|Year : 2020 | Volume
| Issue : 4 | Page : 360-365
Impact of COVID-19 on Indian dentists: A cross sectional survey
Harneet Singh1, Adarsh Kumar2, Ambika Gupta1, Anju Redhu1, Aarti Singh1
1 Department of Oral Medicine and Radiology, PGIDS, Rohtak, Haryana, India
2 Department of Public Health Dentistry, PGIDS, Rohtak, Haryana, India
|Date of Submission||18-Jun-2020|
|Date of Decision||18-Oct-2020|
|Date of Acceptance||29-Oct-2020|
|Date of Web Publication||28-Dec-2020|
Dr. Harneet Singh
Department of Oral Medicine and Radiology, PGIDS, Rohtak - 124001, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: COVID-19 and associated lockdown have had some detrimental effects on the health care professionals. With the maximum fear of getting infected and further transmitting the infection, dentists are suffering from the psychological meltdown along with the physical changes due to altered lifestyle. Aim and Objectives: To evaluate the psychological and physical effects of COVID-19 and consequential lockdown on dentists and to understand the possible reasons for the problems they were facing amidst lockdown due to the changes in their lifestyle. Settings and Design: A questionnaire-based survey to evaluate disaster mental health and analysis of musculoskeletal symptoms was designed and sent to the various groups of dentists. A total of 453 respondents completed the survey. Materials and Method: Cluster sampling method was used and the dentists were segregated into four groups. The responses were evaluated for Post-traumatic stress disorder, Depression, Anxiety and Pain or discomfort. Statistical Analysis: Chi Square test was applied to statistically assess the association of responses. Results: Out of 453 respondents 65.1% were females and 34.9% were males. Based on profession, 23% were academicians, 18.8% private practitioners, 16.8% post-graduate students and 41.5% undergraduates. Females were significantly affected and showed a tendency towards Post traumatic stress disease (PTSD) and potential depression along with pain and discomfort. All the three groups except undergraduate students showed potential symptoms. Conclusion: COVID-19 and the lockdown exhibited significant psychological and physical effects on the dentists. Counselling centers or helplines/portals need to be set up to avoid any grave consequences and untoward losses.
Keywords: COVID-19, dentists, lockdown, physical effects, psychological effects
|How to cite this article:|
Singh H, Kumar A, Gupta A, Redhu A, Singh A. Impact of COVID-19 on Indian dentists: A cross sectional survey. J Indian Acad Oral Med Radiol 2020;32:360-5
|How to cite this URL:|
Singh H, Kumar A, Gupta A, Redhu A, Singh A. Impact of COVID-19 on Indian dentists: A cross sectional survey. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2021 Jan 20];32:360-5. Available from: https://www.jiaomr.in/text.asp?2020/32/4/360/305265
| Introduction|| |
Pandemic virus outbreaks have been significant contributors to the mortality of humans. Today, when we stare at the horror of Corona virus disease alias 2019–nCOV alias Novel Corona virus, it has taken us back to the century-old methods of social distancing and isolation. Topping the charts in chronicles of pandemics, the COVID-19 has already killed more than 2.7 million in the world. India was one of the first few countries to gear up for the fight against the outbreak of corona virus, when only 3000 people across the world had been killed and almost 60 countries were affected. Precisely two weeks before the World health organization declared COVID-19 as a world health emergency, the screening at airports was started and quarantine zones were operational at the satellite places for those who were showing even the slightest of the signs of illness. An extremely pro-active approach was required to face the challenge of a major outbreak. Center for disease control and prevention (CDC) in 2017, defined isolation as the separation of sick people with a contagious disease from people who are not sick and Quarantine as the separation and restriction of the people who were exposed to the contagious disease to see if they become sick., Lockdown or restricted access to control the movement of the people was instituted worldwide to curb the spread of dangerous corona virus. Taking a cue from the evidences across the world, the lockdown was imposed in India as well and rightly so. One month and 3 days into the lockdown, India proved itself to have a considerably slow doubling rate of corona infected people. Although lockdown proved to be beneficial, but a sudden change in lifestyle and the stress of this pandemic had affected the professionals physically and mentally. The restriction of movement, confinement at one's place and additional household/domestic duties without any indulgences lead to psychological stress. In addition to this, the anxiety related to the ever-lurking fear of being gripped by the disease affected the psychology of an individual. Recently, Brooks et al. (2020) reviewed 24 studies to evaluate the psychological impact of quarantine and reported the negative psychological effects like post-traumatic stress symptoms, confusion and anger in people who were quarantined. Certain muscles of the body are programmed to perform in accordance with the routine activities of an individual, whereas other muscles are not accustomed to the strenuous workload. Altered information to the muscle memory and additional work can lead to muscle tenderness and pain which takes 2-4 weeks to subside or the muscles to get programmed. This is arguably the first time in the history of the whole world that the lockdown has been imposed to such an extent. No prior studies have evaluated the psychological and/or physical effects of the lockdown. This survey attempts to elicit the possible psychological and physical effects of COVID-19 and the consequential lockdown of more than 4 weeks.
