Knowledge, attitude and practice among dental practitioners with regard to overcoming the barriers created by personal protective equipment in the COVID-19 era and delivering effective dental treatment: A questionnaire-based cross-sectional study

Background. In the wake of the coronavirus disease 2019 (COVID-19) pandemic, dental professionals are at high risk of contracting the virus owing to their close proximity to patients. Using personal protective equipment (PPE) is necessary to avoid being infected as well as to avoid being the source of infection. Apart from physical limitations, also communication and work efficiency are affected by the barriers created by PPE. Objectives. This study was conducted to assess knowledge, attitude and practice regarding the challenges faced by dental practitioners in India due to the use of PPE as well as to discuss the ways of overcoming these barriers by dentists.


Introduction
The coronavirus disease 2019 (COVID-19) pandemic has tremendously affected the dental profession.Dentists are at high risk of contracting and transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19, alongside paramedics, nurses and other health care workers.The virus is mainly present in the nasopharyngeal and salivary secretions of infected patients, and is spread primarily through respiratory droplets, aerosols and fomites.Dental treatment requires from the dentist to be in close proximity to the patient's mouth and throat, which makes the dental personnel highly exposed to the virus, and contributes to the transmission of the virus to other staff members and patients.Many dental procedures, such as using headpieces and ultrasonic instruments, generate aerosols, increasing the likelihood of spreading the virus, which makes dentistry one of the most high-risk professions. 1 COVID-19 has not only increased the fear of aerosol contamination during dental treatment, but also caused the fear of close contacts. 2he use of disinfectants and personal protective equipment (PPE) remains imperative for maintaining proper working conditions and preventing further transmission.Personal protective equipment minimizes exposure to the contaminated body fluids, reducing the risk of infection. 3t creates a physical barrier between the pathogenic organisms and the operator, thus preventing any droplets from settling on the operator's skin.However, dentists are facing a new set of challenges, both physical and mental, from wearing PPE as they adapt to provide quality dental care in the COVID-19 era.
Along with the physical limitations created by PPE, communication is also affected due to the already increased levels of anxiety and stress created during this health care crisis. 4Understanding the dentist becomes significantly more difficult for patients and the dental assistant due to the added layers of PPE along with the surrounding noise of the compressor, suction, fans, and other equipment.Consequently, it is hard for the patient to follow the operator's instructions during treatment.Personal protective equipment, which includes gloves, gowns, shoe covers, head covers, masks, respirators, face shields, and goggles, hides facial expressions, the main tool for displaying emotions.Smiling, one of the easiest and most pleasing ways to connect with other person, is no longer an option.Masks muffle voices, making it more difficult to catch every word and infer the emotion associated with it.In addition to these barriers, there are several side effects associated with the use of PPE, resulting in physical and emotional exhaustion, which in turn affects the dentist's work efficiency.
This survey focuses on the assessment of the common concerns of practicing dentists in the COVID-19 era and was designed to study the overall effects of PPE on a dental setup.
The aim of the study was to assess the common concerns among dentists related to their practice in the COVID-19 era, to assess their use of PPE on a daily basis, to determine if the pandemic has in any way changed their work routine, and to assess any side effects and difficulty in communication created by the use of PPE.

Study settings and participants
This questionnaire-based cross-sectional study was conducted over a period of 1 month between February 1 and March 5, 2021.The participants consisted of practicing dentists from various parts of India with varying experience, age, sex, and specialty.The study participants were approached by the principal investigator.

Sample size
The sample size was estimated using the OpenEpi software, v. 3.01 (https://www.openepi.com/Menu/OE_Menu.htm), and the 'sample size for frequency in a population' formula.A p-value <0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study of 80%; a total sample size of 390 was derived.

