Keywords
COVID-19 - pandemic - dental care - emergencies - dentistry
Introduction
The novel coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2)
is the virus responsible for the infection called coronavirus disease 2019 (COVID-19)
(coronavirus disease).[1] The manifestation of COVID-19 started in Wuhan (China) and has spread to practically
all countries, with the World Health Organization (WHO) declaring it a high-risk pandemic.
On June 10, 2020, there were 12,102,328 cases contaminated and 551,046 deaths due
to the COVID-19.[2] The coronavirus infection causes respiratory alterations and is more contagious
than severe acute respiratory syndrome and the Middle East respiratory syndrome coronavirus.[3]
Seeking to prevent further spread, the most infected regions declared state of emergency
and restrictions to the population, such as quarantine, stay-in-home orders, and lockdown.
WHO, National Institutes, or Ministries of Health and National Councils are constantly
publishing and updating specific guidelines for each professional area. However, the
coronavirus spread has provided great challenges for Medicine and Dentistry.
The effects of coronavirus in Dentistry included several biosafety measures and recommendations
due to the high risk of contamination during dental care,[3]
[4] and in some regions, dental care was limited to urgencies and emergencies.[5]
[6] As coronavirus is abundantly present in salivary secretions of the affected patients,[7] its spread is predominantly thought to be related to respiratory droplets and aerosols.
Due to the characteristics of dental care procedures, the risk of cross-infection
can be high among patients, dentists, and staff.[3] This way, strict and effective infection control protocols and guidelines for dental
care are being recommended.[3]
[8]
[9]
All routine dental care has been suspended in many countries experiencing COVID-19
disease during the period of the pandemic.[5]
[6] In Brazil, the Federal Council of Dentistry presented guidelines for evaluating
dental urgency and emergency during the coronavirus pandemic.[10] Dentists were advised to manage urgencies and emergencies only; however, the professionals
can decide to maintain the dental offices open or to care only for patients with urgencies
or emergencies.
The objective of this web-based survey was to assess the effects of COVID-19 pandemic
on elective and urgency/emergency dental care and dentists’ positions and concerns.
Material and Methods
This survey was approved by the Ethics Research Committee of the Ingá University Center
Uningá, Maringá, Brazil (IRB n. 30797120.0.0000.5220).
Sample size calculation for questionnaires was performed with a confidence interval
of 95% and margin of error of 5%, considering the population of 338,000 dentists in
Brazil,[11] resulting in the need for 384 dentists answering the questionnaire.
Via WhatsApp Messenger (WhatsApp Inc., California, United States), a Google forms
questionnaire was sent to dentists in Brazil, who were not identified in the survey.
The questionnaire was available for responses from May 5, 2020 to May 20, 2020, when
the curve of the COVID-19 contamination was still rising in Brazil.
The questions included: age, gender, dental office location, specialty, and degree
of dental graduation. Besides, questions regarding what type of dental care was provided
during quarantine, increase of emergencies, the biosafety routine of dental offices,
among others were also included ([Table 1]). The levels of concern about the impact of quarantine on dental care and patient’s
oral health conditions and about the economic impact of quarantine on dental practices
were evaluated with a 0- to 10-point scale.
Table 1
Questionnaires and answers distributions (n = 537)
|
Questions
|
Answers
|
|
1. How old are you?
|
Mean age = 38.44 y (±11.20)
|
|
2. Sex/Gender
|
Females 322 (60%)
Males 215 (40%)
|
|
3. In which state of Brazil is your dental office?
|
More affected states 222 (AL = 1; AM = 1; CE = 2; MA = 1; PA = 1; PE = 1; RJ = 19;
RN = 1; SP = 191; SE = 4).
Less affected states 315 (BA = 4; DF = 14; GO = 4; MG = 25; MS = 11; MT = 29; PI =
4; PR = 191; RS = 15; SC = 15; TO = 3).
|
|
4. What is your specialty?
|
General dentistry 105 (19.6%); Orthodontics 104 (19.4%); Implant dentistry 91 (16.9%);
Prosthetic dentistry 58 (10.8%); Endodontics 52 (9.7%); Restorative dentistry 36 (6.7%);
Oral surgery 22 (4.1%); Pediatric dentistry 19 (3.5%); Periodontics 18 (3.4%); Orofacial
harmonization 16 (3%); Stomatology 6 (1.1%); Radiology 5 (0.9%); Temporomandibular
disorder 3 (0.6%); Hospital dentistry2 (0.4%).
|
|
5. What is your degree of dental graduation?
|
General dentist 83 (15.5%); Specialist 305 (56.8%); Master (MSc) 94 (17.5%); Doctor
(PhD) 55 (10.2%).
|
|
6. How were the dental care appointments in your office during quarantine (most of
the time)?
|
Routine care appointments were maintained 140 (26.1%).
