Impact of COVID-19 Pandemic on Dental Practice: A Questionnaire Survey

1. Postgraduate Student, Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India. 2. Professor, Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India; PhD Fellow, D.Y. Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India.

Abstract

Introduction: Coronavirus Disease-2019 (COVID-19) pandemic had unprecedented health and economic consequences. Dentists encounter maximum aerosol production due to frequent use of ultrasonic and polishing devices or other surgical interventions, thus increasing the risk of nosocomial infections. The situation had caused drastic change in the clinical routines including modifications in infection control strategies, managing of minimally invasive procedures, reducing the patient visits and updating themselves to use telecommunication to cater to the need of patients.

Aim: To evaluate the consequences and impact of COVID-19 pandemic by conducting an online survey using questionnaire amongst dentists as healthcare providers in the country of India.

Materials and Methods: This was a questionnaire-based, cross-sectional survey conducted using online platform in India with a sample size of 225 participants, who were practicing dentists, either graduates or postgraduates, and agreed to give an informed consent. The questionnaire consisted of six segments: participants demographics, changes in clinical routine of the respective dentist, upgrading facilities in clinic, infection control measures, telecommunication and impact on financial aspect of the practitioner. Open-ended questions were also included giving an opportunity to the participant to share his or her perspective. Chi-square test of proportion was performed to assess the difference in proportion of the responses. A p-value <0.05 was considered statistically significant.

Results: The present study has shown that the pandemic has impacted negatively on financial status, patient flow and daily practice. Total 221 (98.2%) clinicians agree to the fact that, COVID-19 has affected their clinical routine, 203 (90.2%) clinician were aware of the aerosol generating procedures and 95 (42.2%) practitioners have installed devices for air purification. A 209 (92.8%) emphasise on the use of Personal Protective Equipment (PPE) kits and majority 84 (37.3%) were delaying elective procedures. About 184 (81.7%) have experienced decrease in number of patient flow and 104 (46.2%) practitioners agreed that their emotional and psychological well-being is affected due to drastic changes made in their practicing protocols due to COVID-19.

Conclusion: The COVID-19 pandemic has affected the social, economic, physical as well as mental well-being of practioners all around the world. More or less the practice is hampered causing frustration and instability. Focusing the light on practicing dentists, they have seen to make significant changes in their zone of practice and have updated to the new normal version of practice.

Aerosols, Coronavirus disease 2019, Dental health professionals

The latest threat to global health was the outbreak of Coronavirus Disease-2019 (COVID-19) (1). According to World Health Organisation (WHO), coronaviruses are known as a large family of viruses that cause illness ranging from common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) (2). The COVID-19, has strangulated the world by spreading its tentacles in all spheres of life, initiated as a pneumonia outbreak in Wuhan, China. Various studies have reported that human coronaviruses can remain viable on various inanimate surfaces from two hours to upto nine days (3).

The spread of COVID-19 posed significant challenges for all healthcare professionals in the affected countries. Like-wise it has also affected the healthcare providers and dental practitioners. dental professionals are at the front line of healthcare, working in the oral cavity, with a potentially increased viral exposure (3). As per Occupational Safety and Health Administration agency (United States of America), all dental healthcare professionals are categorised to be most vulnerable to Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) exposure. This is primarily due to face-to-face contact, nature of treatment causing high-risk of contamination and infection as well (4).

Dentists also encounter maximum aerosol production due to frequent use of ultrasonic and polishing devices or other surgical interventions, simultaneously increasing the risk of nosocomial infections (5). The situation has caused drastic change in the clinical routines including modifications in infection control strategies, managing of minimally invasive procedures, controlling of aerosol generation, reducing the patient visits and updating themselves to consult patients via telecommunication devices, managing financial aspects (4),(6).

The present questionnaire study attempts to evaluate the overall impact caused on the clinical routine of dentists. Although, there are a few studies done previously to understand the dental practitioners’ mindset and awareness regarding the pandemic but very few studies attempted to understand the overall impact caused by COVID-19 pandemic on practitioners in developing countries like India (4),(5). There was an imparity in terms of effect of pandemic between different countries. This is a fact that developed, developing and under developed countries have reacted dissimilarly to the pandemic situation (5). Hence, the present survey was designed to evaluate and understand the impact on clinical practice, financial aspects and alterations clinicians had to make, to cope up with the situation in India.

