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Table of Contents   
ORIGINAL RESEARCH  
Year : 2021  |  Volume : 32  |  Issue : 3  |  Page : 330-335
Knowledge, attitude and practice of dental practitioners, interns and post-graduate trainees about COVID-19 pandemic in Chennai


1 Department of Oral Medicine and Radiology, Thai Moogambigai Dental College and Hospital, Dr. MGR Educational and Research Institute, Chennai, Tamil Nadu, India
2 Department of Internal Medicine, Government Stanley Medical College, Chennai, Tamil Nadu, India
3 Department of Oral Pathology, Thai Moogambigai Dental College and Hospital, Dr. MGR Educational and Research Institute, Chennai, Tamil Nadu, India

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Date of Submission06-May-2020
Date of Decision15-Oct-2020
Date of Acceptance21-Dec-2020
Date of Web Publication23-Feb-2022
 

   Abstract 


Background: Coronavirus disease-2019 (COVID-19) pandemic has been sweeping around the globe and the cases have been reported in India since the second week of March, with Chennai being one of the most affected cities. Healthcare professionals, particularly the dental personnel have a higher risk of infection due to close face-to-face contact and the risk of inhalation of aerosolised particles. Aim: The aim of this study was to assess the knowledge, attitude and practice about COVID-19 among interns, post-graduate trainees and dental practitioners. Material and Methods: A cross-sectional survey was conducted using Google forms among three groups: interns, post-graduate trainees and dental practitioners. Data obtained was analysed by Chi-square test, Kruskal–Wallis and post hoc test using SPSS IBM software. Results: Of total score of 9 for knowledge-based questions, the score obtained by interns, post-graduate trainees and practitioners were 7.2, 7.2 and 7.5, respectively, with no statistically significant difference among the groups (P = 0.24). Of total score of 4 for attitude-based questions, the score obtained by interns, post-graduate trainees and practitioners were 1.6, 2.0, and 1.9, respectively, with statistically significant difference among the groups (0.009). Of total score of 7 for practice-based questions, the score obtained by interns, post-graduate trainees and practitioners were 3.2, 3.3, and 3.1, respectively, with no statistically significant difference among them (P = 0.63). Conclusion: Though the knowledge about COVID-19 appeared adequate, the attitude and practice component needs improvement. Continuing dental education programs and webinars can be conducted to update the dental professionals about the protocols to be followed during COVID-19 pandemic.

Keywords: Attitude, Covid-19, dental, knowledge, practice

How to cite this article:
Krithika C, Srinath S, Marlecha R B, Sridhar C, Sreedevi J, Jeddy N, Vinod Kumar A C. Knowledge, attitude and practice of dental practitioners, interns and post-graduate trainees about COVID-19 pandemic in Chennai. Indian J Dent Res 2021;32:330-5

How to cite this URL:
Krithika C, Srinath S, Marlecha R B, Sridhar C, Sreedevi J, Jeddy N, Vinod Kumar A C. Knowledge, attitude and practice of dental practitioners, interns and post-graduate trainees about COVID-19 pandemic in Chennai. Indian J Dent Res [serial online] 2021 [cited 2022 May 26];32:330-5. Available from: https://www.ijdr.in/text.asp?2021/32/3/330/338126



   Introduction Top


On 30 January 2020, World Health Organization (WHO) declared a public emergency of international concern over a global and baffling spread of coronavirus outbreak[1] following which on 11 February, WHO named the novel coronavirus as COVID-19.[2] COVID-19 (2019-nCoV) is a zoonotic virus belonging to family Coronaviridae of order Nidovirales, collectively called as Coronaviruses.[1] SARS-CoV (Severe Acute Respiratory Syndrome) outbreak in 2002-2003 and MERS-CoV (Middle East Respiratory Syndrome) outbreak in 2012 also belong to the coronavirus family.[3],[4],[5] There are 4 discovered genera of family coronaviruses, α-CoV and β-CoV infect humans and vertebrates and γ-CoV and δ-CoV infect birds. COVID-19 belongs to the β-CoV similar to the SARS and MERS.[1],[6] This genus targets the respiratory, gastrointestinal and central nervous system.[7] 2019-nCoV attacks the host cells by targeting the human angiotensin-converting enzyme-2 (ACE2) receptor by binding to the S protein.[8] The genome was found to be a large, single, plus-stranded RNA[6]

