KNOWLEDGE AND PRACTICE MODIFICATIONS REGARDING COVID-19 AMONG DENTAL PRACTITIONERS OF NEPAL

1* 2 1 3 Rebicca Ranjit , Pra k Manandhar , Soni Bista , Elijma Ranjit


INTRODUCTION
The outbreak of COVID-19 has spread exponen ally worldwide within short mespan and Nepal is not an 1 excep on. Despite adop ng tremendous measures, innumerable cases prevail na onwide, leaving every sectors stands ll, including den stry. The increased threat of crossinfec on and rising financial burden have caused psychological distress to den sts. 2 Most rou ne dental procedures generate aerosols. Moreover, den sts work in close proximity to pa ents, thereby increasing risk of cross-contamina on and infec on spread. Thus, to provide rela vely safe dental care to pa ents and to ensure safety of en re dental team, den sts should upgrade their insight regarding the disease, follow recommended guidelines on infec on control, and consider relevant prac ce modifica ons. Researches across globe have shown that den sts have good knowledge, and prac ce regarding COVID-19, which eventually determines [3][4][5] their preparedness to provide services during pandemic.
To the authors' best understanding, this study is one of the first few a empts undertaken to evaluate knowledge and prac ce modifica ons regarding COVID-19 among dental prac oners from all provinces of Nepal.

METHODOLOGY th
A cross-sec onal study was conducted from 10 August to th 10 October 2020 among the dental prac oners of Nepal using an online ques onnaire prepared through Google Forms. The online survey was preferred due to the pandemic situa on, increased risk of conduc ng a paper-form survey and the urgency of data collec on considering the situa on. Ethical approval was obtained from the Na onal Health Research Council (Regd. No. 551/2020P). Electronic informed consent was provided on the first page of the survey and the posi ve response was considered as implied consent. Consecu ve sampling method was used and sample size of 384 was calculated taking prevalence as 50%. The total sample size of 422 was calculated a er adding 10% non-response rate. The ques ons were developed a er reviewing relevant literatures and various proposed 2,6-10 guidelines by CDC and WHO. Before conduc ng the final study, the ques onnaires were validated by sending it to the experts. It was then pretested amongst 10% of total sample size and the relevant modifica ons were made based on the responses of the par cipants. The subjects of pretes ng were not included in the main sample. All the dental prac oners with Nepal Medical Council (NMC) registra on were included in the study while the respondents from pretes ng, the unwilling/ non-respondents, and those who were not currently prac sing den stry were excluded. The dental professionals were accessed through various social media (email, messenger, viber, etc.). The first set of th th ques onnaires were mailed from 10 to 20 August, 2020. The three reminders were then sent at one week's interval th rd th each on 27 August, 3 September, and 9 September, 2020 th respec vely. The data collec on was then closed on 10 October 2020. The par cipants were enquired for demographic details like gender, age, designa on, provinces they are currently working in, workplace, work se ng and their years of dental prac ce. The ques onnaire consisted of 20 close-ended ques ons (knowledge-11, and prac ce-9). The knowledge was assessed using dichotomous response (Yes/No) and each nega ve response was scored as 0 while the posi ve response was given a score of 1. The prac ce responses were evaluated using a 5-point Likert scale (always-5, o en-4, some mes-3, rarely-2, never-1). At the end of survey, the par cipants were provided with the relevant facts, proposed guidelines and recommenda ons in a concise form with the aim of broadening their knowledge regarding the measures that should be adopted while prac sing den stry during this pandemic. The maximum possible scores for knowledge and prac ce ques ons were 11, and 45 respec vely. The scores for all the ques ons were summed up and the mean scores for knowledge and prac ce were calculated respec vely. The scores were expressed as percentage which were further 8 interpreted as good (≥80%), fair (60-79%) and poor (<60%). The obtained data were entered into the excel sheet and data analysis was done using sta s cal package for social sciences version 16.0. Univariate analysis such as frequencies, percentage, mean and standard devia on of demographic variables, knowledge and prac ce were calculated. Furthermore, independent t-test and ANOVA were used to assess the difference between mean knowledge and prac ce scores in accordance with the various socio-demographic variables.

Socio-demographic Characteris cs:
A total of 422 dental prac oners completed the web-based survey with the response rate of 54.38%. The background characteris cs of the respondents are displayed in Table 1.

