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Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1029-1037

Infection-Control knowledge, attitude, practice and risk perception of occupational exposure to COVID-19 among dentists: A cross-sectional survey

1 Department of Periodontology, King Abdulaziz University, Jeddah, Saudi Arabia
2 General Dentist, Ministry of Health, Jeddah, Saudi Arabia
3 Family Dentist, Ministry of Health, Riyadh, Saudi Arabia

Date of Submission26-Apr-2021
Date of Acceptance19-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. A A Almarghlani
Assistant Professor, Department of Periodontics, Faculty of Dentistry, King Abdulaziz University, PO Box 109725, Jeddah - 21351
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_1459_21

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Background: COVID-19 is a potentially fatal disease that was announced as a global pandemic at the beginning of the year 2020. Aim: The purpose of our cross-sectional study was to evaluate the infection-control knowledge, attitude, practice, and risk perception of occupational exposure to COVID-19 among multinational dentists. Patients and Methods: A self-designed, 33-item, English questionnaire was created and distributed through social media and digital communication platforms. The questionnaire covered the demographic data, knowledge and perception of the occupational risk of the COVID-19 infections, and compared some infection control measures taken before and after this global pandemic. The results were analyzed, and four scores were used to assess the aforementioned parameters. Results: A total of 300 multinational dentists answered our survey, with the majority being females (59%) and aging from 25 to 44 years old (68%). We found that a statistically significant relationship exists between attitude and nationality, country of practice, medical condition, and the practicing specialty (P < 0.05). In addition, risk perception had a statistically significant correlation with nationality, smoking habits, education level, and specialty (P < 0.05). Furthermore, there was a statistically significant correlation between the practice score and the gender, age, smoking habits, education level, nature of the practice (private or governmental), and academia affiliation (P < 0.05). Conclusions: The study sample had good compliance with the instructions and guidelines of the World Health Organization (WHO) and the Centre for Disease Control (CDC), with most of them improving their infection control precautions after the virus's emergence according to the said guidelines. Furthermore, our participants were fearful of the COVID-19 virus and the fact of being potential transmitters. Despite saying that, the significant majority of them reported being confident in treating COVID-19–positive patients.

Keywords: COVID-19, dentists, infection control, occupational hazard, pandemic

How to cite this article:
Almarghlani A A, Alshehri M A, Alghamdi A A, Sindi M A, Assaggaf M A, Al-Dabbagh N N. Infection-Control knowledge, attitude, practice and risk perception of occupational exposure to COVID-19 among dentists: A cross-sectional survey. Niger J Clin Pract 2022;25:1029-37

How to cite this URL:
Almarghlani A A, Alshehri M A, Alghamdi A A, Sindi M A, Assaggaf M A, Al-Dabbagh N N. Infection-Control knowledge, attitude, practice and risk perception of occupational exposure to COVID-19 among dentists: A cross-sectional survey. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 8];25:1029-37. Available from:

   Background Top

A novel coronavirus was officially announced on January 8 of 2020 as the causative pathogen of coronavirus disease 19 (COVID-19) by the Chinese Center for Disease Control and Prevention.[1] The epidemic originated in Wuhan, China, in December 2019,[2] and had been announced within a few months by the World Health Organization (WHO) to be a pandemic and a global public health emergency as the number of people suffering from the coronavirus disease (COVID-19) had increased globally.[3] The causative virus responsible for this outbreak, which was later identified as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), belongs to the family Coronaviridae of the order Nidovirales. This virus comprises a large, single, plus-stranded RNA structurally as its genome.[4],[5] COVID-19 has the potential to cause severe acute respiratory tract infection among infected humans and is mainly transmitted from one person to another via hands, saliva, nasal droplets, and surface contact.[6],[7] The average incubation period of COVID-19 ranges from 4 to 14 days.[8] The symptoms that patients suffering from COVID-19 experience include high-grade fever, dry cough, myalgia or fatigue, and dyspnea, with the less common symptoms manifested being sputum production, headache, hemoptysis, and diarrhea,[9],[10],[11] eventually leading to severe pneumonia and, finally, death in some of the infected patients.[6],[12] As for the dental setting, infected patients may be in close contact with their dentists, leading to a higher risk of spreading infections to the health care workers.[13] Performing procedures inside the patient's oral cavity can particularly expose dentists to aerosols and droplets, leading them to be at a high risk of catching the infection and as a consequence, dentists can be fearful or anxious when treating infected patients.[13],[14] As a result of this fear, some dentists may refrain from treating a confirmed case of COVID-19 in their practice.

