Problema de Investigación

Odontol.
Sanmarquina 2020; 23(2): 139-146 ODONTOLOGÍA SANMARQUINA

http://dx.doi.org/10.15381/os.v23i2.17758
ISSN-L 1560-9111; eISSN: 1609-8617
Artículo de Revisión
Enfermedad por coronavirus Mariela Ramírez-Velásquez 1,a, Priscilla Medina-Sotomayor 1,b,
2019 (COVID-19) y su Ángel Aurelio Morocho Macas 1,c
1
Universidad Católica de Cuenca sede Azogues, Azogues,
repercusión en la consulta Ecuador.
a
Doctora en Ciencias Odontológicas.
odontológica: una revisión Doctora en Odontología.

b
c
Magíster en Administración de Tecnologías de Información.
Correspondencia:
Mariela Ramírez Velásquez: [email protected]
Universidad Católica de Cuenca, Av. 16 de abril y Ernesto
Che Guevara, Azogues, Ecuador, 030102.
ORCID: 0000-0001-7041-4346
Coautores:
Priscilla Medina Sotomayor: [email protected]
Coronavirus disease 2019 (COVID -19) ORCID: 0000-0002-8117-8550
Ángel Aurelio Morocho Macas: [email protected]
and its impact on dental practice: a review ORCID: 0000-0003-2946-1284
Editor invitado:
Donald Ramos-Perfecto
Universidad Nacional Mayor de San Marcos, Perú.
Conflicto de intereses: los autores declaran no

tener conflictos de interés.
Fuente de financiamiento: autofinanciado.

Resumen
La presencia de la nueva pandemia COVID-19 o SARS-CoV-2 evidencia la necesidad Recibido: 16/04/20
de adoptar medidas que minimicen, prevengan y controlen el riesgo de infección y la Aceptado: 20/04/20
Publicado: 09/05/20
propagación del virus en la práctica odontológica. Por lo cual, el objetivo de este artí-
culo es establecer las repercusiones en los distintos ámbitos de la atención odontológica
ante la presencia del virus, en relación con la práctica de control de infecciones denta-
les, las características de contagio de este (en los diferentes escenarios estomatológicos),
los procedimientos odontológicos y las posibles consideraciones durante la pandemia.
Concluyendo que en la práctica odontológica se debe priorizar los procedimientos de
emergencia a aquellos pacientes sin síntomas respiratorios además de la evaluación previa
para descartar cualquier sintomatología relacionada con el virus, precautelando la salud
de profesionales y pacientes que interactúan durante la consulta odontológica.
Palabras clave: Coronavirus; Pandemias; Control de infecciones; Síndrome respiratorio
agudo severo; Cuidado dental (fuente: DeCS BIREME).
Abstract
The presence of the new pandemic COVID-19 or SARS-CoV-2 shows the need to adopt
measures that minimize, prevent, and control the risk of infection and the spread of the
virus in dental practice. Therefore, the objective of this article is to establish the repercus-
sions in different areas of dental care facing the presence of the virus, in relation to the
practice of dental infection control, its contagion characteristics (in different stomato-
logical scenarios), dental procedures and possible considerations during the pandemic.
Concluding that in dental practice, emergency procedures should be prioritized to those
patients without respiratory symptoms in addition to the prior evaluation to rule out any
symptomatology related to the virus, protecting the health of professionals and patients
who interact during the dental consultation.
Keywords: Coronavirus; Pandemics; Infection Control; Severe acute respiratory syn-
drome; Dental care (source: MeSH NLM).
© Los autores. Este artículo es publicado por la revista Odontología Sanmarquina de la Facultad de Odontología, Universidad Nacional Mayor de San Marcos. Este es un
artículo de acceso abierto, distribuido bajo los términos de la licencia Creative Commons Atribucion - No Comercia_Compartir Igual 4.0 Internacional. (http://creativecom-
mons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial, distribución y reproducción en cualquier medio, siempre que la obra original sea debidamente citada.
139
Ramírez-Velásquez et al.
Introducción la OMS continúa aumentando y la situación de preven-

ción y control de la epidemia es sombría.
En un periodo de corto tiempo, el brote de neumonía
causada por un nuevo coronavirus llamado nueva neu- El virus surgió en Wuhan, provincia de Hubei, China
monía por coronavirus (NNC) se presentó por primera y se expandió rápidamente al resto del mundo, trans-
vez en China, extendiéndose rápidamente a 24 países mitido principalmente por inhalación o contacto con
y regiones del mundo. El número de casos confirma- superficies contaminadas, cuenta con un período de in-
dos y muertes continúa aumentando. La Organización cubación de 2 a 14 días con una media de 5 días 2,3.
Mundial de la Salud (OMS) anunció que los brotes del
Los coronavirus son virus con genoma ARN, que po-
nuevo coronavirus han constituido una emergencia de
salud pública de preocupación internacional. El control seen una envoltura lipoproteica, y cuyo diámetro varía
eficaz de la infección puede evitar que el virus se propa- de 60 a 140 nm. En la superficie existen proyecciones
gue aún más 1. en forma de espigas que al microscopio electrónico tie-
nen la apariencia de corona. (Figura 1)
Debido a la especialidad de los entornos de atención
médica bucal, el riesgo de infección cruzada es grave en- El virus ha sido identificado como un coronavirus que
tre los pacientes y los profesionales de la salud bucal, por presenta similitud en un 95% con el coronavirus de
lo cual es urgente implementar protocolos de control de murciélago y un 70% de similitud con el SARS-CoV 2.
infecciones estrictos y eficientes. Todas las personas sin distinción de edad son suscepti-
bles de infección, debido a que las gotas que se generan
A continuación se comunica, una revisión de las pautas durante el estornudo o la tos de pacientes asintomáti-
existentes y las investigaciones publicadas pertinentes a cos llevan gran cantidad de carga viral 4. Los pacientes
los principios y prácticas de control de infecciones den- pueden estar infectados durante todo el tiempo que los
tales, discutiendo principalmente las características de la síntomas duren, incluso en el período de recuperación.
infección en los entornos de la atención estomatológica Las gotas contaminadas pueden alcanzar 1-2 m y depo-
y recomendaciones sobre la evaluación de protocolos de sitarse en las superficies durante un período de tiempo,
control de infecciones en las circunstancias actuales. siendo susceptibles a la desinfección con hipoclorito de
sodio y peróxido de hidrógeno 5.
Revisión de la literatura
En vista de la naturaleza especial de las operaciones de
Antecedentes diagnóstico y tratamiento bucal, además del alto riesgo
Desde el descubrimiento del nuevo coronavirus, en di- de infección cruzada se ha visto la necesidad de tomar
ciembre del 2019, la neumonía causada por él, conoci- medidas de protección correctas durante el diagnóstico
da como NNC es altamente contagiosa y la población y el tratamiento bucal para prevenir infecciones.
es generalmente susceptible. Recientemente este virus
se denominó oficialmente coronavirus 2 del síndrome Manifestaciones clínicas
respiratorio agudo severo (SARS-CoV-2), el número de Las manifestaciones clínicas son variadas, desde un estado
casos confirmados, sospechosos y fatales reportados por asintomático hasta el síndrome de dificultad respiratoria
Figura 1. Partícula del coronavirus 2 del síndrome respiratorio agudo severo (SARS-CoV-2) bajo
microscopio electrónico. Fuente: Tomado de Creative Commons (https://www.flickr.com/photos/
yusamoilov/49679288857/in/photolist-2iFZkM4-2iCBt7X-2iHUFdT-2iLYhir-2iHxBMr-2iFZcRv-
2iKxrbU-2iGhjYY-2iDnLMP-2iDRP1p-2iJveA5-2iGWUaM-2iGGzNJ-2iHatBh-2iG5Bik-2iDtnpd-2iE-
8cWF-2iHvsLH-2iDVEkh-2iKWEGv-2iL4ECe-2iLm4qR-2iG47oH-2iHA83R-2iLm4wN-2iHHPBU-
2iERn99-2iCtzbC-2iQCZ7h-2iGYJoM-2iHKtKP-2iGeCcS-2iBtQz8-2iJmxif-2iF8SQY-2iGLDHy-2iEcY-
jF-2iMVMei-2iRRYae-2iFFbzh-2ipTdX5-2iL78yp-2iPbvmk-2iRRYnZ-2iQXffo-2iAtWAh-2iKdmov-
2iFLoMn-2iRoLvN-2iJe3jK/)
140 Odontol. Sanmarquina 2020; 23(2)

Enfermedad por coronavirus 2019 (COVID-19) y su repercusión en la consulta odontológica: una revisión
aguda y disfunción multiorgánica. Las características clíni- diagnóstico y tratamiento bucal tiene una particulari-
cas más comunes incluyen: fiebre (no en todos los pacien- dad, que durante el examen bucal el odontólogo y el
tes), tos, dolor de garganta, fatiga, dolor de cabeza, mialgia paciente se encuentran cara a cara. El paciente tose o
y disnea. La conjuntivitis también se ha descrito como una estornuda y el profesional corta tejidos duros de las pie-
manifestación clínica 6. Se han reconocido cuatro tipos de zas dentales o usa instrumentos ultrasónicos durante los
coronavirus llamados HKU1, NL63, 229E y OC43, todos tratamientos de la boca, lo que puede provocar que las
ellos circulando en humanos y generalmente causando en- secreciones, saliva o sangre del paciente salpiquen, y sin
fermedad respiratoria leve 2. haber las medidas de protección adecuadas, las partícu-
las grandes o pequeñas de gotas suspendidas en el aire,
La característica común de la enfermedad es el progreso a
podrían llegar a la conjuntiva, mucosa bucal o nasal del
neumonía al final de la primera semana, fallo respiratorio
profesional, causando infección. Además, también exis-
y muerte, esta progresión está asociada a un aumento ex-
te el riesgo de una infección cruzada entre los pacientes
tremo de las citosinas inflamatorias, incluidas IL-2, IL-7,
debido a los instrumentos odontológicos utilizados para
IL-10, GCSF, IP10, MCP1, MIP1A y TNF-α 6.
los tratamientos dentales como la turbina, pudiendo
La media del tiempo de inicio de los síntomas hasta la quedar restos de microorganismos patógenos luego de
disnea se describe de 5 días, la hospitalización de 7 días su uso. Cuando las manos del personal odontológico o
y el síndrome de dificultad respiratoria 8 días. La necesi- los pacientes entran en contacto con estos instrumentos
dad de ingreso en cuidados intensivos está en el 20-30% contaminados, puede haber el riesgo de infección 14.
de los pacientes infectados. Las complicaciones incluyen
Es necesario debido a las particularidades propias de las
lesión pulmonar aguda, síndrome agudo respiratorio
consultas odontológicas con un riesgo de infección cru-
(SAR), shock y lesión renal aguda. La recuperación co-
zada alto entre odontólogos y pacientes, en países y/o
mienza en la segunda o tercera semana, la media de hos-
regiones afectadas o en riesgo de COVID-19, ciertas
pitalización de los pacientes recuperados es de 10 días.
consideraciones para el control y/o prevención del vi-
Los ancianos y aquellos con comorbilidades subyacentes
rus. Este artículo basado en investigaciones relevantes,
(50-75% de los casos fatales) son los más propensos a
presenta consideraciones esenciales sobre COVID-19 y
la muerte. La tasa de mortalidad en pacientes adultos
la infección nosocomial en los consultorios odontoló-
hospitalizados oscila entre los 4 – 11%. La severidad en
gicos y proporciona recomendaciones para profesiona-
los casos de neonatos, lactantes y niños son significativa-
les odontólogos y estudiantes en áreas (potencialmen-
mente más suaves que en los adultos 7. Sin embargo, en
te) afectadas durante y después de superar la pandemia
pacientes con enfermedades preexistentes como enfer-
COVID-19.
medades cardiovasculares, hipertensión, enfermedades
respiratorias, cáncer, obesidad, fumadores, se asocia el En la sala de espera
mayor riesgo de complicaciones y muerte 8,9.
Las clínicas odontológicas deben establecer una clasi-
Vías de transmisión ficación previa al examen para evaluar a los pacientes
con fiebre. La oficina de preinspección o triaje debe
Las principales vías de transmisión son directas y por
mantener una buena ventilación y el personal debe es-
contacto 10 :
tar equipado con instalaciones de monitoreo rápido de
El virus del COVID-19 ha sido recientemente identifi- temperatura, desinfectantes de piel y equipo de protec-
cado en la saliva de paciente infectados, por la tanto la ción personal. Si se encuentra un paciente con fiebre
propagación a través de las gotas del tracto respiratorio durante el triaje se le debe proveer inmediatamente una
cuando el paciente tose, estornuda o habla en voz alta mascarilla e indicarle el hospital más cercano, solo se
son vías de transmisión durante la consulta odontoló- debe realizar el tratamiento bucal después de resolver los
gica 11,12. El contacto personal cercano con una persona síntomas, incluso se ha informado que después de que
infectada es la razón por la que la OMS recomienda el un paciente con infección por SARS-CoV se cura, el
aislamiento social. diagnóstico y tratamiento bucal debe posponerse hasta
Otra forma de contagio se produce al extenderse, en las un mes después del alta 15.
manos, patógenos al contacto con superficies inanima- Protección del personal
das 13 y luego entrar en contacto con la cavidad bucal,
nasal, ojos y otras membranas mucosas. Los patógenos Durante el período de prevención y control de la epi-
en la sangre o los fluidos corporales con sangre también demia, los odontólogos deben aprender activamente a
pueden ingresar al cuerpo humano a través de la mucosa controlar el coronavirus en la consulta diaria, con un
o piel dañada por los aerosoles usados en los procesos buen manejo del paciente para prevenir infecciones cru-
odontológicos y causar infección 1,3,10. zadas y con la correcta protección al personal durante el
diagnóstico y tratamiento, así se previene la propagación
Protocolos clínicos de atención de la epidemia y se garantiza la calidad odontológica y la
odontológica seguridad del paciente.
El contacto cercano y frecuente con los pacientes en la Las medidas estrictas de higiene de manos son para preve-
consulta dental, expone al personal médico bucal a ries- nir cualquier fuente de infección14,15 además, en compara-
go de exposición al nuevo coronavirus, debido a que el ción con otros coronavirus, el COVID-19 sobrevive más
Odontol. Sanmarquina 2020; 23(2) 141

tiempo in vitro 1 reforzando la necesidad de una buena hi- los pacientes. Las decisiones sobre la realización del tra-
giene de manos y la importancia de desinfectar completa- tamiento deben tomarse con el consentimiento apropia-
mente la superficie de los objetos. La higiene de manos se do del paciente 19.
debe realizar antes de contactar con el paciente para una
De igual manera será necesaria ante la aparición de este
operación aséptica, después de contactar al paciente, des-
virus la reorganización oportuna de los servicios en la
pués de la exposición a los fluidos corporales y después de
consulta odontológica diaria en cualquier consultorio
contactar al entorno circundante del paciente, equipados
público, o privado como una estrategia de control de
con agentes de limpieza calificados, antisépticos de ma-
infecciones para prevenir la propagación de la CO-
nos entre otras. La luz ultravioleta de 254 nm también ha
VID-19. La figura 2 representa las divisiones en el área
sido descrita como un inactivador del coronavirus cuando
de atención de emergencia en la Escuela y Hospital de
se encuentra en suspensión, el proceso debe realizarse a
Estomatología, Universidad de Wuhan, durante el brote
puerta cerrada durante quince minutos 16.
de la enfermedad por coronavirus 2019 donde las dis-
Es importante recordar que el uso de guantes no es un tintas áreas están separadas dependiendo del grado de
sustituto para lavarse las manos, y debe hacerse este pro- probabilidad de contagio 20.
cedimiento después de quitárselos 1.
Entre las recomendaciones según la experiencia vivida
El equipo de protección del personal debe incluir guan- en dicho hospital, todo el personal de triaje que labo-
tes, gorras, mascarillas, gafas, máscaras protectoras, trajes re en el área amarilla debe usar mascarilla quirúrgica
de aislamiento y ropa protectora, diseñados para preve- desechable, gorro y ropa de trabajo. En el área naranja,
nir la piel, las membranas mucosas de los ojos, la boca, el personal odontológico debe contar con el equipo de
la nariz, etc. Además, el personal debe poder ponerse y protección personal, que incluye mascarilla desechable
quitarse el equipo de protección de manera correcta y N95, guantes, batas, gorro, cubierta de zapatos y gafas
hábil. La transmisión de gotas es una de las principa- o careta, además de ropa protectora. La clínica de aisla-
les rutas de transmisión del nuevo coronavirus, por lo miento (área roja) destinada para pacientes con sospecha
tanto, las mascarillas médicas pueden proporcionar una de COVID-19, quienes se están recuperando de CO-
protección adecuada para el diagnóstico y tratamiento VID-19 (pero menos de un mes después de ser dados
bucal diario. De acuerdo con la OMS, los pacientes de alta), o para pacientes que necesitan procedimientos
que entran en contacto con el COVID-19, deben usar dentales que producen gotas y / o aerosoles. El área
mascarillas N95 17, ajustarse perfectamente a la cara y debe ser desinfectada una vez cada medio día. Además,
limitando su uso a cinco veces siguiendo las recomenda- toda el área de aislamiento se desinfecta inmediatamente
ciones del fabricante18. Si el equipo de protección llega- después de que finaliza el tratamiento y el paciente se ha
ra a contaminarse durante el diagnóstico o tratamiento, ido. El área de la cuadrícula detrás de la línea roja es solo
debe remplazarse o desinfectarse de inmediato. Después para el personal. El personal puede descansar en la habi-
del uso, las gafas protectoras deben limpiarse y desin- tación (área verde). Se recomienda entrar a la habitación
fectarse con etanol al 75% o colocarse en 500- 1000 por turnos y seguir usando máscaras médicas a menos
mg/L de desinfectante que contenga cloro durante 30 que estén comiendo o bebiendo 20.
minutos, luego enjuagarse con agua corriente y secarse
para su uso 1. Según la OMS 21 es recomendable una orientación sobre
prevención y el control de infecciones durante la aten-
Atención del paciente ción del paciente cuando se sospecha una infección por
COVID-19. Además, es necesario el triaje previo a la
Ante la situación epidemiológica de la enfermedad pro- atención para medir y registrar la temperatura de todos
vocada por el nuevo coronavirus registrada en América los miembros del personal y paciente como un procedi-
y el mundo, quedó limitada la atención odontológica de miento rutinario.
emergencia a aquellas personas sin síntomas respiratorios.
Los pacientes con fiebre serán derivados a los centros
El manejo temprano de las emergencias dentales agudas hospitalarios designados para la atención de pacientes
es importante para evitar que los pacientes por acciden- con COVID-19 luego de su registro 10. Y de ser el caso,
tes y emergencias culminen en ingresos hospitalarios y donde el paciente haya estado en alguna región epidé-
además preocupa que con la suspensión de la atención mica en los últimos 14 días, inmediatamente se sugiere
dental diaria o de rutina, más pacientes de lo habitual la cuarentena durante al menos 14 días, criterios estable-
podrían necesitar admisión para el tratamiento de in- cidos por la OMS 20 (Tabla 1).
fecciones dentales agudas que amenazan las vías respira-
torias y/o requieran cuidados intensivos. Los pacientes Las orientaciones sobre prevención a esta pandemia, de-
con graves inflamaciones pueden progresar a emergen- ben mantenerse permanentemente en las salas de espera
cias potencialmente mortales, lo que puede aumentar por parte del personal la cual además debe disminuir
los riesgos en el contexto de la disminuida disponibili- su capacidad en un 50% evitando las aglomeraciones
dad de atención médica. Para tales pacientes, las extrac- y manteniendo la distancia entre personas de 1 a 2 m,
ciones dentales deben priorizarse sobre un tratamiento por lo tanto, es preferible que asistan solos a la consulta,
restaurador. Debe considerarse además la administra- excepto si acompañan a un niño, o adultos mayores que
ción de antimicrobianos, lo cual es una desviación de la requieran asistencia estrictamente de emergencia y cum-
odontología de rutina que debe discutirse a fondo con pliendo con las medidas de protección adecuada.

Figura 2. Divisiones del área odontológica para el tratamiento de pacientes ante la Pandemia de COVID-19:
Zona amarilla: destinada para el Triaje y zona de espera o recepción. Zona Naranja: Clínica odontológica.
Zona Roja: Clínica de aislamiento. Zona Verde: área de descanso solo para el personal. Se proporcionan
entradas separadas para pacientes (flecha roja) y personal (flecha azul). Fuente: Elaborado a partir de Meng
et al, 2020.
Tabla 1. Distribución de la anamnesis dirigida con preguntas realizadas durante el triaje odontológico
Preguntas de control Conducta Clínica
Si / No Temperatura >37 °C Temperatura < 37 °C
¿Ha tenido fiebre en los últimos 14 días? SI SI

¿Ha tenido problemas respiratorios en los A Cualquier Pregunta A Cualquier Pregunta
últimos 14 días Advertir al paciente sobre posible contagio Paciente debe regresar en 14 días, a excep-
¿Ha viajado a países con elevado número de y remitir a una unidad de salud. ción de presentar alguna urgencia dental.
casos de COVID-19 en los últimos 14 días?
¿Ha estado en contacto con alguna persona
confirmada de COVID-19? NO NO
¿Ha estado en contacto con personas que A Todas Las Preguntas A Todas Las Preguntas
presenten cuadro respiratorio agudo en los Paciente debe regresar en 14 días, a excep- Tratar al paciente con los cuidados y reco-
últimos 14 días? ción de presentar alguna urgencia dental. mendaciones
Fuente: Elaborado a partir de Tuñas IT de C. et al.
Procedimientos odontológicos durante la Antes del examen bucal, los pacientes pueden usar peróxi-
pandemia COVID-19 do de hidrógeno al 0,5% o povidona yodada al 1%, clo-
ruro de cetilpiridinio al 0,05- 0,10% o enjuagues bucales
Antes de cualquier procedimiento odontológico se re- que reduzcan el número de microrganismos en gotas de
comienda disminuir la flora microbiana de la cavidad saliva 10,14,21. Los estudios in vitro han demostrado que los
bucal con un enjuague bucal antimicrobiano en el pa- enjuagues de povidona yodada y el cloruro de cetilpiri-
ciente 21,22. Además, por recomendación de la OMS se dinio pueden inhibir la actividad del coronavirus SARS-
debe evitar procedimientos que puedan causar tos por la CoV 16,23,24. La clorhexidina al 0,12% no es eficaz 10.
emisión de gotas o caso contrario tomar las medidas de
precaución necesarias; de igual manera, se debe evitar el Debido a que la radiografía intraoral es el examen com-
uso de la jeringa triple o de tres vías durante el proceso plementario más utilizado, se debe considerar que po-
de diagnóstico o tratamiento, el uso de dispositivos de dría haber reflejos faríngeos que pueden causar náuseas,
alta succión para succionar la saliva a tiempo, puede re- tos y vómito, por lo tanto, se puede considerar técnicas
ducir la generación de gotas y aerosoles 14. de imágenes extraorales 25.

En relación a los dispositivos y artículos de uso odon- inmediato a un hospital designado para pacientes con
tológico, se debe tratar de elegir los desechables y elimi- COVID-19 y se recomienda tomografía computariza-
narlos inmediatamente en un recipiente que contenga da de tórax para apoyar el diagnóstico de la infección
desinfectante de cloro de 1000 mg/L durante 30 mi- viral, en busca de resultados positivos por imágenes
nutos. En caso de ser esterilizables, utilizar el vapor a como recurso más rápido, aunque se debe sospechar
presión (autoclave). Las telas deben sumergirse en un y estar atentos de varios aspectos en la valoración
desinfectante que contenga cloro de 500 mg/L durante
del paciente como son la combinación de informa-
30 minutos 14.
ción epidemiológica, por ejemplo, el historial de viaje
Los diques de goma y los eyectores de saliva de alta o residencia en la región afectada 14 días antes de la
succión pueden ayudar a minimizar el aerosol o las sal- aparición de los síntomas. Las pruebas de laboratorio
picaduras durante los procedimientos en la consulta específicas para el diagnóstico del COVID-19 son otra
odontológica. alternativa como la prueba de reacción en cadena de la
A continuación, algunas recomendaciones tras la expe- polimerasa con la transcriptasa inversa (RT-PCR), en
riencia vivida en el hospital de Wuhan por la crisis cau- muestras de tracto respiratorio. Cabe mencionar que
sada por la aparición del COVID-19, en los casos que un solo resultado negativo de la prueba de RT-PCR
las patologías requieran asistencia 20: de pacientes sospechosos no excluye la infección. En
–– Se debe proceder al diagnóstico de COVID-19. conclusión, se debe estar atento de los síntomas de los
pacientes sospechosos, antecedentes epidemiológicos
–– Antes de la atención del paciente usar enjuague bucal y los resultados positivos de imágenes de tomografía
antimicrobiano. computarizada de tórax en un primer momento.
–– A los pacientes se les debe evaluar signos y síntomas –– En el caso de dolor espontáneo debido a una fractura
para determinar en que entorno clínico deben atenderse. dental sin caries, se debe utilizar la pieza de mano de
–– Contactar con el paciente 1 a 2 días antes de cual- alta velocidad para la preparación cavitaria, en este caso
quier sesión programada para corroborar si la visita en se debe programar como el último paciente del día para
persona es necesaria o el problema puede resolverse sin disminuir el riesgo de infección nosocomial. Después
una visita al consultorio. del tratamiento, deben seguirse los procedimientos de
limpieza y desinfección ambiental de rutina.
–– En el caso de pulpitis sintomática irreversible la ex-
posición pulpar puede procederse con la remoción quí- –– Alternativamente, los pacientes podrían ser tratados
mica-mecánica de la caries bajo aislamiento con dique en una habitación aislada y bien ventilada o habitacio-
de goma y un eyector de saliva de alta succión después nes aisladas para casos sospechosos con COVID-19.
de la anestesia local; posteriormente, se puede realizar la
Consideraciones para las emergencias
desvitalización pulpar para reducir el dolor.
odontológicas
–– En el caso de necesitarse una extracción dental y su-
Con la finalidad de minimizar la transmisión del CO-
tura, se prefiere la sutura absorbible. VID-19 entre los pacientes y el equipo de profesionales
–– En traumatismo facial de tejidos blandos, se debe en la consulta odontológica, así como proporcionar la
realizar desbridamiento y sutura. Se recomienda enjua- mejor atención en las consultas se presenta las situacio-
gar la herida lentamente y usar el eyector de saliva para nes que son consideradas emergencias para la atención
evitar la pulverización. en el consultorio dental (Tabla 2); se presenta además
el riesgo de trasmisión para el personal y paciente en la
–– Los casos potencialmente mortales con lesiones Tabla 3 basado en la ADA Interim Guidance for Mana-
complejas bucales y maxilofaciales deben ingresarse de gement of Emergency and Urgent Dental Care 26.
Tabla 2. Situaciones consideradas emergencias en pacientes sin síntomas respiratorios
a. Dolor dental severo por inflamación pulpar.

b. Pericoronitis o dolor en el tercer molar.
c. Osteítis postoperatoria quirúrgica, cambios de apósito seco.
d. Absceso o infección bacteriana localizada que produce dolor e hinchazón localizados.
Emergencias sin
e. Fractura de dientes que causa dolor o causa trauma en los tejidos blandos.
síntomas
f. Trauma dental con avulsión / luxación.
respiratorios
g. Cementación final de la corona / puente si la restauración temporal se pierde, se rompe o causa irritación gingival.
h. Reemplazar la obturación temporal en endodoncia por acceso, en pacientes que experimentan dolor.
i. Corte o adaptación de un alambre de ortodoncia o aparatos que perforan o ulceran la mucosa oral.
j. Reprogramar cita y/o orientar sino es emergencia.
Fuente: Elaborado a partir de ADA 2020 26

Tabla 3. Riesgo de trasmisión para personal de salud y paciente según lo expuesto en la tabla 1
Plan de tratamiento recomendado
Riesgos Recomendaciones
para el paciente
Bajo a. No requiere cuarentena de 14 días
b. Usar el juicio clínico y tomar todas las precauciones para evitar la transmisión.
c. Sugerir que el paciente sea examinado para Infección por COVID-19 después del
Moderado Remitir al paciente al departamento
tratamiento dental
d. Si es positivo, debe poner en cuarentena por 14 días de emergencias o al centro dental
que cumpla con los criterios estable-
e. Utilice el juicio clínico y tome todas las precauciones. para prevenir la transmisión. cidos, de no ser factible su asistencia.
f. Si se implementa el tratamiento, exija que el paciente se realice la prueba para
Alto
detectar la infección por COVID-19 inmediatamente después del tratamiento; si es
positivo cuarentena durante 14 días todos los profesionales
Fuente: Elaborado a partir de ADA 2020 26
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Odontol. Sanmarquina 2020; 23(3): 1-10 ODONTOLOGÍA SANMARQUINA
http://dx.doi.org/10.15381/os.v23i3.18130
ISSN-L 1560-9111; eISSN: 1609-8617
Artículo de Revisión
COVID-19 y su trascendencia Jorge Luis Mija Gómez 1, a
en la atención dental: revisión 1

Universidad Nacional Mayor de San Marcos. Lima,
Perú.
y actualización de la literatura a
Maestro en Estomatología.
Correspondencia:
Jorge Luis Mija Gómez: [email protected]
Jr. Pasco 3353 2do piso. San Martin de Porres, Lima,
Perú.
ORCID: 0000-0001-7728-9402
Editor:
Juan Carlos Cuevas-González
Universidad Autónoma de Ciudad Juárez, México.
Conflicto de intereses: el autor declara no tener

