Assessment of fear factors and practice related modifications in response to COVID-19 pandemic outbreak among dental practitioners in Thiruvananthapuram District, Kerala

Introduction

Coronavirus disease-2019 (COVID -19), an infectious disease caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) created an emergency in the health care service and delivery system all over the world. 1 The pandemic created a devastating impact worldwide affecting more than 216 countries within the first 7 months.2 The first confirmed case of COVID-19 traces back to Wuhan, China towards the end of 2019, and the World Health Organization (WHO) declared it as a pandemic on March 11,2020.3 With the emergence of new variants, the existing scenario is becoming even worse.

The frontline healthcare workers are most vulnerable to this pandemic and they possess the highest risk of acquiring infection.4 SARS-CoV-2 virus transmission during dental procedures can happen through the inhalation of aerosol/droplets from infected individuals or direct contact with mucous membranes, oral fluids, and contaminated instruments and surfaces.5 Hence, the dental operatory poses a riskier environment because of the high possibility of cross-infection between dental practitioners and patients.6 Since dentists work in close proximity with the patient and transmitting infection through saliva is the commonest cause, dental practitioners and their families belong to the high-risk group. Further studies have also shown that more than 91.7% of the viral load among infected people resides in saliva. The fact that dentists could potentially spread the infection to their peers, families, and other patients created psychological chaos in their minds.7, 8, 9 As a result, dentists all over the world appear to be psychologically distressed and sort to minimum clinical practice especially during the initial period of the pandemic. More than 70% of the dentists from thirty countries suffered from fear and anxiety during dental practice in the pandemic period.10 More than 40% of the Indian dentists also reported fear during the initial phase of the pandemic.6 Though the terms fear and anxiety are used interchangeably, anxiety refers to an unfocused fear that may persist long.11 Hence, anxiety predisposes to specific psychological distress than fear,12

Dentists all over the world being aware of the transmission of infection, started strengthening the infection control practices. The Centre for Disease Control and World Health Organisation has come forth with universal guidelines preventing the transmission of infection.2, 3, 13 The National and State governments with the help of subject experts have recommended COVID guidelines to be followed in dental practice.14 It is the responsibility of the dentists to follow these guidelines in practice to prevent COVID-19 cluster creation in the dental environment.

Thus, this present study aims to assess the fear and anxiety of COVID-19 among dental practitioners and their knowledge regarding various practice modifications to combat the novel coronavirus disease (COVID-19) outbreak.

Materials and Methods

This cross-sectional study was conducted among the dental practitioners in Thiruvananthapuram, the city capital of Kerala from October to December 2020. The study was started after obtaining ethical approval from the Institutional Ethics Review Board (IEC/E/37/2020/GDCT dated 15.09.2020). All the ethical principles were followed in the study. Confidentiality and autonomy were ensured to the study participants. Informed consent was obtained before questionnaire administration.

The sample size was estimated by using the formula for prevalence study taking a p-value of 87%. But for the want of this study to be beneficial to all dental practitioners, the questionnaire was administered to all dental practitioners whose contact details were available, and registered with the Indian Dental Association, Trivandrum and Attingal branch.

Data was collected using a questionnaire. The questionnaire comprised of 21 questions in three sections. Prior to the first section, the primary investigator has given a detailed description of the study and asked for the participant's informed consent. Those who expressed their consent moved to the first section. The first section included demographic variables like age, gender, designation, qualification, and workplace. The second section focused on the anxiety and fear among dentists related to COVID-19 and the third section gathered information on their practice modifications to combat the COVID-19 outbreak following the Centers for Disease Control and Prevention (CDC) and American Dental Association practice guidelines. Eight questions each related to fear, and practice modifications were adopted from a previous study.6 These sixteen questions were rated by the respondents either as ‘Yes’ or ‘No’. The sum of the responses was assessed to determine their level of fear and knowledge on practice modifications. Five anxiety questions form the Coronavirus Anxiety Scale (CAS). CAS scale was reported to have 90% sensitivity and 85% specificity. 15 The CAS helps clinicians and researchers to efficiently identify cases of individuals functionally impaired by coronavirus-related anxiety and has been proven to be effective in population studies. The response to the CAS scale varied from 0 ‘Not at all’ to 4 ‘Nearly every day’. CAS score was estimated by the sum of all column totals. A score of more than or equal to 9 was considered to have probable dysfunctional anxiety. Any query regarding the questionnaire was clarified by the primary investigator whose contact details were provided to the study participants along with the informed consent form.

Google forms were utilized for questionnaire administration. The link to the Google forms was made available to the study subjects through e-mail and social media platforms. Reminders were sent at an interval of 3 days and those study subjects who failed to participate in the study even after 5 reminders were excluded from the study.

Data so obtained from the questionnaire was entered into Microsoft Excel and analysed using SPSS trial version 22. The individual fear factors, number of dental practitioners suffering from anxiety, and knowledge on practice modifications were expressed in proportions. The anxiety score was expressed in terms of mean and standard deviation. The Chi-square test was used to determine the association of sociodemographic variables such as gender, workplace, and designation with the fear factors, anxiety, and practice modification items. Pearson correlation test was used to determine the relationship of age with fear and practice modifications.

