COVID-19-Related Anxiety among Dental Students in Two Dental Schools in Saudi Arabia.

BACKGROUND: Dentistry can be an overstressed career. Dentists come across countless routes of stress in dental schools. Onset foot in clinical training, they can find that the number and type of stressors often grow. Dental students encounter high levels of academic stress, which can adversely influence them from their study years working with phantom teeth through their preclinical and clinical practice years. The COVID-19 pandemic has revealed the world population to a high risk of infection that comprises a major stress factor, especially for vulnerable groups such as dental students.
OBJECTIVE: The objective of this study was to assess the levels of COVID-19-related stress and anxiety, changes in hygienic and social habits, as well as subjective worries regarding the dental profession among dental students.
MATERIALS AND METHODS: A self-structured questionnaire was sent to dental students of two dental schools in the city of Jeddah. It included demographic data, questions about the level of change in personal hygiene and social habits, students' perception about the sufficiency of information received during the outbreak and its source, subjective worries regarding the dental profession, and the Generalized Anxiety Disorder 7-item Scale. Three hundred and eight responses were received.
RESULTS: Moderate and severe anxieties were reported in 41% and 7% of students, respectively. About 57% of respondents agreed to continue e-learning in the theoretical part only, 1% for the clinical part only, 32% in both, and 10% were not interested in continuing e-learning. Most of the students reported that they received excellent information about COVID-19 during the outbreak, with social media as the main source of information for the majority, followed by the Health Department. A significant number of dentists (66%) wanted to temporarily shut their dental practices until the number of COVID-19 case rates reduces considerably.
CONCLUSION: A considerable percentage of dental students are anxious and changed their hygienic and social habits due to COVID-19. This anxiety reflects worries about the dental profession in one-third of participants that necessitate counseling services and psychological support. Copyright:

INTRODUCTION

In December 2019, the rise of the novel coronavirus disease COVID-19, which escalated across the Asian continent and gradually turned into a pandemic, triggered many difficulties unrelated to the management of viral diseases in health-care areas, including dentistry.[12345] The newest strain of coronavirus is considered to have developed in one of the wet markets in Wuhan, China.[345678] On February 11, 2020, the WHO used the term COVID-19 to explain coronavirus's newest strain.[9] Health-care workers are at a higher risk of getting transmitted the infection due to their work nature as they come in close contact with infected patients. Besides, dental health-care professionals (DHCPs) do their work in direct contact with patients and get the infection when exposed to aerosol and droplets generated from the oral cavity patients.[1011]

The first dentist testing positive for COVID-19 was reported on January 23, 2020, in the Dental Hospital of Wuhan University, China. This was soon accompanied by the recognition of the transference of infection to another eight dental health-care workers.[12] Since then, more health-care workers have tested positive for COVID-19 worldwide.[13] This has made dentists more troubled as they are more vulnerable to the unnecessary risk of contamination as there is an increased likelihood of blood, saliva, body fluids, and respiratory secretions being distributed and resorted to when performing dental treatments. Reciprocal infection between dentists and patients is also possible due to the features of the dental environments' work nature. Infection prevention and control procedures should be explicitly imposed to ensure all dentists and patients' safety and well-being.[1415] Anxiety connected to dental procedure is not just confounding and confusing for patients. Yet, it is likewise a critical factor of distress for DHCPs to treat anxious patients. There is currently enough evidence suggesting that the bodily stress indicators such as increased blood pressure, elevated heart rate, and so on, which DHCPs' experiences are similar to the patients' reaction when treatments are being carried out.[16]

This study aimed to measure the stress level and anxiety associated with COVID-19 among final-year dental students pursuing their degree in one of the dental schools in the Kingdom of Saudi Arabia (KSA). The study's objectives included:

Assessment of stress levels among dental students

Evaluating the relationship of this stress level with personal hygiene and social habits in reaction to COVID-19

Exploring personal worries regarding the dental profession.

MATERIALS AND METHODS

This cross-sectional study was done during the lockdown restriction done in the city of Jeddah during the period of March 19 to May 29. According to convenience, the study participants were selected as a matter of accessibility that included undergraduate dental students from two dental schools from the same city. The study included students from the third (D2), fourth (D3), fifth (D4), sixth (D5), and internship (D6) years. The dentistry program in KSA is a 6-year program with one preparatory year (1st year). Initially, we identified a total of 350 students, and the questionnaire was sent, for which we received a response rate of 88% (n = 308). The Research and Ethics Committee of the main investigator's institution approved the study. All the participants were briefed about the study's benefits and purpose, and those who gave consent were included.

