Knowledge, Perception, and Attitude on Conservative and Endodontic Practice on COVID Pandemic Situation: A Qualitative Research

Abstract

Aim:

The purpose of our study was to analyze the knowledge and attitude of conservative as well as endodontic practice among dental professionals during coronavirus pandemic situation.

Methodology:

A cross-sectional study was conducted over a period of 3 months among 1256 dental surgeons, which included 400 MDS and 856 BDS dentists. Questionnaire assessed knowledge of the participants about COVID-19, risk assessment about the pandemic, preparedness of the participants, as well as specific precautions in cases which require conservative and endodontic treatment strategies against COVID-19.

Results:

It was observed that around 83% of the study participants felt that rubber dams are a useful tool to prevent cross-infections, even COVID-19. However, COVID-19 prevention techniques such as use of low-speed handpiece and chemicomechanical techniques were preferred by a smaller number of participants: 25% of participants by former, only 12% for the latter. To prevent aerosol splatter, use of high-volume suction was preferred by 49% of dental surgeons.

Conclusion:

In our study, we concluded that dental surgeons, who come under high risk category; had good basic knowledge about COVID-19 disease process as well as transmission. However, it is imperative that these clinicians need to be extra cautious in handling cases during this pandemic time and limit the disease spread as well.

INTRODUCTION

COVID-19 has caused a terrifying situation world over, resulting in a devastating pandemic and leading to loss of life and economy everywhere. It is more contagious than other type of coronavirus infections such as MERS and severe acute respiratory syndrome (SARS).[1] According to the International Committee on Taxonomy of Viruses, this virus was named as SARS coronavirus 2 (SARS-CoV-2).[2] This viral infection is caused by the pathogen from the family of Coronaviridae, which has single-stranded RNA as its genetic material.[3] This particular infection resembles SARS and MERS.[4] Till date, four genera of this coronavirus family has been studied, which are α-CoV, β-CoV, γ-CoV, and δ-CoV.[5] In humans and mammals, α-CoV and β-CoV variants affect central nervous system and respiratory as well as gastrointestinal tract systems, and other variants affect mostly broad species.[6] When affected by this disease, the person presents with a plethora of signs and symptoms such as cough, fever, respiratory distress, diarrhea, abnormal opacities in computed tomography scans, and in some cases hemoptysis.[7] Initially it was considered as an zoonotic infection but with evidence from various studies have confirmed the person to person transmission, which is by far the most important route for rapid spreading of this pandemic.[8]

Emergence of this new strain of coronavirus has been amounted to the environmental devastation, which has been caused by humans, resulting in spread of infections from animals to humans.[9] It rapidly spreads, especially in hospital or clinical setting, resulting in serious nosocomial infection.[10] Medical staff are the most susceptible to this particular infection, as they acquire it from the nosocomial settings, which comes under high-risk category.[2] Dental clinics also come under high risk category setting as close contact is very much possible with a virus infected individual and the treating dental doctor.[11] Considering that COVID-19 is extremely contagious, it is generally recommended that the patients suffering from this infection are not supposed to be treated for dental diseases, but emergencies can always turn the situation around. This becomes even more challenging when prolonged incubation period of the disease is considered, which is 5–14 days, where the detection of symptoms is ambiguous, leading to extensive spread in this lay period.[3,12] Hence, asymptomatic patients are a great threat to dental settings, so proper awareness needs to be there in the dental team to handle any type of situations related to COVID-19. Guidelines have been by various health organizations such as CDC and ADA as well as the WHO to slow down the spread of infection of coronavirus. They emphasize on the use of personal protective equipment, thorough screening of the patients and staff, disinfection of the premises of the clinic, rubber dam isolation, etc., It is essential to be familiar with these guidelines and deal with the prevention as well as control of this disease in a sophisticated manner.^[1.13] We carried out this research to assess the knowledge as well as awareness about this infection, how to handle situations in these pandemic times among dental professionals.

Aim of the study

The purpose of our study was to analyze the knowledge, perception, and attitude of conservative as well as endodontic practice among dental professionals during coronavirus pandemic situation.

METHODOLOGY

A cross-sectional study was conducted over a period of 3 months among 1256 dental surgeons, which included 400 MDS and 856 BDS dentists. An online Google Form containing 31 close-ended questions was circulated to assess knowledge, attitude, and preparedness of COVID-19 among Indian dentists. Participants' confidentiality was maintained throughout the study. The questionnaire was created in English language and was divided into five parts concerning with demographic characteristics, knowledge about COVID-19 infection, perception of risk in the present situation, how prepared were they to handle this situation, and finally specific precautions in cases which required conservative and endodontic treatments.

Cronbach's alpha test was used to assess the validity of the questionnaire given to the dental surgeons, which also evaluated that if the questions were easily understandable for the study participants. For knowledge as well as risk perception questionnaire segment, the test values were 0.835 and 0.821, respectively, which established that the questions were well structured and easily understandable among the participants.[14] The collected data were analyzed with the help of Statistical Package for the Social Sciences (SPSS ver 22.0, IBM Corporation, USA), where the categorical variables were n%, and for continuous variables, standard deviation and mean were calculated. P < 0.05 was considered statistically significant.