The 2019-nCOV became a matter of concern when affected patients developed serious respiratory complications.[9],[10] The virus was initially believed to have been transmitted from animal (Bats)-to-human may be via an intermediate host (Pangolins).[8],[11] Now, it is sustained by human-to-human and faecal-oral transmission[9] via contact with droplets from talking, coughing and sneezing.[12] It is more common in men and tends to be more severe in the elderly and those with comorbid conditions.[10] The incubation period for the 2019-nCoV ranges from 1-14 days during which the patient can be symptomatic or asymptomatic.[13] The studies have reported that the 2019-nCoV can spread from asymptomatic individuals which pose a challenge to effective screening, isolation and management.[9]

Of all the professions, dentists have a higher-risk of infection due to near face-to-face communication, inhalation of airborne aerosols which is a mixture of saliva and blood and by handling of sharp instruments.[1] WHO has released guidelines to limit the spread of the 2019-nCoV and ensure that all necessary precautions are taken by the health workers and dentists. As of now, India is trying to curb this pandemic through a nation-wide lockdown for 34 days and currently Tamil Nadu stands seventh in the country with a confirmed case count of 2058 patients (as on 29 April 2020) with Chennai city being most affected. The Government of India and the state of Tamil Nadu are trying hard to control the spread of cases through television and newspaper advertisements on COVID-19 and are urging the citizens to self-quarantine and practice social distancing in the interest of their families and the community. Not much literature is available in this regard. Hence this study was done to assess the knowledge, attitude and practice of dental professionals regarding the COVID-19 pandemic.


   Material and Methods Top


A cross-sectional survey was conducted using an online survey instrument (Google forms) to obtain responses from dental practitioners, dental postgraduate trainees and dental students around Chennai, Tamil Nadu, India during second week of April 2020. The 22 questions in the questionnaire were divided into four parts: first part was to group the age and the qualification of the participants. The second part assessed the knowledge of the current pandemic, third part is about the participant's attitude towards the COVID-19 and fourth part included their current practice approach to COVID-19 outbreak. The last 3 parts were of multiple-choice type where the participant had to choose the right option. The approval for the commencement of the study was obtained from Institute Review Board (IRB) authorised by the Dr. MGR Educational and Research Institute, Chennai (Reference No: Dr. MGRDU/TMDCH/EC/2019-20/25031305) dated 25th March 2020. This questionnaire was self-administered and validated through a pilot sample of 20 participants each in the three categories of dental interns, practitioners and post-graduates who were not involved in the study. Three public health experts evaluated the questionnaire for the face and content validity (I- CVI-0.82) and found it to be relevant and satisfactory. Reliability was assessed using test–retest and was found to be acceptable (k = 0.78). A list was drawn in all three categories of participants and simple random sampling was done using computer-generated random number sequence to select the sample in each category. Link to Google form was sent by mail to 375 participants.

Statistical analysis

A paired group comparison was done using Chi-square test to analyse the differences in the response between three groups followed by Kruskal–Wallis and post hoc test to compare the differences in KAP. The statistical analysis was performed using SPSS IBM software tool (version 19, IBM, Chicago, Illinois).


   Results Top


A total of 310 responses were obtained of the 375 forms sent through Google forms (response rate 82.6%). A total of 310 responses were obtained: 155 interns, 54 dental postgraduate trainees and 101 dental practitioners [Chart 1].



Responses to knowledge based questions

Of total score of 9 (one mark for each correct answer and zero marks for incorrect answer) for knowledge-based questions, the mean score of the interns was 7.25 (SD 1.27) (95% CI 7.24–7.61); that of post-graduate trainees was 7.29 (SD 1.00) (95% CI 6.89–7.55) and that of practitioners was 7.50 (SD 1.13) (95% CI 7.02–7.50). There was no statistically significant difference in the mean score of knowledge-based questions among the three groups (P = 0.24). There was no statistically significant difference among the three groups with regard to questions relating to the incubation period, symptomatology, ACE 2 receptor binding, transmission through saliva and ineffectiveness of Chlorhexidine mouthwash (Question numbers 1, 2, 3, 4, 5, 7, 8, 15) (P > 0.05). The only question with the statistically significant difference among the three groups was the possibility of COVID-19 transmission in hot and humid climate (P = 0.034) for which the percentage correct response were 78.1% for interns, 77.8% for post-graduate students and 90.1% for practitioners [Table 1] and [Chart 2].
Table 1: Responses to knowledge based questions

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Responses to attitude based questions

