The coronavirus disease (COVID-19) is a newly discovered viral infection that started in Wuhan, China and caused the outbreak of pneumonia in the rest of the world. It seems that the rapidly spreading virus is more contagious than severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus [1]. A suggested route of human-to-human transmission is through airborne droplets, touching or coming into contact with an infected person or a contaminated surface. Moreover, other routes such as blood or saliva have not been explored but are possible because of the documented transmission of blood-borne infectious diseases such as HIV/AIDS, hepatitis C virus, and hepatitis B virus through blood or saliva. These routes of transmission increase the concern about a similar route of transmission for COVID-19 in the dental setting [2].

A large number of medical staff were reported to have acquired the disease while working with infected individuals [3]. The dental clinic is not an exception for a similar possibility of transmitting and acquiring the infection between staff or individuals; moreover, the dental clinic could be a riskier environment for spreading the virus because of the close contact with patients and the nature of the dental treatment [4]. Although patients diagnosed with COVID-19 are not supposed to receive dental treatments, dental emergencies can occur, and close contact would be unavoidable. Furthermore, both the relatively prolonged incubation period of the disease (the median incubation period was estimated to be 5.1 days, 95% CI 4.5-5.8 [5] or up to 14 days for some cases [6,7] before any symptoms could even be detected) and the postinfection period make it challenging for medical staff to recognize the existence of COVID-19 infections, which could increase the transmission of the disease during these lay periods. Therefore, patients infected with COVID-19, without showing symptoms, are of a great threat to dentists and other members of the dental team. Dentists, thereby, should entertain a high level of awareness and integrity to deal with the disease and be able to control and manage its spread.

There are practical guidelines recommended for dentists and dental staff by the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), and the World Health Organization to control the spread of COVID-19 [8-10]. Like with other contagious infections, these recommendations include personal protective equipment, hand washing, detailed patient evaluation, rubber dam isolation, antiretraction handpiece, mouth rinsing before dental procedures, and disinfection of the clinic. In addition, some guidelines and reports have provided useful information about the signs and symptoms of the disease, ways of transmission, and referral mechanisms to increase dentists’ knowledge and prevention practices, so they could contribute, at a population level, in disease control and prevention [1,8].

Despite the availability of prevention guidelines and recommendations on disease control, many dental practices lack the minimum requirements of infection control, which resulted from the low interest in taking the mandatory precautions. This lack of interest in making an extra, but essential, effort could be attributed to the high volume of patients treated in clinics that charge low or reduced dental fees [11,12]. This situation is true for many settings, including some dental clinics in Jordan, which, like many other countries, has a wide range of dental facilities from clinics that properly apply infection control measures to clinics that poorly apply prevention measures. It is important to implement sound prevention measures in dental clinics and to increase the level of awareness among dentists to improve their prevention. Hence, this study aimed to assess the level of awareness, perception, and attitude regarding COVID-19 and infection control among Jordanian dentists.

Our study population consisted of dentists who work in Jordan, regardless of their place of work, in either private clinics, hospitals, or health centers. This survey was conducted in March 2020. An online questionnaire using Google Forms was used to collect the data. The sample of dentists was selected through Facebook groups for dentists. These groups were created by members of the Jordan Dental Association, and only dentists who work in Jordan can be involved in these groups by confirming their registration with the Jordanian dental association and their places of work. Although there were numerous groups, only five groups were randomly chosen: Jordanian dentists, dentists without borders, Jordanian dental club, Jordanian society of pediatric dentistry, and Jordanian dentists’ forum. Within the five selected groups, 700 dentists were randomly selected to participate in the study by their Facebook profiles. However, each participant who was randomly selected was contacted individually to make sure that they were a dentist and worked in Jordan. The questionnaires were anonymous to maintain the privacy and confidentiality of all information collected in the study. Ethical approval was obtained from the Institutional Review Board at Jordan University of Science and Technology.

