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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 9  |  Page : 1391-1396

The Impact of Restarting the High-Risk Procedures for COVID-19 Infection in Dental Practice on the Anxiety of Dental Employees: A Study with Repeated Measures


1 Department of Endodontics, Faculty of Dentistry, Yuzuncu Yil University, Van, Turkey
2 Department of Psychiatry, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey; School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands

Date of Submission23-Nov-2020
Date of Acceptance28-Jan-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. U Kirli
Department of Psychiatry, Faculty of Medicine, Yuzuncu Yil University, Van

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_659_20

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   Abstract 


Background: As SARS-CoV-2 is detected in the infected patients' saliva, dental employees performing aerosol-generating procedures are at high risk of being infected/spreading the infection. Aims: This study aimed to assess the impact of restarting the high-risk procedures for COVID-19 infection in dental practice during the pandemic on the anxiety levels of dental employees. Methods: All dental employees (dentists, nurses, data entry/cleaning staff) working in a university dental clinic were invited to the study and eighty-one employees (response rate: 97.5%) participated in the study. The volunteers' anxiety was measured consecutively twice with the State-Trait Anxiety Scale: First, on the day prior to restarting the high-risk procedures and the second, on the day these procedures began. Data were analyzed using t tests and the repeated measures ANOVA. Results: The state anxiety level of the dental employees increased significantly on the day that the high risk procedures were restarted (mean 42.6 vs. 49.0, d = 0.6, P < 0.001). Concerning the subgroups, the increase in state anxiety levels was significant for females (t = 3,7; d = 0,8; P < 0.001), dentists working in departments of endodontics and restorative dental care (t = 3,5; d = 0,9; P < 0.001) and nurses (t = 2,8; d = 0,9; P < 0.001). The analysis showed no significant difference in trait anxiety levels between the assessment days (mean 44.0 vs. 44.2, P = 0.9). Conclusions: Restarting the high-risk procedures for COVID-19 infection in dental practice during the pandemic seems to be an extra stressor for dental employees' who already have high anxiety levels during the pandemic.

Keywords: Anxiety, COVID-19, dental staff, normalization period, prospective studies


How to cite this article:
Kirli M C, Kirli U. The Impact of Restarting the High-Risk Procedures for COVID-19 Infection in Dental Practice on the Anxiety of Dental Employees: A Study with Repeated Measures. Niger J Clin Pract 2021;24:1391-6

How to cite this URL:
Kirli M C, Kirli U. The Impact of Restarting the High-Risk Procedures for COVID-19 Infection in Dental Practice on the Anxiety of Dental Employees: A Study with Repeated Measures. Niger J Clin Pract [serial online] 2021 [cited 2022 Nov 29];24:1391-6. Available from: https://www.njcponline.com/text.asp?2021/24/9/1391/325922




   Introduction Top


The detection of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) in the infected patients' saliva shows that dental employees are at high risk of being infected/spreading the infection.[1] Some dental procedures generate droplets which are smaller than 5 μm, forming the aerosols. These aerosols may stay in the air for a long time and may spread the virus for distances longer than 1 meter.[2] American Dental Association has declared that dentists are at high-risk for the infection and has released some recommendations in order to reduce the risk.[3]

COVID-19 pandemic is an important stressor for health care workers.[4] Health care workers have to cope with the frequent exposure to the virus, death of colleagues and patients, and adapt to a rapid changing stressful environment.[5] Suicides due to anxiety of being infected/spreading the infection have been reported among the health-care workers.[6] Therefore, mental health screening for health care workers is recommended during the pandemic.[7]

A meta-analysis covering 13 studies and 33062 health care workers showed that about one-fourth of the health care workers had clinical anxiety during the COVID-19 pandemic.[8] A limited number of studies were performed in dentists which were based on online surveys, and those studies demonstrated high levels of anxiety among dentists during the pandemic.[9],[10],[11],[12] Studies with similar designs also showed high levels of anxiety among dental patients.[13] However, these studies had two major limitations: First, these studies were performed with cross-sectional designs; therefore none of these studies could provide causal associations by repeated measures. Second, these studies were based on online surveys, with relatively low response rates, which might lead to sampling bias and low representativeness. Furthermore, the effects of restarting high-risk procedures for COVID-19 infection during the pandemic on health care workers, and particularly on dental employees, have not been investigated yet.

At the first months of the COVID-19 pandemic, aerosol-generating procedures in dental care were restricted in Turkey. For the last months, these high-risk procedures for COVID-19 infection were restarted albeit the ongoing pandemic. The aim of this study was to assess the impact of restarting the high-risk procedures for COVID-19 infection in dental practice on the anxiety levels of dental employees via repeated measures conducted before and after restarting these procedures.


   Subjects and Methods Top


Participants and overview of the design

All dental employees working in a university dental clinic who have contact with patients (dentists, nurses, data entry staff, cleaning staff) were the population of this questionnaire-based study. Seven of the ninety employees working in the clinic were on vacation during the assessments. Remaining eighty-three employees were invited to participate in the study. Two employees, who are cleaning staffs, rejected to participate in the study because of their busy workloads. Therefore, eighty-one dental employees participated in the study with a response rate of 97.5%.