The response to attitude-based questions was classified as desirable and undesirable with a mark of +1 being given for every desirable response and zero marks given for undesirable response. Of total score of 4 for attitude-based questions, the mean score of the interns was 1.62 (SD 0.87) (95% CI 0.07–3.29); that of post-graduate trainees was 2.04 (SD 0.95) (95% CI 0.16–3.89) and that of practitioners was 1.92 (SD 1.05) (95% CI 7.02-7.50). There was a statistically significant difference in the mean score of attitude-based questions among the three groups (P = 0.009). The question concerning hand washing with soap and water showed a statistically significant difference among the three groups (P = 0.01) for which the percentage correct response were 6.5% for interns, 11.1% for post-graduate students and 14.9% for practitioners. There was no statistically significant difference among the three groups with regard to questions relating to safe dental procedures, absenteeism from work and source of information (Question numbers 17, 19, and 20) (P < 0.05) [Table 2] and [Chart 3] and [Chart 4].
Table 2: Responses to attitude based questions

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Responses to practice based questions

The response to practice-based questions was classified as desirable and undesirable with every desirable response getting a mark of +1 and zero marks given for undesirable response. Of total score of 7 for practice-based questions, the score obtained by interns, post-graduate trainees and practitioners were 3.2, 3.3 and 3.1, respectively, with 95% confidence interval and no statistically significant difference among them (P = 0.63). There was a statistically significant difference among the three groups with regard to the use of thermal scanners (P = 0.03) and use of environmental disinfectant (P = 0.002). The other questions concerning the type of mask used, hand wash time, use of rubber dams, prescription of Ibuprofen and protocol to be followed for a suspected COVID patient showed no statistically significant difference in the responses among the three groups (Question numbers 10, 11, 13, 14, 16) (P > 0.05) [Table 3]; [Chart 5] and [Chart 6].
Table 3: Responses to practice based questions

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   Discussion Top


Although this is a novel evolving epidemic, little is known about the awareness of the dental professionals and implications in dental practice. The novel coronavirus infection has wreaked havoc around the world in 2020. It is not the same as SARS coronavirus (SARS-CoV) that happened in 2002–2003 as some of the clinical symptoms are different from the latter.[1] The symptoms of the COVID-19 vary ranging from mild to severe and in some cases the disease can be fatal. Symptoms typically include fever, dry cough, shortness of breath, fatigue, muscle pain, headache, itchy/sore throat, loss of smell or taste, diarrhoea and vomiting.[13] Most of the participants answered symptom-related questions correctly, in this study indicating a high level of awareness about the pandemic.

The asymptomatic incubation period for individuals infected with 2019nCoV is 1-14 days and it was confirmed that those without any symptoms too, can spread the virus.[1] This question was answered correctly by most participants. There is a general misconception about coronavirus not surviving in Tamil Nadu and other temperate areas in the world due to the higher temperatures of these areas (more than 27°C). The current fact shows increasing number of confirmed cases irrespective of geographic location and temperature. Although it may be true that the virus may not survive on exterior surfaces exposed to direct sunlight for a very long time, it has not been proven whether this will bring down the transmission rate or the virulence. Hence, currently there is no such study which confirms the temperature tolerance of the 2019nCoV, so far.[14] With regards to this question, practitioners had a better knowledge.

The 2019nCoV binds to the human Angiotensin Converting Enzyme-2 (ACE2) receptor of human cells to invade and promote human to human transmission.[1] These receptors are found abundantly in the respiratory tract and in the salivary gland duct epithelium in human mouth. Thus, a population that expresses higher ACE2 are probably more susceptible to infection.[15] Majority of the participants had adequate knowledge with regard to this question. The 2019nCoV is a respiratory virus which can be transmitted either directly or indirectly through contact of saliva from infected or carrier patients. In the present study, majority of the participants agreed to saliva being a source of transmission. By viral culture method, live viruses were found to be present in the saliva of infected persons.[16] It is also reported that the virus can gain entry via conjunctiva (eyes) to the body.[1] Hence it is mandatory for the dentist and the clinical assistants to wear personal protective equipment (PPE) while screening and handling suspected COVID-19 patients.[17]

As there is a notable increase in demand of the mouth masks worldwide, one must understand that not all are required to wear N95 respirators. For clinicians performing aerosol-generating procedures on suspected or confirmed COVID-19 cases, it is mandatory to use N95 respirators as it filters out over 95% of small droplets and provides a tight seal around the nose and mouth so that air and viral particles cannot get around the sides of respirator. Clinicians handling routine screening in their clinics, are recommended to use 3ply quality disposable medical mouth masks as it provides a good seal to nose and mouth from larger droplets through sneeze and cough.[17],[18] A lot of confusion prevailed among the participants in this study on which mask to be used in the practice.

Hand hygiene is a must during this pandemic. Washing hands with soap and water for at least 20 seconds is the recommended best practice. If soap and water are not available then use of alcohol-based sanitiser and chlorhexidine with at least 60% alcohol is advised.[14],[19] To this question, very few participants gave the right answer. If the patient gives a positive travel history or contact history, shows symptoms and the temperature measures more than or equal to 37.3°C, the patient has to be quarantined from other patients and referred to the nearest hospital.[20] In this study, majority of the participants were not aware of the protocol to be followed in practice.

