientific basis prevailed even in scientific communities. It became imperative to update the literature fast enough to fill in scientific information gaps. Meanwhile, simultaneous research, studies in various countries throwing up newer facts every other day with or without peer review, dental fraternity too was left in dismay. As dental settings have unique characteristics and needs additional infection control considerations. Oral health-care provider forms one of the highest risk groups in acquiring and transmitting the infections. Thereby, Centre of Disease Control (CDC) issued interim guidelines besides following the standard precautions which urged dental practitioners to postpone elective procedures, surgeries, nonurgent dental visits, and to contact the patient before the initial visit. The Indian Dental Association (IDA) and Indian Endodontic Society in a joint position statement strongly recommended that a dental practitioner should not treat a patient in his/her dental office UNLESS they can comply with the emergency preparedness checklist.[7] This checklist includes disinfection and sterilization protocol, personal protective equipment (PPE) including N95 face masks, face shields, and protective outerwear.[7] This advisory also stated those patients only requiring emergency care should be considered for treatment in a well-equipped dental clinic adopting strict protective measures; rest all patients should be tele-consulted, managed pharmacologically and scheduled for the care later on priority once the regular dental services are restored.[7]

This survey is, therefore, an attempt to assess the knowledge, attitude, and practices (KAP) of dentists across North India during the COVID-19 pandemic which could help us evaluate changing dynamics, understanding of dental professional's attitude, and the impact of novel coronavirus on their dental practice.

Aim of the study

The aim is to assess KAP of dentists across North India during COVID-19 pandemic.


  Materials and Methods Top


A cross-sectional questionnaire-based online survey with convenience sampling was conducted. The survey questionnaire was prepared immediately after the lock down in India, to assess their knowledge, attitude, and practices during COVID-19 pandemic and what changes can be incorporated in their dental practices once the services resume. The questionnaire [Annexure 1] was shared in the form of Google document through various channels such as WhatsApp, Facebook messenger, and E-mails to 410 dental practitioners in North India. The questionnaire survey was opened on March 31, 2002, and closed on April 6, 2020 midnight. Participation in the study was totally voluntary. A total of 330 responses were received. These responses were analyzed statistically.



Questionnaire design

The questionnaire consisted of 24 self-prepared questions and had two parts. The first part focused on the demographics that included personal information regarding gender, qualification, years into practice and type of (Private or Government). The second part included questions that assessed KAP of dentists practicing across North India. A pilot study was done for identifying flaws in a questionnaire. Appropriate amendments were done in the questionnaire. A validation questionnaire was sent to the oral health-care professionals practicing across North India.


  Results Top


The data collected were subjected to Statistical analysis using SPSS 21.0 (IBM, Chicago, United States). Chi-square analysis was used to analyze statistical significance difference in the response between different groups. Statistical significance was set at P < 0.05.

Out of a total of 330 responded, there were 129 males (39.1%) and 201 females (60.9%). Qualification distribution revealed 54.5% as dental graduates (BDS) and 45.5% as dental specialists (MDS). 20.6% of the respondents were working in a government set up whereas 79.4% were into private practice. The professionals were also categorized based on the experience; 46.7% were having <5 years of work experience, 24.2% were under the bracket of 5–10 years, while 29.1% had more than 10 years into practice [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Table 1: Demographic profile of survey participants

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Figure 1: Gender distribution of participants

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Figure 2: Qualification characteristics of participants

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Figure 3: Type of practice of survey participants

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Figure 4: Work experience of participants

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The participants irrespective of their qualifications or years into practice were aware of guidelines being issued by various dental associations and knew who all can issue guidelines during a pandemic for oral health-care professionals.

Majority of the respondents whether graduate and postgraduate, young or experienced displayed good knowledge scores regarding cases requiring emergency dental care (93.0%), the effective disinfectant for general areas in clinical settings (63.3%), and the importance of using N95 even during the consultation (71.2%). At the same time, there was a significant difference between the knowledge of postgraduates (79.3%, 93.3%) and graduates (67.2%, 83.3%) regarding aerosol free procedures, the armamentarium (PPE) required besides N95 masks for aerosols producing procedures, respectively. The knowledge regarding the procedures requiring mandatory use of respirators such as N95, FFP2 increased consistently with an increase in the years into practice. One-third of the respondents irrespective of their qualifications were aware of the inefficacy of chlorhexidine against coronavirus as a preprocedural rinse. Almost 20.3% of the respondents knew the age group which is most likely to remain asymptomatic despite being infected. About 27.9% of the respondents were aware for the number of days an infected individual after becoming asymptomatic can be a carrier. One-third of the respondents were aware of the ongoing research and regarding drugs besides hydroxychloroquine[8] for the treatment of COVID-19. Although the knowledge was found to be good (65.8%) regarding the maximum viral load in the 2nd week after getting infected. Surprisingly, only 37.6% of respondents were aware of the drug Ibuprofen to be used with caution for pain relief during COVID-19 pandemic but the difference was found to be statistically significant.

