ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10015-2045
World Journal of Dentistry
Volume 13 | Issue 3 | Year 2022

Infection Control Measures Practiced by Oral and Maxillofacial Surgeons during COVID-19 Pandemic: A Cross-sectional Study


Snehalata Narvekar1, Shridhar D Baliga2, Sulakshana S Baliga3

1,2Department of Oral and Maxillofacial Surgery, KAHER, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India

3Department of Community Medicine, KAHER, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Corresponding Author: Shridhar D Baliga, Professor and Head, Department of Oral and Maxillofacial Surgery, KAHER, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India, Phone: +91 9341102665, e-mail: baliga1974@gmail.com

ABSTRACT

Aim: Since the source of the coronavirus disease 2019 (COVID-19), it has become global health emergency. It is life threatening condition and dentistry has been classified as the high-risk job let alone be the oral and maxillofacial surgeons, because of direct exposure to blood and saliva. The standard although are good are not sufficient during the pandemic like COVID-19. Adequate screening as well as the proper infection control measures are recommended. To know Infection control measures practiced by oral and maxillofacial surgeons during COVID-19 pandemic.

Materials and methods: A cross-sectional study was conducted on 353 oral maxillofacial surgeons to know the infection control measures practiced by them during COVID pandemic.

Results: This study shows that majority of infection control measures were practiced more in government hospitals when compared to private hospitals Chi-square test and logistic regression analysis was used. Statistical significance was set at p <0.05.

Conclusion: This study highlights that oral and maxillofacial surgeon practicing infection control measures like use of prophylactic medication, high volume extraoral suction, negative pressure room, use of heap filters, fumigation system, and use of chemicals for disinfection were less likely to be affected by COVID-19.

Clinical significance: The findings of this study will help us to provide practical advice to oral surgeons regarding appropriate use of infection control measures to protect themselves from the risk of COVID-19 infection during surgical procedures.

How to cite this article: Narvekar S, Baliga SD, Baliga SS. Infection Control Measures Practiced by Oral and Maxillofacial Surgeons during COVID-19 Pandemic: A Cross-sectional Study. World J Dent 2022;13(3):271-276.

Key message: Extensive infection control measures in the field of dentistry should be practiced on daily basis especially during pandemic like COVID-19, to contain spread of infection

Source of support: Nil

Conflict of interest: None

Keywords: COVID-19, Infection control measures practices, Oral and maxillofacial surgeons

INTRODUCTION

Coronavirus disease, also known as COVID-19, has spread to many countries since originating in Wuhan, China in 2019 and has become a global health emergency.1-3 COVID-19 pandemic has affected healthcare system globally especially dentistry due to aerosol generating procedure.3-5

The Occupational Safety and Health Administration (OSHA) report on guidelines for preparing workplaces for COVID-19 has classified dentistry as a very high-risk job.5,6 While the standard precautions are good, they are of little use in containing the highly contagious COVID-19 virus. Protection against infection begins with the patient visit with adequate screening and hand hygiene.5-8 In order to reduce surface contamination by the aerosols generated during the high efficiency particulate air (HEPA) filter process, adequate ventilation, high volume suction, and the use of chemical disinfectants and fumigations are urgently required.2,4,6,7,9

Oral and maxillofacial surgeons working in head and neck region dealing with emergencies such as maxillofacial trauma, space infections, and elective procedures such as oral cancer, orthognathic surgeries have high exposure to novel SARS-CoV2.10 They are exposed to COVID-19 infection due to the close contact with patients as it is very difficult to maintain interpersonal distance of more than a meter and they are also exposed to saliva, blood, and other body fluids during surgical procedures. Very few studies have been done regarding infection control measures especially during COVID-19 pandemic. So, this study regarding infection control measures practiced by oral surgeons will help us to provide practical advice to oral and maxillofacial surgeons regarding appropriate use of infection control measures to protect themselves from the risk of COVID-19 infection during surgical procedures.

Objective

To know Infection control measures practiced by Oral and maxillofacial surgeons during COVID-19 pandemic.

MATERIALS AND METHODS

As the prevalence of use of infection control measures among oral surgeons is varied, a prevalence of 50% was used to calculate the sample size.

where Z value for 95% confidence level 1.96

Absolute error = 5%

We know the population size, so sample size for finite population was

Sampling method: A list of 3000 Oral surgeons in India was obtained from Association of Oral and Maxillofacial surgeons of India (AOMSI). By using systematic random sampling method 353 Oral and Maxillofacial surgeons were chosen. First participant was selected randomly and thereafter every 11th oral surgeon was selected as a study participant.

