BACKGROUND
In December 2019, a novel infection started in Wuhan province in China (1). It is believed that this new coronavirus (2019-nCov) infection has a zoonotic origin and is likely to have started in a wet market where wild animals were sold for human consumption (2). Three months after the first reports about this
new infection, the World
Health Organization (WHO) announced a global pandemic emergency (March 2020) (1).
By July 3,
2020, the pandemic status was such that the virus had reached 216 countries or
territories; around 11 million people had been infected by COVID-19; and it had
led to around half a million confirmed deaths (3,4). Jordan
reported its first COVID-19 case on March 2, 2020 (5). According to
the Jordanian Ministry of Health statistics, by June 17, 2020, 987 people had
the infection; 9 people had died due to the COVID-19 infection (6).
The
Jordanian COVID-19 prevention measures started with awareness messages issued
to the public, followed by a complete lockdown on March 21, 2020 (7). During the
lockdown, only emergency dental cases were treated at specific dental clinics
across the kingdom (8).
However, by the end of April, the Jordanian authorities had started to withdraw
lockdown measures gradually, and dental clinics resumed their activities (8), implementing
precise infection-control measures, such as social distancing in waiting areas,
temperature measurement, limits imposed on patient companions and health
workers’ use of personal protective equipment (PPE) (8,9). A recently
published study found that around 70% of dental patients in the United States
were not comfortable visiting a dental clinic during the COVID-19 pandemic,
although 42% of these reported that they trust the precautions taken by their
dentist to prevent the spread of COVID-19 (10).
It
is well known that dentistry is a high-risk industry in terms of transmission
of SARS-CoV-2 (11).
Due to the unique nature of dental procedures, contaminated aerosols can
develop and spread from high-speed handpieces and other dental instruments (12). Therefore,
regular dental infection-control procedures are not sufficient to protect
dentists and patients from COVID-19 (13).
The
new era of dental care is likely to bring new innovative procedures, equipment
and treatments, enabling safe dental care to resume and minimizing the risk of
exposure to COVID-19, even with close proximity between dentists and their
patients (11,14,15).
A
previous Jordanian study showed a high COVID-19 awareness level among Jordanian
dentists, but it reported limited comprehension of the protection measures
required during the pandemic (9). To
the best of our knowledge, no previous research has studied COVID-19
perceptions among Jordanian dental patients.
The
main objectives of this study were to explore Jordanian dental patients attitudes towards COVID-19 infection-control
procedures; to investigate patients’ trust in dentists’ knowledge about
COVID-19 prevention; and to explore dental care-seeking behavior during and
after the COVID-19 pandemic.
METHODS
This study is a descriptive
cross-sectional survey of a sample of dental patients who were invited to
participate in this research at King Hussein Medical Center. The principal
investigators developed a structured questionnaire based on a previously published
research during the COVID-19 pandemic. Data were collected in June 2020 by a
self-administered questionnaire consisting of 17 closed questions. The
questions were designed to collect data on the following: preventative measures
implemented in dental clinics; and patients’ attitudes towards prevention
measures. (Table I) shows the translated questionnaire.
Table I. Study questionnaire
|
Question
|
Answers
|
|
Age
|
o
20–29
|
|
|
o
30–39
|
|
|
o
40–49
|
|
|
o
≥50
|
|
Gender
|
o
Male
|
|
|
o
Female
|
|
Educational level
|
o
Elementary
school
|
|
|
o
Secondary
school
|
|
|
o
University
education
|
|
In your opinion, how do you rate the risk of transmission of this
virus at dental clinics?
|
o
High
|
|
o
Moderate
|
|
|
o
Low
|
|
|
o
No risk
|
|
Are you afraid to visit a dental clinic during the current
pandemic?
|
o
Yes
|
|
o
No
|
|
Have you visited a dental clinic in an emergency only?
|
o
Yes
|
|
|
o
No
|
|
Are you aware that Royal Medical Services dental clinics only
accept emergency cases?