COVID-19 and its significance in dental conflictos de interés.
care: review and update of the literature Fuente de financiamiento: autofinanciado.
Recibido: 02/06/20
Aceptado: 20/06/20
Publicado: 09/07/20
Resumen
A fines del 2019 se presentaron 27 casos de neumonía atípica de etiología desconocida
en la ciudad de Wuhan, China. Los síntomas de los pacientes que padecían la nueva
neumonía viral fueron fiebre, tos seca, disnea y fatiga. El virus causante fue nombrado
coronavirus de tipo 2 causante del síndrome respiratorio agudo severo (SARS-CoV-2)
y la enfermedad fue nombrada en febrero de 2020 por la Organización Mundial de la
Salud como enfermedad por coronavirus COVID-19. Las rutas de contagio de persona
a persona incluyen transmisión directa por inhalación de gotitas de tos, estornudos, y
transmisión indirecta, por medio de fómites que hagan contacto con las membranas
mucosas orales, nasales u oculares. Los odontólogos debido a la naturaleza única de los
procedimientos que realizan, tienen un alto riesgo de infección cruzada del COVID-19,
ya que al trabajar en la boca del paciente está expuestos a una gran cantidad de gotas de
saliva y aerosoles producidos durante la atención dental. La pandemia del COVID-19
requiere que el odontólogo tenga una preparación especial para la prevención del conta-
gio en la consulta dental. El odontólogo también debe actualizarse sobre cómo el CO-
VID-19 se relaciona con la profesión para estar bien preparado y ser miembro activo en
las medidas sanitarias para controlar la pandemia. El objetivo de esta revisión es presentar
información actualizada sobre el COVID-19, y dar soporte científico para el uso de las
diferentes estrategias para minimizar el riesgo de contaminación cruzada en la práctica
dental durante la pandemia de COVID-19.
Palabras clave: COVID-19; SARS-CoV-2; Atención dental; Bioseguridad (fuente:
DeCS BIREME).
Abstract
By the end of 2019, 27 atypical pneumonia cases of unknown etiology were presented in
Wuhan, China. The symptoms of the patients suffering from the new viral pneumonia
were fever, dry cough, dyspnea, and fatigue. The virus was named coronavirus type 2
causing severe acute respiratory syndrome (SARS-CoV-2) and the disease was named in
February 2020 by the World Health Organization as coronavirus disease COVID-19.
© Los autores. Este artículo es publicado por la revista Odontología Sanmarquina de la Facultad de Odontología, Universidad Nacional Mayor de San Marcos. Este es un
artículo de acceso abierto, distribuido bajo los términos de la licencia Creative Commons Atribucion - No Comercia_Compartir Igual 4.0 Internacional. (http://creativecom-
mons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial, distribución y reproducción en cualquier medio, siempre que la obra original sea debidamente citada.
1
Mija Gómez
The routes of transmission from person to person include direct transmission by inhala-
tion of cough droplets, sneezing, and indirect transmission, through fomites that contact
the oral, nasal, or ocular mucous membranes. Dentists, due to the unique nature of the
procedures they perform, have a high risk of COVID-19 cross-infection, since when
working in the patient's mouth they are exposed to a large number of saliva drops and
aerosols that are produced during dental treatments. The COVID-19 pandemic requires
dentists with special preparation for the prevention of contagion in the dental office. The
dentist should also be updated on how COVID-19 relates to the profession to be well
prepared and to be an active member in sanitary measures to control the pandemic. This
review aims to present updated information on COVID-19 and to provide scientific
support for the use of different strategies to minimize the risk of cross-contamination in
dental practice during the COVID-19 pandemic.
Keywords: COVID-19; SARS-CoV-2; Dental care; Biosecurity (source: MeSH NLM).
Introducción en la boca del paciente están expuestos a una gran can-

tidad de gotas de saliva (Flügge) 8 y producción de ae-
A fines de diciembre de 2019 se identificaron 27 ca-
sos de neumonía atípica de etiología desconocida en la rosoles con gran potencial de transmitir el virus 9. Pa-
ciudad de Wuhan, provincia de Hubei en China 1. Los cientes asintomáticos pueden transmitir el COVID-19
síntomas clínicos típicos de los pacientes que padecían
10
lo que presenta un desafío aún mayor en el control
la nueva neumonía viral fueron fiebre, tos y mialgia o fa- y la prevención de la enfermedad. Por tanto, mientras
tiga con tomografía computarizada (TC) torácica anor- dure la pandemia por COVID-19, solo se debe rea-
mal, y los síntomas menos comunes fueron producción lizar tratamientos dentales de urgencia, para prevenir
de esputo, dolor de cabeza, hemoptisis y diarrea. Inves- la transmisión del COVID-19 entre odontólogo, pa-
tigadores chinos mediante exámenes virales, obtenidos cientes y personal del consultorio. Esta revisión tiene
de hisopado de garganta, aislaron rápidamente un nue- el objetivo de presentar aspectos importantes del CO-
vo virus y secuenciaron su genoma (29 903 nucleóti- VID-19 y su relación con la práctica odontológica, ha-
dos), lo que descartó la presencia de virus comunes que ciendo énfasis en las medidas preventivas para evitar la
causan neumonía, como los virus de la influenza, los infección cruzada durante los tratamientos de urgencia
adenovirus y los coronavirus asociados con el síndrome en el consultorio dental.
respiratorio del Medio Oriente (MERS) y el síndrome COVID-19
respiratorio agudo severo (SARS). Este nuevo patógeno
fue nombrado inicialmente como “nuevo coronavirus La enfermedad conocida como COVID-19 es causada
2019” (2019-nCoV) 2 y oficialmente nombrado por el por el virus SARS-CoV-2, este es un virus zoonótico,
Comité Internacional de Taxonomía de Virus (ICTV) que, al identificar y comparar su secuencia de nucleó-
como coronavirus de tipo 2 causante del síndrome res- tidos se encontró una homología del 96,2% entre su
piratorio agudo severo (SARS-CoV-2) debido al análisis ARN y la del coronavirus Bat-CoV-RaTG13 presente
filogenético y taxonómico de este novedoso coronavirus, en el murciélago de herradura chino (Rhinolophus sini-
y la enfermedad fue nombrada el 11 de febrero de 2020, cus), por lo que se considera a este murciélago como el
por la Organización Mundial de la Salud (OMS), como huésped natural del virus y al pangolín como el probable
enfermedad por coronavirus COVID-19 3. huésped intermedio en la ruta de transmisión de animal
a humano, seguido de contagio masivo de humano a
Debido a la rápida diseminación por diferentes países, humano 11,12. El SARS-CoV-2 tiene una homología del
la epidemia de COVID-19 fue declarada el 30 de enero 80% con el SARS-CoV, de ahí que fue nombrado ini-
de 2020 por la OMS una emergencia de salud pública cialmente como nuevo coronavirus 2019-nCoV 3.
de preocupación internacional 4, y el 11 de marzo preo-
cupados por el nivel de propagación del COVID-19 la Los coronavirus pertenecen a la familia Coronaviridae,
OMS lo declara como una pandemia de amenaza para tienen un material genético de ARN de cadena sencilla
la salud pública 5. (monocatenario) de polaridad positiva [(+) ssARN], con
un tamaño de 27-32 kilobases, y cuatro proteínas estruc-
Al 01 de junio de 2020, la OMS ha notificado 6 057 turales, de las cuales la proteína Spike (S) representan las
853 casos confirmados de COVID-19 a nivel mundial, estructuras más grandes del virus y son esenciales para
incluidas 371 166 muertes 6. En el Perú, el primer caso la entrada en las células huésped 3,13 (Figura 1). Los co-
de COVID-19 se confirmó el 06 de marzo de 2020, y ronavirus se pueden diferenciar en cuatro géneros: alfa,
para el 27 de mayo, según datos oficiales, se habían re- beta, delta y gamma, de los cuales los coronavirus de
portado ya 135 905 resultados positivos los cuales cau- tipo alfa y beta infectan a los humanos, principalmente
saron la muerte de 3 983 personas 7. los sistema respiratorio, gastrointestinal y sistema ner-
Los odontólogos debido a la naturaleza única de los vioso central. Estudios filogenéticos demuestran que los
procedimientos que realizan, tienen un alto riesgo de betacoronavirus incluye al SARS-CoV, el MERS-CoV y
infección cruzada del COVID-19, ya que al trabajar el agente causal COVID-19 14.

COVID-19 y su trascendencia en la atención dental: revisión y actualización de la literatura
Figura 1. Partícula de coronavirus, (material genético de ARN de cadena sencilla de polaridad positiva), constituido
por una nucleocápside y esta a su vez compuesta por (+) ssARN y la Nucleoproteína. ( tomado de: Palacios M, Santos
E, Velázquez M, León M. COVID-19, una emergencia de salud pública mundial. [published online ahead of print, 2020
Mar 20]. Rev Clin Esp. 2020; S0014-2565(20)30092-8.)
Rutas de contagio desafío para el personal de salud en la lucha por con-

El COVID-19 se transmite directamente de persona a trolar la propagación del COVID-19.
persona a través de las gotitas de Flügge (de 0,5 a 10 Características clínicas
μm) originadas al hablar, toser o estornudar por la per-
sona infectada 11, 15, 16. Estas gotitas pueden permanecer Los síntomas iniciales son presencia de fiebre, tos seca,
suspendidas en el aire hasta por 30 minutos y a una dis- congestión nasal, fatiga y otros signos de infección del
tancia máxima de 1 metro, luego se depositan rápida- tracto respiratorio alto. La mayoría de los pacientes con
mente, por tanto, para ser vehículo de transmisión debe COVID-19 presentan sintomatología relativamente
haber un contacto cercano con la persona infectada 8, 17. leve, pero en aproximadamente la cuarta parte de los
También es probable el contagio indirecto por contacto casos, la infección puede progresar a enfermedad grave
con fómites en el entorno de un infectado 15, y luego con disnea y congestión pulmonar severa. La insuficien-
de este contacto se lleve material infectado a la mucosa cia multiorgánica puede dar lugar a insuficiencia respi-
oral, nasal y también esta reportado el contagio a través ratoria, shock, síndrome de dificultad respiratoria agu-
de la conjuntiva del ojo 18. Respecto a la transmisión in- da, arritmia, lesión aguda del miocardio, lesión hepática
trauterina del SARS-CoV-2, la evidencia actual sugiere aguda y sepsis, incluso la muerte 11. Esta progresión está
que la transmisión vertical es poco probable 19. asociada a un aumento extremo de citosinas pro-infla-
La enzima convertidora de angiotensina 2 (ACE2) es matorias, incluidas interleuquinas (IL-1B, IL-2, IL-6,
el principal receptor de las células huésped del SARS- IL-7, IL-10, IL-12), interferones (IFNα, IFNγ), factor
CoV-2 y desempeña un papel crucial en la entrada del de necrosis tumoral alfa (TNF-α), factor de crecimiento
virus en la célula para causar la infección final 20. La pro- transformante beta (TGF-β) y quimioquinas (CCL2,
teína S del SARS-CoV-2 es la responsable de unirse al CCL3, CCL5, CXCL8, CXCL10). Este aumento lla-
receptor ACE2, este receptor se encuentra altamente ex- mado tormenta de citoquinas, conlleva a la muerte por
presado en las células epiteliales de todo el tracto respi- una respuesta inflamatoria sistémica no controlada 23-25.
ratorio, lengua y de las glándulas salivales, lo que explica En pacientes de edad avanzada y pacientes con existen-
el riesgo potencialmente alto de infección a través de la cia de comorbilidades, principalmente hipertensión,
cavidad oral 3,15. diabetes y cardiopatía isquémica, el riesgo de complica-
Periodo de incubación ciones graves aumenta 26,27.
El período de incubación del COVID-19 es de 5 a 6 Está reportado que aproximadamente el 80% de los
días en promedio, llegando en algunos casos a los 14 pacientes con COVID-19 son asintomáticos o con sin-
días 21,22, que son los días recomendados para la obser- tomatología muy leve, sobretodo en pacientes niños y
vación médica y cuarentena de potenciales infectados. jóvenes. Los portadores asintomáticos pueden provocar
Este periodo de incubación relativamente largo, con una transmisión de persona a persona y deben conside-
ausencia de cualquier sintomatología, representa un rarse una fuente de infección del COVID-19 28-30.

Mija Gómez
Las manifestaciones cutáneas son menos frecuentes, (EPN), en relación al aumento de casos confirmados de
pero en casos agudos de COVID-19 se puede presen- COVID-19. La etiología de la EPN puede estar asocia-
tar erupción eritematosa, urticaria localizada o generada con coinfecciones bacterianas que ocurren intraoral-
lizada, sin embargo, puede ser difícil distinguir la causa mente en pacientes con COVID-19. Los análisis me-
subyacente (infección viral o la medicación prescrita) 31. tagenómicos de los infectados con frecuencia detectan
En niños con COVID-19 se ha reportado casos raros de lecturas bacterianas anormalmente altas de Prevotella
eritema multiforme, síndrome hiperinflamatorio multi- intermedia, además de géneros patógenos comunes im-
sistémico similar a la enfermedad de Kawasaki 32,33. plicados en la aparición y progresión de enfermedades
Manifestaciones bucales de COVID-19 orales como: estreptococos, Fusobacterium, Treponema
y Veillonella. P. intermedia se considera una especie bac-
El genoma del SARS-CoV-2 se ha detectado en la sa- teriana etiológica importante para varias lesiones perio-
liva de la mayoría de los pacientes con COVID-19, lo dontales agudas, que junto con las especies de Fusobac-
que indica la posible infección de las glándulas salivales. terium y Treponema, constituyen una gran proporción
En algunos pacientes el SARS-CoV-2 se detectó solo en de la microbiota presente en las lesiones EPN 38.
la saliva, pero no en el aspirado nasofaríngeo. La saliva
también se ha utilizado para detectar al virus en pacien- Atención odontológica en tiempos de COVID-19
tes hospitalizados sin fiebre o síntomas respiratorios 34,35. Los odontólogos son los profesionales de mayor riesgo
La pérdida del gusto y el olfato se ha reportado como de transmisión de COVID-19, ya que por la naturaleza
uno de los síntomas de COVID – 19. La mayoría de los de la atención dental, desde el diagnóstico al tratamien-
pacientes con estos síntomas (91%) informaron la apari- to el odontólogo y el paciente se encuentran cara a cara,
ción de alteraciones del gusto aun antes de los síntomas además que la producción de aerosoles durante proce-
respiratorios. El trastorno del gusto podría explicarse dimientos dentales debido al uso de piezas de mano de
por la alta expresión de ACE2 en el dorso de la lengua, alta y baja velocidad, raspadores ultrasónicos, jeringa
rica en papilas gustativas 27. triple, coloca al odontólogo, personal que trabaja en el
Se ha reportado presencia de gingivitis descamativa, úl- consultorio y pacientes en un alto riesgo de infección
ceras y ampollas compatibles con estomatitis herpética cruzada (Figura 3). La transmisión de COVID-19 en la
recurrente en la mucosa palatina, aparentemente asocia- consulta dental se puede dar por cuatro rutas principa-
do a COVID-19, así como sensación de quemazón y les: (1) exposición directa a secreciones respiratorias del
dolor de la orofaringe 36 (Figura 2). paciente; (2) contacto indirecto con superficies o instru-
mentos contaminados; (3) inhalación de suspensión de
Pacientes con periodontitis moderada o grave no tra- virus en el aire; y (4) contacto de la mucosa (nasal, oral y
tada puede empeorar en casos severos de COVID-19, conjuntival) con gotitas y aerosoles que contienen infec-
en los que un estado inflamatorio persistente parece
ción que se impulsan al toser y hablar sin mascarilla 15.
actuar como un desencadenante de la cascada de coa-
gulación y se asocia con mayores niveles de productos Los pacientes con COVID-19 no deben ser tratados en
de degradación de fibrinógeno (por ejemplo, dímero un entorno de atención dental regular, sino en un am-
D) 37. También se reportó un aumento espontáneo en biente hospitalario en una sala de aislamiento de presión
la prevalencia de enfermedad periodontal necrotizante negativa. Los pacientes asintomáticos (portadores) pueden
Figura 2. A. Múltiples úlceras de color naranja con halo eritematoso y distribución simétrica en el paladar duro derecho del
paciente. B. Múltiples úlceras amarillentas con un halo eritematoso en el paladar duro izquierdo del paciente.
(tomado de: Carreras-Presas M, et al.)

Figura 3. Dinámica de la infección cruzada en el consultorio dental. (Adaptado de Fallahi H, et al. 2020)
presentarse para recibir tratamiento dental y por la difi- preguntas más relevantes para el triaje inicial deben
cultad de identificarlos son de gran riesgo para la trans- incluir cualquier exposición a una persona con diag-
misión de COVID-19. Esta característica epidemiológi- nóstico conocido o sospecha de COVID-19, cualquier
ca de COVID-19 ha hecho su control extremadamente historial de viaje reciente a un área con alta inciden-
difícil, por lo que los tratamientos electivos deben pos- cia de COVID-19 o presencia de cualquier síntoma
ponerse y solo realizar tratamientos de urgencia en el de enfermedad respiratoria y/o fiebre. Una respuesta
consultorio dental, siguiendo protocolos de control de positiva a cualquiera de las tres preguntas debe gene-
infección estrictos. La decisión sobre la realización del rar preocupación inicial, y el cuidado dental electivo
tratamiento debe tomarse con el consentimiento apro- debe diferirse por al menos 2 semanas. Se debe alen-
piado del paciente, quien firmara el consentimiento in- tar a estos pacientes a que realicen la cuarentena y se
formado en el que se debe explicar los riesgos de la aten- comuniquen con su médico de atención primaria por
ción dental en tiempos de la pandemia COVID-19 39. teléfono 40.
El odontólogo y todo el personal que trabaje en la con- Debido a que solo se debe de realizar tratamientos de
sulta dental deben realizarse la prueba diagnóstica de urgencia, una videollamada o un mensaje con foto es
COVID-19 para descartar algún positivo que pueda una herramienta muy útil para determinar la necesidad
contagiar a los pacientes, sin embargo, un resultado ne- de tratamiento del paciente, y así evitar el traslado del
gativo no quita la posibilidad de infección posterior a paciente al consultorio encaso no sea una verdadera
la toma de la muestra, por tanto un resultado negativo urgencia. Aunque su impacto en el entorno clínico ha
no debe descuidar la implementación de las medidas de sido poco investigado, la aplicación WhatsApp Mes-
prevención y control del COVID-19. senger (Facebook Inc., Mountain View, California) se
encuentra entre las herramientas de comunicación más
Evaluación del paciente (triaje)
utilizadas por personas de toda edad 41. El primer paso
Con el propósito de controlar la infección por CO- siempre debe ser la asistencia virtual, y WhatsApp pue-
VID-19, la medida preventiva fundamental radica en el de considerarse una buena herramienta para hacerlo. La
triaje de pacientes que requieran atención dental de ur- asistencia virtual se puede realizar mediante el uso de
gencia en el consultorio. El examen inicial por teléfono fotos y videos. Se recomienda hacer un triaje a través
para identificar pacientes con sospecha o posible infec- de WhatsApp para analizar las urgencias reales que se
ción con COVID-19 se puede realizar de forma remota puedan presentar y evaluar la necesidad de una cita pre-
al momento de programar las citas (Figura 4). Las tres sencial o la posible atención de forma remota 42,43.

Mija Gómez
Figura 4. Flujograma de atención a pacientes durante la pandemia COVID-19. (Adaptado de: Ather A et al.)
Al llegar el paciente a la consulta dental, se debe hacer de medidas administrativas y técnicas eficaces, como por
la desinfección del calzado y colocarse botas descarta- ejemplo el triaje a distancia, lavado de manos, la utilidad
bles. Se debe medir la temperatura corporal del pacien- de los EPP es limitada 45.
te utilizando un termómetro infrarrojo a distancia, los
El uso de guantes no sustituye el lavado de manos y de-
pacientes que presentan fiebre (38 °C) y / o síntomas
bido a la baja resistencia del SARS-CoV-2 a los deter-
de enfermedad respiratoria deben recibir indicaciones
gentes, es la medida más importante en el control de la
para que cumplan cuarentena de 2 semanas y se debe
infección. El lavado de manos debe cumplir con la regla
posponer todo tratamiento electivo, y en caso de tener
del "dos antes y tres después" que incluye antes de tocar
una urgencia que no se pueda controlar con medidas
a un paciente, antes de realizar cualquier procedimiento
farmacológicas, se debe derivar al paciente a un am-
aséptico, después de exposición a fluidos corporales del
biente hospitalario donde pueda atenderse en una sala
paciente, después de tocar a un paciente y después de to-
con presión negativa. En caso el paciente no presente
car los alrededores del paciente o elementos que puedan
ninguna sintomatología que nos indique posible con-
estar contaminados 46.
tagio de COVID-19, antes de recibir atención dental,
debe completar un formulario de historial médico de- El uso de mascarillas como protección respiratoria ha de-
tallado, un cuestionario de detección COVID-19 y la mostrado efectividad en el control de infección del CO-
firma del consentimiento informado detallando los po- VID-19. Un concepto importante sobre la protección
sibles riesgos de atención dental y COVID-19 40,44. Es respiratoria a bioaerosoles es que los microorganismos
de suma importancia que los pacientes se programen son partículas que poseen forma, tamaño y peso, por
con cita previa, con un espacio de tiempo de seguridad lo que pueden ser filtrados. Las gotas son consideradas
entre consultas dentales, evitando el contacto o incluso mayores a 5 μm y los aerosoles menores a 5 μm. Dentro
la proximidad con otros pacientes. de la protección respiratoria para el manejo de microor-
ganismos tenemos las mascarillas quirúrgicas o cubrebo-
Uso de equipo de protección personal (EPP)
cas y los respiradores. Aunque las mascarillas quirúrgicas
El EPP consiste en prendas para proteger a todo el per- tienen cierta capacidad de filtración, no deben usarse
sonal, incluido limpieza y seguridad que este poten- cuando se atienden pacientes con enfermedades causa-
cialmente expuesto a contagio. El EPP estándar con- das por aerosoles (menor a 5 μm). Estas mascarillas no
siste en guantes, mascarilla y mandilón. Sin embargo, están diseñadas para brindar un sello facial; por tanto,
en caso de infecciones transmitidas por el aire como el no filtran alrededor del borde de la mascarilla cuando el
COVID-19, se debe usar equipo adicional que incluya usuario inhala, por lo que la transmisión ocurre por la
guantes, gorro, mascarillas o respiradores, gafas, másca- diseminación de material infeccioso de tamaño tal que
ras protectoras, trajes de aislamiento y ropa protectora, es respirable. Los respiradores son equipos que filtran
diseñados para proteger la piel y las membranas mucosas todo el aire que respira el usuario, aunque con mayor o
de los ojos, la boca y nariz 27. Si bien es cierto que el uso menor eficiencia según el modelo y especificaciones. En
de EPP en la consulta es lo que más resalta para el pa- Estados Unidos los respiradores certificados por el Ins-
ciente, no es más que una de las medidas para prevenir tituto Nacional para la Seguridad y Salud Ocupacional
infecciones cruzadas y no se debe considerar como la (NIOSH) son los N95 y tienen un mínimo de filtración
medida principal de prevención; si no está acompañado del 95% para las partículas más penetrantes (0,1 a 0,3

μm). El respirador N95 tiene que ajustar bien sobre la Se debe evitar la toma de radiografías intraorales, para
cara para prevenir la filtración de aire contaminado. Es- prevenir tos o reflejo nauseoso en el paciente, lo que
tos respiradores vienen en diferentes tamaños, se debe generaría aerosoles. Las radiografías extraorales y la TC
usar el que se ajuste mejor al rostro 47-49. Es importante son alternativas a tomar en cuenta 50.
destacar que los aerosoles pueden permanecer suspendi- Aislamiento absoluto con dique de goma
dos en el aire hasta por 30 minutos, por lo tanto, quitar
la máscara antes de 30 minutos en este entorno puede El aislamiento absoluto con dique de goma, debido a la
aumentar el riesgo de contacto con partículas contami- creación de una barrera en la cavidad oral reduce efec-
nadas 50. Se debe evitar que el respirador haga contacto tivamente la generación de gotas y aerosoles mezclados
con el labio al momento de retirarlo. con saliva y/o sangre del paciente en un 70%. Después
de la colocación del dique, se requiere adicionalmente
La pandemia de COVID-19 ha provocado una gran es- de una succión de alto volumen para evitar al máximo la
casez de respiradores N95, lo que ha llevado a realizar propagación de aerosoles y salpicaduras. El aislamiento
estudios que demuestren la efectividad de su desinfec- absoluto debe ser de rutina en todos los procedimientos
ción para reusarlos, se encontró que el calor seco inacti- dentales que lo permitan 15,42.
va el virus del COVID-19 luego de 5 minutos a 70 ° C
y es uno de los métodos más seguros y que no produce Desinfección de superficies del consultorio
deterioro del respirador, pudiendo realizarse hasta por La investigación ha demostrado que los coronavirus
5 veces, siempre que el respirador no haya sido conta- pueden permanecer en superficies de metal, vidrio y
minado con fluidos del paciente. La irradiación ultra- plástico de manera activa a temperatura ambiente de
violeta (UV) fue una opción secundaria, sin embargo, 2 horas hasta 9 días. Por lo tanto, como las superficies
la luz UV puede afectar la resistencia del material y el en las clínicas dentales sirven como lugares de depósi-
posterior sellado de los respiradores. Finalmente, los tra- to para gotas y aerosoles mezclados con la saliva y / o
tamientos que involucran líquidos y vapores requieren sangre de los pacientes, pueden ayudar efectivamente a
precaución, ya que el vapor, el alcohol y el hipoclori- propagar la infección. Pruebas recientes indican que el
to pueden conducir a la degradación de la eficiencia de SARS-CoV-2 puede ser vulnerable a biocidas como el
filtración, dejando al usuario vulnerable a los aerosoles hipoclorito de sodio al 0,1%, el peróxido de hidrógeno
virales 51,52. al 0,5%, al etanol de 60 a 75%, glutaraldehído al 2,5%,
Uso de colutorios formaldehído 1% y compuestos de amonio fenólico
y cuaternario si se utilizan de acuerdo con las instruc-
Debido a que el SARS-CoV-2 es bastante sensible a la ciones del fabricante. El digluconato de clorhexidina al
oxidación, se debe proporcionar un enjuague bucal con 0,02% es ineficaz 15,59.
agentes oxidantes al paciente antes de comenzar el pro-
cedimiento dental, para disminuir la carga viral en la El uso de luz ultravioleta (UV) para la desinfección del
saliva de un paciente infectado. Se recomienda peróxido consultorio no ha sido probada para inactivar al SARS-
de hidrógeno al 1%, para obtener 15 mL de este coluto- CoV-2, pero si hay evidencia de la inactivación por luz
rio, se mezcla 5 mL de peróxido de hidrógeno a 10 Vol. UV (especialmente la UV-C) de los coronavirus MERS
adicionando 10 mL de agua destilada. También puede y SARS, genéticamente muy parecidos al SARS-CoV-2.
usarse yodopovidona al 0.2%. La clorhexidina parece En caso se cuente con luz UV-C para la desinfección
no tener efecto sobre el SARS-CoV-2, por lo que no es de las superficies del consultorio, se debe usar como un
aconsejable su uso 53,54. complemento y no debe remplazar de ninguna manera
la desinfección con agentes biocidas 60-62.
Reducción de producción de aerosoles.
El riesgo más grande de transmisión de COVID-19 Conclusiones
durante la atención dental, es a través de la generación La declaración de pandemia de COVID-19 por la
de aerosoles, ya que el virus puede permanecer viable OMS nos pone en un escenario pocas veces imagina-
e infectar ya sea por inhalación o por contacto con la do, y el odontólogo debe conocer las características del
mucosa oral, nasal o la conjuntiva del ojo. El uso de SARS-CoV-2, las rutas de transmisión, manifestacio-
instrumental rotatorio y jeringa triple debe evitarse en lo nes clínicas iniciales que lleven a identificar a los pa-
posible, ya que crea un spray visible o aerosol que con- cientes infectados y lo más importante, las medidas a
tiene principalmente gotas de agua, saliva, sangre, mi- tomar para interrumpir la cadena de transmisión. El
croorganismos, y otros desechos, que se van a precipitar odontólogo desde su consulta privada debe participar
por la gravedad contaminando las superficies expuestas activamente en las políticas de salud pública, identifi-
del consultorio 55,56. En caso no se pueda evitar el uso cando posibles contagiados, orientándolos en las medi-
de la pieza de mano, esta debe tener una válvula antirre- das para no propagar la infección y derivándolos para
tracción que evite la aspiración y expulsión de desechos la atención especializada. La atención dental debe res-
y fluidos durante los procedimientos dentales, ya que se tringirse exclusivamente a tratamientos de emergencia
ha determinado que microorganismos pueden contami- y urgencia, siguiendo estrictamente los protocolos de
nar los tubos de agua y aire de la unidad dental si es que bioseguridad y medidas específicas para el control de
no se cuenta con válvula antirretracción 57. COVID-19.