RESULTS

Only 12% of the dental participants had undertaken training for COVID-19 prevention [Table 1]. As far as knowledge about COVID-19 disease was concerned, around 68% of the dental participants were aware about various diseases caused by coronavirus. 77% of the dental participants were aware that real-time polymerase chain reaction was a gold standard test to diagnose COVID-19. However, only 43% of the dental participants knew about the actual incubation period of the disease, which was important to understand and control the disease process [Table 2]. 12% of dentists had wrong perception that COVID-19 was not contagious, and 37% of them believed that wearing just surgical masks will suffice during the time of treatment. However, fortunately, 72% of dentists believed that PPE kits are necessary to prevent COVID-19 spread, which was encouraging. 68% of all participants believed that high aerosol splatter procedures such as ultrasonic scaling and usage of high handpiece should be undertaken with great care, as it causes cross-contamination as well as infection spread [Table 3]. Around 73% of dentists felt the need to train their staff members against COVID-19 prevention techniques. 86% of participants also advocated the use of pulse oximeter and thermal screening for all the patients as well as staff members on a regular basis. In these days, telephonic consultations have become popular for nonemergency cases, but only 12% of the dentists believed that it can be a helpful alternative to conventional visit to dentists for elective procedures. High-efficiency particulate air (HEPA) filters to filter out pathogens from the air were only preferred by 13% of participants [Table 4]. It was observed that around 83% of the study participants felt that rubber dams are a useful tool to prevent cross-infections, even COVID-19, which was also statistically significant (P = 0.001). Disinfection of frequently touched areas by sodium chloride was important according to almost 91% of participants. Most of the participants (83%) were also in favor of using single-use disposable instruments to prevent infection spread. However, COVID-19 prevention techniques such as use of low-speed handpiece and chemicomechanical techniques were preferred by a smaller number of participants: 25% of participants by former, only 12% for the latter. To prevent aerosol splatter, use of high-volume suction was preferred by 49% of dental surgeons, which was not statistically significant (P = 0.603) [Table 5].

Table 1.

Demographic characteristics of the participants

Parameter	Distribution of the study participants (%)
Age group (years)
<30	23
30-40	32
40-50	29
>50	16
Gender
Duration of practice (years)
<5	59
>5	41
Educational status
MDS	31.8
BDS	68.2
Specialty of dentistry
Endodontist	34
Periodontist	18
Oral surgeon	19
Orthodontist	2
Pedodontist	1
Public health dentist	6
Oral pathologist	6
Oral medicine	3
Prosthodontist	10
Training taken for COVID-19
Yes	12
No	88

Table 2.

Knowledge about COVID-19 disease among the participants

Question number	Questions	Correct answer received from participants (%)
1	Among these which is coronavirus?	e) All (68)
	a) Common cold
	b) MERS
	c) SARS
	d) COVID-19
	e) All
	f) Do not know
2	Which is more lethal (high mortality)?	b) MERS (12)
	a) SARS
	b) MERS
	c) COVID-19
	d) Do not know
3	COVID-19 is caused by which of the following virus-	a) SARS-CoV-2 (72)
	a) SARS-CoV-2
	b) SARS-CoV
	c) MERS-CoV
	d) Do not know
4	What is the incubation period of COVID-19 virus? (days)	b) 2-14 days (43)
	a) 2-7
	b) 2-14
	c) 1-5
	d) 1-21
	e) Do not know
5	What is the laboratory test available to diagnose COVID-19?	a) rRT-PCR (77)
	a) rRT-PCR
	b) ELISA
	c) Western blot
	d) DNA hybridization
	e) Do not now

MERS: Middle East respiratory syndrome, SARS: Severe acute respiratory syndrome, rRT-PCR: Real-time reverse transcriptase polymerase chain reaction, CoV: Coronavirus

Table 3.

Risk perception of COVID-19 among the participants

Question number	Questions	Response received from participants (%)
1	Perception about COVID-19
	Contagious	88
	Noncontagious	12
2	Under which category do dentists fall in the risk of exposure?
	High risk	81
	Low risk	19
3	Which mask should be used by dentists in dental settings?
	Surgical mask	37
	N-95 mask	63
4	Are the personal protective equipment kits useful in protecting from confirmed/suspected COVID-19 patients?
	Yes	72
	No	28
5	What dental procedures carry the maximum risk of virus transmission while treating a COVID-19-positive patient?
	Ultrasonic scaling and using high-speed handpiece	68
	Procedures under rubber dam	30
	Lasers	2

Table 4.

Level of preparedness among the dentists for general practice

Question number	Questions	Response received from participants (%)
1	Dentist should provide adequate training to their staff to promote preventive measures
	Yes	73
	No	27
2	Do you know whom to contact if you have an unprotected exposure to a known or suspected COVID-19 patient?
	Yes	56
	No	44
3	Can telephonic consultation be employed for non-emergency procedures?
	Yes	12
	No	86
4	Follow up on patients telephonically, if they have symptoms?
	Yes	9
	No	91
5	Usage of pulse oximeter and thermal screening of patients and other staff members regularly
	Yes	86
	No	14
6	Use of HEPA filters with commercial split and centralized/window ACs
	Yes	13
	No	87

HEPA: High-efficiency particulate air, ACs: Air conditioners

Table 5.

