This was a national survey intended to document the knowledge base, reaction and adaptation of Nigerian dentists and dental facilities to the novel COVID-19 pandemic since its advent in the country. For many reasons, it is not surprising that more than half (55.7%; 175) of the respondents practice in South-Western Nigeria. Firstly, the index case in Nigeria was reported in Lagos, a South-Western state which has become the epicentre of the disease. Coincidentally, the greater proportion of Nigerian dentists practice in the same geopolitical zone and most of the established accredited dental schools are also domiciled in the zone. It therefore stands to reason that a national survey of dentists in Nigeria would record the greatest participation from the South Western region. In general, the survey yielded a wide and robust set of data which could be useful for understanding and planning a structured and co-ordinated dental healthcare management system in the pandemic and post pandemic era. Knowledge and awareness of the dentists about the signs, symptoms and transmissibility of the disease, and appropriate mitigative and adaptive measures for sustainable dental healthcare services were explored.
Signs and symptoms.
The respondents demonstrated good knowledge of the common symptoms of COVID-19 which include fever, dry cough, chest pain, dyspnoea, fatigue and myalgia. this is similar to the findings of Arora et al and Khader et al who reported good knowledge of COVID-19 among Dentists in India and Jordan respectively.
In this study, less common symptoms such as headache, dizziness, nausea, vomiting, diarrhoea, abdominal pain and conjunctivitis were also less associated with COVID-19. In particular, fewer than 50% of participants knew about the association with vomiting, conjunctivitis and salivary gland disorders. However, it is crucial for dentists to know every and the least frequently documented symptom because of their high-risk position. The most intriguing fact about this novel disease is in the fact that it shares symptoms with many common illnesses, including nonspecific viral illnesses that are generally considered mild and self-limiting. A high index of suspicion is therefore required to avoid evitable exposure.
Transmission risk in the dental clinic.
Person to person transmission of SARS-CoV-2 is the predominant mode of spread of the disease. In the dental environment, COVID-19 is transmitted mainly by: 1) direct transmission of the pathogen through inhalation of droplets generated when patients cough or sneeze; 2) direct transmission of pathogens via exposure of the ocular, oral or nasal mucous membranes to infectious droplets; and 3) indirect transmission of the pathogen via contaminated work surfaces. Also, airborne transmission of SARS-CoV-2 can occur during aerosol generating dental procedures (“aerosol generating procedures” (AGPs)). Thus, such procedures should only be done in well-ventilated rooms and with optimal personal protective equipment (PPE).
With aerosol-generating procedures being the main concern of the current challenge for dental services provision, interventions that avoid or limit aerosol generation should be the first choice. Such procedures may replace possibly unsafe “standard” therapies in an emergency situation with airborne pathogens such as SARS-CoV-2. Benzian and Niederman proposed the concept of Safer Aerosol-Free Emergent Dentistry (SAFERDentistry). SAFERDentistry relies on a prioritization of the most common patient needs and comprises of the selection of the most effective evidence-based, and value-based care that do not necessitate aerosol generating procedures. This is very important as the procedures do not require complex technology and are effective and achievable, even for resource-limited settings.
Furthermore, respiratory secretions, droplets or aerosols expelled by infected individuals can contaminate objects and surfaces. Reverse transcription polymerase chain reaction (RT-PCR) detectable viable SARS-CoV-2 and/or RNA can be found on surfaces ranging from hours to days following aerosol generating procedures. This depends on the ambience; including temperature, humidity, the type of surfaces and the concentrations of the emissions which are usually high in health care facilities where patients with COVID-19 are being treated. Transmissions may therefore occur indirectly through touching contaminated surfaces and objects such as dental chair light handle/ switch, trays, chair adjustment buttons, workstation surfaces with subsequent transfer to the mucous membranes of the nose, mouth, or eyes. However, despite consistent evidence of surface contamination and fomite survival, there has not been a report of any specific case of SARS-CoV-2 infection arising from fomite transmission. Nevertheless, it is recommended that all surfaces are cleaned properly with alcohol-based (70-90%), Chlorine-based (5000 ppm), or Hydrogen peroxide-based (>0.5%) surface disinfectant after each patient's visit especially for high-touch surfaces and at least once daily terminal clean. Contact time of a minimum of one minute or adherence to manufacturers’ instructions is recommended in the use of these disinfectants.[11,23]
General preventive measures.
Every patient is potentially infectious as transmission of SARS-CoV-2 can occur in pre-symptomatic and asymptomatic stages. In these situations, medical/travel history or body temperature measurements offer no guarantee of recognising an infected person. Furthermore, unavailability of reliable routine checks and valid point of care testing prior to dental care at this point, is another bane to prompt identification of infected individuals. The only safe haven is in the adoption of universal precautions. Every patient must be considered potentially infectious and should be treated with appropriate aseptic techniques and preventive barriers. One of the findings in this study revealed that up to 17% of the studied population do not carry out temperature checks before admitting patients into the clinic. This may not be unconnected to the fact that the standard protocol of universal infection control is maintained in most of our facilities. However, vigilance in cases of obvious signs of respiratory symptoms must be instituted to prevent undue exposure to the virus.
