key: cord-0879171-2m3erjpw
authors: Mutluay, Merve; Egil, Edibe
title: Effect of Specialty Education and Work Environment on Dentists’ Attitude in COVID-19 Pandemic
date: 2021-05-31
journal: Braz J Infect Dis
DOI: 10.1016/j.bjid.2021.101592
sha: 29e8c0cc877959f632effb49b8b83e381fdbad10
doc_id: 879171
cord_uid: 2m3erjpw

INTRODUCTION: Performing dental procedures during the COVID-19 pandemic carries certain risks in terms of cross contamination. OBJECTIVES: To evaluate the effect of specialty education and work environment on of dentists’ behavior, awareness and attitude regarding cross-infection control in COVID-19 pandemic. DESIGN: The study population consisted of Turkish dentists who work in private clinics, public clinics and university hospitals. Demographics of the participants, awareness of COVID-19 and clinical measures taken against cross-infection were evaluated with an online survey. Between 10th-20th of November 2020, 1,000 surveys were e-mailed to the dentists. RESULTS: A total 454 dentists answered the survey; 29.3% of the participants deliver only urgent care, 59.9% both urgent and routine treatments and personal protective equipment (PPE) were used at rates varying between 75.5% and 98.4%. 90.6% of the dentists stated that they were worried about aerosol generating dental procedures and there was no difference between sexes in this regard (p=0.119). The majority of participants, mainly specialists (p=0.16), applied strict cross-infection control methods during the COVID-19 pandemic (77.2%). The rate of PPE use was statistically higher by women compared to men (p=0.025) and by specialists compared to others (p=0.04). There was a weak positive correlation between level of PPE use and expertise (r=0.121, p=0.01). CONCLUSIONS: Although participants' knowledge about the symptoms of COVID-19, transmission routes and following the guidelines were at a sufficient level, dental specialists apply protection equipment procedures more strictly. Although participants were concerned about dental practices that create microbial aerosols during the pandemic period, still they continue their dental routines using high levels of PPE and taking extra clinical precautions to avoid cross-infection.

Several patients with viral pneumonia were found to be epidemiologically associated with the seafood market in Wuhan in late December 2019. Coronavirus infecting humans was identified, and the detected new virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using next-generation sequencing. 1, 2 This infection, which is confirmed by droplet transmission and human-to-human transmission, is a major public health problem with 88 million reported cases and over 1.9 million deaths globally. 3, 4 SARS-CoV-2 uses "angiotensin converting enzyme II (ACE2)" as cell entry receptor. Patients' typical clinical symptoms are fever, dry cough, dyspnea, headache, and pneumonia. This progressive disease may result in respiratory failure, pneumonia, alveolar damage, and even death. 5 Aerosols are liquid or solid particles containing all kinds of microorganisms suspended in the air. 6, 7 Responsible for airborne transmission of microorganisms, aerosols consist of small particles called droplet nuclei (1-5 μm) or droplets (>5 μm). Aerosols can contaminate surfaces in a range of one seven meters and be a potential route of infection.

Cross contamination is the spread of pathogens from one source to another through direct contact from patient to patient or from patient to clinical staff by droplet transmission.

Droplets and aerosols containing microorganisms produced by infected people may contact the conjunctival, nasal or oral mucosa. 8, 9 Dentists are at high risk of cross-contamination due to frequent direct or indirect contact with dental instruments and surfaces contaminated with aerosols, blood, and saliva. 10 Aerosols containing microorganisms in the patient's oral cavity are generated when high-speed rotating instruments and pressurized sprays are used in restorative dentistry. Aerosols 11, 12 emitted into the air from rotating tools operating at high speed during cavity preparation and polishing of composite resins create risk for cross contamination of dentists. Tooth preparation, removal of fillings, removal of composites after orthodontic band removal, and high-speed ultrasonic scaler calculus cleaning, and oral prophylaxis also procedures that carry risk for contamination. 11, 13 However, the infectious character of aerosols produced in dental procedures depends on virulence dose, pathogenicity of the microorganism, and contaminated contents of the patient such as plaque, blood, calculus, and saliva. 14, 15 According to the American Dental Association (ADA), high amount of aerosol and droplet production is inevitable during routine dental procedures, and the practice of dentistry during the COVID-19 pandemic poses a unique challenge. 16 Effective infection control strategies are needed to prevent the spread of SARS-CoV-2 through dental procedures. 9 For this purpose, the American Centers for Disease Control and Prevention (CDC) recommends applying additional infection prevention and control procedures in addition to standard practices in clinics during the COVID-19 pandemic, taking the highest level of precautions to prevent the spread of microbial aerosols and to protect all materials stored on work surfaces. These procedures should be applied to all patients, not only those with suspected or confirmed SARS-CoV-2 infection. 17, 18 Objective This research aimed to evaluate the effect of specialty education and work environment on dentists' behavior, awareness, and attitude regarding cross-infection control in COVID-19 pandemic.