Study tool: Pretested, predesigned questionnaire was used with nine open-ended multiple-choice questions. Pilot study was done and questionnaire was modified according the feedback obtained. The questionnaire was validated with Cronbach’s alpha score of 0.72. Information regarding infection control measures practiced by oral and maxillofacial surgeons was collected. Information regarding whether active screening of patients for fever and symptoms of COVID-19 was done, was gathered. Information was collected using Google forms and the responses were saved in Microsoft excel sheet. The same was used for performing descriptive analysis on the data. The oral surgeons were grouped into private/government employees. The information regarding any variations in infection control protocols for major and minor surgical procedures by oral surgeons working in private/government setup was recorded. The present study was conducted before the advent of vaccine.

Inclusion criteria: Oral and Maxillofacial surgeons practicing in private/government setup who gave consent to participate in study.

Informed consent was obtained by study participants and confidentiality of identity was assured.

Ethical clearance was obtained from Institutional ethics committee letter dated 3/9/20 vide no 1386.

Statistical analysis: SPSS version 20 was used for analysis. Chi-square test and logistic regression analysis were used. Statistical significance was set at p < 0.05.

RESULTS

In the present study, the use of prophylactic medication by oral and maxillofacial surgeons, active screening for fever or COVID-19 symptoms and RT PCR testing among patients was more in government hospitals which were found to be statistically significant (p < 0.05). Body temperature was recorded prior to each surgical procedure by oral and maxillofacial surgeons who worked in both private and government hospitals. Regarding infection control measures during surgical procedures such as high-volume suction, use of room air purification system, HEPA filter, presence of the negative pressure room was seen more often in government hospitals than in private hospitals, with the exception of natural ventilation, which was better in private hospitals. This difference was found to be statistically significant (p < 0.05). The use of the fumigation system was carried out more frequently in government hospitals compared to private hospitals. This difference was found to be statistically significant (p < 0.05). The use of suitable PPE, N 95 masks, has been practiced by both oral and maxillofacial surgeons, working in private and government hospitals. Whereas distilled dental water and handpieces were not used by government or private hospitals (p > 0.05) (Table 1).

Table 1: Association between type of work place and use of infection control measures
Infection control measures Work place p-value
Government hospital Private
Use of prophylactic medication No 0 (0%) 201 (79.76%) 0. 000,4998*MC
Yes 101 (100%) 51 (20.24%)
Active screening for fever or COVID-19 symptoms No 13 (12.87%) 31 (12.3%) <0. 00,001*
Yes 88 (87.13%) 221 (87.7%)
Recording of body temperature Yes 101 (100%) 252 (100%)
RT PCR testing No 10 (9.9%) 65 (25.79%) <0. 00,001*
Yes 91 (90.1%) 187 (74.21%)
Use of appropriate PPE Yes 101 (100%) 252 (100%)
Use of N 95 masks Yes 101 (100%) 252 (100%)
Use of high volume extraoral suction No 50 (49.5%) 151 (59.92%) <0. 00,001*
Yes 51 (50.5%) 101 (40.08%)
Use of the indoor air cleaning system No 50 (49.5%) 151 (59.92%) <0. 00,001*
Yes 51 (50.5%) 101 (40.08%)
Use of dental chair water unit No 101 (100%) 252 (100%)
Use of hand pieces No 101 (100%) 252 (100%)

