The Perception of Evidence-based Dentistry among Dental Professionals in Saudi Arabia during COVID-19 Pandemic.

Background: The COVID-19 pandemic caused extraordinary changes in dental practices, including evidence-based dentistry (EBD). Despite dental practitioners' positive attitudes toward EBD, implementation has been limited. This study aimed to investigate the knowledge, attitudes, and practices of EBD among dental professionals in Saudi Arabia and explore the COVID-19 pandemic impacts on perceptions of EBD.
Methods: A cross-sectional study was conducted using a questionnaire that was distributed electronically to dentists and dental students in Saudi Arabia. Multiple linear regression and descriptive statistics were used for data analysis.
Results: The mean knowledge score was 48.33 ± 13.63 out of 70 points, with 37.31% to 60.45% awareness of EBD components. Only 37% were aware of the Cochrane Collaboration. Specialist/consultants and participants from the central region had significantly better knowledge scores. Lack of time (75.60%) was the most significant barrier to EBD. Only 36.60% of participants used EBD for treatment procedures. Most (72.4%-80.6%) believed the pandemic increased EBD's importance, 67.70% believed that EBD should be mandatory, and 62.90% believed all decisions in dental clinics will follow EBD in the future. However, 53.50% reported that EBD material was difficult to follow during COVID-19. Conclusions: The level of knowledge about EBD among dental professionals in Saudi Arabia is relatively acceptable. It is difficult to put EBD to practice due to the overwhelming flow of information. More educational and organizational efforts should be implemented to advocate for EBD. Copyright:

INTRODUCTION

The American Dental Association defines evidence-based dentistry (EBD) as a method that involves the systematic evaluation of scientific evidence and clinical experience aligned with patient needs and choice in the field of oral care.[1] For patients, EBD was found to provide more comfort, trust, and satisfaction with the quality of services provided in dental care and as a result, patients were more motivated.[2] This requires the dental professional to be aware of a wide array of concepts and topics, including study design, bias, statistical tests, systematic reviews, the Cochrane Collaboration, odds ratios, relative risks, clinical effectiveness, number needed to be treated, confidence interval, and publication bias.[3] However, only 10% of the practicing dentists used validated research as a basis in providing health care services.[4]

The outbreak of coronavirus disease 2019 (COVID-19) during December of 2019 in Wuhan, China,[5] altered the health-care systems worldwide.[6] It is estimated that more than 23,000 papers published on the subject between January and June 2020.[7] This urged dental professionals to be aware of EBD components and skills to cope with the new evidence about COVID-19.

Among Malaysian dentists, 69.9% had heard of EBD and 97.8% agreed that EBD improved their knowledge and skills.[8] Similarly, 56.1% of the Iranian dentists were aware of EBD, and 82% believed that EBD improves a dentist's knowledge and clinical skills.[3] However, there are many barriers faced by dental professionals that stall the use of EBD in dental clinical practices, such as a lack of personal time, lack of skills, and lack of time to appraise the scientific literature.[9] Most studies reported that lack of time was the main barrier in India (42.85%),[10] Malaysia (64.4%),[8] and Iran (44.1%).[3]

A number of studies in Saudi Arabia investigated the awareness of Saudi dental professionals about EBD; however, most of this research was conducted in a single city. In a study from Riyadh city, the majority (91.8%) of respondents were aware of evidence-based practices, 84.8% of the dentists used evidence-based practices in decision-making, and 59% agreed that their dental practice was inefficient without evidence-based practices.[11] Another study in Riyadh showed that 52% believed that EBD will help with clinical decision-making, and 50% reported that EBD will improve the quality of patient care.[12]

In fact, using EBD in a dental practice is mandatory, especially during the COVID-19 pandemic, given that the results of prior studies have indicated that dentists and dental clinics face the greatest risk of COVID-19 transmission.[13] Nonetheless, and despite the positive attitudes of dental practitioners toward EBD, the implementation of EBD was limited.[14]

Therefore, the present study was designed and implemented with the aim of investigating the knowledge, attitudes, and practices of EBD among dental professionals in Saudi Arabia and to also explore the impact of the COVID-19 pandemic on EBD perceptions.

