The Multifaceted Influence of COVID-19 on Indian Dentists: A Cross-Sectional Survey

Introduction

COVID-19, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus, created unparalleled and severe disruption in our lives. It had an influence on many aspects of life, including social, economic, psychological, political, and interpersonal relationships. COVID-19 was designated an international public health emergency by the World Health Organization on January 30, 2020.^1,2 This unusual scenario had a serious impact on people’s mental health and generated a stressful condition in society.³ These circumstances were especially hard for people working in the healthcare system.⁴ Health-care workers (HCWs) have worked diligently to provide emergency health-care services while also assisting in the containment of the virus’s spread throughout the pandemic. HCWs were impacted on several levels, including stress, infection, mortality, exhaustion, minimal social well-being, occupational injuries, and restricted equipment availability.⁵

COVID-19 emerged from China in December 2019. It quickly escalated from a Chinese-only national problem to a worldwide catastrophe.⁶ On January 27, 2020, India saw its first officially documented case. On March 24, India declared a national lockdown, bringing the whole country to a standstill.^7,8 The first wave of the pandemic during this period saw the closure of every facility except the emergency health-care facilities. During this time, the government limited human movement to just essential services, suspending non-essential services. SARS-CoV-2 is known to spread through the air or by respiratory droplets.⁹ Inhalation or mucous membrane damage from direct or indirect spray renders a person vulnerable.⁹ By coming into direct or indirect touch with mucosal membranes, contaminated surfaces can potentially enhance cross infection.¹⁰

Dentists are particularly susceptible to infection due to the nature of their work involving close quarters to the oral cavity and aerosolized procedures, with Occupational Safety and Health Administration (OSHA) guidelines placing them in the very high-risk category for nosocomial infection.¹¹ Furthermore, infection transmission through asymptomatic persons is a significant difficulty for dental workers in protecting themselves from the virus.

COVID-19 witnessed the implementation of new regulations in dental settings across the world.¹² The Ministry of Health and Family Welfare (Government of India) established comprehensive health-care standards for health-care personnel that were continuously revised in accordance with international criteria. The new standards required dental practitioners to adapt and change dental treatments in order to comply with the new regimen.¹³ During the pandemic, tele-dentistry and tele-consultation were on the increase, and they may soon become a major feature in the area of dentistry.¹⁴ It might have far-reaching implications in a sector that has historically relied on regular patient-doctor interaction. Social isolation and shorter treatment times have also altered our approach to patient care.

Over the last year, researchers have worked tirelessly to learn more about this virus, its potential consequences, and treatment options, resulting in rapidly changing knowledge and guidelines. It has resulted in the development of the COVID-19 vaccine, research into the role of comorbidities within the illness, and the adoption of basic preventative measures such as mask wearing.^15–17

The aim of this questionnaire-based study is to understand the impact of COVID-19 on dentists and analyze the challenges faced by them in terms of access and use of protective equipment, management of staff, dealing with patient anxiety and their own mental health.

Materials and Methods

A nation-wide cross-sectional study was conducted, and an online open survey was designed on Web-based form (Google forms). The survey questionnaire was face validated by experts in the field and ethical consent from the Institutional Ethical Committee (IEC) (CDSH/06/2021) was obtained. A pilot study was conducted on a subset of participants for a one-month period in June 2021 and modifications were made to the questionnaire. A minimum of two years’ work experience was chosen to ensure they could compare at least one year of work experience before the pandemic to their work experience during the pandemic. Consent was received from all those participating in the study. The survey was anonymous and voluntary. Convenience sampling was performed and the dentists’ email ids, SMS information and state of practice were obtained through a Dentist Directory on the Indian Dental Association website (https://www.ida.org.in/Directories/DentistsDirectory). The survey was then emailed as well as messaged to these dentists. Out of the total dentists emailed, dentists per state were emailed in proportion to number of dental colleges in that state. The form was tracked using the software Formstack to obtain data on total form views, unsubmitted incomplete forms and submitted completed forms.

The survey was a 38-question survey which took 3 minutes and 15 seconds to fill on average. It was divided into 4 sections: (i) Personal protective equipment (PPE) use, (ii) clinical operations, (iii) auxiliary management and (iv) personal impact. Some of the survey questions were single answer questions while some were multiple answer questions. The survey was open to new responses for a period of 6 months dating from 1st August, 2021 to 31st January, 2022.