MC, Monte-Carlo’s simulation

In our study, 114 (32.29%) of oral surgeons were COVID-19 positive. The present study found that oral and maxillofacial surgeons who took history of COVID-19 symptoms and recorded body temperature measurements before procedures were less likely to be affected by COVID-19 infection compared to doctors who did not use the infection control measures, which was statistically significant (p < 0.05). The likelihood of not being affected by COVID is 12.0202 (CI: 6.2677–23.0522) times more for surgeons using prophylactic medication compared to surgeons not taking prophylactic medication. Surgeons who implemented infection control measures such as HEPA filters, high volume suction, worked in negative pressure room, and in the presence of natural ventilation during surgery, were less likely to be affected by COVID-19 infection compared to doctors who did not use infection control, which was statistically significant (p < 0.05). The probability of not being affected by COVID is 12.0202 (CI: 6.2677–23.0522) times more for the oral and maxillofacial surgeons who use heap filters compared to the subjects who do not use heap filters. The likelihood of not being affected by COVID is 29.1451 (CI: 3.9696–213.9389) times higher for those who use natural ventilation compared to those who do not use natural ventilation. The probability of not being affected by COVID is 25.7163 (CI: 7.9386–83.3054) for the subjects who use a negative pressure room compared to the subjects who do not use a negative pressure room. Surgeons using a fumigation system and chemical disinfection after surgery were less likely to be affected by COVID-19 infection compared to doctors who did not use infection control measures, which was statistically significant (p < 0.05). The likelihood of not being affected by COVID is 8.6256 (CI: 5,1419–14.4695) times higher for those who use the required chemicals for disinfection compared to those who do not use the required chemicals for disinfection. Whereas active screening for fever and COVID-19 symptoms, RT PCR testing for patients (Table 2).

Table 2: Association between Infection control measures and COVID status of oral and maxillofacial surgeons
Infection control measures COVID-19 status of oral and maxillofacial surgeons Odds ratio CI p-value
Negative Positive
Use of prophylactic medication No 99 (41.42%) 102 (89.47%) 12.0202 6.2677–23.0522 <0.0001*
Yes 140 (58.58%) 12 (10.53%)
Active screening for fever or COVID 19 symptoms No 25 (10.46%) 19 (16.67%) 0.0988
Yes 214 (89.54%) 95 (83.33%)
Recording of body temperature Yes 239 (100%) 114 (100%)
RT PCR testing No 47 (19.67%) 28 (24.56%) 0.293
Yes 192 (80.33%) 86 (75.44%)
Use of appropriate PPE Yes 239 (100%) 114 (100%)
Use of N 95 masks Yes 239 (100%) 114 (100%)
Use of high volume extraoral suction No 102 (42.68%) 99 (86.84%) <0.0001*
Yes 137 (57.32%) 15 (13.16%) 8.8647 4.8626–16.1606
Use of the indoor air cleaning system No 135 (56.49%) 66 (57.89%) 0.8025
Yes 104 (43.51%) 48 (42.11%)

From the table above, we can clearly say that there were only two major significant predictors for the COVID status in the model. The likelihood of not being positive for COVID is 4.8542 times higher for subjects who used chemicals for disinfection compared to oral and maxillofacial surgeons who did not use chemicals for disinfection. The likelihood of not being positive for COVID-19 is 14.8505 times for surgeons who used fumigation system (Table 3).

Table 3: Logistic regression model for predictors of COVID-19 status among oral and maxillofacial surgeons
Estimate Std. Error z value p-value OR (CI)
(Intercept) −1.2024 0.2201 −5.462 <0.0001* 0.3005 (0.192, 0.4565)
Chemicals required No (Reference)
Yes 1.5798 0.3059 5.164 <0.0001* 4.8542 (2.6839, 8.9385)
Fumigation systems No (Reference)
Yes 2.698 0.3241 8.325 <0.0001* 14.8505 (8.041, 28.8145)

DISCUSSION

Infection control especially COVID-19 in the present pandemic situation continues to be one of the most critical issue in health care services worldwide. Transmission of infection during dental procedures may occur through direct contact with bodily fluids or via indirect contact with objects like instruments or environment surfaces.1,2,4 So, there is a need to present and control infection to provide secure environment for health care professionals in general and more specifically for oral and maxillofacial surgeons.9,11,12

In the present study, it was seen that infection control measures were practiced more by the oral and maxillofacial surgeons working in government hospital when compared to private hospitals (Table 4). Compliance with effective infection control practices may be affected by several factors such as knowledge, cost, lack of incentives, and availability of and access to required materials and equipment.13-15 The present study was done before the advent of vaccine. Although in current situation where we have COVID-19 vaccine, unfortunately as SAR-COV2 keeps changing its behavior, the apprehension still remains among the oral surgeons to deliver the care to the patients. Hence the present study highlights the importance of infection control measures in controlling COVID-19. The findings of this study will help us to provide practical advice to oral surgeons regarding appropriate use of infection control measures to protect themselves from the risk of COVID-19 infection during surgical procedures.

