The impact of Covid-19 pandemic over the dental patients

Objective: Covid-19 is a highly infectious disease; it is transmitted by patients’ secretions and respiratory droplets SARS-CoV-2 was detected in patients saliva making dental care professionals more susceptible for contamination and the patient less safe while seeking the dental treatment. Methodology: This quantitative study was elaborated through a questionnaire for patients who frequently seek dental care in private and publica dental care units. A total of 205 over-18 patients were included, those who left one or more questions without answer were excluded. Participants were able to refuse to answer any question or to participate in the questionnaire at all. The questionnaire was composed of five questions. Participants were divided into two groups: Group 1: private dental offices patients (n=98); Group 2: public dental clinic patients (n=107). Results: there was a significant difference between groups 1 and 2, in which 50% of group 1 feel safe while seeking dental care during the Covid-19 pandemic in comparison with 72.89% of group 2. There was no significant difference between groups 1 and 2, in which 93.87 and 94.39% of groups 1 and 2 respectively feel safe with the professionals' PPE and consider it sufficient. About 59.81% of the participants of group 2 do not feel insecure with the cross contamination caused by SARS-CoV-2 in collective health care units. Finally, there was a significant difference between groups 1 and 2, in which 74.48% of group 1 prefer to be attended by vaccinated professionals, instead of only 56.07% of group 2. Conclusion: it was concluded that not all dental patients feel safe while seeking dental treatment during the Covid-19 pandemic, however, they consider the professional PPE sufficient. Patients feel safe to be attended by vaccinated professionals.


Introduction
Severe acute respiratory syndrome coronavirus 2 "SARS-CoV-2" that causes coronavirus disease of 2019 "Covid-19", belongs to β genus Coronavirus of the coronaviridae family (H. Y. Tian, 2020). Its genome characterization suggests similarity with the severe acute respiratory syndrome coronavirus "SARS-CoV" and Middle East respiratory syndrome coronavirus "MERS-CoV" . It has a positive-sense, single-stranded RNA genome of ∼30 kb (Kim et al., 2020) which encodes three membrane proteins (Mandala et al., 2020) making its deactivation possible with sodium hypochlorite (Amjad Abu Hasna & Bresciani, 2021). However, after entry and replication of the genome in host cells, SARS-CoV-2 maintains a series of strategies to prevent the host's immune system from recognizing it, and adheres to receptors throughout the human body in order to replicate (Mohamadian et al., 2021).
The common symptoms of Covid-19 include: fever, cough, shortness of breath, fatigue, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea, among others. However, many variants of SARS-CoV-2 was reported by the world health organization "WHO" (World Health Organization, 2021) using the pangolin "Phylogenetic Assignment of Named Global Outbreak" Lineages nomenclature tool (O'Toole et al., 2021) alerting the need for rapid containing of Covid-19 to prevent further mutations of SARS-CoV-2 (Callaway, 2021).
Covid-19 is a highly infectious disease, it is transmitted by patients' secretions and respiratory droplets (Nishwa, Riaz, Fatima, & Wahid, 2020). SARS-CoV-2 was detected in patients saliva  making dental care professionals more susceptible for contamination (Jurema et al., 2020). The dental care was restricted to emergent and urgent cases upon the pandemic onset (Kılıçarslan, Şenel, & Özcan, 2020) using strict protocols to avoid dentist-patient and patient-patient contaminations (Jurema et al., 2020). National and international health authorities reinforced the use of personal protective equipment "PPE" including N-95 masks and face shields beside the anteriorly used PPE (Jurema et al., 2020; Pan et al., 2020), Research, Society andDevelopment, v. 10, n. 11, e252101119502, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19502 3 in addition to vaccine to control the pandemic (X. Tian et al., 2020) Because of SARS-CoV-2 high pathogenicity, lethality and spreading (Mohamadian et al., 2021), an effective vaccine would be crucial in controlling the pandemic, ending social distancing and resolving the socioeconomic implications caused by the spread of the virus around the world. The vaccine development encompasses a series of clinical and laboratory trials that take years to be finalized and scientifically proven (Lima, Almeida, & Kfouri, 2021). In this race against time, vaccines against Covid-19 were produced in a record time, and four types of vaccines have been applied in Brazil to date.
The objective of this paper was to understand the impact of Covid-19 on dental care service through a questionnaire directed for dental patients. The null hypothesis is that the dental patients feel safe with the professionals' PPE.

