Evaluation of Dental Practices Changes During the COVID-19 Pandemic in Brazil

Introduction

Dentists, among other healthcare professionals, are at the highest risk for coronavirus disease-19 (COVID-19) transmission and contraction. This is because many routine dental procedures create aerosol particles, which have the potential to transmit the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Although it is important to offer treatment to patients who have dental situations that require immediate attention, it is important to prioritize the prevention of transmission to both patients and dental care personnel (Khader et al., 2020).

Considering the current rapid spread of COVID-19, the American Dental Association stated that in addition to following standard universal precautions, dentists should also ask patients about recent travel and assess for signs and symptoms of respiratory tract infections. Furthermore, patients’ body temperature should also be recorded, and the use of mouthwash with 1% hydrogen peroxide before starting any procedure should be recommended. Also, rubber dam isolation and high power suction should be used during procedures. Thorough cleaning and disinfection of public contact areas, including door handles, chairs, and bathrooms, should also be carried out (Ahmed et al., 2020; Khader et al., 2020; Vieira-Meyer et al., 2020).

While healthcare practitioners currently use personal protective equipment (PPE), including gloves, masks, and lab coats, when working with all patients, those working around potential aerial infections, such as SARS-CoV-2, require additional PPE, including goggles or face shields, N95 masks, and disposable outerwear, such as lab coats or coveralls and rubber boots (Odeh et al., 2020).

Due to the COVID-19 pandemic, dentists’ concerns regarding elective and urgent/emergent dental care have been reported (Faccini et al., 2020). It is important to better understand how dental professionals have altered their clinical practices during the ongoing COVID-19 pandemic, especially in countries with vast territorial extensions, such as Brazil (which now has the third-highest number of cases worldwide). In addition to the nonhomogeneous diffusion of the pandemic in each region, a wide representative sample from different locations is required to present the results substantially.

In light of the ongoing global COVID-19 pandemic and the lack of scientific reports regarding the changes in PPE usage by dentists and their routine dental practices during the pandemic, the present study aimed to evaluate how dentists had modified their clinical practices during this ongoing viral outbreak. Additional objectives included assessing workload changes, the use of PPE (the comfort and adverse reactions), and changes in relation to costs.

Materials and Methods

The present study was approved by the Research Ethics Committee of the University of North Parana (UNOPAR), with approval number 4.147.506. According to a previous study by Faccini et al. (2020), there are 338,000 dentists in Brazil; therefore, the sample should have been made up of at least 384 individuals, which would provide a confidence interval (CI) of 95% and a margin of error of 5% (Faccini et al., 2020). The inclusion criteria were as follows: dental school graduates, with or without a postgraduate degree, who were working in dental clinics. Participants who did not meet the inclusion criteria were excluded.

An online questionnaire was developed using Google Forms. Potential participants were contacted by e-mail by dissemination through postgraduate programs and professional councils as well as an active search of e-mails of dental offices. After providing consent, participants answered questions about their knowledge and clinical experiences regarding COVID-19. The questionnaire was administered from June to July 13, 2020.

In the Statistical Package for the Social Sciences (SPSS Statistics 22, IBM Corporation, 2013. JAVA), we performed descriptive statistics. Chi-square test was used to compare the working time before and during the pandemic. In addition, we performed Fisher’s exact test to compare the use of personal protection equipment and Kruskal–Wallis tests to compare biosafety between Brazil regions. A significance level of 5% and a CI of 95% was considered.

Results

A total of 1,357 questionnaires were returned. However, 168 were duplicates and 11 were respondents from other countries. A total of 1178 valid responses were obtained from all 26 Brazilian states. The overall response rate could not be calculated because the questionnaire was sent to various organizations in Brazil, which in turn forwarded it to their constituents. We received 339 responses during the first 24 hours. Respondents were mostly females (75.3%), who had been in practice for < 10 years (42.8%), and who had completed a continuous professional development course > 5 years (43.4%). The region with the highest number of participants was southern Brazil (39.6%). The mean age of the respondents was 37.97 ± 10.46 years, and 25.2% of respondents had at least one chronic disease (Table 1).

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Table 1.