Infection control measures all around the world have become stricter during this pandemic, especially in the dental practice due to the personnel's high susceptibility and the nature of procedures performed daily.[14] As per the WHO measures, the standard precautions are to be implemented at all times in addition to specific measures during this outbreak.[3] Dental practices should be equipped with safe disposal systems and appropriate personal protective equipment (PPE) for all health care professionals and frontline workers at all times. Assurance of patients' safety and prevention of cross-infection are the key goals for every health care professional, but without adequate knowledge and implementation of these precautions, a dental professional is placing his patients, himself, and his family in danger of contracting the infection.[15]

This questionnaire-based study aimed to evaluate the infection-control knowledge, attitude, practice, and risk perception of occupational exposure to COVID-19 among dentists.

   Materials and Methods Top

A prospective web-based, cross-sectional study was conducted using an electronic survey instrument (Google Forms, Google) to obtain responses from multinational dental health professionals who were practicing during the COVID-19 pandemic in July 2020. Ethical approval was obtained from the institutional ethics committee at the Faculty of Dentistry, King Abdulaziz University in Jeddah, Kingdom of Saudi [IRB number 77-08-20]. Confidentiality of the study participants' information was maintained throughout the study by making the participants' information anonymous and requesting participants to provide honest answers.

A 33-items, self-designed, electronic, web-based questionnaire written in the English language was created specifically for the study. To begin the process, a review of the literature was performed by comprehensively searching PubMed in addition to utilizing information from the websites of the WHO and Centre for Disease Control (CDC) as references for the guidelines and the scientific basis for the questionnaire and covered the demographic data, knowledge, perception of the occupational risk of the COVID-19 infections, and some infection control measures taken before and after this global pandemic were compared.

Content validation was conducted; an expert's (a periodontist\statistician) opinion was sought out to evaluate the understandability and validity of the questionnaire. The questionnaire was distributed via e-mail and WhatsApp (social media platforms) due to social distancing recommendations and lockdown in multiple countries. The study was approved by the ethical committee at King Abdulaziz University and was performed following the Helsinki Declaration as revised in 2013.[16] The study was conducted following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).[17]

This study was analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp., Armonk, N.Y., USA) and visually presented using GraphPad Prism version 8 (GraphPad Software, Inc., San Diego, CA, USA). A simple descriptive statistic was used to define the characteristics of the study variables through the form of counts and percentages for the categorical and nominal variables, whereas continuous variables are presented by mean and standard deviations. Four scores (knowledge, attitude, risk perception, and positive practice) were used during the analysis.

A simple additive method was used to calculate each score by using the pointing system. After the calculation, each score was converted to a hundred-point scale and compared to the demographical data. For comparing the scores with two group variables, an independent t-test was used, and for more than two group variables, a one-way ANOVA, with least significant difference (LSD) as a post hoc test was used. These tests were done with the assumption of normal distribution. Otherwise, Welch's t-test for two group means and Games Howell for multiple groups were used as an alternative for the LSD test. Lastly, a conventional P value <0.05 was the criteria to reject the null hypothesis.

   Results Top

Demographic profiles as seen in [Table 1] show that the majority of the studied population was female (59%), aged between 25 and 34 years (38%), were Saudi Arabian (41%), American (11.3%), or Indian (8%), and practicing in Saudi Arabia (49.6%) or the USA (31.3%). Of our participants, 22% reported being heavy smokers (>10 cigarettes/day), whereas for the medical conditions, 77.3% reported being medically free, with 11.3% and 10.7% reporting having diabetes and hypertension, respectively. Regarding the education and practice of our participants, 86% at least have a DDS/BDS, whereas 46.3% are board-certified, and 18.7% have a Ph.D. degree; the majority (44.3%) worked in both the governmental and private sectors simultaneously, and simultaneously, the majority worked as general practitioners (35.3%), with the specialists being mainly oral and maxillofacial surgeons (11.7%), prosthodontists (11.3%), and periodontists (11.3%). Overall, 64.7% did not have any academic affiliation [Table 1]. The distribution of COVID-19-related information sources among the studied dentists is shown in [Figure 1]. The distribution of preventive measures implemented among the staff and patients in their respective clinics is shown in [Figure 2]. The knowledge, infection control risk perception, and attitude results are listed [Table 2] and [Table 3].
Figure 1: What resources do you depend on to learn more about COVID-19?

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Table 1: Demographics

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Figure 2: What preventive measures are you implementing among staff and patients in your practice?