|
o
Yes
|
|
o
No
|
|
Did you try to visit a Royal Medical Services dental clinic
during the lockdown period?
|
o
Yes
o
No
|
|
If yes, which transportation method did you use?
|
o
Private car
|
|
|
o
Public
transport
|
|
Do you believe that the protection procedures implemented
in Royal Medical Services dental clinics are enough to prevent
the spread of this infection?
|
o
Yes
|
|
o
No
|
|
Do you think that the dentist has enough knowledge about
protection methods?
|
o
Yes
|
|
o
No
|
|
Do you think that there is a need to implement additional
procedures for infection control?
|
o
Yes
|
|
o
No
|
|
Is it important to have physical distancing in the waiting area?
|
o
Yes
|
|
|
o
No
|
|
Is it ok to delay routine dental visits as a public safety
measure and for infection control?
|
o
Yes
|
|
o
No
|
|
Do you think that triaging a patient before entering
the OPD is a useful procedure?
|
o
Yes
|
|
o
No
|
|
Would you prefer to go back to the previous (normal) situation
regardless of the risk of spreading the infection?
|
o
Yes
|
|
o
No
|
The study
inclusion criteria required all participants to be literate dental patients
seeking dental care at a King Hussein Medical Center Dental Clinic and to be
native Arabic speakers. Anonymous data were numerically coded and entered into
an Excel spreadsheet (Microsoft® Office Excel). The data were then analyzed
using SPSS statistical data-analysis software (IBM Corporation, version 25.0).
Data analysis was performed using a Pearson’s chi-square (χ2) test or Fisher’s
exact test, and data were interpreted as statistically significant when a
p-value was less than 0.05.
Ethical
approval for the research was obtained from the Research Ethics Committee of
the Jordanian Royal Medical Services. A briefing about the purpose of the study
was given to the patients by the investigators, and verbal voluntary informed
consent was obtained from all participants. No identifying data were collected.
This research was carried out in accordance with the Helsinki Declaration.
RESULTS
Five hundred dental patients agreed to
participate in this research study. Demographic details of the study
participants are presented in (Table II). Around half of the participants were
female patients, and 72.6% of the participants were between 20 and 39 years
old. The most frequently occurring educational level (53.3%) was high-school
education, followed by university education (38.2%).
Table II: Characteristics of study participants
|
|
|
N
|
%
|
|
Age (in years)
|
20–29
|
200
|
40.0
|
|
|
30–39
|
163
|
32.6
|
|
|
40–49
|
79
|
15.8
|
|
|
≥50
|
58
|
11.6
|
|
Gender
|
Male
|
217
|
43.4
|
|
|
Female
|
283
|
56.6
|
|
Educational level
|
Elementary
school
|
43
|
8.6
|
|
|
Secondary
school
|
265
|
53.2
|
|
|
University
education
|
190
|
38.2
|
Almost half of
all study participants perceived dental clinics as a high-risk place for
COVID-19 transmission. The difference in perceived COVID-19 transmission risk
at dental clinics was not statistically significant in terms of the gender or
age group of participant’s p-value 0.0162 and 0.053, respectively (Table III).
