Evaluation of the Relationship between Dentist Knowledge of the COVID-19 and the Using of the Rubber Dam in Endodontic Treatment

Duygu Bilgil¹ and Elmas Pınar Kahraman Kilbaş^2*

^*Correspondence: Elmas Pınar Kahraman Kilbaş, Fenerbahce University, Vocational School of Health Services, Medical Laboratory Techniques Associate Program, Istanbul, Turkey, Email:

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Introduction

Coronaviruses (CoV) which is a member of the Coronaviridae family is an enveloped virus containing single-strand RNA genome [1]. COVID-19 that was reported firstly in Wuhan, China, in December 2019 [2]. In a short time, the World Health Organization (WHO) announced that a public health emergency of international concern (PHEIC) for COVID-19 on January, 30, 2020 [3,4]. According to WHO data, the first case of the COVID-19 in Turkey was confirmed on March 11, 2020 and there have been 2,821,943 confirmed cases until March 11, 2021 [5].

The COVID-19 could transmit from human to human easily [6,7]. The COVID-19 virus spreads primarily via droplets, fluids (like saliva), and aerosols originating from organs of the respiratory system, for example mouth and nose [7,8]. Airborne transmission is also important for COVID-19 [9-11]. COVID-19 transmits via direct (cough, sneeze, and droplet inhalation transmission) and indirect (contact of the oral, nasal and eye mucous membranes) transmission routes [7,9,10].

Considering the transmission routes of the virus, dental clinics have an important place in preventing cross infection. All dentists should apply infection protection protocols against COVID-19. It should be known by the dentists that the COVID-19 is unstable to disinfectants and detergents [1]. Protective measures should be taken against droplets as like as in respiratory illness. These measures including avoiding airborne transmission, isolation airborne and personal protective equipment [11]. There are extra precautions for COVID-19. Dentists follow up-to-date health data and triage protocols should be determined. Fever of the patient should be measured before the procedure [12]. The appointments of suspicious patients should be postponed by contacting the phone before treatment [13]. Materials such as newspapers, magazines, and toys should be removed from clinic [12]. Appointments should be arranged to reduce the number of the patients waiting in clinic. Aerosolized procedures (like ultrasonic scaling, root-surface debridement, and high- or low-speed drilling with water spray) [14] should be reduced if possible. Antiseptic mouthwashes (1% hydrogen peroxide, chlorhexidine gluconate, povidoneiodine) should be used before the procedure (although there is no published evidence for COVID-19 yet) [15,16]. Dentists have to use rubber dam and large-volume cannulas during processes that will create aerosol [15]. Attention should be paid to hand hygiene, applying rules of the sterilization and disinfection. Patients should be treated in individual rooms and visitors should not be admitted to the examination room. Patients without masks should not be admitted to the clinic. Ventilation should be given extra importance [16] and Windows should open during treatment [17]. Special clothing and barrier precautions (masks, gloves and eye protection) should be used (17, 18). Clinic staff should use N95 (FFP2) instead of the surgical mask [15,16].

Generally, preprocedural rinse with antiseptic mouth wash, rubber dam isolation, and high-efficiency particulate air room filters should be used for reducing spreading of the aerosol and increasing infection control, during dental practise [18]. In a study which is about "Severe acute respiratory syndrome and dentistry" it has stated that Samaranayake and colleagues reported using rubber dam reduces airborne particles around a 3-foot diameter of the treatment area up-to-70% [14]. However, in an article published just before the pandemic in Turkey, it stated that the dentists have a very low level of using of the rubber dam (p <0.05) [19]. Furthermore, in a study conducted in 2011 by asking only lecturers in the fields of restorative dental treatment and endodontics, it was stated that 18% of the lecturers never used rubber dam [20]. Although the using of the rubber dam was recommended before the epidemic, with the COVID-19 epidemic, the use of the rubber dam has become mandatory [15]. So, the purpose of our study; to evaluate the differences in the frequency of using rubber dam with COVID-19 pandemic, especially when performing canal treatment. Furthermore, to determine whether there is a relationship between the using of the rubber dam and COVID-19 knowledge level.

