To Evaluate Fear and Assess Practice Modification among Dentist against COVID-19 in India – A Questionnaire Based Survey

Introduction: This highly infective new virus, named Severe Acute Respiratory SyndromeCoronavirus-2 (Sars-CoV-2), is a corona virus responsible of an acute respiratory syndrome, often asymptomatic but potentially lethal, named Corona Virus Disease 19 (COVID-19). Airborne and direct contact contamination is a major infection pathway of Sars-CoV-2. SARS-CoV-2 transmission during dental procedures can therefore happen through the inhalation of aerosol/droplets from infected individuals or direct contact with mucous membranes, oral fluids, and contaminated instruments and surfaces .Therefore, dentists have a high risk of getting infected from patients and potentially spreading it to their peers, families, and other patients. Aim: To evaluate fear and assess practice modification among dentist against COVID-19 in India Materials and Methods: In this cross-sectional study a total of 260 general dental practitioners, postgraduates and graduates across Central India, who were registered under the Dental Council of India, were included in the survey. A questionnaire consisting of 22 Questions with regard to COVID -19 fear and practice modification was designed and the questionnaire was circulated through a web designed program. The responses were collected, and data were analyzed descriptively using SPSS Statistics for Windows version 27.0. Original Research Article Ingole et al.; JPRI, 33(59A): 16-23, 2021; Article no.JPRI.78510 17 Results: There is a description of the fear and anxiety levels of dental care professionals towards COVID-19; 83.85% of participants were afraid of getting infected with COVID-19 from either a patient or a co-worker. While treating a coughing or a patient suspected to be infected with COVID19, 90% were anxious. In terms of using personal protection, 63.85% believed that a surgical mask is not enough to prevent cross-infection of COVID-19. In comparison, 93.08% favored the use of N95 masks for routine dental procedures during the current outbreak. Although the majority 91.15% recommended routine universal precautions of infection control. Conclusion: Overall, this study sheds light on the association of COVID-19 factors and fear and anxiety elevated among dentists during working in this pandemic. Covid-19 spread all over world and is worsening day by day. On current scenario several dental practices have either modified their services according to recommended guidelines to emergency treatment only, or closed down practices for an uncertain period.


INTRODUCTION
An outbreak of novel corona virus disease in China has influenced every aspect of life. Within short span of time, COVID-19 has spread globally. The World Health Organization (WHO) declared it as a controllable pandemic disease. This new highly contagious virus, called Severe Acute Respiratory Syndrome-Coronavirus-2 (Sars-CoV-2), is a corona virus that causes severe, often undetectable but deadly [1], called Corona Virus Disease 19 .
Sars-CoV-2 has a two-week incubation period and clinical manifestations of COVID-19 mainly include cough, fever and dyspnea [2], but also anosmia, ageusia and, in a few cases, diarrhea has been reported [3]. Airborne and direct contact is a major cause of Sars-CoV-2 infection. Air pollution is the result of droplets released by inhalation, coughing or sneezing; the most direct infection is due to contact with the affected area and the eye, nose or mouth mucosa [4]. The outbreak and spread of Sars-CoV-2 and COVID-19 has created an emergency in the world health system. To date, millions of cases have been reported, and many patients have died worldwide (WHO Source of Report 70). India has registered the highest number of COVID-19 cases.
Due to droplet production and exposure to saliva and blood, dentists are at high risk of infection during their routine procedures [5,6,7]. SARS-CoV-2 transmission during dental procedures is therefore possible by inhaling aerosol / droplets from infected people or direct contact with mucous membranes, oral fluids, metals and contaminants [8].
Therefore, dentists are at high risk of transmitting the virus to patients and who may spread it to peers, families and other patients. Under these circumstances, it may be natural for dentists to be afraid of being infected by their patients. Fear and anxiety are powerful emotions that can be associated with shocking reports of the COVID-19 epidemic by social media, electronic, and print media. Minor anxiety is natural and promotes protective and protective behavior [9]. In this day and age, people with chronic anxiety may be frightened and may make mistakes that lead to irrational and behavioral decisions. To be on the list of high-risk specialists, dentists are most likely to be very concerned about the current state of the epidemic [10].
Considering the current rapid spread of infection, the Dental Council Of India (DCI) highlighted the important steps that dentists should take in addition to standard safety measures such as taking recent patient visits; testing for signs and symptoms of RTI; recording body temperature of patients; rinse the mouth with 1% hydrogen peroxide before the start of any procedure; use of a rubber dam and absorb large volumes during the processes; and regular cleaning and disinfection of public areas including door handles, chairs and bathrooms. Although DCI has published guidelines for prevention, many dentists are still hesitant and afraid to treat patients in such a situation. In fact, many dentists may not be aware of the latest guidelines. Therefore, we have conducted a series of questionnaires to assess the response of dentists throughout India. The current study aims to assess the anxiety and fear of infection among dentists who work during an outbreak. In addition, the dentist's knowledge of various anticorona virus (COVID- 19) variables has been evaluated.

