key: cord-0760923-1gxhyiri authors: Nicola, Discepoli; Raspini, Mario; Landi, Luca; Sforza, Nicola; Crea, Alessandro; Cavalcanti, Raffaele; Cairo, Francesco title: COVID‐19 and dental workers: The Italian Society of Periodontology and Implantology (SIdP) survey date: 2021-10-08 journal: Oral Dis DOI: 10.1111/odi.14027 sha: a5540120771a8de76e2700820eb8112837e78618 doc_id: 760923 cord_uid: 1gxhyiri OBJECTIVES: To evaluate the proportion of COVID‐19 infections among a population of Italian Dental workers across different geographical area of Italy and to analyze the impact of both the preventive measures/strategies adopted and the psychological influences. SUBJECTS AND METHODS: The current cross‐sectional survey was administered with a web‐based form. To be eligible for the study, participants had to be 18 years and being dentists or dental hygienists members of the Italian Society of Periodontology and Implantology (SIdP). A 23‐item questionnaire concerning positiveness to COVID‐19, clinical strategies and psychological attitude within the pandemic was administered. Sub‐group analysis was conducted according to geographical macro‐area. RESULTS: A total of 790 dentists and dental hygienists were included. A total of 4.7% participants developed a positive diagnosis to COVID‐19. The Northwest of Italy experienced almost double of COVID‐19‐positive participants (p < 0.05). Preoperatory mouthwashes together with natural air change/ventilation were the most frequent approaches used to prevent COVID‐19 outbreak. Positive and proactive attitudes were predominant among participants. Only a reduced proportion feels some concerns for the future. CONCLUSIONS: Prevalence of positive COVID‐19 among dental workers in Italy was double in Northwest area in comparison with the whole country proportion. Preventive strategies comprise mainly ultrasound reduction and preoperative mouthwashes. very beginning in a lockdown in a bid to stop the virus from continuing to spread and to mitigate the impact on society. Indeed, the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the world has been extremely rapid, suggesting the hypotheses of a crucial role played by those infected persons who remain asymptomatic even if contagious (Buitrago-Garcia et al., 2020) . The main transmission dynamics is owing to the airborne in both asymptomatic and pre-symptomatics Kissler et al., 2020; Prather et al., 2020) . Small virus-containing droplets (5-12 micro) and aerosols (<=5 micro) from infected people are transmitted into the environment through breathing, speaking, and coughing (Kutter et al., 2018) and also by touch of contaminated surfaces and eventually transfer viral fragments/particles to their mucus membrane . In many epidemics, healthcare workers (HCWs) have been reported to be at increased risk of occupational infection and have been suggested to be a source of onward transmission to other HCWs, patients and within their community. The latter tendence was observed also for early reports of COVID-19, where the incidence of infection was higher in HCWs than the general public (Nguyen et al., 2020; Rudberg et al., 2020; Zheng et al., 2020) . For what concerns the dental community, a recent piece of evidence claims that the prevalence of COVID-19 among US dentists as of June 2020 (i.e., first wave of pandemic) was 0.9% (95% confidence interval, 0.5-1.5) (Estrich et al., 2020) ; the latter figure was comparable to those coming from other countries, such as China (1.1%) (Lai et al., 2020) and the Netherlands (0.9%)(Kluytmans- Van Den Bergh et al., 2020) . The outbreak of COVID-19 has also adversely affected the lives of people in different ways such as economy, global health, and human live as a whole. In fact, It is widely discussed that the pandemic has forced countries to adopt lockdowns, quarantines, and restrictive measures, contributing to worsen the world economy, inducing long term negative effects even in the recovery period (Wei et al., 2021) . Furthermore, given the high level of contagiousness, almost every country has adopted different containment measures such as physical distancing, cases isolation, quarantine, and contact tracing according to the infected population and number of deaths. The latter have caused fear, frustration, anger, and long list of complex negative emotions (Fiorillo & Gorwood, 2020; Rubin & Wessely, 2020; Xiong et al., 2020) . Trying to understand pandemic is key for dental teams, as is the need to put strategies and protocols in place for treating patients and protecting healthcare workers while vaccination programs are being developed. In this perspective, several critical issues characterize the dental setting in terms of occupational risk for outbreak. Droplet generation, during routinely operative procedures, comprises spatter (>100 μm in diameter), "droplet" (5-100 μm in diameter), and "aerosolized particle" (<5 μm). These droplets reach the highest concentration within 0.6m around the patient, that at the light of the proximal working distance during dental practice, heighten the potential contamination risk suffered by the dental workers (Leggat & Kedjarune, 2001; Pierre-Bez et al., 2021) . Until the date, despite Italy was the first country in Europe to be overwhelmed by the COVID-19, sparse information is available on the effect of the pandemic's breakthrough among dentists in different geographic area of Italy. A recent piece of evidence quantifies the SARS-Cov-2 