|Year : 2021 | Volume
| Issue : 2 | Page : 90-97
Assessment of knowledge, practice, and level of preparedness of dentists practicing in Nigeria toward COVID-19 pandemic
Titus Ayodeji Oyedele1, Adeola M Ladeji2, Yewande I Adeyemo3, Aderonke A Abah2, Modupe O Coker4
1 Department of Surgery, Benjamin Carson (Snr), School of Medicine, Babcock University; Department of Dentistry, Babcock University Teaching Hospital, Ilisan-Remo, Ogun State, Nigeria
2 Department of Oral Pathology and Oral Medicine, Faculty of Dentistry, Lagos State University College of Medicine, Lagos State, Nigeria
3 Department of Child Dental Health, Bayero University, Kano State, Nigeria
4 Department of Oral Medicine, School of Dental Medicine, Rutgers University, Newark, New Jersey, USA
|Date of Submission||25-Jun-2020|
|Date of Decision||14-Aug-2020|
|Date of Acceptance||18-Oct-2020|
|Date of Web Publication||21-Aug-2021|
Dr. Titus Ayodeji Oyedele
Department of Surgery, Benjamin Carson (Snr), School of Medicine, Babcock University, Ilisan-Remo, Ogun
Source of Support: None, Conflict of Interest: None
Introduction: The coronavirus disease pandemic (COVID-19) had a global impact on health sectors including dentistry. As dental services have to be performed and cannot be withheld for a prolonged period, dentists should prepare themselves to understand the disease process and to face future treatment challenges in affected patients to fully resume dental services. There was a need to evaluate the knowledge of dentists on Covid-19 disease process, and readiness in practicing dentistry in this situation.
Aim: This study aimed at assessing the knowledge, practice, and level of preparedness of dentists in Nigeria towards the COVID-19 pandemic.
Materials and Methods: An online cross-sectional survey involving dentists practicing in Nigeria was carried out using the SurveyMonkey™ platform. The link for the questionnaire from the platform was forwarded to dentists individually and on platforms of various oral health-care providers. The questionnaires tested for knowledge, practice, and preparedness of the respondents to the COVID-19 pandemic. Their biodata and practice experiences were also collected. Data were electronically retrieved from the SurveyMonkey platform in Excel spreadsheet and analysis was done; statistical significance was established at P ≤ 0.05.
Results and discussion: A total of 209 dentists participated in the online survey; there were more respondents from the age group of 25 to 34 years. Majority of the participants practiced in the tertiary setting. Over 97% of the respondents first learned about the novel coronavirus through the media; 97.1% agreed that the main mode of spread of severe acute respiratory syndrome coronavirus-2 is through respiratory droplets on close contact, and 91.4% agreed on spread through respiratory droplets on surfaces. Over 35% had no previous training on infection and prevention control (IPC) and 50% of the centers where the respondents practice had no IPC committee. Ninety-nine percent of the respondents have heard about personal protective equipment (PPE), but only 51.5% had PPE in their clinic, while 33.7% of these have had training on the use of PPE. Over 80% of respondents exhibited fear; junior residents were the most fearful, and 67% of respondents from tertiary institutions have limited their procedures during this pandemic.
Conclusion: This study showed that COVID-19 pandemic poses a new threat to dental practices worldwide and Nigeria in particular. Therefore, the practice of dentistry must evolve in the presence of COVID-19.
Keywords: Coronavirus, COVID-19, dentistry, fear, infection, personal protective equipment
|How to cite this article:|
Oyedele TA, Ladeji AM, Adeyemo YI, Abah AA, Coker MO. Assessment of knowledge, practice, and level of preparedness of dentists practicing in Nigeria toward COVID-19 pandemic. Saudi J Oral Sci 2021;8:90-7
|How to cite this URL:|
Oyedele TA, Ladeji AM, Adeyemo YI, Abah AA, Coker MO. Assessment of knowledge, practice, and level of preparedness of dentists practicing in Nigeria toward COVID-19 pandemic. Saudi J Oral Sci [serial online] 2021 [cited 2021 Dec 1];8:90-7. Available from: https://www.saudijos.org/text.asp?2021/8/2/90/324190
| Introduction|| |
COVID-19 is a highly infectious disease caused by a newly discovered coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The causative agent of the coronavirus disease outbreak was identified and referred to by the World Health Organization (WHO) as the SARS-CoV-2.