Results

One hundred and ninety-two dental practitioners expressed their fear, anxiety, and practice-related modifications in the context of COVID-19. The socio-demographic characteristics of the participants are presented in Table 1. The mean age of the study participants was 34.52+7.11 years.

When the fear level of study participants during the pandemic was assessed, it was found that 88(45.8%) practitioners were having moderate fear,73(38%) were having less fear and only 31(16.1%) reported having a high fear level. We assessed the participant's response to fear-based on eight factors in their daily clinical practice. More than 50% of our study participants expressed their fear in terms of four fear factors; Fear of carrying infection from clinical practice to family (84.4%), Fear of treating a patient with symptoms (76.6%), Fear of deaths due to COVID-19(68.2%) and Fear of getting infected from patient or co-worker (53.1%) (Table 2).

The association of fear with sociodemographic variables showed a statistically significant (p = 0.042) association between the designation of the dental practitioners and fear level. Individual assessment of fear factors associated with various sociodemographic variables in Table 3 showed that specialist dentists were 1.929 times more afraid of treating patients with symptoms, suspected of COVID-19 than general dental practitioners(p=0.013). Female dental practitioners were 1.394 times more willing (p =0.05) to close the dental clinic until there is a reduction in the number of cases than male practitioners. Female gender predisposition was also found in the fear factor of carrying infection from clinical practice to family(p=0.007). Those with MDS qualification were 1.519 times more afraid to do clinical practice on hearing about COVID-19 deaths than those with BDS (p=0.035).

Time trend of fear level as depicted below (Figure 1) showed increased fear level in April 2020, followed by a decline in the following months, and the fear level was found to be lowest in September 2020.

Figure 1

Time trend of fear level.

Discussion

The findings of our study suggested a low prevalence (16.1%) of the high level of fear among dental practitioners. Nearly forty-six percent exhibited moderate fear which is alarming. Time trend analysis showed a gradual decline in the fear level with a mean fear level of 3.37 in March to 2.05 in September 2020. Nearly 85% of the dental practitioners were afraid of carrying the infection to the family. Even though gender, workplace, designation, and qualification were found to have a significant association with individual fear factors, only gender and qualification were significantly associated with knowledge on practice modifications. Anxiety was not significantly associated with any sociodemographic variable. Another interesting finding was the decrease in the level of anxiety with an increase in age.

Dentists all over the world reported varying levels of fear, especially during the pandemic.6 The fear and stigma associated with COVID-19 and dentistry also contributed to both dentists' and patients’ fear.16 More than thirty percent of the doctors in China sought treatment for mental health during the pandemic.17 An increased level of fear among dentists on acquiring COVID-19 infection and transmitting to others was seen globally.16, 18, 19, 20, 21 More than 92 percent of the Egyptian,18 80% from Iraq,16 75% of Pakistani dentists,20 and 70% of dentists from Norway21 were afraid of getting COVID-19 infection and providing treatment to patients suspected with symptoms of infection. This increased prevalence of fear among dentists is very much similar to the general population and can be attributed to several psychological, social, and financial issues.6, 16, 22

Nearly fifty percent of dental practitioners expressed their fear regarding the costs of COVID-19 treatment. This issue is of high significance in a developing country like India. Health insurance is often ignored even by the most elite group of people. This may be due to the technical difficulty in procuring insurance. Hence, measures need to be initiated to make health care insurance accessible and available to health care workers including dentists as they are prone to acquiring viral, bacterial infections, and ergonomic-related health issues.

Severe physical and mental exhaustion was known to affect the quality of treatment.7 Treating and receiving treatment with fear creates an unhealthy dental atmosphere. Hence, dentists need to gain confidence by reducing fear regarding the spread of infection. This is best attained in developed countries by strengthening the infection control procedures.1 Updating knowledge on COVID-19, following COVID preventive guidelines such as wearing an N95 mask, and frequent handwashing along with modifications in infection control may reduce the COVID-related anxiety and fear among dental practitioners. A reduction in fear at the end of six months in our study can be attributed to these factors. Though the dentists reported significant fear related to COVID-19, very few dentists wanted to close the dental clinics. This sheds light on the positive outlook of dentists.