Knowledge regarding COVID-19 and its associa on with sociodemographic variables:
The obtained mean knowledge score was 9.  accordance with sociodemographic variables. Males had greater mean knowledge score than females and specialists were found to have greater mean knowledge score in comparison to general dental prac oners which was sta s cally significant (p-value = 0.005, p-value <0.001, respec vely). A sta s cally significant difference in mean knowledge score was found between different age-groups, workplace and years of dental prac ce. Further analysis with post-hoc (Tukey test) for age-groups showed that there was a sta s cally significant difference in mean knowledge score between 30 years and 31-40 years (mean knowledge of 31-40 years > 30 years, p-value < 0.001) and between 30 years and 41-50 years (mean knowledge of 41-50 years > 30 years, p-value = 0.02). Post-hoc (Tukey test) for workplace showed a sta s cally significant differences in mean knowledge scores between dental prac oners working in hospitals and clinics (p-value = 0.03) and between those working in both and clinics (p-value < 0.001). Dental prac oners working in hospitals and working in both had greater mean knowledge scores than those working in clinics. Mean knowledge score of those who have worked for less than 5 years had lesser mean knowledge scores as compared to those who have worked for 5-10 years and more than 10 years. Further analysis with post-hoc (Tukey test) showed a sta s cally significant difference in mean knowledge scores between those who worked < 5 years and 5-10 years (pvalue < 0.001) and between those who worked < 5 years and > 10 years (p-value < 0.001).Dental prac oners working in Sudurpaschim province, and those prac sing in government set-up had greater mean knowledge score. However, it was not sta s cally significant.  Figure 2 illustrates that most of the dental prac oners adopted the basic prac ce modifica ons during COVID-19 outbreak such as hand hygiene (421, 99.8%), rou ne use of PPE (412, 97.6%), and performing pre-procedural mouth rinse (406, 96.2%). Out of all the sociodemographic variables, the sta s cally significant mean difference in prac ce score was found in designa on only (p-value=0.04), where specialists had more mean prac ce score (Table 2).