The disease was first reported in China on the December 31, 2019, and it has rapidly spread to involve most nations of the world. It was first identified among an outbreak of respiratory illness cases in Wuhan City, Hubei Province, China. By January 30, 2020, the outbreak was declared a public health emergency of international concern, after which the WHO declared it a pandemic on March 11, 2020. The rate of spread however differs from one country to another. The COVID-19 is a highly infectious viral infection, which can spread from person to person, through respiratory droplets and from contact with infected surfaces or objects. The infection is mostly spread when the individual is sick, but the spread is said to be possible even when the person is asymptomatic.
Clinically, the disease is characterized by symptoms that may appear between 2 and 14 days after exposure to the virus. These include fever, dry cough, bilateral lung lesions with chest pain, and pneumonia in severe cases. Others include shortness of breath, fatigue, chills, muscle or joint pain, sputum production, sore throat, vomiting, diarrhea and headaches, while anosmia and ageusia are symptoms from the coronavirus that have recently emerged. The severity of this disease varies from one individual to another. A report showed that 80.9%–82% of the identified cases were mild,, 13.8% were severe, and 4.7% were critical. The mortality rate from COVID-19 has been quite variable across nations, ranging between 0.9% and 8.4%.,,
Since the outbreak of this disease, rising infection and mortality are being reported across the world. As of June 3, 2020, over 6 million people across 213 countries of the world have been infected with the virus, while death toll has risen to about 400,000., High infection and mortality have been recorded among health-care workers who have been at the forefront of managing patients and curtailing the outbreak. They are at higher risk of contracting the infection when performing their duties, partly due to delayed response to the outbreak, shortage of personal protective equipment (PPE), an overwhelming number of patients, and understaffed hospitals.,
The National Health Commission of the People's Republic of China reported that as of February 24, 2020, 2055 health-care workers had been confirmed infected with COVID-19, with 22 (1.1%) deaths. A study also showed that in a facility where 138 people were hospitalized for COVID-19, 29% were health-care workers.
This was attributed to inadequate personal protection of health-care workers, which was suggested to be due to an inadequate understanding of the pathogen, invariably impacting their awareness of personal protection. Other factors attributed to high rate of infection among health-care workers were long hours of exposure to large numbers of infected patients, shortage of PPE due to a high level of demand, and lack of adequate training for infection and prevention control (IPC) for frontline health-care workers.
A report from Indonesia showed that 25 doctors had succumbed to COVID-19 comprising 19 medical doctors and 6 dentists.
The first case of the novel coronavirus in Africa was confirmed on February 14, 2020, in Egypt, while the first in sub-Saharan Africa was confirmed on February 27, 2020, in Nigeria, when an Italian citizen tested positive. Most of the confirmed cases arrived from the United States of America and Europe.,,
Confirmed cases in Nigeria as of June 25, 2020, were over 22,000, with more than 800 of the infected cases reported being health-care workers with 500 deaths in the country.
Reports across the world have also shown that dentists are among the health-care workers at higher risk of contracting COVID-19 infection. This is due to the required proximity to patients during dental management, coupled with exposure to aerosols generated from dental procedures. Contact with droplets during procedures is also a high-risk factor noted. In addition, COVID-19 has been identified in saliva of infected patients, showing that dentists and other oral health workers are at higher risk of contracting this very infectious disease, hence the need for adequate protection against this infection as dentists unknowingly may be providing oral care for infected through asymptomatic patients.
Based on these, it is important for dentists to appraise the preventive strategies to avoid being infected and these strategies may include handwashing/hygiene, and adequate and appropriate donning and doffing of PPE for aerosol-generating dental procedures.
