Dentists’ perceptions on present and future dental practice during the COVID-19 pandemic: An embedded study

Introduction

The emergence of the COVID-19 pandemic has placed a significant burden on everyone. In addition to the economic effects, healthcare systems and healthcare providers (HCP), whose work involves saving lives, faced an enormous burden. According to the World Health Organization (WHO), healthcare workers are people whose primary intent is to enhance health. They include doctors, nurses, paramedical staff, healthcare staff (administrative and support staff), and community workers. These are frontline workers who face a significant risk of COVID-19 infection and death.

With the rapid spread of the disease, many HCPs lost their lives while saving others. According to a systematic review, by May 2020, over 152,888 healthcare workers worldwide were infected, with 1,413 deaths reported.¹ The large majority of them (72%) were women, 51% were doctors, 39% were nurses, and 71% were men. In addition to the risk of COVID-19 infection, the pandemic also caused a significant physical and mental strain for healthcare workers.² Healthcare workers may continue to face the impact during and after the pandemic in the form of burnout, anxiety and depression, and post-traumatic stress disorders.³ They may experience a loss of control, disruption of clinical practice routines, and fear of destabilizing health services.^4–6

Although most dentists are not considered crisis workers during a pandemic, many were required to provide emergency or urgent dental services. Many of these dental care providers may have faced challenges deciding what constitutes a true emergency. They were required to screen patients who required urgent dental intervention with questions based on epidemiological risk factors and COVID-19 symptoms. Overall, dental professionals are at a greater risk for cross-infection because of their proximity to the patient when providing care. Dental procedures, especially the aerosol-generating procedures performed on an infected person, produce debris that will eventually land on the dental personnel’s body, clothes,⁷ and surfaces and the virus can remain viable for an extended period of time.⁸ Also, exposure to the saliva of an infected person can result in the transmission of SARS-CoV-2 to the dental professional.⁹ Lost working hours, the additional cost of personal protective equipment (PPE), and limiting aerosol-generating procedures have created financial pressure on dental practices. As a result, a large number of people working in dental clinics as dental assistants and dental technicians are equally affected due to the financial crisis.^10–13

Researchers in North America have observed a disagreement between their dental team members.¹⁴ The disagreement was based on each of their staff members’ understanding and conception of the COVID-19 pandemic, its modes of transmission, and the risk of infection. As the dentists’ tasks increased, many of their team members experienced more significant work-related stress. Some worried about being an asymptomatic spreader of the virus to their family members, leading them to move away from their homes to protect their families. They also pointed out the possible economic recession affecting their job market, which can cause a financial burden for dental professionals.¹⁴ A cross-sectional study that was conducted with 849 dentists in Italy reported that 80% of the participants were worried about the health of their families, 86% reported some income loss, and 94% feared a drop in the number of patients after the quarantine phase.¹²

As the WHO declared the pandemic in March 2020, dental authorities in different countries developed guidelines to match their social, cultural, and environmental diversity. These recommendations demanded a massive change to traditional dental infection-control procedures. These modifications mandate using additional PPE, modifying the infrastructure of the workplaces, slowing the delivery of care, and limiting aerosol spread. These modifications can cause financial strain for dental care workers, including dental assistants, dental hygienists, and dental technicians.¹⁰ Also, dentists may feel marginalized by the general public due to the nature of their profession.¹³ Thus, the distress experienced by dentists during the COVID-19 pandemic is not limited to the risk of infection and getting the disease but is also modified by additional stressors such as social, cultural, and environmental factors.

Based on current estimations, the pandemic will prevail over months and will not disappear like earlier flu epidemics and is predicted to have periodic cluster outbreaks even after initial containment.¹⁴ This increases the risk for dental health professionals carrying out dental treatment procedures as they cannot practice social distancing. There is also a risk of transmission through aerosol generation during treatment procedures. This could mean an additional burden to dentists in terms of PPE, disinfection, and measures to decrease the spread of aerosol¹⁵ all of which will affect future dental practice. Currently, very little is known about how oral health professionals and their professions could be affected by the pandemic and there is very little guidance available to them at this time, thereby raising their anxiety and fear. Given that, we aimed to investigate the perception of dentists on present and future dental practice in view of the COVID-19 pandemic and to explore how prepared dental professionals are to provide dental care amid the COVID-19 pandemic.

Methods

Results

A total of 976 dentists responded to our survey invitation. Of them, 61.27%(n=598) were females and 68.44% (n=668) 40 years of age or younger, about 38.22% (n=373) were private practitioners, and about 56.76 % (n=554) were working at a dental college or hospital. Among those who had a spouse, 28.68% (n=280) had a spouse who was also a dental professional. A large majority of the participants 72.34% (n=272) did not have a study or practice loan of any kind. The general characteristics of the sample are presented in Table 1. The full dataset can be found under Underlying data.²⁴

Discussion

This embedded study was conducted with Indian dentists to investigate their perceptions on the present and future of dental practice in view of the COVID-19 pandemic and to explore their preparedness in providing dental care during the pandemic. To our knowledge, this is the first study of its kind conducted using both quantitative and qualitative research methods. We observed that a vast majority of participants felt that the pandemic negatively affected their professional life as a dentist, were afraid of being a source of infection to their families and community, and that 73.56% (n=718) were somewhat satisfied with the information they received concerning the return to work. That said, the majority of participants 61.58% (n=601) felt comfortable returning to practice.

