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ORIGINAL ARTICLE
Year : 2022  |  Volume : 40  |  Issue : 2  |  Page : 165-170
 

Assessment of anxiety levels in children aged 4–9 years about the pediatric dentists donning a personal protective equipment during treatment in the COVID-19 pandemic


Departments of Pedodontics and Preventive Dentistry and 1Pediatric and Preventive Dentistry, M.R. Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission13-Aug-2021
Date of Decision21-Apr-2022
Date of Acceptance23-Apr-2022
Date of Web Publication15-Jul-2022

Correspondence Address:
Dr. S Anu
Department of Pedodontics and Preventive Dentistry, M.R. Ambedkar Dental College and Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisppd.jisppd_288_21

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   Abstract 


Background: Managing anxiety in children during the pandemic will be a concern for many pediatric dentists. Aim: The aim of this study was to assess the anxiety levels in children aged between 4 and 9 years about the pediatric dentists donning a personal protective equipment (PPE) for dental treatment during the COVID-19 pandemic era in Bengaluru. Materials and Methods: The study was done in two parts with a sample size of 100 each. The first part was a questionnaire-based survey addressed to the pediatric dentists practicing in Bengaluru. The second part of the study was clinical assessment of dental anxiety at three time intervals (T1, T2, and T3) using the animated emoji scale. Results: The study revealed that 87% use preprocedural behavior management post-COVID. Majority of the dentists donned the PPE before conditioning the child (59%) and 41% wore the PPE after conditioning the child. The mean anxiety level in the study children showed an increase in anxiety level at T2 of 3.58 (P < 0.001 ± 1.32) in children aged 4–6 years when compared to T1 and T3 of 3.27 (P < 0.001 ± 1.64) and 3.07 (P < 0.001 ± 1.32), respectively. Conclusion: Children aged between 4 and 6 years showed increased levels of anxiety compared to the 7–9-year age group to the pediatric dentists donning a PPE during treatment in the COVID-19 pandemic. Pediatric dentists also showed a satisfactory knowledge regarding disinfection and fumigation procedures.


Keywords: Anxiety, children, COVID-19, dental anxiety, pediatric dentist, personal protective equipment


How to cite this article:
Anu S, Shetty V, Srinivasan I, Kibriya S, Khan BS, Radhakrishnan S. Assessment of anxiety levels in children aged 4–9 years about the pediatric dentists donning a personal protective equipment during treatment in the COVID-19 pandemic. J Indian Soc Pedod Prev Dent 2022;40:165-70

How to cite this URL:
Anu S, Shetty V, Srinivasan I, Kibriya S, Khan BS, Radhakrishnan S. Assessment of anxiety levels in children aged 4–9 years about the pediatric dentists donning a personal protective equipment during treatment in the COVID-19 pandemic. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Aug 12];40:165-70. Available from: http://www.jisppd.com/text.asp?2022/40/2/165/351048





   Introduction Top


The novel coronavirus was announced to be the causative pathogen of COVID-19 by the Chinese Center for Disease Control and Prevention on January 8, 2020.[1] As of February 26, COVID-19 has been recognized in 34 countries, with a total of 80,239 laboratory-confirmed cases and 2700 deaths.[2] COVID-19 is transmitted through respiratory droplets and contact routes.[3] Respiratory droplets are defined by the WHO as >5 μm in diameter and can be either aerosols (50 μm).[4] Aerosol-generating procedures are routinely performed in dentistry. Since SARS-CoV-2 has been found in saliva, it is also possible that COVID-19 can be transmitted by aerosolized saliva. The risk of nosocomial transmission is considered high in a dental setting.

The WHO has recommended droplet and contact precautions for health-care workers who are caring for COVID-19 patients. This guideline included additional precautions for airborne transmission in clinical settings for aerosol-generating procedures.[5] The use of personal protective equipment (PPE) is an important part of standard precautions that include caps, protective eyewear, face masks, face shields, protective clothing, and gloves. PPE protects the skin and mucous membranes of health-care workers from exposure to or contact with infectious agents.

The goal of treatment in pediatric dentistry is to resolve dental problems in best interest of the child and receive maximum cooperation from the child. Despite many advancements in the field, the biggest challenge for pediatric dentists is to alleviate the anxiety of the child and enabling them to accept treatment easily. This may deem unfavorable in pediatric dental setup as the donning of a PPE can potentially affect the doctor–child relationship.[6]


   Materials and Methods Top


A questionnaire- and clinical-based study was conducted to assess the anxiety levels in children aged 4–9 years about the pediatric dentists donning a PPE during treatment in the COVID-19 pandemic era in Bengaluru. The approval of the study was obtained from the institutional ethical committee and review board (IEC No: EC110). The study was conducted for a period of 3 months in two parts from September 2020 to November 2020.

Sample size

The sample size for the present study was derived as follows:

N = Z2 (1−α) × PQ/δ2

Z (1−α) = 1.96 (for 95% confidence interval)

P = 0.50 (based on the probability, that approximately 50% of pediatric dentists have adequate inflectional control protocol followed during COVID-19 pandemic).

