The cross-sectional and closed ended questionnaire study protocol received ethical clearance from the Institutional Ethical Committee of Vinayaka Mission’s Sankarachariyar Dental College (VMSDC/IEC/NO: 156). The data collection was done between March 29, 2020, and April 3, 2020. The recommended sample size for the study was 471 as calculated according to the formula: n=z²* p*(1-p)/e² (where: z=2.17 for a confidence level (α) of 97%, p=proportion (expressed as a decimal), e=margin of error. z=2.17, p=0.5, e=0.05 n=2.17² * 0.5 * (1-0.5)/0.05², n=1.1772/0.0025=470.89, n≈471) [9]. Any dental professional in clinical practice/academics or both who gave consent to take part in this online survey were included in the study. Those dental professionals who were not interested in participation were excluded from the study.

The closed ended questionnaire form was prepared in English with 39 questions, nine questions on General Information, 11 questions on Knowledge, four questions on Psychological aspects, and eight questions on Social and Economic aspects. There were seven more questions which were meant for only academicians. A pilot study was done in 10% of the sample size n=50 and Cronbach’s α value was found to be 0.81, hence the internal consistency of the study was found to be reliable.

These questions were validated among ten dental professionals who had a teaching experience of more than ten years. The average value of relevancy, clarity, and simplicity were used as the total Content Validity Index (CVI) of Waltz and Basel [10]. Questions which obtained CVI above 0.8 were included.

Content Validity Ratio (CVR) was calculated based on the responses to the necessity of questions (Ne) with the formula of CVR=(Ne-N/2)/(N/2), where Ne is the number of experts indicating that item as “essential” and N is the total number of experts [11]. To determine the cut-off point for CVR, Lawshe’s table was used [12]. According to Lawshe, for 10 professionals, minimum required CVR for each item is 0.62 and we received a CVR value of 0.71.

The research team consisted of a primary investigator; professor and Oral Pathologist from India, one dental specialist from Saudi Arabia who was also a former professor of a dental college in India and one academician who is Professor and Director, Academics of a university and was the former CEO of a dental college in Malaysia. The participants included friends and students of the investigators working in different parts of India and across the globe. The questionnaire link was prepared in google form and was circulated among dental professionals in India, Saudi Arabia, the United Arab Emirates, Malaysia, the United States, the United Kingdom, and Australia who were in the contact list of the research team via emails, WhatsApp, and Facebook Messenger. There were multiple choice questions with single answer and multiple answers. Social and economic aspect questions had closed ended answers whereas psychological aspects were scored using 5-point Likert scale [13].

Knowledge scores were divided into three levels, namely well informed, moderately informed, and poorly informed. Individual questions were given knowledge scores from score zero to score four. Maximum Score used for knowledge aspect was 30. As in professional courses, where 50% score (15) are needed for pass percentage, in this study less than 50% (Below 15) was considered as poorly informed, 50-75% (15-22) was considered as moderately informed and 75% and above (22-30) was considered as well informed. The questions on psychological aspects had five closed-ended answers that were rated on a 5-point Likert scale based on their level of stress, 1 as not worried at all, 2 being slightly worried, 3 being moderately worried, 4 being severely worried and 5 being extremely worried [13]. The questions on social and economic aspects were closed ended with yes/no answer.

Data were presented as frequencies and percentages. Results obtained were entered in an excel data sheet for statistical analysis, which was done using SPSS software (Version 11.5, IBM Corporation, Armonk, New York, USA). Chi-square test was done correlating knowledge score with demographic factors (age, gender, specialty, country of residence, number of years of experience and number of patients seen) by the participants and p-value was obtained. Null hypothesis of the study stated that there was no difference between knowledge, psychological, social or economic aspects of dental professionals during the COVID-19 pandemic. The p-value less than 0.05 was considered as statistically significant.

Questionnaire was sent to 800 participants of which only 504(63%) responded online. Out of the 504 respondents, 254 (50.40%) were males, and 250 (49.60%) were females.

About 466 (92.46%) respondents did not have COVID-19 positive contacts among friends and relatives.

Among 504 participants, 135 (26.78%) were trained to some extent, and 153 (30.36%) of the respondents were trained well and the rest were not trained at all to handle public health emergencies. Demographic details of respondents are given in [Table/Fig-1].

Knowledge score calculation with scores is given in detail in [Table/Fig-2].