The personal protective equipment (PPE) section pertained to use of N95 masks, use of PPE and its provision to patients, perceptions regarding safety afforded by PPE and its continued use post pandemic. It also delved upon perceptions relating to and psychological impact of using PPE as well as consistent adherence to safety protocols in each COVID wave.

The second part of the questionnaire was related to patient care and operative procedures. It covered patient flow, pre procedural precautions such as reverse transcriptase polymerase chain reaction (RT-PCR) tests, use of mouthwash before and during the pandemic, procedural changes such as regular use of rubber dam and alteration of treatment modalities to fall in line with Ministry of Health and Family Welfare (MoHFW) prescribed guidelines.

The auxiliary management section covered areas such as requirements for specialized training for auxiliary staff, reluctance to report to work, mental health of staff and solutions to ease burden.

The final section explores the impact of the pandemic on the dentist at a personal level. Questions posed include adoption of tele consulting and its future, continued dental education. Questions addressing stress, anxiety and the effect of the pandemic on the dentist’s mental health were included. The participants were also questioned on activities they undertook to offset the mental effects of the pandemic. Descriptive analysis was performed on the responses.

Results

A nationwide survey was conducted from 1st August 2021 to 31st January 2022 to understand the impact of COVID-19 on Indian dentists. Of the 1129 dentists that the questionnaire was sent to, 513 dentists submitted a completely filled questionnaire yielding a response rate of 45.44%.

One hundred and twenty-four dentists viewed the questionnaire and left the survey midway. Characteristics of the participants collected were Age, Gender, Nationality, level of education, i.e Bachelor of Dental Surgery (B.D.S) or Master of Dental Surgery (M.D.S), duration of clinical practice (minimum duration of 2 years), type of practice (group, individual or institutional), location of practice, part time or full time status. Forty eight percent point three respondents were below the age of 29, 46.7% were in the 30–59 range and 5% were above the age of 60. Fifty nine percent respondents were females and 41% were males. All respondents were Indian nationals (100%). Sixty five percent dentists had individual dental practices and 73% practiced full time. Fifty seven percent respondents had completed their Master of Dental Surgery (Table 1). Out of the 513 respondents 18% were from Maharashtra, 16% were from Tamil Nadu, 28% from Karnataka, 7% from Uttar Pradesh, 5% from Kerala, 4% from Andhra Pradesh, 4% from Punjab, 3% from Gujarat, Rajasthan, and Madhya Pradesh, 2% from Telangana and Haryana, 1% from Delhi, Chhattisgarh, West Bengal, Himachal Pradesh, and Jharkhand (Tables 1 and 2). All data collected regarding characteristics apart from geographic locations were self-reported.

Table 1 Data from Questionnaire Regarding Sample Characteristics

Table 2 Data from Questionnaire Regarding Sample Geographical Information

Use of Personal Protective Equipment (PPE)

A total of 65.1% respondents had been practicing clinically for 5 years, 20.9% for 5–10 years, and 14% for more than 10 years. Before the pandemic, 83.7% of dentists did not use personal protective equipment, and 92.9% did not use N95 masks (Figure 1). Following the outbreak of the pandemic, there was an increase in the number of practitioners adopting PPE (95.7%).

Figure 1 Response of the dentists regarding the use of PPE and N95 masks.

Only 41.9% respondents continued to use Personal Protective Equipment (PPE); however, 73.8% believed it is useful in protecting the practitioner (Figure 2). More than half respondents (55.8%) believed PPE should be continued to be used even when the pandemic ends (Figure 2). A total of 72% practitioners reported that they felt providing PPE to patients could be beneficial however less than half of them (20.9%) provided personal protective equipment to their patients (Figure 2). A significant number (48.8%) of dentists reported a beneficial psychological impact of use of PPE on both patient and practitioner with both feeling more safe and secure. An appreciable number of dentists (72.1%) had continued following the safety protocols issued in the first waves in the subsequent waves (Figure 2).

Figure 2 Response of the dentists regarding the use of use of PPE and its impact.

Dental Procedures

A major decline was reported by 45.2% of dentists in patient flow since the onset of the pandemic (Table 3). They also noted a change in patients’ behavior where 81% patients appeared to be taking extra precautions, 52.4% seemed to be more anxious, 35.7% were hesitant to seek treatment while 35.7% opted for tele consultations and 14.3% completely avoided consultations leading to a build-up of dental issues (Figure 3).

Table 3 Data from Questionnaire Regarding Patient Management

Figure 3 Response of the dentists regarding the changes in patient behavior.

