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1. S353
© 2021 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
Aim: The purpose of our study was to analyze the knowledge and attitude of
conservative as well as endodontic practice among dental professionals during
coronavirus pandemic situation. Methodology: A cross‑sectional study was
conducted over a period of 3 months among 1256 dental surgeons, which included
400 MDS and 856 BDS dentists. Questionnaire assessed knowledge of the
participants about COVID‑19, risk assessment about the pandemic, preparedness of
the participants, as well as specific precautions in cases which require conservative
and endodontic treatment strategies against COVID‑19. Results: It was observed
that around 83% of the study participants felt that rubber dams are a useful tool
to prevent cross‑infections, even COVID‑19. However, COVID‑19 prevention
techniques such as use of low‑speed handpiece and chemicomechanical techniques
were preferred by a smaller number of participants: 25% of participants by former,
only 12% for the latter. To prevent aerosol splatter, use of high‑volume suction
was preferred by 49% of dental surgeons. Conclusion: In our study, we concluded
that dental surgeons, who come under high risk category; had good basic
knowledge about COVID-19 disease process as well as transmission. However,
it is imperative that these clinicians need to be extra cautious in handling cases
during this pandemic time and limit the disease spread as well.
Keywords: COVID‑19, dental professionals, pandemic, precautionary measures
Knowledge, Perception, and Attitude on Conservative and Endodontic
Practice on COVID Pandemic Situation: A Qualitative Research
Sumit Khatore1
, Sakshi Kathuria2
, Manoj Kumar Rawat3
, Amar Ashok Thakare4
, Surbhi Abrol5
,
Sai Prashanth Pinnamaneni6
, Rahul VinayChandra Tiwari7
Access this article online
Quick Response Code:
Website: www.jpbsonline.org
DOI: 10.4103/jpbs.JPBS_740_20
Address for correspondence: Dr. Sumit Khatore,
Department of Conservative Dentistry and Endodontics.
Awadh Dental College and Hospital, Jamshedpur,
Jharkhand, India.
E‑mail: sumitkhatore86@gmail.com
the pathogen from the family of Coronaviridae, which
has single‑stranded RNA as its genetic material.[3]
This
particular infection resembles SARS and MERS.[4]
Till
date, four genera of this coronavirus family has been
Introduction
COVID‑19 has caused a terrifying situation world over,
resulting in a devastating pandemic and leading to loss
of life and economy everywhere. It is more contagious
than other type of coronavirus infections such as MERS
and severe acute respiratory syndrome (SARS).[1]
According to the International Committee on Taxonomy
of Viruses, this virus was named as SARS coronavirus
2 (SARS‑CoV‑2).[2]
This viral infection is caused by
1
Department of Conservative
Dentistry and Endodontics,
Awadh Dental College
and Hospital, Jamshedpur,
Jahrkhand, India, 3
Department
of Dentistry, Pt. Jawaharlal
Nehru Government
Medical College, Chamba,
Himachal Pradesh, India,
6
Department of Conservative
Dentistry and Endodontics,
S Nijalingappa Institute
of Dental Science and
Research, Gulbarga,
Karnataka, India, 7
Department
of OMFS, Narsinbhai
Patel Dental College and
Hospital, Sankalchand
Patel University, Visnagar,
Gujarat, India, 4
Department
of Prosthodontist, College
of Dentistry, Al Zufli,
Majmaah University,
Kingdom of Saudi Arabia,
2
Dental Surgeron, Turlock,
California, USA, 5
Boston
Unversity, Boston,
Massachusetts, USA
Submitted: 18‑Nov‑2020
Revised: 20‑Nov‑2020
Accepted: 21‑Nov‑2020
Published: 05-Jun-2021.
Abstract
How to cite this article: Khatore S, Kathuria S, Rawat MK, Thakare AA,
Abrol S, Pinnamaneni SP, et al. Knowledge, perception, and attitude on
conservative and endodontic practice on COVID pandemic situation: A
qualitative research. J Pharm Bioall Sci 2021;13:S353-8.
