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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 98-105

The psychological impact of the COVID-19 pandemic on dental healthcare professionals


1 Department of Conservative Dentistry & Endodontics, Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore, Karnataka, India
2 Department of Orthodontics and Orofacial Orthopedics, Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore, Karnataka, India
3 Department of Biostatistics, Nitte (Deemed to be University), KS Hegde Medical Academy (KSHEMA), Mangalore, Karnataka, India

Date of Submission19-Aug-2020
Date of Decision01-Sep-2020
Date of Acceptance25-Sep-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Raksha Bhat
Department of Conservative Dentistry & Endodontics, Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore 575018, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_283_20

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  Abstract 

Aims and Objectives: The advent of the novel coronavirus disease-2019 (COVID-19) pandemic has sparked a global crisis. Cumulatively, the modifications in patient care and financial restraints are leading to heightened levels of anxiety amongst dentists, making it imperative to comprehend the psychological health implications of the dental professionals. This study aimed to evaluate the psychological impact of the COVID-19 pandemic among Indian Dentists through an online web-based survey.Materials and Methods: The present randomized survey was designed to evaluate the anxiety levels. A total sample size of 405 was calculated. The questionnaire included demographic information and all the variables linked to probable cause of stress during clinical practices and the future prospects of the profession. The questions had to be responded on a scale of 1–10. The responses were statistically analyzed by subjecting the responses to descriptive analysis, Student’s t test, and Pearson’s chi-square tests.Results: A total of 405 responses were received. The levels of anxiety reported were high. Majority of the dentists were troubled by the thought of being in a high-risk profession and of transmitting the disease to others. Almost all questions were responded with a score of >5 on a scale of 1–10 depicting heightened anxiety levels. The fear levels were noted to be elevated in patients aged more than 35 years.Conclusion: Long-term unrecognized anxiety can predispose to significant psychiatric morbidity and fatigue. Identifying and acknowledging adverse factors in a crisis situation will facilitate early intervention to reduce and mitigate the impact of stress.

Keywords: Anxiety, COVID-19, Dental Clinicians, Dentists, Pandemic, Psychological impact


How to cite this article:
Shetty A, Bhat R, Shetty P, Hegde MN, Krishna Nayak U S, D’souza N. The psychological impact of the COVID-19 pandemic on dental healthcare professionals. J Int Oral Health 2020;12, Suppl S2:98-105

How to cite this URL:
Shetty A, Bhat R, Shetty P, Hegde MN, Krishna Nayak U S, D’souza N. The psychological impact of the COVID-19 pandemic on dental healthcare professionals. J Int Oral Health [serial online] 2020 [cited 2021 Jan 24];12, Suppl S2:98-105. Available from: https://www.jioh.org/text.asp?2020/12/8/98/301869


  Introduction Top


The World Health Organization (WHO) declared coronavirus disease-2019 (COVID-19) outbreak a pandemic, at a media briefing in March 2020.[1] The outbreak of the disease was first reported in the area of Wuhan, China that developed exponentially into a public health crisis and progressed rapidly to other parts of the world.[2] Various healthcare models, economic regulation, and political ideologies have governed the acceleration and reverberation to this disease around the world.[3] In all the afflicted countries, the spread of COVID-19 has posed significant challenges in the field of dentistry and medicine. COVID-19 was recently identified in saliva of infected patients gesturing toward the responsibility of the oral and dental health professionals toward diligently protecting against the transmission of the infectious disease.[4]

Dental personnel are at high risk of acquiring the infection due to repeated exposure to respiratory tract secretions, saliva, blood, and other contaminated body fluids, due to the inevitable face to face contact with patients.[5] The spread of the infection in dental clinics can occur by direct exposure to respiratory secretions containing droplets, blood, saliva; indirect contact with contaminated surfaces or instruments; inhalation of suspending airborne viruses and mucosal contact with infection-containing droplets and aerosols propelled in the surroundings by interactions without a mask.[6],[7] By virtue of the novelty of COVID-19, no cases of transmission in or through a dental setting have been identified yet. Nonetheless, modifications in the dental clinic settings and treatment should be adopted in order to maintain a healthy atmosphere for the patients as well as the clinician and the dental team, given the high risk of transmission of the disease, especially considering the generation of aerosols during routine dental procedures.[8]