The participants were informed that the aerosol-generating procedures would be restarted. The anxiety levels of the employees were measured consecutively twice via face to face interviews using a standardized inventory (STAI) by a dentist in immediate supervision of a psychiatrist. First assessments were on the day prior to restarting these high-risk procedures, and second assessments were on the day these procedures began. No participant drop-outs occurred between the assessment days (follow-up rate: 100%). The study was approved by Yuzuncu Yil University Ethics Committee, with the decision number of 2020/04-17. The study was performed in accordance with the precepts of the Declaration of Helsinki. All participants provided written informed consent.

Assessments

The anxiety levels of the participants were measured with the State-Trait Anxiety Inventory (STAI). The inventory has 20 items for state anxiety and 20 items for trait anxiety. State anxiety investigates the anxiety level in a particular event or a condition. Trait anxiety investigates the anxiety level as a personal characteristic, which is independent of events or conditions.[14] The State Anxiety Inventory was used for the main hypothesis testing and the Trait Anxiety Inventory was used for determining the specificity. The Turkish version of the STAI was used in this study. The reliability and validity of the Turkish version of the inventory was previously demonstrated.[15] The Turkish version of the State Anxiety Inventory showed Cronbach's alpha values between 0.83-0.86, and the Turkish version of the Trait Anxiety Inventory between 0.94-0.96.[16] The Turkish version of the inventory was used in various studies before.[17],[18]

Statistical analysis

Data was analyzed using STATA version 13.1. Shapiro-Wilk test was used to assess the normality of the distributions. First, the state and the trait anxiety scores of the entire sample were compared between the assessment days using t tests (the day prior to restarting the high risk procedures vs. the day these procedures began). Then the state and the trait anxiety scores of the subgroups, stratified by age categories, sex and occupation were compared between the assessment days. Results were presented with the mean scores and standard deviations. Effect sizes of the associations were assessed using Cohen's d. Cohen's d values were presented with 95% confidence intervals (95% CI). Based on previous research, the lower bounds of the large, medium and small effect sizes were set to Cohen's d values of 0.8, 0.5, and 0.2, respectively.[19],[20] Then, the increase of the state anxiety scores between the assessment days were compared across subgroups using the Repeated Measures ANOVA. All analyses were two-tailed, and alpha was set to 0.05.


   Results Top


Demographic characteristics

The mean age of the sample was 30.3 ± 6.8 in years. 50.6% were females (n: 41). 55.5% were dentists (n: 45). 31.1% of dentists (n: 14) worked in departments applying aerosol-generating procedures with higher frequency (endodontics and restorative dental care), and 68.9% of dentists (n: 31) were in departments with lower frequency (oral and maxillofacial surgery, oral and maxillofacial radiology, orthodontics, periodontology, prosthodontics). 47.2% of the non-dentist staff were nurses (n: 17), 27.8% were data entry staff (n: 10) and 25.0% were cleaning staff (n: 9).

Change in anxiety scores between the assessment days

The state anxiety scores of the sample on the day prior to restarting the high-risk procedures and on the day these procedures began are presented in [Table 1]. Through restarting the high risk procedures for COVID-19 infection, the state anxiety level of the dental employees elevated significantly (mean state anxiety scores 42.6 vs. 49.0; t: 3.8; P < 0.01). The effect size of the association was medium (d: 0.6). The increases in state anxiety levels through restarting the high-risk procedures for COVID-19 infection were significant in females, nurses and dentists working in departments applying aerosol-generating procedures with higher frequency (endodontics and restorative dental care). The effect sizes of the increases in these subgroups were large (d ≥ 0.8). The comparison of the increases across the subgroups showed that the increase in state anxiety levels were significantly higher in nurses than data entry/cleaning staff (F: 6.03; p: 0.019).
Table 1: Comparison of the participants' state anxiety scores between the assessment days (the day prior to restarting the high risk procedures for COVID-19 infection vs. the day these procedures began)

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The trait anxiety scores of the sample on the two assessment days are presented in [Table 2]. Through restarting the high-risk procedures, no big or significant change was observed in trait anxiety scores of the dental employees (mean trait anxiety scores 44.0 vs. 44.2; t: 0.01; d: 0,001; p: 0.9). Furthermore, no big or significant changes in trait anxiety scores were observed within any subgroup.
Table 2: Comparison of the participants' trait anxiety scores between the assessment days (the day prior to restarting the high risk procedures for COVID-19 infection vs. the day these procedures began)

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   Discussion Top


In the present study, the effects of restarting the high-risk procedures for COVID-19 infection in dental practice on the anxiety of dental employees were assessed via repeated measures. Results show that restarting these procedures significantly increased the anxiety levels of dental employees. A recent study conducted during the COVID-19 pandemic in Turkey reported that the mean state anxiety scores of health care workers was 44.17 ± 4.97.[21] This score is consistent with the baseline mean state anxiety score of the dental employees participated in this study which was measured before restarting the high-risk procedures. However, the assessments on the day that these procedures began showed significant increase in anxiety scores. This result proposes that restarting the high risk procedures for COVID-19 infection during the pandemic may be associated with additional anxiety load on dental employees.

