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Fear, Anxiety and Practice Modifications among Dentists to Fight against Novel Coronavirus Disease (COVID-19) Outbreak in India: A Questionnaire Based Study

Original Research Article Since its emergence in December 2019, corona virus disease 2019 (COVID-19) has impacted several countries, and making it a global public threat. The routes of transmission are direct contact, and droplet and possible aerosol transmissions. Due to the unique nature of dentistry, most dental procedures generate significant amounts of droplets and aerosols, posing potential risks of infection transmission. The current study was conducted to assess anxiety and fear of getting infected among dentists while working during the current novel coronavirus diseases (COVID-19) outbreak and dentist’s knowledge about various practice modifications to combat COVID-19 has been evaluated. The questionnaire study was conducted using an online survey from July 202 0 to December 2020.


INTRODUCTION
The novel COVID-19 came under limelight back (December 2019) and has been declared a pandemic by WHO [1]. By the end of 2019, a pneumonia outbreak with unknown etiology occurred in Wuhan, China. Most of the cases were linked to a local seafood market selling live animals, suggesting that the pathogens were transmitted from animals to humans, soon escalating to human-to-human transmission. The pathogen was identified and named as 2019 novel coronavirus (2019-nCoV), and the disease was named corona virus disease 2019 (COVID- 19), which stands for coronavirus disease 2019 [2].
The COVID-19 is believed to be transferred from animals to humans [3]. The other two similar viruses discovered earlier were severe acute respiratory syndrome coronavirus (SARS-COV) and Middle east respiratory syndrome [4]. The COVID-19 has also been called SARS-CoV-2 but the former name has gained more popularity than the latter name [5]. The COVID-19 causes human illnesses which could range from a common cold to more severe respiratory problems like pneumonia [6]. Unfortunately, there is no vaccine available for COVID-19 and the only form of treatment available is to provide symptomatic treatment to the patients with oxygen supplementation [7].
Dentistry is a profession where the dentist works in close proximity to the patient's mouth and many procedures produce aerosol which is a mixture of water (from a dental instrument like high speed hand piece) and patient's saliva or blood [8]. These aerosols could result in the spread of infection and diseases including COVID-19 [9]. In an article published by the New York Times has identified dentists who are at the highest risk of getting COVID-19 from their patients due to cross infection [10].

MATERIALS AND METHODS
The present study was a cross-sectional questionnaire-based survey conducted among the dentists in India between July 2020 and December 2020. A

RESULTS
The responses of a total of 207 dentists were included in the study. The results of the study are presented with the help of pie charts below.  74.9% of participants were afraid of getting infected with COVID-19 from either a patient or a coworker. 84.5% were anxious, while treating a coughing or a patient suspected to be infected with COVID-19. 71%of dentists did not want to close their dental practices until the number of COVID-19 cases start to decline. 57.5% of participants felt nervous when talking to patients in close vicinity, 92.3% were afraid of carrying the infection from dental practice to their families, and 59.9% were afraid of getting quarantined if they got infected. 58.9% were concerned about the cost of treatment, if they got infected. 98.1% were aware of its mode of transmission of the disease, and 87% were updated with the WHO guidelines for crossinfection control. 94.7% were asking about the patient's travel history. Every patient's body temperature before performing dental treatments recorded by 83.1%, and 77.3% delayed dental treatment of patients who showed suspicious symptoms. 89.4% accepted that a surgical mask is not enough to prevent cross-infection of COVID-19. 92.8% favored the use of N-95 masks for routine dental procedures during the current outbreak. 84.5% were wearing an N-95 mask while treating a patient. Although the majority (88.4%) recommended routine universal precautions of infection control, 87.4% did not use rubber dam isolation for every patient. 63.8% did not use high-volume suction for every patient. Meanwhile, 76.8% did ask their patients to rinse the mouth with antibacterial mouthwash before dental treatment. 98.1% of dentists washed their hands with soap and water or sanitizer before and after treatment of patients. 94.2% were aware of the proper authority to contact if they came across a patient with a suspected COVID-19 infection.