Original Article
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit is
given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
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2. S354 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 1 ¦ June 2021
Khatore, et al.: COVID 19 and endodontic practice
studied, which are α‑CoV, β‑CoV, γ‑CoV, and δ‑CoV.[5]
In humans and mammals, α‑CoV and β‑CoV variants
affect central nervous system and respiratory as well as
gastrointestinal tract systems, and other variants affect
mostly broad species.[6]
When affected by this disease, the
person presents with a plethora of signs and symptoms
such as cough, fever, respiratory distress, diarrhea,
abnormal opacities in computed tomography scans, and in
some cases hemoptysis.[7]
Initially it was considered as an
zoonotic infection but with evidence from various studies
have confirmed the person to person transmission, which
is by far the most important route for rapid spreading of
this pandemic.[8]
Emergence of this new strain of coronavirus has been
amounted to the environmental devastation, which has
been caused by humans, resulting in spread of infections
from animals to humans.[9]
It rapidly spreads, especially in
hospital or clinical setting, resulting in serious nosocomial
infection.[10]
Medical staff are the most susceptible to this
particular infection, as they acquire it from the nosocomial
settings, which comes under high‑risk category.[2]
Dental
clinics also come under high risk category setting as
close contact is very much possible with a virus infected
individual and the treating dental doctor.[11]
Considering
that COVID‑19 is extremely contagious, it is generally
recommended that the patients suffering from this
infection are not supposed to be treated for dental
diseases, but emergencies can always turn the situation
around. This becomes even more challenging when
prolonged incubation period of the disease is considered,
which is 5–14 days, where the detection of symptoms
is ambiguous, leading to extensive spread in this lay
period.[3,12]
Hence, asymptomatic patients are a great threat
to dental settings, so proper awareness needs to be there
in the dental team to handle any type of situations related
to COVID‑19. Guidelines have been by various health
organizations such as CDC and ADA as well as the WHO
to slow down the spread of infection of coronavirus. They
emphasize on the use of personal protective equipment,
thorough screening of the patients and staff, disinfection
of the premises of the clinic, rubber dam isolation, etc., It
is essential to be familiar with these guidelines and deal
with the prevention as well as control of this disease in
a sophisticated manner.[1.13]
We carried out this research
to assess the knowledge as well as awareness about this
infection, how to handle situations in these pandemic
times among dental professionals.
Aim of the study
The purpose of our study was to analyze the knowledge,
perception, and attitude of conservative as well as
endodontic practice among dental professionals during
coronavirus pandemic situation.
Methodology
A cross‑sectional study was conducted over a period of
3 months among 1256 dental surgeons, which included
400 MDS and 856 BDS dentists. An online Google
Form containing 31 close‑ended questions was circulated
to assess knowledge, attitude, and preparedness
of COVID‑19 among Indian dentists. Participants’
confidentiality was maintained throughout the study.
The questionnaire was created in English language and
was divided into five parts concerning with demographic
characteristics, knowledge about COVID‑19 infection,
perception of risk in the present situation, how prepared
were they to handle this situation, and finally specific
precautions in cases which required conservative and
endodontic treatments.
Cronbach’s alpha test was used to assess the validity of
the questionnaire given to the dental surgeons, which also
evaluated that if the questions were easily understandable
for the study participants. For knowledge as well as risk
perception questionnaire segment, the test values were
0.835 and 0.821, respectively, which established that the
questions were well structured and easily understandable
among the participants.[14]
The collected data were
analyzed with the help of Statistical Package for the Social
Sciences (SPSS ver 22.0, IBM Corporation, USA), where
the categorical variables were n%, and for continuous
variables, standard deviation and mean were calculated.
P < 0.05 was considered statistically significant.
Results
Only 12% of the dental participants had undertaken
training for COVID‑19 prevention [Table 1]. As far as
knowledge about COVID‑19 disease was concerned,
around 68% of the dental participants were aware about
various diseases caused by coronavirus. 77% of the dental
participants were aware that real‑time polymerase chain
reaction was a gold standard test to diagnose COVID‑19.
However, only 43% of the dental participants knew
about the actual incubation period of the disease, which
was important to understand and control the disease
process [Table 2]. 12% of dentists had wrong perception
that COVID‑19 was not contagious, and 37% of them
believed that wearing just surgical masks will suffice
during the time of treatment. However, fortunately,
72% of dentists believed that PPE kits are necessary
to prevent COVID‑19 spread, which was encouraging.
68% of all participants believed that high aerosol
splatter procedures such as ultrasonic scaling and usage
of high handpiece should be undertaken with great care,
as it causes cross‑contamination as well as infection
spread [Table 3]. Around 73% of dentists felt the need to
train their staff members against COVID‑19 prevention
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Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 1 ¦ June 2021
Khatore, et al.: COVID 19 and endodontic practice
techniques. 86% of participants also advocated the use
of pulse oximeter and thermal screening for all the
patients as well as staff members on a regular basis.
In these days, telephonic consultations have become
popular for nonemergency cases, but only 12% of the
dentists believed that it can be a helpful alternative to
conventional visit to dentists for elective procedures.