I. Knowledge on COVID-19

Knowledge aspects on COVID-19 are shown in [Table/Fig-3]. The analysis showed that the majority of the respondents had score one for the questions numbered 1, 4,5,7,8,9 and 11 and score 2 for question number 3 and score 3 for question numbers 2, 6 and 10.

Ia. Gender of respondents compared with Knowledge Score on COVID-19

The Knowledge score on COVID-19 was statistically compared with some of the demographic factors of the respondents. Male respondents had better knowledge score compared to females as shown in [Table/Fig-4].

Ib. Age of the respondents compared with Knowledge Score on COVID-19

Respondents who were above the age of 66 were moderately informed and ages 46-55 were well informed about COVID-19, as shown in [Table/Fig-5].

Ic. Specialty of the respondents compared with Knowledge Score on COVID-19

[Table/Fig-6] depicts that dental specialty of Prosthodontics showed that they were well informed compared to others while conservative Dentistry Orthodontics and Periodontics were moderately informed.

Id. Country of Residence compared with Knowledge Score on COVID-19

Respondents from countries like UK and Australia (respondents were very less) were well informed compared to those from Malaysia, USA, Saudi Arabia and UAE who were moderately informed as shown in [Table/Fig-7].

Ie. Number of years in academics/private practice of respondents compared with Knowledge Score on COVID-19

[Table/Fig-8] shows that respondents who had an experience of more than 20 years were well informed whereas respondents with 5-10 years were moderately informed.

If. Number of patients visiting your dental clinic per day compared with Knowledge score on COVID-19

[Table/Fig-9] shows that the well informed respondents treated more than 30 patients in a day whereas the moderately informed dentists treated less than ten patients per day.

II. Psychological Aspects

The analysis showed that majority of the respondents were not worried at all for question number 13, moderately worried for question number 12, and extremely worried about the question numbers 14 and 15. Psychological aspects of COVID-19 are shown in [Table/Fig-10].

III. Social and Economic Aspects

A 98.61% of the respondents stated that after the COVID-19 outbreak, they washed their hands frequently, avoided crowded places, and cancelled social events and travel plans. A 92.06% reported restricted mobility from one city to another during this COVID-19 outbreak.

Social and Economic aspects of COVID-19 are shown in [Table/Fig-11].

IV Responses Given by Academicians

Out of 504 respondents, only 197 (39.1%) of respondents were academicians.

Information given by Academicians during COVID-19 pandemic is given in [Table/Fig-12].

The mode of transmission of SARS-CoV2 virus puts the dental professionals under serious risk of infection. The aerosol cloud and splatter generated from specific dental procedures are very likely to carry oral and respiratory tract pathogens Contact transmission through body fluids, contaminated surfaces and instruments has also been reported [14]. As many emergency patients continue to avail health care services from dental clinics and hospitals even in the time of quarantine and social distancing, it is important for dental practitioners to be factually aware of COVID-19 infection to help contain the spread. Dissemination of health information should create more awareness regarding pandemics and steps should be taken to provide information that increases community health awareness on personal hygiene and safety measures and reduces fear of the spread of disease [15].

During the Ebola outbreak in North West Ethiopia in 2015, Abebe TB et al., reported poor knowledge, negative and incorrect beliefs among doctors and allied health professionals. The team reported that there is a need for intensive training for all Health care Professionals to reduce Ebola virus disease risk [16].

Alfaki MM et al., reported that more in-service training for health care professionals will help them increase their knowledge [17]. Another study reported that medical universities and dental schools need to act fast to prepare Hungary’s students and junior doctors for an inevitable influx of Ebola virus infected patients as there was a lack of awareness among dental students [18]. In present study, some of the areas where the dental professionals lacked knowledge were the most important ways of spread, drugs used for treatment, chemicals used for disinfection, WHO guidelines for dental treatment and methods to diagnose COVID-19, but there was no statistical significance on knowledge score with the demographic details of the respondents.

Another study on flu pandemic had contradictory reports that health care professionals had better awareness in terms of symptoms, casualties, progression of disease, and methods of controls. Better awareness and a positive attitude during pandemics led to lesser levels of anxiety [19]. Some of the participants (9 or 1.79%) in present study had COVID-19 positive contacts. As the present study commenced when the pandemic started in India, further information regarding the positive contacts of participants were not obtained.