Liu et al.[9] have suggested the possibility of the salivary gland epithelial cells to be potentially infected and become a significant source of the virus in saliva. In a study by To et al.,[4] the coronavirus has been isolated from the saliva of 19 COVID-19 patients till date. The presence of the virus strains in saliva for 29 days has been reported, which validates the reports of recusansy of the virus despite patient recovery.[10] The human angiotensin-converting-enzyme-2 receptors are found in a high concentration in the salivary glands. With the SARS-CoV-2 known to bind to human angiotensin-converting enzyme 2 receptors, it gives the possible explanation to the presence of SARS-CoV-2 in secretory saliva.[11],[12] Almost all of the routine dental treatments induce a substantial amount of droplets and aerosols, attributed to the use of devices and equipment such ultrasonic scalers, air-water syringes and air turbine handpieces, increasing the risk of transmission in dental offices.

The worldwide impact of the pandemic on dental services is ambiguous despite the involvement of various dental institutes, regulatory and advisory bodies in determining protocols and devising treatment strategies. Multiple measures have been advocated by the advisories around the world, including closing down the practices for a certain period or reducing the number of routine check-ups to restricting the treatment to emergency cases only. The varying degree and pattern of COVID-19 has led to imprecision in decision making.

SARS-CoV-2 belongs to the family of beta coronaviruses which are known to be the causative organisms for the human severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS). Several studies have shown the healthcare workers succumbing to mental health problems during the SARS and MERS epidemic, with post-traumatic stress disorder and depressive disorders being the most prevalent long-term psychological condition.[13],[14] Earlier experience with outbreaks of severe infectious illnesses in the country has indicated the potential for panic to be often a lot greater than the risk of acquiring the disease.[15] Research-based evidence raises speculations of the effect of the COVID-19 epidemic on the psychological condition of the healthcare workers.[16]

This web-based cross-sectional study aims to assess and determine the anxiety levels and attitude of dentists toward the disease during the pandemic to provide adequate data support for the targeted interventions as and when needed.


  Materials and Methods Top


Study design and participants

The present study was an open, observational, qualitative, randomized, descriptive and adaptive questionnaire-based online survey. To prevent the spread of the virus through droplets or contact, a web-based survey was conducted. The questionnaire was circulated to dentists all around India using the link for Google Forms sent through E-mail. The respondents were required to sign in to Google; thereby eliminating duplication of responses and maintaining uniqueness of each response. The purpose of the present survey to evaluate anxiety which is specific to each person, bias would be unavoidable. Hence, it was reduced by using neutrally worded questions and allowing anonymity.

Informed written consent was obtained from the dentists who volunteered for the study. The objectives and rationale were given in an information letter attached to the link to the questionnaire. The web-based questionnaire was totally voluntary and non-commercial. Institutional ethical board clearance was obtained.

Data collection

The survey period was conducted during the lockdown period over a period of 3 months from March to May 2020. All participants reported their demographic data and information related to knowledge of COVID-19 related information and associated anxiety with regard to clinical practice. To certify the quality of the survey and standardize the responses, most of the questions were to be answered based on a scale of 1 to 10 with 1 being the lowest score and 10 the highest. No specific timeframe was determined to fill the questionnaires. The analyses of responses were restricted to completed questionnaires.

Sample size

On the basis of the pilot study, the estimated Standard deviation of stress level (1–10 scale) was 3.08, estimation of error at 0.3, the sample size was calculated to be n = 405.

The sample size was calculated using the formula:



where α = 0.05, estimated standard deviation (σ) = 3.08, and estimation error (d) = 0.3.

Measures

The questionnaire comprising of seventeen questions on a single screen which could be scrolled down, was divided into two sections: the first regarding the demographic data of the dentists and the second comprised of questions that aimed to assess anxiety levels and attitudes toward COVID-19 and the subsequent infection control practices in dentistry.

