Sri Lankan dental professionals’ knowledge of the Corona Virus Disease-19 (COVID-19): a questionnaire survey
Ruwan Duminda Jayasinghe1a* , Rasika Manori Jayasinghe2b , Pilana Vithanage Kalani Shihanika Hettiarrachchi1c , Lakshman Perera Samaranayake3d
1Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, 20400 Sri Lanka
2Department of Prosthetic Dentistry, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, 20400 Sri Lanka
3Department of Oral Biosciences, Faculty of Dentistry, University of Hong Kong, Hong Kong
aBDS, MS, Professor, Chair; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0002-8054-4301
bBDS, MS, Senior Lecturer, Head; e-mail: email@example.com; ORCIDiD: https://orcid.org/0000-0001-5878-4985
cBDS, MD, Senior Lecturer; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0003-2618-5050
dDSc, DDS (Glas), FRCPath, FDSRCS(Edin), FRACDS, FDS RCPS (Glas), FHKCPath, FCDSHK, Professor Emeritus; e-mail: email@example.com; ORCIDiD: https://orcid.org/0000-0002-9122-336X
Background Dental practitioners are some of the most vulnerable professionals exposed to the risk of contracting the Corona Virus Disease-19 (COVID-19), by virtue of the aerosol generating procedures (AGPs). Hence, an evidence based and detailed knowledge of the disease is important in order to mitigate the effects of the COVID-19 transmission.
Aim To identify the perspective, knowledge, and attitudes of Sri Lankan dental surgeons on the COVID-19 pandemic.
Methods An online web-based, self-administered questionnaire survey (Google) was conducted among Sri Lankan dental surgeons. All questions, in the pre-tested questionnaire were close-ended, and formulated to elicit data on the views, knowledge, attitudes, and infection control practices related to the COVID-19 pandemic.
Results One quarter of the cohort responded and the majority (44.7%) were 30-40 years old with a marginal female preponderance (52.3%). In general, females were significantly more knowledgeable than males on COVID-19, and the post-pandemic preparedness for dental practice (p<0.05). One sixth (18.2 %) incorrectly surmised that, i) pet animals were a source of infection, ii) COVID-19 is not transmitted via surface contact and iii) hand hygiene is not important in preventing infection transmission. All respondents correctly identified AGPs as a high-risk procedure for infection transmission, but approximately two thirds failed to identify specific AGPs in dentistry.
Conclusion Taken together, the knowledge, attitudes and practices of Sri Lankan dental surgeons on the COVID-19 pandemic appear satisfactory, but there are knowledge gaps that need to be fulfilled through further continuous education courses.
Keywords: COVID 19; Dental Practice; Knowledge; Dental Surgeons.
The first case of Corona Virus Disease-19 (COVID-19) caused by the severe acute respiratory syndrome corona virus 2 (SARS‑CoV‑2) was reported in Wuhan, China in December 2019 . Even though scant attention was paid to the disease at the time, within weeks it became a serious health concern leading to an epidemic spread in China, prior to the subsequent pandemic spread the world over. COVID-19 was declared a public health emergency of international concern by the World Health Organization on 30th of January 2020 . As of this writing, in December 2020, the number of COVID-19 cases worldwide has surpassed 75 million, with over 1.6 million deaths . In Sri Lanka, the first case of COVID-19, was reported in a Chinese tourist, in January 2020, and the first, communally transmitted patient reported two months later; at the time of writing (December 2020), Sri Lanka has over 36,000 confirmed cases, with 165 reported deaths. SARS‑CoV‑2 primarily spreads via droplets produced by coughing, sneezing, and talking. When droplets are large and heavy, they usually fall to the ground or onto surfaces, but the smaller particles, called aerosols, are entrained in the air for prolonged periods of approximately 3 hours if the ambient circulation is stagnant [4,5]. A substantial proportion of dental procedures entail aerosol generation due to the high speed instrumentation accompanied by air/water coolants, and hence dentistry is considered a high risk profession in terms of contracting air borne diseases such as COVID-19 . Furthermore, experience from previous epidemics such as the severe acute respiratory syndrome (SARS) has shown the susceptibility of health care providers, including dental health care workers to the risk of possible infection . In order to protect dental professionals, and their patients from COVID-19, many national bodies, including the Sri Lanka Dental Association, have issued guidelines on infection control in dental settings to the profession at large [6,7]. Nevertheless, there has been little follow up after such promulgations and, no feedback elicited from dentists on the adherence to, and implementation of these guidelines in clinical practice. Clearly, such feedback is helpful in rectifying deficiencies, and preparing for future emergencies. Hence the main aim of the current questionnaire survey was to identify the views, knowledge and attitudes of Sri Lankan dental surgeons on the current COVID-19 pandemic through a web-based questionnaire survey. A particular focus of the survey was to evaluate the adherence to the COVID- 19 protective measures and awareness of methods of SARS‑CoV‑2 transmission, infection control precautions that need to be implemented during the pandemic, and the challenges associated with their implementation.