Only emergency or urgency care was scheduled 347 (64.6%).
Dental office closed; no orthodontic care provided 50 (9.3%).
|
|
7. Was there an increase in dental emergencies in your office during this period?
|
Yes 237 (44.1%)
No 300 (55.9%)
|
|
8. What do you think that caused increase in dental emergencies?
|
Increased patient’s anxiety and stress 128 (41.6%).
Absence of routine/elective dental care 161 (52.3%).
Others 19 (6.1%)
|
|
9. What were the main causes of emergency dental care? (select all that apply)
|
Toothache 362 (71.4%); Broken restorations 205 (40.4%); Anterior tooth fracture/Dental
trauma 189 (37.3%); Posterior tooth fracture 161 (31.8%); Breakage of orthodontic
appliance 128 (25.2%); Temporomandibular disorders 48 (9.5%); Emergencies related
to poor oral hygiene 45 (8.9%).
|
|
10. How did your patient get in touch to schedule the emergency care? (Select all
that apply)
|
Messages to the dental office’s WhatsApp 358 (70.6%).
Dental office’s phone call 249 (49.1%).
Personal dentist’s phone call and/or WhatsApp message 195 (38.5%).
Dental office webpage on social networks 73 (14.4%).
Personal dentist’s webpage on social networks 42 (8.3%).
|
|
11. What is your level of concern about the impact of quarantine on dental care and
the oral health condition of your patients?
|
Mean = 8.09 (±2.05)
|
|
12. With the pandemic, was there a change in the biosafety routine of the office?
|
Yes 506 (95.5%)
No 24 (4.5%)
|
|
13. Did you provide dental care (emergency or not) accompanied by your staff?
|
Yes 220 (41.5%)
No 310 (58.5%)
|
|
14. Did your patients seek for elective/routine dental care?
|
Yes 450 (83.8%)
No 87 (16.2%)
|
|
15. Which elective/routine dental care were most frequently sought during quarantine?
(Select all that apply)
|
Prophylaxis and preventive procedures 241 (49.1%)
Esthetic restorations 196 (39.9%)
Orthodontic treatment 177 (36%)
Prosthesis installation 174 (35.4%)
Surgery; teeth extraction 132 (26.9%)
Implant placement 97 (19.8%)
Teeth whitening 72 (14.7%)
Orofacial esthetic procedures 42 (8.6%)
|
|
16. What is your level of concern about the economic impact of quarantine/pandemic
on your dental practice?
|
Mean = 9.03 (±1.62)
|
|
17. During the quarantine period, did you dismiss your staff?
|
Yes, they took a vacation 193 (35.9%).
Yes, but they were at home-office 188 (22%).
No, they continued to work routinely in the dental office 129 (24%).
Staff suspended from activities with government assistance 67 (12.5%).
I had to fire my employee(s) 30 (5.6%).
|
Responses to the questionnaire were tabulated in excel, for statistical analysis.
To test the reliability of the answers, question 7 was repeated twice in the survey,
because it was an important question with yes/no response. This allowed performing
an intraclass correlation coefficient that showed a result of 0.91, indicating an
excellent agreement. This question was chosen because it has only three responses,
including yes or no, and was a critical and important question in the survey.
Descriptive statistics were performed with percentages. Comparison of age and levels
of concerns among dentists that provided routine dental care, only emergencies, or
closed the dental office was performed with one-way ANOVA and Tukey tests. Association
between dentists from more and less affected states with the type of dental care provided
or dental office closed was performed with the chi-square test. Statistical analysis
was performed with Statistica software (version 10.0, Statsoft, Tulsa, Okla, United
States), and results were considered significant at p < 0.05.
Results
As shown in [Table 1], 537 dentists, 60% females and 38% males, with a mean age of 38.44 years, participated
in the research. Dentists were from 21 Brazilian states (26 states and 1 district
capital), 41.3% live in the most affected states by COVID-19, and 58.7% from less
affected states.
