Abstract
Purpose:
Dentists need to access and receive information that is truthful and trustworthy about SARS-CoV-2. The purpose of this study was to determine West Virginia (WV) dentists’ sources of information comparing dentists in practice ≤10 years with dentists in practice >10 years; and, dentists in rural vs. urban practices.
Method:
A cross sectional study design was used. Licensed dentists in WV were provided an anonymous survey in March 2020 (N=1,156). There were 273 respondents (23.7%). Data were analyzed for frequency, bivariate analyses, and logistic regression.
Results:
WV dentists used several primary sources for SARS-CoV-2 information: ADA website (88.7%); the CDC website (76.5%); and the WV State Department of Health website (60.3%). Dentists in practice ≤10 years were more likely to access the CDC website (p = 0.007) and to use the media (p = 0.007) for information than dentists in practice >10 years. Rural dentists were more likely to access the CDC website (p < 0.005) than urban dentists. In adjusted analyses, dentists with rural practices were more likely to access the CDC website for information than dentists with urban practices (AOR=2.49; CI:1.25, 4.95; p=0.010).
Conclusion: Most WV dentists reported accessing and receiving guidance concerning SARS-CoV-2 from the ADA, CDC, state department of health and from the state dental society.
Practical implications:
Dentists seek reputable, scientific authorities for patient and healthcare provider safety and guidance.
Key words:
COVID-19, SARS-CoV-2, informational sources, rural/urban, pandemic
COVID-19 was declared to be a public health emergency by the World Health Organization on January 30, 2020. It was declared to be a global pandemic on March 11, 2020. SARS-CoV-2, the responsible virus, spreads easily between people.1 Morbidity and mortality associated with COVID-19 rose exponentially in Mid-March 2020.2
The standard or universal precautions followed by U.S. dentists were created for protection against blood exposure to blood-borne pathogens (BBP)3 and not for viruses such as SARS-CoV-2. To protect dental personnel and the public, many state officials quickly closed dental practices except to urgent/emergent care in mid-March. These actions were taken as SARS-CoV-2 can transmit as a droplet pathogen and potentially as an airborne pathogen.1 Before the pandemic, most patients with an airborne disease such as tuberculosis, did not present to the dental office. And if they did, they were referred for care in an airborne infection isolation room (AIIR) as per the Transmission-Based Precautions guidelines of 2007.4 Dental offices were not required to have AIIR. In the classic study by Micik, et al. (1969) bacterial aerosols were cultured from the aerosols generated during air spray on dry teeth (72 colony forming units [CFU] /minute), cavity preparation with air turbine and air coolant (58 CFU), cavity preparation with air turbine and water coolant (1000 CFU/minute), and washing teeth with water spray (37,000 CFU/minute).5 Viral transmission of herpes simplex labialis to a dental professional’s eyes (herpetic ophthalmia) could be transmitted similarly. Patients with cold sores, influenza, and colds were rescheduled unless needed care was urgent/emergent.
People with COVID-19 may be able to transmit the virus while being asymptomatic and pose a health risk to dentists, dental hygienists, staff, and other patients in a dental practice.1 The potential risk for disease exposure reported by the Department of Labor’s O*Net risk assessment is: dental hygienists (100%); dental assistants (96%), and dentists (90%).6
As standard or universal precaution infection control guidelines were developed in response to HIV in the 1980’s, transmission-based precaution guidelines are now being adapted for dentists in response to COVID-19. An infection control paradigm shift is expected with the restart of dental care following dental practice shutdowns.
The guidelines will address the safety of dental healthcare professionals, staff, and patients against novel, small, microbial agents that aerosolize in dental offices, such as SARS-CoV-2. SARS-CoV-2 aerosol in samples from two Wuhan, China hospitals were in two size ranges: a submicron size from 0.25 to 1.0 micrometer and a super micron size of 2.5 micrometers.7 Dental healthcare professionals will need to wear specific respirators that filter against these particle sizes and do not allow air infiltration around the respirators.
CDC guidelines in place as of April 27, 2020 included: face coverings for everyone entering a dental practice; COVID-19 screening upon arrival and prior to treatment; dental care in AIIR for patients with known or suspected COVID-19; as well as many other recommendations.8 As people may be asymptomatic for COVID-19, all patients should be considered potentially infected and capable of transmitting COVID-19.1 The major infection control concern is aerosol generation from high speed handpieces, air-water syringes, ultrasonic scalers, etc. Aerosol generation procedures may contaminate the air and surfaces with SARS-CoV-2 and requires PPE precautions such as N95 (or greater) respirators, face shields/goggles, gloves, gowns, and potentially head and shoe coverings. Distancing of patients/staggering of appointments, patients wearing masks before and after treatment, decontamination of treatment areas, and many other procedures will need to be implemented. The new guidelines should be understood and followed. There is a critical need to determine the level of use of the sources that disseminate such information, the knowledge that dentists have, and changes that may be imposed after the pandemic slows/declared ended and/or a vaccine is available.
