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\begin{document}


\def\RunningAuthor{Harshada Ragunathan et al.}
\firstPage{1524}
\articleType{Original Article}
\receivedDate{09 Oct 2020}
\acceptedDate{13 Nov 2020}
\revisedDate{30 Oct 2020}
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\title{Knowledge about emergency and non-emergency dental procedures during covid-19 pandemic}
\author{Harshada~Ragunathan\textsuperscript{*},  
            Krithika~C,  
            Tamanna~M,  
            Tanaaz~Amjad~Khan,  
            Suresh~Kumar~G, 
            Vishali~S~\\[5pt]{Department of Oral Medicine and Radiology, Thai Moogambigai Dental College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, India}}

\begin{abstract}
The novel Coronavirus (COVID-19) pandemic has become a real challenge for healthcare providers around the world. Recently, it has been recorded that among all the health care professionals dentists, dental assistants, and dental hygienists are at high risk as they are in close contact with patients and are exposed to body fluids of patients. To assess the knowledge and create awareness of changes in the practice of emergency and non {\textendash} emergency dental procedures during COVID-19 among dental interns. A cross-sectional study was conducted among 100dental interns. As the study was conducted during the pandemic time, a web-based survey was created using google form which composed of a set of 12 structured custom- made questions. The answers were collected and subjected to statistics.It was seen that more than 80\% of the dental interns were aware of the guidelines issued by various dental associations regarding changes in dental procedures during COVID-19 pandemic situation. Most of the students were also aware of the term `Tele dentistry' and telecommunications for dental care, consultation and education. Adaptations and adjustments in the dental procedures need to be done to avoid the spread of the disease. Hence, it is important and mandatory for dental professionals and students to be aware of the precautions to be taken when performing emergency as well as non-emergency procedures during this pandemic situation. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}ADA,\newline COVID-19,\newline Emergency,\newline Non-emergency,\newline Urgent dental procedures
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Harshada~Ragunathan~\\ Phone:\ +91-9442532241~\\  Email:\ harshada.sragu@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{ Introduction}
The World Health Organization (WHO) labelled the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the globe as a pandemic. The risk assessment caused by it is very high, with a global impact\unskip~\citep{957986:20997141}.

The highest risk for infection spread among the health care professionals are dentists, dental assistants and dental hygienists as they are in close contact with patients and are exposed to their secretions like saliva and aerosol splashes. Dental clinics are, therefore, an important hotspot for disease transmission\unskip~\citep{957986:20997142}. To avoid this type of outbreak, dental clinics and hospitals have been closed. This has also increased the suffering of individuals for a dental emergency, on the other hand. Therefore, On March 18, 2020, the ADA provided its members and their patients with precise information on what to expect as an attempt to mitigate the spread of COVID-19 and relieve the pressure on hospitals and dental emergencies and non-emergency departments \unskip~\citep{957986:20997151}\ensuremath{^{.}}

The dental guidelines provided by the Indian dental association, the American Dental Association, the Polish Dental Association and the Swiss Dental Association have recommended performing only emergency treatments during this pandemic condition\unskip~\citep{957986:20997144}.

\textbf{Aim and Objective}

This study was aimed to evaluate the knowledge level of dental students about the emergency and non-emergency dental procedures that should be performed and avoided during this pandemic situation and the objective of the study is to create awareness about the guidelines for the dental treatment.
    
\section{Materials and Methods}
 A cross-sectional study was conducted among the Dental interns. The sample size was calculated to be 100. The dental students who were in their intern phase and willing to participate were included in the study.