The study thus, aims to evaluate the consequences and impact of COVID-19 pandemic by conducting an online survey using questionnaire amongst dentists as healthcare providers.

Material and Methods

This was a questionnaire-based cross-sectional survey conducted using online platform in India for the duration of three months from October 2021 to December 2021. It was approved by the scientific ethical committee. The questionnaire had an informed consent and the link to its access was circulated through different social media platforms (WhatsApp, Instagram, Telegram). A convenience sampling technique was used considering all the questionnaire answered within three months by clinicians who met the inclusion criteria of the study.

Inclusion criteria: All practicing dentists (graduates or postgraduates) who agreed to participate in the questionnaire survey by checking the box related to informed consent were included in the study.

Exclusion criteria: Dentists who ceased their professional activities more than one year ago, who did not complete the survey or did not agree to provide their informed consent were excluded from the study.

Sample size calculation: A total sample size of 225 participants were included in the study. Sample size was calculated using OpenEpi software. At 5% confidence limit (95% confidence interval) with 82.7% hypothesis percentage frequency of outcome factor in the population from previous literature (7), the sample size estimated was 220. The formula used for sample size estimation was:

n=[DEFF*Np(1-p)]/[(d²/Z²_1-α/2*(N-1)+p*(1-p)]

Where, DEFF (Design Effect=1),
p (proportion)=0.827) and
d (confidence limit=5%)

Questionnaire

The questionnaire for the survey was framed by authors and was validated before use. The questionnaire was divided into six domains.

First domain: Demographics of participants.
Second domain: Changes in clinical routine of the respective dentist.
Third domain: Upgrading facilities in clinic.
Fourth domain: Infection control measures.
Fifth domain: Questions regarding telecommunication.
Sixth domain: Financial aspect of the practitioner.

The survey was a structured

• Multiple-choice questionnaire with seven questions having multiple select and 13 questions having single select.
• Apart from this, six open-ended questions were also included giving an opportunity to the participant to share their perspective.

Likert scale was used to evaluate the psychological well-being of the practicing dentists. It was a self-designed questionnaire administered in English language. Google forms platform was used to generate the layout of the questions.

The face validation of the questionnaire instrument was determined using Cohen’s kappa index on collected data. The kappa index value was 0.7 for inter-rater agreement in the questionnaire. Internal consistency refers to the extent to which all of the items in a scale measure the different aspects of the same attribute. Cronbach’s alpha was determined to assess the internal consistency and the alpha value for the overall questionnaire was 0.90. Pearson’s correlation coefficient was calculated for test-retest reliability on the scores of the participants, who completed the questionnaire twice. The overall reliability was high (r-value=0.80, p-value <0.001).

Statistical Analysis

The data was arranged in an Excel sheet. For all the multiple-choice questions, the frequency of each response for every question was calculated. For open-ended questions, different responses were tabulated and qualitatively analysed. The demographic data of participants was also analysed. Chi-square test of proportion was performed to assess the difference in proportion of the responses. The significance level was set at 95% and p-value <0.05 was considered statistically significant.

Results

Data from 225 practicing dentists was collected and analysed. (Table/Fig 1) summarises the participant demographics.

The second domain included changes made by practitioners in their clinical routine. Practitioners have written responses about modifications made in their working environment. Some of them have placed glass shields, applied barriers to maintain social distancing, placed charts and posters to educate patients regarding sneezing, coughing and sanitisation protocols. (Table/Fig 2) shows the details regarding changes made in clinic routine. Total 152 (67.5%) practitioners, made all of the mentioned changes in their clinical routine (p-value <0.001).

(Table/Fig 3) shows further questions included in the questionnaire regarding the upgrading of facilities in the clinic to subside the production and spread of COVID-19 infection. Amongst all the respondents, 95 (42.2%) dentists have installed devices in the clinic and different practitioners have opted for equipment according to their convenience (p-value=0.253). None of the participant suggested any equipment for air purification in open-ended question.