Mija Gómez
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Article
COVID-19 Outbreak in North Italy: An Overview

on Dentistry. A Questionnaire Survey
Maria Grazia Cagetti 1, Jean Louis Cairoli 2, Andrea Senna 1 and Guglielmo Campus 3,4,*
1 Department of Biomedical, Surgical and Dental Science, University of Milan, Via Beldiletto 1,
I-20142 Milan, Italy; [email protected] (M.G.C.); [email protected] (A.S.)
2 Private Practitioner, President of the Lombardy Chamber of Dentists, Varese, Italy; [email protected]
3 Department of Surgery, Microsurgery and Medicine Sciences, School of Dentistry, University of Sassari,
Viale San Pietro, I-07100 Sassari, Italy

4 Department of Restorative, Preventive and Pediatric Dentistry, University of Bern, Freiburgstrasse 7,
CH-3010 Bern, Switzerland

* Correspondence: [email protected]; Tel.: +41-31-664098
Received: 28 April 2020; Accepted: 25 May 2020; Published: 28 May 2020
Abstract: This survey assessed the symptoms/signs, protective measures, awareness, and
perception levels regarding COVID-19 among dentists in Lombardy, Italy. Moreover, an analysis of
the answers gathered in areas with different prevalence of the disease was carried out. All
Lombardy’s dentists were sent an online ad hoc questionnaire. The questionnaire was divided into
four domains: personal data, precautionary measures (before patient arrival; in the waiting room;
in the operating room), awareness, and perception. Three thousand five hundred ninety-nine
questionnaires were analyzed. Five hundred two (14.43%) participants had suffered one or more
symptoms referable to COVID-19. Thirty-one subjects were positive to the virus SARS-CoV-2 and
16 subjects developed the disease. Only a small number of dentists (n = 72, 2.00%) were confident of
avoiding infection; dentists working in low COVID-19 prevalence areas were more confident than
those working in the Milan area and high prevalence area (61.24%, 61.23%, and 64.29%, p < 0.01
respectively). The level of awareness was statistically significantly higher (p < 0.01) in the Milan area
(71.82%) than in the other areas. This survey demonstrated that dentists in the COVID-19 highest
prevalence area, albeit reported to have more symptoms/signs than the rest of the sample, were the
ones who adopted several precautionary measures less frequently and were the more confident of
avoiding infection.
Keywords: COVID-19; infection; dentist; protective measures; awareness; infection control
1. Introduction
The coronavirus pandemic has deeply affected the world. Up to 12 May, 2020, the total number
of confirmed cases has exceeded four million and a half, with more than two hundred eighty
thousand deaths. The SARS-CoV-2 human-to-human transmission has been described through
airborne droplets or direct contact with cases or with contaminated surfaces [1]. Avoiding close
contact (less than 1 m) with people, especially those with respiratory symptoms, is the most important
preventive measure to be taken to prevent the spreading of the infection.
In May 2020, Italy is still among European countries with the highest number of Covid-19 cases,
now in third place after Spain and the United Kingdom. The majority of cases are concentrated in the
Northern part of the country (Lombardy) and held the sad European deaths record [2]. Another dark
Italian record is the number of health care workers who were infected or who died as a result of the
infection. The official number of infected health workers up to 12 May, 2020, according to the Italian
Superior Health Institute, amounted to 21.981 workers [3]. According to the Italian National
Int. J. Environ. Res. Public Health 2020, 17, 3835; doi:10.3390/ijerph17113835 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 3835 2 of 11
Federation of the Order of Physicians, Surgeons, and Dentists, instead, the number of deceased
physicians up to the 10 May, 2020 amounted to 160 deaths [4], of whom sixteen were dentists.
Although patients affected by COVID-19 are not supposed to receive dental treatments, undiagnosed
infected subjects without or with very mild symptoms could be eligible for dental treatment in
emergency cases. Dental care in Italy is largely provided by private practitioners and mainly financed
by patients’ direct payment, or, to a lesser extent, by private insurance schemes.
The risk of cross-infection in dentistry has been described considerably high [5] since splatters and
aerosols produced during routine dental treatments contribute to increased risk [6]. This issue might be
a relevant professional hazard when infective agents, such as coronaviruses, are widespread in the
population [7]. Dentists and health care professionals working in wards with pneumonia patients are at
higher risk of developing infective diseases during their regular activities [8]. Data on the real risk of virus
diffusion by dental procedures are urgent since none is available in the literature [8,9]. In a recent paper,
the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces was investigated in
experimental conditions, showing that the airborne transmission of SARS-CoV-2 is plausible since
the virus can remain viable and infectious in aerosols for hours [9]. Without data on airborne SARS-
Cov-2 gained in real dental care situations, operational envelopes and disinfection procedures to face
the viral infection are hypothetical.
Well-designed questionnaires are a useful method to easily collect data from participants in
studies [10]. Questionnaires to investigate dentists’ knowledge, attitudes, and perceptions regarding
viral infection control in the dental environment found in the literature [11–14] show that awareness
and precautionary measures carried out by dentists on patients with a viral infection are not always
completely satisfactory. The main aim of this survey was to assess the symptoms/signs, the protective
measures, the level of awareness, and perception regarding the COVID-19 outbreak among dentists
working in North Italy. The ancillary aim was also to appraise if the answers provided bear
resemblance in areas with different prevalence of the disease.
2. Materials and Methods
2.1. Development and Building-Up of the Questionnaire

The first bunch of items related to the health situation, risk, and knowledge of an infectious
disease was derived from the questionnaire developed for the SARS risk [15]. The authors followed
the Stehr-Green scale to build up the questionnaire [16]. The questionnaire was structured into four
domains, the first regarded personal data (age, gender, area of living, and working status), the second
the health conditions (symptoms/signs relative to the COVID-19 flu), the third the working condition
and personal protective equipment (PPE) adopted after the outbreak of the infection, and the fourth
the knowledge and the self-perceived risk of infection (Table 1). Among the PPE included in the
questionnaire, some, such as the use of sterile gloves, do not have a scientific justification but were
deliberately inserted to check whether the answers were selected with the sole logic of demonstrating
that any contrast measures regarding the virus had been implemented or whether the equipment
adopted was the result of a thoughtful choice.
Table 1. Questionnaire items.
Items
male
Gender
female
Age
Zip Code (living)
Zip Code (working)
Private dentist
Working status Private/NHS
NSH
No symptoms/signs
From the start of the COVID-19 you had You resulted COVID-19 positive
You were hospitalized for COVID
I had one/more symptoms/signs

Fever
Cough
Fatigue
Short Breath
Nasal congestion
Headache
Rhinorrhea
Sore throat
Diffuse pain
Diarrhea
Anosmia
Ageusia
Conjunctivitis
Only if you work in the NHS, are you currently Yes
working? No
You kept working as usual
From the 21st February You limited your activity to emergencies
You have stopped all activities
Between 21–23 February
Between 24 February and 1 March
If you have limited your professional activity to
Between 2–6 March
emergencies, when did you start limiting?
Between 7–14 March
After 14th March
Between 21–23 February
Between 24 February and 1 March
If you have stopped your professional activity, when did
Between 2–6 March
this happen?
Between 7–14 March
After 14th March
None
Phone Triage
Spaced appointments so to not saturate the waiting room
Deferring therapies in elderly patients, or patients with
systemic diseases
Handle disinfection several times a day
Disinfection of pushbuttons, Point of sale, chairs several
times a day
Verify the patient’s current health status on access
Detecting the patient’s body temperature
Detecting the body temperature of all co-workers and ask to
leave to those with a temperature above 37.5 °C.
Washing the patient’s hands
Space of at least one meter between patients
Mask for the patient
Frequent ventilation of waiting rooms
Removal of magazines and books from the waiting area
If you have continued working after 21st February, Storage of coats, bags, and other items outside the operating
which of the following measures have you adopted? area
Pre-operative rinse with mouthwash containing 1%
hydrogen peroxide
Pre-operative rinse with mouthwash containing
chlorhexidine 0.12–0.2%
Pre-operative rinse with mouthwash containing 0.2–1%
iodopovidone
Pre-operative rinse with mouthwash containing alcohol and
essential oils
Pre-operative rinse with mouthwash containing
Cetylpyridinium chloride at 0.05–0.10%
Rinse with diluted mouthwash
Ventilation of the operating area for at least 10 min after each
patient
Surface disinfection with 70% ethyl alcohol
Surface disinfection with 0.5% sodium hypochlorite
Surface disinfection with usual disinfectants containing other
active ingredients
Washing operators’ hands before and after each procedure

Removal of all disposable protective devices and disinfection
of non-disposable devices
Surgical mask
Filtering facepiece 2 or filtering facepiece 3 masks
Disposable headset
Sterile microfiber disposable gown
Which of the following protective equipment did you Water-repellent, non-wowen fabric TNT disposable gown
wear/use? Disposable gown
Safety glasses or visor
Sterile disposable gloves
Disposable gloves
Rotating instrument with anti-retraction valve
Yes
Did you follow a course on Covid-19?
No
Yes
Do you think that you know enough on COVID-19?
No
Unlikely
Do you believe that the infection by SARS-CoV-2 is a risk Very unlikely
for the dentist? Likely
Very likely
No confident
How sure are you that you can avoid becoming infected Enough confident
with SARS-CoV-2 during work activities? A bit confident
Confident
Less than the risk run in a supermarket
In a health emergency situation such as the current one,
Comparable to the risk run in a supermarket
do you believe that the risk of infection transmission in
Higher than the risk run in a supermarket
the dental practice is:
A preliminary questionnaire was built up and pre-tested on a small group of dentists (n = 12);
Intraclass Correlation Coefficients (ICC) was run for the test-retest and intra-rater reliability for each
item. An ICC value of 0.80 or higher was considered satisfactory. All the items with a value of ICC
below 0.80 were discussed by the authors and modified following the preliminary study.
An anonymous online survey (Survey Monkey™, SVMK Inc. San Mateo, CA, US) has been
prepared. On the 10th of April, all dentists n = 9247 included in the database of the Order of Physicians,
Surgeons, and Dentists of Lombardy, 89.79% of all dentists registered in Lombardy, received an email
asking their consent to participation in the questionnaire in accordance with applicable privacy laws.
All the participants were asked to declare that they have read the privacy policy and voluntarily
approve data collection and processing. If they answered No, the questionnaire was automatically
closed, and no data were collected. A second reminder was emailed to the non-responders after four
days and the last one on the 16th of April. The survey was stopped one week after its beginning.
2.2. Data Analysis

Answers to the questionnaire were inserted in Excel™ 2019 for Mac. The data were cleaned and
then transferred to STATA16™ (StataCorp LLC, College Station, Texas, USA) for their statistical
analysis. The 12 Lombardy provinces were grouped as follows: Milan province, with a COVID-19
prevalence of 0.53%, was considered alone, and provinces where the prevalence of COVID-19 was
higher than 0.90% (Cremona, Lodi, Brescia, Bergamo) were grouped together. Provinces with lower
prevalence (Varese, Como, Monza, Sondrio, Lecco, Pavia, Mantua) with a mean of 0.44 (data
evaluated 24th April) were also grouped together [5]. Absolute and relative frequencies were
calculated for each item. Difference in proportion was evaluated with χ2 test or Fisher exact test if one
cell had a value of less than five. Multiple testing for post hoc estimation was calculated, such as the
number of observed frequencies, expected frequencies, percentage, and contribution to the chi-
square. The symptoms most frequently reported in the literature (fever, cough, fatigue) were used
for a comparison between areas with different COVID-19 prevalence [17]. A p-value less than 0.05 was
considered statistically significant. The row data are available as Supplementary Materials (Table S1).
3. Results
In the pre-test evaluation, only two items showed an ICC below the threshold (i.e., “Which of
the following protective equipment did you wear/use?” ICC = 0.73 and “Do you believe that the
infection by SARS-CoV-2 is a risk for the dentist?” ICC = 0.78) and, after discussion among the
authors, the questions were slightly modified. A total of 9247 invitations were emailed, and 112
(1.21%) were not delivered by the system. After the first dispatch, 65.95% of the emails were opened:
1.32% refused and 41.60% participated in the questionnaire. At the end of the survey, 4308
questionnaires were returned. Three thousand five hundred ninety-nine questionnaires (response
rate 39.40%) were analyzed (69.27% males and 30.73% females). A statically significant (p < 0.01)
predominance of males was observed among dentists who compiled the questionnaire (Table 2).
Table 2. Participants' distribution by age and gender.
Males Females Total

Age Groups
n (%) n (%) n (%)
<30 years 180 (5.02) 181 (5.05) 361 (10.07)
31–40 years 350 (9.76) 271 (7.56) 621 (17.32)
41–50 years 401 (11.18) 270 (7.53) 671 (18.71)
51–60 years 692 (19.30) 242 (6.75) 934 (26.05)
>60 years 861 (24.01) 138 (3.85) 999 (27.86)
Total 2493 (69.27) 1106 (30.73) 3599 (100.00)
χ 2(4) = 285.48 p < 0.01.
Thirty-one subjects (0.86% of the dentists whose questionnaires were analyzed) were positive to
the virus SARS-CoV-2, and 16 subjects developed the disease. The triage of symptoms/signs related
to COVID-19 showed that 474 (13.47%) participants claimed to have suffered one or more
symptoms/signs referable to COVID-19.
Among the symptoms/signs (Table 3), the sense of fatigue and fever were the most common
(7.63 and 7.21%, respectively), while breath difficulties and conjunctivitis were the less frequent (1.98
and 1.98%, respectively). Almost 10% of the dentists working in area with a high prevalence of
COVID-19 reported to suffer or have suffered from three or more symptoms (χ2(6) = 63.64 p < 0.01 post
ad hoc estimation likelihood-ratio χ2(6) = 62.12 p < 0.01).
Table 3. Prevalence of symptoms/signs related to the COVID-19 in the different Lombardy provinces.
Percentages were calculated per column.
Milan Area High Prevalence Area Low Prevalence Area

OF EF % Cχ2 OF EF % Cχ2 OF EF % Cχ2
No symptoms
1072 1067.47 86.80 0.02 721 784.83 79.41 5.19 1221 1161.69 90.86 3.03
One symptom
38 34.35 3.08 0.39 39 25.26 4.29 7.47 20 25.26 1.50 8.09
Two symptoms
59 57.73 4.78 0.03 61 42.45 6.72 8.11 43 42.45 3.20 6.26
Three or more symptoms
66 75.44 5.34 0.14 87 55.46 9.58 17.93 60 55.46 4.46 5.95
χ = 63.64 p < 0.01 Post ad hoc estimation Likelihood-ratio χ = 62.12 p < 0.01. OF, observed
2(6) 2(6)
frequency; EF, expected frequency; %, percentage; Cχ2, contribution to chi-square.
The three main common symptoms from the literature (fever, cough, and fatigue) were
statistically highly (χ2(6) = 59.20 p < 0.01 Post ad hoc estimation Likelihood-ratio χ 2(6) = 52.31 p < 0.01)
reported from dentists working in Milan and the high prevalence area (Table 4).
Table 4. Prevalence of the most associated symptoms/signs related to the COVID-19 in the different
Lombardy provinces. Percentages were calculated per column.

Symptoms/Signs
OF EF % OF EF % OF EF % OF EF %
Fever 17 16.29 11.97 0.03 21 11.98 13.38 6.80 8 17.73 7.84 5.34
Cough 15 19.50 10.57 1.03 26 14.32 16.56 9.52 14 21.20 13.73 2.45
Fatigue 25 21.61 17.60 0.53 23 18.88 16.65 3.19 13 23.51 12.74 4.70
Fever + Cough 11 10.98 7.75 0.00 10 8.07 6.37 0.46 10 11.95 9.80 0.32
Fever + Fatigue 25 26.56 17.60 0.09 31 19.53 19.74 6.74 19 28.91 18.63 3.40
Cough + Fatigue 11 11.33 7.75 0.01 9 8.33 5.73 0.05 12 12.33 11.77 0.01
Fever + Cough + Fatigue 38 35.77 26.76 0.14 37 26.30 23.57 4.35 26 38.93 25.49 4.30
χ2(6) = 59.20 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(6) = 52.31 p < 0.01.
More than 90% of the responders worked as private dentists and only 242 (6.82%) worked
partially or full-time in the National Health System (NHS). Almost half of the dentists continued to
work after the outbreak of the disease (21st February).
Several precautionary measures were adopted by dentists who continued to work after SARS-CoV-
2 outbreak; in Table 5, the measures were grouped in (1) measures adopted before the patient’s arrival, (2)
measures adopted in the waiting room, and (3) measures adopted in the operating room. Among
measures taken before the patient’s arrival, the delay of the appointments to not saturate the waiting room
was the most adopted (86.07%). Frequent ventilation of the waiting room (88.98%) and the washing of the
operators’ hands before and after each procedure (91.64%) were the most taken measures.
Table 5. Precautionary measures taken by dentists that continued to work after the outbreak of
COVID-19.
Item n (%)
Phone Triage 2542 (82.37)
Spaced appointments as not saturate the waiting room 2656 (86.07)
Before patient
Deferring therapies in elderly patients, or with systemic diseases 1912 (61.96)
arrival
Detecting body temperature of all co-workers and leave those with a
656 (21.26)
temperature above 37.5 °C.
Disinfection of pushbuttons, POS, chairs, several times a day 2525 (81.82)
Verify the patient’s current health status on access 2568 (83.21)
Detecting the patient’s body temperature 725 (23.49)
Washing the patient’s hands 2413 (78.19)
In the waiting
Space of at least one meter between patients 2312 (74.92)
room
Mask for the patient 1011 (32.76)
Frequent ventilation of waiting rooms 2746 (88.98)
Removal of magazines and books from the waiting area 2418 (78.35)
Storage of coats, bags, and other items outside the operating area 2103 (68.15)
Pre-operative rinse with mouthwash containing 1% hydrogen peroxide 813 (26.34)
Pre-operative rinse with mouthwash containing chlorhexidine 0.12–0.2% 1658 (53.73)
Pre-operative rinse with mouthwash containing 0.2–1% iodopovidone 251 (8.13)
Pre-operative rinse with mouthwash containing alcohol and essential oils 190 (6.16)
Pre-operative rinse with mouthwash with Cetylpyridinium chloride at
86 (2.79)
0.05–0.10%
In the operating Rinse with diluted mouthwash 112 (3.63)
room Ventilation of the operating area for at least 10 min after each patient 2379 (77.09)
Disinfection of surfaces with 70% ethyl alcohol 1264 (40.96)
Disinfection of surfaces with 0.5% sodium hypochlorite 611 (19.80)
Disinfection of surfaces with usual disinfectant with other active
1875 (60.76)
ingredients
Washing operators’ hands before and after each procedure 2828 (91.64)
Removal of all disposable protective devices and disinfection of devices 2484 (80.49)
Table 5 reports precautionary measures with more than 80% positive replies, among those of
Table 4, stratified by areas with a different prevalence of COVID-19. Statistically significant
differences were found for all considered items. The delay of the appointments in order to not
saturate the waiting room, the frequent ventilation of the waiting room, and the washing of the
operators’ hands before and after each procedure were the items with the higher differences among
areas (p < 0.01). Surprisingly, dentists from the area with the highest COVID-19 prevalence claimed
to have used some virus containment strategies, such as the disinfection of pushbuttons, point of sale
(POS), and chairs several times a day, the removal of all disposable protective devices, and
disinfection of devices and washing hands, less frequently than dentists who work in the lower
prevalence areas (Table 6).
In addition to the PPE commonly used by dentists, such as the use of disposable gloves (93.22%)
and surgical masks (74.56%), the use of glasses/visors (91.28%), disposable headsets (63.75%), and
facial filters (58.84%) were the equipment most claimed (Table 7).
Table 6. Precautionary measures against COVID-19 stratified by areas with different prevalence of
the disease. The items with 80% or more positive replies were used. Percentages were calculated per
column.

Answers
OF EF % Cχ2 OF EF % Cχ2 OF EF % Cχ2
Phone triage
χ2(2) = 11.41 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 11.44 p < 0.01
No 185 344.3 17.57 3.90 126 252.7 15.91 0.04 233 372.9 18.78 4.27
Yes 868 1092.98 82.43 1.51 666 803.58 84.09 0.02 1008 958.1 81.22 1.66
Appointments delayed so to not saturate the waiting room
χ2(2) = 6.78 p = 0.03 Post ad hoc estimation Likelihood-ratio χ2(2) = 6.84 p = 0.03
No 96 305.1 9.12 1.05 123 223.7 15.53 0.92 211 330.2 17.00 3.14
Yes 957 923.9 90.88 0.35 669 677.3 84.47 0.30 1030 998.8 83.00 1.04
Disinfection of pushbuttons, POS, chairs, several times a day
No 107 352.61 10.16 1.55 202 258.79 25.50 0.67 212 381.59 17.08 3.50
Yes 946 876.38 89.24 0.62 590 643.20 74.50 0.27 1029 948.41 82.92 1.41
Verify the patient’s current health status on access
χ2(2 )= 8.79 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 8.56 p = 0.01
No 161 336.28 15.29 1.81 89 246.81 21.60 0.67 268 363.91 16.78 3.75
Yes 892 892.72 84.71 0.69 703 655.19 78.40 0.23 973 966.09 83.22 1.41
Frequent ventilation of waiting rooms
No 299 275.12 24.33 2.07 204 201.92 22.62 0.02 272 297.95 20.44 2.26
Yes 930 953.87 75.67 0.60 698 700.08 77.38 0.01 1059 1033.04 79.56 0.65
Washing operators’ hands before and after each procedure
χ2(2) = 9.21 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 9.32 p < 0.01
No 262 246.15 21.32 1.02 199 180.46 22.09 1.91 232 266.38 17.44 4.44
Yes 967 982.45 78.68 0.26 702 720.54 77.91 0.48 1098 1063.62 82.56 1.11
Removal of all disposable protective devices and disinfection of devices
χ 2(2) = 9.09 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 9.17 p = 0.01
No 392 365.86 21.32 1.87 281 267.92 22.09 0.64 357 396.22 17.44 3.88
Yes 837 863.14 78.68 0.79 619 632.08 77.91 0.27 974 934.77 82.56 1.65
Only one-third of the dentists reported to have followed a Continuous Educational Course on
COVID-19, but 70.49% of the sample believed to have enough knowledge on the disease and the
protective measures (data not in tables).
About the risk perception of being infected by SARS-CoV-2 (Table 8), the majority of the dentists
(64.50%) replied that the dentistry is a profession at risk; only 2.13% of the dentists claimed to be
confident in avoiding the infection and 68.50% believed that in the actual health emergency, the risk
of infection transmission during the dental practice is higher than that run in a supermarket.
Table 7. Personal protective equipment (PPE) and devices adopted by the dentists.
Items n (%)
Surgical mask 2386 (74.56)
FFP2 or FFP3 facial filters 1755 (54.84)
Disposable headset 2040 (63.75)
Sterile microfiber disposable gown 675 (21.09)
The same variables mentioned above were stratified by areas with different prevalence of
COVID-19 (Table 8). Unlike what could be assumed, even though only a small number of dentists in
all areas believe to be confident in avoiding the infection, dentists working in areas with a high
COVID-19 prevalence are more confident than those working in a lower prevalence area (61.23% vs
64.29% and 66.41%). Dentists from different areas agree that the risk of infection is higher in the dental
setting than in a supermarket, but a statistically significant difference among areas was noted (63.63%
in high COVID-19 area, 68.25% in low COVID-19 area, and 71.82 in Milan area (Table 9).
Table 8. Perception of risk related to COVID-19.
Items as n (%)
Do you believe that the infection by SARS-CoV-2 is a risk for the dentist?
Very unlikely Unlikely Likely Very likely
107 (3.11) 121 (3.52) 993 (28.91) 2214 (64.50)
How sure are you that you can avoid being infected by SARS-CoV-2 during work?
Not confident A bit confident Enough confident Confident
1275 (37.20) 966 (28.19) 1113 (32.48) 73 (2.13)
In a health emergency situation such as the current one, do you believe that the risk of infection transmission in the dental
practice is:
Comparable to the risk run in a
Higher than the risk run in a supermarket Less than the risk run in a supermarket
supermarket
2349 (68.50) 405 (11.81) 675 (19.69)
Table 9. Risk perception of COVID-19 stratified by areas with different prevalence of COVID-19.
Percentages were calculated per column.

Answers
OF EF % OF EF % OF EF % OF EF %
Do you believe that the infection by SARS-CoV-2 is a risk for the dentist?
Very unlikely 48 40.97 3.74 1.21 22 30.40 2.51 2.32 46 44.64 3.57 0.04
Unlikely 38 37.08 2.96 0.02 29 27.51 3.31 0.08 38 40.41 2.95 0.14
Likely 311 344.67 24.26 3.29 289 255.74 32.95 4.33 376 375.59 29.19 0.00
Very likely 785 759.28 61.24 0.87 537 563.36 61.23 1.23 828 827.37 64.29 0.00
How sure are you that you can avoid becoming infected with SARS-CoV-2 during work?
Not confident 482 436.53 40.95 4.74 292 325.26 32.30 3.40 464 476.21 36.13 0.31
Enough
321 334.62 27.27 0.56 278 249.33 31.70 3.30 350 365.04 27.25 0.62
confident
A bit confident 349 380.46 29.66 2.60 286 283.49 32.61 0.02 444 415.05 34.60 2.02
Confident 25 25.38 2.12 0.01 21 18.92 2.39 0.23 26 27.70 2.02 0.10
In a health emergency situation such as the current one, do you believe that the risk of infection transmission in the dental
practice, compared to that run in a supermarket, is
Lower 211 232.78 17.91 2.04 200 173.30 22.80 4.11 249 253.92 19.38 0.09
Comparable 121 140.73 10.27 2.77 119 104.77 13.57 1.93 159 153.51 12.37 0.20
Higher 846 804.05 71.82 2.14 558 598.93 63.63 2.80 877 877.57 68.25 0.01
4. Discussion
The present survey was carried out during the period of maximum diffusion of COVID-19 in Europe.
Lombardy, situated in Northern Italy, with about 10 million inhabitants (more than one-sixth of Italy’s
entire population), is the region with the highest number of SARS-CoV-2 infections and deaths.
The sample of dentists to whom the questionnaire was emailed includes almost all Lombardy
dentists. The response rate was quite low; however, given the high number of questionnaires sent,
the sample of responders is high and representative of the Lombardy dentist population.
At the moment in which this paper was written, three papers were available in literature
reporting data collected through a questionnaire administered to a sample of dentists investigating
different aspects of the COVID-19 in the dental setting [13,14,18]. The first two papers investigated
knowledge, attitudes, and practices of dental practitioners regarding COVID-19, one study involving
a sample of dentists from different countries and continents and the second involving a sample of
dentists from Jordan [13,14,18]. The third study, including a sample of dentists from all over the world,
aimed to assess fear and practice modifications related to COVID-19 [18]. None of these studies addressed
the health conditions of dentists related to the disease. In the present survey, among the interviewed
dentists, the percentage of subjects diagnosed with the new coronavirus (0.86%) is similar to that reported
in the population of high COVID-19 prevalence areas. This data could suggest a greater infection diffusion
among dentists. However, this finding could be due to a possibly higher participation rate in the
questionnaire of subjects infected with the virus or with claimed symptoms/signs. They were reported by
a relatively high percentage of dentists (14.43%). Nevertheless, these symptoms/signs may have been
caused by other conditions such as seasonal flu, still present in the period of the widespread of SARS-
CoV-2. However, the highest prevalence reported by dentists working in the provinces where
COVID-19 had spread, such as Bergamo and Cremona, is startling.
Regarding the precautionary measures taken by dentists that continued to work after the outbreak
of COVID-19, it is possible to compare these data with those reported in a worldwide taken sample of
dentists [19]. Patients’ body temperature before dental treatment was taken by less than a quarter of the
Lombardy sample, while this measure was carried out by more than two-thirds of dentists interviewed
all over the world. In the same study, considering the use of PPE, the majority of dentists reported to
believe that the use of facial filters is a useful habit in the current outbreak, but only a minority claimed to
use it. More than half of the Lombardy sample declared to use these PPE. Only a quarter of the
international sample of dentists make their patients do a pre-treatment mouth-rinse, while in Lombardy,
the majority of dentists use this protective measure on patients. Nevertheless, it is important to note that
half of the Lombardy sample reported using chlorhexidine-containing rinse that appears not to be efficient
against SARS-CoV-2, and only one-third reported to use a mouth-rinse containing more active
compounds [19]. Finally, handwashing before and after each treatment was a habit reported by a high
percentage of dentists from both samples. The majority of dentists from both surveys are afraid of getting
infected with SARS-CoV-2 in the dental environment.
The use of sterile gloves and gown as well as other PPE included in the present questionnaire
do not have a scientific justification in this pandemic situation, as reported above. Regarding the use
of gloves, only a small minority of dentists claimed to use sterile gloves, while the use of sterile gowns
was reported by about a fifth of the sample. However, it is possible to hypothesize that dentists
unprepared for the pandemic used PPE that they already had to protect themselves, albeit knowing
that some, such as sterile gloves and gowns, were not necessary to avoid the infection.
Unlike what could be expected, for both preventive measures and self-perceived infection risk
related to COVID-19, dentists from the areas with the highest prevalence of the disease seem to be
generally less preoccupied: they reported a lower implementation of some of the most frequently
adopted preventive measures than their colleagues from areas at low COVID-19 prevalence as well
as a lower perception of being infected. The different perception of the risk reported by dentists who
live and work in areas with a different prevalence of the disease can be explained by the fact that
where many infected people are present, the risk is seen as general, reducing the perception of a
higher infection risk at the dental chair, while dentists who live and work in areas with a lower
prevalence of the disease consider the occupational risk as higher.
Only one-third of the dentists reported to have followed a Continuous Educational Course on
COVID-19, but more than two-thirds believe to have enough knowledge about the new disease. This
discrepancy could represent a weakness. Throughout this international health crisis, a large amount
of information reaches us every day, involving the circulation of many fake news, which can
represent a danger especially in the health context [20].
5. Conclusions
In conclusion, this survey gives an insight into the dental profession in one of the European areas
where COVID-19 has caused the greatest number of deaths in proportion to the number of inhabitants.
A quite high percentage of the sample reported symptoms attributable to the infection, especially those
working in the high prevalence area. However, only 31 of these subjects were diagnosed with COVID-
19. Even though the majority of dentists adopted several precautionary measures, recognized as valid
by the scientific community, those working in the highest prevalence COVID-19 area reported adopting
several measures less frequently than dentists in low prevalence area. The same unexpected finding
was disclosed regarding the COVID-19 risk perception: dentists in the highest prevalence area were
more confident to avoid the infection than others.
Only one-third of the dentists report to have followed a Continuous Educational Course on
COVID-19, but the majority of the sample believes to have enough knowledge on the disease and the
protective measures to avoid infection.
Supplementary Materials: The following are available online at www.mdpi.com/1660-4601/17/11/3835/s1, Table
S1: Row data.
Author Contributions: M.G.C., J.-L.C., A.S., and G.C. designed and planned the study; M.G.C., J.-L.C., and G.C.
created the questionnaire and tested it; J.-L.C. submitted the questionnaire and collected the data; G.C.
performed the statistical analysis; M.G.C. and G.C. wrote the manuscript draft and created the tables. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: All person that had taken part in the study are mentioned as authors.
Conflicts of Interest: The authors declare no conflict of interest.
Abbreviation
MERS-CoV Middle East Respiratory Syndrome MERS-CoV
SARS-CoV Severe Acute Respiratory Syndrome
COVID-19 Coronavirus Disease
POS Point of sale
PPE Personal Protective Equipment
NHS National Health System
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© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
JCTXXX10.1177/2380084420924385JDR Clinical & Translational ResearchThe Clouds of COVID-19
research-article2020
Vol. XX • Issue X Dental Care under the Clouds of COVID-19
Special Communication
Dental Care and Oral Health