\begin{table*}[!htbp]
\caption{\boldmath {Response of participants about the Emergency and Non-emergency treatment} }
\label{tw-d2e6c6daf739}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4356000000000001\linewidth-2\tabcolsep}p{\dimexpr.4917\linewidth-2\tabcolsep}p{\dimexpr.0727\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Questions & \multicolumn{2}{p{\dimexpr(.5644\linewidth-2\tabcolsep)}}{\cAlignHack Options \& Percentage}\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{1. Are you aware of the dental guidelines issued by various dental association pertaining to dental management during a pandemic?}} &
  Yes &
  88\\
 &
  No &
  8\\
 &
  May be &
  8\\
 &
  Don't know &
  2\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{2. Which of the following association/organization have the rights to issue the guidelines for oral health care professionals during a pandemic?}} &
  IDA &
  7\\
 &
  WHO &
  9\\
 &
  ADA &
  1\\
 &
  All the above &
  83\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{3. Which of the following procedure requires mandatory use of N95?}} &
  Endodontic treatment procedures &
  9\\
 &
  FPD tooth preparation &
  0\\
 &
  Ultra-sonic devices  &
  0\\
 &
  All the above &
  91\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{4. Which of the following is mandatory while dealing with emergency cases required aerosol Generating procedures?}} &
  Negative air pressure  &
  49\\
 &
  Using high volume evacuation procedures &
  5\\
 &
  Protective wear &
  1\\
 &
  All the above &
  45\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{5. According to ADA which of the following are examples of emergency (Immediate threat to life and health) dental procedures.}} &
  Dental abscess with severe uncontrolled pain &
  84\\
 &
  Extraction of asymptomatic teeth &
  6\\
 &
  Esthetic dental procedures &
  6\\
 &
  Orthodontic treatment &
  4\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{ 6.----------------imaging should be restricted, and ----------------radiographs should be utilized to reduce the excessive salivation and gag reflex}} &
  Intraoral, extraoral &
  91\\
 &
  Extraoral, intraoral &
  6\\
 &
  Panoramic, bitewing &
  2\\
 &
  Both can be performed &
  1\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{7. What is a dental emergency?}} &
  Acute one with pain &
  70\\
 &
  Chronic one without pain &
  6\\
 &
  Acute one without pain &
  6\\
 &
  Chronic one with pain &
  18\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{8. What qualifies as a dental emergency?}} &
  Life-threatening condition needs immediate treatment &
  87\\
 &
  Does not need immediate treatment &
  3\\
 &
  Esthetic related cases  &
  0\\
 &
  All the above &
  10\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{9. Which of the following should be treated as an urgent procedure?}} &
  Swelling &
  2\\
 &
  Suture removal &
  1\\
 &
  Uncontrolled bleeding &
  9\\
 &
  Both A and C &
  88\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{10. Intentional RCT for FPD comes under}} &
  Emergency procedures &
  7\\
 &
  Urgent procedures &
  9\\
 &
  Non-emergency procedures &
  78\\
 &
  Not under the above &
  6\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{11. Which of the following drugs to be recommended with caution during a pandemic?}} &
  Acetaminophen &
  39\\
 &
  Ketorolac &
  13\\
 &
  Piroxicam &
  8\\
 &
  Ibuprofen &
  40\\
\multicolumn{1}{p{\dimexpr(.4356000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{12. Which of the following best suits the term teledentistry?}} &
  Virtual communication for dental care &
  18\\
 &
  Appointment for dental care &
  2\\
 &
  Telecommunications for dental care &
  60\\
 &
  All the above &
  20\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Classification of Dental Procedures during Pandemic} }
\label{tw-33f32a4cd524}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{LLL}
\tbltoprule \rowcolor{kwdboxcolor}Emergency Procedures & Urgent Procedures & Non Emergency Procedures\\
\tblmidrule 
Oro-facial swelling  &
  Pulpitis, Dental or periodontal abscess &
  Normal exfoliation symptoms of primary tooth \\
Trauma that may damage the patient's airway &
  Dental trauma with avulsion or luxation. &
  Elective treatment requires high/slow speed bur\\
Uncontrolled bleeding  &
  Severe dental or facial pain  &
  Previously initiated root canal \\
Medically compromised  &
  Failed dental extractions  &
  Regular dental check-up\\
Suture removal for non-resorbable everlasting suture  &
  Behavioural/physical disability and in pain  &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
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\centering \makeatletter\IfFileExists{images/3133b665-cc99-4622-ab5b-a7ad8abca8bf-upicture1.png}{\includegraphics{images/3133b665-cc99-4622-ab5b-a7ad8abca8bf-upicture1.png}}{}
\makeatother 
\caption{\boldmath {The bar chart representation of the percentage of subjects and their respective responses}}
\label{f-bdd7a84ce0ad}
\end{figure*}
\egroup
As this study was conducted during the pandemic time, a web-based survey was created using a google form, which composed of a set of 12 structured custom- made questions. The questions were framed in the English language and vetted with the expert`s opinion. The questionnaire began with the informed consent along with their demographic details followed by the questions regarding emergency and non-emergency dental treatment during a pandemic. The format of the questionnaire was provided with multiple choices with four options. These were done to prevent bias. Each participant was allowed to submit the response only once. The collected data were subjected to statistical analysis.
    
\section{Results }
The survey was conducted among 100 dental students who were in their intern phase. After obtaining the answers, charts were formulated for the easy depiction of the results. 

Table~\ref{tw-d2e6c6daf739} depicted that about 88\% of participants were aware that the dental guidelines were issued by various dental association pertaining to dental management during COVID-19 pandemic. Similarly, 80\% of our participants also had the knowledge that the patients with acute onset of pain and life-threatening conditions like facial trauma, the severe dentoalveolar abscess should be considered as a dental emergency. About 91\% of the participants had knowledge that extraoral radiographic procedures should be preferred rather than intraoral procedures during this pandemic situation. It was clear that most of the students were also aware of the term `Tele dentistry' that is the use of information technology and telecommunications for dental care, consultation and education (Table~\ref{tw-d2e6c6daf739} \textit{, }Figure~\ref{f-bdd7a84ce0ad}).

Table~\ref{tw-d2e6c6daf739}  showing the knowledge of participants about the emergency and non-emergency dental treatment that should be carried out during COVID-19.