In a similar study conducted in Italy during the onset of the pandemic, the authors reported that 75% of the study population said that COVID-19 had an extremely negative impact on their practice.⁵ The proportion of those who reported a negative impact in our study was higher, revealing an urgent need to look into the matter closely. Also, 55.74% of our study participants feared that they would be a source of infection to their family, friends, and community, and such observations have been reported in other studies as well.^5,6 While evaluating the psychological distress in dentists, we found that a higher psychological tension pertained to the fear of getting infected with COVID-19 from a patient.⁵ Ahmed et al. (2020) investigated the fear of dentists in over 30 countries regarding the COVID-19 pandemic.⁹ They reported that the reason for their increased fear of transmitting the infection to families and friends was because of the prolonged incubation time before the development of symptoms and the duration of the virus thriving on various surfaces. Another legitimate fear among dentists, according to this study, was the repercussion of getting themselves and their families quarantined.

It has been found that COVID-19 remains aerosolized for three hours after contamination, and it can stay on plastic surfaces and stainless steel for up to two days.⁸ This makes dentistry a high-risk occupation as working with airotors and ultrasonic scalers is a daily treatment method for most dentists.⁷ In our study, around 41.91% (n=409) of the participants felt that using aerosol-inducing devices such as airotors and ultrasonic scalers would be very dangerous amid this pandemic. When providing the emergency services, 16.09% (n=157) believed their main concern was that the physical structure of the practice would not be ready for adequate aerosol control. Before the AIDS pandemic, dentists were not known to wear gloves, eye protection, or face masks, which now is a strict protocol in a dental set-up. Pandemics before have been known to revolutionize medical facilities.¹⁶ There is a dire need to come up with a solution that can contain the aerosol contamination in a clinical set-up. Commercial air exchange devices and purifiers are being experimented with for dental clinics.¹¹ The idea may seem drastic, but it might be possible to have it as an accepted standard in a few years if COVID-19 persists in the long run.

A large majority of participants expressed concerns about the negative financial impact on their professional life due to the nature of their profession. About 46% felt that they would have to spend more time on infection control procedures to provide safe care to their patients and to protect themselves and their staff. About half of our participants (48%) reported that the lockdown did not affect their survival but caused a severe financial burden, as observed by Ahmed and associates.⁹ A negative financial impact is expected as fewer people seek dental care during the pandemic due to lockdown measures, fear of getting infected, and their own financial strain.¹⁴ Furthermore, 10.14% (n=99) feared that they would incur more expenditure for PPE kits. Along with shutting down the practice for several months and the cost of PPE kits and sterilizing their practices, the financial strain can lead to psychological deterioration, as was observed earlier.⁶

WHO has therefore recommended various protocols on personal safety measures involving using an alcohol-based hand wash with increased frequency in a dental clinic along with using N-95 masks and PPE kits.⁸ There are various other guidelines and protocols given by the Centers for Disease Control and Prevention (CDC) and WHO for dental practitioners and workers to help reduce the spread of COVID-19.^17–21 Despite these guidelines, our participants’ mean distress level was eight for risk of getting infected with COVID-19 from an infected patient in a dental practice set-up, which is alarming. Also, a significant number of the participants were not familiar with the guidelines.^22,23 Timely information resources provided to dental professionals could prove helpful. While such initiatives may exist, they have not yet reached practical momentum for Indian dentists. Hence it is important that the statutory bodies, such as the Dental Council of India (DCI), make it mandatory for dentists to attend training sessions regarding modifications in dental practice in the wake of COVID-19. Professional bodies like the Indian Dental Association (IDA) can be proactive in providing information regarding the guidelines.

The results can vary according to the general conditions of each country and how the country was affected, In India, one of guidelines given by DCI was to improve the ventilation of private dental clinics along with this maintaining the social distance were the biggest challenges Thus, the results of this should be interpreted cautiously and consider the following limitations. First of all, the study was conducted soon after the first wave of the COVID-19 pandemic and India was not significantly affected by the first wave compared to many developed countries. Although India suffers from a high population density and limited healthcare resources, people may have had a false sense of security believing that they have some sort of natural immunity, which protected the majority from getting infected during the first wave of COVID-19. This perception may have changed when India was severely affected in the second wave of COVID-19. Also, the study used a convenient sample of participants. Although we wanted to survey a larger number of dentists in India, we had a very low response rate. Furthermore, we did not use any validated scales, so the study results cannot be generalized to the dentist population of India. In the absence of valid scales, we utilized a mixed-methods research approach that helped us describe some issues related to dental practice in India that we may not have been able to describe otherwise. So present study has given a comprehensive picture on dentists’ perceptions on present and future dental practice during the COVID-19 pandemic.

Conclusions

We observed that a vast majority of participants felt that the pandemic negatively affected their professional life as a dentist, that they were afraid of being a source of infection to their families and community, and that they were somewhat satisfied with the information they received concerning their return to work.

Data availability

Author contributions

All the authors did the search of the articles and review of the articles of the literature from various databases. RS and CD did the data collection. RS and VD developed and validated the questionnaire and analyzed the statistical data. VD prepared the tables. All authors contributed equally to the writing and editing of the manuscript. All authors read and approved the final manuscript.