Dentists have a higher risk of getting contaminated as many dental procedures produce aerosols and droplets contaminated with saliva and blood.[1],[21] Hence, it is best recommended to use a rubber dam, which could significantly reduce airborne particles by 70% in 3-foot diameter of the operational field.[22] Interns had a better knowledge with regard to this question. Likewise, procedures like ultrasound scaling and using of high-speed hand piece is to be avoided as they produce aerosol. The procedures like extraction, and suture removal should still be done with proper protective equipment and sterilisation protocol.[23] In our study, decent number of participants gave the right answer to this question in all the three groups.

Chlorhexidine is used generally as a preoperational antimicrobial mouth rinse as it reduces the number of oral microbes but according to the National Health Commission of the People's Republic of China, Chlorhexidine may not be effective to kill 2019nCoV. In the current study, most of the participants answered this question correctly. The virus is vulnerable to oxidation and those that contain oxidative agents such as 1% hydrogen peroxide or 0.2% povidone is recommended.[1] There is a lot of controversy on the medications that can be used for COVID-19 patients. According to many, it is best recommended to use paracetamol (acetaminophen) to give symptomatic relief over ibuprofen, as the latter exacerbates the condition of the patient. Ibuprofen dampens the immune system, delays the recovery process and aggravates the reduction of a key enzyme that regulates water and salt concentration in blood, which causes pneumonia in extreme cases. A majority of the participants in our study gave the correct response with regard to this question. Further studies have to be performed to draw meaningful conclusions.[24]

Environmental surface disinfection of the dental chairs and operatories is also equally important besides self-disinfection. Preferably, accelerated hydrogen peroxide (0.5%), Benzalkonium chloride (0.05%), ethyl alcohol (70%), isopropanol (50%) and sodium hypochlorite (0.5-1%) are very effective against contamination of blood and body fluids.[25] Very few participants gave the right answer about the disinfectant to be used. Although one of the symptoms of COVID-19 is the presence of fever, it is recommended to measure the body temperature of the visiting patients. A contact-free forehead thermometer is mandatory for screening over a conventional thermometer.[1] Interns appear to have better practice with regard to use of thermal scanners when compared to post-graduates and practitioners.

There are a few studies in literature where the knowledge and attitude of dental students have been assessed with regard to other transmissible viral infections and epidemics. A similar study on Zika virus showed that postgraduates had better knowledge than graduates and practitioners.[26] In another study on HIV/AIDS, the dental students had adequate knowledge about HIV/AIDS but the attitude towards this disease was found to be negative as there was a fear of transmission.[27] A study on H1N1 virus infection showed that 50% of the dental students who participated in the study had enough knowledge but the behavioural response was poor among the respondents.[28] A questionnaire study conducted among 200 dental students to evaluate their knowledge about Middle East Respiratory Syndrome-coronavirus (MERS-CoV) concluded that although dental students had good knowledge about MERS-CoV, more information must be provided for ideal outcomes.[29] All the aforementioned studies relating to awareness of dental students in other similar epidemics and infections generally indicate that the knowledge of dental students appear satisfactory; however, given the high risk of acquiring infections in the dental profession, it is mandatory for everyone in the dental fraternity to acquaint themselves with the most relevant information, latest guidelines and recommended protocols in an epidemic situation to ensure highest levels of safety and protection to the patients as well as caregivers.

In a pandemic situation like COVID-19, it is not sufficient if the medical/dental health care providers alone update themselves and adhere to protocols. Robust community participation is the key in the control of the spread of the disease. Fortunately, recent literature shows that the General population in India has adequate knowledge about its preventive aspects and a favourable attitude towards COVID-19 prevention in terms of peoples' willingness to follow government guidelines on quarantine and social distancing.[30] With appropriate joint efforts of the medical/dental health care providers, general public, media and the government, there is hope that morbidity and mortality associated with COVID-19 can be greatly reduced.


   Conclusion Top


Though the knowledge about COVID-19 appeared adequate among the dental fraternity, the attitude and practice component needs improvement. As the global threat of COVID-19 continues to rise, continuing dental education programs and webinars should be conducted to update the dental professionals about the protocols to be followed during this pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Chandrasekaran Krithika
Department of Oral Medicine and Radiology, Thai Moogambigai Dental College and Hospital, Dr. MGR Educational and Research Institute, Golden George Nagar, Mugappair, Chennai - 600 107, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_436_20

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