Table III: Perception
of COVID-19 risk at dental
|
|
|
High Risk
|
Moderate Risk
|
Low Risk
|
No Risk
|
P-value
|
|
|
|
N
|
%
|
N
|
%
|
N
|
%
|
N
|
%
|
|
|
Overall
|
|
246
|
49.2
|
146
|
29.2
|
74
|
14.8
|
34
|
6.8
|
|
|
Age (in years)
|
20–29
|
100
|
50.0
|
63
|
31.5
|
22
|
11.0
|
15
|
7.5
|
0.053
|
|
|
30–39
|
82
|
50.3
|
49
|
30.1
|
26
|
16.0
|
6
|
3.7
|
|
|
|
40–49
|
37
|
46.8
|
24
|
30.4
|
14
|
17.7
|
4
|
5.1
|
|
|
|
≥50
|
27
|
46.6
|
10
|
17.2
|
12
|
20.7
|
9
|
15.5
|
|
|
Gender
|
Male
|
100
|
46.1
|
60
|
27.6
|
38
|
17.5
|
19
|
8.8
|
0.162
|
|
|
Female
|
146
|
51.6
|
86
|
30.4
|
36
|
12.7
|
15
|
5.3
|
|
|
Educational level
|
Elementary school
|
22
|
51.2
|
10
|
23.3
|
9
|
20.9
|
2
|
4.7
|
0.014
|
|
|
Secondary school
|
115
|
43.4
|
83
|
31.3
|
40
|
15.1
|
27
|
10.2
|
|
|
|
University education
|
107
|
56.3
|
53
|
27.9
|
25
|
13.2
|
5
|
2.6
|
|
Similarly,
46.1% and 51.6% of male and female patients, respectively, reported a high risk
of COVID-19 transmission at dental clinics. On the other hand, 10.2% of
participants with a secondary-level education reported no risk of COVID-19
transmission at dental clinics, compared with 4.7% and 2.6% of participants
with an elementary-level and university-level education. Differences in
perceived risk in relation to educational level between study participants was
statistically significant (p-value 0.014).
Seven
out of ten participants reported being afraid of visiting a dental clinic
during the COVID-19 pandemic, and eight in 10 reported visiting a dental clinic
only in an emergency. Around a quarter of interviewed patients reported trying
to visit a dental clinic during the lockdown period. Meanwhile, eight in 10
patients reported that they believe in the protection procedures in place at
Royal Medical Services dental clinics, and 9 in 10 trust their dentist’s
knowledge about protection methods. Nevertheless, 76.2% of participants
reported that there is a need for additional COVID-19 protection procedures in
dental clinics, and 94.4% believe in the importance of social distancing in the
waiting areas of dental clinics. In the same way, 83.2% believe that it is
acceptable to delay routine dental visits during the lockdown period, and 85%
perceive that triage procedures (measuring temperature) at the OPD entrance is
an effective procedure to guard against COVID-19 transmission. On the other
hand, 4 in 10 patients would prefer to go back to the normal situation (as it
was before the COVID-19 pandemic) (Table IV).
Table IV: Patients’ dental care-seeking behaviors
during the COVID-19 pandemic and perceptions of protection measures
|
|
N
|
%
|
|
·
Afraid of
visiting a dental clinic during the current pandemic
|
352
|
70.5
|
|
·
Visited the
dental clinic only in an emergency
|
388
|
77.8
|
|
·
Knew that
Royal Medical Services dental clinics only accept
emergencies
|
342
|
68.4
|
|
·
Tried to
visit a Royal Medical Services dental clinic during the
lockdown period
|
138
|
27.6
|
|
·
Believe that
the protection procedures at dental clinics are
sufficient
|
386
|
77.5
|
|
·
Think that
the dentist has enough knowledge about
COVID-19 protection
methods
|
455
|
91.0
|
|
·
Think that
there is a need to implement additional protection
procedures
|
380
|
76.2
|
|
·
Think that it
is important to have physical distancing in the
waiting area
|
472
|
94.4
|
|
·
Believe that
it is ok to delay routine dental visits
|
416
|
83.2
|
|
·
Think that
triaging patients before entering the OPD is a useful
procedure
|
425
|
85.0
|
|
·
Would prefer
to go back to the previous (normal) situation
regardless of the risk of spreading the infection
|
199
|
39.8
|
Lastly, a multivariate analysis showed that patients educated to
university level were more afraid of visiting a dental clinic, compared with
patients educated to elementary level (after controlling for other variables)
(p-value 0.036). Meanwhile, gender and age group were not significantly
associated with being afraid of visiting a dental clinic. (Table V) shows the
results of the logistic regression model for factors associated with being
afraid of visiting a dental clinic during the COVID-19 pandemic.
