"Dentist as Smile Weavers" An Online Survey on Infection Surveillance, Emergency Treatment, Economic Setbacks, and Stress Endured by Periodontists of South India during COVID-19.

Introduction: The SARS-CoV-2 virus introduction and subsequent COVID-19 pandemic have had a profound impact on normal dentistry, particularly periodontal treatment, around the world. This cross-sectional study aimed to evaluate the infection surveillance, emergency treatment, economic setbacks, and stress endured by periodontists of South India during COVID-19.
Methods: A cross-sectional study was conducted from March to July 2021 among periodontists in South India. A total of 300 periodontists were chosen through the randomized sampling technique. The data were collected using a self-reported closed-end questionnaire consisting of 38 questions through Google Forms. The information was entered into a database and analyzed using SPSS program version 16.0.
Results: A total of 300 people took part in the survey, 277 (92.3%) dentists responded to the survey in its entirety. Periodontists and postgraduates made up 24.18% and 75.9% of those who responded, respectively. For all of the questions asked, there was a statistically significant difference among the responses. The majority of respondents agreed on questions about periodontists' knowledge, practice, mentality, and financial setbacks concerning the COVID-19 epidemic.
Conclusion: Most of the periodontists that we surveyed have adequate knowledge about SARS-CoV-2 and have been taking adequate measures in preventing the spread of the disease. This pandemic has a negative impact on the periodontists. This study indicates a high level of depression among a significant number of periodontists. It is important to monitor and address the mental health needs of practitioners during the pandemic. The knowledge, awareness, and attitudes regarding teledentistry were found to be satisfactory among the periodontists. Copyright:

INTRODUCTION

The coronavirus disease pandemic of 2019 (COVID-19), which began in Wuhan, China, has become a huge public health threat throughout the world.[1] Dentists are the most vulnerable group at risk of infection due to the nature of dental treatments, which involves frequent face-to-face contact with patients, their saliva, and contaminated material. The potential modes of transmission in dental care settings include aerosols and droplets created during treatments, possible inhalation of airborne germs, and contact with infected tools.[2]

Centers for Disease Control and Prevention guiding principles include face masks, eyewear, gloves, gown, properly cleansed clothing, high-speed suction, high- and low-speed rotary instruments, and adequate ventilation.[3] COVID-19 was recently discovered in the saliva of an infected patient, highlighting the need for oral and dental health experts in preventing the spread of the infectious disease.[4] The importance of masks in periodontal treatment is due to the use of ultrasonic as an initial mode of debridement which contributes to the generation of aerosols, which has been confirmed in various studies. In high-risk professions, both respirators and surgical masks have been advised. Respirators such as N95 prevent inhaling aerosols and surgical masks prevent transmission of the disease. The use of face masks along with personal protective equipment prevent infections; the choice is confounded with new evidence.[5]

There is a perceived impact on routine financial costs of periodontists as a consequence of this pandemic due to changes in clinical routine procedures such as the need to alter the work environment, intensification of handwashing, and the need to modify clinical procedures. It caused a negative impact on the financial stability of the practitioners.[6] The drastic increase in COVID-19 patients has created a significant impact on mental health among frontline health-care workers as well as other health-care providers, including dentists. COVID-19 pandemic has led to an increase in anxiety, depression, fear, stress, and sleep problems among dental practitioners.[7] It is important to understand the depressive symptoms in practitioners and identifying the factors associated with it helps in providing suitable psychosocial interventions for this group.[8]

In the wake of the COVID-19 pandemic, teledentistry could be used as an efficient and effective tool to provide consultancy and treatment.[9] Patients who were in the middle of a dental procedure when the lockdown was declared were mostly affected due to discontinuation of medication and the persistence of dental problems. Teledentistry has become the solution; teleconsultation, telediagnosis, and tele-triage are some of the modules of teledentistry.[10]

This study aimed to assess the challenges and aftereffects of pandemic conditions and also knowledge and attitude toward teledentistry which was conducted among periodontists in South India by means of a questionnaire survey.