Sample Characterization, Work Practice Characteristics and Use of Personal Protection Equipment.

	Mean (SD)	Min–Max	95% CI
Age	37.97 (±10.46)	21–74	37.97–37.97
Variable/Category	n	%	95% CI
Gender	1,178
Male	291	24.7	22.2–27.2
Female	887	75.3	72.8–77.8
Brazilian Region	1,178
Midwest	127	10.8	9.0–12.87
Northwest	256	21.7	19.5–24.1
North	47	4.0	2.9–5.2
Southeast	282	23.9	21.6–26.4
South	466	39.6	36.4–42.4
Years of experience	1,178
<10	504	42.8	40.0–45.7
11–20	357	30.3	27.8–32.8
21–31	219	18.6	16.3–20.9
>30	98	8.3	6.8–10.1
Post-Graduate Course	1,176
Don’t have	89	7.6	6.0–9.1
Ongoing course	199	16.9	14.8–19.0
Conclude 1 - 5 years	378	32.1	29.6–34.8
Conclude > 5 years	510	43.4	40.3–46.2
Chronic Diseases	1,178
Don’t have	881	74.8	72.3–77.2
1 Chronic Diseases	244	20.7	18.4–22.9
2 or + Chronic Diseases	53	4.5	3.5–5.8
Office hours before COVID-19	1,178
<10 h/ week	116	9.8	8.1–11.6
11 a 20 h/ week	200	17.0	14.9–19.0
21 a 40 h/ week	553	46.9	44.1–49.9
>40 h/ week	309	26.2	23.7–28.8
Changed service hours by pandemic	1,178
No	186	15.8	13.8–18.0
Yes	992	84.2	82.0–86.2
Office hours during pandemic	1,178
Does not attend	91	7.7	6.1–9.3
Urgency only	225	19.1	16.9–21.4
<10 h/ week	209	17.7	15.5–20.0
11–20 h/week	324	27.5	24.9–30.0
21–40 h/week	259	22.0	19.7–24.3
>40 h/week	70	5.9	4.6–7.4
Pre-Screening	1,149
No	226	19.7	17.5–22.0
Yes	923	80.3	78.0–82.5
Modified care with Biosafety at Reception	1,148
No	25	2.2	1.3–3.0
Yes	1,123	97.8	97.0–98.7
Added Biosafety care	1,121
No	22	2.0	1.2–2.8
Yes	1,099	98.0	97.2–98.8
The cost has increased	1,178
No	138	11.7	10.0–13.5
Yes	1,040	88.3	86.5 - 90.0
Pass on costs to patient	1,178
No	968	82.2	80.1–84.4
Yes	210	17.8	15.6–19.9
Patient with suspected COVID-19	1,178
No	976	82.9	80.6–85.0
1 patient	83	7.0	5.6–8.5
2 or + patient	119	10.0	8.4–12.0
Flu Symptoms	1,178
No	1,051	89.2	87.4–90.9
Yes	127	10.8	9.1–12.6
Conducted COVID-19 test	1,178
No	857	72.8	70.2–75.4
Yes	321	27.2	24.6–29.8
Use of personal protection equipment Before pandemic	n	%	95% CI
Disposable gloves	1,172	99.5	99.1–99.8
Surgical Mask	1,135	3.7	95.2–97.4
Mask N95 /similar	19	1.6	0.9–2.4
Fabric cap/Surgical cap	438	37.2	34.5–39.9
Disposable cap	928	78.8	76.6–81.1
Closed shoe	979	83.1	81.6–85.4
Lab coat / apron	1,106	93.9	92.5–95.2
TNT Lab Coat/Apron	197	16.7	15.6–18.8
Protective goggles	992	84.2	82.1–86.3
Face shield	33	2.8	1.9–3.8
Disposable TNT shoes	185	15.7	13.6–17.7
Use of personal protection equipment During pandemic
Disposable gloves	1,106	96.3	2.6–4.9
Surgical Mask	788	68.6	66.1–71.5
Mask N95/similar	969	84.3	82.1–86.4
Fabric cap/Surgical cap	222	19.3	17.1–21.6
Disposable cap	1,045	90.9	89.4–92.6
Closed shoe	1,022	88.9	87.1–90.9
Lab coat/apron	845	73.5	70.9–76.2
TNT Lab Coat/Apron	925	80.5	78.1–82.9
Protective goggles	935	81.4	79.1–83.5
Face shield	1,093	95.1	93.9–96.3
Disposable TNT shoes	566	49.3	46.4–52.2
Allergic reaction
No	1,020	88.8	86.9–90.5
Yes	129	11.2	9.5–13.1

Note. SD: Standard Deviation; CI: Confidence interval.