[Table 2] describes the knowledge score of dental professionals.
Table 2: Knowledge

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The attitude of the dental professionals did not vary much based on the qualification except on deciding the list of emergency procedures, most of the graduates were in favor that it should be left at the discretion of the operating dentist himself followed by IDA whereas postgraduates voted for operating dentist himself followed by IDA and specialty associations as well. Young dental professionals were more in favor of IDA deciding for them, reading the list of emergency procedures which shifted toward deciding themselves as the years in the practice increased. Dental professionals were of the view that if the dentists become infected while treating the patients during a pandemic either health insurance companies (45.8%) or the dentist himself (31.5%) should pay for the treatment and surprisingly only 18.8% respondents wanted that it should be paid by the premium on the services paid by the patients.

[Table 3] and [Table 4] depict the attitude and practices of dental professionals across North India during COVID-19 pandemic.
Table 3: Attitude

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Table 4: Practice

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For the number of dentists still working during the lockdown, the difference was not statistically significant. Almost half of the respondents were found to be working either by providing teleconsultations (28.2%), performing all emergency procedures (7.9%), or only nonaerosol-generating emergency procedures (12.7%). More postgraduates versus graduates were doing teleconsultations, aerosols free emergency procedures, and found themselves equipped enough to manage the patients during the pandemic. Half of the respondents (50%) believed to use hydroxychloroquine[8] as a prophylactic measure for their dental team in the present scenario.

Almost all (88.2%) the respondents were eager to upgrade their practices and include all the necessary types of equipment in their daily practice after the COVID-19 outbreak such as visual alert posters, cough etiquettes, hand hygiene protocol, alcohol-based hand rub at the entrance, modification of existing patient waiting area to maintain 1–2 m of social distancing, avoidance of air conditioners unless equipped with HEPA filters, nonoverlapping appointments, providing surgical masks to each patient at the entrance, discouraging patient escorts.


  Discussion Top


Dissemination of uniform, well-proven, evidence-based, workable information is the biggest challenge as of now. It is indeed a herculean task to gather, process, and disseminate changing scientific evidence at a pace that has never been required in the last century. Most studies are short, nonpeer reviewed and do not match the reliability index. Some studies can at best be termed as case series rather than randomized blind/controlled studies. However, in the present scenario evidence-based data as fluid, as it is, is probably the best scientific community has to offer. While doing this study, we knew that this too might have to stand the test of time yet it definitely can prove to be a stepping stone to more concrete steps in the future.

To the best of our knowledge, it is the first time a survey among Indian oral health-care providers has been conducted to assess the knowledge, attitude, practices of dentists in North India during the COVID-19 pandemic.

According to CDC, in most of the dental clinical setups, providing care for patients needing transmission-based precautions is not possible as they are not designed for or equipped to provide this standard of care due to their lacking on airborne infection isolation rooms (AIIRs) or single-patient rooms, a respiratory protection program and N95 respirators.[6] During this period of the extreme shortage of PPEs, controlling exposures to occupational infections is a fundamental method of protecting health-care professionals and prevent its spread.

In the present study, it is promising to know that irrespective of their qualification (Graduate/Postgraduate) dentists were aware of the advisory issued by various dental associations and the majority of the clinical practices were shut following the advisory issued by the government and dental associations. At the same time to provide the best oral health-care professionals was providing teleconsultation and elective emergency care with limited resources. In the study, there was confusion among the professionals about what constitutes a dental emergency needing intervention and what can be treated pharmacologically on an urgent basis. Almost one-third of the professionals believed that it should be left to the discretion of the operating dentist to decide whether a patient needs emergency care or not followed by IDA to decide for them. The majority had the knowledge regarding the efficacy of general disinfectants for clinical settings and the safest method to treat caries without producing aerosols but at the same time, almost one-third of the respondents were not aware of the nonefficacy of chlorhexidine as preprocedural rinse against novel coronavirus.

The majority of the respondents were clear about the timeline of the maximum viral load after getting infected but some of the aspects that were not very well understood about the novel coronavirus were infectivity graph and age groups for the most asymptomatic patients. According to a study conducted by De Chang et al., half of the patients that were treated for COVID-19 infection kept shedding the virus for up to 8 days after symptoms disappeared requiring 2 weeks extended quarantine even after symptomatic recovery.[8] Shen et al mentioned in their experts' consensus statement regarding diagnosis, treatment and prevention of novel corona virus infection that children up to 17 years mostly were found to be asymptomatic or had mild symptoms with a good prognosis.[9]

More than half number of practitioners were in favor of administering hydroxychloroquine[10] to the dental team as a prophylactic measure and had good knowledge about other drugs under trials to combat the effects of the virus and hasten the recovery for the patients infected with COVID-19.[10] It could be implied that the lack of appropriate personal protective measures in place and time taken to upgrade the operatory; all these factors were making the practitioners think of alternative prophylactic measures to protect themselves and the staff.