under the Clouds of COVID-19
Y.F. Ren1 , L. Rasubala1, H. Malmstrom1, and E. Eliav1
C
Abstract: Coronavirus disease 2019 CoV-2 and that oral symptoms, oronavirus disease 2019 (COVID-
(COVID-19), caused by the severe acute including loss of taste/smell and dry 19), caused by the severe acute
respiratory syndrome coronavirus mouth, might be early symptoms of respiratory syndrome coronavirus
2 (SARS-CoV-2), has caused much COVID-19, presenting before fever, dry 2 (SARS-CoV-2), has spread rapidly across
anxiety and confusion in the cough, fatigue, shortness breath, and the globe since it was first reported in
community and affected the delivery other typical symptoms. Oral health China in December 2019. As of April 15,
of vital health care services, including researchers may play a more active role 2020, SARS-CoV-2 has infected >2 mil-
dental care. We reviewed current in early identification and diagnosis lion individuals and resulted in 132,000
evidence related to the impact of SARS- of the disease through deciphering the deaths in 185 countries/regions. While
CoV-2/COVID-19 on dental care and mechanisms of dry mouth and loss government agencies, health care facil-
oral health with the aim to help dental of taste in patients with COVID-19. ities, and medical professionals world-
professionals better understand the Rapid testing for infectious diseases in wide mobilize to contain the virus, miti-
risks of disease transmission in dental dental offices via saliva samples may gate the transmission of the disease, and
settings, strengthen protection against be valuable in the early identification save the lives of patients with COVID-
nosocomial infections, and identify of infected patients and in disease 19, dental care and oral health research
areas of COVID-19–related oral health progress assessment. have rightfully taken a backseat during
research. When compared with other the pandemic to preserve scarce personal
recent pandemics, COVID-19 is less Knowledge Transfer Statement: protective equipment (PPE), observe
severe but spreads more easily, causing This commentary provides a timely social distancing, and protect the employ-
a significantly higher number of evidence-based overview on the impact ees and patients from risks of poten-
deaths worldwide. Protection of dental of COVID-19 on dental care and oral tial exposure and illness. With the rapid
patients and staff during COVID- health and identifies gaps in protection increase in confirmed cases of COVID-
19 is challenging due to the existence of patients and staff in dental settings. 19 in the United States, the Centers for
of patients who are infectious yet Oral symptoms are prominent before Disease Control and Prevention (CDC),
asymptomatic. Dental professionals fever and cough occur. Dental American Dental Association (ADA), and
are ill prepared for the pandemic, professionals may play an important state dental boards and associations have
as they are not routinely fitted for role in early identification and all issued guidance to advise dentists
the N95 respirators now required for diagnosis of patients with COVID-19. to halt elective dental services and treat
preventing contagion during dental only patients requiring emergency dental
treatments. Biological and clinical Keywords: SARS-CoV-2, dental facility, procedures.
evidence supports that oral mucosa urgent care, airborne transmission, dry SARS-CoV-2 differs significantly from
is an initial site of entry for SARS- mouth, ageusia the 2003 SARS-CoV and Middle East
DOI: 10.1177/2380084420924385. 1Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA. Corresponding authors: Y.F. Ren, Eastman Institute for
Oral Health, University of Rochester, 625 Elmwood Ave, Rochester, NY 14620, USA. Email: [email protected]. E. Eliav, Eastman Institute for Oral Health,
University of Rochester, 625 Elmwood Ave, Rochester, NY 14620, USA. Email: [email protected].
© International & American Associations for Dental Research 2020
1
JDR Clinical & Translational Research Month 2020
respiratory syndrome coronavirus (MERS- as negative-pressure isolation rooms overview focuses on issues important to
CoV) not only in genome sequence with HEPA filtration (high-efficiency dental care and oral health and is not
but also in its spike protein structures particulate air), when treating dental intended to be a comprehensive review
(Kandeel et al. 2020; Ren et al. 2020), emergency patients, which essentially of SARS-CoV-2 and COVID-19.
which exhibit higher affinity to the precluded all dental clinics in the state
cellular entry receptor angiotensin- to provide dental emergency care, as Bare Basics of SARS-CoV-2
converting enzyme 2 (ACE2), rendering none of the available dental facilities
SARS-CoV-2 is an enveloped positive-
it much easier for SARS-CoV-2 to enter could meet such stringent requirement.
stranded RNA virus, which is a
human cells than SARS-CoV and MERS- This guidance was later revised to allow
betacoronavirus within the Nidovirales
CoV. Consequently, COVID-19 spreads urgent or emergency dental treatments
order of viruses (Gorbalenya et al. 2020).
much faster than SARS and MERS and with PPEs and disinfection procedures
The host-derived membrane is studded
has caused more deaths than SARS and consistent with usual standard of care in
with glycoprotein spikes and surrounds
MERS combined. Rapid transmission of patients not suspected of having COVID-
the RNA genome. Replication of viral
the disease and exponential increase 19 (Pennsylvania Department of Health
RNA occurs in the host cytoplasm
in number of confirmed cases— 2020).
through the action of RNA polymerase.
coupled with evolving but limited Dental emergency services are vital
The spike protein projects through
information about the transmission, to the community in the time of the
the viral envelope and mediates ACE2
prevention, diagnosis, treatment, and COVID-19 pandemic, which puts a heavy
receptor binding and fusion with the
prognosis of the disease—have caused strain on critical health care resources.
host cell membrane (Xu, Chen, et al.
much anxiety and confusion in the Aside from life-threatening dental
2020). In more simple terms, SARS-CoV-2
community and affected the delivery emergencies, such as uncontrolled oral
can be described as a piece of genetic
of vital health care services, including tissue bleeding, head and neck fascial
material (RNA) wrapped in a coat of
dental treatments for those who need space infection, or facial trauma that
proteins that have spikes helping the
emergency care. may compromise the patient’s airway,
virus enter human cells and hijack them,
Reports from Wuhan, China, the patients with severe dental pain that
creating copies of itself and eventually
epicenter of the pandemic, indicated that cannot be controlled with over-the-
killing the host cells. It is of practical
SARS-CoV-2 infections did occur in a counter analgesics or patients with
importance to understand that the virus
small percentage of dental professionals, minor dental trauma may clog hospital
is only “alive” when inside the cells and
and face masks and gloves were credited emergency rooms that are already
that it is inert and cannot replicate itself
for effectively preventing further spread overburdened with patients with COVID-
when outside the body (Koonin and
of the infections among colleagues in 19 or other medical emergencies. The
Starokadomskyy 2016). While outside
close contact (Meng et al. 2020). These ADA (2020c) developed guidance on
the body, the protein structure of SARS-
authors state that dental staff should dental emergency and nonemergency
CoV-2 can be easily unwrapped or
be provided adequate PPEs when dental procedures, which includes a
disassembled by common disinfectants
providing dental emergency services, rather inclusive list of urgent dental care
within 5 min (Chin et al. 2020), which
including N95 masks, gloves, isolation treatments aiming at minimizing pain,
effectively render the virus harmless
gowns, protective eye goggles, face preventing infections, and reducing
since it will not be able to enter the cells
shields, and head and shoe covers discomforts. As dental professionals
and replicate without the protein coat
(Meng et al. 2020). Such measures of treating emergency patients in the
and spikes.
personal protection were effective, as time of uncertainty in the midst of the
no transmission from patients to dental COVID-19 pandemic, it is urgent that
Spread of SARS-CoV-2
staff was reported in China. However, we develop adequate understanding
from Human to Human
these PPEs are at present in critical short of the disease, especially its modes
supply in the United States, even for of transmission, and adopt prudent Though SARS-CoV-2 was generally
medical staff who provide direct care measures to protect our patients and considered a novel coronavirus
to patients with COVID-19 in hospital our staff to the best of our capacity. We transmitted from bat to human via an
emergency rooms and intensive care therefore provide the following overview intermediate host, such as a pangolin
units, and it is practically impossible for on SARS-CoV-2/COVID-19 and its impact (Lam et al. 2020; Li, Giorgi, et al. 2020) or
dental providers to acquire and utilize on oral health and dental care. We fully other animals (Li, Zai, et al. 2020; Luan
the full list of PPEs included in this understand that knowledge about the et al. 2020) in a wet market in Wuhan,
recommendation. The Pennsylvania state virus and the disease is rapidly evolving, China, a group of leading virologists
health department issued guidance that and we advise caution and reference to from the United States, United Kingdom,
initially required using PPEs similar to the most up-to-date evidence from peer- and Australia recently described that
this list and engineering control, such reviewed scientific publications. This this virus may have been circulating in
2
human populations for an extended is present in air samples in isolation transmission and fecal-oral transmission
period before it acquired the ability rooms and quarantine facilities (Santarpia are also likely, but concrete confirmatory
of causing human diseases through et al. 2020) and in and around hospitals evidence is lacking.
genomic adaptations during undetected and department store entrances (Liu
human-to-human transmissions et al. 2020), while other studies did not Transmission from Asymptomatic
(Andersen et al. 2020). These researchers find the viral RNA in air samples where or Presymptomatic Patients
analyzed available genomic sequence the patients with COVID-19 were treated with COVID-19
data of known coronavirus strains and (Cheng et al. 2020; Ong et al. 2020). In
determined that the receptor-binding a scientific brief published March 27, As mentioned earlier, SARS-CoV-2
domain sections of SARS-CoV-2 spike 2020, the World Health Organization spreads much faster than SARS-CoV
proteins could become so effective in (2020) stated that there is no sufficient and MERS-CoV, which can partially
binding to ACE2 only through a long evidence that SARS-CoV-2 is airborne be explained by a higher binding
process of natural selections. Clinical and that presence of the virus RNA in efficiency of SARS-CoV-2 spike protein
and epidemiologic studies suggest aerosols does not indicate that viable to human ACE2 receptors (Walls et al.
that human-to-human transmission is virus is transmissible. To date, infectious 2020). With increased understanding
most frequently realized through direct disease experts and policy makers in about the natural course of the disease,
or indirect contact with virus-laden countries such as China and South including its virologic and clinical
respiratory droplets discharged from Korea are convinced that SARS-CoV-2 is manifestations, we now know that
infected individuals while coughing transmissible by air, like other infectious COVID-19 is less severe overall, having
and sneezing (Chen 2020; Wu et al. respiratory diseases. As such, they have a lower fatality rate (2%) than SARS
2020). These droplets vary in size, from stringent face mask policies in place for (10%) or MERS (34%; Mahase 2020),
a few micrometers to a hundred, and citizens in public spaces and for health and that many patients with COVID-19
may travel in air for distances from a care workers in medical facilities. Yet, have mild or no symptoms, especially
few feet to several meters (Kunkel et al. the World Health Organization and at early stages of the disease. Virologic
2017; Liu et al. 2017). In theory, smaller policy makers in the United States and studies show that viral load is highest
droplets (5 to 10 µm) or droplet nuclei some European countries have taken a in the first week of COVID-19, when
(<5 µm) produced by coughing or more evidence-based approach while the symptoms are generally mild (To,
sneezing can be inhaled by a person in awaiting more concrete findings on Tsang, Leung, et al. 2020; Wölfel et al.
very close proximity and directly cause the effectiveness of universal masking, 2020). Some individuals infected with
transmission of the disease, as they may namely by insisting that only patients SARS-CoV-2 may never show symptoms
float in the air for an extended period, with confirmed or suspected COVID- themselves but become the source of
especially in a closed space with poor 19 wear face masks as well as the the disease transmission within close
ventilation (An et al. 2020). SARS-CoV-2 health care workers who treat them. As contacts (Hu et al. 2020). A recent
transmission may also occur indirectly, emerging evidence supports that SARS- epidemiologic study indicated that nearly
when a person comes into contact with CoV-2 is transmissible by air during 17% of the patients with COVID-19 are
fomites, such as the hand or clothes of normal talking and breathing (Asadi asymptomatic and that the transmission
an infected patient or the door handles, et al. 2020), more stringent face mask rate from asymptomatic patients (4.1%)
counter surfaces, dinning utensils, and policies in health care facilities and is statistically similar to that from
other objects touched, used, or soiled public spaces are likely to come. symptomatic patients (6.3%; Chen, Wang,
by respiratory droplets from an infected Though fecal-oral transmission has et al. 2020). These findings suggest that
patient. It is believed that SARS-CoV-2 been proposed as a possibility because transmission from asymptomatic patients
cannot penetrate the keratin layer of the viral RNA was detectable in stools to healthy individuals is likely a hallmark
intact human skin but may enter human and anal swabs (Gu et al. 2020; Zhang of COVID-19 that distinguishes it from
body through mucosal surfaces when et al. 2020), a recent study indicated that SARS and MERS and contributes to rapid
contaminated hands touch the mouth, no viable virus could be isolated from spread of the disease in the community.
noses, and eyes. stool samples (Wölfel et al. 2020). The Reports from Japan show that 18%
The possibility for airborne clinical and public health significance to 30% of the infected patients were
transmission of SARS-CoV-2 remains an of fecal-oral transmission is therefore asymptomatic (Mizumoto et al. 2020;
item of debate among infectious disease unclear and needs confirmatory studies. Nishiura et al. 2020). With escalating
experts. SARS-CoV-2 virus was found to In summary, SARS-CoV-2 is most rates of screening and testing, emerging
remain in floating aerosols for up to 3 h frequently transmitted from human data from European countries and
in a laboratory experimental study (van to human through direct contact with the United States point to even higher
Doremalen et al. 2020). Some studies respiratory droplets and through proportions of asymptomatic patients
found that the viral RNA of SARS-CoV-2 indirect contact with fomites. Airborne with COVID-19. News media reported
3
on April 2, 2020, that nationwide or friends was reported to be a risk (Liu et al. 2011). These findings suggest
data from Iceland showed that 50% factor of transmission from symptomatic that oral symptoms may occur due to
of those who tested positive said that and asymptomatic patients in China impediment of salivary flow in these
they were asymptomatic, and the CDC (Chen, Wang, et al. 2020). patients. A cross-sectional survey of 108
director stated that an estimated 25% of Loss of taste (ageusia) has been patients with confirmed COVID-19 in
coronavirus carriers in the United States reported in patients with COVID-19 Wuhan indeed found that 46% of the
have no symptoms (CNN 2020). (Chen, Zhao, et al. 2020; Gautier and patients reported dry mouth as one of
“Asymptomatic patients” reported in Ravussin 2020; Giacomelli et al. 2020). their symptoms (Chen, Zhao, et al. 2020).
scientific literature and mass media refer Approximately 50% of the patients However, the temporal sequence of oral
to individuals who test positive for SARS- reported loss of taste (Chen, Zhao, dryness and COVID-19 diagnosis is not
CoV-2 RNA but do not have any of the et al. 2020; Giacomelli et al. 2020). It clear and warrants further exploration.
hallmark symptoms of COVID-19 at is particularly interesting that loss of In summary, empirical, biological,
the time of the test. Some patients may taste occurred before hospitalization in and clinical evidence supports that oral
never show symptoms, but others may the early stage of the disease in 91% of mucosa is an initial site of entry for
develop symptoms later and are more these patients and that this symptom SARS-CoV-2 and that oral symptoms,
accurately defined as “presymptomatic” is persistent (Giacomelli et al. 2020). including loss of taste/smell and dry
(Kimball et al. 2020). Such distinction Using the COVID Symptom Tracker app mouth, might be early symptoms of
is important only in statistical terms, as developed in King’s College London, COVID-19 before fever, dry cough,
they are counted as different types of researchers found that loss of taste and fatigue, shortness breath, and other
patients. In reality, asymptomatic and smell is a key symptom for patients typical symptoms occur. The mechanism
presymptomatic patients are both major with COVID-19. The app tracked 1,702 and prognosis of oral symptoms of
sources of SARS-CoV-2 transmission, patients tested for COVID-19, with 579 COVID-19 are not clear. Dentists and
as they are covert and show no positive results and 1,123 negative, and dental researchers could play a more
warning signs to health care workers or showed that 59% of patients who were active role in the early diagnosis,
laypersons at the time of contact. COVID-19 positive reported loss of taste prevention, and treatment of COVID-19
and smell, as compared with only 18% of and its related research.
those who tested negative. Self-reported
Oral Health Implications of
loss of taste and smell is much stronger
SARS-CoV-2 and COVID-19 Provision of Dental Care during
in predicting a positive COVID-19
the COVID-19 Pandemic
Oral mucosa has been implicated as a diagnosis than self-reported fever (King’s
potential route of entry for SARS-CoV-2 College London 2020). Taste organs are In response to the rapid spread of
(Peng et al. 2020). The SARS-CoV-2 widely distributed in oral tongue, where COVID-19 across the country, the ADA
cellular entry receptor ACE2 was found 96% of the oral ACE2-positive cells reside issued its initial recommendation on
in various oral mucosal tissues, especially (Xu, Zhong, et al. 2020). Loss of taste as March 16, 2020, for dentists nationwide
in the tongue and floor of the mouth an early symptom of COVID-19 before to postpone elective dental procedures
(Xu, Zhong, et al. 2020). ACE2-positive fever and other symptoms occur lends and focus on emergency dental care
cells were also detected in buccal and support to the hypothesis that oral cavity, only for 3 wk. This recommendation
gingival epithelial cells. The presence particularly tongue mucosa, might be an was extended to April 30, 2020, when
of ACE2 receptors in oral tissues initial site of infection by SARS-CoV-2. the ADA announced the publication
suggests that it is biologically plausible SARS-CoV-2 has been consistently of detailed interim guidance on the
for the oral cavity to be the initial site detected in whole saliva at an early stage management of emergency and
of entry for SARS-CoV-2. Habitual and of the disease (To, Tsang, Chik-Yan Yip, urgent dental care (ADA 2020a) as a
unintentional hand-mouth contact is a et al. 2020) and in saliva collected from complement to the list of emergency
common phenomenon in social and the duct opening of the salivary glands and urgent dental procedures published
private settings, which is consistent at a late stage (Chen, Zhao, et al. 2020). earlier (ADA 2020c).
with the mode of transmission of SARS- It has been shown that ACE2-positive Howitt Dental Urgent Care (HDUC)
CoV-2 described earlier. In addition to salivary gland epithelial cells are early at the University of Rochester Eastman
inadequate hand hygiene and possible targets of SARS-CoV in nonhuman Institute for Oral Health (UR-EIOH) is a
direct transmission through hand- primates and that salivary gland 7-operatory clinic dedicated to treating
mouth contact, oral ingestion of food functions may be affected at an early patients who have dental emergencies
contaminated by infected patients might stage of the disease (Liu et al. 2011). At and are in need of urgent care. Since
be a possibility in regions where dinning 48 h after intranasal viral challenges, viral March 16, 2020, the UR-EIOH started
from shared dishes with friends and loads of SARS-CoV were significantly to postpone and cancel scheduled
family is customary. Dinning with family higher in saliva than in blood samples visits at general dentistry and specialty
4
clinics and adopted policies to provide but benefit our patient long-term. During measures during dental treatments are
only urgent care following the ADA the first 2 wk after the ADA published appropriate for the safety of the patients
guidance. Some patients who are in its urgent care recommendation, and staff.
need of urgent dental care are therefore approximately 30% of patients at HDUC According to the ADA and CDC
diverted from HDUC to general dentistry received tooth extraction and incision guidance, patients with active COVID-
and specialty care clinics to reduce and drainage, and 70% received 19 infection should not be seen in
waiting room crowding and patient palliative treatments and prescription dental settings. Patients who present
and staff densities in the clinic. Patient of antibiotics. This is a significant for emergency and urgent dental
visits to the UR-EIOH were reduced by reversal from the time before COVID- care should be evaluated for signs
approximately 85%, to a total of about 19, when 70% of our patients received and symptoms of COVID-19 and for
80 urgent care visits per day. Most of definitive treatments and 30% received determination of whether they can be
the patients (96%) seen in the urgent palliative treatments and prescriptions seen in a dental office. For patients who
care clinic had moderate to severe pain (unpublished data). With improved have fever and signs and symptoms of
associated with pulpal or periapical availability of PPEs and publication acute respiratory infection or have no
inflammation, dentoalveolar infections, of the ADA guidance on minimizing fever but signs and symptoms of acute
and trauma. These types of pain could risk of COVID-19 transmission, we respiratory infection, the ADA guidance
not be managed with over-the-counter should be able to improve our ability to states that they need to go to the hospital
analgesics, and many patients require provide the best care possible for our emergency department for treatment
antibiotics, prescription analgesics, patients. and the doctor needs to page infection
and/or definitive treatment, such as control. If patients have neither fever
tooth extraction, incision and drainage, nor signs and symptoms or have only
Protection of Patients and Staff
or root canal therapy, to eliminate fever, they can be seen at the dental
in Dental Urgent Care Settings
the disease and prevent spread of setting as the fever might be caused by
the infection. Had the dental urgent In its interim guidance on minimizing dental infections. Patients not suitable
care service not been available, these risk of COVID-19 transmission in dental to be seen in the dental setting include
patients would have likely visited the offices, the ADA (2020b) provided 3 those who had exposure to an individual
hospital emergency department for algorithms to assist dentists in making with suspected or confirmed COVID-19
pain management, adding strains to decisions on patient triage, evaluating infection, traveled to countries currently
the already overburdened emergency for COVID-19, and minimizing risks for under a travel ban, or were exposed
rooms from COVID-19 and other medical patients and staff during emergency or to confirmed SARS-CoV-2 biologic
emergencies. Dental urgent care service urgent dental treatments. The goal is material directly or indirectly, because
is especially important at a time when to minimize risks of transmission while risk of transmission increases with these
most dental clinics are closed following allowing the provision of needed urgent exposures (ADA 2020a). This guidance
the ADA guidance. We anticipate that care. Though the risk to patients and will be able to minimize the risk of
some of the clinics will not be able to staff should be small if the guidance exposures in dental offices provided that
provide urgent care services to their is followed, uncertainties exist given the number of asymptomatic patients
patients due to staffing issues or lack of the high number of asymptomatic with COVID-19 is negligible and that
adequate PPEs. patients and the possibility of airborne the number of confirmed, suspected,
With the extension of the urgent transmission. Screening for fever and or potentially exposed patients is
care–only guidance period, we expect contact history may not be productive low in the surrounding communities.
that more and more patients will because many patients who are infected Otherwise, this screening strategy will
need definitive treatments, as dental with the virus can be asymptomatic or not work because it cannot identify
pain or infection cannot be managed undiagnosed (Bwire and Paulo 2020; asymptomatic patients or those exposed
with medications long-term. Though Hu et al. 2020; Quilty et al. 2020) and to asymptomatic patients and it adds
we have, to a great extent, avoided can equally transmit the disease as the burden to emergency departments
aerosol-generating procedures—such as symptomatic cases (Chen, Wang, et al. that are struggling to save lives of
those needing the use of a high-speed 2020). The prevalence of COVID-19 in the seriously ill. An ideal solution is
handpiece due to the lack of adequate the community remains to be low in to provide rapid COVID-19 testing
PPEs at the earlier stage (hoping that many areas, but it may change rapidly in the dental urgent care clinic with
the pandemic would be over soon and with time. Therefore, we may soon face the available point-of-care test kit
we could resume routine care in a few the question if we should assume that that produces results in minutes. This
weeks)—we now know that we need every patient who comes to a dental can be a great opportunity for dental
to adjust our plan and be prepared to office is a patient with COVID-19 and, professionals to contribute to the fight
perform the procedures that carry risks if so, what preventive and protective against COVID-19 by expanding the
5
testing capacity and identifying patients (bitter) solutions (CDC and National disinfectants. However, the virus may
early. This may be difficult to realize at Institute for Occupational Safety and retain viability for an extended period,
this time due to the shortage of testing Health 2020). As there are many models from several hours to several days, and
equipment but should be considered if and different sizes of N95 respirators, on different surfaces, such as metal,
the equipment becomes available. a successful fit test only qualifies you glass, plastic, wood, or paper (Kampf
According to the interim guidance to use the specific brand and size of et al. 2020; van Doremalen et al. 2020),
of the ADA (2020a, 2020b), if patients respirator that you wore during that but it can be effectively inactivated
have no known exposure to COVID-19, test (CDC and National Institute for in 1 to 5 min by many disinfectants,
recently tested negative, or recovered Occupational Safety and Health 2020). including 70% ethanol, 0.1% sodium
from COVID-19 infection, they can be Therefore, it should be apparent that hypochlorite, 1% povidone-iodine, and
treated in the dental office if they have “N95 respirators fitted to your face” 0.5% hydrogen peroxide (Chin et al.
a dental emergency or urgent condition mean that you and your staff have been 2020; Kampf et al. 2020). Povidone-
that cannot be postponed without fit tested for an N95 respirator that you iodine mouthwash has been shown to
causing significant pain or distress. use in your clinic or facility. However, have strong viricidal activities against
Protection and prevention measures this requirement probably will preclude SARS-CoV and MERS-CoV after 15 s of
depend on if the treatment procedures most, if not all, dentists in private exposure (Eggers et al. 2018). The CDC
will produce aerosols. For non–aerosol- practices from participating in providing (2020) has published an interim infection
generating procedures, surgical face urgent care services during the COVID- prevention and control guidance for
masks and basic clinical PPE (including 19 pandemic, as an annual N95 fit test dental settings during the COVID-
eye protection) are adequate, and is not part of the dental practice routine. 19 response and lists >300 products
approved disinfection procedures should At the UR-EIOH, residents and faculty approved for SARS-CoV-2 disinfection.
be performed immediately after every members who have clinical privileges For aerosol-generating procedures,
procedure. For aerosol-generating at the medical center are fitted for N95 patients should be instructed to use
procedures, fitted N95 respirators, full- respirators annually, but those who work 1% povidone-iodine or 1.5% hydrogen
face shields, and basic clinical PPE in the dental clinic alone have not been peroxide mouth rinses for 1 min before
(including eye protection) are required, fit tested. Though we are working with the procedure, and a rubber dam should
and approved disinfection procedures the medical center to have all residents be used to reduce saliva contamination
should be performed immediately after and faculty members fitted for the N95 and aerosol generation during the
every procedure. If fitted N95 respirators respirators, it takes time to complete procedure. After the procedure, all
and full-face shields are not available, the test. In the mean time, we have exposed surfaces of the operatory,
there might be moderate to high risks of to minimize the number of aerosol- including chairs, desks, cabinets, and
exposure, and the dental team may need generating procedures to protect the door handles, should be cleaned with
to be put into a 14-d quarantine after faculty and resident providers and staff. 0.1% sodium hypochlorite. Though these
the aerosol-generating procedure due to N95 respirators, gloves, full-face steps are all helpful in reducing the
the existence of asymptomatic patients. shields, eye protection goggles with risks of nosocomial infections in dental
We believe that these guidelines are side shields, isolation gowns, and head offices, adequate hand washing with
judicious and useful, but the requirement covers were recommended for aerosol- soap between patients and after touching
“You and your staff have N95 respirators generating procedures by the state any nonsterile objects remains the most
fitted to your face” may deserve further health commission in China and proven effective way to prevent the transmission
explanation. Does this mean that dentists effective, as no staff or patients were of COVID-19.
and staff need to be formally fit tested infected with the disease in dental clinics In summary, protection of patients and
for using the N95 respirators? Or is it throughout the country (Meng et al. staff during COVID-19 is challenging
acceptable to just use an N95 respirator 2020; Peng et al. 2020; Yang et al. 2020; due to the existence of patients who
that you feel fits? In addition to improved Zhang and Jiang 2020). Face shields and are infectious yet asymptomatic. Dental
filtration efficiency, the main advantage eye protection goggles are considered clinics and dental professionals are
of an N95 respirator over a surgical mask essential in dental procedures that not well prepared to perform aerosol-
is that it can achieve a tight seal that produce spatter or aerosol because generating procedures at the time of the
prevents air leakage around the edges. ocular exposure is likely a route of infectious respiratory disease pandemic,
Appropriate use of N95 respirators transmission for the SARS-CoV-2 virus as they are not routinely fitted for the N95
requires an annual fit test via a standard (Li, Lam, et al. 2020; Lu et al. 2020). respirators required for these procedures.
protocol that includes a pass/fail result As described earlier, the SARS-CoV-2 It is fortunate that SARS-CoV-2 is sensitive
that relies on the individual’s sensory virus does not replicate or “grow” outside to many common disinfectants and that
(taste or smell) detection of a test agent, the body, and its protein structure the risks for dental providers and patients
such as Saccharin (sweetener) or Bitrex can be disrupted by many common are small if prudent measures are taken
6
following the ADA and CDC guidance, ies against SARS-CoV-2 will help us to References
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9
JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al
Original Paper
Dentists’ Awareness, Perception, and Attitude Regarding

COVID-19 and Infection Control: Cross-Sectional Study Among
Jordanian Dentists
Yousef Khader1, SCD; Mohannad Al Nsour2, PhD; Ola Barakat Al-Batayneh1, FRACDS; Rami Saadeh1, PhD; Haitham
Bashier2, PhD; Mahmoud Alfaqih1, PhD; Sayer Al-Azzam1, PhD; Bara’ Abdallah AlShurman1, MSc
1
Jordan University of Science and Technology, Irbid, Jordan
2
Global Health Development/Eastern Mediterranean Public Health Network, Amman, Jordan
Corresponding Author:
Yousef Khader, SCD
Jordan University of Science and Technology
Alramtha-Amman Street
Irbid, 22110
Jordan
Phone: 962 796802040
Email: [email protected]
Abstract
Background: Despite the availability of prevention guidelines and recommendations on infection control, many dental practices
lack the minimum requirements for infection control.
Objective: This study aimed to assess the level of awareness, perception, and attitude regarding the coronavirus disease
(COVID-19) and infection control among Jordanian dentists.
Methods: The study population consisted of dentists who worked in private clinics, hospitals, and health centers in Jordan. An
online questionnaire was sent to a sample of Jordanian dentists in March 2020. The questionnaire was comprised of a series of
questions about dentists’ demographic characteristics; their awareness of the incubation period, the symptoms of the disease,
mode of transmission of COVID-19 and infection control measures for preventing COVID-19; and their attitude toward treating
patients with COVID-19.
Results: This study included a total of 368 dentists aged 22-73 years (mean 32.9 years, SD 10.6 years). A total of 112 (30.4%)
dentists had completed a master or residency program in dentistry, 195 (53.0%) had received training in infection control in
dentistry, and 28 (7.6%) had attended training or lectures regarding COVID-19. A total of 133 (36.1%) dentists reported that the
incubation period is 1-14 days. The majority of dentists were aware of COVID-19 symptoms and ways of identifying patients at
risk of having COVID-19, were able to correctly report known modes of transmission, and were aware of measures for preventing
COVID-19 transmission in dental clinics. A total of 275 (74.7%) believed that it was necessary to ask patients to sit far from each
other, wear masks while in the waiting room, and wash hands before getting in the dental chair to decrease disease transmission.
Conclusions: Jordanian dentists were aware of COVID-19 symptoms, mode of transmission, and infection controls and measures
in dental clinics. However, dentists had limited comprehension of the extra precautionary measures that protect the dental staff
and other patients from COVID-19. National and international guidelines should be sent by the regional and national dental
associations to all registered dentists during a crisis, including the COVID-19 pandemic, to make sure that dentists are well
informed and aware of best practices and recommended disease management approaches.
(JMIR Public Health Surveill 2020;6(2):e18798) doi: 10.2196/18798
KEYWORDS
COVID-19; infection; dentist; infection control
http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 1