Ethical approval: The study protocol was approved by the Ethics Committee of Istanbul Gelisim University with the number ethical approval of 2020/29.

Sample size: The target population of this study were Turkish dentists who work in private and public clinics, as well as in university hospitals. The sample size required for the study was calculated based on the total number of dentists (34,045) in Turkey. With a 95% confidence interval, the power analysis estimated that 384 or more people had to be included.

Survey instrument: The first part of the study questionnaire was aimed to learn the demographic characteristics of the participants (sex, age, work experience, workplace profile).

The second part of the questionnaire aimed to evaluate participants' awareness about COVID-19 and clinical precautions against cross infection, based on the "SARS-CoV-2 infection control guidelines" published by CDC. 17 Adequacy of the questionnaire was previously examined by experts in order to evaluate construct validity of the questions. Questions were sent to five specialists (two pediatric dentists, a restorative dentistry specialist, a statistician, and a general dentist). Revisions were made on the questionnaire as a result of the evaluation of the experts. The questionnaire consisting of two parts and 20 closed-ended questions was tested by two experts (pediatric dentist, restorative dentistry specialist) in order to check whether they were consistent with the semantic and conceptual framework. After checking the suitability in terms of language by the Turkish language expert, the questionnaire was created with Google Documents and directed to dentists by e-mail. In the e-mail, it was announced that participation was voluntary and the personal data would remain completely confidential. The study was designed and implemented in accordance with the Helsinki declaration.

Statistical analysis: Survey results were evaluated with descriptive statistics such as the number and percentage. The data were analyzed using IBM ® SPSS ® (version 24.0;IBM,Chicago,IL,USA). Mean, standard deviation, range, and frequency for variables were calculated. Pearson chi-square test was used for categorical variables; the Spearman's rank correlation test was used to assess correlation between sex, specialties, and attitude towards cross infection. A p-value <0.05 was considered statistically significant.

Out of 10,000 dentists who received surveys by e-mail, 454 answered between Nov 10 and 20, 2020. Of these, 41% were aged <30 years, 39.2% between 31-40 years, and 19.8% > 40 years; 67.8% were female (Table 1 ).

In terms of professional experience, 33.5% of the participants had >10 years, 33.5% had 5-10 years, and 33% had <5 years of experience. A large proportion of participants (51.8%) were general dentists, followed by dental specialists (32.4%) and post-graduate students (15.6%).

46% of the respondents worked in private clinics, 22.9% in public clinics, and 31.1% in university hospitals ( Table 1) .

As much as 81.9% of the participants followed the current developments, and 74.2% of the participants followed the guidelines and recommendations published by national or international authorities regarding the COVID-19 pandemic (Table 2 ). In terms of the answers to these questions, there was no statistically significant difference between men and women (respectively=0.374, p=0.974) or specialist and other dentists (p=0.061, p=0.137, respectively). Previous symptomatic SARS-CoV-2 infection were reported by 5.7% of the participants, non-symptomatic by 2.2%, and no COVID-19 by 73.5%. The remaining of the participants were not sure whether they had COVID-19 (Table 2 ).

Participants were aware that the infection could be transmitted by droplet inhalation (98.2%), nasal mucosa (78.6%), fecal-oral route (26.7%), eye mucosa (74.7%), saliva/blood (54.2%), and sharp instruments (20.3%). The knowledge level of specialists about transmission routes was higher than other dentists (p=0.012). There was no statistically significant difference between the transmission route knowledge of female/male participants (p=0.258).

