Repercussions of COVID-19 in Brazilian Dentists’ Personal and Professional Routines: An Online Survey

DISCUSSION

Brazil is divided into five large geographic regions (i.e., South, Southeast, North, Northeast, and Midwest). In the present research, the greatest number of participants belonged to the Southeastern region. This may be explained once that the majority of dentists are registered in the Southeastern region, according to the Brazilian Federal Council of Dentistry.⁸ Moreover, all regions of Brazil were significantly represented, avoiding a possible sample bias.

Respondents identified shortness of breath (91.34%), dry cough (90.26%), high fever (79.81%), sore throat (59.48%), and headache (46.14%) as main symptoms of COVID-19. The Centers for Disease Control and Prevention identifies shortness of breath, dry cough, and high fever as the principle symptoms; the WHO identifies fever, fatigue, and dry cough. Some patients may present muscle aches, runny nose, nasal congestion, diarrhea, or sore throat.¹¹ The symptoms are usually mild and benign gradually. Some individuals may become infected without developing any symptoms or feeling unwell.¹² Recently, Xu et al.¹³ reported that salivary glands may be potential reservoirs for COVID-19 asymptomatic infection.

The immense majority of participants (98.07%) agreed that COVID-19 can be transmitted by saliva, rendering dental procedures hazardous for disease propagation; this is consistent with current scientific evidence.^2,9,12,14 Because dental procedures pose a high risk of transmission, elective treatments should be postponed until the pandemic is stabilized.^9,10 The American Dental Association (ADA) has summarized urgent and emergent situations to provide dental professionals with guidance on how to minimize the risks of COVID-19 transmission when performing dental procedures.¹⁰ The most common situations that necessitate dental treatment during the pandemic period are severe dental pain from pulpal inflammation; pericoronitis or third-molar pain; postoperative osteitis; localized pain and swelling due to abscess or bacterial infection; dental trauma resulting in pain or soft tissue laceration; dental avulsion/luxation; final crown/bridge cementation, if the temporary restoration is lost, broken, or causing gingival irritation; replacement of temporary fillings on endo access openings for patients experiencing pain; and orthodontic wire or appliances piercing or ulcerating the oral mucosa, which must be snipped or adjusted.^9,10

Biosecurity measures are necessary to protect both patients and dental professionals during dental treatment. Therefore, use of PPE (gown, mask, goggles or face shield, and gloves) and safe work practices to protect dental equipment and limit contamination are particularly crucial, such as keeping the hands away from the face, limiting surfaces touched, changing torn or contaminated gloves, and proper handwashing before and after dental care, according to Ather et al.⁹ In this study, 11,691 participants (73.93%) had doubt in the ability of conventional PPE to prevent COVID-19 transmission, and only 18.06% of the respondents considered their workplace’s current biosecurity measures sufficient to prevent possible infection. Biosecurity recommendations for dental procedures have been consistently disseminated by previous studies and should already be employed by dentists and assistants as a routine practice.^9,12 Additional care during removal of PPE is also recommended during the pandemic period to avoid contact with clothing, skin, or mucous membranes, due to the high transmission potential of contaminated materials.^9,12

Dental professionals are at high risk of nosocomial infection and can be potential carriers of COVID-19.^2,9,15 These facts are consistent with the responses of most study participants, particularly those in the Northeast region, who acknowledged that COVID-19 could be transmitted through dental treatment (Table 4). However, some respondents in the Midwest region did not believe COVID-19 could be transmitted through dental treatment (Tables 3 and 4). These findings are concerning because dental treatments produce a large number of droplets and aerosols, the principle transmission routes for COVID-19 infection.^12,16 Additionally, if dental patients cough or sneeze, their secretions, saliva, or blood aerosolize and can infect individuals in close proximity (within approximately 2 m).^9,12,13