| Methodology|| |
A survey was designed to evaluate psychological and physical effects in dentists and dental students. This study was designed after considering the fact that all the study groups underwent similar kind of psychological and physical tribulations due to COVID-19 and associated lockdown. This survey was based on the “Simple Screening Measure for Disaster Mental Health developed by Fuji et al. and “Standardized questionnaires for the analysis of musculoskeletal symptoms” developed by Kuorinka I et al. A few of the questions were added and modified in the survey to correlate with the current scenario of corona outbreak. After deliberations with the experts related to the field of dentistry, working in the specialty of oro-facial and musculoskeletal pain and stress-related disorders, the questionnaire was finalized. In this survey of 34 questions, questions related to the psychological effects were prepared in concurrence with “Simple Screening Measure for Disaster Mental Health”.,, Questions evaluating the aspect of musculoskeletal pain or discomfort concentrated on ten anatomical regions of the body viz. TMJ, Neck, Shoulders, Elbows, Wrists/Hands, Upper back, Lower back, Hips/Thighs, Knees and Feet/Heels. These regions were selected because these were the common sites for the symptoms to accumulate and the specified locations were easily distinguishable from each other. Survey was validated by distributing it among a small group of students as a pilot procedure to determine its relevance. Internal consistency was estimated via the split-half reliability index in which alternative odd/even questions were segregated into two forms, which were given again to the same participants and the responses were correlated.
This study utilized cluster sampling technique in which Dental colleges of Haryana and its adjoining states along with regional IDA branches were included. Institutional ethical permission was obtained from the Institutional Ethics Committee, PGIDS (via certificate no PGIDS/A-II/8200 dated 24/06/2020). The contact details of academicians, postgraduate students and undergraduate students were procured from the respective colleges, whereas the details of private practitioners were collected from IDA branches. Sample size was estimated based on the following formula: Z<Subscript>1-</Subscript>α<Subscript>/2 </Subscript>2P (1-P)/d2, Where z is normal deviate, d is the level of precision adjusted at 0.07. Prevalence was considered to be at 70%, as it was anticipated that 70% of the dentists will be affected. Design effect of 2 was taken to compensate for the cluster effect. As it was an online survey, to compensate for the 50% non- participation another 50% was added to the sample. Thus, the final sample size was calculated to be 700. A link to the survey was e-mailed and/or sent across through social media platforms to 700 dentists and dental students across Haryana and adjoining states. As the first question of the survey was regarding the consent to participate in the survey, those who filled the forms were considered to have consented for participation in the study and those who did not fill the form were eliminated and not considered. The study was conducted by following all the protocols and principles under the purview of Helsinki declaration (1964 and later). The questionnaire was available on Google forms for 2 weeks. Incomplete forms were scrutinized, and the cleaning of the data was done by asking the respondents to rectify the improper or partially filled forms.
IBM SPSS Statistics 21.0 for Windows was used for data analysis. Reliability of the survey was evaluated through the Cronbach's alpha reliability test with α score of 0.618 indicating an acceptable reliability. Scoring of PTSD and depression was calculated by evaluating the response percentage for the individual questions. Statistical significance of the association of responses of different study groups was tested using Chi-square test. Questions regarding appetite, tiredness, difficulty in sleeping along with feeling of depression, irritability, and difficulty in enjoying things were considered as the symptoms of depression whereas the questions related towards falling asleep, nightmares about the event, irritability, hypersensitivity towards sneezing or coughing, avoidance of places, people or topics related to COVID-19, thoughts about corona virus and lockdown, trouble enjoying things, getting upset if someone reminded of the outbreak and lockdown and if the respondent was making an extra effort to forget about the calamity were considered to be the stressors of PTSD. Added two questions regarding the continuous and repeated checking of news or websites and believing the information received on social media platforms evaluated the anxiety related to the outbreak and the lockdown cessation.
| Results|| |
A total of 453 participants responded and completed the questionnaire. Out of the total respondents, 65.1% were female and 34.9% were male. Distribution of the respondents was also done according to the professional details. 23% of Academicians performing dual duties of both teaching and managing the emergency patients, 18.8% of Private Practitioners, 16.8% of Postgraduate students of dentistry and 41.5% Undergraduate students pursuing BDS participated in the survey.
