High volumes of aerosols and droplets are disseminated into the air during dental procedures. As SARS-CoV-2, the virus responsible for COVID-19, is transmitted during human−human interactions,6 dental health practitioners are highly susceptible to COVID-19 disease. Furthermore, they may serve as carriers of the virus, transmitting the disease to their patient’s dental practitioners need to be aware of the symptoms of asymptomatic COVID-19 disease and implement strict protocols, including pre-procedure patient screening, in dental practices . In this study, we investigated treatment screening procedures and protocols adopted by dentists in three different settings (public, private, and university hospitals) in Indonesia in response to the COVID-19 pandemic.
The results showed that 100% of dentists who work in university answered the question about the modes of COVID-19 transmission correctly. The majority of the dentists (99%) of the dentists employed in government hospitals and private dental clinics were also aware of the various modes of COVID-19 transmission. Almost 98% of dentists who work in university hospitals answered the question about patient care in terms of infection control correctly. This may be because dentists who work in educational institutions feel they have to update their knowledge. After all, as teachers, they must transmit up-to-date knowledge to their students. This result is in line with that of similar previous studies , which showed that dentists working in educational institutions had better knowledge about the modes of Covid-19 transmission than dentists working in government hospitals and private practices .
Infection control plays an important role in preventing the spread of COVID-19. The WHO and CDC have issued recommended protocols on the management of patients, so that both dentists and patients are protected during dental treatment . The dentist’s practice room poses a particularly high risk of COVID-19 transmission to dentists, dental assistants, and patients through airborne dissemination of the virus via aerosols or droplets . As noted above, almost all the respondents in the present study were aware of the importance of updating their knowledge about the modes of COVID-19 transmission and infection control. Thus, dentists are aware that their profession poses a high risk of both contracting and transmitting COVID-19.
As shown by the results of this study, almost all the respondents (96%) check their patients’ body temperatures prior to dental treatment. Checking a patient’s body temperature before treatment is a useful screening method, as an elevated temperature is one of the symptoms of COVID-19. The body temperature check is usually carried out before entering the building by a building screening officer, but it is common for patients to have their body temperature checked again before dental treatment by a dental assistant as part of pre-procedure screening. The American Dental Association recommends checking a patient’s body temperature as part of an in-office registration procedure using a no-touch forehead temperature scanning device .
Currently, there are several areas in Indonesia where the spread of COVID is high and others where it is low. There are four regional risk categories related to the spread of COVID-19: high-risk areas (red zone), moderate-risk areas (orange zone), low-risk areas (yellow zone), and unaffected areas (green zone). Particular health protocols must be implemented and adhered to in each of these color zones. Information on these protocols can be accessed through the government’s website or a mobile application, and the information is updated daily . By questioning patients about their travel histories before dental treatment, dentists can be aware of potential risk and take steps, including preventive measures, to address these risks. The American Dental Association has recommended always asking patients about their recent travel histories prior to dental treatment as part of pre-procedure dental treatment screening .
Almost all the respondents (99%) in the three dental practitioner settings said that they would postpone dental treatment if a patient showed symptoms of COVID-19. This shows that dentists are aware of the importance of precautionary measures to prevent COVID-19 transmission. An increase in the number of dentists who have contracted COVID-19, together with an increase in the number of people infected with COVID-19, means that dentists are more diligent than ever in terms of dental care screening . Thus, dentists have put in place stricter patient screening procedures.
N95 masks are designed to provide protection against airborne particles and aerosols . Their protective ability is due to the presence of four layers of polypropylene and a particle filtration capacity of 0.3 µm. The outer layer is composed of hydrophobic non-woven polypropylene that is moisture resistant. The second and third layers are made of melt-blown nonwoven polypropylene, which captures particles of various sizes through inertial impaction, interception, diffusion, and electrostatic attraction . The innermost layer is composed of moisture resistant nonwoven polypropylene material . Due to the tight fit of the mask on the user’s face, there is little leakage [29–31]. Therefore, this mask is highly recommended for dentists during dental treatment as a prevention and infection control method . Almost all the respondents (99%) said they wear an N95 mask during dental treatment. On the other hand, in a similar study on Turkish dentists, of 1,095 respondents, only 38.4% used N95 masks during dental treatment . This may be because at the time the data in the Turkish study were collected, the N95 mask was very new to the market . Furthermore, even if available, the mask was expensive. However, it is different with dentists in Indonesia, who may not do dental practice during pandemic, if they do not use an N95 mask.
The results of this study indicate that approximately only 50−60% of dentists provide RATs to their staff (Fig. 7) and 30% of dentists administer RATs to patients with symptoms (Fig. 8). The RAT, despite its lower accuracy and other limitations compared to quantitative reverse transcription Polymerase Chain Reaction (RT-qPCR) detection, is an efficient and easy-to-use test, which requires no special training for COVID-19 detection. Providing RATs prior to visiting dental offices can help mitigate COVID-19 transmission, both to staff and patients. Ideally, the need for RATs should be incorporated into dental treatment screening procedures during the pandemic, and the frequency of the test should be increased. The latter applies to both dental staff and dental patients, as an individual who appears healthy may be an asymptomatic carrier . Another preventive measure to reduce COVID-19 transmission is having patients gargle with mouthwash before having a dental procedure. The results of this study showed that most of the dentists always recommend to their patients that they gargle with a mouthwash prior to dental treatment (Fig. 9). In the present study, the most commonly used mouthwash was povidone-iodine (PVP-I) (Fig. 10). Research has yet to show a clinically effective reduction in the salivary load of SARS-CoV2 at a large population scale associated with gargling with mouthwashes, although gargling with chlorhexidine , 1–1.5% hydrogen peroxide , cetylpiridinium chloride (CPC) , or PVP-I  mouthwashes in advance of dental procedures has been reported to reduce viral loads in vitro, which in turn may inhibit COVID-19 transmission during dental procedures [38, 39]. At present, the recommended antimicrobial mouthwashes are chlorhexidine gluconate, cetylpyridinium chloride, PVP-I, and hydrogen peroxide . Rubber dams can also be used to prevent viral transmission. Dentists are recommended to use a rubber dam whenever possible .
Since the pandemic, direct human−human interactions have been severely limited with the aim of preventing COVID-19 transmission. Due to available technologies, many employees, even health workers, can work remotely. Telemedicine involves a combination of current technologies, such as smartphones and the Internet, in addition to health workers’ expertise, to enable clinical examinations to be performed remotely as there is no direct contact with the patient, telemedicine reduces the potential risk of COVID-19 transmission . Dental health workers can also provide oral health examinations (teledentistry) remotely.
Teledentistry is suitable for the management of minor dental complaints, as well as some more severe complaints. However, in some cases, it will be necessary for the patient to attend a dental clinic in person. As shown in Figure 11, a relatively high percentage of dentists in educational facilities (±60%) perform teledentistry versus a comparatively low percentage in public (government) hospitals and private hospitals. Therefore, dentists in university hospitals are more aware of teledentistry than those in government and private hospitals [41, 42]. The results of this study highlight the value of teledentistry during the pandemic. The findings may also encourage greater take-up of teledentistry among dentists in all settings (i.e., public and private hospitals) in the future.