While only 5.1% of the participants stated that they did not work during the pandemic period, 5 .7% stated that they were only examining and diagnosing, 29.3% were only performing emergency treatments, and 59.9% were providing both emergency and routine treatments.

77.2% of the participants were applying strict cross-infection control methods. Experts adhere cross-infection control measures more strictly than other dentists (p=0.16). There was no statistically significant difference between sexes in terms of implementing cross infection control measures (p=0.261).

Personal protective equipment (PPE) were used at rates varying between 75.5% and 98.4%.

The rate of PPE use was higher among females compared to males (p=0.025) and especialists compared to other dentists (p=0.04). There was a weak positive correlation between level of PPE use and expertise (r=0.121, p=0.01) with 90.6% stating that they are worried about aerosol generating dental procedures and there was no difference between sexes in that regard (p=0.119). A total of 46.7% of the participants reported not having suspended any dental procedures. Only 11.3% of the participants applied rubber-dam and 16.3% apply oral aerosol vacuum during dental procedures with no difference between sexes (p=0.235) regarding that question. While the rate rubber-dam use by general dentists was statistically higher than that used by other dentists (p=0.005), there was no difference between participants in terms of using oral aerosol vacuum. that they Use of mouthwash before the dental procedure was reported by 49.9% of dentists.

Use of hydrogen peroxide mouthwash by especialists was significantly higher (p=0.008), but no significant difference was observed for other types of (p> 0.05).

Extra-precaution regarding dental unit and sterilization of hand instruments were reported by 32.4% and 29.8% of the participants, respectively. In order to prevent contamination, 92.8% of the participants took precautions towards patients and their relatives in the waiting room and 92.2% for clinical assistant personnel.

Dental procedures include the use of rotary instruments found in dental units, compressed airwater spray, and other processes that generate aerosol. Due to microbial spread that occurs during dental procedures and microorganisms that survive in aerosols, 19 dental clinics are among the highest risk environments in terms of cross contamination. 15 Therefore, all clinical staff, especially dentists, are faced with the risk of cross-infection caused by aerosols that can move deeper into the respiratory tract and even the lungs during the COVID-19 pandemic. 8, 20 The presence of SARS-CoV-2 in the saliva of infected patients poses an additional risk after an aerosol-forming dental procedure. 21 A recent report suggests that coronaviruses associated with severe acute respiratory syndrome can survive in aerosols for at least three hours, even if their infectious titer is reduced. 22 In order to minimize the microbial load in the aerosols produced, it is necessary to establish and implement cross-infection control measures.

This research was conducted to evaluate dentists' attitudes towards cross infection control The demographic characteristics of the participants in the present study are shown in Table 1 .

According to Table 2 , the majority of the participants (81.9%) follow the current developments related to the COVID-19 pandemic and the guidelines and recommendations published by national/international authorities (74.2%). Also, 5.7% of participants reported to have had symptomatic COVID-19 infection. There was no significant difference between sexes and qualification variables in terms of responses to these questions (p> 0.005).

According to a study conducted in Lombardy, Italy, 4.43% of the participants had suffered one or more symptoms related to COVID-19 and only 2.0% of dentists were confident in avoiding infection. 23 Table 2 reveals that while awareness of the participants about droplet inhalation (98.2%), nasal mucosa (78.6%), eye mucosa (74.7%) and saliva/blood (54.2%) was high, the level of knowledge was found relatively low for the fecal-oral route (26.7%) and sharp tools (20.3%).

The awareness of specialist dentists on this issue was higher than of other dentists (p=0.012).