The demographic variables included the gender, age group, years of clinical experience, highest academic degree obtained, and speciality.

The COVID-19 related variables included the level of risk of contracting the virus due to the profession, stress of working after the outbreak, anxiety of falling ill each time after treating a patient after the outbreak, stress of having no control over contracting the disease or survival after contraction of the virus, apprehension toward clinical practice and passing on the disease to others and concern of family and friends due to contact with patients. The willingness of the dentist to treat symptomatic, asymptomatic with travel history or positive COVID-19 patients under cases of extreme emergency was also included. Further, the effect of the pandemic on clinical practice, the timespan required for to return to normalcy was also assessed. The questionnaire included specific questions addressing knowledge of cross-infection control practices such as the use of personal protection equipment; monitoring patients, as well as knowledge that the COVID-19 infection might be spread in the dental office through aerosol transmission. All the questions had a non-response option in case the respondents did not wish to report the answer. The option to review the answers before the final submission was provided to the volunteered respondents.

The questionnaire was validated by establishing face validity,[17] that is two experts in the field were assigned to read through and validate the questionnaire. Cronbach α factor was determined prior to initiation of the study to ascertain the reliability and consistency of the questionnaire valued at 0.7.

Statistical analysis

Student’s t test and Pearson’s chi-square test analysis for comparison of the attitudes toward COVID-19 between age groups.


  Results Top


Four hundred and five participants completed the web-based questionnaire survey. The demographic characteristics are presented in [Table 1]. A total of 239 (59%) females and 166 (41%) males took part in the study. A total of 285 (70.4%) of the participants were under 35 years of age and 6 (1.5%) above 56 years of age. Most of the participants 292 (72.1%) were relatively newcomers in the profession with under 5 years of clinical experience with only around 31 (7.7%) of participants having an experience of more than 16 years. A total of 240 (59.3%) respondents were private practitioners with a Bachelors degree, 158 (39%) possessed a Masters degree, 5 (1.2%) and 2 (0.5%) had pursued PhD and post-Doc, respectively. Only 68(16.8%) of the respondents were postgraduate students.
Table 1: Demographic characteristics

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Majority of the dentists believed in the profession putting them at a higher risk of contracting the SARS-CoV 2 virus (8.18 ± 2.39) and were subsequently apprehensive of passing on the disease to others (7.61 ± 2.66). Most of the respondents were anxious about resuming work following the outbreak (7.23 ± 2.57). Few respondents reported to be afraid of falling ill each time following patient treatment (6.87 ± 2.76) and were concerned about having little or no control over getting infected (6.47 ± 2.61). The respondents were moderately worried about transmission to acquaintances from them (6.31 ± 2.97) and most got anxious thinking about the disease (6.16 ± 2.73). More than half the clinicians confirmed to having thoughts of taking off from practice until the outbreak was over (5.95 ± 3.14) and also anxious about ignorance from friends and family (5.33 ± 3.1). Limited number of respondents were willing to treat symptomatic (5.2 ± 3.2) and asymptomatic (5.43±3.18) emergency cases with a history of travel. Small fraction of the dentists were willing to treat potentially diagnosed cases of COVID-19(4.9 ± 3.39). Most of the dentists were positive of recovery under a scenario of infection with the virus (4.6 ± 2.6) [Table 2].
Table 2: Descriptive statistics of the questionnaire response scores

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After the outbreak of COVID-19, 308 (76.1%) dentists treated the patients as potentially COVID-19 positive. A majority of them agreed the outbreak affected their clinical practice (91.1%) and agreed the practice will stay affected for a certain period of time even after it subsides (94.3%). Most of them felt it would take more than 6 months (35.8%) to up to 6 months at least (35.8%) for things to return back to normal on the work front. A large fraction of the respondents however felt the necessity of using hazmat suits when treating patients especially in cases of aerosol emissions (96.6%) [Table 3].
Table 3: Descriptive statistics of the questionnaire response to attitude toward COVID-19