Material and Methods

The questionnaire used in the study was designed as an online questionnaire on Google Forms. through various channels to fill out the questionnaire (university websites, social media) reached 438 faculty members in the department of endodontics universities in Turkey and found 110 gave positive feedback. Apart from this, dentists who are specialized or not specialized were reached through different channels (Turkish Endodontic Society website, social media). A total of 389 participants were reached within the scope of the study, 131 among the participants were specialized in the field of endodontics. A message was sent to all who could be reached who met the inclusion criteria, asking them to support the study first. Afterwards, a questionnaire was sent to those who accepted to participate. The online survey was distributed between February 8 and March 3, 2021.

A pilot study was conducted before the questionnaire was distributed to the participants. The pilot study was applied to participants including 8 specialist dentists (2 from endodontics, dental diseases and treatment, prosthesis and Pedodontics branches) and 2 dentists. Participants they made comprehensive suggestions so that the content of the questionnaire reflects the purpose of the research. In addition, supervision was received from a professor in the field of endodontics for the questionnaire. The content of the questionnaire was reviewed in line with these feedbacks. The questionnaire was finalized by removing and revising the questions that were misunderstood, detailed, and containing typos.

The questionnaire consists of 3 parts and 31 questions in total. In the first part, there are 8 questions about the demographic characteristics of the participants, 7 questions in the second part that evaluate the use of rubber dam by the dentists, and in the third part there are 16 questions that measure their knowledge level about COVID-19. In the second part of the questionnaire, participants who did not use rubber dam were asked to pass questions about using rubber dam. The question number that participants should skip due to a technical error was incorrectly specified. Therefore, they should answer "If you do not always use the rubber dam during endodontic treatment, what are your reasons/reasons for not using it?" Some of the participants did not answer the question. A scoring determined by the researchers was given to the questions regarding COVID-19 knowledge levels in the third part of the questionnaire. The researchers who gave correct answers to the questions included in the scoring in the last section received 5 points for each question. The differences between the total score levels and various variables were analyzed statistically.

Statistical analysis

The responses of the participants were downloaded from Google Forms in a spreadsheet format. Data analysis was done in IBM SPSS Statistics, Version 25.0. Armonk, NY. Ethics committee approval is not required for the study.

Results

A total of 389 dentists participated in our study, 59.4% of them were women and 40.6% were men. The clinical experience of 34.7% of these participants is 0-5 years, 34.7% is between 6-10 years, and 30.6% is 11 years and above. It has been determined that 38.6% of the dentists participating in our study do not have expertise, 35.2% of them are experts, and 33.7% of the participants who are experts are endodontists. 51.4% of the participants stated that they received training about COVID-19 (Table 1).

Table 1: Demographic findings of the participants.

It was found that only 38.6% of the participants included in our study and 82.44% of the endodontists used rubber dam. 39.8% of those using rubber dam reported that they used endodontic and 11.3% for restorative procedures. Of the participants who used rubber dam, 19.3% stated that they used rubber dam equally in all teeth and 14.9% most often on their back teeth during endodontic treatment. Of those who do not always use rubber dam during endodontic treatment (180 people who do not rubber dam answered this question), 12.9% application takes time, 12.1% required use 11.6% stated that they did not see it, and that they did not use it because the patients were unwell. 27.5% of all participants reported that the frequency of rubber dam use increased during the COVID-19 pandemic process (Table 2).

Table 2: Answers to questions about the use of rubber dam.

The responses of the participants to the questions about COVID-19 are given in Table 3. In the scoring made to measure the knowledge level of the participants about COVID-19 (min. 0, max. 40), the average score was determined as 27.6 ± 6.75, and the average score of endodontists as 26.85 ± 7.43. It was concluded that dentists' knowledge of COVID-19 differs according to gender as a result of the independent sample t test (p <0.05), and the knowledge level of women was higher than that of men (Table 4). However, it has been found that COVID-19 knowledge levels do not differ according to education about COVID-19 and use of rubber dam. (p> 0.05).

Table 3: Answers to questions about COVID-19 disease.

Table 4: Independent sample t test results of COVID-19 knowledge scores of the participants.