The questions on the survey were developed after reviewing pertinent literature and the international guidelines [1,8-10]. The questionnaire was designed in English and comprised of a series of questions pertaining to sociodemographic characteristics, the knowledge of dentists, and their attitudes and perceptions toward COVID-19 and infection control in dental clinics. The survey was a structured multiple-choice questionnaire divided into sections: dentists’ demographic and profession-related characteristics; dentists’ awareness of incubation period, the symptoms of the disease, the mode of transmission of COVID-19, and infection control measures for preventing COVID-19; and dentists’ attitude toward treating patients with COVID-19.

Data were analyzed using SPSS (IBM Corp). Descriptive statistical analysis was used to describe items included in the survey. Means and standard deviations were used to describe the continuous variables, and percentages were used to describe the categorical data.

This study included a total of 368 (245 females and 123 males) dentists, forming a response rate of about 52.6% (386 participated out of 700 invited dentists). Their age ranged from 22-73 years with a mean of 32.9 (SD 10.6) years. Years of dental practice ranged from 1-30 years with a mean of 9.4 (SD 8.9) years. The participants’ characteristics are shown in Table 1. A total of 112 (30.4%) had completed a master or residency program in dentistry, 195 (53.0%) had received training in infection control in dentistry, and 28 (7.6%) had attended training or received lectures regarding COVID-19.

When asked about the incubation period, over one-third of dentists correctly reported 1-14 days. The percentage of dentists who reported the different symptoms of the COVID-19 infection are shown in Table 2. The majority reported fever and cough as symptoms. Diarrhea, vomiting, and runny nose were reported by almost one-third of dentists. Joint and muscle pain was reported by only a few dentists. Over one-third of the dentists reported that patients with COVID-19 infection may present with no symptoms. When they were asked about aspects that should be considered to identify patients at risk of having COVID-19, 316 (85.9%) mentioned the presence of symptoms of a respiratory infection, 347 (94.3%) mentioned history of travel to areas experiencing transmission of COVID-19, and 345 (93.8%) mentioned history of contact with possible infected patients. In addition, most dentists correctly reported known modes of transmission (Table 2).

The majority of the 368 dentists reported that cleaning hands frequently by using alcohol-based hand rub or soap and water, routinely cleaning and disinfecting surfaces in contact with known or suspected patients, and wearing personal protective equipment can help prevent transmission from patients with known or suspected COVID-19. The percentages of dentists who reported other specific measures are shown in Table 3. Almost all dentists (n=359, 97.6%) reported that it is important to change both masks and gloves regularly to decrease the possibility of transmitting infections to patients and to themselves.

A total of 65 (17.7%) of the 368 dentists perceived COVID-19 as very dangerous, 264 (71.7%) perceived it as moderately dangerous, and 35 (9.5%) perceived it as not dangerous. Almost one-third (n=135, 36.7%) of dentists believed that COVID-19 is not a serious public health issue. The majority (n=360, 97.8%) reported that it is important to educate people about COVID-19 to prevent the spread of the disease.

More than half (n=203, 55.2%) of the 368 dentists reported that COVID-19 symptoms often resolve with time and do not require any special treatment. Regarding dentists’ precautionary actions in the dental clinic, a total of 275 (74.7%) believed that it was necessary to ask patients to sit far from each other, wear masks while in the waiting room, and wash hands before getting in the dental chair to decrease disease transmission, while 80 (21.7%) believed that this was not necessary and could cause panic. However, a total of 304 (82.6%) dentists reported that they prefer to avoid working with a patient with a suspected case of COVID-19.

Dentists reported different attitudes toward a patient sneezing or coughing in their clinics: 161 (43.8%) mentioned that they would refer the patient to the hospital without treating them, 17 (4.6%) mentioned that they would refuse treating the patient and ask them to leave the clinic, 182 (49.5%) mentioned that they would treat the patient and ask them to go to the hospital.

Moreover, a total of 119 (32.3%) dentists reported that they would allow any of their dental staff to work with patients if they had flu-like symptoms. Only 214 (58.2%) reported that they know whom to contact in a situation where there has been an unprotected exposure to a patient with known or suspected COVID-19, and 279 (75.8%) reported that they know what to do if they have signs or symptoms suspected of COVID-19 infection.

For the dentists’ role in spreading information and increasing awareness, a total of 249 (67.7%) dentists reported that the dentist role in teaching others about COVID-19 is very significant, and 94 (25.5%) reported that it is moderately significant.