Within the U.S., the incidence of COVID-19 and state responses to it have been different. In this study we are focusing upon the dentists in a rural state, WV. WV is the only state entirely in the Appalachian region as defined by the Appalachian Regional Commission and it has 15 counties (of 55 total counties) that are economically distressed.9 The unique mountainous, rural landscape, culture, and economic distress of counties in WV impede access to health care. The lack of healthcare utilization paired with the inherent culture of the region itself is conducive to a population where many citizens are in poor health. The plethora of health problems/illnesses of many WV citizens makes them very vulnerable to infections in general.
Since SARS-COV-2 is a disease affecting the respiratory system, any existing cardiovascular, respiratory illness, or condition which compromises the immune system (such as diabetes and cancer) as well as age makes those citizens more vulnerable.10 Subsequently, these citizens bear a high risk of death if contracting SARS-COV-2. WV had early stay-at-home orders in place (March 24, 2020 at 8 p.m.). As of May 1, 2020, WV had 1,125 cases with 44 deaths yielding a death rate of 3.8% from January 1, 2020 to May 1, 2020.11 The reopening date in WV was May 11, 2020.
We were interested in what informational sources different cohorts of dentists seek. The outcome was the informational source sought. We were interested if years in practice and practice setting influenced what sources were used. The central hypothesis for this study is that there is no difference in the use of official websites for information based upon a WV dentists’ years of practice. Our specific aim is to compare WV dentists’ sources of information between dentists who have practiced ten years or less with dentists who have practiced more than ten years. Our secondary aim is to compare the dentists based upon practice location (rural vs. urban).
Method
Ethical statement:
This study was approved as having had exempt status acknowledgement from the West Virginia University Institutional Review Board (protocol number 2004962144).
Study design:
A cross-section research design was used.
Sample size:
The entire population of currently licensed dentists listed by the WV Dental Board (N=1,156 dentists) were invited to participate. The number of dentists participating in the study was 273 (23.6%).
Dependent variable:
Participants were asked to respond as to if the CDC website was accessed for guidance concerning COVID-19. Possible responses were strongly agree, agree, neutral, disagree, and strongly disagree. The responses were dichotomized to a yes, no variable with strongly agree and agree categorized as “yes,” and neutral, disagree, and strongly disagree categorized as “no.”
Key independent variables:
The key independent variable was the number of years in practice (≤10 years, >10 years). A secondary independent variable was the practice location as self-reported by the dentist (rural, urban).
Other variables:
Participants were also queried about the other sources of guidance concerning COVID-19, supplies and opinions about COVID-19. The questions were developed during the initial stages of the COVID-19 pandemic. These were basic knowledge questions related to an infection transmission of serious diseases such as TB, which were not treated in typical stand-alone dental practices. It was the beginning of a paradigm shift in patient dental care. The questions were developed with the WVU School of Dentistry Chairperson of the COVID-19 task force, TC.
Procedures:
An initial recruitment email/cover letter request with a hyperlink to an anonymous, online survey was sent to currently licensed WV dentists in April 2020. A second, follow-up email was sent two weeks later with the same hyperlink. Study data were collected and managed using REDCap electronic data capture tools hosted at West Virginia University.12,13 REDCap (Research Electronic Data Capture) is “a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.”12,13
Statistical Analysis:
The responses were described by frequency and percentages. Bivariate analysis of years of practice with the key independent variable was conducted with Chi Square analyses. The other variables were also analyzed versus years of practice. IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) was used for data analysis. Significance was determined with an a priori P-value of <.05.
Results
There were 273 responses (23.7% of licensed dentists in WV) to the survey. Participants were primarily male (n=172, 63.5%), and in practice for more than 10 years (n=206, 76.3%). Most worked full time (n=182, 66.7%), were general dentists (n=210, 76.9%), and owned their own practice (n=153, 56.7%). There were 123 (45.4%) of responding dentists who reported having a rural practice. A description of the participants is presented in Table 1.