A considerable amount (34.1%) of practitioners noted changes in patient management in terms of safety protocol, infection control, first line of treatment compared to before the pandemic and 90.2% practitioners considered altering treatment due to the pandemic (Table 3). A large number (92.5%) of respondents stated they adhered to guidelines issued by the Ministry of Health and Family Welfare (Table 3). Just more than half (51.2%) clinicians used oral rinses regularly before the pandemic with the value changing to 78% during the pandemic (Table 3). However, only 48.8% believed it could aid in the halt of infection (Table 3). Chlorhexidine (76.3%) over Povidone iodine was the preferred choice for dental practitioners (Table 3). One-third (23.8%) practitioners made RT-PCR tests for patients mandatory before treatment (Table 3). A small number of practitioners (37.5) used rubber dams during various procedures pre pandemic; however, this changed to 60.3% during COVID-19 (Table 3). A whopping number (87.8%) of practitioners have been educating themselves regarding COVID-19 since the start of the pandemic while 7.3% did not educate themselves and a small number of dentists (4.9%) thought about educating themselves about COVID-19. After understanding the recent development related to COVID-19, large group of dentists (90.2%) altered the treatment protocols (Table 3).

Auxiliary Staff

A substantial (70.7%) number of respondents stated that they think that dental assistants require special training post pandemic (Table 4). The measures used to combat psychological stress by auxiliary staff included educating (80%), counseling (57.5%), providing financial assistance (42.5%), flexible work schedule (45%) and an advance on salary (17.5%) (Table 4). Almost all (95.9%) dentists noticed an increase in concerns by auxiliary staff. They noted the majority feared contracting the virus (58.5%), followed by more anxious nature (29.3%), and hesitance to work (22%), while very few (9.8%) had apprehensions regarding salary (Table 4) (Figure 4). Considerable number of dentists (34.2%) experienced their auxiliary staff quitting their jobs (Table 4).

Table 4 Data from Questionnaire Regarding Auxiliary Staff and Their Management

Figure 4 Response of the dentists with respect to the concerns shown by dental assistants during COVID-19.

Personal Impact

It was seen that 61% dentists felt that treatment and patient management had changed during the pandemic including the way they had to approach patients, new protocols, and an overall sense of fear that they had to deal (Table 5). A bulk (53.7%) of respondents practiced tele-dentistry during the pandemic and 39% felt it will play an important role in dentistry in the future (Table 5). Almost three quarters (65.9%) respondents felt distance learning has gained traction and will be important in the future (Table 5). Various difficulties were faced by dentists during the pandemic with 29.3% respondents having to move out of their clinic (Table 5). Half of (53.8%) respondents experienced poor financial returns while 20.5% had to downsize their team and let off staff members (Figure 5). A meager (12.2%) respondents also considered changing their profession during the pandemic (Table 5). Considerable number (67.5%) of respondents have seen partial economic recovery, while 12.5% have experienced continued losses (Table 5).

Table 5 Data from Questionnaire Regarding Professional Impact

Figure 5 Response of the dentists regarding the economic repercussions.

A considerable number (70%) of respondents said their mental health was affected during the pandemic with 55% experiencing an increase in anxiety, 50% more stressed, 22.5% felt isolated,20% felt low and 17.5% faced anger management issues (Figure 6). Dentists used various measures to manage their mental health during the pandemic such as spending time with family (40%), educating themselves regarding COVID-19 (40%), meditation and yoga (30%), friends (27.5%), music (27.5%), sports (12.5%) (Figure 7).

Figure 6 Response of the dentists regarding the effect on mental health.

Figure 7 Response of the dentists regarding the measures taken for mental health management.

Discussion

The study results described the dentists’ experiences during the pandemic. While an inclusion criteria was that all the respondents had to have an experience of minimum of 2 years that had to be self-reported, majority of those who completed the questionnaire had been practicing clinically for less than 5 years (65.1%), a smaller percentage had been practicing for 5–10 years (20.9%), and the remainder had been practicing for more than 10 years (14%) hence the results are a more appropriate representation of recently graduated professionals (Table 1). The greatest percentage of respondents were from Karnataka (28%), Maharashtra (18%), and Tamil Nadu (16%) (Table 2).

Surgical masks or cotton fabricated masks were used more prevalently and N95 was restricted to a very few (0.7%) dental professionals on a daily routine basis pre-pandemic. The use of N95 masks was on a rapid rise during the COVID-19 pandemic.¹⁸ The main advantage of a N95 mask was its filtration efficiency and tight seal, thus preventing air leakage around the edges.¹⁸ While respirators provide more protection, they may be more difficult to tolerate or wear continuously.

