Knowledge and Attitude towards Dental Clinical Practice Related to COVID-19 Pandemic among Dental Interns in Saudi Arabia.

BACKGROUND: The newly emerged pandemic has created many dilemmas in dental clinical practice all over the world. Most of the practicing dentists and dental students are at higher risk of getting infected and transmitted the disease. The study aimed to explore the knowledge and attitudes among dental interns in Saudi Arabia related to the COVID-19 pandemic.
MATERIALS AND METHODS: An online questionnaire survey was carried out among dental students pursuing their internship at different universities in Saudi Arabia. A combination of convenience and snowball sampling was used to identify interns from each province of the Kingdom. The questionnaire was validated and pretested, which recorded the knowledge, attitude, and concerns related to dental practice and COVID-19.
RESULTS: The knowledge related to COVID-19 and its importance in clinical dental practice was below average among dental interns, and only 22.2% gave a correct response to all questions. About 80.8% and 85% of the dental students were worried about contracting the infection during dental practice and transmitting it to family and friends, respectively.
CONCLUSION: Dental students showed satisfactory knowledge, attitude, and practices related to COVID-19, and most of them were aware and adhering to the preventive guidelines set by the ministry of health. Copyright:

INTRODUCTION

The emergence of the newly identified β-coronavirus commonly known as COVID-19 occurred in Wuhan, China, has evolved rapidly into a public health crisis and has spread exponentially to other parts of the world.[1] As of June 23, 2020, a total of 8,993,659 cases of COVID-19 have been confirmed throughout the world including 469,587 deaths and Saudi Arabia has alone reported 164,144 with 1346 deaths.[2] No doubt this pandemic has created much chaos and panic among all sectors of the society including health-care professionals.

The incubation period of COVID-19 is estimated to be from 1 to 14 days, which is also the recommended duration of medical observation and quarantine in infected patients.[3] Patients who are infected often show clinical manifestations that include fever, cough, and shortness of breath.[4] It is reported that more than 80% will experience mild respiratory infections and about half of the infected will have pneumonia. Severe illness has been reported in 15% of the patients, of which 5%–7% need critical care treatment.[56] Some rare cases will have severe respiratory problems, kidney dysfunction, and also could lead to death. Specific symptoms experienced by the patients include dry cough and fever and also nonspecific symptoms such as difficulty in breathing, eye inflammation or redness, pharyngitis, emesis, diarrhea, fatigue, and body pain are also common.[578]

The spread of this COVID-19 has challenged all the health-care professionals including dentists, who are at elevated risk of getting infected due to their frequent exposure to body fluids (saliva and blood) and aerosol or droplet generated from the oral cavity during the various dental interventions. Consequently, this particular virus's transmission can occur by inhaling aerosols generated from the infected persons or by direct contact with saliva, mucous membrane, and contaminated instruments and objects.[910] Dentistry involves procedures that generate aerosol production and that make this profession a high-risk category for COVID-19 transmission.[111213] Knowledge related to this pandemic including its transmission, prevention, and management among dental health professionals is very much essential, as this would help to reduce the risk of getting infected and transmitted. Thus, this survey aimed to explore the knowledge, attitude, and practices toward dental treatment among dental interns studying in the Kingdom of Saudi Arabia.

MATERIALS AND METHODS

Our study was a cross-sectional study done among dental interns in dental schools in Saudi Arabia. The survey was conducted using a validated questionnaire, which was tested for its content and face validity that was done by a group of expert evaluation. We used a principal component analysis (common factor analysis) to check the construct validity. The questions with low correlation coefficient (r = <0.7) were excluded. The questionnaire showed an internal consistency of 0.791. The questions were then classified based on three components, such as knowledge, attitude, and practices.

A minimum of 146 sample size was calculated considering values of the standard deviation of scores obtained from the pilot study done in 25 interns.

We used the sample size formula,

Where S= standard deviation (10.19), Z= 1.96, mean = 9.87; d= mean difference (0.2316); α= significant level (95%) and 1-β= power of study (80%).

The Institutional Ethics Committee of the institution approved and gave permission for this survey. The questionnaire was sent randomly to selected dental interns after contacting them either through phone and/or e-mail. We used a mixed method of convenience and snowball sampling where interns from each province were identified and asked to answer the questionnaire. They were also requested to forward to their colleagues and other dental interns from other provinces to ensure a larger participation. The participants were briefed about the need and benefits of the study and anonymity of their responses was assured.

