key: cord-0761265-4jbv4arj
authors: Martinho, Frederico C.; Griffin, Ina L.
title: A CROSS-SECTIONAL SURVEY ON THE IMPACT OF CORONAVIRUS DISEASE 19 (COVID-19) ON THE CLINICAL PRACTICE OF ENDODONTISTS ACROSS THE UNITED STATES
date: 2020-10-12
journal: J Endod
DOI: 10.1016/j.joen.2020.10.002
sha: 2e3a457ffa937d68eec3ce6a974897f624850170
doc_id: 761265
cord_uid: 4jbv4arj

INTRODUCTION: This survey investigated the effect of the COVID-19 pandemic on the clinical practice of endodontics among the AAE members by evaluating the impact on clinical activities, patient screening, infection control measurements, potential transmission, clinical protocols as well as psychological concerns. MATERIAL AND METHODS: A descriptive, cross-sectional survey was developed to query AAE members from all seven districts. The survey consisted of 24 questions, eight demographic questions, and 16 questions related to the COVID-19 pandemic impact on the clinical practice. RESULTS: A total of 454 AAE members participated in the survey. As of July 2020, most endodontists were active in front line treatment of dental patients (82%). N95 respirator face mask was described by 83.1% of the participants as special measures beyond the regular PPE. Rubber dam isolation was recognized by the majority of the participants at some level to reduce the chance of COVID-19 cross-infection. Most of the endodontist participants acknowledged trauma followed by swelling, pain, postoperative complication to be emergencies. The majority of respondents reported being concerned about the effect of COVID-19 upon their practice. No differences in worries about COVID-19 infection were related to demographics (p>.05). CONCLUSIONS: The majority of the Endodontists are aware of the COVID-19 pandemic, taking special precautions, and are concerned about contracting and spreading the virus. Despite the conflict between their roles as health care providers and family members with the potential risk of exposing their families, most of them remain on duty providing front line care for dental treatment.

There was an outbreak of coronavirus disease 2019 disease in late December 2019 (1) . The World Health Organization (WHO) declared a public health emergency of international concern over this pandemic outbreak on 30th January 2020. Since then, the number of cases and confirmed deaths has increased globally, as indicated by the weekly operational update COVID-19 provided by WHO (2, 3) .

As of now (Aug 21, 2020), there have been 21,294,845 cases confirmed and 761,779 deaths (2) . There is an interactive map of the global cases of COVID-19 by the Center for Systems Science and Engineering at Johns Hopkins University, which is continually updated (3) .

The COVID-19 disease is caused by the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, formerly known as 2019-nCoV) (4) . The most commonly reported routes of SARS-CoV-2 transmission are inhalation or direct inoculation (5) . The inhalation may occur from respiratory droplets or aerosols from infected individuals within a 6 feet radius. Additionally, the direct inoculation of SARS-CoV-2 infected particles occurs by touching surfaces contaminated with infected respiratory droplets as transmission via an inanimate vector (5) .

Due to the dual risk of high aerosol-generating procedures in dentistry, plus salivaborne SARS-CoV-2 in both symptomatic and asymptomatic individuals, dental societies/associations immediately responded to the COVID-19 disease. The response of dental associations to curb the clinic-associated nosocomial transmission of SARS-CoV-2 varied at that time. At the early stage of the pandemic, the Public Health England under the guidance of the Chief Dental Officer (6) recommended not providing aerosol generating procedures. Instead, they were screening and sending true emergencies to a central location J o u r n a l P r e -p r o o f where dentists were carrying out aerosol generating procedures. In contrast, the American Dental Association guidelines at that time (7) restricted dental treatment to only addressing emergencies and reducing the number of routine check-ups and follow-up appointments.

Despite the guidance, practitioners were still reluctant and felt fearful of treating patients in such a situation.

Endodontists are in a unique situation as they manage odontogenic pain, swelling, and dental alveolar trauma. Because of the chances to encounter patients suspected or confirmed with SARS-CoV-2, they had to act diligently to provide care and, at the same time prevent nosocomial spread of the infection. For that, endodontists had to adopt special measurements to screen their patients, enhance infection control measurements, and follow specific dental treatment recommendations.

Here we assess endodontists' knowledge and awareness about COVID-19 disease.

Additionally, we evaluate the impact of COVID-19 on clinical activities, patient screening, infection control measurements, potential transmission, clinical protocols, and psychological concerns on the clinical practice of endodontists across the united states. (Table 1) .