(Table/Fig 4) shows all the detailed responses regarding the infection control. Practitioners have stated in the open-ended question that they have instructed their receptionists to tell patients to sanitise their hands before entering the clinic. And also, the most preferred device was the hand sanitiser dispenser opted by 203 (90.2%) participants (p-value <0.001). Practitioners have made modification in their working environment like placing glass shields, application of barriers to maintain social distancing, placing of charts and posters to educate patients regarding sneezing, coughing and sanitisation protocols as answered in the open-ended slot.

The next questions in the questionnaire were about telecommunication. The most preferred telecommunication opted by many practitioners is telephone call 173 (76.8%) (p-value <0.001). None of the participant mentioned procedural changes in your practice in open-ended slot. (Table/Fig 5) shows the modes of communication opted by practitioners and the type of services provided by them to the patients.

The services provided by dentists via telecommunication included scheduling appointments to their patients along with palliative care. Symptomatic treatment is provided by about 152 (67.5%) practitioners so as to relieve pain or discomfort in their patients. Around 37 (16.4%) respondents opt discussing treatment plan with their patients via telecommunication (p-value=0.015). None of the participant mentioned procedural changes in your practice in open-ended slot.

The next and last domain in the questionnaire was regarding financial aspect of the practitioners. It has affected the income source in various manners presented in following (Table/Fig 6). There was no other reason stated in the open-ended section regarding any other causes affecting the economy of the individual. Out of total, 49 (21.7%) were not in favour of increasing the cost (p-value <0.001), reason as stated in the open-ended slot being that common people were already in stress and facing various challenges in their day-to-day living. Majority of practitioners agree to the fact that the ongoing pandemic has affected their psychological well-being negatively (p-value=0.042).

An open-ended question regarding impact of pandemic on the physical, mental and emotional well-being of the clinicians was asked in the questionnaire. Dentists have put up their various opinions in this section. Amongst the respondents the new and young generation with fresh knowledge mention that there is lack of exposure to the clinical practice which is a noteworthy point. They also mention lack of confidence, finding less opportunities and were emotionally drained. Practicing dentists also mention increase in stress levels, non productivity, decreased peace of mind, depression and facing work related anxiety. The increased stress levels have also caused an effect on sleep cycles, increased frustration and confusion. Life seems to be monotonous and dull than before for many practitioners.

Apart from the negative responses from the dentists some of the practitioners also had a positive perspective about the pandemic. Participants gave an opinion that they were getting time to focus on themselves. Some mention practicing exercise, yoga and meditation keeping themselves more physically and mentally fit. Practitioners had got a chance to enhance themselves in other leisure activities and have got a chance to segregate between their priorities and materialistic things. The other possible positive impact of COVID-19 pandemic is the rise in international and national interactions. Virtual backgrounds of the conferences have increased the chances of sharing knowledge and newer techniques by conducting online programs for the new practitioners.

Discussion

This study has shown that the pandemic has impacted negatively on financial status, patient flow and daily practice. The questionnaire study has accomplished the goal of understanding the impact of COVID-19 pandemic on the dental practice. The dentists who participated in the survey have given their respective opinions about the changes caused in their clinical routine. About 221 (98.2%) clinicians agreed to the fact that COVID-19 has affected their clinical routine. Dentists emphasise on following various disinfectant measures and have increased the use of PPE simultaneously. Out of total, 36 (16%) of them vote in favour of reducing the number of patient visits and have switched to updating themselves to using telecommunication devices to communicate with patients. About 152 (67.5%) practicing dentists have made all the mentioned changes in their clinical routine. Various guidelines were issued which were supposed to be followed by all the practicing dentists so as to avoid the further spread of infection and about 222 (98.6%) participants have claimed to follow the guidelines issued by Dental Council of India (DCI) and Indian Dental Association (IDA), which shows the high percentage of awareness amongst the practitioners.