MATERIALS AND METHODS

A cross-sectional study with self-reported, closed ended questionnaire consisting of 38 questions was coordinated using Google Forms (https://surveyheart com/form/60e56435acc3670c1431c417) conducted among 300 periodontists in South India from March to July 2021. The respondents include both private and government sectors. The samples were randomly chosen by distributing the Google Form link among periodontists in South India through various social platforms.

The current isolation strategy argues for limiting face-to-face contact and avoiding big gatherings, as the study took place during the COVID-19 epidemic. As a result, it was decided to collect the data via the Internet. Using Google Forms, an online semi-structured questionnaire was created. The survey link was shared with the target periodontists via E-mails and WhatsApp groups. Before they started filling out their questionnaire, they had to give their informed consent using the Google Forms. Participants after receiving and clicking the link are automatically sent to research material. All participants provided demographic information as well as information about their understanding of COVID-19-related information, anxiety, economic setbacks, and challenges in clinical practice. There was no set deadline for completing the questionnaires. Only completed questionnaires were used in the response analysis.

Ethical considerations

The periodontists were given full freedom whether to participate or leave the survey link provided. The respondents' identities were protected. As per the Internet protocol address, only one response was used in the response analysis.

Data analysis

Data were analyzed using the computer software, Statistical Package for the Social Sciences (SPSS), Version 16, manufactured by (International Business Machines Corporation company, United States of America) for Windows Operating System.. To analyze the relationship between different categorical variables, descriptive statistics were obtained and a Chi-square test was used. When the percentage of the test was greater than the threshold, the result was judged significantly (P < 0.05).

RESULTS

Two hundred seventy-seven participants completed the web-based questionnaire survey, while 23 participants did not respond. Majority (67.1%) of the participants belong to the age group 25–35 years. A total of 59.6% of respondents were females; 48.4% of respondents were from Kerala. Most of the participants (40.1%) had clinical experience of 3 years. The highest reported academic degree was MDS (75.9%).

The infection surveillance, economic setbacks, and emergency treatment methods in current pandemic conditions among periodontists were measured using 11 questions with multiple options [Table 1].

Table 1

Practitioners knowledge and understanding of the COVID-19 infection control risk and emergency

Question	Option	n (%)
Do you agree with perceived changes in periodontology post-COVID-19?	a. Use of hand scalers and curettes instead of ultrasonic electric devices	145 (52.3)
	b. COVID-19 pandemic will impact periodontology in future	16 (5.7)
	c. Reduced volume of patients per day and frequency of their follow up	96 (34.7)
	d. Needing to avoid periodontal surgeries	20 (7.3)
How do you think that the spread of COVID infection is controlled among periodontists?	a. Educating people is more	129 (46.6)
	b. Avoid treating patients with symptoms	11 (4)
	c. Proper use of personal protective	110 (39.7)
	d. All of the above	27 (9.7)
Which of the following is the most effective method for the prevention of COVID-19?	a. Use standard precaution	107 (38.6)
	b. Get vaccination	170 (61.3)
What personal equipment do you prefer using while doing dental procedures on patients who had been confined with or under investigation of COVID-19?	a. N95 mask, gloves, and goggles	98 (35.4)
	b. Surgical mask, gloves, and goggles	29 (10.5)
	c. N95 mask/surgical mask, gown, goggles, and gloves	150 (54.1)
Which color bag do you have used to dispose of used masks?	a. Yellow	200 (72.2)
	b. Red	34 (12.3)
	c. Black	43 (15.5)
Which kind of mask do you prefer while doing aerosol-generating periodontal procedures?	a. N95 mask	190 (68.6)
	b. Surgical mask	54 (19.5)
	c. 3ply cloth masks	5 (1.8)
	d. Combination of any two (double masking)	28 (10.1)
During COVID-19, how many appointments are required to complete periodontal flap surgery after phase 1?	a. 1	31 (11.2)
	b. 2	180 (65)
	c. 3	25 (9)
	d. 4	41 (14.8)
What would you do if a patient’s COVID-19 symptoms were observed during screening?	a. Refuse to treat patients and asking them to leave the clinic	45 (16.2)
	b. Treat patients and ask them to go to the hospital	160 (57.8)
	c. Refer patients to hospital without treating them	72 (26)
Measures taken for preliminary patient screening to assess emergency	a. Patient history	141 (50.9)
	b. video call and audio call	136 (49.1)
What are the emergency treatments provided?	a. Swelling	33 (11.9)
	b. Trauma	28 (10.1)
	c. Uncontrolled bleeding	26 (9.4)
	d. Pain	190 (68.6)
The category of points of contacts in teledentistry used by you?	a. Point-to-point system	198 (71.4)
	b. Point-to-multipoint system	49 (17.7)
	c. Multipoint-to-point system	22 (8)
	d. Multipoint-to-multipoint system	8 (2.9)