A questionnaire was designed and tested for its validity and reliability, which was mailed to the identified participants' E-mails. A group of four experts, including a biostatistician, were involved in the validation process. The questionnaire demonstrated good internal consistency reliability (intraclass correlation coefficient = 0.81, 95% confidence interval [CI]: 0.62–0.87), good internal consistency (α = 0.77), and moderate construct validity (r = 0.63, 95% CI: 0.26–0.81, P < 0.05). The questionnaire included four sections: the first section included a state of confidentially and anonymity and sociodemographic characteristics of the students; the second section included items related to hygiene behaviors and social behaviors in response to COVID-19, which was recorded using a 5-point Likert scale; the third section had items about opinion about the support and information they received about the pandemic during the lockdown and also items on person worries and fear regarding future of dentistry using Generalized Anxiety Disorder 7-item (GAD-7). To eliminate response bias, the online form was drafted to accept the submission of fully answered questionnaires, and every respondent was permitted a single submission only.

Data obtained were transferred to a Microsoft Excel sheet and were tabulated accordingly. The data cleaning was done, and an independent biostatistician performed statistical analysis using SPSS 23 (IBM Corp., Armonk, NY, USA). Categorical variables were presented in the form of percentages and frequencies using descriptive analysis. Mean and standard deviation were used for continuous variables after confirming the normality of the distribution. Pearson's Chi-square test was used to test the association between categorical variables. A significance level of P < 0.05 was considered a critical probability value for statistical significance.

RESULTS

The responders were 308 students out of 350 total students from the two dental schools, giving a response rate of 88%, with 168 (54.5%) females and 140 (45.45%) males, and an age range of 18–28 years. The participants included 52 (16.8%) 3rd-year, 58 (18.8%) 4th-year, 69 (22.4%) 5th-year, and 63 (20.4%) 6th-year students, and 66 (21.4%) were dental interns.

Social media was the primary source of information to the greatest number of students (n = 201 [65%]), followed by Ministry of Health (MOH)-related media (28.5%), followed by other social media including TV news (6.1%, n = 19). Most of the students (44.8%, n = 138) reported that the information they received was excellent, and 108 students (35%) considered it as good, 33 students (10.7%) thought it was fair, and 29 (9.5%) thought it was poor.

The mean score for anxiety was found to be 11.95 ± 4.21, and only 7.14% showed a severe level of anxiety in response to COVID-19, whereas 40.9% and 51.9% showed moderate and low anxieties, respectively [Figure 1]. The comparison of different anxiety levels between different study years of students showed that 6th-year students had comparatively more “severe” stress than other students and more D4 and interns showed low-stress level compared to others, which showed a statistically significant association (χ2 (8, 308) = 19.94, P = 0.021) [Table 1].

Figure 1

Distribution of levels of anxiety among students

Table 1

Year-wise distribution of study participants by the level of dental anxiety due to COVID-19 outbreak

Level of anxiety	Participant’s year of study (%)					Total	P*
	Third (D2)	Forth (D3)	Fifth (D4)	Sixth (D5)	Interns (D6)
Low	23 (7.47)	35 (11.36)	37 (12.01)	34 (11.04)	31 (10.06)	160 (51.95)	0.021*
Moderate	36 (11.69)	35 (11.36)	15 (4.87)	24 (7.79)	16 (5.19)	126 (40.91)
Severe	6 (1.95)	6 (1.95)	3 (0.97)	6 (1.95)	1 (0.32)	22 (7.14)
Total	65 (21.10)	76 (24.68)	55 (17.86)	64 (21.10)	48 (15.58)	308 (100)

*P<0.05 statistically significant

When asked about views about E-learning, according to 57% (n = 176) of students, it fulfilled the theoretical requirement more than clinical, and only 1% (n = 3) mentioned it fulfilled the clinical requirement. The fear and anxiety assessment among students showed that 87% were afraid of getting infected from COVID-19 from a patient or colleague, 90% were anxious about providing care for suspected patients, and 66% wanted to stop clinical work [Table 2].

