Introduction

The COVID-19 crisis is the current outbreak crisis of viral origin originally originated in the city of Wuhan, China (Hubei province of China) (Zhu, 2019). The current scenario as of May 2020 has shown to spread around 213 countries and Territories. The coronavirus (CoVs) are named due to the presence of crown-like spiked proteins on their surface. They are positive-sense RNA based viruses with four different groups predominantly present, namely alpha, beta, gamma and delta (Fehr & Perlman, 2015).

Currently, there are seven strains of coronavirus seen to affect human, 229E (alpha coronavirus), NL (alphavirus), OC43 (beta coronavirus), HKU1 (beta coronavirus), MERS-CoV (Middle East respiratory syndrome or MERS), SARS-CoV (the beta coronavirus causes severe acute respiratory syndrome or SARS) and the current SARS-CoV-2 (COVID-19) (Shereen, 2020).

Due to the virulence of current pathogen SARS-CoV-2 which was shown to have human to human transmission through respiratory droplets (Sohrabi, 2020), it is reported that dental professionals are at high risk of nosocomial infection and could be a potential carrier of the disease (Wax & Christian, 2020). Many factors contribute to these factors such as aerosol generation, handling of sharps and proximity of the dental care providers to the patients oropharyngeal region (Peng & Ren, 2020). It is of primordial importance that all dental practitioners should follow correct protocol to prevent any further transmission for the safety of the health care professional and the patient.

Since a variety of procedures are carried out by dental practitioners such as treatment of tooth fractures (Jose, 2020), endodontic treatment (Ramamoorthi, 2015), veneers (Ravinthar & Jayalakshmi, 2018) correct protocol should be followed to prevent any cross-contamination. Various studies have shown the effect of different intracanal irrigants (Manohar & Sharma, 2018; Noor & Pradeep, 2016; Teja, 2018) that can have an effect on reduction on viral load if treatment is done in covid positive patients.

For the diagnosis the use of different diagnostic factors can play a crucial role than the conventional pulp vitality testing method, innovative methods such as custom made sensors can play a better alternative for the diagnostic procedure (Janani, 2020). The use of CBCT in this pandemic is an alternative since it reduces the incidence of exposure for the operator without the patient coming directly in contact. (Ramanathan & Solete, 2015).

CBCT can help assess different morphology which helps the clinician to assess better and formulate a treatment plan (Kumar & Antony, 2018). During the pandemic period, the use of better higher strength restorative material can play a crucial factor for the success of the treatment (Nasim & Nandakumar, 2018; Nasim, Hussainy, Thomas, & Ranjan, 2018; Rajakeerthi & Nivedhitha, 2019). This survey aims to assess the knowledge, attitude, the practice of dental practitioners and the different protocols to be followed during COVID-19 pandemic crisis in the South Indian population.

Materials and Methods

A self-administered questionnaire in English format comprising a total of 10 questions was distributed to the dental population residing in the South Indian region via Electronic media (Google forms, Google Inc, USA).

The questionnaire consisted of 3 significant parts aimed to assess different aspects of the clinician being four questions to assess the knowledge, 3 to assess attitude and the remaining questions to assess the practice protocol. The sample size was taken using a sample size calculator with the confidence interval set at 95%. Convenience sampling was to be taken into considerations.

Results and Discussion

The results consisted primarily of dental practitioners with a masters degree (MDS) which comprised 76.7% of MDS in various fields and 19.5% of MDS in Conservative Dentistry and Endodontics 3.8% of the Dental practitioners were practitioners who had a graduate degree (BDS).

Table 1 Statistical analysis was done using Chi square test for intercomparison between the different dental practitioners who responded for the survey and p value <0.005 was found to be statistically significant.

Figure 1, Majority of the respondents were from MDS — Other speciality (76.69%), MDS — Endodontics (19.55%) and BDS (3.76%).

Figure 2, Majority of the respondents selected the option “1% hydrogen peroxide” (87.2%), next majority responses selected the option “0.2% Povidone Iodine” (8.27%) and remaining selected the option “2% Chlorehexidine” (4.51%).

Figure 3, Majority of the respondents selected the option “Tooth preparation with aerotors” (83.46%), other majority selecting the option “Radiographs” (11.28%), remaining respondents selecting the option “Ultrasonics scaler” (5.26%).

Figure 4, Majority of the respondents selected the option “Dry cough” (83.46%), others selecting the options “Dysgeusia” (8.27%), “None of the above” (4.52%), “Hyposmia” (2.26%) and “Myalgia” (1.50%).

Figure 5, Majority of the respondents selected the option “Gender - Female” (93.23%), “Age — 50 and above” (4.51%), “Cardiovascular disease” (0.75%) and “Immunosuppression” (1.5%).