The pandemic has required dentists to make some changes to their work routines, such as conducting COVID-19 testing (27.2%), reducing office hours (48.1%), or even temporarily suspending clinical services (7.7%), as seen in Tables 1 and 2. Only 10.8% of the respondents acknowledged having any flu symptoms, although 17% of the dentists declared that they had seen at least one patient with confirmed COVID-19. Screen and triage everyone entering the dental office for signs and symptoms of COVID-19 was conducted by 80.3% of dentists who kept working, as a new procedure.

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Table 2.

Association of Working Time Before and During COVID-19 Pandemic.

Before COVID-19	During COVID-19 pandemic
	Closed practice	Urgency	Kept practice	Reduce practice	Increase practice
- 10 h/week (n = 116)	28 (24.1%)	40 (34.5%)	37 (31.9%)	—	11 (9.3%)
11–20 h/week (n = 200)	18 (9.0%)	50 (25.0%)	43 (21.5%)	86 (43.0%)	3 (1.5%)
21–40 h/week (n = 553)	38 (6.8%)	99 (17.6%)	131 (23.7%)	280 (50.6%)	5 (0.9%)
+ 40 h/week (n = 309)	7 (2.3%)	36 (11.7%)	65 (21.0%)	201 (65.0%)	—

Chi-Square test: (p < 0.001).

The dentists indicated that they had made changes in biosafety at the reception desk (97.8%) and had added biosafety measures in the office (98.0%). Improving biosafety because of the pandemic increased operating expenses for 88.3% of the dentists, but only 17.8% stated that they had transferred those increased costs to patients (Table 1).

Table 1 shows the changes in the weekly working hours. The majority (84.2%) changed their service hours during the pandemic. Of the dentists who stopped clinical practice during the pandemic, 24.1% had a lower workload (<10 hours/week). Out of the dentists with higher weekly workloads, 21–40 hours or > 40 hours, 50.6% and 65% reduced their working time, respectively. Only a few respondents (9.3%) who worked < 10 hours per week before the pandemic had to increase their workload. Of the dentists who worked 11–20 hours and 21–40 hours per week, their workloads increased by 1.5% and 0.9%, respectively (Table 2). A significant reduction in practice was reported by a majority of the dentists during the pandemic.

Various types of PPEs were added based on the airborne transmission of SARS-CoV-2 (Figure 1), with significant differences between their use before and their use during the pandemic. These additions included N95 masks, or those with similar particulate filtering (p < 0.001), disposable caps (p < 0.001), closed-toe shoes (p < 0.001), disposable lab coats/aprons (p < 0.001), protective goggles (p < 0.001), face shields (p < 0.001), and disposable shoe covers (p < 0.001). On the other hand, there was a significant reduction in the use of disposable gloves (p < 0.001), surgical masks (p < 0.001), fabric caps (p < 0.001), and fabric coats/aprons (p < 0.001). A large percentage of dentists reported greater discomfort due to the addition of PPE during the pandemic (58.6%), and 11.2% had allergic reactions due to the use of PPE (Table 1).

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Figure 1.

Use of personal protection equipment before and during COVID-19 pandemic.

Neither the educational level of the participants nor their years of experience affected the biosafety changes made in their dental offices. Even dentists who did not have chronic diseases were concerned with improving biosafety measures. Of the dentists who underwent COVID-19 testing, 52.10% worked with two or more patients with confirmed COVID-19 (p < 0.001).

When comparing regions, significant differences in changes to biosafety were not found between the regions (p = 0.385), as seen in Table 1. Additionally, all regions in Brazil had marked changes in relation to the workload (84.20%), with no statistically significant difference between the regions (Kruskal–Wallis = 0.416).