Among the professionals, there were general dentists and specialists from more than
ten expertise areas in Dentistry. Most of them were specialists (56.8%) with more
than 10 years of clinical experience, in addition to general dentists (15.5%), MScs
(17.5%), and PhDs (10.2%).
During quarantine, 64.6% of the dentists attended only urgency/emergency dental care,
26.1% maintained routine appointments, and 9.3% closed the dental offices. More dentists
from the less affected states maintained routine dental care than dentists from the
states with more confirmed cases of COVID-19, and this difference was statistically
significant ([Fig. 1]). Furthermore, dentists that maintained routine dental cares were younger and presented
a significantly lower level of concern about dental treatments and oral health conditions
of their patients ([Fig. 2]).
Fig. 1 Association between dentists from most or least affected states and type of dental
care provided or dental office closed (p < 0.000).
Fig. 2 Comparison of age, and levels of concerns among dentists that provided routine dental
care, only emergencies or closed the dental office (asterisk indicates the presence
of a statistically significant difference, p < 0.000).
Regarding urgency/emergency appointments, only 44.1% reported an increase in demand
for emergency care during quarantine, and this was attributed mainly to increased
patient’s anxiety and stress (41.6%) and unavailability of routine/elective dental
care (52.3%). The main causes of urgencies/emergencies were toothache (71.4%), broken
restorations (40.4%), dental trauma (37.3%), breakage of orthodontic appliance (25.2%),
and temporomandibular disorders (TMD) (9.5%). Most patients got in touch to schedule
the emergency appointment by message to the dental office’s WhatsApp (70.6%), a phone
call to the dental office (49.1%), and through message or call to the dentist’s personal
phone (38.5%).
The mean level of concern of the dentists about the impact of quarantine on dental
care and patient oral health condition was 8.09 in a 0-to-10-point scale ([Fig. 3]).
Fig. 3 Histogram of the level of concern about the impact of quarantine on dental care and
the oral health condition of the patients.
Almost all dentists (95.5%) changed the biosafety protocols of the dental offices
to reduce the risk of coronavirus spread, and most of them (58.5%) attended emergency
appointments without staff.
Most professionals (83.8%) reported that patients sought elective dental care, and
most of them were adults (87.8%). In this situation, 54% of the dentists performed
elective/routine procedures. The most sought elective procedures were prophylaxis
and preventive procedures (49.1%), esthetic restorations (39.9%), orthodontic treatment
(36%), prosthesis installation (35.4%), teeth extraction (26.9%), implant placement
(19.8%), teeth whitening (14.7%), and orofacial esthetic procedures (8.6%).
The mean level of concern about the economic impact of quarantine on dental practices
was 9.03 ([Fig. 4]). Moreover, 35.9% of the dentists gave their employees vacations, or they were maintained
at home-office (22%). Only 24% of the employees maintained regular work at the dental
office, 12.5% were suspended from activities with government assistance, and 5.6%
were fired.
Fig. 4 Histogram of the level of concern about the economic impact of quarantine/pandemic
on dental practices.
Discussion
Brazil is a continental country. Disregarding the Russian territory, Europe has a
territorial extension similar to Brazil. Consequently, the regions of Brazil were
affected in different ways and intensities by COVID-19, and the most affected were
southeast (population: 85 million people) and northeast regions (population: 50 million).[12] To avoid the coronavirus spread, Federal and State governments declared the quarantine
period as a restrictive social contact protocol. Two hundred and twenty-two dentists
(41%), who answered the questionnaire, live in the most affected states, while the
remaining 315 professionals (59%) live in the least affected states ([Table 1]).
In dental care, the fear of dissemination of COVID-19 and the need for time to implement
a novel biosafety protocol motivated the dentists to reduce elective procedures. In
the beginning, there was not much information on how to deal with dental care appointments,
especially for urgencies and emergencies. Currently, according to the present results,
95.5% of the professionals reinforced biosafety protocols of dental offices, such
as the use of face shields and disposable personal protective equipment discarded
after each appointment, improved suction to avoid aerosols/droplets dispersion, mouth
rinsing with chlorhexidine before dental procedures, rubber damn isolation, and increase
in time between dental care appointments. Dentists and dental staff reinforced the
handwashing procedures, equipment disinfection using sodium hypochlorite, and mandatory
use of disposable masks all the time.