As a result of the One Way Anova test, it was determined that the COVID-19 knowledge levels of all participants did not differ according to the variables of the university they graduated from, clinical experience, title and specialty branch. (p values 0.289, 0.207, 0.559, 0.626, respectively) When we also evaluated the endodontists, it was found that the COVID-19 knowledge levels did not differ according to the variables of the university they graduated from, clinical experience and title. (p values are 0.209, 0.659, 0.932, respectively) (p>0.05).

Discussion

The aim of our study was to evaluate the differences between dentists' knowledge of COVID-19 and the frequency of using rubber dam when performing root canal treatment, especially of endodontists. In addition, to determine whether there is a relationship between the use of rubber dam and multiple variables and the level of knowledge of COVID-19.

According to the study of Hatipog�� lu et al. participants working in private clinics used more rubber dams than the public (p<0.05) and no significant difference was found in terms of gender and experience [19]. In our study, the rate of using rubber dam in universities, private clinics and public sector was 62.85%, 31.25% and 16.19%, respectively. Although the use of rubber dam in our study was higher in university employees; Since no statistically significant difference was found between the knowledge levels of university employees on COVID-19 compared to those working in other institutions, this situation could not be associated with the level of knowledge about COVID-19. Most of the dentists working in the public hospital that they do not use the rubber dam because they are not in the institution where they are working and it increases the duration of the procedure performed on the patient. Considering that the patient density is high in public institutions, it can be interpreted that physicians do not want to use rubber dam because the time allocated to the patient is shortened in parallel. However these results may have been obtained because we wanted participants working in more than one institution to mark the institution where they mostly care for patients in our study. In the following studies, we think that the questionnaire question can be asked specifically as "the institution where they do root canal treatment".

Martinho et al. reported that 42.3% of the endodontists used an air cleaning unit during the COVID-19 pandemic process and that 16.9% of them used rubber dam and oral aerosol vacuum in addition to personal hygiene measures [21]. In our study, 27.5% of all participants and 56.4% of endodontists reported that the frequency of using rubber dam during endodontic procedures increased during the COVID-19 pandemic. The importance of rubber dam isolation to minimize the spread of aerosol or droplets contaminated with saliva and blood has been emphasized in previous studies [14].

COVID-19 is a new virus, since the risk of cross infection during dental treatments is high, infection control training is given to dentists during their undergraduate education. Also at the beginning of the pandemic, patients and health professionals as protection for a variety of online training organized by dental organizations in Turkey and the information it is given. In our study, the rate of participants who received training on COVID-19 was found to be 51.4%. In the scoring made to measure the level of knowledge of all participants about COVID-19, the average score they got out of 40 was determined as 27.6 ± 6.75, and the average score of endodontists was 26.85ï?±7.43. Providing training to all employees of institutions about COVID-19 will ensure that dentists, who are most closely related to crosscontamination, protect themselves and their patients from the risk of transmission as much as possible during and after the pandemic.

In our study, although we have seen that the frequency of use of rubber dam by endodontists increased by 56.4% with the COVID-19 pandemic; since the number of participants in Pedodontics and restorative dental treatment branches, which are likely to use rubber dam in dental treatments, such an evaluation could not be made. This issue should be considered while generalizing for other branches. In addition, we think that the distribution of the universities from which the participants graduated in our study is not homogeneous. Not every university has the same sensitivity to rubber dam use before COVID-19. This situation should be kept in mind while evaluating the findings. However, since we think that the knowledge levels of dentistry students on protection from infection may vary greatly depending on their undergraduate education and that the use of rubber dams before COVID-19 is not within their authority, the participants of our study were asked to graduate. For this reason, dentistry students were not included in our study.

Conclusion

Although the increase in the frequency of the rubber dam usage achieved as a result of this study is a nice improvement, this level is still not enough. However, it is important to know the factors affecting the increase of the rubber dam usage. In this study, it was observed that there was no relationship between the knowledge level of the COVID-19 and the using of the rubber dam. Therefore, more studies should be done on the factors that may increase the frequency of the rubber dam usage. Furthermore, in order to standardize the using of the rubber dam as it should be, the study’s’ findings should be put into practice.

Conflict of Interest

We have no conflict of interest to declare.

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