Recent findings suggest that saliva is an important mode of transmission of COVID-19.^2,13 Once that COVID-19 may be present in asymptomatic patients, dentists should observe standard, contact, and airborne biosecurity precautions, including appropriate use of PPE (disposable medical caps, disposable surgical masks, goggles, face masks, and a work coat with external insulation or surgical clothes, and disposable latex gloves) and hand hygiene practices.^2,12,16 The use of half-mask filtering facepiece respirators, as N95 respirators, is essential to prevent aerosol and droplet transmission, presenting better protection than surgical masks.¹⁷ Another recommendation is to perform a preprocedural mouth rinse with 0.2% povidone–iodine^9,12,18 or 0.5–1.0% hydrogen peroxide¹⁹ to reduce the viral load in saliva. Ather et al.⁹ observed that the use of disposable devices, such as powerful suction pumps, is encouraged to avoid cross-contamination, as is the use of a rubber dam to minimize splatter. Clinic staff should take care to disinfect surfaces using chemicals recently approved for COVID-19 and to maintain a dry environment.²⁰ Respondents in this study who considered their workplace’s biosecurity measures and PPE sufficient to prevent COVID-19 transmission were more likely to perform both elective and emergency dental procedures (Table 3). However, a limitation of this study’s results is that the actual biosecurity measures employed by these dentists were not investigated. So, the observation with biosecurity during dental procedures should be adopted in all appointments, with all patients.

The latest update (March 16, 2020) from the ADA recommends American dentists defer elective dental treatment for the next 3 weeks, focusing only on emergency care.¹⁰ Similarly, the Brazilian public health system recommends prioritizing cases of pain, infection, and suffering.^21,22 However, dentists’ likelihood of providing emergency care differs according to their field of specialty. In the present study, 71.9% of public health specialists performed emergency dental care and thus face greater exposure to potential COVID-19 infection (Table 3). It should be noted that these professionals are commonly linked to primary and secondary public health-care services, which have continued their activities during the COVID-19 pandemic and provide urgent dental care, as recommended by public health authorities.

This study observed that the majority of dentists in the North region continued to perform elective dental procedures. Thus, these professionals are also at greater risk of contracting and spreading COVID-19 (Table 4). Lower awareness of and adherence to disease control strategies are associated with a greater risk of susceptibility to infectious diseases, such as COVID-19. Therefore, to mitigate the effects of the disease, public health policies should target groups at higher risk of contracting and transmitting COVID-19.

Prevention of infection in dental offices is difficult if dentists are not concerned with adherence to the biosecurity protocol. The appearance of a clean office does not necessarily indicate that surfaces and equipment are properly disinfected and sterilized. An effective dental office, whether public or private, should incorporate biosecurity measures into its permanent routines, according to Garbin et al.²³ In Brazil, private offices are frequently seen as models of infection control.²³ This is consistent with the responses received in this study, showing that dentists working in private practice were more likely to consider their workplace’s biosecurity measures and PPE sufficient to prevent COVID-19 transmission (Table 3). However, some studies have revealed flaws in biosecurity protocol even in private clinics,^23-25 with negligent use of PPE being one of the most frequent.^23,24 Professionals have reported that biosafety protocols are difficult to follow, one factor that relates to noncompliance with biosecurity measures.

In contrast, an association between lower financial resources and investment in an office and worse infection control conditions has also been observed.²³ In humble areas, limited dental offices had conditions adequate to ensure cross-infection control. The worst conditions were found in public dental services and private clinics in peripheral regions. This is consistent with the present study’s results, in which respondents working in primary or secondary public health services and popular or franchised private dental clinics were less likely to consider PPE and biosecurity measures sufficient to prevent COVID-19 transmission (Table 3). Similarly, Garbin et al.²³ observed more flaws in public offices than private offices in the use of protective barriers: Caps were used by 55% of public sector professionals versus 90% of private-sector professionals; proper glove changing was observed in 100% of private-sector professionals versus 60% of public-sector professionals; and only 25% of public dental offices supplied protective glasses for patients versus 65% of private offices. According to the present study’s results, mistrust of biosafety measures also extends to dentists working in public hospitals (Table 3).

Brazil is a country with continental dimensions and immense economic and social inequality between regions. The regions of the central south axis (Midwest, Southeast, and South) are more economically privileged than the North and Northeast regions.⁶ Implementation of infection control barriers can be influenced, among other things, by economic issues.²⁶ In the Northeast region, 79.80% of the respondents reported that PPE was insufficient to prevent COVID-19 transmission, and 79.10% considered their workplace’s biosecurity measures insufficient (Table 4). Economic issues may have influenced the implementation of biosecurity barriers in health facilities in the Northeast region, as reflected in these participants’ responses.