(page number not for citation purposes)
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Objectives
Introduction
Despite the availability of prevention guidelines and
Background recommendations on disease control, many dental practices lack
The coronavirus disease (COVID-19) is a newly discovered the minimum requirements of infection control, which resulted
viral infection that started in Wuhan, China and caused the from the low interest in taking the mandatory precautions. This
outbreak of pneumonia in the rest of the world. It seems that lack of interest in making an extra, but essential, effort could
the rapidly spreading virus is more contagious than severe acute be attributed to the high volume of patients treated in clinics
respiratory syndrome coronavirus and Middle East respiratory that charge low or reduced dental fees [11,12]. This situation
syndrome coronavirus [1]. A suggested route of is true for many settings, including some dental clinics in Jordan,
human-to-human transmission is through airborne droplets, which, like many other countries, has a wide range of dental
touching or coming into contact with an infected person or a facilities from clinics that properly apply infection control
contaminated surface. Moreover, other routes such as blood or measures to clinics that poorly apply prevention measures. It is
saliva have not been explored but are possible because of the important to implement sound prevention measures in dental
documented transmission of blood-borne infectious diseases clinics and to increase the level of awareness among dentists to
such as HIV/AIDS, hepatitis C virus, and hepatitis B virus improve their prevention. Hence, this study aimed to assess the
through blood or saliva. These routes of transmission increase level of awareness, perception, and attitude regarding COVID-19
the concern about a similar route of transmission for COVID-19 and infection control among Jordanian dentists.
in the dental setting [2].
Methods
COVID-19 and Dental Treatment
A large number of medical staff were reported to have acquired Study Population
the disease while working with infected individuals [3]. The Our study population consisted of dentists who work in Jordan,
dental clinic is not an exception for a similar possibility of regardless of their place of work, in either private clinics,
transmitting and acquiring the infection between staff or hospitals, or health centers. This survey was conducted in March
individuals; moreover, the dental clinic could be a riskier 2020. An online questionnaire using Google Forms was used
environment for spreading the virus because of the close contact to collect the data. The sample of dentists was selected through
with patients and the nature of the dental treatment [4]. Although Facebook groups for dentists. These groups were created by
patients diagnosed with COVID-19 are not supposed to receive members of the Jordan Dental Association, and only dentists
dental treatments, dental emergencies can occur, and close who work in Jordan can be involved in these groups by
contact would be unavoidable. Furthermore, both the relatively confirming their registration with the Jordanian dental
prolonged incubation period of the disease (the median association and their places of work. Although there were
incubation period was estimated to be 5.1 days, 95% CI 4.5-5.8 numerous groups, only five groups were randomly chosen:
[5] or up to 14 days for some cases [6,7] before any symptoms Jordanian dentists, dentists without borders, Jordanian dental
could even be detected) and the postinfection period make it club, Jordanian society of pediatric dentistry, and Jordanian
challenging for medical staff to recognize the existence of dentists’ forum. Within the five selected groups, 700 dentists
COVID-19 infections, which could increase the transmission were randomly selected to participate in the study by their
of the disease during these lay periods. Therefore, patients Facebook profiles. However, each participant who was randomly
infected with COVID-19, without showing symptoms, are of a selected was contacted individually to make sure that they were
great threat to dentists and other members of the dental team. a dentist and worked in Jordan. The questionnaires were
Dentists, thereby, should entertain a high level of awareness anonymous to maintain the privacy and confidentiality of all
and integrity to deal with the disease and be able to control and information collected in the study. Ethical approval was obtained
manage its spread. from the Institutional Review Board at Jordan University of
Science and Technology.
There are practical guidelines recommended for dentists and
dental staff by the Centers for Disease Control and Prevention Study Instrument
(CDC), the American Dental Association (ADA), and the World The questions on the survey were developed after reviewing
Health Organization to control the spread of COVID-19 [8-10]. pertinent literature and the international guidelines [1,8-10].
Like with other contagious infections, these recommendations The questionnaire was designed in English and comprised of a
include personal protective equipment, hand washing, detailed series of questions pertaining to sociodemographic
patient evaluation, rubber dam isolation, antiretraction characteristics, the knowledge of dentists, and their attitudes
handpiece, mouth rinsing before dental procedures, and and perceptions toward COVID-19 and infection control in
disinfection of the clinic. In addition, some guidelines and dental clinics. The survey was a structured multiple-choice
reports have provided useful information about the signs and questionnaire divided into sections: dentists’ demographic and
symptoms of the disease, ways of transmission, and referral profession-related characteristics; dentists’ awareness of
mechanisms to increase dentists’ knowledge and prevention incubation period, the symptoms of the disease, the mode of
practices, so they could contribute, at a population level, in transmission of COVID-19, and infection control measures for
disease control and prevention [1,8]. preventing COVID-19; and dentists’ attitude toward treating
patients with COVID-19.

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Data Analysis participated out of 700 invited dentists). Their age ranged from
Data were analyzed using SPSS (IBM Corp). Descriptive 22-73 years with a mean of 32.9 (SD 10.6) years. Years of dental
statistical analysis was used to describe items included in the practice ranged from 1-30 years with a mean of 9.4 (SD 8.9)
survey. Means and standard deviations were used to describe years. The participants’ characteristics are shown in Table 1. A
the continuous variables, and percentages were used to describe total of 112 (30.4%) had completed a master or residency
the categorical data. program in dentistry, 195 (53.0%) had received training in
infection control in dentistry, and 28 (7.6%) had attended
Results training or received lectures regarding COVID-19.
Participants’ Characteristics
This study included a total of 368 (245 females and 123 males)
dentists, forming a response rate of about 52.6% (386
Table 1. The characteristics of the 368 dentists enrolled in the study.

Variable Dentists, n (%)
Gender
Female 245 (66.6)
Male 123 (33.4)
Age (years)
<30 199 (54.1)
≥30 169 (45.9)
Years of practice
<5 185 (50.3)
5-10 59 (16.0)
>10 124 (33.7)
Region
Middle 190 (51.6)
North 148 (40.2)
South 30 (8.2)
Health sector
University clinics 112 (30.4)
Military sector 28 (7.6)
Private sector 144 (39.1)
Public sector 84 (22.8)
reported that patients with COVID-19 infection may present

Awareness About the Incubation Period, Symptoms, with no symptoms. When they were asked about aspects that
and Mode of Transmission of the COVID-19 Infection should be considered to identify patients at risk of having
When asked about the incubation period, over one-third of COVID-19, 316 (85.9%) mentioned the presence of symptoms
dentists correctly reported 1-14 days. The percentage of dentists of a respiratory infection, 347 (94.3%) mentioned history of
who reported the different symptoms of the COVID-19 infection travel to areas experiencing transmission of COVID-19, and
are shown in Table 2. The majority reported fever and cough 345 (93.8%) mentioned history of contact with possible infected
as symptoms. Diarrhea, vomiting, and runny nose were reported patients. In addition, most dentists correctly reported known
by almost one-third of dentists. Joint and muscle pain was modes of transmission (Table 2).
reported by only a few dentists. Over one-third of the dentists

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Table 2. Dentists’ awareness about incubation period, symptoms, and mode of transmission of the coronavirus disease infection (N=368).
Variable Dentists, n (%)
Incubation period (days)
1-14 133 (36.1)
2-7 12 (3.3)
7-14 162 (44.0)
7-21 days 61 (16.6)
Symptoms of the COVID-19a infection

Fever 363 (98.6)
Cough 335 (91.0)
Shortness of breath 316 (85.9)
Diarrhea 147 (39.9)
Vomiting 119 (32.3)
Runny nose 133 (36.1)
Sore throat 105 (28.5)
Red eyes 28 (7.6)
Skin rash 21 (5.7)
Joint or muscle pain 7 (1.9)
May present with no symptoms 127 (34.5)
Mode of transmission
Coughing and sneezing 333 (90.5)
Hand shaking 315 (85.6)
Touching surfaces such as doorknobs and tables 343 (93.2)
a
COVID-19: coronavirus disease.
equipment can help prevent transmission from patients with

Awareness of Measures for Preventing COVID-19 known or suspected COVID-19. The percentages of dentists
Transmission in Dental Clinics who reported other specific measures are shown in Table 3.
The majority of the 368 dentists reported that cleaning hands Almost all dentists (n=359, 97.6%) reported that it is important
frequently by using alcohol-based hand rub or soap and water, to change both masks and gloves regularly to decrease the
routinely cleaning and disinfecting surfaces in contact with possibility of transmitting infections to patients and to
known or suspected patients, and wearing personal protective themselves.
Table 3. Dentists’ awareness of measures for the prevention of coronavirus disease transmission in dental clinics (N=368).
Measures for prevention Dentists, n (%)
Frequently clean hands by using alcohol-based hand rub or soap and water 354 (96.2)
Routinely clean and disinfect surfaces in contact with known or suspected patients 347 (94.3)
Personal protective equipment such as dental goggles, masks, and gloves 342 (92.9)
Put facemask on known or suspected patients 325 (88.3)
Avoid moving and transporting patients out of their area unless necessary 310 (84.2)
All health staff members wear protective clothing 304 (82.6)
Place known or suspected patients in adequately ventilated single rooms 284 (77.2)
one-third (n=135, 36.7%) of dentists believed that COVID-19

Perception of COVID-19 is not a serious public health issue. The majority (n=360, 97.8%)
A total of 65 (17.7%) of the 368 dentists perceived COVID-19 reported that it is important to educate people about COVID-19
as very dangerous, 264 (71.7%) perceived it as moderately to prevent the spread of the disease.
dangerous, and 35 (9.5%) perceived it as not dangerous. Almost

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Attitude Toward Treatment of Patients With of the spread of the disease [1]. Dentists response to prevention
COVID-19 measures were better for personal protective equipment and
disinfection and sanitation procedures than for measures applied
More than half (n=203, 55.2%) of the 368 dentists reported that
to dental staff or patients, such as special clothing or ventilation.
COVID-19 symptoms often resolve with time and do not require
The latest precautionary actions could possibly be viewed by
any special treatment. Regarding dentists’ precautionary actions
dentists as extra protective measures that are not necessary when
in the dental clinic, a total of 275 (74.7%) believed that it was
combined with their understanding that infections occur mainly
necessary to ask patients to sit far from each other, wear masks
through direct contact between mucous membranes and
while in the waiting room, and wash hands before getting in the
contaminated hands [9].
dental chair to decrease disease transmission, while 80 (21.7%)
believed that this was not necessary and could cause panic. There has been no evidence-based specific treatment for
However, a total of 304 (82.6%) dentists reported that they COVID-19, and management of COVID-19 has been largely
prefer to avoid working with a patient with a suspected case of supportive [8]. The current approach to COVID-19 is to control
COVID-19. the source of infection; use infection prevention and control
measures to lower the risk of transmission; and provide early
Dentists reported different attitudes toward a patient sneezing
diagnosis, isolation, and supportive care for affected patients
or coughing in their clinics: 161 (43.8%) mentioned that they
[17]. This fact was reflected by the response of participants to
would refer the patient to the hospital without treating them, 17
treatment; almost half of dentists thought that the disease
(4.6%) mentioned that they would refuse treating the patient
self-resolves over time with no need for special treatment. This
and ask them to leave the clinic, 182 (49.5%) mentioned that
perception about the disease self-resolution resulted in most
they would treat the patient and ask them to go to the hospital.
participants perceiving COVID-19 as moderately dangerous
Moreover, a total of 119 (32.3%) dentists reported that they (n=264/368, 71.7%), and almost one-third believed that
would allow any of their dental staff to work with patients if COVID-19 was not a serious public health issue. Although their
they had flu-like symptoms. Only 214 (58.2%) reported that perception about the disease self-resolution could have been
they know whom to contact in a situation where there has been explained by their perception about its threat; there were no
an unprotected exposure to a patient with known or suspected “local” cases in Jordan at the time of data collection. In addition,
COVID-19, and 279 (75.8%) reported that they know what to dentists’ perception about the seriousness of the disease could
do if they have signs or symptoms suspected of COVID-19 be because some (n=80, 21.7%) did not see a need to ask
infection. patients to sit far from each other, wear masks while in the
waiting room, or wash hands before getting in the dental chair
For the dentists’ role in spreading information and increasing
to decrease disease transmission. However, the vast majority
awareness, a total of 249 (67.7%) dentists reported that the
(n=304, 82.6%) would prefer to avoid working with a patient
dentist role in teaching others about COVID-19 is very
with suspected COVID-19 because of the possibility of disease
significant, and 94 (25.5%) reported that it is moderately
transmission during incubation periods, during which no
significant.
symptoms may appear [1].
Discussion The attitude of dentists regarding what to do in case a patient
was sneezing or coughing in their clinics varied; 43.8% (n=161)
This survey provides an insight on the level of awareness, would refer the patient to the hospital without treating them,
perception, and attitude of Jordanian dentists on infection control 4.6% (n=17) would refuse treatment, and 49.5% (n=182) would
with a special emphasis on COVID-19 at the time of the treat the patient and then refer them to the hospital. Some
outbreak in 2020. This study included a sample of Jordanian dentists (n=119, 32.3%) would allow their dental staff to work
dentists. Females were predominant in this sample, which might with patients if they had flu-like symptoms. During the outbreak
be explained because the number of female dentists in Jordan of COVID-19, dentists should evaluate risk of transmission
is higher than the number of male dentists based on the latest through measurements of the temperature of every staff and
Jordan Dental Association statistics [13]. patient as a routine procedure. Patients should be asked about
The estimated incubation period of COVID-19 is up to 14 days their health status and any history of recent contact or travel
[6,7]. Dentists in this study varied in their knowledge about the [8]; patients and their accompanying persons should be provided
incubation period of the disease, but it is essential to know the with medical masks upon entry to the clinic. Patients with a
right incubation period because of its role in determining the fever should be registered and referred to designated hospitals.
safe period to treat suspected patients [14]. However, it’s If a patient has been to any epidemic regions within the past 14
imperative for dentists to carry on with preventive measures for days, quarantining for at least 14 days is recommended. In areas
all their patients, all the time. Knowledge about respiratory where COVID-19 spreads, nonurgent dental treatment should
disease contagion was noticed in other studies to be lower be postponed [18]. It is still not known when treatments can be
among dentists [15] than among other health care providers done.
[16], despite the proximity of patient to provider present in Over half of the dentists (n=214, 58.2%) knew whom to contact
dental care [4]. Nonetheless, Jordanian dentists in this sample in a situation of an unprotected exposure to a known or
could identify the main symptoms of COVID-19, which helps suspected COVID-19 patient, and 75.8% (n=279) reported that
dentists to recognize the threat and take the necessary actions they knew what to do if they had signs or symptoms of a
and is considered essential in the management [14] and control suspected COVID-19 infection. By now, there has been no
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consensus on provision of dental treatment during the Moreover, this pandemic has caused many to be busy with
COVID-19 epidemic. Based on relevant guidelines and research, watching the news and taking care of personal affairs. This
dentists should take strict personal protection measures and means that those who were active on social media during the
avoid or minimize operations that may produce droplets or short period of data collection were the only ones that had the
aerosols [18]. A 4-handed technique is useful for infection chance to participate in the study. This could result in selection
control, and use of saliva ejectors with low or high volume bias and sampling error, which prevents the ability to generalize
reduces droplet and aerosol production [1,9]. The consensus of our results.
the vast majority (n=360, 97.8%) of dentists about the
In conclusion, Jordanian dentists were aware of COVID-19
importance of educating others about COVID-19 to prevent the
symptoms, mode of transmission, infection control, and
spread of the disease was high, but they should follow the
measures in dental clinics. However, dentists had limited
guidelines from the CDC and ADA and recommendations for
comprehension of the extra precautionary measures that protect
infection prevention and control based on the local epidemic
the dental staff and other patients from COVID-19. Guidelines
situation.
released by reputable institutions should be sent by the regional
Despite the findings introduced here, it is important to stress and national dental associations to all registered dentists during
that this survey had limitations, including the relatively low a crisis, including this COVID -19 pandemic, to make sure that
response rate, which resulted in a smaller than expected sample dentists are well informed and aware of the best practices and
size. This could have been caused by the short period of data recommended disease management approaches.
collection. However, this is considered a moderate sample size.
Conflicts of Interest
None declared.
References
1. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine.
J Dent Res 2020 Mar 12:22034520914246. [doi: 10.1177/0022034520914246] [Medline: 32162995]
2. Ibrahim NK, Alwafi HA, Sangoof SO, Turkistani AK, Alattas BM. Cross-infection and infection control in dentistry:
knowledge, attitude and practice of patients attended dental clinics in King Abdulaziz University Hospital, Jeddah, Saudi
Arabia. J Infect Public Health 2017;10(4):438-445 [FREE Full text] [doi: 10.1016/j.jiph.2016.06.002] [Medline: 27422140]
3. Secon H. Nearly 3,400 Chinese healthcare workers have gotten the coronavirus, and 13 have died. Business Insider 2020
Mar 04 [FREE Full text]
4. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment.
PLoS One 2017;12(5):e0178007 [FREE Full text] [doi: 10.1371/journal.pone.0178007] [Medline: 28531183]
5. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of coronavirus disease 2019
(COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med 2020 Mar 10. [doi:
10.7326/m20-0504]
6. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among
travellers from Wuhan, China, 20-28 January 2020. Euro Surveill 2020 Feb;25(5) [FREE Full text] [doi:
10.2807/1560-7917.ES.2020.25.5.2000062] [Medline: 32046819]
7. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel
coronavirus-infected pneumonia. N Engl J Med 2020 Mar 26;382(13):1199-1207. [doi: 10.1056/NEJMoa2001316] [Medline:
31995857]
8. World Health Organization. 2020 Mar 13. Clinical management of severe acute respiratory infection when COVID-19 is
suspected URL: https://tinyurl.com/s23yv4p
9. Centers for Disease Control and Prevention. 2020 Mar 27. CDC recommendation: postpone non-urgent dental procedures,
surgeries, and visits URL: https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html
10. The American Dental Association. 2020 Mar 27. Coronavirus frequently asked questions URL: https://success.ada.org/en/
practice-management/patients/coronavirus-frequently-asked-questions
11. Matsuda JK, Grinbaum RS, Davidowicz H. The assessment of infection control in dental practices in the municipality of
São Paulo. Braz J Infect Dis 2011 Feb;15(1):45-51. [doi: 10.1590/s1413-86702011000100009]
12. Mehtar S, Shisana O, Mosala T, Dunbar R. Infection control practices in public dental care services: findings from one
South African Province. J Hosp Infect 2007 May;66(1):65-70. [doi: 10.1016/j.jhin.2007.02.008] [Medline: 17433494]
13. Jordanian Dental Association. URL: https://www.jda.org.jo/index.php/component/k2/item/544.html
14. Gaffar BO, El Tantawi M, Al-Ansari AA, AlAgl AS, Farooqi FA, Almas KM. Knowledge and practices of dentists regarding
MERS-CoV. A cross-sectional survey in Saudi Arabia. Saudi Med J 2019 Jul;40(7):714-720 [FREE Full text] [doi:
10.15537/smj.2019.7.24304] [Medline: 31287133]
15. Baseer M, Ansari S, AlShamrani S, Alakras A, Mahrous R, Alenazi A. Awareness of droplet and airborne isolation
precautions among dental health professionals during the outbreak of corona virus infection in Riyadh city, Saudi Arabia.
J Clin Exp Dent 2016 Oct;8(4):e379-e387 [FREE Full text] [doi: 10.4317/jced.52811] [Medline: 27703605]
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16. Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern
among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infect Dis 2017 Jan 03;17(1):4
[FREE Full text] [doi: 10.1186/s12879-016-2096-8] [Medline: 28049440]
17. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel
coronavirus-infected pneumonia in Wuhan, China. JAMA 2020 Feb 07. [doi: 10.1001/jama.2020.1585] [Medline: 32031570]
18. The American Dental Association. 2020 Mar 16. ADA recommending dentists postpone elective procedures URL: https:/
/tinyurl.com/wpp647r
Abbreviations
ADA: American Dental Association
CDC: Centers for Disease Control and Prevention
COVID-19: coronavirus disease
Edited by T Sanchez; submitted 19.03.20; peer-reviewed by O Beni Yonis, M Alyahya; comments to author 31.03.20; revised version
received 31.03.20; accepted 02.04.20; published 09.04.20
Please cite as:
Khader Y, Al Nsour M, Al-Batayneh OB, Saadeh R, Bashier H, Alfaqih M, Al-Azzam S, AlShurman BA
Dentists’ Awareness, Perception, and Attitude Regarding COVID-19 and Infection Control: Cross-Sectional Study Among Jordanian
Dentists
JMIR Public Health Surveill 2020;6(2):e18798
URL: http://publichealth.jmir.org/2020/2/e18798/
doi: 10.2196/18798
PMID:
©Yousef Saleh Khader, Mohannad Al Nsour, Ola Barakat Al-Batayneh, Rami Saadeh, Haitham Bashier, Mahmoud Alfaqih,
Sayer Al-Azzam, Bara’ Abdallah AlShurman. Originally published in JMIR Public Health and Surveillance
(http://publichealth.jmir.org), 09.04.2020. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete
bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license
information must be included.

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Editorial
Rev Estomatol Herediana. 2020 Ene-Mar;30(1):5-6

DOI: https://doi.org/
Esta obra está bajo
una Licencia Creative Commons
Atribución 4.0 Internacional
NUEVO CORONAVIRUS 2019 (COVID-19):

Consejos para el odontólogo
New Coronavirus 2019 (COVID-19): Tips for the dentist
Se ha generado preocupación mundial por la propagación de un nuevo coronavirus, que apareció en la ciudad
china de Wuhan. La Organización Mundial de la Salud (OMS), el día 11 de febrero del 2020, anunció que
el nombre oficial de esta enfermedad que está causando el brote del nuevo coronavirus 2019 es COVID-19.
Los Centros para el Control y la Prevención de Enfermedades (CDC) están vigilando de cerca este brote de
enfermedad respiratoria causada por este nuevo coronavirus. Esta es una situación emergente que está cambiando
rápidamente y los CDC continuarán brindándonos información actualizada a medida que esté disponible, para
proteger la salud de las personas, y actúa rápidamente cada vez que hay un problema potencial para la salud
pública (1). En total más de 30 países están afectados por el coronavirus COVID-19, por lo que la OMS advierte
sobre el riesgo de una pandemia, por lo que ahora es momento de prepararse.
Es probable que este virus haya surgido originalmente de una fuente animal, pero se ha confirmado que puede
transmitirse de persona a persona a través de ñas gotitas de flugge (hasta 1 metro de distancia) (2). En relación
al diagnóstico, la secuencia genética del COVID-19 se puso a disposición de la OMS el 12 de enero de 2020 y
esto ha facilitado a los laboratorios de diferentes países a producir pruebas de diagnóstico de PCR específicas
para detectar la nueva infección. El COVID-19 es un β CoV del grupo 2B con al menos un 70% de similitud en
la secuencia genética con el SARS-CoV (3).
En las infecciones confirmadas, los síntomas de los casos de enfermedad notificados han variado desde
personas levemente enfermas hasta personas gravemente enfermas y que han muerto. Los síntomas
pueden incluir: fiebre, tos, dificultad para respirar. Los CDC creen que los síntomas podrían aparecer
en tan solo 2 días o hasta 14 días después de la exposición (1).
El nuevo coronavirus (COVID-19) es una amenaza de enfermedad infecciosa nueva y emergente. Todavía hay
mucha incertidumbre en torno a su presentación clínica, pero el espectro de la enfermedad puede variar de
leve a moderada, a neumonía o infección respiratoria aguda grave. Las personas con COVID-19 “posible” o
“confirmado” no deben ser atendidas para recibir atención dental de rutina y se les debe pedir que pospongan su
tratamiento hasta la resolución clínica (4).
En la práctica dental general, se recomienda que antes de la cita se puede evitar que las personas con COVID-19
“posible” o “confirmado” lleguen a la consulta. Si una persona asiste a la cirugía dental y que padece síntomas
respiratorios y confirma que ha viajado a un área de riesgo, se le debe recomendar que regrese a casa y se
comunique con su médico. No deben asistir a su cirugía. Si un caso “posible” o “confirmado” presenta un
problema dental agudo que requiere atención dental urgente, el paciente deberá ser derivado para su manejo
en un entorno apropiado con medidas de prevención y control de infecciones. Una vez que el individuo ha
sido transferido de las instalaciones, no debe usarse la habitación donde fue colocado o aislado. La puerta de la
habitación debe permanecer cerrada hasta que se haya limpiado con detergente y desinfectante. Una vez que se
Rev Estomatol Herediana. 2020 Ene-Mar;30(1) 5
NUEVO CORONAVIRUS 2019 (COVID-19): Consejos para el odontólogo
Editorial / Editorial Sonia Sacsaquispe-Contreras
ha completado este proceso, la sala se puede volver a usar de inmediato. Se debe seguir las instrucciones para la
limpieza ambiental después de un caso sospechoso (4). Seguir escrupulosamente todas las normas universales de
desinfección y esterilización habituales.
En relación a la prevención, importante porque, no existe una vacuna para prevenir esta cepa del coronavirus. La
OMS, recomienda evitar el contacto cercano con personas que sufren infecciones respiratorias agudas. Estas
medidas incluyen (5):
• El lavado de manos es clave para la prevención. Se recomienda hacerlo con frecuencia, principalmente, tras
el contacto directo con personas enfermas o su entorno.
• Evitar tocarse con las manos sin lavar, los ojos, la nariz y la boca.
• Evitar el contacto cercano con personas enfermas.
• Si está enfermo, quedarse en casa.
• Al toser o estornudar, cubrirse la nariz y la boca con un pañuelo desechable y luego eliminarlo.
• Los objetos y las superficies que se tocan frecuentemente, limpiar y desinfectar usando un producto común
de limpieza de uso doméstico.
Los dentistas están sometidos a riesgo de generar aerosoles, por lo que se recomienda el uso de mascarillas FFP2
valvuladas. Algunas recomendaciones acerca de las mascarillas (5):
• Si está usted sano, solo necesita llevar mascarilla si atiende a alguien en quien se sospeche la infección.
• Lleve mascarilla si tiene tos o está estornudando.
• Las mascarillas son eficaces si se combinan con el lavado frecuente de manos con una solución hidroalcohólica
o con agua y jabón.
• Si usa una mascarilla quirúrgica habitual (las de tela no se recomiendan), aprenda a usarla y eliminarla
correctamente cada 2 horas para evitar su deterioro y pérdida de eficacia.
Como se sabe, no hay ningún tratamiento antiviral específico que se recomiende, por lo que su conocimiento y
prevención son fundamentales. Las personas infectadas deben recibir cuidados de apoyo para ayudar a aliviar los
síntomas y en casos graves, debe incluir atención médica para apoyar el funcionamiento de los órganos vitales (3).
Sonia Sacsaquispe-Contreras 1,a,b,c,d
REFERENCIAS BIBLIOGRÁFICAS Nacional de Salud; 2020. (Citado el 17 de febrero del 2020)

Disponible en: https://dsi.ins.gob.pe/coronavirus/
1. Organización Panamericana de la Salud. Actualización Epi-
4. Health Protection Scotland. COVID-19 Advice for Dental
demiológica: Nuevo coronavirus (COVID-19) 14 de febrero
Teams. National Services Scotland. Glasgow: Health Pro-
de 2020. Washington DC: Organización Panamericana de la
tection Scotland; 14 February 2020. (Citado el 17 de fe-
Salud; 2020.
brero del 2020) Disponible en: https://www.hps.scot.nhs.
2. Organización Panamericana de la Salud. Coronavirus di-
uk/a-toz-of-topics/novel-coronavirus-2019-ncov/
sease Covid-19 [internet]. Washington DC: Organiza-
5. Centros para el Control y la Prevención de Enfermedades.
ción Mundial de la Salud;2020. (Citado el 17 de febrero
Coronavirus 2019 (COVID-19). Washington DC: Centros
del 2020) Disponible en: https://www.paho.org/hq/index.
para el Control y la Prevención de Enfermedades; 2019. (Ci-
php?option=com_content&view=article&id=15696:coro-
tado el 17 de febrero del 2020) Disponible en:https://www.
navirus-disease-covid-19&Itemid=4206&lang=es
cdc.gov/coronavirus/2019-ncov/index-sp.html
3. Instituto Nacional de Salud: Coronavirus. Lima: Instituto
1 International Association of Oral Pathologists. Sheffield, Inglaterra.

a
Cirujano Dentista.
b
Especialista en Medicina y Patología Oral.
c
Magister en Estomatología.
d
Doctor en Estomatología.
6 Rev Estomatol Herediana. 2019 Oct-Dic;29(4)

Critical Review
Public Health
Biological and social aspects of

Coronavirus Disease 2019 (COVID-19)
related to oral health
Luciano José PEREIRA(a) Abstract: The expansion of coronavirus disease 2019 (COVID-19)
Cassio Vicente PEREIRA(b) throughout the world has alarmed all health professionals. Especially
Ramiro Mendonça MURATA(c) in dentistry, there is a growing concern due to it’s high virulence
Vanessa PARDI(c) and routes of transmission through saliva aerosols. The virus keeps
Stela Márcia PEREIRA-DOURADO(a) viable on air for at least 3 hours and on plastic and stainless-steel
surfaces up to 72 hours. In this sense, dental offices, both in the public
Universidade Federal de Lavras – UFLA,
(a) and private sectors, are high-risk settings of cross infection among
Departamento de Ciências da Saúde, patients, dentists and health professionals in the clinical environment
Lavras, MG, Brazil. (including hospital’s intensive dental care facilities). This manuscript
Centro Universitário de Lavras – Unilavras,
(b) aims to compile current available evidence on prevention strategies for
Faculdade de Odontologia, Lavras, dental professionals. Besides, we briefly describe promising treatment
MG, Brazil.
strategies recognized until this moment. The purpose is to clarify
East Carolina University – ECU, School of dental practitioners about the virus history and microbiology, besides
(c)
Dental Medicine, Greenville, SC, USA.

