This is the first nationwide study that has been undertaken in Pakistan which looked into the fear and anxiety levels and also assessed dentists’ knowledge and practice modification (according to CDC, WHO, ADA guidelines) during the current pandemic. A survey conducted in 2012 showed that out of 13,000 dentists registered in Pakistan, only 8500 of them were actually working. However, the current study revealed that only 313 dentists across Pakistan participated and submitted the form. This low number depicts that most of the dentists were not working during the COVID-19 era, as the questionnaire was only to be filled by practicing dentists during that time. This could be due to the lockdown situation in the country or because the dentists were actually afraid to practice during that time.
In situations like the ongoing pandemic with increasing mortality rate, fear and anxiety are natural psychological implications . The fear of getting infected while treating a patient or carrying the infection back home has been reported as a factor causing psychological trauma in healthcare workers [20, 21]. The current study revealed that a large number of dentists (75%) were afraid of getting infected in the workplace and even a larger number (92%) were afraid to carry the infection back home. Similar results were observed by a Turkish study which reported that 90% of the dentists were afraid of getting infected and 95% of them were concerned about carrying the virus to their family .
Taking patients history is very important specially during this ongoing pandemic since a COVID infected patient with acute symptoms is a potential source of infection. In the current study, 93% of the dentists in Pakistan were taking patients history of COVID-19 symptoms and 68% of them were avoiding aerosol generating procedures.
Dentists have always been at higher risk for airborne infections, therefore they should be even more cautious while attending patients during this current pandemic. Use of face shields and goggles is recommended to prevent spatter during a dental procedure. In Pakistan most of the dentists were well aware of the CDC guidelines regarding the use of PPEs (eyewear 80%, face shield 82% and protective clothing 73%). Surprisingly 69% of the dentists were using N95 masks while treating patients compared to only 12.36% Turkish dentists . This high percentage may be because Pakistan being a third world country has received a lot of foreign aid during this time.
Dental dams have been recommended by CDC to minimise droplet spatter and aerosols especially during the COVID-19 pandemic. The current study revealed that only 28% of the dentists were using rubber dam isolation for aerosol generating procedures compared to 13.84% Turkish dentists . This low percentage is because a lot of dentists find it difficult and time consuming using rubber dam on every patient. Regarding the use of rubber dam similar responses (14%) were seen in a survey conducted in 30 different countries .
According to CDC guidelines there is no published evidence regarding the clinical effectiveness of pre procedural mouth rinses (PPMRs) but they suggest its use to reduce the level of oral microorganisms in aerosols generated during dental procedure. Ahmed et al. reported 24% of the dentists were using pre procedural mouth rinse in different countries across the world , whereas in our study 50% of the Pakistani dentists were using mouth rinse before the procedure.
In the present study data was collected from different regions of Pakistan. Regional differences were also noted regarding the awareness in practice modification. In Balochistan lack of adherence to the CDC guidelines was noted as discussed in the results. This may be because of the distant nature and security situation in this region that the healthcare professionals are deprived of essential information and equipment .
One of the significant findings of our study was a positive correlation between awareness level and qualification/designation and workplace setting, showing that the awareness level rises with the rise in qualification/designation of the doctor. Similarly, the doctors of private hospitals have more mean awareness score as compare to the doctors of government setup. The major reason for this correlation is that private hospitals have always worked on maintaining their good repute by constituting and adhering to cross infection protocols and strict supervision, as they are adequately funded to achieve the patients trust and satisfaction.
One of the limitations of our study was that very few dentists were practicing during the pandemic and so a low response was obtained which can affect the generalizability of the study. Another limitation was that we could not get equal representation from all the regions of Pakistan. Only 13 dentists from Balochistan filled and submitted the questionnaire. Therefore, due to the limited data from this region, the results should be carefully interpreted.