METHODS

This cross-sectional study used the convenient sampling technique to collect data in Saudi Arabia from September to October 2020. Potential respondents, dentists, and dental students, were contacted through social media platforms such as WhatsApp, Twitter, Instagram, Facebook, and Snapchat, which are commonly used by dental professionals.[15] The data collection was part of a larger study assessing the EBD research project in Saudi Arabia, which is approved by the faculty of dentistry at Umm Al-Qura University (project number 195-20).

Invitations to participate in the study were sent to private groups that specialize in dentistry in both the private and governmental sectors. In addition, other invitations targeted student social media groups and class leaders in different dental schools across Saudi Arabia. The inclusion criteria were dental students and dentists in Saudi Arabia. Participants who did not accept the study's informed consent were excluded. The minimum required sample size was calculated to be 384, with values of an expected population of 50%, a confidence interval of 95%, and an alpha level of 5% used in the sample size equation.

The questionnaire was sent as an online link, and all participants were required to approve the study's consent form before they could answer the questions. By clicking a button labeled “approve,” participants were considered to have signed the consent form for the study. The time spent answering the questionnaire ranged from 3 to 5 min. All data were used completely anonymously, and any recognizable data that indicated anything about a participant's identity was removed.

The questionnaire was derived from questionnaires used in multiple prior studies,[310161718] with modifications. It encompassed 45 questions allocated in five parts. The first part collected sociodemographic characteristics. The second part assessed the dentists' knowledge about EBD with 14 components rated on a scale from 1, “no knowledge at all,” to 5, “I have strong knowledge.” The component scores were summed for a total knowledge score, with 70 as the maximum and 14 as no knowledge at all. The components were also categorized for the answers indicating the respondent was aware (score of 4–5) or unaware (score of 1–3) of that component. The third part of the questionnaire asked about eight potential barriers to the use of EBD. The fourth section was composed of four questions to assess the respondent's experience with and practice of EBD. Finally, the last part assessed the relationship between COVID-19 and perceptions about and practice of EBD through six questions with possible answers of Yes or No. The questionnaire was tested in a pilot with 10 participants who were excluded from the main study. This piloting aimed to validate the questionnaire in terms of organization, logical flow, syntax, grammar, spelling, and understanding.

Statistical analysis

Data were tabulated, and descriptive statistics were determined using SPSS v. 21 (IBM Corp., Armonk, NY, USA). Descriptive statistics (univariate analysis) were illustrated as the mean, standard deviation, frequency, and percentages. Data were analyzed using multiple linear regression, and a value of <0.05 was considered significant.

RESULTS

A data set of 402 participants is presented from this study. The demographic data of the participants are presented in Table 1 and shows that the participant age was 27.7 ± 7.57 years, and the clinical experience was a median of 3 years with interquartile range of 4 years (minimum = 0, maximum = 23). There were 133 (33.08%) males and 269 (66.92%) females. In regards to the qualifications of the participants, 168 (41.79%) were students, 29 (7.21%) dental interns, 140 (34.83%) general dentists, and 56 (16.17%) specialists or consultants. The workplace for the participants: 186 (41.79%) were students, 109 (27.11%) work in the governmental sector, 70 (17.41%) work in the private sector, and 55 (13.68%) currently are not working. The distribution of the participants within Saudi Arabia was as the following: 66 (16.42%) from the Central region, 244 (60.70%) from the West region, 36 (8.96%) from the East region, 35 (8.71%) from the North region and 21 (5.22%) from South region. The participants were from 14 different cities across Saudi Arabia, including Abha, Alkharj, Alqunfudah, Alqurayat, Dammam, Jeddah, Hail, Kohabber, Almadinah, Makkah, Najran, Riyadh, Taif, and Yanbu. The students in this study were from 15 different universities and colleges, including Umm Al-Qura University, King Saud University, King Abdulaziz University, Al-Farabi Dental Colleges, Aljouf University, Batterjee medical colleges, Imam Abdulrahman Bin Faisal University, Ibn Sina College, King Khalid University, King Saud bin Abdulaziz University for Health Sciences, Majmaah University, Najran University, Prince Noura University, Prince Sattam University, and Taibah University.