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Dentists above 35 years found practicing to be extra stressful and the mean scores of contracting COVID-19 was significantly higher compared to respondents below 35 years (P = 0.001).The mean scores of dentists above 35 years apprehensive to falling ill with COVID-19 each time they treated a patient after the outbreak was significantly higher compared to dentists below 35 years (P = 0.022). Dentists above 35 years felt they had little control over whether they would get infected or not compared to below 35 years and it was statistically significant (P = 0.011). The anxiety of dentists above 35 years toward people avoiding family because of the profession was significantly higher compared to less than 35 years (P = 0.007). The number of dentists willing to treat symptomatic emergency cases were significantly higher (P = 0.001) in the age group of below 35 years [Table 4].
Table 4: T test analysis for comparison between age groups

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There was a significant association between the age groups in treating the patients as potentially COVID-19 positive (P = 0.024). There was a significant association between the age groups in feeling anxious about the effect of the outbreak on clinical practice (P = 0.002). There was a significant association between the age groups feeling the clinical practice would be affected even after the outbreak subsides (P = 0.001) There was no significant association between the age groups and wearing a hazmat suit (P = 0.159). There was a significant association between the age groups and time span required for practice to return to normalcy (P = 0.015) [Table 5].
Table 5: Pearson’s chi-square test analysis for comparison of the attitudes toward COVID-19 between age groups

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  Discussion Top


COVID-19 can be described as a critical pandemic that led to a crippled society within a few months of its inception. The Chinese Preventive Medicine Association 2020 has advocated the SARS CoV-2 to be a zoonotic virus similar to SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) with the Chinese horseshoe bats known to be the most probable origin and pangolins, the most likely intermediate host.[18],[19] Research suggests the possibility of the COVID-19 outbreak via an initial animal-to-human transmission, followed by subsequent and continuous human-to-human spread.[19] It has now been established that this interpersonal transmission occurs majorly through respiratory droplets and contact transmission.[20] Hence, in order to reduce the rate of transmission and prevent the strain on the healthcare systems; economic sealing, lockdown and social distancing deemed to be a necessity. In amidst of this all, dentistry was classified as a high-risk profession due to aerosol transmission which led to vexation amongst the dental professionals. Also, as per government regulations, clinical practice had to be restricted to emergency treatment. The present study analyzed the anxiety scores among dental practitioners practicing in India during the 2020 COVID-19 outbreak in India. The response rates recorded would have precisely emulated the feel of the respondents as anonymity and confidentiality of responses were judiciously maintained.

Response rates were highest by general practitioners (59.5%), lowest from the nonclinical branches; oral medicine and radiology (2%), oral pathology (1.2%), public health dentistry (1%) and intermediate for the specialities; endodontists (17%), prosthodontists (7.2%), orthodontists and periodontists (3.2%), Oral Surgeons (3%) and pedodontists (2.7%). The differences may be due to differing levels of motivation and varied job natures of respondents. Gender was found to be significantly correlated with higher anxiety score among the dental practitioners. In the present study, women reported to have higher anxiety score compared to males. The finding is in accordance with earlier studies and can be justified by the proven fact that women are more comparatively more concerned about health issues and get them addressed at the earliest.[21],[22]