PPE supply to patients was uncommon in pre-pandemic dentistry facilities. Various studies affirmed the importance of PPE in protecting the dental professionals as well as the patients in the dental operatory.^20,21 Majority dentists (73.8%) believed that PPE was an important aspect in controlling the spread of COVID-19 infection in the dental operatory. This brought about a change in perspective regarding use of PPE and regarding provision of PPE to patients (72%). Following the commencement of the pandemic, there was a surge in the percentage of practitioners adopting PPE (95.7%). A significant proportion of dental professionals (88.4%) made the use of PPE mandatory after the first wave, whereas the rest gradually reduced their usage of PPE over time (11.6%). The decrease in PPE usage can be ascribed to variables such as communication challenges (visual, auditory, or verbal), heat, pressure, or discomfort, and dizziness or difficulty concentrating. Despite a steady drop in PPE use throughout the course of the pandemic, it is worth noting that more than half of respondents believed that PPE use should continue after the pandemic.

Fear and anxiety are emotional issues that may be linked to the widespread coverage of the COVID-19 pandemic in social, electronic, and print media. A total of 40.5% of dentists reported a minor decrease in the number of patients, which is relevant because of the outbreak; however, it raises the question of how many patients neglected treatment because of which they potentially reported at a later stage when tooth had been irreversibly damaged. Armfield et al discovered that people with high fear were more likely to have a longer duration since their last dental visit in a study of Australian residents¹⁹ According to Pohjola et al, high fear was associated with irregular dental attendance among Finnish adults.²⁰ Analogously, in Iran, Saatchi et al unearthed that patients who attended irregularly were more afraid than regular attendees.²¹ This denial of dental care due to fear may exacerbate pre-existing oral conditions, create a negative spiral of dental fear, enhance treatment needs, and deteriorate oral health status.²²

Dentists observed that majority of patients (81%) became more careful while visiting the dental clinic. These patients’ donned N95 masks in addition to surgical masks, latex gloves before and after entering the dental setting, and hand sanitizers. During this time span, a considerable number of patients (52.4%) began to be more nervous, which might be connected to the fear of contracting infection in the dental setting or the use of PPE by themselves during dental treatments. Some patients (35.7%) were apprehensive to visit the dental clinic and indicated greater interest in telemedicine (35.7%). During this time, a portion of patients (14.3%) entirely skipped dental care. In Beijing, China, a retrospective analysis revealed that 1567 patients gained emergency dental services prior to the COVID-19 epidemic, compared to 970 patients during the pandemic. This revealed a 38.1% decline in emergency dental care usage, indicating that the COVID-19 epidemic had a significant impact on emergency dental care utilization.²³

Because of the characteristics of the COVID-19 virus’s dissemination, majority of dentists (40.5%) made the negative RT PCR test essential only for certain treatments. Around 35.7% of dentists did not request RT PCR testing for any of the treatment operations, but the remaining dentists (23.8%) made negative RT PCR tests necessary for all dental treatments, which might be associated with safeguarding everyone in the dental operatory.

Because of the proximity to the patient during dental treatment, the elevated production of aerosols, and the identification of SARS-CoV-2 in saliva, the oral cavity has been viewed as a possible reservoir for COVID-19 transmission. To decrease the number of microorganisms in aerosols and drops throughout dental procedures, preoperative antimicrobial mouth rinses with chlorhexidine gluconate (CHX), cetylpyridinium chloride (CPC), povidone-iodine (PVP-I), and hydrogen peroxide (H2O2) have been suggested. Even before the pandemic, antiseptic mouthwashes were widely used in dentistry, particularly preoperatively.²⁴ Because of the antiseptic nature of mouthwashes, more than half of dentists (51.4%) used them in pre-operative procedures. The usage of mouthwashes increased substantially following the onset of COVID-19 (78%). The majority (76.3%) utilized chlorhexidine, while the remainder used povidone iodine solution (23.7%). SARS-CoV-2 was eliminated from the oropharynx of those who used chlorhexidine as an oral rinse, according to one investigation.²⁵ Studies were carried out to understand if mouthwashes could halt or reduce the spread of COVID-19 infection.^26–28 Based on different studies, it was understood that antiseptic mouthwashes lower the chances of spread of COVID-19 infection.²⁴ The same was reflected by just less than half of the dentists (48.8%) who believed that mouthwashes could halt the spread of infection.