Table 1

Participant levels of knowledge about components of evidence-based dentistry

Component	Score, mean±SD*	Awareness, n (%)**
EBD	3.46±1.43	220 (54.73)
Study design	3.73±1.25	243 (60.45)
Bias	3.63±1.37	233 (57.96)
Statistical tests	3.52±1.25	203 (50.5)
Systematic review	3.76±1.21	240 (59.7)
Meta-analysis	3.41±1.34	199 (49.5)
Critical appraisal	3.27±1.37	192 (47.76)
Cochrane collaboration	2.95±1.41	150 (37.31)
Odds ratio	3.3±1.35	194 (48.26)
Relative risk	3.49±1.3	206 (51.24)
Clinical effectiveness	3.76±1.23	243 (60.45)
Number needed to treat	3.44±1.36	200 (49.75)
Confidence interval	3.26±1.32	178 (44.28)
Publication bias	3.36±1.36	203 (50.5)

*Data in continuous format, **Data in categorical format (awareness=score of 4-5). EBD: Evidence-based dentistry, SD: Standard deviation

The participants' level of knowledge about all components is shown in Table 1. The total knowledge score was 48.33 ± 13.63 out of 70 points.

Multiple linear regression was conducted to predict total knowledge scores by age, gender, qualifications, region, and years of experience, with the backward elimination method. A significant regression model was found (F (1399) =15.198, P < 0.001), with an adjusted r2 = 0.066) based on qualification (B = 2.832, standard error = 0.567, beta = 0.242, P < 0.001) and region (B = 1.388, standard error = 0.536, beta = 0.125, P = 0.01) only. Using ANOVA and LSD as post hoc tests showed that specialists/consultants had significantly higher total knowledge scores than did students (P < 0.001), interns (P = 0.005), or general dentists (P < 0.001). Furthermore, participants from the central region had significantly higher total knowledge scores than those from the Eastern (P = 0.009) and Western regions (P = 0.030), as illustrated in Table 2. However, other subclasses were not significantly different from each other in the qualification and region variables.

Table 2

ANOVA and least significant difference test as post hoc for multiple regression

Variable	Mean±SD
Qualification
Student	45.57±14.50
Intern	49.14±11.64
General dentist	47.30±12.31
Specialist/consultant	57.35±11.07*
Region
East	44.92±12.10
West	48.16±13.91
North	47.11±14.36
South	45.90±15.46
Central	52.26±11.75**

*Specialists/consultants had significantly higher total knowledge scores than students (P<0.001), interns (P=0.005), and general dentists (P<0.001), **Participants from the central region had total knowledge scores that were significantly higher than those in the Eastern (P=0.009) and Western regions (P=0.030). , SD: Standard deviation

Regarding the barriers to EBD, the participants had a variety of answers, as shown in Table 3. Participant experience and practice with EBD are displayed in Table 4. Participants answered differently about the impact of the COVID-19 pandemic on perceptions of EBD among dental professionals, and the responses are shown in Table 5.

Table 3

Participants’ barriers to evidence-based dentistry

Barrier	Count	Percentage
Lack of time	304	75.60
There is too much evidence that confuses me	246	61.20
No subscription to journals	240	59.70
There is no availability or access to information	228	56.70
EBD is difficult to understand	191	47.50
I think it is research and not applicable to clinical practice	175	43.50
Evidence not related to the context of general dentistry	159	39.60
No internet access	156	38.80

*Participants could choose more than one answer. EBD: Evidence-based dentistry

Table 4

Participants’ experience and practice with evidence-based dentistry

Question	Choice	Count	Percentage
If you have any uncertainties about a treatment procedure, which sources do you use to resolve the uncertainty and find a proper solution?	Refer to reference books	110	27.40
	Ask colleagues	118	29.40
	Refer to electronic sources and databases	147	36.60
	Continue the procedure based on personal experience and judgment	27	6.70
To what extend do you practice EBD?	Always	79	19.70
	Sometimes	182	45.30
	Rarely	73	18.20
	Never	68	16.90
Have you ever studied EBD?	Yes	232	57.70
	No	170	42.30
Have you ever taken part in an EBD workshop?	Yes	146	36.30
	No	256	63.70