It was generally agreed that hand hygiene is the ﬁrst step in curtailing the spread of the virus; the WHO guidelines stipulate that meticulous hand-washing be performed before any aseptic procedure, before touching a patient, after touching a patient, after exposure to body fluids, and after touching a patient’s surroundings. Also, patients should be requested to wash their hands before admittance into the clinic. Most of the participants in this survey prepared multiple hand hygiene options in their facilities. This shows the readiness of the oral health care personnel in forestalling the spread of the infection. However, with only about 65% of the respondents using wash hand basins and 10% with no hand hygiene measures at the clinic entrance, there is need for all dental clinics across the country to scale up their facilities and ensure adequate arrangement is made for hand hygiene measures.
During the COVID-19 pandemic, prevention of oral health problems and self-care remained of high importance. Information on keeping and maintaining good oral hygiene should be escalated to patients through remote consultations or/and social media channels. If and where possible, patients should be screened before their appointments either by virtual/remote technology or telephony.
Despite the increasing utilization of teledentistry in our study population, the use is still minimal compared to other countries[24,25]. This may be related to unavailable or inaccessible uninterrupted internet supply in many parts of the country. Also, some patients may not be adequately technologically empowered to communicate with the Clinician for tele-consultation, even when and where such facilities are available. Therefore, there is still a need to emphasize the importance of integration of health information management technology into patient management and to improve information technology infrastructure.
Patient flow and common presentations.
The participants in this study reported that majority of the clinics were partially or totally closed during the lockdown period in Nigeria. This is similar to the findings of the American Dental Association (ADA) Health Policy Institute (HPI) which showed that at the height of the pandemic in the United States, about 80% of dental practices oﬀered only partial emergency services, and 17% of dental clinics did not see patients at all. Furthermore, similar reports were received from other parts of the world as dental clinics were advised to close down or scale down activities as a preventive measure. However, many clinics were already reopening at the time of this study.
According to WHO, routine oral health care such as oral health checks, scaling and polishing, aesthetic and preventive care should be deferred or carried out remotely until there has been appreciable decrease in COVID-19 transmission incidence from community transmission to cluster cases. However, the urgent oral health care services that are vital for preserving a functional oral complex, managing severe pain or maintaining quality of life that is essential should be provided.
Pre-procedural mouth rinses have been shown to reduce the oral viral load, since SARS-CoV-2 is sensitive to oxidation[14,28]. Peng et al., proposed rinsing the mouth with 1% hydrogen peroxide or 0.2% povidone-iodine for 30 seconds before commencing a dental procedure. However, over 40% of our respondents do not ensure any form of preprocedural mouth rinse. It is advised that this cheap and effective means of reducing oral pathogens be instituted in our clinics.
Administrative intervention and training.
Dental health care practitioners have a significant role in the worldwide fight against pandemics like COVID-19 because they are knowledgeable in cross-infection control procedures and barrier techniques.
All dental care facilities should develop a simple-to-apply infection prevention and control protocol. The assignment of a focal person in charge of infection prevention and control is a laudable development as several of our participants alluded to this in their facilities. It is however worrisome that less than half of the respondents have received formal training on infection control concerning COVID–19 and less than 40% have had training on the rational use of PPE. It is imperative to ensure that dental health care personnel are formally trained in infection prevention and control, choice and appropriate use of Personal Protective Equipment (PPE) and in following a risk assessment and standard infection precautions. PPE include gloves, eye protection (face shield that covers the front and sides of the face or goggles), fluid resistant disposable gown, and a medical mask. This training needs to be taken as a major intervention strategy as less than half of our study participants have had such training.
This is the right time for dental schools to advance the learning outcomes of their courses to include added roles of dentistry that take into account natural disasters and pandemics preparedness.
It is noteworthy that most centres have reduced the number of patients accommodated in their waiting rooms but the maintenance of physical distance must still be emphasized and all patients in the reception area should use face masks.
Definitive airflow is a major consideration in maintaining a safe workspace during the COVID-19 outbreak. Ventilation engineering should be recognized as an important means of reducing airborne transmission as it controls how quickly room air is evacuated and changed over a period of time. Ventilation plays a key role in eliminating exhaled virus-laden air, thus dropping the overall concentration and any subsequent dose inhaled by the room occupants. This reduces the possible risk of transmission in any oral health care facility. The use of split air conditioning systems or other types of recirculation devices should be circumvented, and facilities should consider fixing filtration systems or exhaust fans. However, any modification of the ventilation system in an oral health care facility needs to be done with caution, taking into consideration the cost of the initial design, procurement, early and late maintenance and potential impact on the established airflow in other parts of the healthcare facility.
Personal Protective Equipment (PPE).
The availability and sufficiency of PPE was a concern for majority of our respondents. It is important to emphasize that, regardless of the treatment planned, dental healthcare professionals must adhere to strict protocols related to clinic dressing and personal protective equipment. Hair caps, surgical gowns, surgical masks or N95, special foot wears, protective goggles, and protective visors are essential[12,34]. The use of personal items should be minimised in the clinic as much as possible, instead, scrubs and clinic uniforms should be encouraged. It is important that all DHCP undertaking or assisting in procedures are trained and understand how to properly done, use, and doff appropriate PPE to prevent self-contamination. A fit tested N95 or FFP2 respirator (or higher) is necessary when Aerosol Generating Procedures (AGP) are performed, however, majority of our respondents have no fit tested N95 masks available for their work. This situation gives credence to the need for such participants to avoid AGPs.