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Table 2: Knowledge assessment

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Table 3: Infection control, risk perception, and attitude assessment

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With regards to the scoring system that we used, the results revealed average scores of 39.69 ± 23.5 for the risk perception, 41.28 ± 19.8 for the attitude, 49.38 ± 27 for the knowledge, and 62.76 ± 18.7 for the positive practice among the studied dentists [Table 4].
Table 4: Scoring

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The association of the attitude score was found to be statistically significant when paired with the nationality (i.e., Saudi Arabian, Indian), the country of practice (i.e., Saudi Arabia, USA), the medical history of the participants (i.e., diabetes, hypertension), and their specialty (i.e., general practitioners, periodontists) (P < 0.05). Additionally, there was a statistically significant correlation between the risk perception score and the nationality, smoking status (i.e., heavy smoker, nonsmoker), level of education (i.e., DDS/BDS, board-certified), and specialty (P < 0.05). Furthermore, the positive practice score was found to have a statistically significant association with the gender (i.e., male, female), age (i.e., 20–24 years, 25–34 years), smoking status, level of education, sector of practice (i.e., governmental, private), and academic affiliation (i.e., associate professor, professor) (P < 0.05). The knowledge score was found to not have any statistically significant correlation with any of the variables [Table 5], [Table 6], [Table 7], [Table 8].
Table 5: Knowledge score analysis

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Table 6: Attitude score analysis

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Table 7: Risk perception score analysis

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Table 8: Positive practice score analysis

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   Discussion Top

Infection control measures in the dental practice have been modified globally to accommodate the ongoing COVID-19 pandemic. The knowledge and perception of the risks associated with operating a dental practice and treating the susceptible population have become a topic of critical importance, in order to maintain COVID-19 among dentists. Dentists need to have very good knowledge about COVID-19 in order to implement the correct precautionary measures for the well-being of both their patients and themselves. Our web-based survey aimed to evaluate the infection-control knowledge, attitude, practice, and risk perception of occupational exposure to COVID-19 in the most optimal way while simultaneously decreasing the potential for cross-infection to the lowest possible level. Quadri et al.[15] investigated awareness among dental interns, dental auxiliaries, and dental specialists in Saudi Arabia. The study reported that the basic knowledge of COVID-19 among dental health care workers in Saudi Arabia is acceptable, with an overall mean baseline knowledge score of 10.74 (2.32), whereas Singh Gambhir et al.[18] conducted a similar study on Indian dentists that in addition to the aforementioned parameters, investigated the hygiene practices and reported that there was a lack of knowledge of some essential aspects of COVID-19. Our results demonstrated no statistically significant differences between the multiple different nationalities of the respondents. However, the Ghambir study results could have been affected by the fact that the disease was still emerging at the time.

The WHO reported older age, smoking, and multiple underlying systemic medical conditions to be associated with a higher risk of developing severe manifestations when infected with the virus. Some of these systemic diseases are diabetes, hypertension, chronic respiratory diseases, organ transplant surgeries, cardiovascular diseases, and cancer.[3] This evidence-based correlation has had an effect on both the attitude and the risk perception of individuals who reported to be smokers or had underlying systemic conditions that could endanger them to more severe manifestations of the disease. Therefore, it was concluded in this study that there was a statistically significant correlation between participants who are older or suffering from medical conditions and the attitude score towards the virus outbreak. As for the smoking effect on attitude and risk perception scores, the fact that heavy smokers had higher scores than medium and light smokers is attributed to the increased respiratory impairment. As reported in the literature, the risk of aggravated respiratory disease increases with the presence of chronic bronchitis in smokers who consume more than one pack per day (Relative risk RR = 1.63) followed by moderate smokers (RR = 1.45) and nonsmokers (RR = 1.16).[19] Consequently, individuals who have higher risk perception and attitude scores have modified their precautionary measures to better prevent the spread of the disease. Coupled with the fact that a great portion of our participants are above the age of 45 (11.4%) with some being over 65 (0.7%), these numbers say that the dental population is at great risk of developing severe manifestations if the virus is contracted and that precautions are of vital importance for the well-being of this said population.

We found the influence of age and gender of our participants in correlation with the knowledge scores and attitude to be of no significance; however, both age and gender presented a statistically significant correlation with the practice scores. We think the findings related to the age aligned well with what we expected as old age is a great risk factor in developing severe manifestations when contracting the COVID-19 virus and in our results, we found participants aged 55–64 to be more careful and more compliant with the precautionary practices when compared to participants aged 54 and younger. When it comes to gender, our results implied that male participants had had higher positive practice scores than their female counterparts; we hypothesize that the subjective nature of our questionnaire could have led to this bias.

We found the correlation between risk perception and nationality to be statistically significant, and that can be attributed to how different countries used varying measures to face the pandemic, and how the level of control, which can be evident in the number of cases and daily graphs, is different from one country to another. Cagetti et al.[20] reported that only 2% of the investigated 3599 dentists in north Italy involved in their study were confident about avoiding infection; dentists working in low COVID-19 prevalence areas were more confident than those working in high prevalence areas (P < 0.01). Therefore, the confidence of practitioners in managing cases during the pandemic can be affected by how prevalent it is in their country of practice.

