2021, Number 2
Impact of knowledge/perception of COVID-19 on the risk of contagion in dental students and dentists
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Language: English/Spanish [Versión en español]
References: 36
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ABSTRACT
Introduction: Dental practice is considered a high-risk profession, being in direct contact with fluids such as saliva, secretions, and blood, students and professionals should be prepared and have the knowledge to know how to act in the face of a pandemic such as SARS-CoV-2. Objective: The objective of this cross-sectional, descriptive, and exploratory study was to evaluate whether there is a relationship between professional experience, perception, and level of knowledge of COVID-19 with the risk of infection. The study population consisted of undergraduate and postgraduate dental students and professionals in private and/or public practice. Material and methods: The instrument applied was a questionnaire of 35 multiple choice questions, divided into three sections: 1) sociodemographic variables, 2) perception of the risk of becoming infected with SARS-CoV-2 virus and becoming ill with COVID-19, and 3) knowledge of three different aspects: a) etiopathogenesis, b) recognition of the clinical characteristics or early diagnosis of COVID-19 and c) diagnostic tests for COVID-19 (23 questions). Results: 847 subjects were surveyed, of these 723 were dental students and 124 were dentists. The percentage of confirmed COVID-19 positivity in students was 6.8% and 31.5% of suspected cases; in dentists 12.2% of confirmed positivity and 17.7% of suspected cases. Both students and dentists perceived that their level of knowledge of COVID-19 is sufficient, they perceive that during their clinical practice they have a high risk of being infected by SARS-CoV-2, however, our results indicate that having less professional experience has been determinant in increasing the risk of COVID-19 infection. Conclusions: Undergraduate and graduate dental students and dentists should include protocols in their daily practice for the timely detection of patients with COVID-19.INTRODUCTION
Dental clinics or dental offices are an essential part of our society, where multiple oral ailments related to pain and infections are treated, patients come to restore their health and improve their quality of life.1 In the current pandemic context, in march 2020, the New York Times published an article entitled "The Workers Who Face the Greatest Coronavirus Risk", describing that dentists are the health care workers most at risk of infection with the coronavirus that causes COVID-19.2 In response, the American Dental Association (ADA) updated its website in march 2020, including a link to frequently asked questions for dentists about personal protective equipment and communicating with patients.3 Several recommendations have been published for dentists and dental students to have appropriate management of patients with COVID-19.4 Among the most important are described personal protection measures, avoiding or minimizing procedures that may produce droplets or aerosols; using high volume saliva ejectors, as well as hand washing and surface disinfection.4-6
It has also been recommended that dentists only attend urgent dental conditions during an outbreak of COVID-19, both to reduce interpersonal contact and to reduce waiting time and patient stay in dental offices.5,6
Despite the international context, in Mexico, governmental strategies to contain the pandemic have taken different directions, limiting social and economic activities have been limited, even at the time of the highest number of cases, adhering to time restrictions and focusing more on some sectors of society, However, to the detriment of high mortality, strategies have been based on hospital capacity and on avoiding immediate effects on the productive sector, rather than on the containment and timely detection of cases and the consequent reduction of mortality.7
The arrival of vaccines has given hope to our society, however, the national vaccination strategy established that only dental personnel in the public sector would be vaccinated8 and in a statement our Undersecretary of Health mentioned "that the risk of SARS-CoV-2 infection for dentists was comparable to that of public transport or home delivery personnel",9 so vaccination of dentists and students has been carried out only in accordance with age groups. Contradictorily, most dental care in our country is provided by the private sector, despite its impact on the primary management of oral diseases such as periodontics, endodontics, and prostheses, which are not considered in the public sector and those who require this type of care always do so in the private sector or in dental schools.10
In this context, dentistry in our country has been reactivated at an accelerated pace, it should be said that many professionals and institutions no longer only attend dental emergencies, for several months all types of treatments have been performed, most clinicians have adopted in their offices, different infection control measures according to the pandemic situation and the level of biosafety has been raised during patient care. However, case containment remains a constraint for both staff and patients.