According to 52.3% of participants, the use of hand scalers and curettes instead of ultrasonic devices can be deemed as changes in periodontology post-COVID-19.

About 46.6% of respondents think that education of people is more important to control the spread of the infection. About 61.3% of participants agreed that vaccination is the most effective way to prevent COVID-19 infection. About 54.1% of responders preferred to use N95 masks, gloves, gowns, and goggles when performing periodontal procedures on patients who have been diagnosed with or are being suspected of COVID-19. About 68.6% of respondents agreed that using an N95 mask while conducting aerosol-generating treatment procedures was necessary.

During COVID-19, about 65% of participants finish periodontal surgery in patients within two appointments. About 50.9% of the participants prefer patient history to assess the emergency condition of the patient in the present scenario.

The concerns including disease transmission, stress, and technological advancement in the fields were measured using 21 questions in the YES/NO format [Table 2].

Table 2

Concerns of periodontists in disease transmission, stress, and technological advancements

Questions	Yes, n (%)	No, n (%)
Do you believe that your profession was putting you at greater risk of contracting COVID-19 than the general population?	236 (85.2)	41 (14.8)
After the outbreak of COVID-19, did you treat all patients as potentially COVID-19 positive?	139 (50.9)	138 (49.1)
Do you find it difficult wearing a mask or following COVID protocols during procedures?	250 (90.3)	27 (9.7)
Would we need to wear a hazmat suit in the near future while treating patients in case of procedures involving aerosol splatter?	250 (90.3)	27 (9.7)
Do you think that the aspects of periodontology are likely to be affected by changes imposed on the profession in response to COVID-19	180 (65)	97 (35)
Use of N95 in a continuous model offered better protection for respiratory infection	220 (79.4)	57 (20.6)
Do you agree with the use of powered air purifier respirators during periodontal treatment of suspected patients?	175 (63.2)	102 (36.8)
Use of sanitizers and handwashing using soap after every patient is necessary to prevent cross-infection	250 (90.3)	27 (9.7)
Have you attended any training or received lectures regarding COVID-19 or have any knowledge about infection control in periodontics	67 (24.2)	210 (75.8)
How important it is to change masks and gloves frequently after treating patients to decrease the possibility of transmitting infection to patients and myself	270 (97.5)	7 (2.5)
Do you think about asking patients to sit apart from each other wearing masks while sitting in waiting room, washing hands before and after getting into dental chair is necessary	240 (86.6)	37 (13.4)
Would you allow any of your dental staff to work with patients if they have flu-like symptoms	80 (29)	197 (71)
Do you think dentists have a role in teaching others about COVID-19?	260 (94)	17 (6)
Should the total cost of periodontal treatment change due to pandemic?	222 (80.1)	55 (19.9)
Have work routine changes led to increased financial cost of periodontal treatment?	247 (89.2)	30 (10.8)
Do you agree that the number of patients reduced when compared with the prepandemic period?	267 (96.4)	10 (3.6)
Do you think the number of patients will return to pre COVID-19 levels in a year	145 (52.3)	132 (47.7)
Are you depressed regarding your professional practice?	227 (81.9)	50 (18.1)
Do you have concerns about receiving COVID-19 from patients?	181 (65.3)	96 (34.7)
Have you come across the use of telecommunication for the purpose of diagnosis of patient	203 (73.2)	74 (26.8)
Are you satisfied with the technological requirements for teledentistry	219 (79.1)	58 (20.9)