Data collection
A structured, self-explanatory questionnaire was created in English on the Google Forms platform.It consisted of a brief introduction to the study, followed by 2 sections.Section I collected the demographic data, and section II consisted of 12 open-and closed-ended questions regarding the participants' knowledge, attitude and practice with regard to the use of PPE, changes in their diet and work routine, the side effects of PPE, and effects on communication and work efficiency (Table 1).The study participants were approached by the principal investigator via personal connections and the Internet/e-based technologies (e.g., online platforms and e-mail).A pilot study was initially conducted with 10 participants.According to their responses and feedback, the following changes were made: -the questions were divided into 2 sections -section I consisted of questions related to the sociodemographic data, while section II consisted of questions related to the use of PPE in a dental setup; -multiple option checkboxes were added wherever necessary.
The questionnaire was then sent to the study participants and their responses were kept confidential.Timely reminders were sent as well.Participation was completely voluntary and all the participants could opt out of the study by not completing the questionnaire.No.

Questions Answer options
Section II: Questions related to the use of PPE in a dental setup 5. As

Statistical analysis
The data was compiled in a Microsoft Office Excel spreadsheet (v.2019; Microsoft Corporation, Redmond, USA).The data was subjected to the statistical analysis with the use of the IBM SPSS Statistics for Windows software, v. 26.0 (IBM Corp., Armonk, USA).Descriptive statistics like number and percentage (n (%)) were used for categorical data.Numerical data was expressed as mean and standard deviation (M ±SD).The comparison of frequencies for the categories of variables between the groups was made using the χ 2 test.For all statistical tests, p < 0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study of 80%.

Results
This survey had a sample size of 390 dentists who completed the questionnaire (201 general dentists and 189 specialists).More than half of the participants (n = 273; 70.00%) were between 20 and 30 years of age, with 269 (68.97%) having worked less than 5 years.Among all the participants, 158 (40.51%) were male and 232 (59.49%) were female.A total of 174 (44.62%) respondents were practicing at an institution/college and 104 (26.67%) were practicing at a private clinic.The distribution of specialists was as follows: 45 prosthodontists; 33 orthodontists; 23 pedodontists; 19 endodontists; 18 oral pathologists; 15 oral surgeons; 15 periodontists; 14 radiologists, and 7 public health dentists.These details are presented in Table 2.
Approximately ⅓ of the participants (n = 142; 36.41%)used a gown, a mask/respirator, a head cover/hood, and a face shield as part of their PPE on a daily basis.Among the respondents, 283 (72.56%) agreed that N95 masks were the most effective ones, and 224 (57.44%) used an N95 mask regularly.It was found that 163 (41.79%) of the participants removed their PPE 2-3 times a day, while 109 (27.95%) never removed their PPE during a normal workday.
As per the responses recorded, 133 (34.10%) participants did not take any lunch/water breaks between patients.As compared to pre-COVID times, 117 (30.00%) respondents changed their food intake pattern.The survey found that 40 (10.26%)dentists decided to have healthier foods, such as freshly prepared home-cooked meals, including vegetables, fruits and eggs (i.e., a fibrous, proteinaceous, vitamin-rich diet).There were 30 (7.69%) who answered that they skipped meals or had delayed meals, whereas 28 (7.18%) maintained a strict diet routine and hygiene, and avoided in-between snacking.
According to 331 (84.87%) participants, wearing PPE had affected their work efficiency, while 59 (15.13%) responded that it had not.Just over ⅓ of the participants (n = 137; 35.13%) had to spend more time per patient, had their vision impaired and felt exhaustion.It was found that 89% of the respondents had difficulty in communication due to the use of PPE, while 11% stated that they had no difficulty.Among the participants, 38% responded to the open-ended question on how they overcome this difficulty in communication.For 21.54% of the dentists, this involved repeating loudly, 9.74% preferred other means of communication (like providing instructions via text messages or calls, writing on a piece of paper, or using a microphone with a small speaker), 4.62% preferred communicating before/after the procedure, and 2.56% removed the mask or the face shield for a moment.Among the respondents, 28% agreed that the patient seemed more anxious upon seeing the dentist in PPE.When asked how they alleviate this anxiety, 41 (10.51%) stated that they had a conversation and reassured the patient, 23 (5.90%) explained the importance of wearing PPE to the patient and 14 (3.59%) lightened the mood with a joke.The majority of the participants (n = 231; 59.23%) responded that they explained the treatment plan and gave post-operative instructions to the patient on the dental chair while wearing their PPE, 84 (21.54%) provided this information at the front desk after doffing their PPE, and some used a mobile phone/ WhatsApp.These results are presented in Table 3.
Highly statistically significant differences were observed in the response rates for certain categories (p < 0.010), with higher frequencies for the response 'female' (Table 4), for the participants falling within the age group of 20-30 years (Table 5) and for the participants working in the institutional/dental hospital type of practice (Table 6).When the response rates were compared with regard to the number of years of experience, there was a higher frequency for the participants with less than 5 years of experience (p < 0.010) (Table 7).When comparing specialties, there was a statistically higher response rate from the participants practicing as general dentists (p < 0.010) (Table 8).
Figure 1 presents the responses regarding side effects: 287 participants experienced profuse sweating; 203 participants experienced breathlessness; 168 participants suffered from headaches; 145 participants had a dry mouth; 113 participants experienced a dry throat; 111 respondents experienced skin irritation or oily skin; 83 participants had a blocked/stuffy nose; and 28 participants experienced a hoarse voice.