Table V: Factors associated with patients being afraid of visiting dental
clinics during the COVID-19 pandemic (results of logistic regression analysis)
|
Variable
|
|
Odds Ration
|
P-value
|
|
Age (in years)
|
20–29
30–39
40–49
≥50
|
Reference
1.3
0.9
0.6
|
0.318
0.823
0.072
|
|
|
|
|
|
|
|
Gender
|
Male
Female
|
Reference
0.9
|
0.776
|
|
|
|
Educational level
|
Elementary school
Secondary school
University education
|
Reference
1.5
2.3
|
0.269
0.036*
|
|
|
|
|
*
Significant at α < 0.05 level
DISCISSION
During their practice, dentists and
maxillofacial surgeons come into close proximity with their patients (16–18). Usually,
dental interventions are aerosol-generating procedures which present a high
risk due to the possibility of contaminated saliva and blood ejectors (1,19,20). Previous
studies have reported that dental clinics are associated with a high risk of
SARS-CoV-2 nosocomial infection (16,21,22). In addition,
this infection presents a particularly high-level occupational hazard for
dental practitioners (19,21,23).
Therefore, it is not surprising that half of the study participants perceived
dental clinics as a high-risk place in terms of transmission of COVID-19. Sun
et al. reported similar risk perception among parents of pediatric dental
patients in China (24).
However, it seems that patients educated to secondary level might have lower
perceptions of COVID-19 risk, so they might benefit from targeted
awareness-raising activities.
Widespread
modern media messages may seem to be providing plenty of public information
about SARS-CoV-2 incubation periods and common symptoms (24,25). Not knowing
the mode of SARS-CoV-2 transmission could jeopardize infection-control efforts
in dental clinics because patients play a significant role in applying certain
infection-control procedures, such as handwashing, wearing face masks and
social distancing (19,23).
During
the COVID-19 lockdown period in Jordan and other countries, all routine dental
visits were cancelled, and only emergency dental services were available. The
participants in our study indicated that they support delayed routine visits.
An American study reported that 43% of patients had delayed their visits to
dental clinics (10,26).
However, the same American study showed a lower level of trust in dentists’
procedures for COVID-19 prevention. In the USA, only 42% of the studied
population reported that they trusted dentists’ protection measures, compared
with 78% of Jordanian patients reporting that the protection procedures in
dental clinics are sufficient to protect people from COVID-19 (10,18). Furthermore,
it seems that Jordanian patients have a very high level of trust in their
dentist’s knowledge regarding COVID-19 (91%). This high level of trust should
be maintained by keeping dental teams up to date with COVID-19 developments (27). Fortunately,
a recent social media survey has shown that Jordanian dentists are well
informed about COVID-19 (9,28).
On
the other hand, delaying seeking emergency dental treatment could have negative
consequences (such as development of complications), which could potentially be
life-threatening if there is a risk of airway obstruction (18,29,30). Therefore,
emergency cases (such as maxillofacial injuries or dental abscesses not
responding to drug management) should be encouraged to seek urgent dental care,
and primary dental practitioners could have a crucial role in triaging and
referring these urgent cases to timely dental care (1,15,16).
Several
attempts have been made to introduce new procedures and protocols in order to
provide safe dental care during the COVID-19 pandemic (1). The general
theme of these procedures is to focus on the use of PPE, changes in dental
clinic structures (e.g., use of new equipment or minimizing use of high-speed
handpieces), having 30-minute slots between dental appointments and fresh air
ventilation (21,23).
Further measures such as social distancing in waiting areas (or totally
abolishing the waiting area concept) and rapid COVID-19 tests (31) are also
encouraged. Lastly, teledentistry has plenty of potential in terms of providing
effective remote care, which could eliminate the risk of COVID-19 transmission.
This could be used for triage purposes and to provide dental consultations,
follow-up care for patients and other benefits (16,27,32).
The
convenient sampling method used in this study could limit the generalizability
of the findings. However, to the best of our knowledge, this study is one of
the very first studies to explore dental patients’ knowledge about COVID-19 and
attitudes towards seeking dental care during the pandemic.