[Table 1] exhibits the sex-based responses of the questionnaire. The percentage-based analysis between the different sexes revealed that the female were more vulnerable to the current situation. Present study indicates significant differences in responses related to the appetite 30.5% (P =0.005), tiredness 31.9% (P =0.000), feeling depressed 15.6% (P - .044) and irritability 38.6% (P- .003). They also felt significantly upset 52.2% (p - 0.000) when someone talked about COVID-19 or lockdown. Headache was the most common complaint with 35.1% respondents reporting of it with significant majority of female participants 39.3% (p-.010). 18.0% of the females (p-003) also reported of upper back pain which was significantly higher than the 7% of males who reported for the same.
[Figure 1] illustrates the main reason which the both the sexes thought to be responsible for their discomfort. Both the sexes gave analogous replies to the questions and it was statistically significant (p-0.002).
[Table 2] summarizes the responses of participants according to their professional engagements.
[Figure 2] illustrates the profession-based differentiation of major reason for the effects experienced by the respondents.
|Figure 2: Profession based response regarding the main reason for the trouble|
Click here to view
| Discussion|| |
Pandemic of COVID-19 has given rise to a lot of perplexities in the minds of the entire human race with every individual going through personal and professional turmoil. Apart from denting the infrastructure and economies of the affected countries, it has challenged every aspect of health care services. Joining the league with various other occupational health risks in dentistry; Corona virus has brought the dentists and dentistry to a standstill. When “The New York Times” reported, that dentistry was the most vulnerable profession and it had the most risk of any profession concerning COVID-19, it warped the confidence of both the dentists and the dental students. Lockdown has had its repercussions which will strive in the society for a very long time. The practitioners suffered due to monetary loss, those working in teaching institutes have had to suddenly become tech savvy and take online classes, manage emergency OPD and perform domestic chores as well. On the other side, those pursuing dentistry are also holed up at their respective places. They have to attend online classes, do domestic work, and study their subjects in an absolute uncertainty. All this is taking place with the danger of getting infected from COVID-19. Psychological and physical effects, due to the corona virus associated lockdown were anticipated. In this manuscript, an attempt has been made to elaborate on the physical effects corroborating with the mental state of dental professionals going through the scare of COVID-19 and related lockdown.
“Simple Screening Measure for Disaster Mental Health”, used a two-structured format to diagnose (Post Traumatic Stress Disorder) PTSD and depression. In our study, parameters related to the impact of events, perceived stress and the physical effects on the body were incorporated to evaluate the holistic effect of the present situation. Moreover, the evaluation has been done during the imposed lockdown, which further substantiates this survey. According to a meta-analysis done by Ozer, Best, Lipsey& Weiss in 2003, the peri-traumatic risk factors were the strongest predictors of PTSD. Schüffel et al. stated that the traumatic events can possibly lead to the radical changes in the lives of those affected from the disaster. These effects may eventually result in significant psychosomatic or physical illnesses. The lockdown imposed due to corona has also acted as a potential stressor, whereas the change in lifestyle has led to the occurrence of pain in different parts of the body which the respondents had not experienced earlier.
On evaluating the total responses, it was found the maximum responses towards the questions directed towards PTSS and potential Depression were given by the females. As reported by Irish et al. in 2011, females are at higher risk than males for developing posttraumatic stress disorder symptoms (PTSS) following exposure to trauma, which can be due to the differences in initial physiological and psychological responses. It has also been reported that females were almost two times more vulnerable to PTSD as compared to males,, even though they might have fewer exposure to the traumatic experiences. In this study, only 2% of the females accepted that they were thinking about it every time and 61% said that it was only sometimes. Exactly similar response was given by the male respondents as well. The indicators of acute intrusion, avoidance, and hyper arousal along with the potential depression-like symptoms, clearly defined that the corona virus pandemic and lockdown have had a significant psychological effect on the fairer sex.
The persistent complaint of headache could also be attributed to the fact that the stress (23.6%) played major part., Although, lack of outdoor activities was the key factor which affected both the sexes. Lower back was another commonly reported complaint. Apart from this, pain in relation to neck, shoulders, upper back, and lower extremities were mainly seen in women as compared to men. They ascribed this fact to the added domestic work in addition to the daily chores.
Dentists have been touted to be at the high risk of exposure with risk of getting infected and further transmitting it to their patients, families, and colleagues., Amidst this tumultuous atmosphere all around, the dentistry has gone into a shell and dentists are nothing but depressed and anxious about the ongoing conundrum.,,,,
Considering the responses garnered from the dentists of different affiliations, academicians were found to be moderately affected with the symptoms of PTSD. Private practitioners were the most affected of the lot with the maximum responses indicating towards severe PTSD and anxiety towards the present scenario. Post graduate students were the second most affected group as the responses were almost equally inclined towards the symptoms of PTSD and Depression. Responses of undergraduate students indicated that they were the least affected.