Patients were instructed to wear disposable shoes cover and to clean their hands with
70% alcohol at the entrance door. As the incubation period of COVID-19 is up to 14
days,[13]
[14] dental staff triage patients before the schedule regarding symptoms or contact with
COVID-19 diagnosed people. If necessary, the appointment would be postponed. Body
temperature is measured before the dental procedure looking for asymptomatic patients.
These protective measures allowed some dentists to maintain routine dental care (only
26.1% maintained routine/elective appointments) since the population is feeling more
secure and safer as more information regarding COVID-19 is published.
Most dentists (64.6%) who answered the questionnaires attended only urgencies/emergencies
during quarantine, and 58.5% provided dental care without staff. According to the
present survey, a higher percentage of dental professionals from less affected states
maintained routine dental care compared with dentists who live in states with more
confirmed cases of COVID-19, and this difference was statistically significant ([Fig. 1]). Besides, dentists that maintained routine dental care were younger and less concerned
with the dental treatments to be performed, as well as with the patient oral health
than dentists that closed dental offices or provided only emergency dental care ([Fig. 2]). Younger people reported lower anxiety levels with the pandemic in a previous study,
may be because older people are facing greater family and job concerns, and financial
worries.[15] This lower level of concern may also be related to the continuity of dental treatments
that started before the COVID-19 outbreak/quarantine protocols and the confidence
that the reinforced biosafety protocols would be an effective protocol to provide
a safe environment for dental appointments.
It registered an increase in urgency/emergency procedures by 44.1% of the dentists,
mostly due to the unavailability of routine/elective dental care and increased patient
anxiety and stress. During the quarantine period, 71.4% of dental appointments were
related to toothache, a clinical condition that cannot be postponed. Other leading
causes of urgency/emergency appointments were dental trauma and broken restorations
were the main causes of dental appointments. However, these conditions are common
in urgent dental appointments.[16] Emergencies related to the breakage of orthodontic appliances are possibly due to
the increased or delayed interval between appointments imposed by the quarantine.[17]
[18] TMDs were related to 9.5% of the dentists as the cause of emergency dental care
during the quarantine. This may be related to increased patient’s anxiety and stress
during the pandemic/quarantine.[19]
[20] Some psychological disturbances are important risk factors for the development of
signs and symptoms of TMD.[21]
In this sense, teledentistry can be used to help to relieve patient’s anxiety and
stress, like tips for maintaining oral health, avoiding the need for a face-to-face
dental appointment,[22] since most dental problems can be prevented with regular dental care and steps to
minimize risks of oral trauma.[16] Some urgencies in dentistry will need face-to-face appointments, but focus on high-quality
nonvisit care would work well for many patients.[23]
A very interesting data are that, despite the stay-in-home recommendations, 83.8%
of the dentists reported that their patients sought for elective dental care, like
prophylaxis and preventive procedures (49.1%). Patients may have sought for elective
dental treatment because they are not respecting the quarantine as recommended by
the local authorities or probably because patients live in states with lower COVID-19
incidence. Also, the population may not entirely respect or agree with less social
distance.[22] Another probable cause for this great demand for elective and preventive procedures
may be due to fear of worsening of the pandemic, and consequently, fear by the patients
of not being able to receive any dental treatment in the next months.
Some procedures, like prophylaxis, the most sought elective dental care by the patients,
cause great production of aerosols, thus increasing the chances of contamination.
Dental procedures involving aerosols should be avoided in places during the COVID-19
outbreak. Besides, in addition to standard precautions, some special precautionary
measures should also be implemented during this special period.[24]
During these difficult times, we must ethically decide whether or not to maintain
dental care, taking into account the needs of patients and also the protection of
dental staff, patients, and the entire community. However, shutting down, even temporarily,
is a cause for concern not just for patients but for dentists that reported a high
level of concern about the economic impact of the quarantine on dental practices,
as well as those of their staff members. In addition to the economic concern, some
dentists have expressed their intention to continue the day-to-day practice. This
may have been motivated, in part, by a sense of avoiding harm to employees who would
have their income reduced if the practice is not able to meet payroll for a period.
Conclusions
COVID-19 caught governments and people off guard. The purpose of quarantine is to
reduce social contact so that the spread of the virus decreases, thus preventing those
hospitals from being overwhelmed. On the other hand, self-employed professionals need
to work to maintain their companies and families. The pandemic/quarantine has negatively
affected the clinical routine of dental offices, and personal protection/hygiene care
must be adopted and reinforced by dental professionals/staff and patients to make
the dental procedures safer.