antibody prevalence in a sample of dentists, dental hygienists, and other personnel employed among the dental staff in Lombardy region. It shows that the prevalence of infection was around 10%, in line with estimates on other healthcare professionals (Gallus et al., 2021) . For such background, the present investigation aims to evaluate the proportion of COVID-19 infections among a population of Italian Dental workers (Dentists, Dental Hygienists) across different geographical area of Italy. Furthermore, the impact of both the preventive measures/strategies adopted by dental offices and the psychological influences that pandemic had on the dental private practice were also analyzed. The current descriptive cross-sectional survey was administered with a web-based form from January 13 through February 20, 2021, during the late phase of second "wave" of COVID-19 pandemic in Italy. For the preparation of the present analysis, we followed the STROBE guidelines for cross-sectional studies (von Elm et al., 2014) . To be eligible for the study, participants had to be 18 years or older and to be part of the following working categories: Ordinary and Active Members of the Italian Society of Periodontology and Implantology (SIdP), dentists, dental hygienists (both dental office owner and collaborator were admitted). A digital inform consent was signed before participants starts to fulfill the 23-questions survey that was designed for the current research. Study participants were categorized in the following geo- The survey subministers were articulated in six different sections. Demographic section included age (categoric variable), current professional status, and number of dental chairs per dental office (continuous variable). COVID-19 prevalence based on self-declaration was identified according to information organized as SARS-CoV-2 experience for the individual, the dental office team and for the patients; they were turned into a positive answer in relation to a positive result after any SARS-CoV-2 tests available. The survey also asked for information regarding a positive case of the dental staff after direct contact with a positive patient. According to the time span, the survey was administered and the Italian Minister of Public Health policy on vaccinations; dental workers were not vaccinated. The second section comprises details about the source of information regarding the guidelines to adopt in the dental clinic against the spread of the pandemic and in which measure they were followed/implemented. The third section relates to the personal protective equipment that operative and administrative staff are asked to wear. The fourth section deals with the clinical strategies applied to reduce aerosol and the disinfection of solid surfaces. Furthermore, it was implemented with information regarding the changes that pandemic has induced in the organization of the dental practice. The fifth section comprises the information about performing diagnostic tests settled out by the dental office for monitoring the SARS-Cov-2 infection. The last section of the investigation was written to obtain information about the psychological state and changes in attitude during the pandemic. Stata software (Stata © 15 IC) was used to conduct statistical analysis (Descriptive and inferential). Continuous variables were described as mean and confidence interval at 95%. Categorical and dichotomous variables were described as proportions and Wilson's confidence interval at 95%. Shapiro-Wilk test for normality (command swilk). Differences between continuous variable were tested using analysis of variance and between categorical variables using chi-square tests, with statistical significance set at.05 (commands oneway and prtest/mgof). Multivariate regression analysis was modeled considering the proportion of infected case as dependent variable. The final model who best fit for the data was chosen according to the lower value of AIC (Akaike information Criterion). The independent variables of the initial model were as follows: age, patient positive to COVID-19 test, team component positive to COVID-19 test, use of personal protective equipment, use of ultrasounds/air abrasive/ rotatory instruments, and use of COVID-19 diagnostic tests (command allsets). A total of 790 dentists and dental hygienists answer to the webbased survey, through an original sample of 1784, with a response rate of 44.3%. The more representative age category was 50-59, with 75% of dentists who are owner of the dental clinic. Dental clinics allocated in Northeast have more dental chairs in comparison with center and northwest of Italy (Table 1) . A total of 4.7% participants developed a positive diagnosis to COVID-19: Northwest of Italy experienced almost double of COVID-19-positive participants than the other geographic area (Table 1) . The most frequent source of information about COVID-19 and its preventive measure were webinars and scientific literature. Dentist of southern Italy has used webinars as a source of information more extensively. Globally, dentists perceived to have a satisfactory level of information and admit having follow, and in half of the cases implemented, official recommendations with no differences among regions. Eventually, the dental settings were deemed as low-risk environment (Table 2 ). Patients were kept informed about dental office preventive strategies mainly via verbal instructions and information (Table 3) . To prevent COVID-19 breakthrough, visors and FFP2/3 masks were implanted in the daily routine both for the clinical and for the administrative staff. Italy southern area used more visors and FFP2 masks also for the administrative staff ( Table 3) . Half of the cohort changes FFP2 masks every 5-6 hours, and they were reconditioned only by a limited proportion of dentists (24%). The latter procedure was more used in the center area of Italy. Preoperatory mouthwashes together with natural air change/ventilation were the most frequent approaches used. Mouthwashes were implemented less on southern Italy (Table 4 ). Among dental instruments whose use has been reduced for preventive purposes, the abrasive air system was the most, particularly on Northwest (p = 0.032). South of Italy was the region that reduces the least both Ultrasonic instrument and Air abrasive system (Table 4) . As this regard, the combined strategy ultrasound plus antimicrobial solution was the most frequently deployed. Additional time dedicated to implement all the strategies within the daily routine was around 10-20 minutes for the most of participants, and the rate table was maintained unaltered for 76% of participants. Half of the participants carried out diagnostic tests in the dental clinic, mainly in case of suspicion: The most used were the serological test and the rapid salivary antigenic test. Only a small proportion of participants will refuse to get vaccinated. The main attitude that arises from the participants can be defined as positive and proactive. Only a reduced proportion feels some concerns for the future (Table 5 ). The main doubts concern the changes that the profession will have to undergo in economic terms and the chance that they will last another year (Table 5) . The final model obtained ( Figure 1 ) acknowledges the role of one or more contagions occurred at dental team's stakeholder as covariates able to augment the probability to be COVID-19 positive with an OR of 3.53 and 4.76, respectively (p < 0.00). A patient with a positive diagnosis of COVID-19 demonstrates a protective role against the probability to develop an infection for the dentist/dental hygienist (OR = 0.46). The model obtained shows a Pseudo-R 2 of 13%. To the author's best knowledge, this is the first investigation aimed to compare COVID-19 outbreak across different Italian's geographical area. In fact, the current web-based cross-sectional survey estimates the proportion of dentists/dental hygienists SARS-CoV-2 infected in a cohort of participants belonging to the Italian dental Community. The proportion of positive cases was in line with that of healthcare workers in Washington (U.S.A) by a molecular test (PCR) (U.S Seattle, 5.3%) (Mani et al., 2020) but significantly higher than that reported retrospectively by information derived from a molecular test (PCR) for health workers of China (1.1%) (Lai et al., 2020) and in U.S dentists (0.9%) (Estrich et al., 2020) . In the latter investigation, positiveness to COVID-19 was reported to be assessed either with nasal or throat swab test, blood sample, or saliva. observed in the general population, with a substantial gradient at the latitude levels with the highest spread in the northern regions and the lowest in the southern regions/main islands (Prezioso et al., 2020) . The proportion of COVID-19 infections among dental workers observed in our experiment could be explained keeping into consideration the timing pandemic has spread throughout the country and the difference in density of population that characterizes these two different areas. As a matter of fact, Italy's first case of COVID-19 disease was recorded in Lombardy on February 20, 2020, but recent data confirm that it was present in the north of Italy on asymptom- Interestingly, the proportion of dental workers resulted positive after a contact with a confirmed positive patient was extremely low (0.08%, IC (95%) 0.03-2.2). The latter data seem to account for both a tangible sign of the dental setting's safety in terms of Pandemic's diffusion and for the high response of dental workers in terms of followed recommendations (Table 2 ). In the struggle to reduce the risk of SARS-CoV-2 infection in the dental setting, the personal protection equipment most frequently adopted was the surgical masks together with filtering facepiece 2 or 3 masks (FFP2-FFP3); no differences were detected among the different area of Italy analyzed. This strategy was already described for dental settings and is in line with previous data acknowledging the protective measures adopted among dentist in Lombardy, Italy (Cagetti et al., 2020) . Likewise, the concern about wearing a filtering mask was addressed in a cross-sectional online based survey completed by 650 dentists from 30 countries Considering both the high risk level of cross-infection in dentistry (Harrel et al., 1998; Szymańska, 2007) , owing to aerosols produced during a variety of dental procedures, and the way of transmission of SARS-CoV-2, great attention was early dedicated to the prevention of splatters and aerosol to reduce the potential risk of SARS-CoV-2 outbreak. The most frequent strategies from our cohort were the use of natural ventilation between patients and the use of preoperatory mouthwashes ( Table 3 ). The latter were used with high frequency throughout the whole national territory, but more consistently in the obtained in a survey of dentists in