Table 2

Fear and anxiety assessment of dental students (n=308)

	Yes, n (%)	No, n (%)	Unaware, n (%)
Are you afraid of getting infected with COVID-19 from a patient and colleague?	267 (87)	31 (10)	9 (3)
Are you anxious when providing treatment to a patient who is coughing or suspected of being infected with COVID-19?	277 (90)	21 (7)	9 (3)
Do you want to stop clinical work until the number of COVID-19 cases started declining?	203 (66)	71 (23)	34 (11)
Do you feel nervous when talking to patients in close vicinity?	221 (72)	74 (24)	12 (4)
Do you have fear that you could carry the infection from your dental practice back to your family?	283 (92)	18 (6)	6 (2)
Are you afraid of getting quarantined if get infected?	237 (77)	58 (19)	12 (24)
Are you anxious about the cost of treatment if you get infected?	225 (73)	68 (22)	15 (5)
Do you feel afraid when you hear that people are dying because of COVID-19?	262 (85)	37 (12)	9 (3)

DISCUSSION

The emergence of the COVID-19 pandemic has really upset the whole universe, compelling the people worldwide to rethink all the social relationships to avoid the epidemic.[17] Undergraduate dental education is generally observed as a high-pressure atmosphere, and one of the described stressors covering dental graduates is the fear of infection, which can lead to clinical anxiety.[1819] The theory evaluated in the study was that dental students would have raised stress and anxiety during the COVID-19 outbreak, which may affect personal hygiene behaviors and social habits and subjective worries about the dental profession.

In this survey, the mean total anxiety score signals that most of the respondents have mild anxiety, while a few of them have moderate-to-severe anxiety. The same anxiety scale (GAD-7) was used to evaluate anxiety during the COVID-19 pandemic among dental students in the United Arab Emirates and announced a higher level of moderate-to-severe anxiety levels in almost half of their students.[20] However, much lower percentages of moderate (2.7%) to severe (0.9%) anxiety were found in medical students in China.[21] The percentages were nearly the same among dental practitioners in Italy, whether in the mean GAD-7 score (6.56) or in the recorded levels of moderate (15.2%) and severe (8.7%) anxieties.[22]

The current study reported a nonsignificant difference in anxiety levels among students in different levels, with no students who described severe anxiety in all years. This could be due to their ignorance of the disease and lack of experience in treating patients in the clinic. Most of the students reported that they received excellent information about COVID-19 during the outbreak, with social media as the common source of information for the majority, followed by the MOH. Only a few students got their information from college and university announcements. In comparison, Saddik et al. detailed social media as the common source of information for 46.7% of their medical/dental study group, with the second source the MOH (39.8%), while 31.3% got their information from university announcements.[19] Reporting the MOH as the second major source of information could be elucidated by the regular messages sent to all mobile phones with information regarding preventive measures against COVID-19.

Most of the students without the consideration of their anxiety level thought that they would prefer (66%) to postpone their training until COVID-19 cases decline or a vaccine is available, 87% scared of getting infected from patients/coworkers, and 92% were afraid that they might take the infection back to their families from the clinical practice. These results are in accordance with a previous study by Ahmed et al., where 66% of their study participants do not want to do the clinical practice until the amount of COVID-19 cases starts to decline.[22]

However, the study was confined to two dental schools in Jeddah, and hence, the authors suggest conducting extensive studies covering more dental schools (cross-sectional study) to intricate final guidelines that help facing a pandemic-related public health emergency. Our study also poses some shortfalls and limitations. Initially, this study has got a cross-sectional nature, and thus, it is significant to contemplate that the concept of dental anxiety could change at any time. Thus, the relationships recognized in such studies should not be confirmed for a causal relationship. Second, it is a self-administered questionnaire study, where the participants may camouflage their true feelings and also may have unpublicized their dental fear, anxiety, and unpleasantness related to delivering dental care.

CONCLUSION

COVID-19 produced some degree of anxiety among dental students. Therefore, attempts should be made to reduce student anxiety in dental colleges through counseling and creating a supportive teaching atmosphere. Furthermore, dental schools should sufficiently prepare to face an upsurge of COVID-19 and other emerging infectious diseases with the newest up heard information about its modes of spread and preventive measures. Other COVID-19-associated stressors, such as stress related to money, quality of life, and delay in academic matters, were not covered. Thus, further study on a larger cohort of dental students is suggested, together with inquiry of other factors that could lead to stress and anxiety during the COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.