MATERIALS AND METHODS
This cross-sectional study was conducted in India, April 2021 at Nagpur. The questions used in the survey were taken from the reference article by Muhammad Adeel Ahmed et al which was validated through intra-class correlation with a strong relation of 0.74 [11].

Inclusion Criteria
A total of 260 dentist across Central India; registered under the Dental Council of India, were included in the survey. Graduates, General dental practitioners and Postgraduates were included in the study.

Exclusion Criteria
Any paramedical staff, physician, hygienist, people not willing for study and dental students were not included in this survey.

Sample Size Calculation
The sample size was calculated using sample size formula for qualitative data for similar type of study conducted in India.  Six questions were related to the demographic data (Gender, age, designation, qualification, workplace and work setting).  Eight questions related to fear and anxiety assessment of dental care professionals.  Fourteen questions related to Knowledge and practice of dentists about COVID 19.
Subsequently, the questionnaires about fear and practice modification among practicing dentist against COVID-19 were randomly administered to be answered on an anonymous basis and the responses were collected. The results of the survey were tabulated in Google Sheets.

RESULTS
Cross-sectional study was conducted using an online survey questionnaire from 10th to 17th March 2021. For this purpose, a well-constructed questionnaire was designed .The online survey link was circulated through social media and an e-mail to dental professionals and received total of 260 responses through an online survey submission. The initial part of the questionnaire acquires demographic data which consist of gender, age, designation, qualification, workplace, work setting. Questionnaire consists of 22 questions comprising of two sections .Eight questions were based on the level of fear and anxiety. Fourteen questions related to practice modification of habits due to COVID 19. Data was collected and analyzed descriptively using SPSS Statistics for Windows version 27.0 V, Graph pad Prism 7. V. Table 1. Of the 260 participants, 106 were males and 154 females, with age brackets between the ages of 20 and 30 (68.85%). By appointment, 120 were regular dentists, 126 specialists, and only 14 were out of the consultant category. Similarly, 120 were graduates and 140 were postgraduates and 182 dentists were from private institutions, 40 were independent and 38 were working in government. Out of total, 143 were at hospital practice and 117 were practicing at their own clinics ( Table 1). The current study did not report a significant relationship (rho-0.2), (P 0.61) between the responses of gender dental professionals and their level of education.

