key: cord-0800978-jpxz910x
authors: Jum’ah, Ahmad A.; Elsalem, Lina; Loch, Carolina; Schwass, Donald; Brunton, Paul A.
title: Perception of health and educational risks amongst dental students and educators in the era of COVID‐19
date: 2020-11-29
journal: Eur J Dent Educ
DOI: 10.1111/eje.12626
sha: 20485fb8a0268c61e2e6108260c560178c1c24c4
doc_id: 800978
cord_uid: jpxz910x

OBJECTIVE: To investigate the perceived educational and health risks associated with the COVID‐19 pandemic amongst dental students and educators. METHODS: A 17‐item electronic survey was sent to 496 undergraduate dental students and 53 clinical faculty members who attended clinical sessions during the outbreak period. The survey explored various aspects related to primary sources and prevention of disease exposure, dental management of suspected cases, impact of COVID‐19 on students’ clinical performance and effects of suspension of educational activities on academic performance and clinical competence. RESULTS: The response rate of the students’ was 60.7% (n = 301). The majority of students reported that performing clinical work during the outbreak posed significant health concerns, resulted in a significant stress and negatively affected their clinical performance. The majority of students believed that aerosols generated during dental procedures are the major source for disease exposure and universal protective equipment is not effective for prevention. The decision to suspend teaching activities was supported by 89% of the students. Opinions were divided regarding the impact of the suspension on the academic performance and clinical competence. Educational videos were the most preferred form of distance education. The response rate of faculty members was 60.4% (n = 32). Responses of faculty members were similar to students, though fewer concerns were reported regarding the risk of disease transmission. All respondents agreed that extra‐precautionary measures are required to ensure optimum protection against disease exposure. CONCLUSIONS: The recent COVID‐19 outbreak has adversely affected various elements of dental education. High levels of major health risk perception were noted amongst students and educators. The interruption to academic and clinical activities may lead to an inevitable skill deficit within the new generation of dental graduates. Educators are under significant pressure to accommodate abrupt changes in teaching methods, find solutions to mitigate skill deficit and ensure safe clinical practice once clinical activities are resumed.

The emergent coronavirus disease-2019 (COVID- 19) pandemic has led to a significant global crisis owing to the rapid spread and high morbidity and mortality rates. 1 Respiratory droplets containing the novel virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are the primary contagion of the disease. 2 The spread of the causative agent is primarily mediated by inhalation of respiratory droplets or direct contact with contaminated surfaces. 3 Faecal-oral and air-borne routes of transmission have also been reported. [4] [5] [6] The role of asymptomatic and pre-symptomatic infected subjects in COVID-19 transmission to close contacts and healthcare providers is still controversial. 7 Family clusters have been related to cases positive for SARS-CoV-2 RNA 7-9 whilst other reports demonstrated a lack of evidence to support such findings. 7, 10, 11 Prevalence of asymptomatic cases is dependent on disease activity, the number of confirmed cases and the number of random tests. 7 Studies from areas with varied disease activity and at different stages of the pandemic revealed that the prevalence of asymptomatic COVID-19infected cases can be in the range of 0.003%-1.4%. 7, [12] [13] [14] The COVID-19 pandemic has increased the burden on already strained health services worldwide. 15 The lack of a tested vaccine for the SARS-CoV-2 or evidence-based treatment protocols with longterm positive outcomes have added to the distress of the current situation. 16 Several countries have undertaken extreme and radical measures in an attempt to achieve containment of the disease and to flatten the COVID-19 curve. Nationwide lockdowns have been imposed, home quarantines have been instated, travel restrictions and borders shutdown have been witnessed across the globe.

In several countries, suspension of educational activities has been implemented in all academic institutions aiming to reduce disease transmission amongst large cohorts of staff and students.

