Knowledge and attitude of dental professionals toward COVID-19 in Riyadh, Saudi Arabia: a cross-sectional survey

Among the 650 dental professionals who participated in the present study, 430 were UG, 100 interns, 50 PG, and 70 were dental faculty (Table 1). Among the participants, were 323 (49.7%) men, and 327 (50.3%) were women. Most of the participants received information about COVID-19 from peers (31%) and social media (29%) (Table 2). Among the participants, only 376 (57.8%) knew the causative virus for COVID-19. Most of the participants, 632 (97.2%), had knowledge that infection spreads through cough, sneeze, or droplet inhalation through the so called “danger triangle” of the face. Only 252 (38.7%) of the participants responded correctly to the question concerning the mortality rate of SARS-CoV-2 infection; among them, 150 (34.8%) were UG. Among the study participants, 445 (68.4%) participants knew about the incubation period for COVID-19, 598 (92%) were aware that patients with comorbidity (diabetes, hypertension, respiratory disease) are more susceptible to infection, and dental faculty responded with the highest correct response rate 68 (97.1%). Overall, 546 (84.0%) were aware of symptoms of COVID-19, of whom 365 (84.8%) were UG, 467 (71.8%) were aware that there was no vaccination available for COVID-19 at the time of the study, 394 (60.6%) knew that antibiotic prescription was not a first-line treatment for the infection, and only 404 (62.1%) knew that (real-time) reverse transcriptase polymerase chain reaction (RT-PCR) is a standard criterion test for diagnosing COVID-19, 35 (70%) among them being interns. We found that 588 (90.4%) of the participants correctly responded that smokers had increased risk for COVID-19 (Table 3). Among the participants, 425 (65.3%) knew that rinsing the mouth with an antimicrobial solution or 1% hydrogen peroxide before the dental procedure mitigates the transmission of infection, and 564 (86.7%) participants agreed dental clinics could promote the transmission of infection. Among the participants, only 357 (54.9%) knew the CDC hand hygiene guidelines, and 377 (58%) were aware of WHO hand hygiene guidelines; 595 (91.5%) knew about using PPE during the treatment, 545 (83.8%) preferred washing hands with soap and water for 30 s or using 60% alcohol-based hand sanitizers, and 513 (78.9%) knew to use N-95 and filtering face-piece (FFP2) masks while treating COVID-19 patients. Fewer participants, 503 (77.3%), responded that a rubber dam could be used for isolation or a high-volume saliva ejector could be used to avoid the aerosols during emergency treatment; 516 (79.3%) participants knew to take extra precautions during aerosol-producing procedures (Table 4).

Based on the scoring system among 650 study participants, 182 (28%) scored low, 403 (62%) average, and 65 (10%) scored high. Thus, 468 (72%) participants showed sufficient knowledge about the COVID-19 (Figure 1).

Figure 1

We found an excellent positive attitude response among dental graduates and faculty regarding the prevention of COVID-19. Among study participants, 613 (94.3%) believed in disseminating information regarding COVID-19 among peers and other dental health care workers, and 617 (94.9%) participants believed sterilization of clinical and nonclinical areas in the dental clinic reduces the transmission of infection. We found 588 (90.4%) participants believe that there is an association between hand hygiene and the spread of COVID-19 infection; among them, 395 (91.8%) were UG and 88 (88%) interns (Table 5).

Because the COVID-19 pandemic is spreading rapidly, health care professionals need to understand the pathology of the disease to protect themselves from the virus and prevent the spread of the virus. Dental professionals need to know about the disease, as they are a high-risk group for infection, and dentists can educate the patients about personal preventive measures. According to the study participants, the majority (31%) received information about COVID-19 primarily from peer groups, and secondly from web-based social networking. Social media has been the leading facilitator of data broadcasting. In the medical services framework, data broadcasting is crucial to the early dissemination of information [16]. By contrast, social media can be disastrous by spreading false news regarding the disease. Considering this, people should approach general physicians or the MOH for information regarding the disease.

We found that substantially few (57.8%) participants knew that SARS-CoV-2 was the causative agent for COVID-19. This lack of knowledge may be because, during new episodes of infection, there is a lack of information among the participants about the name of the infective agent and perhaps because the disease name is not the same as the name of the infection [17]. In the present study, most participants (97.2%) knew that the COVID-19 infection spread by coughing, sneezing, and droplet inhalation. Gravity settles the heavy droplets, but aerosols produced by a dental procedure can spread to long distances. Using ultrasonic instruments and aerators can produce aerosols in substantial amounts [18].

Along with cough, sneezing, fever symptoms accompanied by ARDS are the leading and life-threatening COVID-19. During infection, the organ-protective effect of angiotensin-converting enzyme 2 and an increase in cytokine levels can lead to a so-called “cytokine storm” in the immune system [19]. It is essential for dental professionals to understand the pathophysiology, diagnosis, and differential diagnosis of the disease.