According to 65% of participants, changes to treatment planning as a result of COVID-19 will have an impact on periodontology in future. About 63.2% of respondents promote powered air purifiers while treating patients. To prevent cross-contamination, 90.3% of participants believe in using hand sanitizers and washing hands with soap before treating the next patient.

Most of the periodontists (89.2%) think that changes in work routine have led to an increase in the financial cost of periodontal treatment. Almost 96.4% say that patient volume has reduced since this pandemic has started. About 52.3% of periodontists believe that number of patients will return to a normal level within a year. About 81.9% of periodontists are suffering from depression. About 65.3% of practitioners are concerned with receiving COVID from patients. About 73.2% of periodontists use teledentistry for the diagnosis of patients and 79.1% of the respondents are satisfied with their technological requirements.

DISCUSSION

This study assessed periodontists' knowledge, attitudes, behaviors as well as psychological reactions to the COVID-19 outbreak. Age, gender, level of experience, education, and location were all sociodemographic characteristics.

The most significant factor in preventing the spread of COVID-19 infections is public education. This was agreed upon by 46.6% of the participants. Only 24.2% of participants had attended any clinical training or lectures on COVID-19, indicating a lack of expertise and awareness of the condition. The use of hand scalers and curettes rather than ultrasonic or powered devices can be considered as a post-COVID-19 shift. Vaccination is considered the most preferred precaution against COVID-19 infections.

Most periodontists recognized changes in the routine of the periodontal treatment during the COVID-19 pandemic. They have a perception of an increase in the periodontal treatment cost, and a reduction in the volume of patients. This study found a high prevalence of depression among periodontists in South India, and most of them have a fear of contracting COVID-19 from patients. About 52.3% of participants in the survey stated that using hand scalers and curettes instead of powered ultrasonic devices could be a shift in periodontology in the post-COVID-19 era, which is similar to a study conducted in Uni Suleiman, Iraq, by Dler A Khursheed.[11]

About 59.2% of participants concurred that vaccination is the most effective strategy to prevent COVID-19 infection which is found similar to a study by Sanjeev Kumar India.[12] About 54.1% of respondents use N95/surgical mask along with goggles, gloves, and gowns as protective equipment while treating patients who were under observation or confirmed COVID-19, which is similar to a study conducted by Guangwen Li china.[13]

According to the study, 57.8% of the periodontists prefer to treat their patients even though they have any COVID-19 symptoms and then refer them to the hospital, which is in contrast to a study conducted in Saudi Arabia where 65.4% of dentists refused to treat their patients and refer them to the hospital without any treatment.[14]

As per the findings of the study, about 63.2% of participants agreed that using a powered air purifier respirator in suspected patients is beneficial in preventing COVID-19, which is similar to a study by Frank Chow, Tufts University of Dental science.[15]

The study consists of 79.4% of participants agreeing that the use of N95 masks on a continuous basis can prevent respiratory infection in dentists, which is similar to another randomized controlled study by P. Bradford Smith, Beijing, China.[16]

According to this study, work routine changes have led to financial implications, as was previously reported by a recent Brazilian study.[17] The results of this study indicate depression in the majority (81.9%) of participants and were also in line with a previous study among dentists performed in Israel.[18]

The study was unable to conduct face-to-face interviews due to the risk of infection spreading. Using web-based media for data collecting would have eliminated professionals who were unfamiliar with Internet media or persons who were preoccupied with personal matters.

CONCLUSION

Based on the findings of the study, the periodontists have many concerns relating to COVID-19, including economic, social, ethical, health, and professional factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.