Q = 1 − P

δ (margin of error) = 0.10

N = 96.04, rounded off to 100

The sample size N = 100.

Sample size selection

Informed consent was obtained from the parents of the children. Participants willing to participate in the study were recruited using simple random sampling from the Outpatient Department of Pedodontics and Preventive Dentistry, MR Ambedkar Dental College, Bengaluru, India.

Questionnaire

Part I: A total of 100 pediatric dentists practicing in Bengaluru were included in the study. An online validated questionnaire with a hyperlink was sent to them. Inclusion criteria were doctors with a MDS in pedodontics and preventive dentistry in India and students doing postgraduation in pedodontics and preventive dentistry in India.

The online questionnaire consisted of 22 questions excluding personnel information. The questionnaire covered queries regarding the usage of PPE in a pediatric dental setup, behavior management of the child, disinfection, and fumigation during COVID-19 pandemic period.

Procedure

Part II: A total of 100 children aged 4–9 years were included in the study for clinical evaluation using the animated emoji scale[7] after the pediatric dentists donned their PPE. The anxiety rating was recorded at three time intervals in the child's first procedural visit (T): once the child entered the clinic (T1) [Figure 1] and before and after conditioning the child (T2 and T3) [Figure 2] and [Figure 3].
Figure 1: Recording anxiety rating as the patient enters the clinic

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Figure 2: Recording anxiety rating before wearing personal protective equipment and conditioning the child

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Figure 3: Recording anxiety rating after wearing personal protective equipment and conditioning the child

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Statistical analysis

Descriptive analysis of all the demographic and Knowledge, Attitude, Practice (KAP) variables was done using mean and standard deviation for quantitative variables and frequency and proportions for categorical variables. Windows version 22.0 with SPSS software was used to perform statistical analysis, and P < 0.05 was considered statistically significant.


   Results Top


The questionnaire was answered by 105 pediatric dentists in Bengaluru, of which 100 responses were selected. Five incomplete responses were omitted. Twenty-five percent of them had 11–15 years of experience in the field, 36% had 6–10 years of experience, and 39% had 1–5 years of experience. Practice was resumed by 28 of them in August 2020, 21 of them by July, 14 of them by June, 11 of them by May, 11 of them by September, 7 of them by November, 6 of them by October, and 3% did not start services even by December 2020.

Part I

Disinfection and fumigation

Fumigation of the clinic was done by 73%, of which 79% used hydrogen peroxide for fumigation. Disinfection of the clinic was done by 98%, of which 86% used sodium hypochlorite for disinfection. This was statistically significant at P < 0.001.

Awareness on personal protective equipment

The study revealed that 96% wore PPE when treating pediatric patients (P < 0.001), of which 88% wore PPE, N95, facial shield, and double gloves; 2% wore only the PPE suit; 2% wore N95 and gloves; and 2% wore mask, gloves, and face shield.

Use of personal protective equipment in pediatric dental practice for behavior management

Most of the pediatric dentists answered that the PPE affects their working efficiency (91%), 6+3=9; 34+49=83. This was statistically significant at P < 0.001 [Table 1].
Table 1: Comparison of differences in responses to questions on the use of personal protective equipment in pediatric dental practice using Chi-square test

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Management of anxious children in dental practice post-COVID-19

In the present study, among the various behavior management procedures, tell-show-do (TSD) was used by 93%, voice control by 59%, desensitization by 48%, and modeling by 19%. When these methods did not prove effective to manage an anxious child in the dental clinic, physical restraints were used (20%). The parent was allowed inside the operatory by 82% of the pediatric dentists if the child was anxious even after conditioning, and if the parent was allowed inside the operatory, 27% equipped the parent also with a PPE suit. This was statistically not significant at P = 0.35.

If the child became uncooperative, 81% let their dental assistant help and 77% opted for GA/conscious sedation for very uncooperative children.

The child became more cooperative on the second dental visit when seeing the pediatric dentist in PPE (95%), which was statistically significant at P = 0.51.

Part II

[Table 1] shows the age and gender distribution of study participants.

The mean anxiety level among study children showed a significant difference between different time intervals at P < 0.001. The mean anxiety level at T1 was 2.67 (P < 0.006 ± 1.63), T2 was 3.06 (P 0.31 ± 1.38), and T3 was 3.06 (P < 0.001 ± 1.37). The multiple comparisons of mean anxiety levels between different time intervals showed T2 having increased mean anxiety level compared to T1 and T3 at P = 0.006 and P < 0.001, respectively. However, the mean anxiety level between T1 and T3 did not show a significant difference at P = 0.31 [Table 2].
Table 2: Comparison of mean anxiety levels between different time intervals using Friedman's test followed by Wilcoxon signed-rank post hoc test

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The mean anxiety level in study children showed an increase in anxiety level at T2 of 3.58 (P < 0.001 ± 1.32) in children aged 4–6 years when compared to T1 and T3 of 3.27 (P < 0.001 ± 1.64) and 3.07 (P < 0.001 ± 1.32), respectively.