Figure 6, Majority of the respondents selected the option “Aerosol” (87.22%), “All of the above” (12.78%). “Fomites” and “Fecal-Oral route) were not selected as options by any of the respondents.

Figure 7, Majority of the respondents responded selected the option "Till three days" (52.63%), other selecting the options "5 days" (37.59%) and "3-5 days" (9.77%).

Figure 8, Majority of the respondents selected the option “Gown-Mask-Goggles/FaceShield-Gloves” (56.39%), and others selecting the option “Gown-Goggles-Gloves-Mask” (36.09%), “Mask-Goggles/Face Shield-Gloves-Gown” (7.52%).

Figure 9, Majority of the respondents selecting the option “Sometimes” (66.17%), next majority selecting the option “Always” (26.32%) and others selecting the option “Never — Use only mask and gloves” (7.52%).

Figure 10, Majority of the respondents selected the option “Yes” (89.47%), the next majority selecting the option “Sometimes” (7.52%), and others selecting the option “No” (3%).

Figure 11, The X-axis represents the educational qualification and Y-axis represents the number of respondents who answered 0.2% Povidone-iodine (blue), 1 % hydrogen peroxide (green) and 2% Chlorhexidine (beige). According to the responses seen, MDS endodontists and other speciality MDS specialists preferred 1% hydrogen peroxide as the preferred mouth rinse, which is shown to be effective against COVID-19 pathogen and this difference is statistically significant. (Chi-square test, Pearson’s Chi-square value: 16.363, p value: 0.003 (p<0.05 which is statistically significant)).

Figure 12, The X-axis represents the field of practice. The Y-axis represents the number of respondents who answered Radiographs (blue), Tooth preparation with aerators (green) and Ultrasonic scaler (beige). According to the responses seen, tooth preparation with aerotors was seen to be the most avoided dental procedure among MDS endodontists and other speciality MDS specialists during the COVID-19 pandemic. (Chi-square test, Pearson’s Chi-square value: 44.400, p value: 0.000 (p<0.05 which is statistically significant)).

Figure 13, The X-axis represents the field of practice. The Y-axis represents the number of respondents who answered Dry cough (blue), Dysgeusia (green), Hyposmia (beige), None of the above (red) and Myalgia (yellow). According to the responses seen, dry cough is the most commonly presented symptom for suspected COVID-19 patients according to MDS endodontists and other speciality MDS specialists. (Chi-square test, Pearson’s Chi-square value: 40.205, p value: 0.000 (p<0.05 which is statistically significant)).

Figure 14, The X-axis represents the field of practice. The Y-axis represents the number of respondents who answered Age -50 and above (blue), Cardiovascular disease (green), Gender - Female (beige) and Immunosuppression (red). According to the responses seen, MDS endodontists and other speciality MDS specialists assumed Gender-Female is the highest risk factor for COVID-19 infection. (Chi-square test, Pearson's Chi-square value: 18.009, p value: 0.006 (p<0.05 which is statistically significant)).

Figure 15, The X-axis represents the field of practice. The Y-axis represents the number of respondents who answered Aerosol (blue) and All of the above (green). According to the responses seen, aerosols is thought to be the most common route of spread of COVID-19 infection in dental practice by MDS endodontists and other speciality MDS specialists. (Chi-square test, Pearson's Chi-square value: 21.234, p value: 0.000 (p<0.05 which is statistically significant)).

Figure 16, The X-axis represents the field of practice, the Y-axis represents the number of respondents who answered 3-5 days (blue), five days (green) and till three days (beige). The responses varied according to the speciality, according to majority of MDS Endodontists thought viability period of SARS CoV-2 in the form of aerosol was till three days while majority other specialist MDS specialists responded the viability period of SARS CoV-2 in the form of aerosol to be for five days. (Chi-square test, Pearson’s Chi-square value: 38.280, p value: 0.000 (p<0.05 which is statistically significant)).

Figure 17, The X-axis represents the field of practice. The Y-axis represents the number of respondents who answered Mask-goggles/face shield-gloves-gown (blue), Gown-Goggles-Gloves-Mask (green) and Gown-Mask-Goggles/FaceShield-Gloves (beige). According to the responses, very few dentists knew the proper sequence of wearing PPE (Mask-goggles/face shield-gloves-gown), while many MDS endodontists and other speciality MDS specialists assumed the correct sequence to be Gown-mask-goggles/face shield-gloves. (Chi-square test, Pearson’s Chi-square value: 53.632, p value: 0.000 (p<0.05 which is statistically significant)).

Figure 18, The X-axis represents the field of practice, the Y-axis represents the number of respondents who Always answered (blue), Never - Use only mask and gloves (green) and Sometimes (beige). According to the responses seen, PPE is used only sometimes by MDS endodontists and other speciality MDS specialists in regular dental practice. (Chi-square test, Pearson's Chi-square value: 15.691, p value: 0.000 (p<0.05 which is statistically significant)).