In-depth screening has been proposed by different experts,11 however, it is not a generality and the adoption that, at the moment, all patients are high risk, is not the dominant thought during dental practice. Dentists and students should not only perform in-depth screening for their own care, it is essential that they perform a timely diagnosis of COVID-19, especially in the early stages of the disease, which would contribute to the necessary containment measures to reduce contagion, as well as to follow clear and simple guidelines for the management of patients during the dental consultation and make dentists work with the lowest risk. In this context, the public, private, or community dentist and dental students can play a key role in the early detection of cases that are likely to be positive, as well as in health information and education regarding the health recommendations for this type of patient and in the prevention of the rest of the population.12 The dentist usually has contact and communication not only with the affected patient, but also with family members and caregivers, and it should be noted that many of the infections are occurring in the family or home environments, gatherings with friends, social events, among others; therefore, the detections made by the dentist can be key to early care and to reduce the risk of complications.
Based on the above, the objective of the present study was to evaluate if there is a relationship between professional experience, perception, and level of knowledge of COVID-19 with the risk of infection, for this purpose a population of undergraduate and postgraduate dental students, as well as professionals in private and/or public practice, were studied. The level of knowledge evaluated included the symptomatology associated with COVID-19 and diagnostic tests. Finally, an action protocol is proposed for the timely detection of COVID-19 in clinical personnel and in patients with COVID-19 in early stages who attend dental clinics or dental offices.
MATERIAL AND METHODS
A cross-sectional, descriptive, and exploratory study was carried out in undergraduate and graduate dental students, as well as in professionals in private and/or public practice. The study was carried out between November 2020 and May 2021. The inclusion criteria for the selection of participants in this study were as follows: students enrolled in a dental school, dental interns, students in a specialty, and professionals in private and/or public practice. Incomplete or incorrectly completed questionnaires were eliminated. A probability sample was obtained with a simple random sampling type. Informed consent was obtained electronically for those who participated in the study. The questionnaire was applied using the online data collection platform Google Forms.
The instrument consisted of 35 multiple-choice questions, which were divided into three sections: the first on sociodemographic variables with eight questions. They were asked if they had been infected with COVID-19, whether they had a positive test, symptoms, or suspicion if the respondent had been in close contact with a family member diagnosed with COVID-19. The second section of the survey included four questions to assess the respondents' perception of their risk of becoming infected with SARS-CoV-2 and becoming ill with COVID-19. No scores were assigned in this section since perceptions, emotions, and feelings regarding the disease are individual and are not structured on a scientific basis. The third section included 23 questions where knowledge was assessed with respect to three different aspects: 1) etiopathogenesis, 2) recognition of clinical features or early diagnosis of COVID-19 and 3) diagnostic tests for COVID-19.
Each of the questions had only one correct answer based on the literature (Table 1), so each correct answer was assigned a score. In the "Etiopathogenesis of COVID-19" section, four questions were posed; each correctly answered question was assigned five points. The maximum total score in this section was 20 points. In the section "recognition of clinical features or early diagnosis of COVID-19" they were asked to identify seven symptoms described as highly frequent, each of them was assigned a score of two points, and seven symptoms were described as moderately frequent, each of them was assigned one point; in addition, two essential questions were asked about oxygen saturation and temperature of a patient with suspected COVID-19, these two questions were assigned five points to the correct answer, the maximum total score for this section was 31 points.
In the "diagnostic tests for COVID-19" section, three questions were asked about the existing diagnostic tests and according to the phase of the disease: asymptomatic phase, pre-symptomatic (from two days before onset), first phase of symptoms (one-seven days), second phase (eight-14 days) and third phase (> 15 days). Each correct answer was assigned five points for a total of 15 points. The level of knowledge of etiopathogenesis, clinical characteristics, and diagnostic tests of COVID-19 was obtained by adding a maximum score of 66 points with all correct answers.