Discussion
This study assessed the common concerns among dentists about practicing during the COVID-19 pandemic as well as the overall effects of the pandemic on dental setups.Apart from its influence on clinical practice, the pandemic has also affected dental schools and dental university hospitals, resulting in partial or full closure.This in turn has had a negative impact on dental training and education, despite online teaching protocols. 5Personal protective equipment prevents exposure to an infectious agent or a body fluid by creating a barrier between the potential infectious material and the health care worker. 6It includes gloves, gowns, shoe covers, head covers, masks, respirators, face shields, and goggles.The responses indicate that 36% of the participants used gowns, masks/respirators, head covers/hoods, and face shields.It was found that 57% of the participants used an N95 mask, and 25% used both an N95 mask and a surgical mask for additional protection (Table 3).There are 2 issues to be considered with regard to the efficacy of a face mask -the filtration of the material and the fit of the design. 7A surgical mask is a loose-fitting, disposable mask and does not provide complete protection.An N95/ FFP2 respirator is designed to achieve a very close facial fit and very efficient filtration of airborne particles.The edges of the respirator are designed to form a seal around the nose and the mouth.The donning and doffing of PPE is a critical process that requires significant attention to detail.This process, particularly the removal and disposal of the contaminated PPE, is considered a very important step in limiting exposure to pathogens. 1 When examining the changes introduced by the participants regarding their food intake pattern, 34% of the participants did not take any lunch/water breaks between patients and 33% preferred completing all of the patients for the day, and then removing their PPE.This could lead to ill effects, like dehydration, fatigue, irritability, and constant hunger, which could in turn affect their work.Eating more nutritious, immunity-boosting, vitamin-rich food was preferred by many, especially in this COVID-19 era.Some dentists skipped or delayed their meals because of an ongoing patient or to avoid the inconvenience of removing their PPE.This can prove harmful in the long run by causing serious side effects that include fatigue, skin problems, depression, and weight loss.According to this survey, 85% of the dentists reported that the arduous use of PPE affected their work efficiency.In fact, 35% of the participants said that they spent more time per patient owing to the use of PPE.Some endodontists responded that it took more time to complete a root canal, since their tactile sensation was diminished due to the use of double gloves.According to a survey conducted by Swaminathan et al., vision is impaired due to the presence of a face shield, and thus using a microscope has become difficult. 8In the present study, it was found that the participants had a constant feeling of exhaustion due to the heat and perspiration caused by the use of PPE.Dental professionals of all ages are experiencing increased levels of physical and emotional discomfort since resuming the routine care.The study found that 43% of the participants reported headaches, which is the 3 rd most often reported side effect of implementing the advanced PPE protocols (Fig. 1).This could be a sign of dehydration. 9To avoid or minimize headaches and dehydration, it is important to drink enough fluids during the day.Profuse sweating was reported by 74% of the respondents and 52% reported breathlessness.Taking short breaks throughout the day that allows one to remove their PPE may help overcome these difficulties.Reduced O 2 in the inspired air, CO 2 retention, rebreathing, and increased temperature, in isolation or combination, during prolonged PPE use could be a cause of physical exhaustion and breathlessness. 10In the present survey, 28% of the respondents reported skin irritation or oily skin due to the use of face masks.The constant rubbing of the mask against the skin causes micro-tears, allowing easier entry for bacteria and dirt to clog the pores. 11xposure duration is considered to be the main risk factor for facial dermatitis, particularly when masks and goggles are worn for over 6 h.Washing hands more than 10 times a day may increase the risk of hand damage. 12he study findings support the authors' assumption that there is difficulty in communication due to the use of PPE (as reported by 89% of the participants).With the mouth being completely covered, safety glasses covering the eyebrows and face shields further muffling sound, in addition to the noisy working environment, both patients and the dental staff struggle to comprehend each other (as reported by 53% of the participants).Dentists have adapted themselves to overcome this communication gap.For example, 22% stated that repeating their instructions loudly was effective.However, in addition to frustration or miscommunication, raising one's voice for prolonged periods may lead to issues with voice strain and abuse. 12 further 10% resorted to other means of communication, such as providing instructions via text messages or calls, writing on a piece of paper, or using a microphone with a small speaker.Non-verbal communication with hand gestures and other movements also proved to be effective.
Generally, when interacting with an unfamiliar face, people tend to focus their attention on the mouth and the eyes, as these are most expressive.For health care workers, it is difficult to convey a feeling of calmness or happiness, as almost 85% of the face is covered with PPE. 13 This can add to the stress and anxiety patients already feel owing to this health care crisis. 14To alleviate this anxiety, the participants explained the importance of wearing PPE and how it provides safety to both the operator and the patient. 15Having a conversation and reassuring the patient, or lightening the mood with a joke proved to be helpful.Communication is not just simply talking; the tone of the speech and expressions are important factors that influence it.Not only does the current use of masks and safety glasses make communication difficult, but it also causes digging on the bridge of the nose and the sides of the face, which may cause skin irritation.Prolonged side effects, like dehydration, sweating, fatigue, breathlessness, and headaches could be detrimental in the long run.
The use of PPE has been amplified during the COVID-19 pandemic; however, protection needs to be comfortable, not only to prevent fatigue or physical pain, but also for psychological well-being. 16