China (Wuhan Province) in December 2019 showed a B-coronavirus in which they found a cluster of pneumonia cases. This coronavirus was of similar origin to previously reported SARS-CoV-1 and had a different mode of pathogenicity compared to it (Doremalen, 2020) with WHO officially naming the disease as coronavirus disease (COVID-19) and International committee of a coronavirus study group giving a name of SARS-COV-2 (Gorbalenya, 2020; Jiang, 2020) both in February 2020. In the present study, most of the practitioners (40.6%) had given a correct response of naming of the pathogen according to WHO and (24.8%) had reported it as SARS- CoV- 2.

SARS-CoV-2, reportedly a mutation of the previous generation and is the 7th known coronavirus to affect humans. The genome of SARS- CoV-2 is reportedly unclear with the most possible way of transmission accepted at the moment being a natural selection from animal host via zoonotic transfer specially bats (Andersen, 2020) and 44.4% to COV-1 and 21.1% to MERS CoV-1. Though the theory is not yet proven, it is shown to be most accepted being a zoonotic spread and not a mutational change of the previously reported SARS-CoV-1 (Li, 2005; Zhang, 2020).

The reproductive number is an indicator of the contagiousness or transmissibility of infectious disease and plays a crucial factor of the spread of infection. WHO estimates the reproduction number to be around 1.4 to 2.5 (Cheng & Khan, 2020) but was contradicted by a recent report by (Liu, 2020) saying the reported reproduction number being 2.6-4.7 which is more than SARS-CoV-1. The knowledge assessment in our study showed 24.8% had given a correct response within the reported range and 67.7% majority reporting to be more than 2.6-4.6% which was an acceptable range.

Patients with COVID-19 usually present with symptoms such as fever, dry cough and myalgia and other symptoms being nausea, diarrhoea, reduced sense of smell (hyposmia) and dysgeusia (Paramasivam, 2020; Zheng, 2020). During a dental practice it is always advised to do a preprocedural rinse which helps to reduce the viral/bacterial load (Jesudasan, 2015; Mohapatra, 2019; Prabakar, 2018; Ramesh, 2016; Selvakumar & Np, 2017).

Previous reports have shown that SARS-CoV and MERS-CoV were highly effective the usage of povidone mouth rinse and is suggested to be used currently with no reports proving the efficacy against the current strain of pathogen (Ather, 2020; Rajendran, 2019). It was seen that 0.2% of Povidone Iodine might reduce the coronavirus load in saliva (Eggers, 2018; Rajendran, 2019). Another alternative is 0.5-1% hydrogen peroxide mouth rinse showing nonspecific virucidal activity against all strains of previously reported coronavirus (Kampf, 2020). The current study of ours showed 87.2% that 1% hydrogen peroxide is provided and 8.3% consisting of 0.2% povidone-iodine usage in practice. (Shetty, 2013; Siddique, 2019).

Other than airborne transmission, the other mode of transmission is contact transmission through droplets (Wu, 2020). The rational use of personal protective equipment (PPE) has shown some degree of the spread of infections and allowing healthcare workers to provide crucial care to critically ill patients (Park, 2019). The current model of the correct proper sequence of PPE application being Gown- Mask-Goggles/Face Shield- Gloves is the current recommended protocol and our study reported 52.6% of professionals to do it correctly and the remaining 36.1 % downing gloves followed by a mask.

The application of PPE was sometimes 66.2% and always 26.3% and many still were not wearing 7.5% PPE for the procedure. This could have a devastating impact and could be a potential source of strength to various individuals (Rohini & Kumar, 2017; Subashri & Maheshwari, 2016; Teja & Ramesh, 2019). From the results achieved from the survey, it can be seen knowledge was seen to be adequate, but their implications in clinical practice were still varied and not wholly followed. The limitations of the study were limited sample size and more questions aimed at clinical practice guidelines would give a better perspective of the different treatment methodology followed during this pandemic.

The future scope being with the event of a pandemic it is of crucial importance to gain sufficient knowledge in this field to decrease the risk of transmission. A comparative evaluation between the general practitioners and specialists would have possibly shown the difference between the two population treatment during the pandemic.

Conclusion

Within the limitations of the study, it was observed that there was a good understanding about the precautionary measures to be undertaken by the dental practitioners. However, the implementation of such measures was still found to be inadequate or even lacking in some instances. This could have a negative impact and be a potential source for the spread of the disease in dental practice. Dentistry is known to be at very high risk, due to various aerosol producing treatment procedures being performed. To avoid this, dental practitioners are advised to follow the necessary protocols to reduce the risk of spread. Webinars and educational programs on implementing such safety measures can help the widespread reach of information in the dental fraternity, which in turn can help carry out dental practice with necessary precautions during this pandemic.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.

Funding Support

The authors declare that they have no funding support for this study.