For the analysis of the information, the data were tabulated and analyzed in the SPSS version 20 program (IBM Chicago, USA). Demographic data and prevalence of COVID-19 positive individuals were obtained. The independent variables were grouped into three domains: 1) professional experience, 2) perceptions regarding COVID-19, and 3) knowledge of COVID-19 (included four variables: knowledge of etiopathogenesis, clinical data, diagnostic tests, and total score) of the variables of this last domain the minimum and maximum values, means and standard deviations were obtained. The dependent variable was COVID-19 positivity. For the inferential analysis, χ2 tests were performed to determine associations of positive cases with demographic data, professional experience, and perceptions regarding COVID-19. Finally, differences in positivity according to knowledge were evaluated using Mann-Whitney U tests. For all cases, values of p ≤ 0.05 were considered statistically significant.
RESULTS
A total of 847 subjects were surveyed, 643 female, 203 male, and one intersex. Of these, 723 were dental students and 124 were dentists. The prevalence of COVID-19 in the sample studied was 37.1% (314 of 847 cases). However, not all of them had a confirmatory test, fragmenting the prevalence as shown in Table 2. Among students, the percentage of confirmed positivity was 6.8%, the majority reported a possible route of infection in the family environment (29 of 49 cases) and there was a report of 31.5% of suspected cases, with 128 of 228 cases acquired in the family environment and 68 cases of not knowing the possible route of infection. For the case of dentists, there is a report of 12.2% of confirmed positivity, 17.7% of suspicion, with five of 15 cases respectively acquired in the family environment and two of 15 cases respectively acquired during clinical practice.
Most of the respondents had an age range of 20 to 22 years and lived mainly in San Luis Potosi, Mexico City (CDMX), Guanajuato, Sinaloa, Veracruz, and the State of Mexico. The analysis of the complete demographic data is presented in Table 2. Of the 723 dental students or dental interns and specialty students, 562 were women, 160 were men and one was intersex, the majority between 20 and 22 years of age, residents of the state of San Luis Potosi (47.4%), Mexico City, Sinaloa, Veracruz, and Guanajuato. Of the 124 dentists, 81 were women and 43 were men, the majority between 34 and 44 years of age, residents of San Luis Potosí, Guanajuato, CDMX, Oaxaca, and Puebla. Most of them had a specialty, more than 20 years of professional experience, and were in private practice.
Regarding perception (Table 3), most of the respondents perceived that their level of information about the disease is sufficient, they perceive a very likely risk of being infected by SARS-CoV-2 during their clinical practice, as well as that the patient can also be infected by SARS-CoV-2 during the dental consultation. In addition, the dominant feeling for respondents during this pandemic was anxiety. Respondents' knowledge regarding COVID-19 was variable according to the topic, mean scores are shown in Table 4.
Inferential statistics. No differences of positive and negative cases were observed about age, gender, or residence. But of the 314 positive cases, 295 were between 17 and 33 years old. Regarding professional experience, a difference was found between positive and negative cases when compared with the degree of studies (Fisher's exact test p = 0.043), with more positive cases in students than in dentists. The rest of the variables in this domain did not present differences, however, the time of professional experience (Pearson's χ2 p = 0.075), the specialty (Pearson's χ2 p = 0.075), and the type of clinical practice (Pearson's χ2 p = 0.051), presented borderline differences.
Regarding professional experience, it was observed that most of the positive cases were concentrated in professionals with one to five years of experience and also in those with 20 or more years (Figure 1). The specialties with positive cases were prosthodontics, endodontics, and pediatric dentistry. In addition, it was observed that the vast majority of positive cases were found among dentists in private practice (Figure 2).
Regarding the perceptions regarding COVID-19, the only associated variable was the possible route of contagion (Pearson's χ2 p < 0.001). It is noteworthy that most of the positive cases reported having been infected in the family environment and not in clinical activity. Comparisons concerning knowledge of COVID-19 showed differences in knowledge of clinical data, diagnostic tests, and total scores. This was not the case for etiopathogenesis, which could explain the positivity (Table 4). It is important to note that the means of knowledge are higher in positive cases when compared to negative cases, which would indicate that knowledge in specific areas of the COVID-19 context may translate into the development of confidence that derives from the risk of infection.