Discussion

The present study sought to collect information regarding changes in clinical practice by Brazilian dentists in response to the COVID-19 pandemic. The use of social media as a facilitator in the process of accessing and disseminating the questionnaire was fundamental to reaching and including dental professionals from all over Brazil. The majority of the responses were from dentists in southern Brazil, likely because that was where the research was generated, although dentists from all regions participated. Although some authors (Gelinas et al., 2017; Topolovec-Vranic & Natarajan, 2016; Weller, 2015) have indicated that social media has a greater range of recruitment in the younger population, in the present study, we were able to obtain responses from professionals between 21 and 74 years of age (Table 1), generating a broad representative sample of the Brazilian dentist population.

The results of the present study found that neither the educational level nor the years of experience of the respondents affected the biosafety changes made in the dental office. This outcome differs from the results found by Kamate et al. (2020), in which questionnaires were administered to a worldwide sample of dentists and indicated that dentists with higher qualifications (postgraduates) had significantly higher knowledge scores than did the dental school graduates. (Kamate et al., 2020) Regardless of their chronic disease status, dentists were concerned about biosafety care and considered infection control measures to be essential for practice.

The COVID-19 pandemic has brought countless changes not only in the personal lives of individuals but also in the clinical routines of health professionals. Despite the fact that dentists are among the professionals with the highest risk of contamination and spread of the virus, Epstein et al. (2020) stated that no clusters of respiratory-transmitted diseases, including SARS-CoV-2, have been reported in dental providers or patients in a dental setting. Nonetheless, most dentists found it prudent to make changes to protect themselves, their team members, and their patients. The main changes reported in our study were workload changes, additional PPE, and additional biosafety measures which are similar to what was found by Faccini et al. (2020) wherein, 95.5% of the professionals reinforced biosafety improvements, such as the use of face shields and disposable PPE. A decrease in demand and use of emergency dental services was noted by Guo et al. (2020). This may also highlight the changing demands for dental services, as many patients have avoided leaving home because of the pandemic, and sought care only in urgent or emergent cases.

The additional expenses from the addition of PPE and biosafety measures can negatively impact the fiscal performance of dental offices (Table 1). In a study by Schwendicke et al. (2020) in Germany, the financial impact on dental clinics that have adopted additional preventive measures in response to COVID-19 was considerable. They noted that government financial aid may be required in the longer term, and practice owners may need to consider practice re-organization to reduce costs and maintain minimum profitability (Schwendicke et al., 2020)

A large number of dentists reported greater discomfort and some allergies due to the additional PPE (Table 1), consistent with the findings by Yuan et al. (2020), who found that a total of 94.57% of professionals surveyed reported discomfort regarding PPE use. The main complaints of adverse reactions and discomfort were adverse skin reactions, respiratory difficulties, heat stress, dizziness, and nausea (Yuan et al., 2020).

Although Brazil is a country with a vast territorial size with many regional and cultural differences, these differences were not very evident with regard to changes in dental office biosafety among professionals of different regions. Most dentists reported changes in biosafety measures, showing that the vast majority of these professionals were aware that the adoption of these infection prevention practices is essential to halt the spread of COVID-19.

One of the limitations of the present study was that no distinction was made between professionals from public and private clinics. There are likely differences inherent in the practices of each sector, including operating costs and access to PPE (Vieira-Meyer et al., 2020). Another limitation concerns gender, in response to which future studies should include proportional responses from women and men. The primary concerns of dentists all over the world during the ongoing COVID-19 pandemic are more than clinical practice modifications. These professionals, especially those who work in private clinics, are faced with the critical choice of stopping work to ensure their health or to continue working for the upkeep of their home and family. Therefore, it is up to each professional, based on their circumstances, to assess the risks and benefits when making their decisions.

Conclusion

Based on the results of the present study, we have concluded that most Brazilian dentists have altered their routine dental practices in response to the COVID-19 pandemic. The biggest changes reported were a decrease in the workload, the use of additional PPE, and the addition of biosafety measures.