In children aged 7–9 years, there was an increase in the mean anxiety level at T2 of 2.42 (P < 0.001 ± 1.20) when compared to T1 and T3 of 1.93 (P < 0.001 ± 1.30) and 1.82 (P < 0.001 ± 1.11), respectively [Table 3].
Table 3: Comparison of mean anxiety levels based on the age group at different time intervals using Mann–Whitney test

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The children aged 4–6 years showed an increase in the mean anxiety levels compared to children aged 7–9 years. There was no statistically significant difference in mean anxiety between males and females [Table 3].


   Discussion Top


The current study was undertaken to observe any changes in the anxiety of the child to the pediatric dentists donning a PPE during the COVID-19 pandemic in Bengaluru. Dental anxiety and fear of dental procedures are very common in children. To deliver quality dental care, fear must be alleviated from the child.[8],[9] PPE has become an inevitable part of the clinical operatory because of COVID-19; the set consists of a head cover, face shield, goggles, masks, gloves, coveralls/gowns, and shoe cover. It is of absolute importance for dentists and dental assistants to be adequately trained regarding the use of every component and proper donning and doffing of the PPE.[10] In the present study, majority of the pediatric dentists (59%) stated that they donned the PPE before conditioning the child. TSD technique remains the most commonly used technique in pediatric dentistry and justifies being the method of choice as the backbone of child education and behavior guidance during initial examination.[11],[12],[13] Although there is no particular study that states whether it is better to don the PPE before/after conditioning the child, a brief video modeling with a child-friendly PPE before examination might reduce dental anxiety.[14] After donning the PPE, 75% showed an increase in anxiety and 49% of the parents felt uncomfortable to the dentist treating their child in PPE. This was in accordance with the study done by Glaros et al.[15] and Ravikumar et al.[16] and not in accordance with the study done by Tong et al.[17] and Shulman and Brehm.[18]

Eye contact and verbal communication are the basis of nonpharmacological behavior management. The use of PPE affects the doctor–child relationship and working efficiency of the dentist as communication with the child is hampered due to the N95 mask and face shield. The tone of voice is not recognizable, facial expression, body language is masked while wearing a PPE. The use of a child-friendly PPE will reduce dental anxiety significantly in children.[19]

Behavior management of anxious children is still challenging. Majority of the dentists preferred TSD followed by voice control and live modeling, and if these methods deemed ineffective, they preferred physical restraints. This finding was in accordance with the study done by Radhakrishna et al.[20] and Farhat-McHayleh et al.[21] The use of mobile phones and toys is avoided as we have to restrict physical contact and control aerosol splutter.[16]

In the second part of the study, the children were divided into two groups, children aged 4–6 years and 6–9 years, and anxiety levels at different intervals were recorded. Children aged between 4 and 9 years were chosen as they are in the preoperational phase and the latter have good cognitive skills.[13],[22] The present study was evaluated by a single, qualified, pediatric dentist, so that the risk of bias on the outcome measures could be minimized. Younger children showed an increased anxiety in comparison to the older children; this justifies Jean Piaget's theory statement of increasing level of understanding and maturity level among children as their age advances.[23] Children aged 4–6 years showed an increase in the mean anxiety levels compared to children aged 6–9 years. This was in accordance with the study done by Kilinç et al.[24] Another finding noted was that there was no statistically significant difference in the mean anxiety between males and females. This was in accordance with the study done by Mohammed et al.,[25] and not in accordance with Holtzman et al.[26] and Asokan et al.,[27] who stated that females showed increased dental anxiety compared to males as females pay more attention to bodily symptoms and express emotional distress in relation to health problems and the inability to appropriately cope with cognitive appraisals may trigger a greater anxiety response.[28]

Disinfection and fumigation are of utmost importance as sprays of respiratory droplets from an infected individual may also land on surfaces where the virus could remain viable and can serve as a source of transmission.[29] The degree of effectiveness of all the surface disinfectants is dependent on their concentration and exposure time. Ethanol (62%–71%), 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite is most commonly used. It is imperative to clean the surface with soap and water before applying any surface disinfectant. Fumigants have been traditionally employed for a long time for their germicidal tendencies.[30] Recently, a study used hydrogen peroxide as a fumigant to disinfect N95 masks.[31]

The results of the study reflect the anxiety levels of children to a pediatric dentist donning a PPE during treatment in the initial stages of COVID-19 pandemic. Further studies with a larger sample size covering other geographical locations can give further knowledge on the topic.

The authors would like to suggest that the use of PPE in the present scenario (2022) can be considered for certain treatment procedures. PPE need not be donned for simple procedures like oral examination and extractions but can be donned when performing aerosol procedures.


   Conclusion Top


Younger children showed an increase in dental anxiety compared to the older age group, and no significant difference in dental anxiety was seen between males and females. The use of PPE affects the doctor–child relationship, which is primarily based on verbal communication and eye contact. The dentist's working efficiency is also compromised to an extent in a pediatric dental operatory setup.

Acknowledgment

The authors would like to thank and acknowledge Dr. Santhosh for helping with statistical analyses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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