DISCUSSION
Patients or dental personnel themselves, including students, may present with a series of presumptive symptoms of SARS-CoV-2 infection. In the pandemic context and view of the great dynamism presented by COVID-19 during 2021, it is important to adequately define the symptoms to establish guidelines and containment measures for the cases that require it. The review presented in Table 113-29 complies with this concept; however, it should be updated as the pandemic progresses.
Knowledge of etiopathogenesis, symptomatology, and diagnostic tests were assessed according to those reported in the literature, as well as the perception of COVID-19. They were also asked whether they have had COVID-19 with either a laboratory result or high suspicion (with or without symptoms plus close contact with a positive family member). The voluntariness, anonymity, and clear explanation of the objectives of the study to the respondents give a high degree of certainty to what was reported. Let us remember that health policies in Mexico have resulted in one of the lowest SARS-CoV-2 virus detection rates in the world,30 which makes it very likely that the real statistics of the cases of contagion will never be known. Our results represent the first report of COVID-19 cases in dental students and dentists. We reported 314 cases of infection or high suspicion out of a population of 847 (39.1%), representing more than one-third of this population. The prevalence of confirmed SARS-CoV-2 positivity for students was 6.8% and for highly suspected cases it was 31.5%, the vast majority reported the family environment as a possible route of infection, for dentists the prevalence of confirmed cases was 12.1%, and for suspected cases, it was 17.7%. If we add the cases of confirmed positivity and suspected cases we have a prevalence for students of 38.3% and dentists of 29.9%. In the case of dentists, the prevalence of cases associated with clinical practice was 10.8% of the positive cases (confirmed or suspected) and in the case of students, eight cases were reported of students who were working in an office and reported clinical activities as a possible route of infection, which represents 2.8% of the total number of positive cases (confirmed or suspected). In this regard, the prevalence of cases associated with clinical practice is a cause for concern; there are very little data on this subject, the most important reference being the study carried out in the USA, where a prevalence of 0.9% was reported for 2,195 dentists studied.31 However, the results on the perception of the risk of infection indicate that most of the population studied perceive a high risk of being infected by SARS-CoV-2 during their clinical practice, as well as a high risk for the patient during the consultation.
In addition to the above, in the total population studied, which includes dentists and dental students, we have observed a high risk of infection (37.1% of the total population with positive or suspected infection), so these results should trigger public policies and higher education institutions to increase efforts to reduce this high number of cases, considering that this increases the likelihood of infecting patients during clinical practice and also remember that health personnel in Mexico have the highest mortality rate in the world.32
Our results indicate that having less professional experience has been a determining factor in the increased risk of infection with COVID-19, so that information and knowledge about the etiopathogenesis of the disease and the most frequent symptoms, as well as the correct application of the tests are very important to reduce the risk of infection during clinical practice, not only within the professional environment but also among patients.
Young people between 17 and 33 years of age were the group most affected in cases of infection in our study population, this can be explained in the context that they are the age group most reported among the asymptomatic or mild cases and therefore form the bulk of the cases with the least containment, which means that they will be infecting a large number of people during their infection, so information should be reinforced to increase knowledge about the disease, with the consequent change in perception and awareness that will reduce risk procedures and behaviors. After more than a year of the pandemic in our country, the dominant feeling among dental students was anxiety, which coincides with multiple studies around the world.33 While among dentists the most reported feeling was acceptance and tranquility. This should be taken into consideration since anxiety can lead to errors or omissions of preventive measures due to stress, but on the other hand acceptance and tranquility can provide overconfidence in some cases.