Data collected were entered into MS Excel by a calibrated investigator and statistical analysis was done using SPSS ver 23 (IBM Corp. USA) by an independent biostatistician. Categorical variables were summarized as proportions and frequencies and any possible relationship of the variables was analyzed using Pearson's Chi-square test. Continuous variables obtained were expressed as mean and standard deviation. The significance value (P value) ≤ 0.05 is considered statistically significant.

RESULTS

In our study, we had included a total of 203 dental interns from various provinces of Saudi Arabia who gave consent to participate in the research. The mean age of the participants was 24.12 ± 2.25 years that included 54.2% (n = 110) females and 45.8% (n = 93) males. The responses to questions related to the COVID-19 infections are depicted in Table 1. The participants who gave correct responses to all the knowledge questions were 22.2% (n = 45) and there was no statistically significant relationship of these responses with the gender of the participants (P = 0.220) [Table 2]. The mean score of knowledge questions was 7.45 ± 2.63 and there was no statistically significant difference observed in these mean scores between male (7.34 ± 2.55) and female (7.55 ± 2.71) interns, (t(201) = 0.542, P = 0.588).

Table 1

Knowledge related to COVID-19 and its effect on dentistry

Questions	Responses, n (%)
	True	False	I don’t know	Total
Tele-screening to identify patients with suspected or possible COVID-19 infection can be performed remotely at the time of scheduling appointments	122 (60.1)	42 (20.7)	39 (19.2)	203 (100.0)
Main clinical symptoms of COVID-19 are fever, fatigue, dry cough, and myalgia	171 (84.2)	26 (12.8)	6 (3.0)	203 (100.0)
Thermal scans are an effective preliminary screening method to ascertain if a patient is positive for COVID-19 virus	148 (72.9)	33 (16.3)	22 (10.8)
The incubation period for COVID-19 can range from 0 to 24 days	111 (54.7)	67 (33.0)	25 (12.3)	203 (100.0)
There is a potential for transmission of COVID-19 via aerosol, fomites, respiratory droplets or the fecal-oral route that may contribute to nosocomial spread in the dental office setting	156 (76.8)	30 (14.8)	17 (8.4)	203 (100.0)
People in contact with a COVID-19-positive individual should be immediately isolated in a proper place. In general, the observation period is 14 days	170 (83.7)	22 (10.8)	11 (5.4)	203 (100.0)
Dental professionals are at high risk for nosocomial infection and can become potential carriers of the disease	146 (71.9)	28 (13.8)	29 (14.3)	203 (100.0)
Structure of the COVID-19 virus consists of a single-stranded RNA with a nucleoprotein within a capsid of matrix protein	108 (53.2)	23 (11.3)	72 (35.5)	203 (100.0)
Preprocedural mouth rinse with 0.2% povidone-iodine effective to reduce the load of coronaviruses in saliva?	109 (53.7)	35 (17.2)	59 (29.1)	203 (100.0)
Negative pressure room can be effective to perform dental treatment for infected patient	128 (63.1)	32 (15.8)	43 (21.2)	203 (100.0)
Patient who is suspected COVID-19 infection should be seated in a separate, well-ventilated waiting area at least 6 feet from unaffected patient-seeking care	144 (70.9)	30 (14.8)	29 (14.3)	203 (100.0)

Table 2

Relationship of gender with participants answered all knowledge questions correctly

Responses of knowledge questions (11)	Gender, n (%)		Total, n (%)	P* (χ2)
	Female	Male
All correct, n (%)	28 (62.2)	17 (37.8)	45 (22.2)	0.220 (1.504)
Not all correct, n (%)	82 (51.9)	76 (48.1)	158 (77.8)
Total, n (%)	110 (54.2)	93 (45.8)	203 (100.0)

χ2=Pearson’s Chi-square test value, Degree of freedom=1; *a P<0.05 is considered statistically significant

When we inquired about the participant's practices during the COVID-19 times, 69.5% reported that they did not go to crowded places and 66.5% agreed that they followed preventive guidelines along with usage of N95 masks. Attendance to online courses that are related to the dental practice and COVID-19 was reported among 69.5% of the participants and 59.6% mentioned that they searched for scholarly/research articles on dentistry and clinical practice during COVID-19 pandemic. When we assessed the attitude and concerns of the participants, it was found that 80.8% were worried about contracting the COVID-19 infection when providing dental care for the patients. Approximately 71% of the participants had the opinion that nonemergency dental appointments should be performed with adequate precaution with the use of personal protective equipment (PPE). The majority of the participants were worried about spreading infections to their family and friends (85.7%) and also worried about the spread through aerosols during dental procedures (86.2%) [Table 3].