An online web-based questionnaire survey was conducted among dental specialists and dental surgeons in Sri Lanka. Those with access to the World Wide Web, both in the government service and in private practice, were included in the study. A self-administered pre-tested Google form (Appendix 1) was used as the study instrument.
The questionnaire, formulated by the authors (LPS, RJ), was first pre-tested among a group of 10 dental surgeons to ensure clarity of interpretation, and ease of completion by the participants. The questionnaire, of all close-ended questions, compri-sed demographic data and specific questions on the views, knowledge and attitudes of Sri Lankan dental surgeons on the current COVID-19 pandemic. The pre-tested questionnaire was then converted into a Google form and the survey link was disseminated as a Uniform Resource Locator (URL) web address among the cohort, via social media and email. A cover letter was included with the questionnaire, which described the purpose of the study and its outline, and instructions were given on completing the questionnaire; the confidentiality and anonymity of the data provided were assured. The data management and statistical analyses were performed using the statistical software SPSS version 21.0. Frequencies and percentages were obtained for categorical data, and Chi-square test was used to determine the association between variables. P level <0.05 was considered significant). Ethical clearance for the study was obtained from the Ethics Review Committee of the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka.
3.1. Demographic and personal information
The survey was transmitted to a cohort of 1598 dental surgeons, of which 302 (25%) responded. Most respondents were aged 30-40 years (44.7%), with a marginally female preponderance (52.3%). Two thirds of the respondents were dental surgeons (n=120) working in the dental clinics of the Ministry of Health, Sri Lanka, with the rest, though employed by the Ministry of Health, were concurrently enga-ged in private practice. Most of the respondents had only the primary qualification of BDS (n=177) while 45 (15%) also had a postgraduate diploma; 60 were specialists with anMD/ MS degree (Fig. 1). Questioned on the attendance and participation in continuing education programs during the COVID-19 pandemic, a majority (60%) responded in the affirmative. Of these, 74% were respondents younger than 30 (p<0.05).
3.2. Knowledge and belief related to COVID-19 patient identification
The vast majority of the respondents (91%) was aware of the incubation period for SARS-CoV-2 infection as 2-3days, but that it may take up to 21 days. Almost all of the respondents (96%) under 30 provided an accurate response to this question. All participants identified at least one symptom of the infection, while 18% identified all the stated symptoms of the disease. Similarly, 96% of the respondents believed that patients with chronic diseases run a higher risk of contracting COVID-19. Awareness that older populace run a higher risk of contracting the COVID-19 than the younger individuals was also very high (97%) and only 4% (12/ 302) respondents incorrectly believed that the mortality rate for young population is zero (Table 1).
3.3. Knowledge regarding transmission of COVID-19
All respondents were aware that the aerosol generating procedures (AGPs) were a high risk activity for the infection transmission, but only one third (39%), accurately identified that implants placement, scaling and restorative procedures as high risk interventions that may transmit the infection (Table 1).
Surprisingly, a sixth of the respondents (55/302; 18.2 %) incorrectly surmised that, i) pet animals were a source of infection, ii) COVID-19 is not transmitted via surface contact and iii) hand hygiene is not important in preventing infection transmission. Nevertheless, 82% were aware that the infection spreads through droplets or nasal discharge (p<0.05). Further, 93% of the respondents believed that COVID-19 infection can be transmitted through the fluid of an infected person (p<0.05). Nearly 85% have correctly identified 1 meter as the minimum social distance to be kept in order to minimize transmission of infection.
3.4. Preparedness in treating dental patients during and post pandemic period
Most of the participants (92.4%) had purchased personal protective equipment, but two-fifths (40.4%) did not possess N95 masks. Almost two thirds of the respondents (62.3%) had treated emer-gency patients during the peak month from 15th March to 15th April 2020 when Sri Lanka was under the lockdown. One half of the respondents (52.2%) were confident of starting dental practice once the pandemic subsided, whereas 25.2% were hesitant, and 6% were not confident in doing so. Although over 92% have been provided with personal protective equipment (PPE), only 57% had access to N 95 masks during the initial period of the COVID-19 pandemic. All respondents were planning to implement precautions during the post-pandemic practice. The majority were to introduce temperature checks for all patients (88.4%), and the staff (75%), but planned use of reusable gowns per each session and of disposable over wear for both patients and clinicians were low (Fig. 3). Ninety one percent of the respondents felt it is highly important to know the residential area of the patients, while 97.7% thought knowing the patient’s travel history is important before treating them. The highest fear among the respondents to start dental practice was the limited availability of resources for protection such as PPE (Table 2). The answers covering the respondents’ knowledge on the pandemic and the plans in relation to the maintenance of post-pandemic dental practice were analyzed according to their gender, and females almost always responded better than males (p<0.05). In terms of the age group, the plans for triage of the clinic attendees, was highest for the 36- 45 years age group (p<0.05) (Table 3).