A majority of the respondents reported anxiousness of acquiring the infection due to the profession (8.18 ± 2.39), transmitting it to family, friends and acquaintances (7.61 ± 2.66) and vice versa (6.31 ± 2.97) and also of ignorance from kith and kin due to the same (5.33±3.1). The dental clinicians also expressed concern about reopening clinics (7.23 ± 2.57) as they presume they have no complete control over getting infected (6.47 ± 2.61). Although most of them were moderately anxious about the disease (6.16 ± 2.73), they did possess thoughts of taking off from work for a considerable period of time (5.95 ± 3.14). However, only a few clinicians were accepting of treating asymptomatic (5.43 ± 3.18), symptomatic (5.2 ± 3.2) or potentially diagnosed cases of COVID-19 (4.9 ± 3.39). A larger fraction of the tests admitted to treating all the patients reporting to the clinic after existence of the disease in the country as potentially positive cases (76%). Almost all agreed to the outbreak affecting (91.1%) and bringing a stall onto clinical practice up to a certain timeframe (94.3%), probably for a period of 6 months or more (74.1%). The anxiousness and trepidation can be ascribed to the hypochondriac concerns and fear of transmission through asymptomatic carriers.[23] Also, droplet transmission has proven to be the primary vector of the COVID-19 infection with contact transmission relatively playing a minor role.[24] Possibility of the virus becoming aerosolized under specific conditions has been advocated, suggesting the prospects of airborne transmission. In dental clinics, a majority of the patients reporting are usually asymptomatic or pre-symptomatic, who cannot be identified by routine screening procedures, raising fundamental concern.[25] Treatment of these patients generating aerosols could likely endanger the health of the dental team and other patients visiting the clinics. In the present study all the respondents felt the necessity to wear hazmat suits when treating patients particularly the aerosol-generating procedures (96.6%). Currently no universal guidelines or protocols are in place for dental clinics to treat active or suspected COVID-19 cases. The lack of guidelines increases the risk of the nosocomial SARS CoV-2 transmission through dental clinics. Few dentists were positive of recovery under a scenario of infection with the virus (4.6±2.6). Keeping oneself connected emphatically and adding to each other’s psychological prosperity gets pivotal in such trying times.

In the present study, age of the dental clinicians was found to be a positive factor and directly proportional to a high anxiety score. Majority of the respondents above 35 years of age were noted to be relatively more anxious in all aspects [Tables 4] and [5]. In fact, a significantly higher number of practitioners below 35 years of age were inclined toward treating symptomatic emergency cases (P = 0.001). With progression in age, high risk of COVID-19 transmission is imperative due to a decrepit immune system, most commonly associated underlying health issues. Hence, this factor can attribute to stress and apprehension amongst the respondents over 35 years of age. Also, the present study is in accordance with the epidemiological studies which has shown psychological effects to be rare in the first three decades of life.[26],[27]

The response scores of anxiety in this study indicate the greater psychological pressure on the dentists due to the uncertainty of the progression of the pandemic. The present study targeted toward acquiring salient findings in order to promote mental health interventions especially designed for dental health care workers to routinely screen for symptoms of occupational anxiety and stress and to advocate therapy and mediations to reduce it. Further, prevenient identification will help prevent the progression of stress into severe psychological consequences leading to depression and economic loss. In addition, it will also help improve the caliber of an affected individual’s life. Future investigations with a larger sample size are required to incorporate sourcing the stressors, also dividing the response rates state-wise to getting a thorough idea and likewise, to incorporate more markers and apparatuses to assess for stress and anxiety.

Conclusion

In conclusion, the present study determined a major psychological health burden amongst the dental clinicians during COVID-19 pandemic. The awareness of the importance of mental health related to occupational stress is low and no specific guidelines have been issued, which is currently the need of the hour during the pandemic period. Hence, routine supervision and monitoring of the psychological consequences related to the outbreak of such life-threatening diseases should be established with early targeted psychological interventions a regular part of worldwide efforts to curb the issue.

Future scope

There exists a significant psychological health burden of the COVID-19 pandemic amongst the dentists. Alterations in patient care and financial pressures contribute to increased rates of dental anxiety. Defining and addressing undesirable triggers in this chaotic situation will enable early intervention to alleviate and reduce the impact of stress

Acknowledgement

Not applicable.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.

Author contributions

All authors have equally contributed to the conception of the study, data collection, data acquisition and analysis, data interpretation, manuscript writing and final reviewing and all the authors approved the final version of the manuscript for publication.

Ethical policy and institutional review board statement

Ethical clearance has been obtained from the Institutional Ethical Committee from Nitte (Deemed to be University), Cert. No. ABSM/EC/2/2020, date of approval: 19-05-2020.

Declaration of patient consent

Not applicable.

Data availability statement

The data used in this study are available in Google forms and will be available on request from Dr. Raksha Bhat (e-mail ID: [email protected]).

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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