EBD: Evidence-based dentistry

Table 5

Impact of coronavirus disease 2019 pandemic on evidence-based dentistry perceptions among dental professionals in Saudi Arabia

Question	Yes, n (%)
Did the COVID-19 pandemic increase the importance of EBD to you as dental professional?	324 (80.60)
Do you think the COVID-19 pandemic increased the demand to use EBP in dental practices?	291 (72.40)
Do you think EBP should be mandatory to cope with the COVID-19 pandemic?	272 (67.70)
Do you think COVID-19 made you look for EBD material before you take clinical decision?	271 (67.40)
Because of COVID-19, do you think all decisions in dental clinics will follow EBD?	253 (62.90)
Do you think that EBD material was difficult to follow during COVID-19?	215 (53.50)

COVID–19: Coronavirus disease 2019, EBD: Evidence-based dentistry

DISCUSSION

The present study investigated the level of knowledge regarding EBD and the effects of the COVID-19 pandemic on participant perceptions of EBD. In terms of knowledge, our data were presented in both continuous and categorical formats to make it easy to compare with the literature. The mean knowledge score was higher than the midpoint, and the awareness of EBD components ranged from 37.31% to 60.54%, indicating acceptable levels of EBD component awareness. More specifically, however, only 54.73% were considered to be aware of EBD in general. This was similar to the levels of EBD awareness in Iran (56.1%), which had scores of 3.66 ± 1.19 out of 5,[3] and India (62.08%).[10] However, the level was lower than in other studies from Malaysia (69.9%)[8] and Riyadh, Saudi Arabia (91.8%).[11] Nevertheless, another Saudi study in Jeddah indicated that only 7.7% could identify the components of EBD.[16]

We found that age, gender, and years of experience were similar to Malaysian dentists.[8] Moreover, we found a significantly greater level of knowledge in the central region of Saudi Arabia, which seems to be aligned with the previous study in the central region[11] in comparison to a study from the western region of Saudi Arabia.[16] This wide range of differences might be due to different educational materials and practices between counties, regions, and universities. It has also been strongly suggested that the different questions and components used in these studies played a major role in this variation. It seems that the measurement of EBD requires that a more unified, reliable, and validated questionnaire be used internationally and at the local level to have a better comparison. It should be noted that this study was the first to gather information from different locations across Saudi Arabia, making it relatively more representative than other studies in Saudi Arabia.[111216]

Our study highlighted that 75.60% of respondents reported that a lack of time was the major barrier they faced to practicing EBD. This has been well documented in several studies across the world, including studies in Sweden,[19] India,[20] Malaysia,[8] and Iran.[3] In fact, lack of time was also a major problem in a previous study in Jeddah (54.6%),[16] although not necessarily the most prevalent one; the main barrier in that study was difficulty in understanding the EBD material (88.9%).[16] We had 47.50% of respondents report difficulty in understanding as their primary barrier. It appears that these dental professionals are overwhelmed with clinical duties and workloads, making it much more difficult to spend time learning to practice EBD, as explained by previous studies.[316]

It is interesting that some barriers found in previous Saudi studies were different from the results in our study, which can be explained by recent changes occurring in Saudi Arabia. For example, internet access was the least prevalent barrier in our study, similar to another Saudi study.[16] However, a prior study in conducted in Riyadh in 2004 had the opposite results.[21] This might indicate that internet access was a major problem that was behind this barrier at that time. However, since the launch of Saudi Arabia Vision 2030 in 2016, rapid changes have occurred at various levels, especially in digitalization, given the Vision 2030 goals numbered 3.3.2–Develop the Digital Economy– and 5.2.4–Develop e-Government,[22] which indirectly helped evolve internet services, allowing for removal of that barrier to EBD.