High‑efficiency particulate air (HEPA) filters to filter
out pathogens from the air were only preferred by 13%
of participants [Table 4]. It was observed that around
83% of the study participants felt that rubber dams are a
useful tool to prevent cross‑infections, even COVID‑19,
which was also statistically significant (P = 0.001).
Disinfection of frequently touched areas by sodium
chloride was important according to almost 91% of
participants. Most of the participants (83%) were also
in favor of using single‑use disposable instruments
to prevent infection spread. However, COVID‑19
prevention techniques such as use of low‑speed
handpiece and chemicomechanical techniques were
preferred by a smaller number of participants: 25%
of participants by former, only 12% for the latter. To
prevent aerosol splatter, use of high‑volume suction was
preferred by 49% of dental surgeons, which was not
statistically significant (P = 0.603) [Table 5].
Discussion
Coronavirus infection has infected millions of people
worldwide, especially the health‑care professionals.[15]
Dental professionals work in close contact with blood
and saliva, so they also come under this very high‑risk
category.[16]
Even though during daily practice, those
professional have been handling cases with tuberculosis
and HIV, but handling a pandemic is proving to be a
tough task ahead for them.[17]
SARS infection in a dental
Table 1: Demographic characteristics of the participants
Parameter Distribution of the
study participants (%)
Age group (years)
<30 23
30-40 32
40-50 29
>50 16
Gender
Duration of practice (years)
<5 59
>5 41
Educational status
MDS 31.8
BDS 68.2
Specialty of dentistry
Endodontist 34
Periodontist 18
Oral surgeon 19
Orthodontist 2
Pedodontist 1
Public health dentist 6
Oral pathologist 6
Oral medicine 3
Prosthodontist 10
Training taken for COVID-19
Yes 12
No 88
Table 2: Knowledge about COVID-19 disease among the
participants
Question
number
Questions Correct answer
received from
participants (%)
1 Among these which is
coronavirus?
a) Common cold
b) MERS
c) SARS
d) COVID-19
e) All
f) Do not know
e) All (68)
2 Which is more lethal (high
mortality)?
a) SARS
b) MERS
c) COVID-19
d) Do not know
b) MERS (12)
3 COVID-19 is caused by which
of the following virus-
a) SARS-CoV-2
b) SARS-CoV
c) MERS-CoV
d) Do not know
a) SARS-CoV-2
(72)
4 What is the incubation period
of COVID-19 virus? (days)
a) 2-7
b) 2-14
c) 1-5
d) 1-21
e) Do not know
b) 2-14 days (43)
5 What is the laboratory
test available to diagnose
COVID-19?
a) rRT-PCR
b) ELISA
c) Western blot
d) DNA hybridization
e) Do not now
a) rRT-PCR (77)
MERS: Middle East respiratory syndrome, SARS: Severe acute
respiratory syndrome, rRT-PCR: Real-time reverse transcriptase
polymerase chain reaction, CoV: Coronavirus
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4. S356 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 1 ¦ June 2021
Khatore, et al.: COVID 19 and endodontic practice
clinical setting was first observed in the year 2003, but
this infection has an acute phase of fever, which prevented
them to visit clinic again during the symptomatic period.
So, people used to self- isolate themselves due to the
acute phase which is not the case in COVID infection,
where asymptomatic patients spread the infection further
rapidly.[18]
However, in case of COVID, the situation is
much worse due to asymptomatic patients, where the
presence of virus in saliva results in spreading in clinic
setting much faster.[19]
Aerosol splatter has proven to be
the most effective way for the spread of coronavirus,
which can spread to a distance of even 18” or more.[20]
ADA has, therefore, provided some guidelines, so that
only emergency treatment should be given preference
over the elective ones with minimal contact or
preferable no contact methods like teledentistry.[19]
Dental surgeons are these days very much concerned
about working in this pandemic situation.[21]
Hence,
adequate knowledge regarding COVID disease, will
be the only way ahead.[22]
In an endodontic setting,
Table 4: Level of preparedness among the dentists for general practice
Question
number
Questions Response received
from participants (%)
1 Dentist should provide adequate training to their staff to promote preventive measures
Yes 73
No 27
2 Do you know whom to contact if you have an unprotected exposure to a known or suspected
COVID-19 patient?