This study therefore aimed at assessing knowledge, practice, and preparedness of dentists in Nigeria toward the outbreak of COVID-19. This assessment could identify gaps in infection control and contribute to direct efforts in training and retraining toward infection control in dentistry.
| Materials and Methods|| |
This was an online cross-sectional survey involving dentists practicing in Nigeria. The study involved all dentists across all age groups and across all dental specialties. The survey was carried out by sending validated structured self-administered questionnaires to all dentists utilizing different dental social platforms and subspecialty dental social platforms. Questionnaires were worded in the English language, which is the official mode of communication in Nigeria. These questionnaires were operator designed, based on information from the WHO's guide to developing knowledge, attitude, and practice (KAP) surveys and previous KAP surveys of respiratory infections.,,
It contained a brief description of the study, this was followed by 38 questions, which were divided into four sections, namely sociodemographics, knowledge, attitude, and preparedness. Twelve questions assessed dentist's baseline knowledge on spread, transmission, and prevention of COVID-19; 7 questions assessed their level of anxiety, behavioral perception toward prevention, and attitude toward patients' management, while 12 questions on preparedness assessed their compliance and utilization of preventive measures. Participation was voluntary, anonymous, and written consent was sought from participants. The dentists were also appealed to, to forward the questionnaires to their personal contacts practicing dentistry in Nigeria. They were subsequently sent reminders every 24 h. The survey lasted for weeks after which the responses were collated for the analysis.
This was carried out using questionnaires that tested for knowledge, practice, and preparedness of the respondents to the COVID-19 pandemic. The biodata of participants and practice experienceswere also collected.
All the study participants were asked to tick yes or no on the survey form to signify their consent to participate in the study, their confidentiality was also guaranteed, as no name was required. Ethical clearance for this study was obtained from the Aminu Kano Teaching Hospital Research Ethics Committee (AKTH/MAC/SUB/12A/P-3/VI/2067).
Data collected were retrieved from the SurveyMonkey™ platform in an Excel spreadsheet and were subjected to analysis using STATA version 13 for Mac Air. Descriptive analysis was done for all discrete variables and a test of association was carried out using Pearson's Chi-square test. Statistical significance was also established at P ≤ 0.05.
| Results|| |
A total number of 209 participants filled this online survey, 53.1% were males and 46.9% were females, with a male-to-female ratio of 1.1:1. The respondents were more in the age group of 25–34 years (34.5%) and 35–44 years (38.3%). A little over one-third of the study participants were consultants/specialists (33.5%), closely followed by dental officers (25.4%), while the least respondents were the dental house officers/dental interns (6.7%) [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
|Figure 1: (a) Age distribution. (b) Gender distribution. (c) Level of practice. (d) Year of practice|
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Majority of the respondents (66.0%) practised in tertiary centers (teaching hospitals), while the remaining respondents (34.0%) practised in a secondary setting which comprised private dental clinics, federal medical centers, state general hospitals, and military hospitals. The mean year of practice of the respondents was 12.1 ± 9.3 years.
The majority of the respondents (97.1%) knew about COVID-19 for the first time through media outlets, while a few respondents learned through literature (7.7%). [Table 1] shows that 97.1% of respondents agreed on the mode of spread of coronavirus to be through respiratory droplets on close contact, 91.4% agreed on the spread through respiratory droplets on surfaces, 70.8% believe it is airborne, 19.6% through fecal–oral route, while 7.2% believe spread could be through many other routes. All the respondents agreed that dentists are at higher risk of contracting COVID-19 while performing various dental procedures.
The response to training showed that 64.7% had previous training on infection control and prevention, while 35.4% had no previous training. Among those who had previous training on infection control and prevention, 33.8% had it less than a year ago, while the remaining respondents had it more than a year ago. Of the study respondents, 50% of their centers have IPC committees, while 71.7% have infection control policy/guidelines as well.
The results also showed that 99.0% of the respondents knew about PPE, but only 51.5% had PPE in their clinics, while the remaining neither have it nor know if their clinics have PPE. A large percentage of the respondents' clinics had safety goggles (78.6%), 62.9% had N95 face masks, 64.3% had protective gowns, while the least available PPE was elbow length gloves (38.8%) [Table 2].
