Introduction

By the end of 2019, a new virus named Coronavirus appeared in China and due to its rapid spread, a pandemic warning had to be officialized by the World Health Organization (WHO) in March 2020. Coronavirus, a single-stranded RNA virus was first found in the province of Wuhan, China where it was reported as pneumonia of unidentified origin [1]. After the rapid rise of this viral pneumonia, on 9 January 2020, the World Health Organization announced the causative agent to be a novel Coronavirus which was never found in humans, first designated as 2019-nCoV and formally entitled as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses. India reported its first coronavirus case on 30th January 2020 in a student who arrived in Kerala state from Wuhan city, China, and reported its first COVID-19 death on 12 March 2020 in Karnataka [2]. COVID-19 infection in India is reported strikingly low stressing that the level of revival among affected patients is 63.45 percent in the country whereas the mortality rate is 2.3 percent compared to the world average [3]. The coronavirus is responsible for infectious respiratory syndrome, which is now widely known as Corona Virus Disease 19 (COVID-19) [4, 5]. Symptoms of individuals identified with SARS-CoV-2 generally include fever, cough, shortness of breath which show up within 2-14 days [6]. As SARSCoV-2 is airborne, it has the potential to infect people in close contact with infected individuals and health care workers (HCWs) are considered to be at high risk [2, 7].

Considering the plethora of concomitant conditions, HCWs including dental professionals are at a greater risk of getting exposed to the virus. Possible transmission routes for COVID-19 in dental practice include airborne spread through aerosols and droplets produced during a dental procedure, contact spread, and contaminated surfaces spread. Conflict of humanitarianism and professional duty, on one side, with fright and suspicion of potentially exposing their relatives to a deadly virus, on the other side, has been a huge stress for several medical personnel during the COVID-19 outbreak [8].

COVID-19 posed immediate challenges for dental care and education because of the high rate of spread of the virus in dental settings and the precision in clinical practice [9]. The Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), and WHO have proposed specific recommendations for dentists and dental workers to monitor the escalation of COVID-19. Like for other communicable diseases, such precautions involves personal protective equipment, thorough patient evaluation, hand washing, rubber dam protection, anti-retraction handpiece, pre-procedural mouth rinsing and clinic disinfection [10].

In a healthcare environment, Personal Protective Equipment (PPE) is used to protect health care workers (HCWs) vulnerable to pathogens and to prevent the transmission of pathogens to different patients. The key types of PPE used against these critical hospital-acquired pathogens to protect HCWs and other patients include standard masks, gowns, gloves, goggles, and face shields [11]. Medical mask is required for droplet precaution and goggles/face shields are necessary for shielding the eyes and for preventing contact spread fluid-resistant gowns and gloves with long sleeves are endorsed [12]. Hence it is vital to know the distinction between respiratory shielding equipments as well as protective clothing. Generally, masks can be ranked as respirators, medical masks, and non-medical masks. The potential of masks depends on a few factors such as their filtration efficiency, facial fit and the number of layers [13].

Medical masks are also called surgical masks. They are loose-fitting masks that act as a barricade to hinder droplet spread from the dentists to the patients and also protect the dentist from the patient’s bodily fluids, respiratory droplets, and blood that may become airborne during the procedure. According to US National Institute for Occupational Safety and Health (NIOSH), particulate filtering facepiece respirators (FFRs) are classified into 9 categories based on their filtration efficiency (95%, 99%, and 99.7%) and their capability to filter oil droplets ( N95,99,100: not resistant to oil, R95,99,100: mildly resistant to oil, P95,99,100:highly resistant to oil).

The N95 title denotes that it can filter 95% of 0.3-micron size aerosol particles [14]. The guidelines by WHO and CDC urged the use of fluid-repellent gowns as well as gloves During this pandemic period when caring for patients. Based on their impermeability to liquid and microbes, gowns are classified into high performance and standard performance by the European standard EN13759. However, to protect the HCWs from contagious sources gowns should have the standard EN14126, which comprises tests for resistance to perforation by fluids, blood or microbes under varying hydrostatic pressure from Class 1(0 kPa) to Class 6 (20kPa) [12]. Face shields and goggles are auxiliary measures alongside surgical masks or respirators [14].

The outbreak of the Ebola virus disease (EVD) in 2014–2016 showed the need for more scientific evidence on best practices for safely donning and doffing of PPE [15]. Appropriate use of PPE becomes critical when HCWs treat patients who can be symptomatic or asymptomatic carriers with highly pathogenic species such as coronavirus. Hence, this study intended to evaluate the knowledge and perception of PPE kits among dental professionals in India during the COVID-19 outbreak.