Table 3

Opinions of dental interns related to clinical practice during COVID-19 pandemic times

	Agree, n (%)	Disagree, n (%)	I don’t know, n (%)	Total, n (%)
Nonemergency dental appointments can be performed with adequate precautions and the use of PPE, n (%)	144 (70.9)	30 (14.8)	29 (14.3)	203 (100.0)
I am worried as a dental health-care provider of contracting the infection, n (%)	164 (80.8)	39 (19.2)	0 (0.0)	203 (100.0)
I am worried as a dental health-care provider of spreading the infection to my family and friends, n (%)	174 (85.7)	29 (14.3)	0 (0.0)	203 (100.0)
I am worried about the spread of infection with aerosol produced during dental procedures, n (%)	175 (86.2)	28 (13.8)	0 (0.0)	203 (100.0)

PPE: Personal protective equipment

DISCUSSION

It is very much evident that COVID-19 transmission risk is higher for people those who come in close proximity with the infected persons that include dentists who do procedures directly in the oral cavity. Thus, there is a huge risk of getting infected and transmitted to other health-care workers and relatives. The dentist's immediate and appropriate responses have a crucial role to control the spread of this pandemic. In our study, the majority of the interns had good knowledge regarding the clinical symptoms of COVID-19.[14]

Clinical appointments should be made after performing an initial screening through teleconferencing methods, which will help to record the travel history, movement history for both patients and relatives in his/her residence. It would also help the dentist to discuss the protocols and preventive guidelines that they should follow when coming for dental appointments considering the incubation period of the virus, which is 0–14 days.[15] Patients, who are recently recovered or still active with infections, should be considered for treatment after getting a physician's consent and treatment should be done following all the preventing guidelines.

In our findings, 72.9% agreed that thermal scans are necessary preliminary methods for positive COVID-19 patients. A person with a COVID-19 infection usually experiences an elevated temperature, and this is one of the standard methods used in screening an individual who has the disease. However, an asymptomatic and afebrile infected person could also be contagious. Thermal imaging scanners and noncontact temperature assessment devices could be utilized for screening people's temperature who are visiting dental clinics.[1617] Nearly half of the participants only agreed that using 0.23% of povidone-iodine mouthwash before any dental treatment procedures would help to reduce the virus load in the oral cavity. Evidence shows that this preprocedural mouth rinse for at least 15 s can reduce the viral load in the patient's saliva.[18] Some of the other treatment consideration that should be followed to minimize the spread of infection are utilization of extraoral imaging and restriction of intraoral imaging techniques, use of disposable and single-use instruments and devices, rubber dam should be used whenever possible, minimize or avoid aerosol-generating treatments, and procedures should be as minimally invasive as possible.[1920]

The findings of our study showed that the majority of the dental interns had shown satisfactory attitudes in professional and personal life related to COVID-19 pandemic delaying the appointments in nonemergency dental treatments, use of PPE when treating all types of patients, etc., The majority of the interns were also concerned and worried about of spread of infection to their family and friends. Approximately 70% of them agreed that they did not get crowded places during these pandemic times. About 69.5% and 59.6% of the participants reported attendance to online continued dental education courses on dental practice during COVID-19 pandemic and search for scholarly articles regarding the same topic, respectively. Dental interns should utilize this unprecedented period to learn and understand not only the information of pandemic but also should put effort to do research and innovations that can hugely contribute to dentistry as well as public health.

Some of the limitations that should be considered before interpreting our study findings are as follows. There is a possibility of social desirability bias, which was tried to minimize by not asking the participants their name or any identifying details and also assuring the anonymity and confidentiality of the responses they provided. Second, as we followed convenience and snowball sampling techniques, there is a possibility of selection bias. To minimize this, we tried to personally contact the interns either through phone or e-mail.

CONCLUSION

In our study, dental interns showed good knowledge, attitude, and practices required to combat the COVID-19 pandemic. Dental interns should mandatorily use the recommended preventive guidelines given by the concerned health authorities such as Ministry of Health, Centers for Disease Control and Prevention, and WHO. They should make utilization of this pandemic time to learn and research innovations that can contribute both to the public and also the scientific community. Dental schools should provide advanced and motivational education methods to educate the residents to prepare for possible future pandemics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.