Only 33.7% of the respondents have had training on how to use appropriate PPE for different case selections. Among those that claimed to have PPE, 65.5% were from tertiary settings, while among those that make use of PPE during dental procedures, majority (59.6%) were from secondary practice settings [Figure 2].
|Figure 2: Association between practice setting and availability of personal protective equipment/personal protective equipment use|
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With respect to fear and anxiety toward COVID-19, over 19% of the respondents reported no fear, while the remaining 80.9% reported some level of fear [Table 3]. Among those that reported fear, 38.8% had moderate fear, while 10.1% were extremely fearful.
[Table 4] shows an association between various levels of fear, years of practice, and the level of practice of the respondents. A larger percentage (38.1%) of the respondents with 6–10-year practice experience exhibited an extremely fearful level compared to others, while junior residents exhibited the extremely fearful level (52.4%) and the specialists exhibited the very fearful level (48.9%) compared to others.
|Table 4: Association between level of fear, years of practice, and levels of practice|
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[Figure 3] shows the number of respondents that limited the procedures done in their practice during the COVID-19 era and those that did not carry out procedures during this period, in association with the practice setting. Over 67% of the respondents from tertiary settings limited their procedures during this period and 77.6% of those who did not carry out procedures at all during this period were from tertiary institution settings.
|Figure 3: Association between practice setting and practices during COVID-19|
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[Table 5] shows the association between level of fear and willingness to carry out dental procedures by dentists during COVID-19 pandemic. Thirty-five (35.7%) of the respondents who exhibited moderate fear were not willing to perform any procedure, compared to the extremely fearful, who only (12 [12.2%]) were not willing. There was no statistically significant difference between those who were willing to continue services and those who were fearful (P = 0.36).
|Table 5: Association between level of fear and willingness to carry out procedures during COVID-19|
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The reasons for the fear exhibited were based on fear of contracting the virus in 75.6% of the respondents due to lack of PPEs in 74.4%, lack of health insurance in 52.2%, and life insurance in 47.8%, while 14.4% attributed their fear of performing any dental procedure to personal underlying medical conditions.
| Discussion|| |
To our knowledge, this is one of the first studies to evaluate the KAP of dental care workers in Nigeria. Our results showed no statistically significant gender differences among the respondents but higher respondents from the younger age groups when compared to older age groups. This may be due to the fact that younger age groups are more active on online activities and this study was an online survey. The majority of the respondents were consultants/specialist working in tertiary health institutions, followed by dental officers practicing in a private dental clinic. Higher respondents from tertiary institutions may be a reflection of the distribution of dentists and dental facilities in Nigeria, as tertiary institutions in the country are undertaking most of the dental health care services. The majority of the study participants had over 10 year of clinical practice.
The first knowledge about this novel coronavirus as indicated by the respondents was through various media outlets and few respondents indicated first knowledge through literatures. This underscores the benefit of media outlets in disseminating important information to the larger society. This study also showed that all the respondents had good knowledge about the mode of spread of COVID-19 through respiratory droplets on close contacts, on surfaces, and on objects. This finding is in agreement with previous reports that COVID-19 is a highly infectious virus,, which is attributable to its shedding ability, its infectivity in nonsymptomatic individuals, and even during the incubation period. It is clinically comparable because of its flu-like symptoms and its infective ability to other viral respiratory infections such as Middle East respiratory syndrome coronavirus (MERS-CoV), which was first reported in Saudi Arabia in September 2001 and SARS-CoV, which was reported in February 2002 but was traced back to November 2002. Both were believed to be caused by transmission from bats that are also reservoirs for SARS CoV-2. From the genome sequence analysis, they belong to the Betacoronavirus genus that includes four other lineages that comprise Bat SARS-like coronavirus, SARS-CoV, and MERS-CoV. SARS-CoV-2 is more phylogenetically related to Bat SARS-like coronavirus with the assumption that it has a different viral evolution from SARS-CoV and MERS-CoV. In addition to transmission via respiratory droplets, other modes of spread through airborne and fecal–oral routes were indicated by survey respondents, although presently, there is no general concession about the spread of the virus through airborne.