Most participants accessed the CDC website for information about COVID-19 (76.5%). Most participants also accessed the national ADA website (88.7%) and 60.3% accessed the WV state Department of Health website. There were 80.2% who reported receiving information from the WV state dental society. Most (82.6%) of the dentists would refer a known/suspected person with COVID-19 case to a medical center. There were 36.4% correctly disagreeing that BBP guidance applied to aerosol generation. 68.6% correctly reported N95 masks protect against aerosols; 60.9% correctly reported that N95 masks were intended for one-time use. There were 82.6% who reported known patients with COVID-19 should be treated in AIIR. 33.6% reported that it was incorrect that pre-procedural mouth rinse such as H2O2 have been proven effective in the prevention of COVID-19. 71.0% correctly reported that level 1 masks were not protective against aerosols. (Table 2).
In bivariate analysis, dentists in practice ≤ 10 years were more likely than dentists in practice > 10 years to have accessed the CDC website for guidance upon COVID-19 (p = 0.007). There were no significant differences between the groups in accessing the national ADA website or the WV State Department of Health website. Dentists in practice ≤ 10 years were more likely to receive information about COVID-19 through media than dentists in practice > 10 years (p = 0.007). There were no significant differences in current supplies of personal protective equipment (PPE), cleaning supplies, routine PPE purchases, or plans for purchasing N95 respirators. In terms of questions relating to COVID-19, dentists in practice ≤ 10 years were similar to dentists in practice >10 years in their responses except for the statement that N95 respirators are meant for single use (75.0% of dentists in practice ≤ 10 years agreed, and 56.4% of dentists in practice >10 years agreed); and the effectiveness of pre-procedural rinse in transmission of COVID-19 (59.4% of dentists in practice ≤ 10 years disagreed it was effective, and 77.7% of dentists in practice >10 years disagreed). (Table 3)
When analyzed by rural/urban status, dentists with rural practices were more likely to view the CDC website for guidance upon COVID-19 than dentists with urban practices (P<.005). They were also more likely to have a month’s supply of PPE (P = 0.035) and cleaning supplies (P = 0.017). (Table 4).
In unadjusted logistic regression analyses, dentists with ≤10 years were more likely to access the CDC website for guidance upon COVID-19 than dentists with >10 years (Unadjusted Odds ratio (UOR) = 3.06; 95% Confidence Interval (CI): 1.32, 7.11; p = 0.009). They were also more likely to receive information from the media than dentists with > 10years. However, the differences did not remain significant in adjusted analyses. Length of time in practice was not significantly associated with other sources of information (Table 5).
Dentists with rural practices were more likely to access the CDC website for guidance upon COVID-19 information than dentists with urban practices in unadjusted (UOR=3.34; 95% CI: 1.76, 6.37; p<.005) and adjusted analyses (AOR=2.49; 95% CI: 1.25, 4.95; p = 0.010). Rural/urban status was not associated with other sources of information about COVID-19 guidance (Table 5).
Discussion
The COVID-19 pandemic brought to light an urgent need for change in the infection control practices related to aerosol generating procedures in dental practices. Standard precautions do not protect against aerosol transmission of infection. Transmission-based precautions at the level of droplet precautions and aerosol precaution s were necessary implementations for dental practices in response to SARS-CoV-2. Much was unknown about SARS-CoV-2 in March 2020, therefore the government officials in various states provided differing mandates for dentistry that varied from no changes in dental practices to practice closures with only urgent/emergent care to be provided. In WV, the officials followed the conservative ADA and CDC guidance to restrict dental care to urgency/emergency. Dentists in WV became aware of such guidance through accessing several primary sources: the ADA website (88.7%); the CDC website (76.5%); and the WV State Department of Health website (60.3%). The WV Dental Society (WVDS), a highly active state society, provided much guidance to state dentists and 80.2% of the dentists in this study indicated that they received information from the state society.
There were only a few differences between dentists based on years of practice or location. Dentists in practice ≤10 years were more likely to access the CDC website and to receive information about COVID-19 through media sources in unadjusted analyses; however, these differences failed to reach significance in adjusted analyses. Dentists practicing in rural practices were more likely to access the CDC website than dentists practicing in urban practices (AOR=2.49; 95% CI: 1.25, 4.95; p = 0.010).