Yes 56
No 44
3 Can telephonic consultation be employed for non-emergency procedures?
Yes 12
No 86
4 Follow up on patients telephonically, if they have symptoms?
Yes 9
No 91
5 Usage of pulse oximeter and thermal screening of patients and other staff members regularly
Yes 86
No 14
6 Use of HEPA filters with commercial split and centralized/window ACs
Yes 13
No 87
HEPA: High-efficiency particulate air, ACs: Air conditioners
Table 3: Risk perception of COVID-19 among the participants
Question
number
Questions Response received
from participants (%)
1 Perception about COVID-19
Contagious 88
Noncontagious 12
2 Under which category do dentists fall in the risk of exposure?
High risk 81
Low risk 19
3 Which mask should be used by dentists in dental settings?
Surgical mask 37
N-95 mask 63
4 Are the personal protective equipment kits useful in protecting from confirmed/suspected
COVID-19 patients?
Yes 72
No 28
5 What dental procedures carry the maximum risk of virus transmission while treating a
COVID-19-positive patient?
Ultrasonic scaling and using high-speed handpiece 68
Procedures under rubber dam 30
Lasers 2
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Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 1 ¦ June 2021
Khatore, et al.: COVID 19 and endodontic practice
COVID patients should be entertained only for
emergency treatments or palliative (pharmacologically)
with adequate precautionary measures. It is imperative
to handle working in the pandemic situation, to divide
dental procedures on the basis of the urgency. The
treatments can be divided into ones which are emergency
procedures and procedures that are elective and can
be postponed for a later date. According to the CDC
guidelines, it is mandatory to wear N95 masks with eye
goggles or face shields for the dental professionals to
reduce cross‑contamination due to aerosol. In case of
endodontic microscopes, a plastic barrier can be created
attached to the binoculars, so that a physical barrier
is created. Whenever possible, extraoral radiography
like cone‑beam computed tomography needs to be
encouraged to have minimal contact with the patient.
If intraoral radiographs are a necessity, it should be
in limited amount. To limit the aerosol spread, usage
of rubber dam has been strongly advocated, so that
maximum coverage of patient tissues is there and less
of blood and saliva contact. This can reduce the airborne
spread by 90%.[23]
Vacuum suction can also be utilized
as it removed the contaminated air up to 2.83 m3
/min.[24]
HEPA filters are also an effective device, which removes
99.97% of the airborne particles measuring 0.3 µm,
which can be utilized to purify air in dental settings.[25]
Single visit treatments need to be encouraged, so that
canal disinfection can be done in cases of symptomatic
apical periodontitis or in cases of apical abscess. If
treatment cannot be completed in a single setting, after
complete debridement of canal, intracanal antibacterial
medicament needs to be placed in cases requiring
immediate intervention.[26]
Vital pulp therapies are
effective in case where single sittings are preferred
as they can reduce pain as well as are successful
treatment strategies. To minimize posttreatment pain
and discomfort, occlusal reduction would be an ideal
strategy.[27]
In case of traumatic injuries, it is advisable
to refer the patient to a dental setting where special
equipment are present to handle such situations;
meanwhile, the avulsed tooth needs to be transported
properly in a storage medium like milk. IADT guidelines
Table 5: Specific precautions in case of conservative and endodontics
Question
number
Questions Response
received from
participants (%)
P
1 Are rubber dams useful for infection control in COVID-19?
Yes 83 0.001
No 17
2 Disinfection of frequently touched surfaces with NaOCl and ethanol 0.003
Yes 91
No 9
3 Preference of low-speed handpiece for access opening?
Yes 25 0.041
No 75
4 Preference for chemicomechanical methods for necrotic pulpal tissue cleaning over conventional
methods
Yes 12 0.011
No 88
5 Preference to only emergency treatments
Yes 31 0.523
No 69
6 Use of high-volume suction
Yes 49 0.603
No 51
7 Disposable single-use instruments
Yes 83 0.04
No 17
8 Division of treatments based on endodontic emergency needs, urgent care, and for elective reasons
Yes 23 0.2
No 77
9 Single visit treatment preferred
Yes 67 0.348
No 33
*P<0.05 significant
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6. S358 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 1 ¦ June 2021
Khatore, et al.: COVID 19 and endodontic practice
need to be followed for any recovered COVID patients.
However, pharmacological interventions should take
a front seat during these pandemic times.[28]
In our
study, we noticed that most of the dental professionals
were aware of the pandemic situation as well as the
measures taken to control the same in their clinics. The
respondents have recorded a good judgment about the
risk perception as they know they fall in the high‑risk
exposure category and showed a positive attitude toward
performing dental treatment in the current COVID‑19
crisis. However, certain modifications were needed their
way of working to adjust to the COVID era of working.
Conclusion
Dental surgeons come under high‑risk group, so they
need to extra prepared to handle and prevent the spread
of COVID‑19. They should follow the guidelines given
by the WHO and CDC verbatim along with training
programs, so that safe as well efficient treatment can be
provided to the patients in this pandemic era.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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