DISCUSSION
Since the outbreak of COVID-19, the chaos created by it has been escala ng worldwide leaving every sector gridlocked, including den stry. With the intensifying repercussions of COVID-19 all over the world, various den sts either have tailored their prac ces to emergency treatment only or have 8 stopped dental services for an indecisive me. It is an undeniable fact that dental prac oners should be aware of the risks and seriousness of this pandemic situa on and should adopt a high level of awareness to deal with disease 6,11 and be able to control and manage its spread. This survey on knowledge and prac ce regarding COVID-19 aids in collec ng the informa on on what is known believed and done by dental prac oners of Nepal.
In the present study, majority of the dental prac oners in Nepal (343, 81.3%) have a good knowledge regarding COVID-19, which is similar to the findings among the den sts 3,6,12,13 of several countries. Be er knowledge score was found in males than female counterparts, which is consistent with 14 the findings by Althomairy et al. On the contrary, no significant rela onship between sex and knowledge scores 4,8 was found in studies by Gambhir et al, and Singh et al. Furthermore, the par cipants with ≥51 years of age-group and those who have been prac sing den stry for >10 years had be er knowledge score which could be due to the increasing knowledge and learning experience with the growing age. Good knowledge scores were significantly associated with the years of prac ce in a study conducted among the den sts of various countries while some studies have shown no significant rela onship between knowledge 3,4 scores and work experience of subjects. Moreover, knowledge scores of den sts prac sing in both hospital and clinics were more and this finding is in congruence with the 4 study done by Gambhir et al.
Overall prac ce score among the dental prac oners of Nepal was found to be poor (44.6%). In contrast to the finding of our study, good prac ce scores were observed in 3,15 the den sts of other countries. The main reason behind the poor prac ce modifica ons despite good knowledge scores could be the lack of minimum requirements for infec on control in the developing countries like Nepal. More than 90% of dental prac oners adopted basic prac ce modifica ons like measuring the temperature of each pa ent, pre-procedural mouth rinses, use of PPE while performing dental procedures. In a study conducted among the den sts of 30 different countries, 74% did not ask their pa ents to perform pre-procedural mouth rinses although 7 it is believed to reduce salivary oral microbes. Similarly, hand hygiene has been considered the most vital measure for minimizing the risk of transmi ng microorganisms to pa ents. In our study, 99.8% of subjects used alcohol-based hand rub or soap and water to clean their hands a er trea ng pa ents, which is consistent with the study done by 16 Alzoubi et al (99.7%). Although majority of den sts agreed that the recommended precau ons should be prac sed for every pa ent, unfortunately, only handful number of respondents have been using effec ve cross-infec on control measures such as rubber dam, high-volume evacua on (HVE) system, and high-efficiency par culate air 7 (HEPA) filters. In addi on to these, fumiga on of the dental operatory with drawers open should be done at least once a week to make the opera ng area completely sterile. However, only 59.7% of subjects rou nely fumigated their dental set-ups in our study. Among the sociodemographic parameters considered in this study, good knowledge and prac ce scores were observed among the specialists. This finding is consistent with the studies amongst the den sts of 4,8,12 other countries.
stressing on the posi ve impact of educa on and learning experience on knowledge scores and their implementa on in prac ce. On the contrary, age, sex, province, work se ng, and years of dental prac ce did not show any significant differences in prac ce scores.
Currently, recommenda ons are based on experiences and per nent guidelines in addi on to the universal cross- 17,18 infec on control precau ons.
Some of the prac ce modifica ons that should be adopted during this pandemic include thermal monitoring of pa ents, taking medical and travel history, pre-procedural mouth rinses, hand hygiene, proper donning and doffing of PPE (gown, eyewear, face shields, boots with or without covers, cap, double gloving), use of filtering face piece respirators (FFP) available at different performance levels such as FFP2/N95, FFP3/N99, proper ven la on, disinfec on, andr ou ne fumiga on of 2,[18][19][20][21][22] set-up Addi onally, replacing intra-oral radiographs by extra-oral radiographs such as orthopantomogram, and cone-beam computed tomography wherever possible, subs tu ng periodontal procedures u lizing ultrasonic scalers with hand scalers can reduce the produc on and 2 spread of aerosols, and spla er. Similarly, the use of rubber dam, high-volume suc on helps to reduce aerosols and prevent droplets origina ng in the pa ent's oral cavity and Original Research Ar cle respiratory tract from spreading and poten ally transmi ng 7 infec on. Currently, dental regulatory authori es in the world are urging den sts to conduct only emergency dental treatments and defer all the elec ve or non-essen al 2,7 procedures un l the situa on is under control. However, the public need for emergency dental care even during this pandemic will always be inevitable. Therefore, the den sts must be fully prepared for providing rela vely safe dental services and must a ain proper awareness to limit the 8 disease spread. Un l then, incorpora ng teleden stry into rou ne dental prac ce can offer a novel solu on to resume dental prac ce that can, at least, complement the exis ng 23 compromised dental system during the current pandemic.

CONCLUSION
This study provides an insight into the level of knowledge and prac ce about COVID-19 among dental prac oners of Nepal and shows that they have poor prac ce modifica ons despite having a good knowledge regarding the disease. Prac sing den stry amidst the upsurge of COVID-19 should be a learning experience for Nepal not only on emergency management but also towards developing a strong surveillance system and taking preven ve ac ons for similar events in future. This study brings into no ce about the exis ng flaws, which in turn, may help in shaping future guidelines, strategies and implemen ng effec ve infec on control policies in dental se ngs.

LIMITATIONS OF STUDY
This study s ll bear some limita ons. The responses were based on prac oners' self-assessment rather than being provided under the supervision of the inves gators. Addi onally, it is an undeniable fact that the knowledge of den sts may alter with the emerging research and possible treatment strategies.

ACKNOWLEDGEMENT
We would like to acknowledge all the par cipants who spared their me to fill the ques onnaires. We would also like to express our special thanks to Dr. Nuwadu a Subedi, Associate Professor, Department of Forensic Medicine, Gandaki Medical College, Pokhara for helping us throughout the manuscript, Dr. Anju Khapung, Lecturer, Department of community Den stry, Nepal Medical College, Kathmandu and Dr. Nisha Gurung, Lecturer, Department of community Medicine, Gandaki Medical College, Pokhara for their significant help with sta s cs, and valuable sugges ons for preparing the manuscript.