While the awareness of dentists in the Milan region was reported to be 71.82%, 23 90% of dentists reported to be aware of COVID-19 in a similar study. 24 According to Peng et al. 9 , dental professionals play important roles in preventing the transmission of SARS-CoV-2. They should take extra infection control measures during dental practice to prevent person-to-person transmission in the clinics. During the COVID-19 pandemic, the first step of the infection control protocol recommended by ADA 16 and CDC 17 is to evaluate whether the patient is at an emergency situation or not. Elective and nonemergency procedures should be postponed, and dental treatments should be offered after considering the risk of SARS-CoV-2 transmission during the pandemic. According to Table   2 , 29.3% of the participants performed only urgent care and 59.9% both urgent and routine treatments. Since the pandemic is present in our country since March 2020, this may be the reason why many dentists resumed routine dental procedures. Similarly, even in Lombardy and Milan, which are the European regions where the pandemic caused most deaths, most of the dentists continued dental routine care by taking preventive measures. 23 Moreover, the majority of participants (77.2%) adhere to strict cross-infection control methods during the COVID-19 pandemic, with specialists adhering even more (p=0.16). In a similar study, 64%-89% of the participants implemented infection control measures related to According to ADA 16 and CDC, 17 the second step is to determine PPE competence to perform dental procedures. 16 The use of PPE against saliva or other body fluids in dental routines in dentistry is considered the most important protection strategy. 16, 17, 25 According to The adoption of professional precautions in dental practices that create microbial aerosols during the pandemic should be considered on a universal basis and standard precaution procedures should include more detailed and careful protection methods. 19 According to Dawson et al. 20 aerosols produced by operating the rotary devices reach all levels of the respiratory tract. Therefore, aerosol-forming procedures, including the use of high-speed rotary instruments, air/water spray and ultrasonic scalers, should be avoided or PPE should be used during the pandemic. 16, 20 According to a study evaluating bacterial load in dental treatments, the amount of bacterial load in bioaerosols at a distance of 1.5 meter from the patient's oral cavity was found to be higher compared to one meter of distance. When using a high-speed rotary device, significant contamination was demonstrated at all sampled distances in the room (average 970 CFU/m 2 /hour). 18 According to present results, most of participants (90.6%) worried about aerosol generating dental procedures. 53.3% of participants suspended aerosol generating procedures while 42.2%, 37.2%, and 24.8% of them stated to have suspended oral scaling, esthetic dental procedures and restorative procedures, respectively.

Other methods recommended to minimize droplet splash and aerosols are the application of minimally invasive/atraumatic restorative techniques, and use of high-powered saliva ejector and rubber-dam. 17 Rubber-dam isolation can reduce airborne particles by up to 70% within a 3-foot diameter of the operational field. 9, 27 The present survey reveals that 11.3% and 16.3% of the participants prefered rubber-dam and oral aerosol vacuum during the dental procedures, respectively. The rate of use of rubber-dam by general dentists was statistically higher than by other dentists (p=0.005). Although 80% of endodontists from the United States reported to be concerned about dental procedures, 82% were performing treatments during the pandemic.

The majority of them were using rubber-dam and 16.9% added oral aerosol vacuum to their practice. 26 Mouthwashes containing antimicrobials (chlorhexidine gluconate, essential oils, povidoneiodine or cetylpyridinium chloride) can be used to reduce SARS-CoV-2 viral load or to prevent contamination. 17,25 According to the present results, hydrogen peroxide is the preferred mouthwash by 22.8% of dentists, and the majority of especialits (38.7%) prefer hydrogen peroxide mouthwash (p=0.008). Koletsi et al. 19 reported that use of 0.2% tempered chlorhexidine (CHX) before routine ultrasonic scaling resulted in a significant reduction in aerosol-associated bacterial load. Peng et al. 9 suggested that CHX may not be effective to kill SARS-CoV-2. As the virus is vulnerable to oxidation, it is recommended to use a mouthwash with an oxidative (H 2 0 2 ) before the procedure.