According to our results, students have a higher risk of contagion than dentists, this raises two situations, firstly their level of knowledge should be increased; and secondly, as long as these aspects have not been reinforced, the reactivation of clinical activities in universities should be carefully analyzed. On the other hand, we could observe among the professionals, that those who had the highest level of knowledge were the group most affected by COVID-19, this may be due to excessive confidence in their practice, which would explain why this group was the most affected with contagions, it will be necessary to promote the right balance between knowledge, information, and best practices. Among the dentists surveyed we observed that with a professional experience of fewer than five years and more than 20 years more cases of positivity were reported, on one hand, younger age and experience result in a combination of higher risk, in this sense, higher education institutions play a very important role in reversing this condition. While for the older ones it is important to reinforce their continuing professional education and training for timely detection, application of containment measures, and infection control.
Although knowledge of the disease and its timely detection is an opportunity to reduce the risk of contagion,34 this should also increase the application of measures in the family and social environment, since in this study we observed that many positive cases reported referring that the contagion occurred in the family environment, which indicates the need for dental professionals and students to reinforce their measures and actively participate in the health education of patients, family members, and their social environment. It is essential that dentists carry out a thorough screening, that they perform timely detection, and that they are trained to perform and interpret diagnostic tests. In this regard, we propose, as in other countries, that the use of diagnostic tests be incorporated before dental consultation in those patients detected to be at risk of infection.35 The ADA has published the document "COVID-19 & lab testing requirements toolkit", which is a guide for dentists interested in offering their patients timely detection of COVID-19.36
CONCLUSIONS
Based on the results obtained, we conclude that it is essential that dental students of all levels and professionals include in their clinical routines the application of a protocol for the timely detection of cases of COVID-19, in Table 5 we present the proposal in this sense.
REFERENCES
World Health Organization. Clinical management of severe acute respiratory infection (SARI) when novel coronavirus infection is suspected: interim guidance. 2020. Available in: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(NCoV)-infection-is-suspected
Consejo General de Dentistas de España. Protocolo de detección precoz de la infección activa por SARS-CoV-2 en pacientes de clínicas dentales. Consejo dentistas. Organización Colegial de Dentistas de España. 2020. Disponible en: https://www.consejodentistas.es/pdf/coronavirus/PROTOCOLO_DETECCION_PRECOZ_SARS-COV.pdf
Stawicki SP, Jeanmonod R, Miller AC, Paladino L, Gaieski DF, Yaffee AQ et al. The 2019-2020 novel coronavirus (severe acute respiratory syndrome coronavirus 2) pandemic: a joint american college of academic international medicine-world academic council of emergency medicine multidisciplinary COVID-19 working group consensus paper. J Glob Infect Dis. 2020; 12 (2): 47-93.
Mancilla-Galindo J, Vera-Zertuche JM, Navarro-Cruz AR, Segura-Badilla O, Reyes-Velázquez G, Tepepa-López FJ et al. Development and validation of the patient history COVID-19 (PH-Covid19) scoring system: a multivariable prediction model of death in Mexican patients with COVID-19. Epidemiol Infect. 2020; 148: e286.
Secretaría de Salud. Comunicado 255. Secretaría de Salud presenta resultados preliminares de la Encuesta Nacional de Salud y Nutrición COVID-19. 2020. Disponible en: https://www.gob.mx/salud/prensa/255-secretaria-de-salud-presenta-resultados-preliminares-de-la-encuesta-nacional-de-salud-y-nutricion-COVID-19?idiom=es
AFFILIATIONS
1 Facultad de Estomatología, Universidad Autónoma de San Luis Potosí. San Luis Potosí, México.
2 Facultad de Odontología, Universidad De La Salle Bajío. León, Guanajuato, México.
3 Facultad de Odontología, Universidad Nacional Autónoma de México. Ciudad de México, México.
4 Especialidad de Periodoncia, Facultad de Estomatología, Universidad Autónoma de San Luis Potosí. San Luis Potosí, México.
5 Comisión de Control de Infecciones y Laboratorio de Bioquímica y Microbiología. Facultad de Estomatología, Universidad Autónoma de San Luis Potosí. San Luis Potosí, México.
CORRESPONDENCE
Luis Octavio Sánchez Vargas. E-mail: octavio.sanchez@uaslp.mxReceived: Septiembre 2021. Accepted: Diciembre 2021.