CONCLUSION
Dental patients in king Hussein medical Centre strongly support the new
protection measures that were implemented to minimize the risk of SARS-CoV-2
transmission, and they have high levels of trust in dentists’ knowledge
regarding COVID-19. Most dental patients perceive visiting a dental clinic to have
a high degree of risk in terms of SARS-CoV-2 transmission. One out of four
patients think that there should be even more protection procedures in dental
clinics. The dental industry is expected to enter a new era with ‘a new normal’
regarding protection measures (11,31).
Patients’ involvement and the use of new technology and innovations could
provide effective and practical solutions to the challenges associated with
dental care during and after the COVID-19 pandemic (24,32).
REFERENCES
1 .Naqvi K, Mubeen
SM, Ali Shah SM. Challenges in providing oral and dental health services in
COVID-19 pandemic. J Pak Med Assoc. 2020 May;70(Suppl 3)(5):S113–7.
2 .Ranganathan
K, Smitha T. COVID - 19 fact sheet for the dental professional. J Oral
MaxillofacPathol. 2020;24(1):8.
3 .Suryakumari
VBP, Pallavi Reddy Y, Yadav SS, Doshi D, Surekha Reddy V.
Assessing Fear and Anxiety of Corona Virus among Dental Practitioners. Disaster
Med Public Health Prep. 2020 Sep 11;1–16.
4 . Rahman
Oany A, Mia M, Pervin T, Junaid M, Zahid Hosen SM, Moni MA. Design of novel
viral attachment inhibitors of the spike glycoprotein (S) of severe acute
respiratory syndrome coronavirus-2 (SARS-CoV-2) through virtual screening and
dynamics. International Journal of Antimicrobial Agents. 2020 Sep 25;106177.
5 .Samrah
SM, Al-Mistarehi A-HW, Ibnian AM, Raffee LA, Momany SM, Al-Ali M, et al. COVID-19 outbreak in
Jordan: Epidemiological features, clinical characteristics, and laboratory
findings. Annals of Medicine and Surgery (2012). 2020 Sep;57:103–8.
6 .Olaimat AN,
Aolymat I, Elsahoryi N, Shahbaz HM, Holley RA. Attitudes,
Anxiety, and Behavioral Practices
Regarding COVID-19 among University Students in Jordan: A Cross-Sectional
Study. Am J Trop Med Hyg. 2020;103(3):1177–83.
7 .Khatatbeh M.
Efficacy of Nationwide Curfew to Encounter Spread of COVID-19: A Case From
Jordan. Frontiers in Public Health. 2020;8:394.
8 .Odeh ND,
Babkair H, Abu-Hammad S, Borzangy S, Abu-Hammad A, Abu-Hammad O.
COVID-19: Present and Future Challenges for Dental Practice. Int J Environ Res
Public Health. 2020 30;17(9).
9 .Khader Y, Al
Nsour M, Al-Batayneh OB, Saadeh R, Bashier H, Alfaqih M, et al.
Dentists’ Awareness, Perception, and Attitude Regarding COVID-19 and Infection
Control: Cross-Sectional Study Among Jordanian Dentists. JMIR Public Health
Surveill. 2020 Apr 9;6(2):e18798.
10 .Today D.
COVID-19 Leaves Patients Concerned About Dental Care [Internet]. [cited 2020
Jun 20]. Available from:
https://www.dentistrytoday.com/news/industrynews/item/6304-covid-19-leaves-patients-concerned-about-dental-care
11 .Proffitt E.
What will be the new normal for the dental industry? Br Dent J. 2020
May;228(9):678–80.
12
.Pethani AS, Allana RR, Hussain M. Emerging
Challenges and Threats for Dental Health Care Sector Attributable to COVID-19:
Tale of a Developing Country. Asia Pac J Public Health. 2020 Jun
4;101053952093270.