There were differences between dentists with rural and urban practices in terms of supplies available in the office. Dentists with rural practices were more likely to have a month’s supply of PPE and cleaning supplies. One possible explanation is that rural dentists in WV have difficulty in receiving just-in-time winter deliveries. WV has winter road closures and delays in winter shipments to rural areas. Another possible explanation is the concern for supplies freezing before they are received. Often rural dentists are encouraged in autumn to purchase a large supply of composite restorative materials, anesthetics, and other supplies that can be damaged by the cold. This is not the typical inventory management recommendation in other areas with few delays in deliveries and where many supplies are available with overnight shipments. Basic inventory management is encouraged through practice management programs and the literature14,15 as well as by many dental supply company sales personnel. The ADA recommends, as a basic practice, that any single month’s supply charges should not be more than 6% of the previous month’s collections.14
In terms of the questions asked about PPE and the guidance in place in early 2020, there were approximately one-third (36.4%) who correctly responded that BBP guidance did not apply to aerosol generation. Over two-thirds, 68.6%, correctly reported N95 masks protect against aerosols; 60.9% correctly reported that N95 masks were intended for one-time use. There were 82.6% who reported known patients with COVID-19 should be treated in AIIR. Approximately one-third, 33.6%, correctly reported that it was unknown if a pre-procedural mouth rinse such as H2O2 was effective in the prevention of COVID-19. 71.0% correctly reported that level 1 masks were not protective against aerosols.
Study strengths and weaknesses
This study has an adequate sample size to examine differences in sources of information by time in practice and by rural/urban practices; however, it is limited by the sample being WV dentists. A study strength is that the entire population of licensed WV dentists were invited to participate in the research and 23.6% did. An additional strength is the representation of rurality with the potential to generalize to the national level. Another limitation is that in dichotomizing the responses, neutral responses to accessing websites and receiving information were included with “no” responses.
Paradigm changes
Everyone is aware that the knowledge being gained about SARS-CoV-2 is accumulating daily and actions in response to the knowledge will also need to evolve. Until a vaccine is widely available or treatments are discovered, this pandemic will impact all aspects of life. Having and accessing trustworthy sources for guidance is crucial for all aspects of life, but especially in fields such as dentistry where risk of transmission is so high. Regulating agencies, such as the CDC, the National Institute for Occupational Safety and Health, and societies such as the ADA are sources that have provided reliable information for dentistry. Our results indicate that dentists in WV have accessed and utilized these reliable sources for guidance on infection control practices.
Future research
Additional research is deeded to evaluate the problems related to the supply chain and PPE use. Many months have passed and there remain limited respirators. Acceptable respirator substitutes for N95 respirators must be vetted to verify adequate protection. Some items donated through excess national supplies are out-of-date. The level to which these circumstances are occurring is needed to be understood for policy makers to determine steps to improve the supply chain.
Conclusion
Most dentists in the rural state of WV state reported accessing and receiving guidance concerning SARS-CoV-2 from the ADA, CDC, state department of health and from the state dental society. Dentists practicing in rural practices were more likely to access the CDC website than dentists practicing in urban practices.
__________
Dr. R. Constance Wiener, Associate Professor
West Virginia University, Department of Dental Practice and Rural Health, School of Dentistry,
104a Health Sciences Addition, PO Box 9415, Morgantown, WV 26506
Office: 304 581-1960
Fax: 304 293-8561
Email: rwiener2@hsc.wvu.edu; corresponding author
ORCID: 0000-0003-0371-6699
Dr. Tammy Chipps, Assistant Professor
PO Box 9495
School of Dentistry Department of Restorative Dentistry One Medical Center Drive Room 1276 Health Sciences Center South Morgantown, WV 26506-9495
Email: tchipps@hsc.wvu.edu
Dr. Fotinos Panagakos, Dean School of Dentistry
West Virginia University, Department of Dental Research, School of Dentistry,
118 Health Sciences Addition, PO Box 9448, Morgantown, WV 26506
Office: 304 293-3396
Email: fotinos.panagakos@hsc.wvuedu
ORCID: 0000-0003-0371-6699
Acknowledgement:
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 5U54GM104942-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Accessed May 15, 2020. - ARC (Appalachian Regional Commission) 2020.
“https://www.arc.gov/appalachian_region/TheAppalachianRegion.asp.” Accessed May 15, 2020. - Centers for Disease Control and Prevention. Assessing Risk Factors for Severe COVID-19 Illness. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/assessing-risk-factors.html Accessed July 22, 2020.
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- American Dental Association, Dental Supplied-inventory Control. 2020
https://success.ada.org/en/practice-management/guidelines-for-practice-success/managing-finances/dental-supplies-inventory-control - Doniger S. Basic inventory management. Dentistry IQ. Nov 18, 2020.
https://www.dentistryiq.com/front-office/article/16364354/basic-inventory-management
This submission is included in the JADA+ COVID-19 monograph as a Clinical Observation entry and has not been peer reviewed.
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