Clinical activities within dental schools were amongst the earliest to be suspended. This was attributed to the risk of disease exposure and transmission in dental settings. 17 Dentists and allied dental personnel were ranked amongst the high-risk category according to the risk of disease exposure per profession. [18] [19] [20] Such risk can be attributed to the close physical proximity to patients during treatment, high possibility of contacting respiratory droplets and contaminated body fluids, a moral obligation to treat patients in pain and inability to make a decision for self-isolation. Almost all dental procedures generate significant contaminated splatter and aerosols that can be suspended in air for extended periods. 3, 4 Instruments and surfaces contaminated with various body fluids of an infected individual are another source of virus transmission. 3, 17 Inhalation of such aerosols or direct contact with mucosal membranes may lead to transmission of the disease to dental personnel and other patients. Injuries with contaminated sharp objects can also lead to disease transmission. 3, 17 The pace and extent of disease transmission can be alarming particularly in dental teaching facilities. The increased risk can be related to (a) the large number of patients and their companions who are present in a confined space, (b) the large amount of aerosolised body fluids generated during the use of multiple hand-pieces and ultrasonic scalers simultaneously, 3 (c) the architectural design of teaching clinics where aerosols can affect several individuals through the interconnected dental units, (d) inadequate adherence to infection control protocols by less experienced undergraduate students and (e) administrative staff members who have access to dental clinics without personal protective equipment (PPE) who can possibly spread the infection through their workplaces. That being said, strong adherence to cross infection control policies seems to limit disease transmission in dental settings. In Wuhan city where the pandemic started, nine staff members of Wuhan School and Hospital of Stomatology have been diagnosed with Epidemiologic investigation of the nine cases suggested that the infection was not acquired as a result of clinical activities within the dental school. Further, the number of cases did not increase despite the large number of patients who attended the dental school during the peak of the pandemic. 20 Moreover, a recent study has demonstrated a low risk of COVID-19 transmission in dental offices as a result of the already instated infection control policies and precautionary measures. 7 The suspension of educational activities poses few challenges in theoretical disciplines. Advances in internet based-communication, videoconferencing applications and educational blogs have facilitated efficient delivery of the theoretical educational content. In fact, it has been reported that teaching didactic dental subjects by videoconferencing was as effective as traditional face-to-face seminars. 21, 22 However, clinical courses are designed primarily to ensure students' competence in routine dental procedures. Such clinical skills and expertise cannot be optimally gained without a supervised patient treatment experience.

The entire educational sector has been disturbed by the current global crisis. Dental students and educators are amongst the most affected being at risk of exposure to an unprecedented and potentially fatal disease. 3, 20 Furthermore, significant interruption to the educational process may adversely affect the development of students' competencies. The aim of this study was to investigate, using an electronic survey, the health and educational risks of COVID-19 as perceived by dental students and educators.

A focus group comprised of four faculty members who were actively involved in dental education developed an initial version of the survey. A pilot questionnaire was distributed to five faculty members and twenty-five students. Feedback was collected regarding the clarity and order of questions, and whether questions 

The response rate was 60.7% (n = 301) for dental students and 60.4% (n = 32) for faculty members. Table 1 summarises the demographics of the respondents.

The majority of students (n = 279, 92.7%) considered themselves being at an increased health risk whilst practicing in the dental teaching clinics during the early period of the COVID-19 pandemic.

A lower percentage was reported amongst respondent faculty members (n = 25, 78.1%). Spreading the disease to family members was the primary concern of the majority of students and faculty members (n = 285, 86% and n = 24, 75%, respectively). 

Universal precautions and standard PPE were considered ineffective by 59.1% (n = 178) of the respondent students and 40.6% (n = 13) of the respondent faculty members. The majority of faculty members (81.3%, n = 26) reported that they would instruct students not to treat any patient with obvious symptoms of a respiratory tract infection. Further, only one-third (n = 10) of faculty members would allow students to treat a patient who had recently travelled to a country with a high incidence of COVID-19. Less than two-thirds of students stated that they would refuse to treat any patient with an obvious respiratory tract infection (64.5%, n = 194) or recent travel history to COVID-19 hotspots (65.1%, n = 196). Patient flow and commitment to dental appointments were adversely affected during the COVID-19 outbreak according to 59.8% (n = 180) of students and half (n = 16) of faculty members. The respondents reported the use of, or the need for, several additional precautionary measure(s) to prevent the exposure to COVID-19 such as advanced PPE, restriction of dental treatment to emergency cases only and measuring patients' and staff members' body temperature as a precautionary measure ( Figure 2 ). of students. Institution updates and social media platforms were utilised by 57.3% (n = 173) and 54.8% (n = 165) of the students, respectively. Less than 50% of the students referred to news reports and scientific papers. Scientific papers (n = 24, 75%,) were the second most utilised resource, whilst social media platforms (n = 11, 34.4%) were the least visited for this purpose by the respondent faculty members.