Around one-third of our participants (36.6%) consulted electronic sources and databases when uncertain about a treatment procedure. This is similar to an earlier study in Iran (40.3%),[3] but lower than a study in Malaysia (66.7%).[8] In fact, the percentages of other responses, including “refer to a textbook,” “ask colleagues,” or “continue the procedure based on personal experience and judgment” were lower in our study than in prior studies.[38] The most notable reason for this is that our participants could choose only one answer, while participants in other studies were allowed to choose multiple answers. It is more likely that dental professionals tend to choose a method on a case-by-case basis. Some researchers highlighted that the internet is now much easier to use for information retrieval than textbooks, which are often outdated.[3] However, it is important to ensure that internet sources are evidence based. Two studies have indicated that a majority (70.8%–80.49%) of dental professionals in Saudi Arabia use social media to find clinical information or watch procedures.[1523] Social media cannot be excluded from critical appraisal and cannot be uncritically considered a reliable source of EBD information; many articles have highlighted the volume of misinformation found on social media by researchers.[24252627] In fact, dental professionals should be encouraged to use electronic EBD resources such as the Cochrane Library, Web of Science, Scopus, and PubMed. This is important; our data showed that a majority were unaware of a key electronic resource - the Cochrane Collection.

Our study indicated that 36.3% to 57.70% had undergraduate EBD studies or took EBD courses earlier, which is similar to a previous study in Jeddah (40%),[16] but a greater number than previous studies in Iran (18.4%)[3] and England (14%).[28] It is noteworthy that EBD has been incorporated in many dental schools in Saudi Arabia in the last decade as part of undergraduate curricula, including Umm Al-Qura University and King Abdulaziz University,[16] indicating a major shift has occurred. However, the percentage is still considered humble in relation to the explosion of information and misinformation.

Another interesting aspect of our study is the result that COVID-19 had a good impact on EBD perception; most participants believed that the pandemic increased the importance and demand of EBD. Additionally, two-thirds of participants said COVID-19 convinced them that EBD should be mandatory and that all future dental clinic decisions should follow EBD. However, around half of the participants reported that EBD material was difficult to follow during COVID-19. In fact, COVID-19 had a tremendous impact on evidence-based practices in health care generally, as most peer-reviewed journals made their content open access during the pandemic and moved into rapid sharing of data with the World Health Organization and others; researchers were also more willing to share data and early findings in response to the pandemic.[29] This explosion of the information left many dental professionals unable to cope with the volume of information, which was similar to the results from a study in Jordan.[30] However, the pandemic's magnification of the importance of EBD for dental professionals means there should be structural integration of EBD in educational activities for dental professionals to optimize the use of EBD, as suggested by another Saudi study.[16] It is crucial to use the change momentum from COVID-19 to build EBD's usability and foster EBD incorporation in all dental schools and continuing education. This will ensure the advantages of EBD for health care, including more consistency, reliability, better quality, and reduced costs.[3132] It is also recommended to make it easier for junior dental professionals to access EBD resources via official organizational websites that can provide up-to-date evidence-based material.

This study addressed the impact of COVID-19 on the perception of EBD among dental professionals, which had not been previously investigated, to the best of our knowledge. This study may be one of a few studies assessing EBD use in Saudi Arabia and presenting data from different cities and universities. However, it is hard to ensure the external validity of the results because it was a convenience sample. The study may also have self-reported bias. Despite online questionnaires typically having low response rates, our study exceeded the calculated sample size and the online questionnaire was more useful due to the pandemic limitations and social distancing regulations.

CONCLUSIONS

The present study showed that knowledge about EBD components among Saudi dental professionals is considered acceptable. Age, gender, and years of experience were not significantly related to the level of knowledge. However, specialists/consultants and participants from the central region had significantly better scores than the comparison groups. Most participants reported the major barrier to EBD use was a lack of time, and only one-third of participants refer to electronic sources for uncertainties in treatment procedures. Around half of the participants had previous education or courses about EBD. Interestingly, COVID-19 was found to positively influence EBD perception in terms of its importance and the urgency to mandate its future use in dental clinics; most participants said that the pandemic increased the importance of EBD. Nevertheless, the explosion of scientific research to face COVID-19 made it difficult for participants to optimally use EBD. It is recommended that serious organizational and educational efforts be made to incorporate EBD into professional dental undergraduate and continuing education to make it much easier for junior dental professionals to use EBD resources.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.