Surprisingly, only 16.4% dentists wanted the patient to bear the cost of their treatment while others believed that insurance companies, dental associations, and the dentist himself should pay for the event of treating dentists getting infected during the pandemic. This can be implied from this survey that there is an urgent need for insurance companies to provide better health-care plans to support the oral health-care providers and dental staff both during pandemics and in normal situations.

It was reassuring to see that a large majority of dentists understood the importance of every component including N95 face masks, protective eyewear, protective outerwear and face shields, high volume evacuation, and negative pressure or airborne infection isolation rooms for treating patients during such outbreaks. The providers had a good understanding of aerosols generating procedures and aerosols free procedures. Providers seemed to be highly motivated in bringing a total change in the functioning and setup of their operatory including visual alerts posters, cough etiquettes, hand hygiene protocol alcohol-based hand rub at the entrance, modification of existing patient waiting area to allow 1–2 meters of social distance, avoidance of air-conditioners unless equipped with HEPA filters, nonoverlapping appointments, providing surgical masks to each patient at the entrance, and discouraging patient escorts. It was encouraging to see that dental professionals have established their scientific knowledge and are eager to provide evidence-based oral health care to the community.


  Conclusion Top


The current study strongly recommends the need for the central authority of dental professionals to provide interim regulations in the form of mandatory Online CDE programs and training with constantly upgrading guidelines. As the anticipated timeline for return to routine levels of PPE is not yet known this authority must assess, calculate, and facilitate the PPE optimization within a stipulated time for both government and private sectors. A high-level research committee may discuss and provide a detailed plan to the authorities related to required research, knowledge flow, patient education, types of equipment to meet the challenge posed by novel COVID-19 to the humanity. This will not only prevent the transmission or acquisition of the novel viruses while providing dental care to the patients but also protect dental practitioners, patients, and dental teams from increasing threat from emerging novel viruses and pandemics. From the study, we concluded that oral health-care professionals have risen to occasion with an intent to serve the community; trying to acquire the latest know-how of research, studies, and situations while being equally concerned about their patient's needs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
PM Calls for a Complete Lockdown of the Entire Nation for 21 Days. Available from: https://pib.gov.in/PressReleseDetail.aspx?PRID=1608009. [Last accessed on 2020 Apr 02].  Back to cited text no. 2
    
3.
Holmes KV, Lai MMC. Coronaviridae and their replication. In: Fields BN, Knipe DM, Howley PM, editors. Fields Virology. 3rd edn. Lippincott-Raven; Philadelphia: 1996. p. 1075.   Back to cited text no. 3
    
4.
Monchatre-Leroy E, Boué F, Boucher JM, Renault C, Moutou F, Ar Gouilh M, et al. Identification of Alpha and Beta Coronavirus in Wildlife Species in France: Bats, Rodents, Rabbits, and Hedgehogs. Viruses 2017;9:364. doi: 10.3390/v9120364. PMID: 29186061; PMCID: PMC5744139.  Back to cited text no. 4
    
5.
Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol 2019;17:181-92.  Back to cited text no. 5
    
6.
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Available from: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. [Last accessed on 2020 Apr 02].  Back to cited text no. 6
    
7.
Endodontic and Dental Practice During COVID-19 Pandemic: Position Statement from Indian Endodontic Society. Available from: https://www.ies.org.in/images/dental-practice-covid19.pdf. [Last accessed on 2020 Apr 02].  Back to cited text no. 7
    
8.
Chang D, Mo G, Yuan X, Tao Y, Peng X, Wang FS, Xie L, et al. Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection. Am J Respir Crit Care Med. 2020;201:1150-2. doi: 10.1164/rccm.202003-0524LE. PMID: 32200654; PMCID: PMC7193851.  Back to cited text no. 8
    
9.
Shen K, Yang Y, Wang T, Zhao D, Jiang Y, Jin R, et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement. World J Pediatr 2020;16:223-31. doi: 10.1007/s12519-020-00343-7. Epub 2020 Feb 7. PMID: 32034659; PMCID: PMC7090771.  Back to cited text no. 9
    
10.
Hydroxychloroquine Reduces Viral Load in COVID-19 Patients. Available from: https://www.virology.ws/2020/03/19/hydroxychloroquine-reduces-viral-load-and-symptoms-in-covid-19-patients. [Last accessed on 2020 Apr 02].  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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



 

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