All data were transferred from the Qualtrics forms into Microsoft Excel (Microsoft 

From the 5191 invited to take the survey from all 7 AAE districts, 454 participated in the survey. Despite efforts through the survey design to prevent skipping questions, some respondents did not answer all the questions. A total of 324 males and 120 females participated in this survey ( reported that the number of patients decreased compared with the same time a year ago. In comparison, only 17/454 (4%) reported no effect or an increase in the number of patients ( Figure 1A ). As of July 2020, most endodontists took part in endodontic care in the front line treatment of dental patients (322/ 397, 82%) ( Figure 1B) Figure 1C ). In addition to the regular PPE, 100% of the participants reported having taken special protective measures for routine root canal therapy, with the most common ones being the N95 respirator face mask (330/397, 83.1%), face shield (234/ 397, 58.9%), and head cover (219/ 397, 55.2%) ( Table 1) . Besides, some respondents (168/397, 42.3%) reported implementing an air-purifying unit in their operatory (Table 1 ). Other protective measurements were also reported by the respondent (Table 1) .

Most participants agreed at some level to be concerned with contracting/ spreading the COVID-19 virus. Rubber dam isolation was recognized by the majority of the participants at some level to reduce the chance of COVID-19 cross-infection from routine endodontic procedures. Two hundred ninety-eight participants (298/374, 80%) reported being worried about the effect of COVID-19 upon their practice ( figure 1D ). The reasons behind their worries were mostly common staff and/or family becoming infected ( Table 1 ). The majority of the participants agreed at different levels with the COVID-19 phase in their state.

As of July 2020, most of the states were in phases 2 and 3 ( Table 1 ). Most of the respondents agreed at some level that most of their staff worry about the chronic effects of COVID-19

( Table 2 ). The great majority of respondents ranked the order of most to least important protection measures against COVID-19 as an N95 mask, hand wash, and hand sanitizer (200/ 369, 54.2%) ( Table 1 ). Our results indicated no significant differences in worries about COVID-19 infection related to the gender, years of experience, type of practice, location, nature of the practice, and practicing district (p>.05).

In this survey, endodontists that resumed their activities at some level as well as those who discontinued their practices shared that they were afraid of becoming infected, carrying infection from their dental practice to their families, staff becoming infected, as well as requested chest X-ray for COVID-19 screening in their dental practice, although chest X-ray might show patchy shadows and ground-glass opacity in the lung (14) . It is worth pointing out that only a few participants reported uncooperative patients for the COVID-19 screening measurement adopted in their practice.

Patients with COVID-19 usually present with symptoms such as fever, cough, sore throat, fatigue, myalgia, headache, shortness of breath, and in some cases, diarrhea (11, 15) .

Here, most of the Endodontists identified flu-like symptoms, body temperature higher than The salivary gland and tongue are potential targets for SARS-CoV2 due to the expression of AC2 (18) (19) , but AC2 is also expressed in the gastrointestinal tract (19) , and individuals may present with diarrhea (20) .

Despite different screening techniques, 80% of positive patients have only mild symptoms that resemble flu-like symptoms and seasonal allergies. This might lead to an increased number of undiagnosed cases (21) . Of concern, these asymptomatic patients can act as "carriers" and also serve as a reservoir for re-emergence of the infection (11) .

Because of the high likelihood of SARS-CoV-2 transmission in the dental care setting, personal protective equipment (PPE) is discussed in most every COVID-19 surveybased research regarding dentists during COVID-19 pandemic. Here, most of the endodontists described taking special measures beyond regular PPE. The use of the N95 J o u r n a l P r e -p r o o f respirator face mask was reported by 83.1% of the participants. The percentage of practitioners that enhanced PPE utilization with the use of N95 respirator face mask varies across the surveys ranging from 12%-90% (11, (22) (23) . The lack of adherence to the N95 respirator face mask may not only be explained as a lack of willingness to implement adequate procedures but also by the shortage of PPE announced in March 2020 by WHO (24) . Some respondents also reported the use of other additional COVID-19 protection such as the face shield, head cover protective suit, as well as plexiglass aerosol shield for microscope and others. 27. American Dental Association (2020). ADA adds frequently asked questions from dentists to coronavirus resources. Available at: https://www. ada.org/en/publications/ada-news/2020archive/march/ada-adds-frequently-asked-questions-from-dentists-to-coronavirus-resources. Accessed 25 August, 2020. 

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