The unprecedented COVID-19 pandemic caused by SARS-CoV-2 has taken the world by surprise. It is now clear that aerosols are the main mode of COVID-19 transmission, and dentistry, being an important branch of health care has come under intense scrutiny due to the many AGPs that entail clinical dental practice. Hence, infection control procedures in dentistry have been freshly reviewed with revised guidelines promulgated by various bodies including US Centers for Disease Control . A good awareness and knowledge of the mode of transmission of COVID-19 among dental professionals is essential to implement these guidelines. Although a number of reports are available on the dentists’ awareness of the pandemic and attitudes towards the implementation of clinical guidelines [9,10] no such data are available from Sri Lanka. Hence, we conducted the current electronic, online survey to elicit the knowledge and practices of 1598 dental surgeons and dental specialists working in the public and private sector in Sri Lanka . A pre-tested questionnaire was sent via email to the cohort and open invitations for response were posted in the social media platforms, including Facebook and specific groups created among dental surgeons. Our study demonstrated a relatively poor response rate with only a quarter (25%) of the dental surgeons and specialists responding to the questionnaire. Low response rates are common in electronic questionnaire surveys and non-respondent bias may have affected the outcome of our results. Given this caveat, the findings of our survey shed light on the knowledge of, and attitudes to infection control in Sri Lankan dental surgeons during the pandemic period. Overall, a large majority of respondents had envisioned and anticipated the impact of COVID-19 on their clinical practices, as they demonstrated a very satisfactory knowledge of the disease symptomatology and preventive measures. It was encouraging to note that most of them attended webinars to improve their knowledge of COVID-19, in contrasts to a recent similar study from Turkey that has shown low attendance rates at continuing education courses by dentists .
Prevention of COVID-19 is mainly achieved by proper hand washing, social distancing and by respiratory protective measures such as the use of face masks/face shields . In contrast to the findings of other similar surveys [10,12], almost a fifth of our respondents incorrectly mentioned that hand hygiene is not important in preventing infection and pet animals are a major source of infection. Personal protective equipment (PPE) is an essential prerequisite for the safe delivery of dental care, as well as for the protection of the dental surgeon and the dental team. A number of organizations including the US Centers for Disease Control  and the Sri Lanka Dental Association  have emphasized the importance of PPE in dentistry. PPE include gloves, respirators or face masks, face shields or goggles and protective clothing . Most of the respondents (92.4%) in our survey had purchased PPE, but only 60% had N95 masks. This is better than the figures reported in similar studies on Indian and Turkish dentists, respectively [12,15]. As fever is one of the demonstrable early symptoms of COVID-19, dental health care providers must as a routine, measure the patients’ body temperature as well as those of his staff and him/herself, prior to entering the clinic premises . The majority were aware of this recommendation as 80% were planning to measure the temperature of the patients, and 65% in both the patients as well as the staff.
As a health care worker, it is the solemn duty of a dental surgeon to provide essential and emergency care to patients, irrespective of the pandemic circumstances. Hence it was heartening to note that some two thirds of the respondents (62.3%) managed patients with dental emergencies during the island-wide, lock-down period in Sri Lanka (from 15th March to 15th April 2020). This is in contrast to only one fifth of the dentists (22.8%) in India who rendered such emergency services during a similar lock-down period in India .
It is the general consensus that COVID-19 pandemic is unlikely to subside in the immediate term, and is likely to smolder, and remain as an endemic disease in most regions of the world for the foreseeable future. Yet, dental professionals, like all other similar care providers, need to maintain their services to the public while taking the necessary precautions to minimize infection spread. Due to the high levels of morbidity and mortality associated with COVID-19, there is nevertheless a reluctance, fear and anxiety amongst dentists to return to work, as shown in some recent studies [9,15]. This was clearly expressed in our survey, as one fourth of responding dental surgeons were hesitant to start their post-pandemic dental practice in the short term, and 6% were not confident in doing so at all. However, it was heartening to note that approximately, one half of the respondents (52.4%) were very confident in returning to work after the lock-down period. This number is significantly higher than the figure reported by Kinariwala et al., where 54.3% of respondents in their study were not confident, and 35.7% were hesitant to commence their post-pandemic dental practices . In addition, the availability of COVID-19 vaccines in the near future, for countries such as Sri Lanka, should help improve the prospects of dentists returning to work without much ambivalence.
In general, the knowledge, attitudes and practices of Sri Lankan dental surgeons on the COVID-19 pandemic appear satisfactory but there are significant gaps in their knowledge that need to be addressed such as the knowledge on the method of transmission. Highest fear among the respondents was limited availability of resources to practice dentistry. Health authorities and professional associations need to consider these factors when preparing guidelines for the management of patients in the dental clinics during the pandemic. Gender as well as educational qualifications-related differences were
noted in some responses. Our survey highlights the importance of continuing education and further educational programs on COVID-19 for dental professionals in Sri Lanka.
Conflict of Interest
The authors declare no conflict of interest.
We like to thank all the dental surgeons who helped disseminate and respond to the questionnaire during a difficult period.
RDJ: plan the study, plan the questionnaire and assisted in data collection and did the first draft. RMJ: was involved with the data collection, preparation of questionnaire, statistical analysis and finalizing the manuscript. PKH: was involved with the data collection, preparation of questionnaire and finalizing the manuscript. LPS: came up with the idea, assisted in preparation of questionnaire, supervise the project and assisted in finalizing the manuscript.
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