A study by Gambhir RS et al., in India on H1N1 virus infection reported that knowledge gaps existed among dental professionals and highlighted the need for continuous education programs regarding infectious diseases [20]. Gambhir RS et al., reported from India that one-third of the participants were not aware that Personal Protective Equipment (PPE) should be used while rendering dental treatment [21]. The present study also highlighted the importance of increasing the knowledge of dental professionals.

COVID-19 diagnosis can be made by using nasopharyngeal and oropharyngeal swabs. It has been demonstrated previously that saliva also has an equally important role in the detection of Coronavirus, like other viruses affecting the respiratory tract [22].

A recent study on undergraduate and postgraduate health professionals revealed their moderate awareness level regarding the symptoms, spread, and control of COVID-19. The study reported that the educated and health care people were sensitised, and the participants frequently used hand wash, masks, and sanitisers. They had agreed to social distancing, avoided travel, and would go into self-quarantine if needed [23]. In the present study, more than half of the participants reported that they had missed scientific events during COVID-19 pandemic. 98.61% of the respondents reported that they have improved attitudes in self-hygiene and social distancing after the pandemic.

In the present study, we identified that the respondents faced difficulty in procuring daily essentials and while traveling from one place to another. In a recent study, people went for panic buying, which led to the exhaustion of resources for others [24]. Incorrect reports about shortage of food, other resources, and essential things resulted in more panic buying [23]. In this study, almost 42% of the respondents were ready to volunteer if needed during the COVID-19 pandemic. This highlights their social responsibility and commitment. A 72% of the participants were affected economically due to the pandemic in present study.

In this present study, respondents had reported maximum psychological stress reading the news in social media, and there was fear of contracting the disease from the workplace and about passing it to their close contacts. Equal proportions of participants had responded 3, 4 and 5 in Likert scale about the fear from social media about COVID-19. The psychological stress can be resolved via tele-psychological consultations and spread of awareness regarding these consultations. In a recent study including medical professionals, inappropriate behaviors were reported by participants due to anger, restlessness, and worry about COVID-19 [23].

In the present study, more than 72% respondents were affected economically because of the pandemic. The present study showed the lack of knowledge of 42.8% of dental professionals in public health emergencies. The present study showed that different roles of academicians were academic teaching, research, mentoring, and preparing online courses during the lockdown period. The academicians of the present study coordinated undergraduates, postgraduates and Doctorate students in dentistry. Most of the academic activities were carried out online by the participants. The regulatory bodies should manage education-related challenges for medical and dental schools, as many countries managed this during SARS and other infectious disease periods. UNESCO has reported the response of different countries in the conduct of important examinations during the pandemic [25]. A recent report suggested that research teams should be focused on developing rapid chair-side tests for the detection of COVID-19, which will help to develop successful strategies for its prevention, especially for dentists and healthcare professionals who perform aerosol-generating procedures [22]. There was a significant adverse impact of COVID-19 pandemic on high-contact industries, including dentistry. As strict social distancing guidelines were imposed by many states, dental clinics and general practice physician offices remained closed.

To keep dentists and patients safe from the adverse health effects of COVID-19 and to conserve PPE, the ADA issued on March 16, 2020 a guidance that “dental practitioner should postpone elective procedures and should only provide emergency or urgent care. ADA recommended dentists to postpone radiographs, oral examinations, aesthetic dental procedures, routine cleaning and preventive therapies, and orthodontic procedures that don’t involve pain management. Urgent dental care includes extensive dental caries involving pain, uncontrolled oral bleeding, facial trauma, dental trauma, tooth fractures and biopsies of abnormal tissues. It is estimated that demand in high-contact industries will decline by 51 percent and that their gross output will fall by 47 percent [26].

The strength of the present study is that more than 500 dental practitioners were covered, the majority of them being from India during the early stage of the COVID-19 outbreak with almost equal representation of male and female participants. Thus, the present study gives a good representation of dental professionals; more questions exploring the effects of COVID-19 can be incorporated in the future.

The limitation of the present study was that most of the dental professionals were from India and thus the study doesn’t give a global representation.

Based on the results obtained from the study the following conclusions were drawn. Awareness should be provided to dental professionals to manage dental emergencies so as to prevent the spread of the disease. Psychological, social and economic support should be rendered to the dental professionals by experts. Dental teaching curriculum in instituitions should also include public health emergencies.