Recent studies have shown that an important proportion of dentists have substantial levels of anxiety regarding the COVID-19 pandemic.[9],[10],[11],[12] The results of this study are in line with these previous observations. It has been proposed that anxiety in crisis situations is associated with the interplay between the severity of the stressors, the perception of control over the stressor and the perceived social support.[22] Severe clinical progresses and deaths of some patients infected by COVID-19, the imperceptible nature of the infection and lack of an effective treatment lead to feelings of uncertainty. Therefore, dental employees face a severe stressor with low perception of control over. Furthermore, social distancing and isolation may diminish the perceived social support. To this end, COVID-19 pandemic is a suitable environment for anxiety. The results of this study show that dental employees, who are already prone to anxiogenic effects of the pandemic, have to cope with extra stressors during the pandemic.

The results demonstrate the particular anxiogenic effects of restarting the high-risk procedures for COVID-19 infection on females, nurses and dentists working in endodontics and restorative dental care. Previous studies also reported that females and nurses were at high risk for the anxiogenic effects of the pandemic.[8],[11],[23],[24] As far as we are aware, no studies have compared the anxiogenic effects of the pandemic across the departments of dental medicine, which we can compare the results of this study with. However, it's not surprising that restarting the aerosol-generating procedures has a more clear effect on dentists working in departments applying these procedures with higher frequency. Dentists in these departments may perceive higher risk of infection regarding these high risk procedures. Particular attention for the effect of the pandemic is warranted regarding the mental health of females, nurses and dentists working in these departments during the pandemic.

The main sources of anxiety in health care workers during the pandemic were reported to be the risk of leaving the family alone due to being infected and transmitting the infection to close relatives.[11],[12],[25] The possibility of being asymptomatically infected and spreading the virus may increase the anxiety of health care workers.[26] Conservation of resources theory stresses on the importance of pro-active coping behavior in crisis situations.[27] During the period that the dental employees' anxiety levels increase due to restarting high risk procedures for COVID-19 infection, the safety of dental employees should be prioritized. Sufficient personal protective equipment (PPE) and safe work environment may decrease the perception of the risk of being infected and transmitting to close relatives, thus may enhance the mental well-being of dental employees. Furthermore, preventive mental health plans, such as adequate education about the infection and protection, psychoeducation, support groups, mental screening if needed, may contribute to the prevention of subsequent mental disorders and related impairment.

Strengths and Limitations

As far as we are aware, this is the first study which evaluates the anxiety of health care workers, in particular dental employees, with repeated measures during the COVID-19 pandemic. Studies to date on the area have had a cross-sectional design, which is limited in providing causal associations. This study included assessments before a particular stressor that the entire population was exposed to, and immediate re-assessments on the day of the stressor, which could provide causal associations. Furthermore, investigations to date were mostly based on online surveys, with low response rates, which might cause sampling bias. The population of this study covers almost the entire employees of a university dental clinic, has a high response rate, and no drop-outs occurred between the assessment days. These points empowered the representativeness. Inclusion of data entry/cleaning staff besides dentists and nurses, who are also prone to the anxiogenic effects of the pandemic, is one of the other strengths. Furthermore, face to face contact of the investigators with the population might increase the reliability of the results in comparison with the online surveys.

Besides these strengths, many limitations of the study are also recognized. First, the assessments covered only one dimension of psychopathology, thus cannot be generalized to other dimensions of psychopathology. Second, any diagnostic interviews (e.g. Structured Clinical Interview for DSM-5) could not be conducted by a physician. However, both the risk of transmission of the virus and the busy workloads of the employees do not comply with such long interviews during the pandemic. Third, the assessments were conducted in a single university dental clinic. Therefore results cannot be generalized to all dental clinics. Fourth, there is no control group in the study that the increase in anxiety levels can be compared with. Furthermore, data on plausible confounders of the anxiety levels (e.g. personal and family history of mental disorders) were not collected. However, short duration between the interviews and the before-after stressor design may reduce the risk of confounding of other factors. Fifth, due to the relatively small sample size, some associations with small-medium effect sizes were below the conventional threshold of significance. Therefore, the anxiogenic effects of performing high-risk procedures for COVID-19 infection during the pandemic on health care workers, and on dental employees in particular, should be assessed in studies with larger samples including multiple centers and with more comprehensive assessments.


   Conclusion Top


Restarting the high-risk procedures for COVID-19 infection in dental practice seems to be an extra stressor for dental employees who already have high anxiety levels during the pandemic. It is crucial to prioritize the safety of dental employees and make preventive mental health plans during the pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given thier consent for their clinical information to be reported in the journal.

Key Messages: Through restarting the high risk procedures for COVID-19 infection during the pandemic, the anxiety levels of dental employees elevated significantly. The effects on females, dentists working in departments applying aerosol-generating procedures with higher frequency (endodontics and restorative dental) and nurses took particular attention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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