Despite showing a considerable level of fear, the dental practitioners in our study showed minimal anxiety. While fear is often associated with reaction to external stimuli, anxiety deals with an internal conflict.10 Thus, from the study findings, it can be inferred that the fear experienced by dental practitioners is temporary. This high amount of fear currently can be considered natural owing to the existing scenario with increasing infection rate and COVID-related mortality.21 Similar psychological health status was also seen among the health care workers after SARS 2003 outbreak.12 From the previous disease outbreaks, personal resilience was found as a potential factor for psychological health.12, 23, 24 Dentists especially in India have been facing challenges in their profession in terms of work, finance, and income over the last two decades.25 These challenges have enabled them for rapid recuperation. As a result, dental clinics are presently functioning normally, following all the COVID guidelines. Dentists also feel that it is their responsibility to assure the patients of a safe working dental environment.26

Females were found to be more afraid of various factors relating to COVID-19 and readily adopted practice modifications as compared to males in our study. A similar female predisposition to fear has been reported in literature.5, 19, 20, 27 This can be either due to the participation of a greater number of females in those studies or reflecting on the delicate but positive attitude of the female dentists. When we reviewed the literature regarding dental fear among patients also, a similar gender predisposition was noted.20

The workplace plays an influential role in the mental health of medical workers. Those working in the Government sector were found to have a significant amount of fear regarding dental practice. This may be due to the shortage of personal protective equipment, manpower, or other infrastructural constraints experienced by government dentists. The work-life balance of dental professionals is mainly determined by the physical and mental health status, relationships, and work place.28 Potential job insecurities among Italian dentists resulted in depressive symptoms1 A study in Norway found that the workplace did not play a role in feeling about losing control of life and fear of death. However, more than eighty percent of the health care workers in well-equipped workplaces reported less amount of fear.21 Thus, it can be concluded that a supportive workplace can increase the confidence of health care workers while dealing with COVID-19 patients.

Though specialists’ dentists were found to have a better knowledge of practice modifications, they presented with a significant amount of fear as compared to general dental practitioners. This finding is similar to the studies done in Iraq and Egypt.16, 18, 19 The increased fear among specialist dentists may be due to their ability to foresee the complications pertaining to breach of personal protective equipment or other COVID-19 precautionary measures.

The severity of anxiety decreased with age in our study. While a few studies showed the relationship of anxiety with work experience, the majority of studies claimed no correlation of age with anxiety. Reduced anxiety was seen among those dental practitioners having more than 10 years of experience.29 This varying result shows the need for further research to determine the relationship of age with anxiety.

The compliance of dental care auxiliary personnel to infection control practices was low as compared to dentists before the pandemic.30 But with the onset of a pandemic, all dental health care workers irrespective of the designation strictly adhered to infection control practices.31 Among the dental practitioners, certain optional practice modifications such as rubber dam use were preferred by specialist dentists in our study. Virus transmission can be reduced by using a rubber dam especially during implant and sinus lift surgeries.32 Recording travel history prior to dental treatment was considered routine practice in Taiwan. Dental patient triage followed the American Dental Association guideline in Taiwan and other countries.33 Data from thirty countries showed that almost ninety percent of the dentists were aware of the practice modifications and sixty percent strictly adhered to the protocol.6 The lesser proportion of dentists knowing practice modification in this study may be due to their lack of academic interest or the negative influence of fear related to COVID-19. However, exploring the knowledge of full-time academicians in this context might have increased knowledge of practice modifications.

Though data collection of the study was done in 2020, this study is of immense importance as COVID-19 is an ongoing pandemic. The scientists or experts have not yet come up with a medicine with 100% cure rate or vaccine with cent percent efficacy. Hence, currency of the study is established as the dentists are still at a high risk of getting infected and spreading infection to others.

Limitations

The response rate of the questionnaire was much lesser than that expected by the researchers. Though the questionnaire was sent to all dentists registered with the association local branch, only forty percent responded. This can be due to their busy schedule, other priorities, or lack of research interest. The dentists are multitaskers and are found to face challenges in maintaining a balance between personal and professional life.34 It is not possible to increase the response rate of the dentists in the current scenario but providing rewards can be tried in the future studies to increase their response rate. As seen with any questionnaire study, selection bias might have occurred as we were able to approach only those dental practitioners whose contact details were accurate. The primary investigator has thoroughly communicated with the dental practitioner and has assured anonymity of data for avoiding the social desirability bias. Further studies are required to establish the causality of fear and anxiety with various factors. Since the data was collected post the first half of the pandemic, the results may not be at par with the current scenario as there have been changes in the attitude and behavioral practices of dental health practitioners.

Conclusion and Recommendations

This study highlights a considerable amount of fear among dental practitioners at the beginning of the pandemic, which further showed a decline. The less prevalence of anxiety reflects on the personal resilience of dental practitioners. Despite having a high amount of fear among females and specialist dentists, they readily adopted the practice modification measures. Thus, adequate measures need to be taken by the state government in ensuring a favorable dental working environment. Regular counseling sessions till the wane of the pandemic and a few years post-pandemic, periodic mental health screening among dental practitioners, and easy availability of financial schemes supporting dental practitioners especially in the private sector are a few measures that can be taken by the Government, and Department of health as a support mechanism for this high-risk group. Addressing fear among dentists help in increasing the doctor-patient trust. Evidence has also shown that doctors suffering from psychological distress such as fear will not be able to deliver quality treatment to the patients.35

Further studies are required to explore the reasons for increased fear among females, specialist dentists, and those working in the government sector. A qualitative study among the dentists in various regions of India will help in gaining a better understanding of the adversities of dental practice during the pandemic.

Source of Funding

None.

Conflict of Interest

None.