In addition, respondents were of the strong opinion that dentists are at higher risk of contracting this coronavirus while carrying out various dental procedures. This may not be unconnected to various reports which showed that dentists are among the health-care workers at higher risk of contracting COVID-19 due to proximity to patients during dental treatment and aerosol-generating procedures.,
In a study by Sarfaraz et al., it was reported that a little over half of the participants strongly agreed to a high risk of contracting the SARS-COV-2 in dental practice when assessing their attitude toward disinfection against coronavirus.
This is a novel coronavirus that broke out in the last 8 months and preparation toward combating it has been difficult. However, infection prevention and control should be a regular practice, which necessitates adequate preparation and training and retraining of all health-care workers. This study showed that a large percentage of respondents have had previous training on infection control, but only 33.8% had it less than a year, while the remaining had it more than a year. This may imply that most respondents are not adequately prepared for any infection outbreak in their practice. This is rather unfortunate, since it seems every few years, there has been an outbreak of coronavirus infection, and optimal preparation for any outbreak is required at all times. The training and retraining on infection control is to ensure that the workforces are competent to carry out their activities. Prevention of infections should be the common primary aim of all health-care workers. Understanding how infection occurs, how different microorganisms spread, and how it can be prevented is vital in disease prevention within a dental setting.
Although 99% claimed they have heard about PPE before, only 51.5% had it in their facilities and the most common PPEs reported were safety goggles and facemasks. The lack of PPE to the frontline health-care workers as warned by the WHO may be attributed to stockpile, panic buying by the populace, and rising demands. This study also showed that about a third of the respondents have had training on the appropriate use of PPE, wearing of PPE, and doffing of PPE.
This study showed a high level of fear in a higher percentage of the respondents; this fear may not be unconnected to reported high infectivity of coronavirus, high mortality rate associated with it,,, and high infectivity of health-care workers. The reasons the respondent attributed to their fear included fear of contacting the virus, lack of PPE to protect them from contracting the virus, lack of health insurance, and lack of life insurance. However, few attributed their fear to underlying medical conditions, which has been shown to increase morbidity and mortality.
Interruptions to dental care delivery have far-reaching long-term impacts that cannot be undermined. Our results show that due to the fear of contracting this virus, many respondents were unwilling to carry out any dental procedure during this period. This practice of abstaining from practicing may pose a great danger to the populace, as many that need dental treatment may be denied the opportunity, some conditions may lead to morbidity; for instance, patients with facial nerve palsy if not intervened promptly can lead to permanent facial deformity and some may lead to death from oral cancer. Oral health care should be a public health priority as we anticipate a deterioration of medical and dental conditions worldwide, particularly for the most vulnerable.
The very framework of dental care delivery, particularly in populous low-middle income countries like Nigeria, has been shaken by the pandemic. COVID-19 has challenged the dental practice, highlighting the need for creative solutions and strategies to prevent transmission in the dental setting. This lack of practice during this pandemic was also expressed by the president of Nigeria Dental Association in a letter written to the government for intervention in providing PPE to dental practitioners in the country, which is one of the major reasons among many other factors why dentists will be unwilling to see patients.
| Conclusion|| |
No doubt, the COVID-19 pandemic poses a new threat to dental practices worldwide. Dental practice involves close person-to-person contact and aerosol-producing procedures; therefore, the practice of dentistry must evolve in the presence of COVID-19 and prepare for future pandemics. Understanding COVID-19 fears and anxieties provides a detailed insight into the practice modifications needed for the benefit of both dental health-care personnel and patients.
A major limitation of the study is the low number of respondents which reduces the statistical power of the study and generalizability of the data to the larger number of practicing Nigerian dentists. Future similar studies should target much larger target populations. It is also recommended that all professionals in clinical dental care should be engagingly exposed to structured infection control measures as a continuing education process.
The authors appreciate all the study participants who agreed to participate in the study and who filled the online survey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]