DISCUSSION
The current divisive study reported anxiety and fear of infection among dentists while working during the present outbreak. To the current end, a questionnaire focused on closed-ended questions was used to gather information about the dentists' fears and any changes made to combat the COVID-19 epidemic. Questionnairebased research is proven to collect information about preferences, attitudes, opinions, and participant's knowledge; however, careful data collection and interpretation is required [12].
The effects of this current rapid spread of COVID-19, which has affected millions of people worldwide, from solitary confinement to death have resulted in severe psychological distress and fear. As the foremost route of transmission of corona virus is by droplets and aerosols [13], this increases the probabilities of dentists and dental health workers becoming infected and  continuing to spread the virus. Recent research has found that a lot of dentists are fearful of getting infected by their patients or colleagues [14]. Most dentists are afraid to offer treatment to any patient who reports suspicious symptoms. As COVID-19 is rapidly infecting a lot people across the country, the fear of infection is justified. A high level of tension was seen as a lot of proportion of dentists sought to shut their practice which could have a major economic impact on dentists and dental health professionals.
Current guidelines on the outbreak of COVID-19 have suggested that everywhere non-essential dental treatments to be discontinued, and only patients having pain, inflammation, bleeding, and trauma are advised to be treated [15]. In the present scenario, all special or non-essential dental treatment for all patients should be postponed until the condition is reversed or within control. A study by the Beijing Emergency Department, China [16], saw the impact of the COVID-19 pandemic on dental reporting, which dropped in the emergency department compared to pre-COVID-19 reporting. The corona virus resides in various locations for a few hours to few days [17]. These, combined with the long incubation period before symptoms appear, are factors that make it extremely difficult to limit its spread. Fear of confinement because of a suspected illness or infection is also a legitimate fear when one thinks of how other members of family might suffer due to numerous factors. The burden on the health care system and also the costs incurred during treatment put a human mind at danger. Health facilities might not be fully funded by the government worldwide and as a result insignificant financial burden.
The COVID-19 testing is widely sponsored by government agencies in many countries around the world, which inspire citizens to get tested for COVID-19 if they are suspected of being infected. A positive feature that was also included within the current study was that almost all participants were conscious of the distribution and transmission of COVID-19. As a part of infection control measures, such information is crucial during dental practice. It is important within the face of this pandemic to still follow procedures and guidelines that concentrate on reducing the quantity of aerosol produced and to deal with it effectively. Similarly, it absolutely was encouraging that a lot number of dentists were responsive to this guidelines issued by the Disease Control (CDC) and WHO for the control of dental infection in dental work including questioning patient history and recording patients' body temperature [18]. Thus, both of those facts may provide a summary of probably infected patients and their prudent management of dental work. However, standard safety measures that have already been recommended and approved by various disease control and control authorities around the world to prevent dental infection in dentistry should be strictly adhered to in the current environment.
Although most dentists have agreed that these safety precautions should be taken in every patient, unfortunately, a large number of participants reported that they do not use the basic methods of infection such as the rubber dam in every patient. The use of a rubber dam is an effective means of controlling the infection by cutting down the spread of aerosols through a patient's acceptance of dental procedures. Considering the benefits, there is no reason not to use a rubber dam during dental procedures, especially when using rotary tools that produce large quantities of aerosols and drops. The use of high volume suction is also considered an important means of controlling aerosol loss during dental procedures and should be used by most patients at the beginning of any dental procedure, oral mouthwash baths also significantly reduce microbial load [19,20]. This practice is recommended in this pandemic; however, most dentists have reported neglect.
There is currently no evidence available on the effects of oral antibodies commonly used in COVID 19. Therefore, this recommendation may be based on the fact that fraud has been reported to reduce viral load and spread by removing oropharyngeal protease and related viral replication [21]. In addition, mouthwash containing agents with anti-viral activity such as povidone-iodine has been shown to be effective against various respiratory infections [22,23]. During the outbreak of COVID-19, the importance of hand hygiene has been repeatedly emphasized and this is even more important in the case of dentists. Studies have shown that proper hygiene of the hands, including washing hands with soap and water and cleaning with alcohol-based antibiotics, is an important step in controlling the spread of respiratory infections, including SARS [24,25].
Therefore, the WHO recommends regular hand washing or the use of an alcohol-based disinfectant for dental work. The use of a respirator with a component similar to N-95 is recommended for the treatment of patients suspected of having COVID-19. Periodic procedures using ultrasonic scalers should be replaced with hand scalers that aim to reduce the production and distribution of aerosol and splatter. In addition to regular use of the rubber dam, high volume absorption helps to maintain aerosols and prevent droplets from the patient's mouth and respiratory tract from spreading and transmitting potential infections.
This study highlights the importance of the dentist's fears and anxieties during outbreaks of infectious diseases. Fear among dentists may have long-term consequences and, as such, will have future training implications, such as the need to provide mental health workshops to promote independence and increase mental health education as part of primary dental education.

CONCLUSION
Majority of Dentist practicing in government and private sectors in spite of having knowledge and practice experience faced anxiety and fear during COVID 19 pandemic situation. In this current study, most of the practitioners have modified their existing practice with reinforcement usage of N 95 mask, rubber dam, high volume suction, anti bacterial mouth wash, hand wash and sanitizer before and after treatment. Dentist referred suspected COVID19 infection to appropriate authority centre. In the current situation a few dental procedures have changed their services according to the recommended guidelines.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
The research protocol was approved by the Institutional Ethics Committee with ethical clearance number -SDKS/PG/STRG/PROSTHO1/DATED 21-12-2020.