Kamate et al.[21] reported in their study that the knowledge scores were significantly associated with the level of education and years of practice. However, higher practice scores were associated with the level of education only. These findings are consistent with our findings that higher risk perception scores were attributed to Ph.D. holders, whereas the practice scores were higher in general practitioners. These correlations can be attributed to the constant involvement of recent post-graduates in research for the purposes of evidence-based practice and publications. Individuals affiliated with academia were found to have higher practice scores; this can be due to the involvement of academia in the motivation of pre-graduates in adhering to guidelines and protocols enforced by the dental school and in aiding them in their research projects.

Harrel et al.[22] reported in their study that when it comes to aerosol contamination, ultrasonic and sonic scalers are considered the biggest aerosol-generating source, followed by air polishing, air-water syringe (3-way syringe), tooth preparation with air-turbine handpieces, and tooth preparation with air abrasion. In the present study, more than 40% (42.6%, n = 127) reported that ultrasonic and sonic scaling dental devices produce the greatest risk for airborne contamination and aerosol generation, which is the correct answer. Subsequently, when we asked our population regarding which specialty-specific procedures they think set the highest risk of contracting the disease through the aerosol generation and airborne contamination, one-third of the participants reported periodontal surgeries to produce the greatest risk of acquiring airborne contamination (32.9%, n = 97), whereas one-fourth (25.4%, n = 75) reported for the prosthetic procedures. Based on the study done by Harrel et al., periodontists and periodontal procedures are thought to be the ones associated with the highest risk. This is no surprise as not only do they use sonic and supersonic scalers the most, but many preventive measures, such as the use of rubber dams, are completely inapplicable in their field, and the fact that the greatest majority of their procedures are associated with blood and other bodily fluids contributes to the risk of contamination.

Given the nature of the signs and symptoms that accompany COVID-19 infection, an increase in the temperature is considered among the most recognizable signs and as such, checking the temperature of every patient before they are allowed into the dental clinic is of critical importance to limit the spread of the infection and to have a well-controlled environment to treat the non-suspected patients. The majority of our participants (91.7%) check the patient's body temperature before they enter the clinic as a precautionary measure. Furthermore, when performing aerosol-generating procedures, it is recommended to use suitable PPE such as a face shield, N95 mask, and eye protection.[23] Similarly, the literature recommended that in high-risk situations, waterproof and fluid-resistant gowns should be worn.[24] In accordance with that, nearly two-thirds of our respondents modified their infection control measures during the COVID-19 pandemic (64.3%) by wearing the PPE recommended by the WHO. These numbers reflect great compliance with the WHO- and CDC-issued guidelines for both the local and international, private and governmental dental practices.

The WHO reported that a surface-disinfectant contact duration of 1 min is sufficient to prevent the transmission of COVID-19.[23] When asked, 75% of the respondents modified the duration of disinfecting the dental clinic surfaces during COVID-19. Of them, 65.7% modified the disinfection duration to 3 min. Compared to the situation before COVID-19, 66.7% used to follow the WHO protocol of surface disinfection for 1 min. While 3 min is over the recommended surface-disinfectant contact duration and given how at the time of collecting the responses the guidelines were being continuously updated, we think that this did more benefit than it harmed as no one can guarantee that every disinfection procedure is being performed to the utmost details, and we are hoping that longer duration of contact can cover for areas of potential weakness in the disinfection or the disinfectant being used.

This study has the limitations of the small sample size and the inability to generalize the results to any specific population due to the low numbers of respondents for some of the nationalities. Additionally, the response rate could not have been measured due to the nature of distribution, and response bias cannot be assessed, thus, it is not possible to judge the representativeness of the respondents and the study population. More studies should evaluate the same domains across bigger populations with a wider variation, to ensure the generalizability of the findings. Future studies should be conducted at intervals using quasi-experimental designs to provide a comparative analysis. This would also help to evaluate the effect of continuing education programs during the pandemic phase. The results of such future studies could help in planning and developing supportive policies and programs.

   Conclusion Top

To successfully manage any pandemic, knowledge, positive attitudes, and evidence-based practice in place can help minimize the impact of the disease. This can be achieved through the efforts of various entities, including government and global health organizations. The knowledge, attitude, infection control measures, and practice scores were found to be acceptable. Dental health care workers should keep their knowledge updated regarding emerging health issues, maintain their infection control measures, and keep them up to standards.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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