DISCUSSION
Aerosol transmission is also a possible route of transmission when there is an exposure to high concentrations of aerosols in a relatively closed environment. Routine dental procedures generate aerosols, which pose potential risks to the dental care personnel and patients [11]. In the present study 92.3% of the dentist were afraid of carrying the infection from dental practice to their families, studies on previous outbreaks of similar infectious diseases, healthcare workers showed the fear of getting infected while treating an infected patient, or infecting a family member [12,13]. . Patient screening: As is the routine, dentists should take a thorough medical history from each patient and confirm the health status at each recall visit. During this outbreak, targeted screening questions for COVID-19 must be asked. These questions should include personal, travel, and epidemiological history. Temperature and lower respiratory tract symptoms should be closely monitored [11].
In the present study the majority of the participants were aware of the COVID-19 mode of spread and transmission and the guidelines issued by the WHO for cross-infection control in the dental practice including asking patient's travel history and recording patient's body temperature [14]. During dental procedures that generate aerosols, rubber dam provides barrier protection from the primary source and will virtually eliminate all pathogens emerging from respiratory secretion.
In the present study majority of the dentist (87.4%) did not use rubber dam, only 11.1% of the participant used it in their practice. If the rubber dam is placed correctly, the only source of contamination would be the tooth that is undergoing treatment [15]. Application of rubber dam during cavity preparation showed a significant reduction in the spread of microorganisms by 90% [16]. Rubber dam is applied in all aerosol-generating procedures. The use of highvolume suction is also considered an essential means to control aerosols evacuation during dental procedures and should be used for the majority of patients [11], but in the present study 63.8 % didn't use and 35.3% used high -volume suction. Meanwhile in comparison with the use of rubber dam the use of high-volume suction is more.
Preprocedural mouth rinse is one of the most effective methods of reducing the proportion of microorganisms in oral aerosols [17,18]. A meta analysis showed that the use of pre procedural mouth rinse, including chlorhexidine (CHX), essential oils, and cetylpyridinium chloride (CPC), resulted in a mean reduction of 68.4% colony-forming units in dental aerosol [19]. Although the effect of preprocedural mouth rinse against corona virus is still unknown, it has been proven that CHX is effective against several infectious viruses, including herpes simplex virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) [20]. About 0.12% CHX was used as a pre procedural mouth rinse. For patients who develop mucosal irritation or other side effects such as tongue stain, 0.05% CPC could be a good alternative [18].
There is a growing awareness of the importance of hand washing in the prevention of acute respiratory infections. During the outburst of SARS, several epidemiological studies suggested that hand washing with soap and 70%-90% alcohol-based hand rubs (ABHRs) was effective in curbing SARS transmission [21,22]. The WHO (2020c) stated that hand hygiene includes either cleansing hands with an ABHR or with soap and water; both methods are equally effective [23]. ABHRs are preferred if the hands are not visibly soiled; if the hands are visibly soiled, water and soap should be used. As suggested by WHO, hand hygiene should be performed before touching a patient, before any cleaning or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient's surroundings [24]. At minimum, a medical mask (surgical or procedure mask) was used if working at a distance of less than 1 m from the patient. When performing aerosol generating procedures (using highspeed handpiece, air-water syringe, and ultrasonic scaler), a particulate respirator that is at least as protective as a National Institute for Occupational Safety and Health (NIOSH)-certified N95, or equivalent, was used. When performing emergency dental treatment with suspected COVID-19 cases, a higher level of respiratory protection should be considered [11].

CONCLUSION
Overall, this study sheds light on the association of COVID-19 disease and practice modification in the field of dentistry. Dentists, by nature, are at high risk of exposure to infectious diseases. The emergence of COVID-19 has brought new challenges and responsibilities to dental professionals. A better understanding of about transmission and its implication in dentistry can help us identify and rectify negligence in daily dental practice. In addition to the standard precautions, implementation of special precautions could prevent disease transmission from asymptomatic carriers. These special precautions would not only help control the spread of COVID-19 but also serve as a guide for managing other respiratory diseases.