Figure~\ref{f-bdd7a84ce0ad} depicts the bar chart representation of the percentage of subjects and their respective responses, Blue colour denotes option a, Red denotes option b, Grey for option c and Yellow for d.
    
\section{\textbf{Discussion }}
In December 2019, scientists isolated acute respiratory syndrome of coronavirus 2 (SARS-CoV-2) in Wuhan, China. The WHO declared the disease as a Public Health Emergency of International Significance (PHEIC) and named it 'COVID-19'. The health care professionals, especially dentist, are at high risk in the transmission of the disease. So the dentist should always know to differentiate between the procedures that should be performed immediately and the procedures that should be avoided/postponed during this pandemic situation to avoid the bidirectional spread of infection. 

Emergency dental treatments are necessary, even in this COVID-19 situation. This was shown in the study by \unskip~\cite{957986:20997140}  where 56\% of patients have reported periapical abscesses and toothaches during this pandemic condition which are considered to the emergency treatment \unskip~\citep{957986:20997140}. Dental associations in several countries have issued guidelines for the dentists regarding the procedures that should be performed during a pandemic and the procedures that should be avoided/postponed during this time. According to ADA, dental procedures are classified into Emergency procedures, urgent procedures and non-emergency dental procedures which are shown in Table~\ref{tw-33f32a4cd524}. 

A study done by \unskip~\cite{957986:20997143}  showed that 80\% of their participants were aware about the guidelines issued by the dental associations. This was in accordance with our present study were 88\% of students were also aware of about this\unskip~\citep{957986:20997143} . 

During this pandemic condition, routine dental check-up and procedures cannot be preferred due to the outbreak of the disease. Only emergency treatments should be carried out in the dental clinics and hospitals. Appealingly 84\% of the participants in our present study were aware that only the emergency procedures should be carried out in this Pandemic. This was similar to the study done by \unskip~\cite{957986:20997143,957986:20997149} where they showed more than 90\% of populations awareness towards it.

In this study, when the participants were asked regarding the usage of N95 masks, 91\% of our study participants said that it is mandatory to use N95 in all dental procedures. This was in line with a study conducted by \unskip~\cite{957986:20997143,957986:20997148}.

AIR (Airborne Infection Isolation Room), formerly known as the Negative Pressure Isolation Room, is a single-occupancy patient care room used to isolate patients with a suspected or documented infectious airborne disease. In the present study, about 49\% of dental interns answered that only AIR is mandatory whereas 45\% have chosen that AIR, HVE (high volume evacuator), as well as PPE, are mandatory while performing an emergency procedure that generates aerosols. \unskip~\cite{957986:20997146}  were the first to report on personal protection equipment (PPE) that protected dental professionals during the COVID-19 epidemic in Wuhan, China \unskip~\citep{957986:20997146}.\ensuremath{^{}}

In this study, when the participants were asked regarding the usage of N95 masks, 91\% of our study participants said that it is mandatory to use N95 in all dental procedures. This was in line with a study conducted by \unskip~\cite{957986:20997143,957986:20997148}. In a similar study done by \unskip~\cite{957986:20997145} only 12\% of the participants reported using the N-95 mask in Turkey\unskip~\citep{957986:20997145}.

Non-steroidal anti-inflammatory drugs (NSAIDS) are medication that is used widely to reduce pain, swelling and mainly to bring down the body temperature. They also have many side effects. In our present study, 40\% of interns were aware that NSAIDS should be prescribed with caution as it could be an aggravating factor for the infection. This was similar to the study conducted by \unskip~\cite{957986:20997143} that showed 31.1\% of participant's awareness towards it \unskip~\citep{957986:20997143}.

In the present study, 60\% of subjects had basic knowledge about teledentistry. Teledentistry is a type of telehealth devoted exclusively to dentistry that uses electronic medical records, information and communication technology (ICT), digital imaging, and the Internet for consultation, supervision, or continuing education \unskip~\citep{957986:20997147}. \unskip~\cite{957986:20997150} reported that the use of teledentistry would allow patients to screen and monitor cases while limiting human contact, thus decreasing the risk for COVID-19 transmission\unskip~\citep{957986:20997150}.  Although reducing face-to-face consultation is important to reduce the risk of infection, dental surgeons need to ensure the quality of treatment. But in a study done by \unskip~\cite{957986:20997148}  showed that only 43\% of doctors said that they offer tele screening\unskip~\citep{957986:20997148}.
    
\section{\textbf{\space }Conclusion}
During the time of the pandemic outbreak, healthcare professionals should be aware of the situations to protect themselves and their patients from transmission of the diseases. Proper training and knowledge of the personal protection measures, hand hygiene, the use of PPE and infection control methods as given by various associations should be followed. The healthcare professionals should be aware, create awareness and be appreciation on the updates regarding this kind of pandemic situations. 

\textbf{Funding Support}

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

\textbf{Conflict of Interest}

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

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