Various studies report that pain in different parts of the body vary according to the different occupations and most often there is an increased prevalence of symptoms in particular anatomical regions corresponding to the local physical demands., Alexopoulos et al. in 2004 reported in their study that at least 62% of dentists reported with at least one musculoskeletal complaint. In this survey an attempt was made to know if there were any added musculoskeletal pain symptoms which were not there earlier but occurred only during the time of lockdown. It has been advocated that due to the repeated activity of the same muscles, mirror activity in several brain regions including the human primary motor cortex takes place., Any change in the muscular activity or muscle fatigue leads to deposition of symptoms in certain body parts. Lockdown has led to a significant change in the day to day activities of most of the professionals. Maximum pain and discomfort was reported by the academicians and the private practitioners whereas students did not report of any significant physical effects. With the lack of routine movement, added domestic chores and enhanced screen time, the pain in muscles has been one of the important findings. Similar findings have also been stated by Skovlund et al. in 2020, who reported that various factors influenced by occupation and lifestyle have negative impact on the work ability. The key factors include old age, obesity, mental and physical health problems, and compromised physical capacity and low levels of leisure-time physical activity.
It can be concluded that COVID-19 and the consequential lockdown is beginning to show detrimental psychological and physical effects on the dentists and if this catastrophe prevails in the world, it can lead to serious complications apart from the disease itself. A holistic approach with immediate counseling centers or help lines/portals need to be set up to curb the auxiliary effects of what may prevail in the society for some time now.
Limitations and Future Prospects
As this was an online survey, there were certain limitations of the study like poor response rate, difficulty in judging the seriousness of the responses and the absence of potential participants lacking internet skills. Response bias was also considered to be one of the limiting factors, as the participants respond mandatorily and not voluntarily in such surveys and this is religiously true when the students are involved. So, the future studies can be conducted using one on one interview methods and including further parameters like the financial implications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al
. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Fujii S, Kato H, Maeda K. A simple interview-format screening measure for disaster mental health: An instrument newly developed after the 1995 Great Hanshin Earthquake in Japan--the Screening Questionnaire for Disaster Mental Health (SQD). Kobe J Med Sci 2008;53:375-85.
Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen F, Andersson G, et al.
Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon 1987;18:233-7.
Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 Outbreak: An Overview on Dentistry. Int J Environ Res Public Health. 2020;17:2094.
Rubin GJ, Wessely S. The psychological effects of quarantining a city. BMJ. Published online January 28, 2020:m313.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-60.
Schueffel W, Schade B, Schunk T. A Brief Inventory to investigate Stress-Reactions : Posttraumatic Symptom Scale (PTSS-10) by Raphael, Lundin and Weisaeth. Published online January 1, 2004.
Irish LA, Fischer B, Fallon W, Spoonster E, Sledjeski EM, Delahanty DL. Gender differences in PTSD symptoms: An exploration of peritraumatic mechanisms. J Anxiety Disord 2011;25:209-16.
Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Arch Gen Psychiatry 1998;55:626-32.
Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychol Bull 2006;132:959-92.
Björling EA. The momentary relationship between stress and headaches in adolescent girls. Headache 2009;49:1186-97.
Cathcart S, Bhullar N, Immink M, Della Vedova C, Hayball J. Pain sensitivity mediates the relationship between stress and headache intensity in chronic tension-type headache. Pain Res Manag J Can Pain Soc 2012;17:377-80.
Ge Z, Yang L, Xia J, Fu X, Zhang Y. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci B. 2020;21:361-368.
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-595.
Coulthard P. Dentistry and coronavirus (COVID-19)-moral decision-making. Br Dent J. 2020;228:503-5.
Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al
. Fear and practice modifications among dentists to combat Novel Coronavirus Disease (COVID-19) outbreak. Int J Environ Res Public Health 2020;17:2821.
Sadique MZ, Edmunds WJ, Smith RD, Meerding WJ, de Zwart O, Brug J, et al
. Precautionary behavior in response to perceived threat of pandemic influenza. Emerg Infect Dis 2007;13:1307-13.
Juul-Kristensen B, Jensen C. Self-reported workplace related ergonomic conditions as prognostic factors for musculoskeletal symptoms: The “BIT” follow up study on office workers. Occup Environ Med 2005;62:188-94.
Alexopoulos EC, Stathi I-C, Charizani F. Prevalence of musculoskeletal disorders in dentists. BMC Musculoskelet Disord 2004;5:16.
Krakauer JW, Shadmehr R. Consolidation of motor memory. Trends Neurosci 2006;29:58-64.
Stefan K. Formation of a motor memory by action observation. J Neurosci 2005;25:9339-46.
Skovlund SV, Bláfoss R, Sundstrup E, Andersen LL. Association between physical work demands and work ability in workers with musculoskeletal pain: Cross-sectional study. BMC Musculoskelet Disord 2020;21:166.
[Figure 1], [Figure 2]
[Table 1], [Table 2]