Lombardy (Cagetti et al., 2020) , in which the majority of participants used preoperatory chlorhexidinebased mouthwashes: Interestingly, chlorhexidine resulted the most used, albeit its efficacy against SARS-CoV-2 is still debatable (Carrouel et al., 2020) , and other active agents have proven their in vitro superiority (Muñoz-Basagoiti et al., 2021) . The clinical approach for aerosol limitation has also included the reduction/elimination of mechanical/rotatory instruments. The World Health Organization has recommended droplet and contact precautions when caring for patients with COVID-19 and airborne precautions during the delivery of aerosol-generating procedure (AGPs; World Health Organization Europe (WHO Europe), 2020). Contamination produced by ultrasonic scaling and air polishing was recently systematically reviewed (Johnson et al., 2021) : The results obtained demonstrated that both procedures produce contamination even in the presence of suction, and that droplets take between 30 min and 1 hour to settle. As such, in the current group of participants, air abrasive devices received the higher attention, with half of the participants that, at least, limit their use during pandemic with a statistically significant discrepancy between north and south of Italy (Table 3 ). The usage of ultrasonic devices was also reduced asymmetrically between north and south of Italy, with almost one half of the participants that choose to apply antimicrobic solutions to supposed virulence charge. Only a reduced proportion of dental workers have completely abandoned their use. Organization of the dental office agenda was also modified during the pandemic: Preventive measures applied have changed noticeably the timetable of the daily routine. For most participants, the time needs to cushion these changes was between 10 and 20 minutes and no additional costs were charged to the patients. The letter was homogeneous across the different geographical area, except for the Northeast, in which rate table changes were more frequent than in other regions. Dental practice re-organization seems to be mandatory for cost reducing and profitability owing to the financial distress that affects dental clinic private practice with a greater negative influences on those with higher operational costs, like those from northern area (Schwendicke et al., 2020) . The dental cost fluctuation during pandemic was evaluated throughout several countries. Contrarily to our findings, Rossato and co. (Rossato et al., 2021) highlight that more than 80% of dental offices in Brazil has increased costs to overcome change of expenditure caused by pandemic emergency. The negative financial impact was also evaluated on a Likert (0-5) scale from a cohort of dentists worldwide (LG et al., 2021) ; the highlighted mean value for European dentists was 4.7(0.7). Diagnostics tests were implemented on the dental practice under COVID-19 by half of the participants homogeneously throughout the whole country ( (Bielicki et al., 2020; Consolo et al., 2020) . A survey conducted in north of Italy (Reggio Emilia-Modena) immediately after the first pandemic wave and involving 356 dentists, unveils that half of the participants felt lightly scared (41%) and anxious (23.6%) with 12% felt intensely sad (Consolo et al., 2020) . The latter state of mind was not perceivable in our cohort, with only 5% of participants resulted concretely concerned for the future of their profession; moreover, more than 50% of participants has considered pandemic as an opportunity for concretes improvements for the dental office. This different attitude can be related to the period of the pandemic; the survey has been deployed; indeed, we asked to answer to the questionnaires at the beginning of 2021 at the end of the second wave and when vaccination process was already arranged. The multivariate logistic regression model aimed to evaluate which was the best model to explain the probability of a dental workers to be positive to The current web-based survey was conducted to determine the prevalence of COVID-19, behavioral practices, and psychological attitudes among a cohort of private dentists and dental hygienists from the members of the Italian Society of Periodontology and Implantology (SIdP) in Italy. Within the limitations of positiveness self-declaration, the prevalence of COVID-19 was 4.7% for the whole sample with a peak of 8.8% from the Northwest area of the country. Preventive clinical strategies (aerosol reduction) and personal protective equipment were homogeneously adopted among the different geographical area of the country. Despite the difficulties caused by the pandemic outbreak, dentists and dental hygienists from this sample have reacted positively and have full confidence in the future of the profession. Future research should monitor the rate of the pandemic and analyze further the risk factors involved in the spread of the pandemics at the dental office level. F I G U R E 1 Multivariate regression model: best model obtained, considering proportion of infection as dependent variable and age of the participants, presence of any component of the dental team positive to COVID-19, use of surgical mask, and use of diagnostic COVID-19 tests None. No conflict of interest has been declared by the authors. The peer review history for this article is available at https://publo ns.com/publo n/10.1111/odi.14027. 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