Infection control is another important aspect in the maintenance of sanitisation. Total 90.2% practitioners have placed hand sanitiser dispensers outside the clinic, so that patients and visitors can apply the sanitiser before entering the clinic. In the present study, 90.2% of the clinicians were aware of aerosol production during various dental procedures. Aerosol production proves to be an important aspect as it can be the potential cause of infection in the clinic. A trial conducted by Mohan M and Jagannathan N in 2016 showed that Colony Forming Units (CFUs) decreased in patents, who had a pre-rinse with chlorhexidine mouthwash when compared to patients with saline mouth rinse (6). A recent German study had stated that longer the COVID-19 crisis continues, the more will be the financial distress in dental practice (7).

Various changes made in the clinic like incorporation of devices necessary to maintain sanitisation and avoid risk of infection are mentioned. Four categories of transmission routes have been proposed: (a) symptomatic transmission; (b) pre-symptomatic transmission; (c) asymptomatic transmission; (d) environmental transmission. There is current evidence that most transmission occurs from symptomatic people to others not wearing PPE and in close contact (8). But this in return has also caused significant rise in the treatment costs. According to a survey conducted by the Irish Dental Association about the impact of COVID-19 outbreak on dental practices, it was found that around 20% of dental care providers have closed their practices for a limited time or permanently (9). Meng L et al., reported nine cases of COVID-19 among 169 dental practitioners, thus emphasising the high-risk of professional contagiousness (10).

Apart from all these aspects the practitioners have acclimatised themselves to using telecommunication devices to avoid unnecessary gathering and exposure increasing the risk of infection. In an article “COVID-19: Changing Trends and Its Impact on Future of Dentistry” by Bhanushali P et al., more attention is given to changing trends like for example teledentistry (11). Teleconsultation provides the practitioners with contact-less consultation. It not only eliminates any chance of exposure to the virus but also decreases the service cost and helps in patient education (12). Telescreening and teledentistry could be promoted (13). But even if this fact is true, teledentistry does have limitations when it comes to dental practice. Emergency treatments cannot be done without physical presence of the dentist unlike other medical professionals.

Dentists being healthcare providers should keep themselves updated for the further challenges similar to the ongoing pandemic. This will avoid the sudden necessity of changes to be made in the future practice. Ultimately it will only ensure improvement in self-care measures and avoid spread of infection (14). Dentists should first prioritise their health rather than financial aspect. The results of the present study are compared and discussed with related studies in (Table/Fig 7) (7),(8),(15),(16),(17),(18),(19),(20),(21).

Limitation(s)

Despite the relevance of findings in the study, some limitations need to be highlighted. As this was an observational study, based on a questionnaire, conclusions drawn were dependent on responses of the participants and there was no way to assess the authenticity of the responses. Other limitation of the study was the participants interest in responding to the questionnaire. Response rate for open-ended questions were comparatively low. In future, study targeting specific areas (like urban or rural) or specific population (like Institution or private practice) with more sample size can be conducted as there can be disparity between the effect of COVID- 19 on different group of clinicians. Thus, a multicentric study with a multiphase sampling can be designed in future.

Conclusion

The survey has shown that the pandemic has impacted negatively on financial status, patient flow and daily practice. Focusing the light on practicing dentists, they had to make significant changes in their zone of practice and had updated to the new normal version of practice like paying additional attention on sanitisation, selfcare measures and modifying clinical setups with purification devices. Teledentistry is an upcoming concept which all should acclimatise to. It enables the interaction with patients and providing healthcare advices but to a minimal extent. Every outbreak provides an opportunity to gain knowledge and also, access to new window of opportunities. Thus, the emerging concept of new normal shall be accepted.

Acknowledgement

The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publication of the present article. The authors, thank Dr. Vineet Vinay for contributing to the formulation, design of study and data acquisition and Mr. Saurabh Galinde for providing technical support in the development of the study. All authors gave their final approval and have agreed to be accountable for all aspects of the work.

DOI and Others

DOI: 10.7860/JCDR/2022/56871.17107

Date of Submission: Apr 30, 2022
Date of Peer Review: Jun 06, 2022
Date of Acceptance: Sep 16, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 02, 2022
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ETYMOLOGY: Author Origin