During the pandemic, attention should be paid to the maintenance of dental units and clinical equipment. One should be aware of potential risks that may arise from contaminated water intake and colonization of pathogenic microbial species. 28 During the pandemic, it is recommended to use water filters in dental units, 3-6% hydrogen peroxide disinfection, CHX or specially designed biofilm removal systems. 29 Attention should be paid to the standard maintenance of the dental unit and unit water system. The unit water quality must comply with the safe drinking water standard (<500 CFU/mL). 30 Extra-precaution regarding dental unit and sterilization of hand instruments were reported by 32.4% and 29.8% of the participants, respectively. However, routine cleaning and maintenance of autoclaves, air compressors, suction systems and aspirators, radiography equipment, amalgam mixers and other dental equipment should be meticulously done according to the manufacturer's instructions to avoid cross infection. It is also recommended to use suction systems and aspirators with high suction power and the use of antiseptic agents applied to the water system of dental units. 28, 30 In addition, SARS-CoV-2 has been shown to remain infectious from two hours to nine days and survive longer at 50% compared to 30% relative humidity, at room temperature. Therefore, maintaining a clean and dry environment in the clinic will help reduce the persistence of SARS-CoV-2. 9 Providing cross infection control training to clinical staff, keeping only the required sterile consumables for the dental procedure in the clinic, keeping all other materials away from possible contamination in a closed cabinet, and carefully sterilizing contaminated equipment after procedures are other important strategies to prevent cross infection. 17 When participants were asked about the precautions they have taken regarding clinical staff and administrative order, PPE use (92.2%), social distancing measures (69.5%) and providing special courses (64.7%) were reported. As shown in Table 2 The limitations of our study are middle-sized sample, data collection limited to a short time period, and low level of e-mail responders due to the pandemic. New studies evaluating dentists' awareness and attitude towards the COVID-19 pandemic should be planned using larger samples with fewer variables.

Although participants' knowledge about the symptoms of COVID-19, transmission routes and adherence to the guideline were at a sufficient level, dental specialists complied with protection equipment procedures more strictly. Participants were concerned about dental procedures that create microbial aerosols during the pandemic period, and yet they continue to deliver dental care using high levels of PPE and taking extra clinical precautions to avoid cross infection. The spread of the pandemic should be tackled by adhering to high-level cross infection methods during dental procedures that generate microbial aerosols by healthcare professionals.

M.M., design, data analysis, and interpretation, drafted and critically revised the manuscript;

E.E. contributed to conception, data acquisition, contributed to analysis and interpretation, critically revised the manuscript; All authors gave final approval and agree to be accountable for all aspects of the work.

Tables: Table 1 : Description of the demographic and professional characteristics of participants. 

A Novel Coronavirus Genome Identified in a Cluster of Pneumonia Cases -Wuhan

A Novel Coronavirus from Patients with Pneumonia in China

Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding

World Health Organization. Coronavirus situation report

A pneumonia outbreak associated with a new coronavirus of probable bat origin

The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet

Infection prevention and control measures for acute respiratory infections in healthcare settings: an update

Transmission routes of 2019-nCoV and controls in dental practice

A scoping review on bio-Aerosols in healthcare & the dental environment

Airborne particles produced during enamel cleanup after removal of orthodontic appliances

Cytotoxic and genotoxic potential of respirable fraction of composite dust on human bronchial cells

Efficacy of Two Pre-Procedural Rinses at Two Different Temperatures in Reducing Aerosol Contamination Produced During Ultrasonic Scaling in a Dental Set-up -A Microbiological Study -PubMed

Aerosols and splatter in dentistry: A brief review of the literature and infection control implications

Healthcareassociated viral and bacterial infections in dentistry

Bacterial aerosols in dental practice -a potential hospital infection problem?

Interventions to Reduce Aerosolized Microbes in Dental Practice: A Systematic Review with Network Meta-analysis of Randomized Controlled Trials

Microbiological assessment of aerosol generated during debond of fixed orthodontic appliances

Saliva is a reliable tool to detect SARS-CoV

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

COVID-19 outbreak in North Italy: An overview on dentistry. A questionnaire survey

Pandemic preparedness of dentists against coronavirus disease: A Saudi Arabian experience

Martinho FC., Griffin IL. A Cross-sectional Survey on the Impact of Coronavirus Disease 2019 on the Clinical Practice of Endodontists across the United States

The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination -PubMed

Do contaminated dental unit waterlines pose a risk of infection?

Efficacy of BRS® and Alpron®/Bilpron® disinfectants for dental unit waterlines: A six-year study

Comparative evaluation of chlorhexidine and cinnamon extract used in dental unit waterlines to reduce bacterial load in aerosols during ultrasonic scaling

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

No funding