guiding on how to proceed during emergency consultations based on
international documents. Dentists should consider that a substantial
number of individuals (including children) who do not show any signs
and symptoms of COVID-19 may be infected and can disseminate the
virus. Currently, there is no effective treatment and fast diagnosis is still
a challenge. All elective dental treatments and non-essential procedures
should be postponed, keeping only urgent and emergency visits to the
dental office. The use of teledentistry (phone calls, text messages) is a
Declaration of Interests: The authors
very promising tool to keep contact with the patient without being at
certify that they have no commercial or
associative interest that represents a conflict risk of infection.
of interest in connection with the manuscript.
Keywords: Coronavirus; Public Health; Practice Management, Dental;
Infections; Dentistry.
Corresponding Author:
Luciano José Pereira
E-mail: [email protected]
Introduction
Coronavirus is a family of viruses that causes respiratory infections

https://doi.org/10.1590/1807-3107bor-2020.vol34.0041
including the new coronavirus (SARS-CoV-2) discovered in December 2019
in China. Coronaviruses represent enveloped, positive stranded RNA virus
that contains four genera: Alpha-, Beta-, Gamma-, and Deltacoronavirus.1 Six
different coronavirus have been identified in humans: HCoV-OC43, -229E,
HCoV-NL63, HKU1, the Middle East respiratory syndrome (MERS)-CoV
Submitted: April 7, 2020
and (SARS)-CoV.2 Although the latter virus became widely discussed
Accepted for publication: April 13, 2020
Last revision: April 14, 2020 recently, the first human coronaviruses were isolated for the first time in
1937.3 The denomination coronavirus was due to its microscopic aspect
Braz. Oral Res. 2020;34:e041 1

Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health
resembling crown-like spikes on its surface and were monitored and tested in the laboratory for
the main host receptor for humans seems to be the coronavirus and possible influenza infections. On
angiotensin-converting enzyme 2 (ACE2).4 January 7, 2020, Chinese authorities announced that
This recent COVID-19 turned into a global a new type of Coronavirus was isolated: the new
public health outbreak. 5,6 It is transmitted after Coronavirus, nCoV.14
contact with infected surfaces and with infected This new viral agent, which until that moment
patient’s fluids, including saliva and aerosol.6,7 These has not been identified in humans before, was called
characteristics place the dental offices as main risk SARS-CoV-2 and is able to cause respiratory infectious
settings of cross infection among patients, dentists disease that is called COVID-19. Previous occurrence
and health professionals in the clinical environment, of coronavirus such as the Severe Acute Respiratory
including hospital’s dental intensive care facilities.8 Syndrome (SARS) (SARS-CoV) and Middle East
Dental practitioners are exposed to close contact to Respiratory Syndrome (MERS) (MERS-CoV) left 774
patients, to saliva aerosol, blood and handle sharp and 850 dead, respectively, reflecting the severity
contaminated instruments.9 of the threat and the urgency to control this new
After the World Health Organization (WHO) outbreak as soon as possible.15
pandemic declaration, institutions like the General T he genom ic s e quence of t he new v i ra l
Coordination of Oral Health from the Brazilian Health Coronavirus was immediately defined by public
Ministry published a Technical Note with the main health support and online community resources
clarifications regarding dental practice considering “virological.org” on January 10 th (Wuhan-Hu-1,
the Coronavirus pandemic.10 Centers for Disease GenBank accession number MN908947)16 followed
Control and Prevention (CDC) and American Dental by four other deposited genomes on January 12th in
Association (ADA) are recommending dentists to the database of viral genomic sequences maintained
postpone elective procedures and concentrating on by the Global Initiative on Sharing All Influenza
emergency or urgent dental care in order to reduce Data (GISAID).17 The clinical signs and symptoms
COVID-19 infection,11,12 similar to what several cities in the beginning suggested the presence of a virus
in China have done.13 closely related to SARS outbreak in 2002/2003. This
As health professionals, it is extremely relevant species also comprised a large number of viruses
that dentists be aware of the biological and social detected in rhinolophid bats in Asia and Europe.
characteristics involved in COVID-19 pandemic, 17
After sequencing, the SARS-CoV-2 genome was
contributing to the clarification of the population and found to be 96.2% identical to the Bat RaTG13 coV,
adopting finest clinical measures to avoid unnecessary while sharing 79.5% identity with the SARS-CoV. In
risks to contain the perioperative transmission.8 Based this way, the similarity between the genomes of the
on the current available evidence related to oral health viruses shows that the bat is the natural host of the
care, the aim of the present critical appraisal is to virus and SARSCoV-2 may have been transmitted to
compile prevention strategies for dental professionals humans, in an unknown way, through intermediate
and clarify dental practitioners about the virus history, hosts. Several studies suggest that the bat is the
pathogenesis, current pharmacological clinical trials, potential reservoir of SARS-CoV-2. However, there
and measures to minimize economic and health is evidence that the origin of SARS-CoV-2 was the
consequences to the oral health system. seafood market in Wuhan, China.18 Coronaviruses
(CoV) α- and β-CoV are capable of infecting mammals,
Microbiological aspects while γ- and δ-CoV tend to infect birds. Although
This new health problem emerged from a public the six CoVs identified as human-susceptible viruses,
market in which animals are kept and traded alive in presented low pathogenicity, causing mild respiratory
Wuham – China. It became the focus of global attention symptoms similar to a common cold; SARS-CoV and
after the spread of an unknown cause epidemic MERS-CoV may lead to severe and potentially fatal
pneumonia. At first, these cases of pneumonia respiratory tract infections.18,19
2 Braz. Oral Res. 2020;34:e041

Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM
Viruses are complex pathogens with a high capacity receptors (PRRs) that respond to RNA viruses.23 The
to infect multiple host species, causing a variety domains then initiate an antiviral signaling cascade
of diseases with numerous symptoms. CoVs are by leading the phosphorylation and activation of
pleomorphic RNA-viruses (subgenus sarbecovirus, IRF3 and NF-κB, leading to the production of type I
subfamily Orthocoronavirinae) characterized by high IFN. IFN-β secretion induces IFN-stimulated genes,
speed of gene recombination due to constant errors which will induce the expression of host antiviral
in their RNA polymerase-dependent replication effector factors.24
process (RdRP).18,20 The main steps involved in the Viruses have developed the capacity to escape
replication cycle of SARS-CoV-2 are: recognition host immune detection and to suppress the host
and binding to the host cell via membrane fusion IFN system. 25 Viruses encode viral proteins
or endocytosis mechanism. After the invasion, the that interfere with PRRs signaling pathways to
viral genome is released; then occurs translation of increase an early benefit against host defense. For
the viral polymerase protein; RNA replication; sub- example, the SARS-CoV N proteins inhibit RIG-I
genomic transcription; translation of viral structural ubiquitination and thus suppress the release of type
proteins; viral structural proteins combination with I IFN,26 SARS-CoV M proteins prevents the TRAF3/
the nucleocapsid; formation of mature virions and TBK1 complex formation and inhibits TBK1/IKKε-
finally the release of mature virions by exocytosis. At dependent activation of IRF3/IRF7 transcription
the end of the cycle, newly mature virions are released factors.27 Lastly, the repressive modifications that
and may infect new targets and the cycle repeats are induced by the nonstructural SARS-CoV nsp1
itself continuously.15 During their replication cycle, protein blocks host mRNA translation28 and mediates
two-thirds of the viral RNA encode 16 non-structural host mRNA degradation.29
proteins (NSPs). The other one-third of the virus Human-to-human transmission of SARS-CoV-2
genome encodes four essential structural proteins, occurs primarily between family members, including
including: spike glycoprotein (S), small envelope relatives and friends who have more intimate contact
protein (E), matrix protein (M) and nucleocapsid with infected or asymptomatic patients or carriers.
protein (N), and also other accessory proteins.18,21 As an emerging acute respiratory infectious disease,
Host factors can also influence susceptibility to COVID-19 spreads mainly through the respiratory tract
infection and disease progression. Research shows pathways through droplets, respiratory secretions and
that SARS-CoV-2 use angiotensin-converting enzyme direct contact even at a low infectious dose. Likewise,
2 (ACE2). The S-glycoprotein located on the surface of the presence of SARS-CoV-2 in swabs from fecal and
the coronavirus can bind to the ACE2 receptor on the blood samples has been identified, indicating the
surface of human cells. After binding to the host cell possibility of multiple routes of infection.18
membrane, the RNA of the viral genome is released Based on the current epidemiological investigation,
into the cytoplasm and translates two polyproteins, the incubation period is from 1 to 14 days, mainly from
pp1a and pp1ab that encode non-structural proteins 3 to 7 days, being contagious in its latency period. It
and form the replication and transcription complex is highly transmissible in humans, especially in the
(RTC) and the replication cycle continues as stated elderly and people with underlying diseases. Patients
above 18. Host antiviral defense plays an important with COVID-19 have symptoms such as fever, malaise
role in the course of SARS-CoV-2 infection. As the and cough. Most adults or children infected with
first line of defense against viruses, type I interferon SARS-CoV-2 have mild flu-like symptoms. However,
(IFN) plays a critical role in initiating host antiviral a few patients also progress to a critical condition and
responses. Following virus infection, the host innate rapidly develop acute respiratory distress syndrome,
immune system is activated by the recognition of respiratory failure, multiple organ failure and even
viral-specific components such as ssRNA, dsRNA or die.18,30 There are still many gaps in knowledge about
glycoproteins.22 The Toll-like and RIG-I-like receptors the epidemiology and clinical overview of COVID-19,
are the most common host pattern recognition including the exact incubation period, the possibility

of transmission from asymptomatic carriers and the The fourth arm of SOLIDARITY combines
rate of transmissibility. However, human-human lopinavir-ritonavir with interferon-b. The activation
transmission has been rapidly proven and remains of innate antiviral response by interferon should
responsible for the continued spread of the disease. have beneficial effects at least in the initial stage of
Reliable laboratory diagnosis is among the infection. However, cautions should still be observed
priorities to facilitate public health interventions. In and the possibility that interferon might exacerbate
acute respiratory infections, RT-PCR is routinely used inflammation during the late phase of SARS-CoV-2
to detect viruses caused by respiratory secretions. infection cannot be excluded.42
During international health emergencies, the viability Lastly, clinical trials are being conducted to
of real-time detection of the virus by real-time evaluate the use of SARS-CoV-2 convalescent plasma
RT-PCR has been demonstrated through coordination from persons who have recovered from COVID-19
between public laboratories and universities. 17 that potentially contain antibodies to treat patients
with life-threatening viral infections.43 A group led
SARS-CoV-2 Drug Therapy by Lei Liu44 gave convalescent plasma (total dose:
Drugs tested effective for SARS-CoV and/or MERS 400 mL with a SARS-CoV-2-specific antibody-IgG
have been included in the WHO mega clinical trial – titer greater than 1:1,000) to five critically ill patients
SOLIDARITY.31 For its study, WHO chose a nucleotide and the symptoms diminished in all of them within
ten days. Even though these cases reported by Shen
analogue Remdesivir; the malaria medication
et al 44 are compelling, this investigation has some
chloroquine (and its analog hydroxychloroquine);
limitations. The intervention was not evaluated
a combination of the anti-HIV drugs lopinavir and
in a randomized clinical trial, and the outcomes
ritonavir; and that combination plus interferon-b.
in the treatment group were not compared with
Re mde s iv i r i s a n a nt iv i r a l p r o d r ug o f
outcomes in a control group - patients who did not
remdesivirtriphosphate with in vitro activity against
receive the intervention. Moreover, patients received
coronaviruses.32,33 Remdesivir-TP acts as an inhibitor of
numerous other therapies (antiviral and steroids),
RNA-dependent RNA polymerases and competes with
and the convalescent plasma was administered up
adenosine-TP for incorporation into emerging viral
to 21 days, and it is not clear whether this timing is
RNA chains.34 Hydroxyhloroquine and chloroquine
optimal or if earlier administration potentially have
have in vitro activity against SARS-CoV-2 32,35–37
been associated with different outcomes. Despite
and the mechanism of action includes inhibition
these limitations, the study does provide important
of viral enzymes (RNA polymerase), viral protein evidence to support the possibility of evaluating this
glycosylation, virus assembly, new virus particle therapy in more rigorous studies.
transport, and virus release. Other mechanisms
may also involve ACE2 receptor inhibition, decrease Dental practice in the Covid-19
acidity in endosomes, and immunomodulation of scenario
cytokine release.5,32,36
The third arm of SOLIDARITY combines two Risk scenario
HIV protease inhibitor drugs, lopinavir-ritonavir. Dentists are among the professionals with the
The combination shown in vitro and in vivo potential greatest exposure to COVID-19. The oral cavity and the
activity for SARS-CoV and MERS-CoV 38,39 and the work environment represent a high potential source
mechanism of action involves the inhibition of Mpro, for transmissibility and susceptibility to this and other
an essential enzyme for coronavirus replication 40. etiological agents.7,45,46 The context of undocumented
Recent report published in The New England Journal of infections is significant, which facilitates the rapid
Medicine41 was not encouraging and the combination spread of SARS-CoV-2. A substantial number of
of lopinavir-ritonavir did not differ significantly from individuals do not show any signs and symptoms
“standard care” group. or have mild symptoms. These individuals serve

as the primary source for the majority of reported or ultrasonic scalers generates aerosol (very small
cases and, therefore, for health teams that can particles or droplets) that can be inhaled, absorbed
become multipliers.47,48 by the skin or set in nearby surfaces.62 According
The rapid identification of COVID-19 cases is crucial to the last Scientific Brief published by the World
for the containment of the pandemic. However, it is Health Organization, 63 the transmission of the
still challenging due to the lack of pathognomonic SARS-CoV-2 can occur by respiratory droplets from
symptoms, coupled with the limited capacity to direct contact with an infected person (distance
perform specialized polymerase chain reaction less than 1m), indirect contact with contaminated
(PCR) tests49 - which also have limitations. The need surfaces or objects and by aerosol produced during
to develop fast accurate molecular diagnostics is procedures performed on infected patients. Based
mandatory to identify a large number of infected on that, dental and health organizations have issued
patients and asymptomatic carriers, in order to recommendations to postpone all elective dental
prevent the transmission of the virus and ensure treatments and non-essential procedures and limit
proper conduct.50,51 Rapid tests can facilitate elective services only to urgent and emergency visits.10,11,12
care in the future since the risk of contamination by Dental health care personnel (DHCP) should be aware
SARS-CoV-2 would be ruled out. However, the dentist of the mechanisms of transmission, the expanded
can never neglect the existence of other diseases infection control procedures, be able to identify
transmitted by saliva and aerosol, such as hepatitis patients with signs / symptoms of COVID-19 and
B, measles and tuberculosis.52,53,54 have a clear understanding of what characterizes
Dentists should receive and make great efforts a dental emergency, urgent dental care and non-
regarding preventive care and testing, as they can emergency dental treatment.
seriously affect the flattening of the epidemic curve, During the COVID-19 pandemic, DCHP should use
avoiding the collapse of the health system. Several telecommunication or teledentistry prior the dental
modeling studies and scenario comparisons - both treatment to evaluate the needs of the patient and
related to the current pandemic situation and those to minimize the risk of infection, asking if patient
already experienced especially in China and Italy has fever, cough or shortness of breath (ADA)64 and
- have shown that combined interventions must have traveled national or internationally (CDC).65,66
be implemented, both for the population and for When possible, dentist should offer advice, prescribe
health professionals. General measures for all health medication for analgesia and/or antimicrobial (when
professionals including dentists comprise daily appropriate) and postpone the visit of the patient to
monitoring of the temperature and testing the health the office, but keep direct contact with the patient
care provider team; use of N95 masks; distance from by phone or text message.67 If patient presents a
the workplace (when possible) with the implementation dental emergency (potentially life threatening), as
of network communication technologies with patients; an uncontrolled bleeding, or an urgent dental need
social distance; mobility restriction measures; avoid that requires relieve of severe pain and/or risk of
crowd places; diagnostic tests and isolation of infected infection,68 and present sign/symptom of respiratory
individuals as well as their families.55–60 Especially for infection, this patient should not be seen in a dental
dentists it is necessary to follow guidance protocols office and should be referred for an emergency care
and new tools/technologies for dental practice aimed facility where Transmission-Based Precautions (N95
at safeguarding oral health professionals, as well as masks, Airborne Infection Isolation Room for example)
the population under their care.59,61 are available (ADA).64
In the United Kingdom, the National Health
Dental treatment during the Covid-19 Service (NHS) is working with dental practices
Pandemic and community dental services to establish Local
Due to the nature of the dental treatment, several Dental Urgent Care System in every region. These
procedures, as the use of high-speed handpiece dental offices will accommodate visits of all types of

patients, including those with suspected or confirmed of COVID-19 and the dentist does not have a N95
COVID-19, patients that are shielded, vulnerable or mask or higher level, he/she must wear surgical
patients without any of those specific conditions. In mask in a single use, goggles and face shield to treat
those places dental public health practitioners will be a patient, but be aware that the risk of contamination
available and will have access to the FFP3 respirator will be moderate.64 There is a limitation in following
to perform the treatment.67 this procedure since there is current community
In most countries, cases of dental emergency or spread of COVID-19 with asymptomatic cases in
urgent dental care on patients without any signs and the population. Current research shows that the
symptoms of COVID-19 can be treated at the dental prognosis of patients with COVID-19 is worst for those
office. However, since there is a large number of older than 60 years of age or presenting underlying
asymptomatic cases of Covid-19,47 the dentist should diseases (diabetes, hypertension or cardiovascular
take extra precautions when seeing the patient disease, for example).70 In this sense, members of the
and not assume he/she is COVID-19 free. Besides health team must use clinical judgment and take all
the asymptomatic patients, dental practitioners precautions to prevent transmission.
should be aware that children represent a significant In this unprecedented situation, it is advisable
transmission risk to the virus since they present to look for and apply the most recent protocols and
milder symptoms than adults.69 It is important to guidance from your local dental organizations in
maintain patient isolation (have only one patient in your country that are based in the current literature
the waiting room), adhere to the infection control and be aware that the COVID-19 pandemic brings
protocol: standard procedure of putting on and challenges to the dental health care providers
removing all Personal Protective Equipment (PPE), not only on their practices but on their financial
including gown, goggles, N95 mask with face full situation as well. A general flowchart (Figure) was
shield and gloves.64 Before every treatment, patient constructed based on the ADA’s Interim guidance
should use a mouth rinse with 1% or 1.5% hydrogen on minimizing COVID-19 transmission risk when
peroxide or 0.2% povidone 9,64 and should wear goggles treating dental emergencies.64 As also stated in this
and bib during the whole procedure. To minimize ADA’s document,64 Figure 1 does not constitute legal
the aerosol production, dentists should use hand advice or legal guidance. It only helps clinicians
instrumentation, high-volume saliva ejector and for their own judgment about the risks of infection
dental dam during the treatment and refrain to use while working in dental offices.
3-in-1 syringe.61
Intraoral radiographs should be avoided since Perspectives
it can induce coughing; the office space should Health professionals are facing new challenges in
be limited to the patient and to the operator and providing care to their patients. Remote treatment via
dental assistant. After the treatment, the DCHP chat, video conversation, telemedicine, teledentistry
should wear appropriate PPE to proceed with the and other technologies have given rise to a new look
cleaning and disinfection of the room and equipment at the professional-patient relationship, opening
using the recommended disinfecting products.64 doors to an untapped universe, since most dentists
Besides, dentists should reconsider the use of sedation do not use them as part of their daily work.71It is
(inhalation and pharmacological) to manage severe estimated that by 2025 over 60% of the population
anxiety or phobia in the dental settings and focus will be using mobile internet.72 Therefore, mobile
on non-pharmacological techniques to minimize the technologies, including phones, are great allies to
potential risk of needing life support measures that community health even in low and middle-income
involve the manipulation of airways and aerosolization population.73–75 Individuals that still do not have
(inhalation sedation).8 access to mobile services would also benefit due to
In a specific situation where the patient has an diminishing waiting lines in local health assistance,
unavoidable emergency and no signs and symptoms at the nearest Primary Health Units.

*Use of N95 mask denotes low risk of infection

# If no N95 available, refer patient to a facility that has N95. If not feasible, use your clinical judgment and precautions of infection control.
Dentist and staff must wear surgical facemasks, goggles and full-face shields, with other basic clinical PPE and follow disinfection procedures
immediately after every procedure. Use of surgical facemasks denotes moderate risk of infection. DCHP should quarantine for 14 days and
communicate with patients that were seen after that day. Procedures involving aerosol should be scheduled for the last appointment of the
day. Dentists should avoid intra-oral radiographs, prefer hand instrumentation, and use high-volume saliva ejector and dental dam during the
treatment.
This figure was constructed using free images obtained at: https://smart.servier.com/ and https://www.freepik.com/.
Figure 1. Flowchart based on the American Dental Association Interim Guidance for Management of Emergency and Urgent
Dental Care on 04/01/2020 and do not constitute legal advice or legal guidance.
In private offices, the limitation on dental and concerning this urgent moment to guarantee social
medical activities to only urgent and emergency security for all and to go beyond the packages
procedures presents a strong impact on the economy proposed by governments.77 Such strategies must
of these sectors.76 This economic crises have raised be sustainable, long-term, with a view to protecting
reflections and concerns that go beyond clinical the self-employed and avoiding an unprecedented
security and social detachment and have highlighted economic crisis.
the importance of social security and financial
education. Such factors must also be taken into account Conclusions
by the entities that guide dental practice, in order to
generate discussions to support the dentists on those This recent COVID-19 turned into a global public
occasions where they will have to keep distance from health outbreak. It is transmitted after contact with
their routine clinical tasks during COVID-19. infected surfaces and with infected patient’s fluids,
The dental class, which comprises in its vast including saliva and aerosol. A substantial number
majority, autonomous professionals, should recover of individuals do not show any signs and symptoms
the issues of financial education, frequently so distant and may disseminate the virus. These characteristics
from the contents of the academic curriculum. There put the dental offices as main risk settings of cross
is an evident scarcity of articles related to financial infection among patients and dentists. Currently
education for dental offices. Emergency financial there is no effective treatment and fast diagnosis is
reserve, funds to deposit this reserve and long-term still a challenge. All elective dental treatments and
investments, public or private pension, should be non-essential procedures should be postponed,
part of the incisive recommendations to this group. keeping only urgent and emergency visits to the dental
Other professional classes are raising these issues office. Unexpected situations like this pandemic,

brings financial issues to the dental team; in this way, Acknowledgments

financial education become very important subject National Council for Scientific and Technological
to be discussed during the professional school. The Development (Conselho Nacional de Desenvolvimento
use of telecommunication (phone calls, text messages) Científico and Tecnológico - CNPq), and the
and teledentistry are very promising tools to keep Coordination for the Improvement of Higher Education
contact with the patient without put them in high Personnel (Coordenação de Aperfeiçoamento de Nível
risk of infection. Superior - CAPES).
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Braz. Oral Res. 2020;34:e041 11

Putrino et al. BMC Oral Health (2020) 20:200
RESEARCH ARTICLE Open Access
Coronavirus (COVID-19) in Italy: knowledge,

management of patients and clinical
experience of Italian dentists during the
spread of contagion
Alessandra Putrino1* , Mario Raso2, Cosimo Magazzino3 and Gabriella Galluccio4
Abstract
Background: The coronavirus infection that emerged in China in the last few months of 2019 has now spread
globally. Italy registered its first case in the second half of February, and in a short time period, it became the top
country in Europe in terms of the number of infected people and the first in the world in terms of deaths. The
medical and scientific community has been called upon to manage the emergency and to take measures. Dentists
also need to take new precautions during their clinical activity to protect themselves, coworkers and patients from
the risks of contagion and to avoid further spread of infection.
Methods: Following the data published in the international literature as well as the guidelines and directives
constantly updated by the WHO and by the national health authorities, a questionnaire to be completed
anonymously was submitted online to Italian dentists using social tools and online professional platforms. The
collected data were processed statistically, providing descriptive data and analysis of correlations of the most
significant parameters using the Pearson’s χ2, the Likelihood-Ratio χ2, Cramér’s V, Fisher’s exact test, Goodman and
Kruskal’s γ, and Kendall’s τb (p < 0.05).
Results: A total of 535 dentists from Italy participated in the survey. A good level of scientific knowledge about
coronavirus and the extra precautionary measures needed to limit the spread was related to the age of
respondents and their sex. Coming from areas with higher concentrations of cases affected knowledge, level of
attention and perception of risk related to dental activity.
Conclusions: At the moment, there are no therapies or vaccines to contain the infection with the new coronavirus
that is causing many infections, many of which are fatal, worldwide. Dentists are one of the categories at highest
risk of encountering diseases and infections because they work in close proximity with patients, and in their
procedures, there is always contact with aerosols with high bacterial and viral potential. Therefore, during this
COVID-19 emergency, it is important that dentists are properly informed and take the appropriate precautionary
measures.
Keywords: 2019 novel coronavirus, COVID-19, Dentistry, Health management, Knowledge, Survey
* Correspondence: [email protected]
1
Advanced Training Course in Risk Management in Healthcare and
Professional Responsibility, University “Sapienza” of Rome, Piazzale Aldo Moro
5, 00185 Rome, Italy
Full list of author information is available at the end of the article
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Putrino et al. BMC Oral Health (2020) 20:200 Page 2 of 15
Background there are many cases of recovery, the number of de-

Human coronaviruses are a group of RNA viruses able ceased subjects has increased with the spread, particu-
to cause respiratory, gastrointestinal and central nervous larly affecting older subjects with previous severe
system diseases. The first human coronavirus (HCoV) pathologies [11, 12]. The first detection of the virus in
was detected in the mid-1960s [1]. In December 2019, Italy was in a case of two Chinese tourists from Wuhan
the seventh coronavirus known to infect humans was who were later treated at the Spallanzani Hospital of
found in China (Wuhan city, Hubei Province) [2]. On 12 Rome. The entire tourist group of the Chinese couple
January 2020, the World Health Organization (WHO) was then quarantined for two weeks in the same hospital
announced the temporarily named nCoV-2019, now and then released after negative results of the clinical
called SARS-CoV-2, as the novel coronavirus pathogen and serologic controls [13].
responsible for the increasing number of new pneumo- On 21 February, the first locally transmitted case, a
nia cases [3, 4]. Since that day, the number of cases in 38-year-old man who never travelled in China, emerged
China and progressively in many other parts of the in northern Italy, Lombardy region, Codogno town, and
world has increased (Fig. 1), and with it, the number of since then, the number of cases has increased (Fig. 3) in
people who died because of this infection as the primary the whole area and progressively increased in many
or contributory cause of preexisting illness [5]. On 11 other northern regions until the virus has spread to
March 2020, the WHO stated that the novel coronavirus affect the entire Italian territory. As the number of swab
outbreak was a pandemic (Fig. 2). The scientific commu- tests for suspected cases has continued to increase, the
nity is still making numerous efforts to clarify the eti- Italian authorities have started to adopt preventive mea-
ology, pathogenicity, and characteristics of the virus to sures to try to isolate the affected areas and block the
establish the mechanisms underlying human-to-human spread of the infections and a nationwide lockdown
transmission and possible treatments [6–10]. Although went into effect on 10 March. The death toll, at the
Fig. 1 Confirmed cumulative cases. Data Source: World Health Organization. Updated to March 28th 2020
Fig. 2 Confirmed cumulative cases by country. Data Source: World Health Organization. Updated to March 28th 2020
Fig. 3 Trend of confirmed cases in Italy. Data Source: Italian Civil Protection Department. Updated to 28th March 2020
Table 1 COVID-19 National trend updated to: March 28th 2020 a

REGIONS CONFIRMED CASES RECOVERED CASES DEATHS TOTAL CASES SWAB TESTS
Lombardy 24.509 8.962 5.944 39.415 102.503
Emilia-Romagna 9.964 1.075 1.344 12.383 52.991
Veneto 6.913 655 362 7.930 89.380
Piedmont 6.851 203 617 7.671 21.511
Tuscany 3.511 108 198 3.817 25.613
Marche 2.999 10 364 3.373 9.884
Lazio 2.181 200 124 2.505 27.179
Trentino-Alto Adige 2.163 267 184 2.614 14.729
Liguria 2.086 378 358 2.822 8.177
Campania 1.407 76 109 1.592 10.616
Apulia 1.358 29 71 1.458 11.500
Sicily 1.242 60 57 1.359 13.096
Friuli-Venezia Giulia 1.120 229 87 1.436 12.723
Abruzzi 1.027 30 76 1.133 7.003
Umbria 898 43 28 969 7.028
Sardinia 569 29 26 624 4.225
Calabria 523 11 21 555 7.760
Valle d’Aosta 468 2 41 511 1.380
Basilicata 178 1 3 182 1.421
Molise 98 16 9 123 807
Total 70.065 12.384 10.023 92.472 429.526
a
data source: Italian Civil Protection Department- Ministry of Health
moment, has reached 10,023 persons (mostly elderly contact, conceivable due to the characteristics of dental
people with other preexisting diseases), and the number of activity, require a great deal of attention from dentists,
infected cases is greater than 70,065, with 12,384 recov- who should adopt simple but effective practical strategies
ered (Table 1). Italian government, the Ministry of Health, to stop the possible spread of the virus. The suggested
Civil Protection and other competent bodies at the local procedures include preappointment patient risk evaluation
level are constantly engaging in this emergency, providing through a specific questionnaire; frequent hand hygiene;
instructions to citizens and health workers and updating appropriate individual protective equipment; insulation of
the population on the evolution of the situation [14–17]. the oral cavity with a rubber dam after mouth rinses,
Even dentists have been involved in the management of which are suggested with peroxide 3%; the use of antire-
this emergency through indications on prevention and traction handpieces; disinfection after every dental treat-
safety measures to be observed in their clinical activity ment; and appropriate waste management [20]. In Italy
due to the high level of exposure for operators and dental there are more than 58,000 dentists (about 1 per
patients. In the last weeks the number of health workers 1000 inhabitants), differently distributed at the re-
infected has risen: many nurses and doctors on the cor- gional level (Table 2). The management of dental ac-
onavirus front lines are working without adequate per- tivity can play an important role in limiting the
sonal protective equipment (PPE), exposing themselves to infections. Due to the increasing involvement of a
great risk and some of them have been infected while on large part of the population in the global epidemic
duty. Already, 50 doctors have died, and 4 of them were situation in Italy, the present study aimed to assess
dentists [18]. A direct correlation between their death and the knowledge about the new coronavirus, the percep-
coronavirus infection was not, however, ascertained but tion of risk and the clinical management of the risk
many of them were engaged in the management of infec- related to infection during the first month of the Ital-
tions. The novel coronavirus was recently identified in the ian epidemic in an online survey of Italian dentists.
saliva of infected patients. Dental clinical procedures gen- Moreover, due to the rapid change in the number of
erate droplets and aerosols that can lead to viral transmis- infected individuals, a further analysis aimed to evalu-
sion [19]. Contamination on surfaces and diffusion by ate the progressive perception of the risks.
Table 2 Distribution of dentists in Italy by Region