The mortality rates for COVID-19 in China were estimated at 5.6%, and outside China, it was estimated to be 15.2%; and the mortality rate of MERS was at the highest, ranging from 6% to 28% [20, 21]. Only 38.7% of our participants were aware of the mortality rate of COVID-19. This may be because COVID-19 has infected a sizable proportion of the population, and biased information about the disease's mortality rate has spread. COVID-19 has a high mortality rate in the elderly [22]. The incubation period of COVID-19 is a challenge for control; most patients become symptomatic within 11 days or 12 days, and most of them within 14 days [23]. A similar study among dental professionals reported 46.1% of the respondents as having knowledge about the incubation period, compared with the 68.4% in our study [24]. A dental professional should know that an asymptomatic patient may be in the incubation period and spread the infection. It is recommended to suspect every patient as infectious [25].

In the present study, most participants knew that patients with comorbidity are more susceptible to COVID-19, and that their prognosis will be poor. This might be because most dental experts are aware that comorbidities, like hypertension, diabetes, and respiratory ailments, can lead to susceptibility to many illnesses [26]. RT-PCR is the criterion standard test used for the etiological diagnosis of COVID-19 on respiratory tract specimens, and awareness of this test was found in substantially fewer of the study participants [27].

In the present study, 60.6% knew that antibiotics are not the first line of treatment, and that the empirical use of antibiotics recommended by WHO to reduce bacterial superinfections would not help to treat this disease [28]. To the date the study was conducted, few vaccines were available for COVID-19, SARS-CoV, and MERS. Awareness programs or online information are needed to create awareness about the vaccine and first-line treatment protocol among dental professionals [29].

In the present study, most participants (90.4%) agreed that smoking would increase the susceptibility to COVID-19. To date, there are limited data available about smoking and COVID-19. However, it is being assumed that smoking is associated with a negative impact on lung health. There is evidence that a larger proportion of smokers with COVID-19 were in intensive care units than other patients who were nonsmokers; and moreover, symptoms were more severe in smokers. A previous review study suggests that smoking will worsen the progression and adverse outcomes associated with COVID-19. Smokers are 2.4 times more likely to be admitted to an intensive care unit, need mechanical ventilation, or die compared with nonsmokers [30, 31]; patients with smoking and influenza would have the worst disease prognosis. Smoking patients with MERS had a high mortality [32].

Dental clinics invariably have a high risk for transmission of COVID-19 infection because of the specific treatment methods used, which involve face-to-face interaction with patients, frequent exposure to blood, saliva, and other body fluids, and the use of sharp instruments. The pathogenic virus can be transferred from one patient to another in dental settings through breathing of airborne microorganisms that remain present in the air for an extended period [17]. Aerosol-producing procedures like ultrasonic scalers, aerator, and using a 3-way syringe may spread the infection. Aerosols may infect over long distances. Using a rubber dam is highly recommended [3]. In our study, 86.7% of the participants agreed dental clinics could transmit infection by the aerosols produced and contact spread.

Before beginning a dental treatment procedure, it is advisable to use an antimicrobial mouthwash to rinse the patient's mouth. This decreases the viral load in saliva and avoids spatter. Because SARS-CoV-2 is susceptible to oxidation, the use of a mouth rinse, such as one containing 1% hydrogen peroxide or 0.2% povidone is recommended [20]. In the present study, 65.3% of the study population knew that rinsing the mouth with the antimicrobial solution before the commencing dental treatment could help prevent the spread of infection.

Among the study population, only 54.9% knew about CDC hand hygiene guidelines, and 58% were aware of WHO hand hygiene guidelines; 83.3% preferred washing hands with soap and water for 30 s or using 60% of alcohol-based hand sanitizers. There is evidence that hand hygiene can reduce respiratory infections.

Using a mouth mask and proper hand hygiene reduces influenza transmission successfully [33]. Dentistry is a profession that needs to adopt evidence-based scientific procedures to avoid transmission [34]. As per the CDC and WHO guidelines, comparatively fewer participants knew about the scientific procedure of washing hands before and after examining the patients [35]. This may be the result of a lack of awareness programs among dental professionals.

Most of the study participants (91.5%) knew about using PPE during the treatment. Wearing PPE, such as masks, gloves, eyeglasses, and gowns can help avoid most infections, and most of the study participants had good knowledge about PPE [3], and that N-95 or FFP2 masks are recommended to avoid transmission of virus particles [36].

We found a positive attitude response among dental graduates and faculty regarding the prevention of COVID-19. Among study participants, 94.3% believed in disseminating information regarding COVID-19 among peers and other dental health care workers. Disseminating the information among dental health workers without delay is recommended. The attitude among study participants is similar to that found in an earlier study conducted about the attitude toward MERS [14].

Among the study participants, 94.9% believed in sterilizing clinical and nonclinical areas in the dental clinic helps prevent the infection. The results showed that 90.4% of participants believed that there is an association between hand hygiene and the spread of COVID-19 infection. The lack of a scientific approach toward hand hygiene was recorded among study participants. This shows that the study participants had a positive attitude toward preventing the disease.

A limitation of the present study is that it was restricted to only one institution, and social desirability bias may affect the results by over-reporting good knowledge and attitude. Further similar studies need to be conducted in Saudi Arabia to assess knowledge and attitude among dental professionals and are warranted.

We conclude that there was a lack of knowledge about the COVID-19 pandemic and COVID-19 infection preventive measures among dental students and faculty, and that greater awareness is needed to control the spread of this disease. We have provided an insight into COVID-19, and suggestions to be followed by the public, governments, and the health care sector to control the spread of COVID-19 infection.