Materials and Methods

A web-based survey was conducted using Google forms in May 2020. Ethical clearance was granted by KAHER University (Sl No: 1364) and consent was acquired from participants before the study. The study included dental practitioners and dental postgraduate students all over India. The study excluded the participants who were not practicing dentistry. A self-designed questionnaire was prepared and validated using Chronbach alpha and the value was 0.84. The questionnaire was distributed through social media applications like Whatsapp, Instagram, Facebook, and Twitter. The confidentiality of study participants was maintained throughout the study. The questionnaire included 22 questions out of which 16 were knowledge-based (k1 to k16) and 6 on perception (p1 to p6) and all the questions were closed-ended. Survey feedback was gathered from May 2020 to July 2020. A total of 589 responses were obtained. Demographic details included name, age, gender, years of working experience, region, and designation of the study participant. Respondents were asked about the recent protective measures used during COVID 19 outbreak, knowledge regarding Covid-19, PPE, difficulties faced while using PPE, and their attitude towards them. Survey responses were downloaded into a Google sheet and descriptive analysis was performed using SPSS version 22. Comparison of demographic details was done using Mean and standard deviation. Linear comparison between knowledge was done by chi-square t-test in which a p-value less than 0.05 was considered as significant. Correlation between knowledge and perception scores was analyzed using Karl Pearson’s correlation coefficient method. Paired t-test and ANOVA were also used to compare between different groups.

Results and Discussion

589 subjects were involved in the study of which 79.46% were from the age group of 25 – 35 years and only 5.9% were from the age group of 45-55 years. Out of the responses received, 70% had their working experience of fewer than 5 years. Demographically, 52% of study participants were from South India and the remaining were from East (15.9%), West (12.9%), and North (18.34%).

A greater part of the subjects was aware of COVID-19 symptoms (98.6%), among which 86.9% of the people feared the risks involved in the dental profession and 98.5% of them were aware of different protective measures adapted during the COVID-19 outbreak. The majority of them (98.8%) were aware of the different components of a PPE kit, whereas only 60.3% understood protocols regarding donning and doffing, and out of that only 46% of people knew the proper course of donning and 62.3% regarding doffing procedures and this suggested the chances of cross-contamination due to protocol deviation by dental professionals.

Except for the questions “Do you feel that you have sufficient knowledge regarding the use of PPE and how safely you can work in a dental clinic” (p-value= 0.008) and “whether you know how to dispose of the PPE kit properly” (p-value= 0.018) all other questions estimated statistically insignificant according to chi-square test. It was also observed that dentists of higher age groups (45-55 years) were more aware of the protocols regarding PPE (Table 1).

Table 1. Comparison of age groups with correct knowledge in each item of respondents

*p<0.05

When years of experience and knowledge of participants were compared, only for the questions “Are you aware of donning and doffing protocols” (p-value = 0.005) and “Filtering facepiece respirators referred as” were accounted to be statistically significant and further questions remained statistically insignificant (Table 2).

Table 2. Comparison of Years of experience with correct knowledge in each item of respondents

*p<0.05

When region and knowledge of the participants were compared, 95-100% of dentists from western and southern regions responded correctly and no significant difference was seen for all the questions except for a few such as ‘‘What all are the different types of masks?’’ and ‘‘difference between mask and respirators’’.

About half of the (58.4%) study participants had started wearing PPE kits in their daily dental practice and 73.2% agreed that the use of PPE kits in a dental clinic is a mandatory requirement than a normal surgical gown. Various responses were recorded regarding the question ‘‘How to limit the use of PPE kit in a dental clinic’’, 31.9% of study participants opined that nonurgent procedures should be postponed, whereas 71.5% suggested use of alternate tools such as telemedicine, 45.5% of study participants felt patient contact should be limited and PPE could be reused with proper decontamination guidelines according to 49.4% participants. Among the study population, 93.9% of participants agreed to the fact that they fear the misuse of PPE kits can lead to infection. Concerning the difficulties of wearing the PPE kit, 46.5% claimed that there was an inconvenience. More than half of the population (52.3%) reported that they have increased the treatment costs due to the growing trend of usage of PPE kits in a dental clinic.

When age groups with correct perception were compared a statistically significant (p-value= 0.028) difference was seen with the question on ‘‘Importance of usage of PPE in a clinic than a surgical gown’’ (P2) according to chi-square test (Table 3).

Table 3. Comparison of age groups with correct perception in each item of respondents

*p<0.05

Also when years of experience with correct perception were compared, a statistically notable variation (0.05) was noted with the question on ‘‘Do you have fear that misuse of PPE can get you infected’’ (P4) suggested that irrespective of years of experience dental professionals had fear of misuse of PPE can get them infected, with the highest being in the 5-10 years (Table 4). Mean knowledge scores were obtained using Oneway ANOVA and no significant difference was noted except for working in different sectors (p-value=0.009) (Table 4). It was also found that the Correlation between knowledge and perception scores by Karl Pearson’s correlation coefficient method was significant (p-value: 0.001).

Table 4. Comparison of years of experience with correct perception in each item of respondents

*p<0.05