Regions Number of Dentists Percentages Population Inhabitants/Dentist rate number Dentist number for 1000 inhabitants
Piedmont 4.64 7,33 4.457.335 1.045 1,0
Valle d’Aosta 79 0,14 128.230 1.623 0,6
Lombardy 9.807 16,85 9.917.714 1.011 1,0
Trentino A.A. 827 1,42 1.037.114 1.254 0,8
Veneto 4.464 7,67 4.937.854 1.106 0,9
Friuli V.G. 1.539 2,64 1.235.808 803 1,2
Liguria 2.108 3,62 1.616.788 767 1,3
Emilia-Romagna 4.366 7,50 4.432.418 1.015 1,0
Tuscany 3.948 6,78 3.749.813 950 1,1
Umbria 945 1,62 906.486 959 1,0
Marche 1.839 3,16 1.565.335 851 1,2
Lazio 6.419 11,03 5.728.688 892 1,1
Abruzzi 1.199 2,06 1.342.366 1.120 0,9
Molise 303 0,52 319.780 1.055 0,9
Campania 4.779 8,21 5.834.056 1.221 0,8
Apulia 3.494 6,00 4.091.259 1.171 0,9
Basilicata 418 0,72 587.517 1.406 0,7
Calabria 1.883 3,24 2.011.395 1.068 0,9
Sicily 3.973 6,83 5.051.075 1.271 0,8
Sardinia 1.549 2,66 1.675.411 1.082 0,9
Total 58.203 100,0 60.626.442 1.042 1,0
Methods The generated link was shared on professional group

This study used a questionnaire-based survey. The ori- and contact networks on the main social channels (Lin-
ginal version of the survey was piloted among a group of kedIn, Facebook, and WhatsApp), inviting Italian den-
dentists to ensure suitability, validity, practicability and tists to share the link with other colleagues in further
interpretation of answers. On the basis of the comments professional groups to widen the spread of the survey as
and suggestions obtained, the questionnaire was revised. much as possible. The assurance that those who would
The questionnaire was developed and forwarded to ital- respond to the survey were regular dentists was given by
ian dentists in Italian and translated into English for the the fact that all online professional groups and networks,
presentation of this research (Supplementary file 1). Sci- of which none of the Authors are an administrator, re-
entific bases for the development of questions about the ferred to (also for the dissemination of the question-
new coronavirus came from consultation of the scientific naire) by regulation are closed and approve registrations
literature available on this subject, more specifically ad- only when the registration number of the national pro-
dressed to virologists, specialists, biologists, and general fessional register is originally provided. The responses
practitioners and epidemiological content that traced the were validated only for fully completed questionnaires,
data on coronavirus infection since its first appearance in fact the system automatically rejected incomplete
in China [2–10]. questionnaires.
Additionally, as a source of scientific information and The data collected were absolutely anonymous, and
as an aid for the processing of a part of the question- tracing the identity of the subjects was not possible.
naire presented to Italian dentists, circulars issued by the A total of 24 open- and close-ended questions were
Ministry of Health containing protocols and guidelines developed (Table 3). Seven questions helped to obtain a
aimed at health professionals during the outbreak and profile of the practitioner (age group; sex; type of clinical
informative material disclosed by dental associations activity-private, hospital or both; qualification-specialist
were also considered. or not; territorial provenance-specifying region; the
The questionnaire was uploaded online to the free sur- number of citizens of their city; and the number of pa-
vey platform Survio.com (© Survio, Hlinky 70, Brno, tients treated daily). Six questions were intended to
Czech Republic) through a specially created user profile. evaluate the direct influence of the coronavirus epidemic
Table 3 Questionnaire and results

QUESTIONS AND ANSWERS RESULTS
1. Where do you work? (Choose an answer)
A) In a private dental office 416 77.8%
B) In a public hospital 18 3.4%
C) Both 101 18.9%
2. Which age group do you belong to? (Choose an answer)
A) Up to 35 years 174 32.5%
B) From 36 to 45 years old 146 27.3%
C) From 46 to 60 years old 179 33.5%
D) Over 60 36 6.7%
3. Are you a man or a woman? (Choose an answer)
A) Man 261 48.8%
B) Woman 274 51.2%
4. Are you a specialist? (Choose an answer)
A) Yes, in orthodontics 90 16.8%
B) Yes, in oral surgery 62 11.6%
C) Yes, in paediatric dentistry 9 1.7%
D) No 224 41.9%
E) No, but I predominantly practice a specific branch (e.g. implantprosthesis, endodontics, etc.) 150 28.0%
5. In your region (the one where you practice your professional activity) there
have been cases of Coronavirus infection? (Choose an answer)
A) Yes 374 69.9%
B) No 161 30.1%
6. In which region do you exercise your professional activity? (Open answer)
Results
detailed in
Fig.4
7. How many inhabitants are there in your city? (Choose an answer)
A) Less than 10,000 58 10.8%
B) 10,001 to 330,000 217 40.6%
C) Between 330,001 and 660,000 82 15.3%
D) Between 660,001 and 1 million 46 8,6%
E) Over 1 million 132 24.7%
8. How many patients attend your practice every day? (Choose an answer)
A) Less than 10 101 18.9%
B) No more than 10 172 32.1%
C) Beyond 10 262 49.0%
9. Since the Coronavirus outbreak, have you noticed a decrease in access to your dental office or public hospital you work in? (Choose an answer)
A) Yes 94 17.6%
B) No 270 50.5%
C) Yes, only after the spread of cases in our Country 122 22.8%
D) I don’t know 49 9.2%
10. From a scientific point of view, how much do you think you are informed about Coronavirus? (Choose an answer)
A) Not at all 5 0.9%
B) Little 78 14.6%
C) Enough, I think I’m sucly informed 250 46.7%
Table 3 Questionnaire and results (Continued)

D) Very, I think I am properly informed 152 28.4%
E) Very much, my knowledge on the topic is going hand in hand with updates from the international community 50 9.3%
11. How did you get the scientific informations about Coronavirus? (Choose one or more answers)
A) Television, online and/or print newspapers and social media 220 20.8%
B) Institutions (Minister of Health, Italian Government, Order of Physicians, etc.) 398 37.6%
C) Other colleagues 78 7.3%
D) Scientific literature 171 16.1%
E) Professional associations 180 17.0%
F) Other 8 0.8%
G) I am not informed 2 0.2%
12. Coronaviruses are a large family of viruses, known to infect both humans and some animals, whose primary target cells are those epithelial of the
respiratory and gastrointestinal tract.
How do you judge this statement? (Choose an answer)
A) True 390 72.9%
B) False 88 16.4%
C) I don’t know 57 10.7%
13. What does nCov mean? (Choose an answer)
A) A strain of coronavirus that had not previously been identical in humans 338 63.2%
B) The virus of the common cold 29 5.4%
C) The SARS virus 51 9.5%
D) I don’t know 117 21.9%
14. Is the SARS-Cov-2 virus causing the current coronavirus outbreak? (Choose an answer)
A) No it’s the SARS virus name only 120 22.4%
B) Yes, and it belongs to the same family of acute respiratory syndrome (SARS) virus 90 16.8%
C) Yes, and can also be named 2019-nCov 56 10.5%
D) Answers B and C are correct 236 44.1%
E) none of the previous 33 6.2%
15. What does COVID-19 mean? (Choose an answer)
A) The virus that causes the current outbreak 366 68.4%
B) The disease caused by the new coronavirus 143 26.7%
C) The drug used to treat infected patients 2 0.4%
D) None of the previous answers 24 4.5%
16. What are the most common symptoms in current coronavirus infection? (Choose an answer)
A) Just colds and coughs 2 0.4%
B) Fever, cough and respiratory difficulties 53 9.9%
C) From mild symptoms such as colds, sore throats, fever, muscle aches, coughs to more severe symptoms such as respiratory 463 86.5%
difficulties and pneumonia
D) Fever and pneumonia 16 3.0%
E) None of the above answers 1 0.2%
17. How is the new Coronavirus transmitted from person to person? (Choose an answer)
A) Only through saliva 3 0.6%
B) Through saliva, coughing, sneezing, contaminated hands 169 31.6%
C) Through direct personal contact with infected people 36 6.7%
D) None of the previous answers 1 0.2%
E) Options B and C are correct 326 60.9%
Table 3 Questionnaire and results (Continued)

18. Are you aware of the existence of a free online course on Coronavirus available to all medical and dental operators promoted by Fnomceo
(National Federation of Surgeons and Dentists)? (Choose an answer)
A) Yes and I’ve already done it 31 5.8%
B) Yes, I will 142 26.5%
C) Yes, but I don’t think I do 24 4.5%
D) No, I didn’t know it now and I will 284 53.1%
E) No, I didn’t know but I don’t think I do 54 10.1%
19. Did your patients ask you questions about Coronavirus? (Choose an answer)
A) Yes 349 65.2%
B) No 186 34.8%
20. Do patients seem concerned about the possibility of receiving dental visits/treatments safely? (Choose an answer)
A) Yes 207 38.7%
B) No 328 61.3%
21. Since the spread of Coronavirus in our Country have you taken precautions or taken special measures during the course of the professional
activity? (Choose an answer)
A) Yes 369 69.0%
B) No 166 31.0%
22. Which of these prevention methods are you possibly adopting? (Choose one or more answers)
A) Air exchange always between patients and periodically also in the waiting room 177 14.9%
B) In the history include informations about symptoms compatible with infection or recent trips to areas affected by contagion or 118 10.0%
frequenting with people from those areas (recommended by phone)
C) Constant use of IPR (individual protective devices) by all dental office/hospital staff 218 18.4%
D) Frequent hand and cleaning of the contact surfaces (e.g. handles or buttons) 234 19.7%
E) Alcohol disinfectant available to patients and carers for hand cleaning at the entrance 115 9.7%
F) All previous 300 25.3%
G) None of the previous 14 1.2%
H) Other 9 0.8%
23. How concerned are you about the spread of Coronavirus infection in our country? (Choose an answer)
A) Not at all 8 1.5%
B) Little 125 23.4%
C) Enough 270 50.5%
D) Very 89 16.6%
E) Very much 43 8.0%
24. One last question... Do you think that dental activity can be considered safe and free from the risk of contagion and spread of the virus for
operators and patients? (Choose an answer)
A) Yes 67 12.5%
B) No 468 87.5%
on the dentist’s clinical activity (presence or absence of The remaining eleven questions aimed to assess the
infected cases in their region; questions of patients about level of scientific knowledge on coronavirus from a
coronavirus; patients appearing to be worried or not qualitative point of view and the dentist’s perception of
about possible infections with coronavirus during dental the problem related to this emergency in dental clinical
procedures; effective decrease or not in patient appoint- practice.
ment number since the coronavirus outbreak onset; Each respondent to the questionnaire corresponded to
adoption of special measures taken during professional a form with all answers provided. The subjects were an-
activity since the coronavirus emergency started in Italy; onymous and were marked only with a number that
and which prevention methods are possibly used). reflected the chronological order of compilation. The
form showed the day and time when the questionnaire Results
was completed. The survey was online for 3 weeks from 23 February
The project did not need formal ethical approval 2020 to 15 March 2020. The link received 795 visits, but
since it collected general opinions that do not con- only 535 dentists responded to the survey by completing
tain clinical data and neither personal data. Accord- it. The results of the descriptive statistics were collected
ing to the current Regulation of the Ethics in Table 3.
Committee of the Higher Institute of Health (Istituto Most dentists carried out their professional activity in
Superiore di Sanità), the ethical aspects that need a private practice (77.8%).The age group of up to 35
evaluation, approval and monitoring of trial proto- years old (yo) and the group between 46 and 60 yo were
cols relate to epidemiological, evaluation and the most represented (respectively, between 32.5 and
medical-social projects that require the collection of 33.5%). The distribution between the two sexes was
personal data. According to the National Data Pro- equivalent (48.8% males and 51.2% females).
tection Authority (Garante per la Protezione dei Dati Over 41.9% of dentists were General Dentists, 28% are
Personali), “personal data” are first and last name, Dentists without a recognized dental specialty (Italian
images, tax code, IP address and license plate num- Universities provide 3 years of postgraduate programs in
ber. The compilation of the survey was anonymously Orthodontics, Oral Surgery and Pediatric Dentistry.
carried out on a voluntary basis without the possibil- They are the only recognized Dental Specialties) and
ity to trace the identity of the subjects, as the system 30.8% are Dental Specialists (16.8% were orthodontists,
does not store even the IP addresses of the users approximately 12% were oral surgeons, and just over 2%
accessing the link. Before the start of the survey, in- were specialists in pediatric dentistry).
formed consent was presented on the main page; the The answers related to the geographical location of
participant had to agree (by checking a box) that the workplace mapped across the whole country, repre-
their anonymously provided answers could be used senting Italy from north to south and including the lar-
in this research for scientific purposes. ger islands (Sicily and Sardinia) (Fig. 4).
For statistical examination of the data, the online plat- Most of the respondents (40.6%) were from moder-
form automatically generated descriptive statistical ana- ately or highly populated cities. Fourty 9 % of the den-
lysis on the main page; the analysis could therefore be tists who participated in the survey treat more than 10
downloaded as an Excel or SPSS spreadsheet for further patients per day. Almost 70 % of dentists completed the
statistical analysis. In this study, descriptive statistical questionnaire when there were positive cases in their re-
analysis was carried out. Several measures of association gion of SARS-CoV-2 infection.
was performed including, the common Pearson’s χ2, the Fifty percent of respondents did not notice a decrease
Likelihood-Ratio χ2, Cramér’s V, Fisher’s exact test, in visits since the outbreak spread. More than 65% of pa-
Goodman and Kruskal’s γ, and Kendall’s τb. The level of tients asked questions about coronavirus to their dentist.
statistical significance was set at 0.05. The software used According to the clinicians who participated in the
is STATA 15.1 (StataCorp LLC, TX, USA). study, the majority of patients (more than 61%) would
The Pearson’s and Likelihood-Ratio χ2 test for the in- not be worried about getting coronavirus infection dur-
dependence of the rows and columns. The null hypoth- ing dental treatment.
esis (H0) is that there is no relationship. To reject this Almost 47% of dentists said they were fairly informed
we need a P < 0.05 (at 95% confidence). about coronavirus. Despite of the self-estimated know-
Cramér’s V is a measure of association between ledge about the infection, answers to the following ques-
two nominal variables. It goes from 0 to 1, where 1 tions assessing knowledge on the subject revealed a
indicates strong association. γ and τb are measures different reality. Most respondents obtained scientific in-
of association between two ordinal variables (both formation about coronavirus through Italian institutions
have to be in the same direction, i.e. negative to (37.6%); television, newspapers and social media (20.8%);
positive, low to high). Both go from − 1 to 1. Nega- professional associations (17%); scientific literature
tive shows inverse relationship, closer to 1 a strong (l6.1%); and other colleagues (7.3%). Only a very small
relationship. γ is recommended when there are lots percentage (0.8%) specified other channels of informa-
of ties in the data. τb is recommended for square tion or that they were not fully informed (0.2%).
tables. Almost 73% correctly answered the questions about
Fisher’s exact test is used when there are very few the definition of coronavirus, the 63.2% correctly an-
cases in the cells (usually less than 5, with an overall fre- swered about nCoV and 44.1% about SARS-CoV-2.
quency of less than 20%). It tests the relationship be- Most respondents, on the other hand, incorrectly an-
tween two variables. The null is that variables are swered the question on the definition of COVID-19 (al-
independent [21–25]. most 69%).
Fig. 4 The rectangles with the names of the different regions of Italy are accompanied by the number of dentists who participated in the survey.
The color scale distinguishes the different distribution of confirmed cases (data source: Italian Civil Protection, updated to March 28th 2020)
Almost 87% of the subjects were very clear about the considered the dental profession neither safe nor free
types of possible symptoms that accompany the infec- from the risk of contagion for both patients and health-
tion, and in 60.9% of cases, they correctly indicated how care professionals.
the new coronavirus is transmitted from person to The measures of association results were collected in
person. Tables 4, 5 and 6. In regards to the sex (Table 4), both
However, the 63.2% of dentists knew that the National χ2 test statistics show a significance level < 0.05 for qual-
Federation of Surgeons and Dentists (Federazione ity of information (question number 10), level of infor-
Nazionale dei Medici Chirurghi ed. Odontoiatri- mation related to questions 12 and 17 and for risk
FNOMCEO) has provided healthcare professionals with perception related to question 23; so we can safely as-
a free online course to disseminate useful information sume that some differences exist between groups. There-
about the virus. fore, we conclude that there is evidence of a statistically
Sixty nine percent of dentists who completed the ques- significant difference between male and female on these
tionnaire had taken safety and prevention measures variables. We can confidently reject the null hypothesis
against workplace infection since coronavirus spread. Al- that these two variables are statistically independent in
most 26% of them had taken all the recommended safety that population. In other words, we can conclude that
measures (telephone history collection, increased fre- there is some relationship between sex and each of these
quency of washing hands and environmental surfaces, four variables. In fact, for these variables the Cramér’s V
and personal protective equipment such as gloves, dis- values are > 0.13, which indicates a non-negligible asso-
posable gowns and facemasks with adequate filters). ciation. Moreover, the Goodman and Kruskal’s lambda
Fifty point 5 % of respondents were concerned for the relationship between sex and level of information
‘enough’ about the spread of infection in Italy. Overall, related to question number 12, and sex and risk percep-
almost 88% of dentists who took part in the survey tion related to question 23 is > 0.22, in line with previous
Table 4 Measures of association -gender

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb Fisher’s exact test
1. Gender- 9.6496** 9.8368** 0.1343 −0.0319 − 0.0185 (0.044)
QUALITY OF INFORMATION(10) (0.047) (0.043) (0.069) (0.040)
2. Gender- 3.8129 3.8238 0.0844 − 0.0871 −0.0491 (0.434)
LEVEL OF INFORMATION(18) (0.432) (0.430) (0.071) (0.040)
3. Gender- 9.2567*** 9.3697*** 0.1315 0.2681 0.1254 (0.010)
4. Gender- 1.5626 1.5670 0.0540 −0.0029 −0.0015 (0.674)
5. Gender- 0.7400 0.7403 0.0372 0.0243 0.0145 (0.947)
6. Gender- 2.8786 3.6511 0.0734 0.0664 0.0318 (0.492)
7. Gender- 5.1846 5.6270 0.0984 0.1794 0.0623 (0.190)
8. Gender- 10.5200** 10.9648** 0.1402 −0.1012 −0.0523 (0.015)
9. Gender- 1.7211 1.7214 −0.0567 −0.1221 − 0.0567 (0.192)
CORRECT RISK MANAGEMENT(22) (0.190) (0.190) (0.092) (0.043)
10. Gender- 24.9374*** 25.7561*** 0.2159 0.2272 0.1322 (0.000)
RISK PERCEPTION(23) (0.000) (0.000) (0.067) (0.040)
11. Gender- 1.2709 1.2717 0.0487 0.1466 0.0487 (0.296)
RISK PERCEPTION(24) (0.260) (0.259) (0.128) (0.043)
Notes: unequal variances assumed, after some checks. P-Values in parentheses. For Goodman-Kruskal’s γ and Kendall’s τ-b the Asymptotic Standard Errors (ASE)
are reported. p < 0.10, p < 0.05, p < 0.01
Table 5 Measures of association- age

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb Fisher’s exact test
12. Age- 39.3684*** 38.2612*** 0.1566 −0.0835 − 0.0580
13. Age- 17.6918 18.1606 0.1050 −0.0814 −0.0547
14. Age- 1.5170 1.5206 0.0377 −0.0131 −0.0072 (0.947)
15. Age- 15.2818* 15.6249* 0.0976 −0.2079 −0.1289
16. Age- 20.0687* 19.5222* 0.1118 −0.1332 −0.0948
17. Age- 7.0758 7.9172 0.0664 0.1031 0.0588 (0.488)
18. Age- 8.8334 10.1643 0.0742 0.0679 0.0280 (0.545)
19. Age- 19.3533* 19.2796* 0.1098 0.0726 0.0446
20. Age- 1.1150 1.1188 0.0457 −0.0303 −0.0166 (0.777)
21. Age- 13.6528 13.6826 0.0922 −0.0193 −0.0132
RISK PERCEPTION(23) (0.552) (0.550) (0.056) (0.038)
22. Age- 6.8839* 5.9705 0.1134 0.1004 0.0402 (0.093)
RISK PERCEPTION(24) (0.076) (0.113) (0.101) (0.041)
are reported. p < 0.10, p < 0.05, p < 0.01
Table 6 Measures of association- region

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb
23. Region- 63.4819 68.3577 0.1722 −0.0254 −0.0197
24. Region- 95.6957 99.0171* 0.2115 −0.0046 −0.0035
25. Region- 43.3894 47.8005 0.2014 −0.0396 −0.0246
26. Region- 88.8741*** 97.3943*** 0.2353 −0.0473 −0.0329
27. Region- 114.5570*** 104.4948** 0.2314 0.0086 0.0068
28. Region- 77.3373* 50.7542 0.2195 −0.0732 −0.0472
LEVEL OF INFORMATION(15) (0.065) (0.797) 0.058 (0.037)
29. Region- 77.2407 64.3017 0.1900 −0.0493 −0.0229
30. Region- 76.1563 54.2159 0.1886 −0.0450 −0.0309
31. Region- 42.1485*** 44.5656*** 0.2807 0.0276 0.0172
32. Region- 66.2305 68.6691 0.1574 0.0420 0.0322
RISK PERCEPTION(23) (0.996) (0.993) (0.045) (0.035)
33. Region- 23.0833 22.4473 0.2077 0.0816 0.0367
RISK PERCEPTION(24) (0.285) (0.317) (0.089) (0.040)
are reported. p < 0.10, p < 0.05, p < 0.01
results. All these findings are confirmed by Fisher’s exact the period of contagion outbreak from the new corona-
test results, since in these four cases the hypothesis of virus, information about the virus has become increas-
variables’ independence is rejected, and we conclude that ingly the subject of attention of the media, such as
there is some kind of relationship between variables. television, the internet, and social channels. However, it
Concerning the age (Table 5), the Pearson and was only when the first cases began to register in Italy
Likelihood-Ratio χ2 tests present a P-Value < 0.05 only that professional associations and dental professionals
for the relationship with the variable quality of informa- began to take a deeper interest in the problem. Dental
tion (question number 10). We reject the null hypothesis professionals had to refer only to the official communi-
of no association at conventional level of statistical sig- cation of the ministry, whose law decrees lacked specific
nificance, because it emerges a dependence of the rows references to the dental profession.
and columns. Thus, in this case we can conclude that Male dentists believed to be very well informed about
some differences emerge between groups. Moreover, in Coronavirus unlike female colleagues who had a more
this case Cramér’s V is > 0.15: there is a small but statis- cautious opinion on their knowledge of the subject
tically significant association between these variables. (Pearson χ2 test 9.6496- p 0.047; LR χ2 test 9.8368- p
If we consider the region (Table 6), the Pearson and 0.043). Dentists between the ages of 46–60 believe they
LR χ2 tests show a P-Value < 0.05 for level of informa- were well informed compared to younger colleagues
tion related to questions number 13 and 14, and correct who judged sufficient their knowledge (Pearson χ2 test
risk management related to question number 22; there- 39.3684- p 0.000; LR χ2 test, 38.2612 –p 0.000). Male
fore, we conclude that some relationship exists between dentists showed to have a significantly clearer idea of the
region and each of these three variables. Here, the Cra- taxonomic characteristics of the virus (Pearson χ2 test
mér’s V are > 0.23, which indicate a statistically signifi- 9.2567- p 0.010; LR χ2 test 9.3697- p 0.009). Most were
cant association. aware of the main features of coronaviruses but con-
fused the term COVID-19 with the virus itself (68.4%).
Discussion The definition of COVID-19 was provided more cor-
Since SARS-CoV-2 can be transmitted from person to rectly by the dentists of Lazio, Lombardy, Emilia-
person by droplets, contact and through saliva, dental Romagna and Sicily but the same regions, with the ex-
patients and dentists and their coworkers can be easily ception of Sicily, reported the greatest number of incor-
exposed to novel coronavirus infections [19, 26, 27]. In rect answers (which overall exceeded the correct ones)
and attributed to this term the meaning of “virus that people or of trips to the areas where the infection has
causes the disease”(Pearson χ2 test 77.3373- p 0.065). spread. Many dentists (10%) who responded to the sur-
The question containing the request to identify the cor- vey chose to ask this question of their patients, judging
rect definition of COVID-19 was absolutely, among all it to be important. At the time of the virus’s main
the questions in the questionnaire provided with the aim spread, it was recommended to perform a telephone tri-
of assessing scientific knowledge on the subject, the one age even before seeing the patient to assess whether to
for which the largest number of wrong answers were visit or to postpone the appointment.
recorded. At the time of the survey, performed between February
In addition, most believed that the term SARS-CoV 2 23rd and March 15th, just over 50% of dentists did not
is not related to the new coronavirus but is rather the notice a reduction in the number of visits despite the
name of the SARS virus that caused an epidemic in spread of the virus. It must be specified that after two
2002–2003 (22.4%). Dentists aged between 36 and 45 weeks from the start of this research many work activ-
have identified the correct answer in a significantly ities were suspended by the government by extraordin-
higher percentage than younger and older colleagues ary decree, but the clinical dental activity was allowed
(Pearson χ2 test 20.0687 - p 0.066; LR χ2 test, 19.5222 only for the management of emergencies provided by
-p 0.077). Also on this definition, the dentists of Lazio dentists equipped with adequate personal protective
and Lombardy were those significantly better informed, equipment (PPE). The definition of “adequate PPE” for
followed by their colleagues from Emilia-Romagna and dentists is a matter of debate because above all the surgi-
Campania (Pearson χ2 114.5570- p 0.007; LR χ2 test cal masks used routinely by dentists would not have suf-
104.4948- p 0.034). ficient filters to protect from infection. The use of
The most informed dentists on the possibility to access facemasks with ffp2 or ffp3 filters, highly protective than
a free online course on the new Coronavirus promoted the surgical ones, does not seem to be considered neces-
by the FNOMCEO (National Federation of Surgeons sary for routine dental activity, even if this has not been
and Dentists) were those from Lazio, followed by those clearly said nor denied.
from Lombardy, Sicily and Tuscany (LR χ2 test 99.0171- The absence of a sample calculation and the method-
p 0.073). ology used in the dissemination of the survey represent
Quite important for the population and for the spread limitations in this research. Anyway the distribution of
of epidemics is the preventive approach of dentists. For the respondents in the national territory was quite
the possibilities of transmission from person to person, homogenous (proportionate to the extension of the indi-
most are properly informed (60.9%). Female dentists vidual regional territories) and the greatest proportion
were better informed on this aspect (Pearson χ2 test came from medium-large cities. Although 65.2% of den-
10.5200- p 0.033; LR χ2 test 10.9648- p 0.027). Com- tists said that patients have asked questions about cor-
pared to age, younger dentists were significantly better onavirus, they agree that patients feeling worried about
informed about the transmission routes of the virus than contracting the infection through dental care has not
other age groups (Pearson χ2 test, 19.3533- p 0.080; LR emerged (61.3%). Most of the dentists (69%) adopted
χ2 test 19.2796- p 0.082). additional preventive practical measures, a sign of a
More than 87% of respondents to the survey were growing and widespread awareness (87.5%) of the risk of
aware of the wide variety of symptoms with which the contributing to the spread of contagion through dental
infection can occur, which is encouraging because it activity. There were regions where the number of den-
means that a diagnostic suspicion and a report to the au- tists who claimed to have taken additional contagion
thorities regulating the execution of swab tests of poten- prevention measures during their clinical activity was
tially infected individuals can also be appropriately significantly higher than others. This was especially true
carried out by a dentist. It is important to consider that for regions such as Lazio, Lombardy, Emilia Romagna
transmission may occur through asymptomatic patients and Campania. It is interesting to note that regions such
and that symptoms when COVID-19 is present can also as Veneto which since the beginning of the spread of the
be mild and confused with a simple cold or flu [28]. Its virus in Italy has been one of the first regions and
manifestation does not always culminate with severe among the most affected had not the same attitude
symptomatology accompanied by respiratory failure up (Pearson χ2 test, 42.1485- p 0.003; LR χ2 test 44.5656- p
to interstitial pneumonia. The asymptomatic incubation 0.001).
period takes approximately 1–14 days, and in these days, The female gender appeared significantly more con-
persons without symptoms can spread the virus. For this cerned than the male gender about the spread of Cor-
reason, it is important to add to the information re- onavirus infection (Pearson χ2 test 24.9374- p 0.000; LR
quired of the patient in the medical history, the report of χ2 test 25.7561, p 0.000). Dentists belonging to the
a possible contact with infected or potentially infected younger age groups were found to be much more
convinced than their older colleagues that this epidemic spread can be crucial to control the pandemic. For this
has future repercussions on the dental profession as it is reason, dentists, similar to other medical practitioners,
not without risk (Pearson χ2 test, 6.8839- p 0.076). aware of the risk associated with carrying out their pro-
Dental treatment procedures always involve close con- fessional activity, at this moment limited to the manage-
tact with the patient, and this setup does not allow the ment of dental emergencies only, have the responsibility
maintenance of an adequate safe distance. It is extremely in this situation to know the characteristics of the virus
important that dentists equip themselves with appropri- through precise and accurate information and to assume
ate individual safety devices (masks, gloves, protective a careful and proactive attitude for the protection of
goggles, hair caps and shirts). A recent article in the their patients and of their entire community, working in
New York Times, referring to the database “O’NET” the containment of this social emergency even if not dir-
used by the Department of Labor to describe the various ectly involved in the treatment of affected patients.
physical aspects of different professions, highlighted that Dentists at this time, however, should only work if
the occupational categories in which you come into they have the individual protective equipment recom-
physical contact with others are those where the risk of mended to high-risk healthcare workers [32, 33]. After
COVID-19 is highest. Dentists are at the top of the rank- the pandemic emergency when people’s professional ac-
ing for work-related risk [29]. In this survey, dentists af- tivities and lives can slowly return to normal, the experi-
firmed the constant use of these safety devices as ence and the not-quite-finished risk of a recurrence of
prescribed by the Italian medical guidelines of safety in new cases of infection will require that dentists also fol-
workplaces [30]. When aerosol procedures are carried low new health safety protocols whose definition will be
out, the presence of saliva and blood increases the necessary.
spread of germs, bacteria and viruses. Ensuring a change
of air in the workplace and in the waiting room is a sim- Supplementary information
ple but important measure chosen by 14.9% of dentists Supplementary information accompanies this paper at https://doi.org/10.
1186/s12903-020-01187-3.
in this survey. This measure should always be adopted
by dentists and not only in this situation. Equally essen-
Additional file 1. “Questionnaire” contains the English version of the
tial is to wash hands more frequently and disinfect them questionnaire realized for the survey in this research.
with alcohol-based solutions. This provision should also
be encouraged for patients before entering the operating Abbreviations
dental unit. These recommendations, together with WHO: World Health Organization; PPE: Personal Protection Equipment
those of not shaking hands with anyone, were accepted
Acknowledgments
by 9.7 and 19.7% of respondents, respectively. The data Not applicable.
that emerged on the cleansing measures also include the
cleaning of the clinical contact surfaces, such as buttons, Authors’ contributions
AP designed the study and was the major contributor to writing the
handles and work surfaces. Thorough cleaning has manuscript. MR coordinated the development of the online questionnaire,
proven to be a mandatory and indispensable choice for data management and extrapolation. CM was responsible for statistical
prevention, as it is proven that the coronavirus family, analysis of the results. GG researched the bibliography sources and reviewed
the final manuscript. All authors read and approved the final manuscript.
including SARS-CoV-2, can survive on plastic, metal
and glass surfaces for up to 9 days and can be efficiently Funding
deactivated through disinfection procedures with 62– No funding needed.
71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium
Availability of data and materials
hypochlorite within 1 min. The use of 0.05–0.2% ben- The datasets used and/or analysed during the current study available from
zalkonium chloride or 0.02% chlorhexidine digluconate the corresponding author on reasonable request.
does not have the same effectiveness [31]. It must be
Ethics approval and consent to participate
said that the majority of dentists paid great attention to This research does not contain data require ethics approval. The current
the measures to be taken; indeed, 25.3% of them said Regulation of the Ethics Committee of the Higher Institute of Health (Istituto
they had adopted all the preventive measures listed so Superiore di Sanità, Rome 12th May 2015) stipulates that projects with
epidemiological, medico-social and evaluative contents need evaluation, ap-
far. proval and monitoring of trial protocols only if they contain personal data
according to the legislative decrees on clinical trials and function of the eth-
Conclusions ics committees (decreto legislativo 24 giugno 2003, n.211; decreto minister-
iale 8 febbraio 2013). The official definition of “personal data” is given by the
This is the most severe epidemic that has hit Italy in the National Data Protection Authority (Garante per la Protezione dei Dati Perso-
past 100 years, and it will probably be one of the most nali, https://www.garanteprivacy.it/home/diritti/cosa-intendiamo-per-dati-per-
severe viral pandemics of modern times. As no specific sonali – Regolamento (UE) 2016/679 art.9). The term “personal data” includes
information about first and last name, images, tax code, IP address and li-
therapies are available at the moment for the new cor- cense plate number. The platform on which the anonymous questionnaire
onavirus, prevention and early containment of further was completed does not allow to trace the IP address of the person who
connected to the survey. Informed consent was presented on the main page 16. Protezione Civile Italiana. Emergenze Coronavirus. 2020. http://www.
of the online platform used to complete the survey. Before the start of the protezionecivile.gov.it/attivita-rischi/rischio-sanitario/emergenze/coronavirus
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Consent for publication fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/
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ORIGINAL ARTICLE
COVID-19: A SURVEY ON KNOWLEDGE, AWARENESS