The majority of respondent students (n = 268, 89%) agreed that the • reduction of the number of clinical requirements (n = 10, 31.3%),

• reduction of the difficulty index of exam questions (n = 4, 12.5%),

• grading on a curve to boost students' grades (n = 4, 12.5%) and

• no additional measures should be in place as the suspension will have no impact on the educational outcomes (n = 8, 25%).

Pairwise Pearson correlation analysis was used to identify the variables that had significant association with:

• the perceived increased health risk,

• the increased stress levels during clinical activities,

• refusing treating patients who travelled to epidemic areas or showing symptoms of respiratory tract infection and

• perceived negative impact on academic performance or clinical competence.

Variables that exhibited significant correlation with the above-perceived educational and health risks amongst respondent students and staff members are listed in Table 2 .

The situation of COVID-19 pandemic is rapidly unfolding owing to the novelty and rapid spread of the disease. The initial response of some countries has changed from taking minimal actions to deal with "just a flu" to announcing a nationwide state of emergency and lockdown in a very short period. 23 This might have negatively affected the response rate as answering all questions was mandatory. Despite that this study was very timely to address an area of immediate concern in dental education, the influence of the timing of the survey could be twofold;

(a) respondents were experiencing significant uncertainty as the pandemic was in its early stages which may have meant that respondents were overly concerned, and (b) the announced lockdown period was fourteen days only at the time of survey distribution, which might have led to underestimation of the sequela of the pandemic on dental education.

The overwhelming majority of respondent students considered working in dental teaching clinics during the outbreak as a major risk for exposure to COVID-19. The most frequently cited causes for such concerns were the novel nature of the virus, lack of vaccines or effective treatments, emerging reports indicating that the disease can be decapacitating to all age groups, 30 close proximity to untested patients, high risk to inhale or contact respiratory droplets and saliva in the confined space of the dental unit, and the lack of patients' awareness regarding the disease and precautionary measures. Similar findings were reported in a study where third-and

fourth-year students submitted a written reflection as part of a mandatory assignment for the dental geriatric modules. 31 The vast majority of students in the latter study expressed concerns regarding the risk of disease exposure and transmission. 31 Such findings suggest the urgent need for efficient counselling and psychological support in order alleviate students' stress and concerns. 7, 20 The minority of respondent students (n = 35, 7.3%) who marginalised the health risk of COVID-19 trusted their infection control practices and believed that the severity of COVID-19 was One disconcerting finding was that less than half of the respondent faculty members observed that over half of the students were overly stressed during the outbreak. Many students reported being very distracted in the clinics as they were focusing on infection control and keeping distance from the patient rather than the treatment itself. This, of course, had an impact on competence development and increased the incidence of errors in clinical sessions. Students also reported, which was also observed by faculty members, performing fewer procedures and reduced acceptance of new cases.

The vast majority of respondents were concerned that they might spread the disease to their families. All concerned respondents emphasised that they were particularly anxious regarding spreading the disease to vulnerable subjects such as senior family members with complex medical histories or children.

There was an agreement amongst all respondents that aerosolised respiratory droplets, saliva and blood were the major sources 32 Given that the filtration efficiency of a N95 respirator is primarily dependent on the size and not the type or origin of the particles, N95 respirators can effectively prevent inhalation SARS-CoV-2 virus as it exhibits a larger diameter when compared to H1N1 counterpart. 7,32,33 Furthermore, using N95 respirators significantly reduced COVID-19 infections amongst healthcare professionals (0.06%) compared to the early stages of the pandemic when health workers did not use N95 respirators (2.83%). 7 Further protection can be obtained by face shields as they prevent contact between mucus membranes and mediums containing pathogens. 7, 34 Face shields reduced viral exposure by 96% to particulates produced by a cough from 18 inches distance. 34 Face shields also have the advantage that they can be disinfected and re-used. Moreover, face shields tend to reduce autoinoculation as they break the habit of face touching whilst in place. Consequently, they have been highly recommended as part of the standard PPE in dental practices. 35 Regarding management of dental patients during the pandemic, there was a consensus amongst the majority of published guidelines/protocols regarding the virtue of patient triage and reduction of microbial load prior to commencing dental treatment. 3, 20 It was reassuring that the majority of respondents in this study were aware of such guidelines as they reported the importance of triage, history taking and body temperature measurement. Moreover, reduction of generated aerosols, the use of antimicrobial mouthwash prior treatment 15 and rubber dam isolation, which is also known to reduce nosocomial infections, 20 Adopting online distance education was essential during the suspension period in order to achieve the educational objectives. 20