Rubber dam is an important aid used during the treatment mainly for isolation procedures. A whopping number of dentists (67.5%) stated that they had not been using rubber dams in dental procedures while the rest had been using rubber dams. Guidelines and safety protocols were released by the Government of India in line with the guidelines released by the WHO. Almost all (92.5%) adhered to all the guidelines released to ensure safety for everyone in the dental setup. A small number of dentists (7.5%) did not follow the guidelines. Around 87.8% of dentists made an effort to understand COVID-19ʹs impact on dentistry using available evidence. And 90.2% altered treatment approach in accordance. Non-emergency procedures were postponed, treatment time was shortened, aerosol generating procedures were suspended and emphasis was placed on ventilation of the operatory.²⁹

COVID-19 presented a conflicting situation to dentists in terms of not simply taking care of themselves but also the auxiliary staff employed at their clinics.^29,30 The survey showed that the auxiliary staff showed an increase in fear of contracting the virus (58.5%), greater anxiety (29.3%), hesitation in working (22%) as well as no shows to work (2.4%). Staff management combined with patient fears and an explosive outburst of disease posed a daunting challenge to dentists. One year later dentists have been able to evaluate the staffs as well as their preparedness for situations like these in the future. The survey showed that 70.7% respondents believe dental assistants require special training post pandemic. The crux of the problem potentially lies in poor availability of simplified information to understand the rapid changes in information relating to disease and the associated protocols. Continued education programs and regular updating of staff with changes in medicine can aid in doing away with fears and make staff members more secure in the work they do. The scope of additional training could include common diseases encountered as well as diseases that require universal precautions. Further training in infection control, regular updating of protocols and counselling to aid in dealing with high stress situations could aid in improved patient outcomes. Measures such as educating, counseling and providing financial assistance with flexible work schedules were some of the measures taken up by dentists to reduce psychological stress and need to be carried forward beyond the pandemic.

The survey also showed that 34.2% of staff members left their jobs. Finding new staff members posed an added challenge to dentists. Creation of a national portal with registered dentists and auxiliary staff members as well as their region of practice/residence could simplify hiring especially when manpower resources are limited. It could also provide staff members with increased options and control when searching for jobs.

Distance learning took on a new important role and 65.9% respondents in the survey felt distance learning is and will continue to be crucial. Increasing availability of such courses and making them more accessible through subscription services could promote continued education. Technology is rapidly changing conventional dentistry. Tele-medicine provided a way to interact and manage patients while in isolation. Further development of this field could potentially aid in delivering universal healthcare.

The economic impact was felt across the profession with a downturn in regular income. This yielded a section of dentists to shut down their clinics, lay off workers or simply absorb losses dipping into previous savings. Aid and stimulus packages by the government could have aided dentists. Discussions and policy changes need to be tabled by the Dental Council of India in conjunction with the government to ensure security for dentists in lieu of future crises like this.

Mental health has also been deeply impacted during the pandemic. Between one and two of every five health-care workers reported anxiety, depression-related symptoms, distress, and/or sleep problems.^31,32 A focus on self-care, therapy and social support through friends and family could aid in combating the mental effects of the pandemic. The most commonly reported protective factor associated with reduced risk of mental health problems was having social support.³¹ However, what is interesting is that the focus on individual risk and resilience factors and pathology in research may hinder the discovery of underlying organizational faults, which could be more appropriate targets of intervention. In Mueller’s systematic review it was seen that in two studies participants specified that they had a greater need for personal protective equipment than for psychological help. Chung and Yeung reported this in a survey that allowed health-care workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse.³³ This points to the need to rapidly assess and diagnose faults at individual as well as institutional level.

A limitation of the present investigation was that it was limited to Indian dental practitioners. Also, the years of practice was self-reported. The analysis also does not quantify the type of economic hardships endured by dentists. Additionally, it presents hardships faced by auxiliary from a dentist’s perspective and does not represent the staff members views. Further, despite repeatedly following up with dentists, responses from some states were not received.

Conclusions

As a result, while the COVID-19 pandemic persists, new cases are still being noted, and the hazard of reciprocal transmission of infection between patients and dental care providers necessitates additional precautionary measures to limit COVID-19 spread. According to the current data, the COVID-19 pandemic influenced how dentists practiced, with elevated use of PPE for themselves and patients. During the COVID-19 pandemic, fear was common among patients, with a significant proportion exhibiting high dental fear and anxiety. There was a decrease in dental patient flow, increased anxiety among patients and auxiliary staff. Dentists were heavily affected economically and recovery has been slow but steady. Investigating its timeline, stimulus packages and potential future infrastructure requirements could be interesting.