AND HYGIENE PRACTICES AMONG DENTAL HEALTH
PROFESSIONALS IN AN INDIAN SCENARIO
Ramandeep Singh Gambhir1, Jagjit Singh Dhaliwal2, Amit Aggarwal3, Samir Anand4,
Vaibhav Anand5, Amanpreet Kaur Bhangu6
1
Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
2
PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
3
Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, MM (Deemed
to be University), Mullana, India
4
Department of General Dentistry, Aesthetics-The Smile Partners, Zirakpur, Punjab, India
5
Department of Public Health Dentistry, Shaheed Kartar Singh Sarabha Dental College and Hospital,
Ludhiana, India
6
Department of General Dentistry, Community Dental Centre, Chandigarh, India
ABSTRACT
Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) continues to spread globally.
It has become a major cause of concern for health care professionals all over the world.
Objective. The aim of this study was to assess knowledge, awareness and hygiene practices regarding COVID-19 among
private dental practitioners practicing in Tricity (Chandigarh, Panchkula and Mohali) in India during these critical times.
Materials and Methods. A total of 245 private dentists participated in this cross-sectional survey and finally 215 constituted
the final sample size. A self-administered, multiple choice type questionnaire (verified by a specialist) was administered to
obtain information from the subjects. The questionnaire was divided into two parts and included 15 questions on knowledge
and awareness regarding COVID-19. Statistical analysis was done using ANOVA and Student’s t-test.
Results. Percentage of subjects who answered correctly regarding main symptoms of COVID-19 and primary mode of
transmission was 87% and 82.5% respectively. One-third of the subjects were not aware regarding Personal Protective
Equipment (PPE) to be used while rendering dental treatment. 75% of subjects were of the opinion that supportive care is
the current treatment regime for COVID-19. Less than one-third of subjects (30.2%) reported high scores. Education level
(p=0.018) and health sector profile (p=0.024) of the subjects were significantly associated with mean knowledge scores.
Conclusion. The findings of the present study showed that some notable deficiencies in knowledge existed among dental
professionals regarding some vital aspects of COVID-19. Therefore, there is an urgent need for improving dentists’
knowledge via health education and training programs. Further studies on the subject are also warranted once the situation
normalizes.
Key words: knowledge, pandemics, coronavirus, COVID-19, dentists, emergencies
INTRODUCTION the globe [13]. Two main unique features of the virus
are its low pathogenicity and high transmissibility
COVID-19 (Coronavirus Disease, 2019 & SARS- that distinguish it from other members of the
CoV-2) is the newly discovered emerging respiratory coronavirus family such as SARS-CoV (Severe Acute
disease that is caused by a new member of the Respiratory Syndrome) and MERS-CoV (Middle
coronavirus family called novel coronavirus [14]. The Eastern Respiratory Syndrome) [12]. It is a highly
epidemic of the disease which started in the month of infectious disease and its clinical symptoms include
December 2019 in Wuhan city of China, has become fever, dry cough, myalgia and fatigue and severe cases
one of the major public health problems of this century progressing to acute respiratory distress syndrome
and is claiming thousands of lives everyday across leading to bleeding and coagulation dysfunction [2].
Corresponding author: Dr Ramandeep Singh Gambhir, Department of Public Health Dentistry, Rayat and Bahra Dental College and
Hospital, Mohali, Punjab, India, PIN-140104, Tel. +91-99156-46007, Fax- +91-160-5009680, e-mail: [email protected]
© Copyright by the National Institute of Public Health - National Institute of Hygiene
224 COVID-19: knowledge, awareness and hygiene among dental health professionals in India No 2
The risk of increased severity is noticed in the elderly of dental health professionals who are engaged in
and individuals with underlying chronic diseases. private practice in the Tricity (Chandigarh, Panchkula
Human-to-human transmission of the virus is and Mohali). List of all private dental practitioners of
occurring through airborne droplets, contact or touch the Tricity was obtained from Local Indian Dental
of an infected person or from a contaminated surface. Association (IDA) bodies through email.
According to recent reports, COVID-19 positive The sample size required for the study was
cases have crossed 30000 in India, taking the total calculated using the following formula for sample size
number of deaths to 1583 [10]. However, still there calculation:
is no community transmission of the virus in India
as per reports of the Health Ministry barring a few n = Z²1-(α / 2) × S2 / d2
places of virus cluster designated as hot spots. The
entire country is in a state of ‘Lockdown’ (till 3rd May where:
as of now) and the government is issuing advisories Z - is the standard normal score with 95%
on daily basis for its citizens particularly regarding confidence interval (CI) (a=0.05);
delivery of essential health services and various S - is the standard deviation of the variable;
protective measures to be taken to guard oneself from d - is maximum acceptable error.
getting infected; the most important being staying at
home (Isolation and Social-Distancing) [10]. To take account of potential errors and sample loss,
Health care workers are amongst the most which is common in cross-sectional studies, a final
vulnerable group who have the greatest risk of getting sample size was estimated to be 245.
infected. There have been reports of medical staff In order to pick the study subjects from our sampling
acquiring the disease while taking care and treating frame (list of all practicing dentists), a simple random
infected individuals [11]. The dental operatory poses sampling methodology was used. However, only 215
a riskier environment because of high possibility subjects returned the questionnaire that constituted
of cross-infection between dental practitioners and the final study sample.
patients. Although most of the dental clinics are closed
during these times, however dental emergencies do Research instrument
come and it’s our moral duty to treat them thereby A self-designed questionnaire written in
establishing a close contact [6]. A COVID-19 positive English language was made specifically for the
case can go symptomless for many days, therefore study. A specialist in infectious and communicable
various guidelines are recommended by Centre for disease was consulted to verify the content of the
Disease Control and Prevention (CDC) and World questionnaire. The questionnaire was pre-tested
Health Organization (WHO) for dental health care for validity and reliability. The reliability of the
workers that adequate precautions can be taken [1, questionnaire was good (0.84). The questionnaire was
15]. Still, the exact behaviour of the virus is not fully divided into two sections: (1) Section A was ‘General
understood by the scientists, making it even more section’ which comprised of socio-demographic
risky for a health practitioner. Therefore, the present and professional details of the subjects (gender,
questionnaire survey was carried out to assess the educational status, type of practice etc.). (2) Section
basic essential knowledge, awareness and hygiene B comprised of 15 questions depicting knowledge and
practices among dental health professionals regarding awareness regarding COVID-19 (common symptoms,
COVID-19 in an Indian setting. mode of transmission, availability of vaccine,
various preventive measures, details of hygiene
MATERIALS AND METHOD practices etc.). The questionnaire was delivered to
the study subjects via email and WhatsApp (Social
Ethical clearance and informed consent Media Application) and not handed over personally
Ethical clearance from the Institutional Ethics because of city ‘Lockdown’ to prevent the spread of
Committee and was obtained prior to the start of the the virus. The subjects were given one week time to
study. Informed consent was obtained from the subjects fill the questionnaire and return it. Total knowledge/
for their willingness to participate in the study. The awareness score was calculated on the basis of each
study was conducted in March, 2020. Participation in subject’s response. Each positive response was
the study was voluntary and identification information awarded a score of ‘1’ and negative response as ‘0’.
was not collected from the study subjects. The total score of the subject was calculated by adding
the sum of responses which ranged from 1 to 15, on
Study population and study sample a Likert Scale. The final scores were categorized at
The present study was a descriptive cross-sectional three levels: low (0-5), medium (6-10) and high (11-15).
(questionnaire) study. The study population consisted
No 2 R.S. Gambhir, J.S. Dhaliwal, A. Aggarwal et al. 225
Statistical Analysis included a total of 215 subjects in which male subjects

Calculations were done using descriptive statistical (133, 61.8%) were in clear majority as compared to
analysis. Number and percentages were used to female subjects (82, 38.2%). Also, more number
compute results on categorical measurements. SPSS of subjects held a graduate degree (120, 55.8%) as
package version 19.0 (SPSS, Chicago, IL, USA) was compared to subjects holding a post graduate degree
used to statistically analyze the results. To find the in dentistry and majority of the subjects (127, 59%)
significance of study parameters between three or were engaged in both academic and private practice.
more groups of subjects, Analysis of Variance test Regarding years of practice, 59 (27.5%) subjects were
(ANOVA) was used and Student’s t-test was used to practicing for more than 10 years.
find significance between two groups. The significance
level was set at <0.05. Response to questions regarding COVID-19
Subjects’ response towards questionnaire regarding
RESULTS COVID-19 is depicted in Figure 1. Percentage of subjects
who answered correctly regarding main symptoms of
Socio-demographic and professional characteristics COVID-19 and primary mode of transmission was
Socio-demographic and professional profile of 87% and 82.5% respectively. One-third of subjects
study subjects is depicted in Table 1. The present study (33%) were unaware regarding mandatory Personal
Table 1. Socio-demographic and professional profile of study subjects

Profile Number Percentage
Male 133 61.8
Gender
Female 82 38.2
Graduate (BDS) 120 55.8
Educational status
Postgraduate (MDS) 95 44.2
Private clinic 88 41
Health Sector
Combined (Private & Academic) 127 59
Up to 5 74 34.4
Years of practice 5-10 82 38.1
More than 10 59 27.5
Figure 1. Subjects’ response to questionnaire on COVID-19

Protective Equipment (PPE) that is required while that 94.2% (202) used alcohol rub or soap and water
rendering dental treatment. When asked about any to clean their hands after treating patients. Routinely
nearby government designated facility for virus testing, cleaning and disinfecting clinic surfaces were done by
64.5% of subjects answered correctly. Approximately 86.2% (184) of subjects. Surprisingly, only 35.2% (75)
42% of subjects had adequate knowledge regarding of subjects were conducting fumigation of the dental
vaccine trials to prevent COVID-19. Only 8.5% of the operatory every week and only 32.4% (69) of study
subjects were providing emergency treatment at their subjects were disinfecting the lab work area daily.
practice in these critical circumstances and 12.5%
of subjects showed their willingness to help health Knowledge/awareness level of subjects
workers in times of need. Two-third (75%) of the Only 30.2% (55) of subjects reported high
subjects were of the opinion that supportive care is the knowledge scores and 38.1% (92) of subjects were
current treatment for COVID-19 and health authorities having low knowledge scores (Table 2). There
can effectively prevent community transmission of the was a statistically significant association of mean
virus. In addition, 59.5% of subjects had knowledge knowledge scores with education level (p=0.018) and
regarding recent guidelines recommended by WHO health sector profile (p=0.024) of the subjects whereas
for health care workers. no significant difference of knowledge score was
observed with gender and years of practice (p>0.05)
Personal and clinic hygiene practices (Table 3).
Details regarding personal and clinic hygiene
practices are mentioned in Figure 2. It was reported
Figure 2. Personal and clinic hygiene practices among subjects
Table 2. Final knowledge scores of study subjects regarding COVID-19 (on the basis of Likert scale)
Number Percentage
Knowledge score 95% CI
of subjects of subjects
Low 82 38.1 48.27-56.52
Medium 68 31.6 32.42-41.17
High 65 30.2 23.36-29.76
Total 215 100
Table 3. Mean knowledge scores of subjects according to different socio-demographic variables
Socio-demographic profile Knowledge/Awareness score P-value
Gender Mean Standard Deviation

Male 7.42 1.36 F=1.512
Female 5.36 2.62 P= 0.062
Total 6.39 2.65
Education level
Graduate (BDS) 5.22 2.21 F= 2.826
Postgraduate (MDS) 7.76 3.26 P=0.018*
Total 6.49 2.42
Health sector
Private 5.12 1.23 F=2.225
Combined 8.01 4.55 P= 0.024*
Total 6.56 2.54
Years of practice
Up to 5 4.55 3.34
F= 3.454
5-10 4.67 2.75 P= 0.172
More than 10 6.71 4.21
Total 5.31 4.12
P<0.05 (Statistically significant), Tests used: Student -t test, ANOVA
DISCUSSION Following the pandemic alert by WHO, Government

of India provided diagnostic facilities for novel
The pandemic spread by COVID-19 has put the whole coronavirus testing for suspected cases at designated
world in a state of emergency as thousands of individuals centres throughout the country [10]. More than 60%
are losing their lives every day because of this life of subjects were aware of such facility in our study.
threatening disease [16]. To the best of our knowledge, the The most effective and economical means to prevent
present study is first of its kind in the Indian subcontinent and control infectious diseases is though vaccines.
examining the knowledge and awareness of dental health While most of the vaccines against COVID-19 are
professionals regarding this deadly disease. A close- under design and preparation, there are some that
ended questionnaire was used in the study in order to have entered efficacy evaluation in animals and initial
achieve a quicker response from the subjects in this state clinical trials [17]. Only 41.6% of dental practitioners
of crisis [4]. It was observed in the study that majority in our study had basic knowledge regarding vaccine
of the subjects had fair knowledge regarding COVID-19 developments.
and there were noteworthy deficiencies in some of the Dental emergencies can occur and exacerbate in
important aspects. a short period and therefore need immediate treatment.
Recent research has observed that asymptomatic Till now, there has been no consensus on the provision
patients and patients in their incubation period are of dental services during the current pandemic [15].
also carriers of this particular virus which can lead to Though it is matter of personal choice, it was observed
disease transmission [7]. More than 80% of subjects that 8.5% of dental practitioners were providing
were aware of this fact in the present study which is emergency dental services at their clinic. Moreover,
in congruence to findings of some other study as well 12.5% of the subjects were willing to help health care
[6]. The use of PPE, like masks (N-95), gloves, gowns, workers in case there is shortage of health care staff.
and goggles or face shields, is recommended to protect Currently there is no specific treatment available
skin and mucosa from (potentially) infected blood or to treat COVID-19, so the management of COVID-19
respiratory secretions [3]. Appropriate use significantly has been largely supportive that includes infection
reduces risk of viral transmission. Astonishingly, one- prevention and control measures to lower the risk of
third of subjects in the present study were not fully transmission and isolation [9]. Two-third of the subjects
aware regarding mandatory PPE which is in contrast to in our study agreed to this fact which is in contrast to
findings of some other studies [6, 11]. findings of a recent study conducted on health care
workers in China [5]. The present study also reported
that more than 60% of subjects were knowledgeable efficient strategies can be formed to prevent, control,
regarding recent WHO guidelines for health care and stop the spread of COVID-19. Recent guidelines
workers while dealing with COVID-19 patients. recommended by WHO and CDC should be followed
Hand hygiene has been considered the most vital while treating patients in dental practices and dental
measure for minimizing the risk of transmitting schools. Further studies involving larger sample size
microorganism to patients [8]. More than 90% of subjects should be conducted once things are under control
used alcohol rub or soap and water to clean their hands and this deadly disease is eradicated from the world.
after treating patients in our study. Coronavirus-2 can Lastly, as a health care professional, it’s our moral
persist on surfaces for a few hours or up to several days, duty to support health care workforce in times of need
depending on the nature of surface, the temperature, or during this global epidemic.
the humidity of the environment [15]. A vast majority of
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Clinical Oral Investigations
https://doi.org/10.1007/s00784-020-03248-x
LETTER TO THE EDITOR
Coronavirus COVID-19 impacts to dentistry and potential

salivary diagnosis
Robinson Sabino-Silva 1,2 & Ana Carolina Gomes Jardim 3 & Walter L. Siqueira 1
Received: 15 February 2020 / Accepted: 17 February 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020
Summary respiratory disease, with severe cases leading to pneumonia,

kidney failure, and even death. The severe respiratory illness
A novel coronavirus (COVID-19) is associated with human- caused by the COVID-19 was first detected in Wuhan, Hubei,
to-human transmission. The COVID-19 was recently identi- China, and infections have spread worldwide [2]. Currently,
fied in saliva of infected patients. In this point-of-view article, the available COVID-19 genome sequences from clinical
we discuss the potential of transmission via the saliva of this samples suggest that this viral emergence is related to bat
virus. The COVID-19 transmission via contact with droplets coronaviruses [3]. Although the coronavirus infection in
and aerosols generated during dental clinical procedures is humans frequently presents with mild severity, the
expected. There is a need to increase investigations to the betacoronavirus infection of either the severe acute respiratory
detection of COVID-19 in oral fluids and its impact on the syndrome coronavirus (SARS-CoV) [4] or the Middle East
transmission of this virus, which is crucial to improve effec- respiratory syndrome coronavirus (MERS-CoV) [5] resulted
tive strategies for prevention, especially for dentists and in higher mortality rates [6]. Given the novelty of COVID-19,
healthcare professionals that perform aerosol-generating pro- some characteristics of the virus remain yet unknown. The
cedures. Saliva can have a pivotal role in the human-to-human COVID-19 outbreak serves as both a reminder and an oppor-
transmission, and non-invasive salivary diagnostics may pro- tunity to assist. Considering that COVID-19 was recently
vide a convenient and cost-effective point-of-care platform for identified in saliva of infected patients [7], the COVID-19
the fast and early detection of COVID-19 infection. outbreak is a reminder that dental/oral and other health pro-
fessionals must always be diligent in protecting against the
spread of infectious disease, and it provides a chance to deter-
Current point of view mine if a non-invasive saliva diagnostic for COVID-19 could
assist in detecting such viruses and reducing the spread.
The present outbreak of the 2019 coronavirus strain (COVID- The Chinese Centre for Disease Control and Prevention iso-
19) constitutes a public health emergency of global concern lated the COVID-19. It published the viral genome sequence data
[1]. International centers for disease control and prevention immediately in international database banks GenBank and the
are monitoring this infectious disease outbreak; symptoms of Global Initiative on Sharing All Influenza Data (GISAID) [8, 9].
COVID-19 infection include fever, cough, and acute This action enabled laboratories in several countries to develop
unique PCR tests focusing on the diagnosis of COVID-19 [8,
Robinson Sabino-Silva, Ana Carolina Gomes Jardim and Walter L. 10]. Currently, the COVID-19 transmission routes are still to be
Siqueira contributed equally to this work. determined, but human-to-human transmission has been con-
firmed [10, 11]. The laboratory diagnostic tests should be per-
* Walter L. Siqueira formed using nasopharyngeal, oropharyngeal, and blood sam-
[email protected] ples. Expectorated sputum and other specimens in severe respi-
1
ratory disease should be considered as lower respiratory tract
College of Dentistry, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
samples [2, 12, 13]. Several potential scenarios of COVID-19
2
transmission have been described. The transmission via contact
Department of Physiology, Institute of Biomedical Sciences, Federal
University of Uberlandia, Uberlandia, Minas Gerais, Brazil
with droplets from talking, coughing, sneezing (related to human
3
respiratory activities), and aerosols generated during clinical pro-
Laboratory of Virology, Institute of Biomedical Sciences, Federal
University of Uberlandia, Uberlandia, Minas Gerais, Brazil
cedures is expected, as it would be for other respiratory
Clin Oral Invest
infections. The origin of droplets can be nasopharyngeal or oro- via salivary ducts. It is essential to point out that salivary gland
pharyngeal, normally associated with saliva. Larger droplets epithelial cells can be infected by SARS-CoV a short time
could contribute to viral transmission to subjects nearby, and, after infection in rhesus macaques, suggesting that salivary
on the other side, the long-distance transmission is possible with gland cells could be a pivotal source of this virus in saliva
smaller droplets infected with air-suspended viral particles [14]. [22]. Additionally, the production of SARS-CoV-specific se-
Considering that laboratory diagnostic tests are also performed in cretory immunoglobulin A (sIgA) in the saliva of animal
blood samples, the transmission by contaminated blood should models intranasally immunized was previously shown [23].
also be considered. In this context, healthcare workers, such as Considering the similarity of both strains, we speculate that
dentists, may be unknowingly providing direct care for infected, salivary diagnosis of COVID-19 could also be performed
but not yet diagnosed COVID-19 patients, or those considered to using specific antibodies to this virus.
be suspected cases for surveillance [12, 13]. Asymptomatic in- Further studies are needed to investigate the potential diag-
fections seem to be possible [15] and transmission may occur nostic of COVID-19 in saliva and its impact on transmission
before the disease symptoms appear. A recent clinical study in- of this virus, which is crucial to improve effective strategies
dicates that 29% of 138 hospitalized patients with COVID-19- for prevention, especially for dentists and healthcare profes-
infected pneumonia in Wuhan, China, are healthcare workers sionals that perform aerosol-generating procedures. Saliva can
[16]. As in bronchoscopy [17], inhalation of airborne particles have a pivotal role in the human-to-human transmission, and
and aerosols produced during dental procedures on patients with salivary diagnostics may provide a convenient and cost-
COVID-19 can be a high-risk procedure in which dentists are effective point-of-care platform for COVID-19 infection.
directly and closely exposed to this virus. Therefore, it is crucial
for dentists to refine preventive strategies to avoid the COVID-19 Funding information This research was supported by the Canadian
Institutes of Health Research (CIHR grant nos. 106657 and 97577). The
infection by focusing on patient placement, hand hygiene, all
authors received financial support from the Royal Society – Newton
personal protective equipment (PPE), and caution in performing Advanced Fellowship (grant reference NA 150195) and FAPEMIG (Minas
aerosol-generating procedures. The Interim Guidance for Gerais Research Foundation - SICONV 793988/2013; APQ-02872-16 and
Healthcare Professionals from CDC has been updated, and it is APQ-03385-18). ACGJ received productivity fellowship (311219/2019-5)
from the CNPq (National Counsel of Technological and Scientific
subject to change as additional information on COVID-19 infec-
Development). The Brazilian funding agencies CNPq, CAPES
tion and transmission becomes available. (Coordination for the Improvement of Higher Education), and FAPEMIG
Diagnosis of COVID-19 can theoretically be performed provide financial support to the National Institute of Science and
using salivary diagnosis platforms. Some virus strains have Technology in Theranostics and Nanobiotechnology - INCT-Teranano
(CNPq-465669/2014-0).
been detected in saliva as long as 29 days after infection [18,
19], indicating that a non-invasive platform to rapidly differ-
entiate the biomarkers using saliva could enhance disease de- Compliance with ethical standards
tection. [20] Saliva samples could be collected in patients who
Competing interests The authors declare that they have no competing
present with oropharyngeal secretions as a symptom [12, 13]. interests.
Bearing in mind the requirement of a close contact between
healthcare workers and infected patients to collect nasopha-
ryngeal or oropharyngeal samples, the possibility of a saliva
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Odontol.

Sanmarquina 2020; 23(2): 139-146 ODONTOLOGÍA SANMARQUINA

2019 (COVID-19) y su Ángel Aurelio Morocho Macas 1,c

odontológica: una revisión Doctora en Odontología.

Conflicto de intereses: los autores declaran no

Fuente de financiamiento: autofinanciado.

Introducción la OMS continúa aumentando y la situación de preven-

140 Odontol. Sanmarquina 2020; 23(2)

Odontol. Sanmarquina 2020; 23(2) 141

142 Odontol. Sanmarquina 2020; 23(2)

¿Ha tenido fiebre en los últimos 14 días? SI SI

Fuente: Elaborado a partir de Tuñas IT de C. et al.

Odontol. Sanmarquina 2020; 23(2) 143

Tabla 2. Situaciones consideradas emergencias en pacientes sin síntomas respiratorios

a. Dolor dental severo por inflamación pulpar.

Fuente: Elaborado a partir de ADA 2020 26

144 Odontol. Sanmarquina 2020; 23(2)

Referencias bibliográficas 13. Doerrbecker J, Friesland M, Ciesek S, Erichsen TJ, Ma-

Odontol. Sanmarquina 2020; 23(2) 145

146 Odontol. Sanmarquina 2020; 23(2)

en la atención dental: revisión 1

Conflicto de intereses: el autor declara no tener

care: review and update of the literature Fuente de financiamiento: autofinanciado.

Introducción en la boca del paciente están expuestos a una gran can-

2 Odontol. Sanmarquina 2020; 23(3)

Rutas de contagio desafío para el personal de salud en la lucha por con-

Odontol. Sanmarquina 2020; 23(3) 3

4 Odontol. Sanmarquina 2020; 23(3)

Odontol. Sanmarquina 2020; 23(3) 5

6 Odontol. Sanmarquina 2020; 23(3)

Odontol. Sanmarquina 2020; 23(3) 7

Referencias bibliográficas 13. Palacios M, Santos E, Velázquez M, León M. CO-

8 Odontol. Sanmarquina 2020; 23(3)

Odontol. Sanmarquina 2020; 23(3) 9

10 Odontol. Sanmarquina 2020; 23(3)

COVID-19 Outbreak in North Italy: An Overview

Viale San Pietro, I-07100 Sassari, Italy

CH-3010 Bern, Switzerland

Received: 28 April 2020; Accepted: 25 May 2020; Published: 28 May 2020

Keywords: COVID-19; infection; dentist; protective measures; awareness; infection control

2. Materials and Methods

2.1. Development and Building-Up of the Questionnaire

Table 1. Questionnaire items.

I had one/more symptoms/signs

Washing operators’ hands before and after each procedure

2.2. Data Analysis

Table 2. Participants' distribution by age and gender.

Males Females Total

Milan Area High Prevalence Area Low Prevalence Area

frequency; EF, expected frequency; %, percentage; Cχ2, contribution to chi-square.

Milan Area High Prevalence Area Low Prevalence Area

Milan Area High Prevalence Area Low Prevalence Area

Table 8. Perception of risk related to COVID-19.

Milan Area High Prevalence Area Low Prevalence Area

Funding: This research received no external funding.

Conflicts of Interest: The authors declare no conflict of interest.

Vol. XX • Issue X Dental Care under the Clouds of COVID-19

Dental Care and Oral Health

Dentists’ Awareness, Perception, and Attitude Regarding