Conclusions
Even though the use of PPE has become more important than ever, the results of this study show that it is a challenge for dentists in a clinical setup.As reported by the participants, there is difficulty in communication due to the added layers and the muffling of sound, and changes in work routines and food intake patterns may cause malnourishment and dehydration.There was a significant decrease in work efficiency owing to the added layers and their side effects.The most frequent side effect of PPE was profuse sweating, while the least experienced was a hoarse voice.All of the dentists faced side effects like dehydration, headaches, sweating, and fatigue, which could be detrimental in the long run.
In order to mitigate these problems, adapting to other means of communication, alleviating the patient's anxiety, taking regular breaks, drinking plenty of water, and having a healthy and balanced diet are essential for dentists in the COVID-19 era.
the dental chair while wearing PPE b) at the front desk after doffing PPE c) by clicking pictures and explaining them to the patient over WhatsApp d) any other 12.How do you give post-operative instructions and medications to the patient?a) on the dental chair while wearing PPE b) at the front desk, by the receptionist c) over phone/WhatsApp d) any other PPE -personal protective equipment; COVID-19 -coronavirus disease 2019.

Table 1 .
Questionnaire used in the study

Table 2 .
Demographic details of the participants (N = 390)

Table 3 .
Overall responses to the questionnaire Response n (%) What components of PPE do you use most commonly?gown, mask/respirator, head cover/hood, face shield (36.41) gown, mask/respirator, face shield (25.64)Fig. 1.Side effects of personal protective equipment (PPE)

Table 5 .
Comparison of the responses according to age

Table 4 .
Comparison of the responses according to sex

Table 6 .
Comparison of the responses according to type of practice

Table 7 .
Comparison of the responses according to the number of years of experience

Table 8 .
Comparison of the responses according to the specialty