13
.Spicciarelli V, Marruganti C, Viviano M, Baldini N, Franciosi G, Tortoriello
M, et al. A new framework to identify dental emergencies in the COVID-19
era.J Oral Sci [Internet]. 2020 [cited 2020 Jun 20]; Available from:
https://www.jstage.jst.go.jp/article/josnusd/advpub/0/advpub_20-0208/_article
14 .Ather A,
Patel B, Ruparel NB, Diogenes A, Hargreaves KM.
Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care. J
Endod. 2020 May;46(5):584–95.
15 .Alharbi A,
Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic.
The Saudi Dental Journal. 2020 May;32(4):181–6.
16 .Bhanushali
P, Katge F, Deshpande S, Chimata VK, Shetty S, Pradhan D.
COVID-19: Changing Trends and Its Impact on Future of Dentistry. International
Journal of Dentistry. 2020 May 29;2020:1–6.
17
.González-Olmo MJ, Ortega-Martínez AR, Delgado-Ramos B, Romero-Maroto M,
Carrillo-Diaz M. Perceived vulnerability to Coronavirus infection: impact on
dental practice. Braz oral res. 2020;34:e044.
18 .Ren YF,
Rasubala L, Malmstrom H, Eliav E. Dental Care
and Oral Health under the Clouds of COVID-19. JDR Clin Trans Res.
2020;5(3):202–10.
19 .Gurzawska-Comis
K, Becker K, Brunello G, Gurzawska A, Schwarz F.
Recommendations for Dental Care during COVID-19 Pandemic. JCM. 2020 Jun
12;9(6):1833.
20 .Izzetti R,
Nisi M, Gabriele M, Graziani F. COVID-19
Transmission in Dental Practice: Brief Review of Preventive Measures in Italy.
J Dent Res. 2020;99(9):1030–8.
21 .Zhang X, Qi
Ling J. Guidelines on the Prevention and Control of Disease in Dental Practice
during the Coronavirus Outbreak. Chinese
Journal of Dental Research. 2020 Jun 16;23(2):89–94.
22 .Falahchai
M, BabaeeHemmati Y, Hasanzade M. Dental care
management during the COVID-19 outbreak. Spec Care Dentist. 2020 Sep 19;
23 .Amato A,
Caggiano M, Amato M, Moccia G, Capunzo M, De Caro F.
Infection Control in Dental Practice During the COVID-19 Pandemic. Int J
Environ Res Public Health. 2020 02;17(13).
24 .Sun J, Xu
Y, Qu Q, Luo W. Knowledge of and attitudes toward COVID-19 among parents of child
dental patients during the outbreak. Braz oral res. 2020;34:e066.
25 .Wadia R.
Transmission routes of COVID-19 in the dental practice. Br Dent J.
2020;228(8):595.
26 .Peloso RM,
Pini NIP, SundfeldNeto D, Mori AA, Oliveira RCG de, Valarelli FP, et al. How
does the quarantine resulting from COVID-19 impact dental appointments and
patient anxiety levels? Brazilian oral research. 2020;34.
27
.Yeung CA. Provision of dental hospital services during the COVID-19 epidemic.
Evid Based Dent. 2020 Jun;21(2):63–63.
28 .Al-Ansari
A. Dentists thoughts about COVID-19. Evid Based
Dent. 2020 Jun;21(2):60–1.
29 .Abramovitz
I, Palmon A, Levy D, Karabucak B, Kot-Limon N, Shay B, et al. Dental
care during the coronavirus disease 2019 (COVID-19) outbreak: operatory
considerations and clinical aspects. Quintessence Int. 2020;51(5):418–29.
30
.Meng L, Hua F, Bian Z. Coronavirus Disease 2019
(COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent
Res. 2020;99(5):481–7.
31
.Madurantakam P. How can dentistry get back to work safely? Evid Based Dent. 2020
Jun;21(2):48–48.
32
.Ghai S. Teledentistry during COVID-19 pandemic. Diabetes & Metabolic
Syndrome: Clinical Research & Reviews. 2020 Sep;14(5):933–5.