Specific precautions in case of conservative and endodontics

Question number	Questions	Response received from participants (%)	P
1	Are rubber dams useful for infection control in COVID-19?
	Yes	83	0.001
	No	17
2	Disinfection of frequently touched surfaces with NaOCl and ethanol		0.003
	Yes	91
	No	9
3	Preference of low-speed handpiece for access opening?
	Yes	25	0.041
	No	75
4	Preference for chemicomechanical methods for necrotic pulpal tissue cleaning over conventional methods
	Yes	12	0.011
	No	88
5	Preference to only emergency treatments
	Yes	31	0.523
	No	69
6	Use of high-volume suction
	Yes	49	0.603
	No	51
7	Disposable single-use instruments
	Yes	83	0.04
	No	17
8	Division of treatments based on endodontic emergency needs, urgent care, and for elective reasons
	Yes	23	0.2
	No	77
9	Single visit treatment preferred
	Yes	67	0.348
	No	33

*P<0.05 significant

DISCUSSION

Coronavirus infection has infected millions of people worldwide, especially the health-care professionals.[15] Dental professionals work in close contact with blood and saliva, so they also come under this very high-risk category.[16] Even though during daily practice, those professional have been handling cases with tuberculosis and HIV, but handling a pandemic is proving to be a tough task ahead for them.[17] SARS infection in a dental clinical setting was first observed in the year 2003, but this infection has an acute phase of fever, which prevented them to visit clinic again during the symptomatic period. So, people used to self- isolate themselves due to the acute phase which is not the case in COVID infection, where asymptomatic patients spread the infection further rapidly.[18] However, in case of COVID, the situation is much worse due to asymptomatic patients, where the presence of virus in saliva results in spreading in clinic setting much faster.[19] Aerosol splatter has proven to be the most effective way for the spread of coronavirus, which can spread to a distance of even 18” or more.[20] ADA has, therefore, provided some guidelines, so that only emergency treatment should be given preference over the elective ones with minimal contact or preferable no contact methods like teledentistry.[19] Dental surgeons are these days very much concerned about working in this pandemic situation.[21] Hence, adequate knowledge regarding COVID disease, will be the only way ahead.[22] In an endodontic setting, COVID patients should be entertained only for emergency treatments or palliative (pharmacologically) with adequate precautionary measures. It is imperative to handle working in the pandemic situation, to divide dental procedures on the basis of the urgency. The treatments can be divided into ones which are emergency procedures and procedures that are elective and can be postponed for a later date. According to the CDC guidelines, it is mandatory to wear N95 masks with eye goggles or face shields for the dental professionals to reduce cross-contamination due to aerosol. In case of endodontic microscopes, a plastic barrier can be created attached to the binoculars, so that a physical barrier is created. Whenever possible, extraoral radiography like cone-beam computed tomography needs to be encouraged to have minimal contact with the patient. If intraoral radiographs are a necessity, it should be in limited amount. To limit the aerosol spread, usage of rubber dam has been strongly advocated, so that maximum coverage of patient tissues is there and less of blood and saliva contact. This can reduce the airborne spread by 90%.[23] Vacuum suction can also be utilized as it removed the contaminated air up to 2.83 m³/min.[24] HEPA filters are also an effective device, which removes 99.97% of the airborne particles measuring 0.3 μm, which can be utilized to purify air in dental settings.[25]

Single visit treatments need to be encouraged, so that canal disinfection can be done in cases of symptomatic apical periodontitis or in cases of apical abscess. If treatment cannot be completed in a single setting, after complete debridement of canal, intracanal antibacterial medicament needs to be placed in cases requiring immediate intervention.[26] Vital pulp therapies are effective in case where single sittings are preferred as they can reduce pain as well as are successful treatment strategies. To minimize posttreatment pain and discomfort, occlusal reduction would be an ideal strategy.[27] In case of traumatic injuries, it is advisable to refer the patient to a dental setting where special equipment are present to handle such situations; meanwhile, the avulsed tooth needs to be transported properly in a storage medium like milk. IADT guidelines need to be followed for any recovered COVID patients. However, pharmacological interventions should take a front seat during these pandemic times.[28] In our study, we noticed that most of the dental professionals were aware of the pandemic situation as well as the measures taken to control the same in their clinics. The respondents have recorded a good judgment about the risk perception as they know they fall in the high-risk exposure category and showed a positive attitude toward performing dental treatment in the current COVID-19 crisis. However, certain modifications were needed their way of working to adjust to the COVID era of working.

CONCLUSION

Dental surgeons come under high-risk group, so they need to extra prepared to handle and prevent the spread of COVID-19. They should follow the guidelines given by the WHO and CDC verbatim along with training programs, so that safe as well efficient treatment can be provided to the patients in this pandemic era.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.