Table 4: Distribution of study participants according to Barriers for infection control measures
Yes No
Barriers Cost effective 202 (57.22%) 151 (42.78%)
Patient not willing to pay for PPE’s essentials 202 (57.22%) 151 (42.78%)
Difficulty in procuring 0 (0%) 353 (100%)
Difficulty in performing the procedure with PPE’s 251 (71.1%) 102 (28.9%)

In our study, 114 (32.29%) of oral surgeons were COVID-19 positive. This high prevalence of infection among our study participants could be due the inappropriate use of one or the other infection control measures but also may be due to their exposure to COVID patients outside their clinical practice. In this study it was observed that in spite of recording body temperature, use of PPE, use of N 95 masks, use of dental chair water unit, use of Hand pieces and use of UV light for major and minor surgical procedures, majority of the surgeons tested COVID positive. This observation can be due to improper fit of N 95 masks, non-adherence of proper donning, doffing and use of protocols which is essential for the success of disease prevention among the surgeons. It was seen that oral and maxillofacial surgeons who practiced with adequate infection control measures were less likely to be affected by COVID-19 than those who did not practiced infection control measures (Tables 2 and 3 ). Similarly, in a study conducted in United States showed dentists who practiced infection control measures were less likely to get COVID-19.14,16

In the present study use of chemicals for disinfection and use of fumigation system were the predictors of COVID-19 status among oral surgeons (Table 3). A systematic review conducted on environmental disinfection of a dental clinic during the COVID-19 pandemic showed that using environmental disinfection is protective. Similar results were found in a study conducted in turkey.12,17,18

In this study, various barriers to use infection control measures were identified like cost of equipment, the willingness of patients to pay for various measures, difficulty in procuring the equipment’s. Similarly, a study conducted on the implementation of COVID-19 infection control measures by German dentists showed that major barriers were lack of knowledge, guidelines, and recommendation as well as limited availability and high costs of equipment’s.19

CONCLUSION

The dental health care professionals especially oral and maxillofacial surgeons are potentially at risk of exposure to COVID-19. The finding of this study has highlighted the need for infection control measures.

Recommendations

  • Regardless of whether the health care professionals acquire infection at workplace or community, it is essential to practice appropriate infection control measures like use of personal protective equipment, sterile instruments and devices, clean and disinfected environmental surfaces.

  • Adequate information regarding basis infection control measures should be provided to oral and maxillofacial surgeons through continuing education programs by dental association and government agencies.

Limitations

The study relies on self-reported information and might therefore represent overestimation of practices of infection control measures. The association of COVID positive status among the oral surgeons cannot be completely associated with their inappropriate use of infection control measures solely, but may be due to their exposure to COVID patients outside their clinical practice also.

QUESTIONNAIRE

  1. Name:___________________

  2. Age:____________

  3. Zone/state of practice:_________________________

  4. Where do you work:

    • Private setup ⬜

    • Government setup ⬜

  5. Which of the following measures you have adapted to combat the COID 19 situation:

    • Use of prophylactic medication ⬜

    • Screening of patient: History ⬜

    • Body temperature ⬜

    • Blood COVID testing ⬜

    • Use of appropriate PPE and face shield ⬜

    • Use of N 95 masks ⬜

    • Fumigation systems ⬜

    • High volume extraoral suction ⬜

    • The indoor air cleaning system ⬜

    • The dental chair water lines should be equipped with ant retraction valves n valves ⬜

    • Used hand pieces with antiretraction valves only ⬜

    • Chemicals required for disinfection ⬜

    • Heap filters ⬜

    • UG light ⬜

    • Natural ventilation ⬜

    • Negative pressure room Any others:_______ ⬜

  6. Have you treated any COVID positive patient:

    • Yes ⬜

    • No ⬜

  7. Have you been tested positive for COVID 19:

    • Yes ⬜

    • No ⬜

  8. Did you develop the symptoms:

    • Yes ⬜

    • No ⬜

  9. What are the barriers in adapting the protocols:

    • Cost effective

    • Patient not willing to pay for PPE’s

    • Difficulty in procuring

    • Difficulty in performing the procedure

ACKNOWLEDGMENT

Authors would like to thank oral and maxillofacial surgeons who participated in the study for their cooperation. We would also like to thank the college authorities for their permission to conduct the study.

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