Methodology
This quantitative study was elaborated through a questionnaire for patients who frequently seek dental care in Minas Gerais state, at private dental offices in the cities of Pouso Alegre and Itajubá, dental clinic of the National Institute of Higher Education and Post-graduation Priest Gervásio "INAPÓS", and at primary health unit "UBS" in the city of Cambuí.
This study was approved and authorized by the Ethics Committee of São Paulo State University, Institute of Science and Technology ICT-Unesp (protocol 4.909.386). All participants signed an informed consent form. Participants were able to refuse to answer any question or to participate in the questionnaire at all.
• Patients who answered all the questions.
• Patients who accepted to sign the informed consent form and participate in the questionnaire voluntarily.
• Patients who left one or more questions without answer.
• Patients who refused to sign the informed consent form and participate in the questionnaire voluntarily.

Patients' questionnaire
This study was performed in July 2021. The questionnaire was composed of five questions. A total of 205 participants were included in this study and divided into two groups: • Group 1: private dental offices patients (n=98); • Group 2: dental clinic of INAPÓS and UBS patients (n=107).
All participants of both groups received a standardized questionnaire focusing on their safety while seeking dental care during the Covid-19 pandemic, their acceptance of the professionals PPE and protocols, and their acceptance of the vaccine (Table 1). . This macro requires two input columns, where the first column contains the number of successes (or the right answers), and the second column contains only integer data. In questions 1, 2, 3 and 5, the answer YES was considered as success or right answers. It was not possible to analyze the data of question 4 as it was assigned for group 2 only.

Patients' questionnaire
In question 1, all the participants of both groups confirmed that they have been attended during the period of the Covid-19 pandemic. In question 2, there was a significant difference between groups 1 and 2, in which 50% of group 1 feel safe while seeking dental care during the Covid-19 pandemic in comparison with 72.89% of group 2 ( Figure.1).  Finally, in question 5, there was a significant difference between groups 1 and 2, in which 74.48% of group 1 prefer to Research, Society andDevelopment, v. 10, n. 11, e252101119502, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19502 6 be attended by vaccinated professionals, instead of only 56.07% of group 2 ( Figure.3).

Discussion
Covid-19 pandemic affected the dental care services all over the world (Bhanushali et al., 2020;Wu, Wu, Nguyen, & Tran, 2021;Yang, Zhou, Liu, & Tan, 2020). Diverse studies were published in the literature trying to propose protocols to decrease the risk of contamination among patients and health workers including dentists (Jurema et al., 2020;Kılıçarslan et al., 2020;Pan et al., 2020). To the best of our knowledge, little or no questionnaires were elaborated to understand the impact of the Covid-19 pandemic over the dental patients.
There is no doubt that the covid-19 affected the dental patients' choices, alternatives and behavior (Jiang, Tang, Mei, rate of compliance to the used protocols during the Covid-19 pandemic to control the virus spread in dental clinics especially during the orthodontic treatments (Umeh, Utomi, Isiekwe, & Aladenika, 2021).
In question 4, which was only destinated for the participants of groups 2, it was found that 59.81% of the participants do not feel insecure with the cross contamination caused by SARS-CoV-2 in collective health care units. Again, this may be related to the patient financial conditions and their awareness about the pandemic (Schwendicke et al., 2020), and to the influence of the dentists on dental patients choices (Ahmed et al., 2020).
In question 5, it was found that only 56.07% of group 2 prefer to be attended by vaccinated professionals, while a significant difference was found with group 1 that reached 74.48%. there is no doubt that the covid-19 vaccines are facing problems to be accepted by the patients all over the world, and in some cases among dental and medical students . However, it was found that dentists may help in revealing patients concerns about the Covid-19 vaccines Marquez, Gosnell, Thikkurissy, Schwartz, & Cully, 2021), and the first step should be the professionals themselves being vaccinated serving as example (Kaplan, Sahin, Parildar, & Adadan Guvenc, 2021) to enhance the populations acceptance about the Covid-19 vaccines (Papagiannis et al., 2021).

Conclusion
• Not all dental patients feel safe while seeking dental treatment during the Covid-19 pandemic.
• Dental patients feel safe with the professional PPE and consider it sufficient.
• Patients feel safe to be attended by vaccinated professionals.