Educational videos were the preferred distance education method amongst all respondents. Videos and animations demonstrating clinical techniques are amongst the most attractive and effective educational materials. 42,43 They can replace, or at least, be a very effective adjunct to a static series of slides. This in turn, may maximise the educational benefits of the interaction with the teaching material by providing an enhanced and diverse learning environment. 44 Furthermore, our experience indicates that students already utilise educational videos as a succinct, accessible and readily available resource in order to help them prepare for clinical work. They were also utilised by students to get access to contemporary materials and techniques that dental schools may not be able to provide/demonstrate for students in the undergraduate programs. Such videos may satisfy students' scientific curiosity and motivate them to further explore various disciplines of dentistry. The authors of this study conducted a relatively similar study at the University of Otago-Faculty of Dentistry, New Zealand. 45 The used survey was modified in order to adapt to situation there as students were still working at the time when the survey was distributed.

There was an agreement between the findings regarding the key aspects explored in both studies. Though the New Zealand study reported a more pronounced negative impact on academic performance and clinical competence by students and staff members. 45 The world is currently observing an increased incidence of emerging, contagious diseases. As dental professionals and students may be at a high risk of infection and transmission, dental practice and education may have to undergo a significant transformation in order to prepare for such events. This and similar studies are pivotal to improving risk assessment and quality control processes during such pandemics. The findings of this study may potentially improve the utilisation of distance education as a method to reduce the negative impact of any suspension period on students' academic performance and clinical competence. Leading regulatory bodies should proactively work on strategies to mitigate the deficits created by such pandemics. Immediate strategies and guidance are urgently required to address the reduced clinical exposure of the current final

year students and to coordinate their enrolment in VT and speciality training programs. Dental educators and institutes should seize the opportunity to re-visit the current strategies in order to strengthen dental educational systems. Long-term guidance and strategies are required to regulate various aspects that may contribute to the risk of disease transmission within dental teaching clinics such as the number of admitted students, infection control policies and armamentarium, and exploiting advanced technologies and artificial intelligence to optimise distance education and simulated clinical training.

A comprehensive analysis of the currently available experimental and clinical evidence is required to ensure safe return of students, educators and patients to dental schools. Biosafety committees comprised of students, administrative and academic staff can play an important role in addressing the concerns of all parties regarding teaching and clinical activities. Further studies are warranted to evaluate and develop the current students' assessment methods and to explore how the reduced clinical exposure and the pandemic will potentially impact graduates' future career plans.

In the opinion of the respondents to this study, the COVID-19 outbreak had adversely affected various elements of the dental education. Concerns regarding acquiring and transmitting the disease amongst students and faculty members were raised during the early stages of the pandemic. The significant interruption to the academic and clinical activities of this student cohort may lead to an inevitable skill deficit within the new generation of dental graduates. Educators are under significant pressure to accommodate the abrupt changes in the teaching methods, find solutions to mitigate skill deficit and ensure safe clinical practice once clinical activities are resumed.

Fundamental changes and improvements are urgently needed to reform our educational systems and strategies to accommodate the impact of the current pandemic and similar events that could take place in the future.

The authors would like to acknowledge with gratitude Dr Nosayba

Alazzam for her help with statistical analysis. We also deeply thank all students and faculty members who responded to this survey in the Faculty of Dentistry at JUST.

None of the authors of this manuscript have any conflict of interest to declare.

Data sharing not applicable to this article as no data sets were generated or analysed during the current study.

Ahmad A. Jum'ah https://orcid.org/0000-0001-5628-0230

Lina Elsalem https://orcid.org/0000-0002-3814-4865

Carolina Loch https://orcid.org/0000-0001-8949-4008

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