The main objective of this study is to retrospectively examine the level of adherence to the provisions of the "Provision of Dental Services under COVID-19 Pandemic Conditions" checklist prepared by the Deputy for Treatment and Medical Education of Alborz Province in dental clinics in Karaj. Since the beginning of 2022, Iran and the world are still struggling with the COVID-19 pandemic. Investigating issues related to COVID-19 is one of the crucial current issues that are valuable and significant from various aspects of medical and dental sciences.
In the results of our study on 76 clinics in Karaj, 66 clinics (86%) adhered to the checklist provisions, while 10 (13%) did not follow the instructions. This indicates that dentists, personnel, and management of dental clinics in Karaj have relatively good awareness and practice of COVID-19 and its transmission risk factors.
The systematic review by Amiri et al. (2019) aimed to investigate the performance of dentists in complying with general guidelines during the COVID-19 epidemic in Iran showed unfortunately, the performance of dental specialists during the COVID-19 pandemic conditions is not desirable (9). To compare and analyze the cases studied in this article more accurately, we will examine them individually. In this systematic review, six primary studies were reviewed. The following results were obtained:
1. Mask use during a dental procedure
According to the study by Amiri et al., among the entire study population (1295 graduates of dentistry and 1156 dental specialists), more than two-thirds of participants used masks during dental procedures, which is higher compared to our study. In our study, almost two-thirds of all dental clinic staff use N95 masks continuously or two-layer surgical masks if N95 masks are not available to prevent aerosol entry during working hours.
The results of the study by Golbabaei et al. emphasize that using masks is the most effective method of preventing COVID-19 transmission (8). This is because the need to use masks in medical environments, especially dental clinics, due to the close and direct contact between dentists and patients and the high probability of aerosol transmission is a much more critical issue and should be given more attention.
Another serious issue related to mask use is proper use and timely replacement. According to our results, only 1% of personnel replaced N95 masks on time after 8 hours of continuous use or completely if there was rich contamination. Only one-third of dental clinic staff were aware of performing a seal check of valve masks. Therefore, it can be concluded that although the issue of mask use is relatively well observed among healthcare personnel, and they have almost sufficient knowledge about the timing of its replacement, there is insufficient knowledge about how to use it properly and comply with the mask seal.
2. Screening patients (measuring body temperature and checking for coughing)
Amiri et al. show that two-thirds of participants measured fever when admitting patients during the COVID-19 pandemic. Also, more than two-thirds postponed dental procedures for patients with a cough (9). Our study found that two-thirds of the reception staff and half of the dentists in the reviewed clinics screened patients accurately. Kazeminia et al. demonstrated that the prevalence of fever and cough are the main factors in identifying patients with COVID-19 (10). This highlights the importance of screening patients upon arrival at healthcare facilities, especially dental clinics, and justifies this point in monitoring checklists.
3. Hand hygiene
Amiri et al. reported that 91% of participants regularly washed their hands after each dental treatment or surgery (9). Our study looked at this topic from three different aspects. Three-quarters of dental clinics in Karaj had hand sanitizer gel or solution in the waiting or reception room. Nearly three-quarters of dental clinics had hand washing and disinfecting facilities. They had visual aids or posters for visitors. Half of the staff were aware of 5 steps of hand hygiene. So, they washed and sanitized their hands properly. Effectively providing hand sanitizing options to staff and employees contributes to improved adherence to health protocols.
Mohaghegh et al. emphasized the role of repeated hand washing with soap and water in preventing the spread of the virus as a useful solution (11). Overall, Amiri et al. showed that the performance of dentists during the COVID-19 pandemic was satisfactory. This article suggests dental professionals should receive more training on following health guidelines during the pandemic. Also, measures should be taken to increase the awareness of dental specialists about this virus and how it spreads so that they can demonstrate appropriate performance.
In conclusion, the significant role of examining health protocol compliance in dental clinics in reflecting the performance of personnel and staff indicated their knowledge and awareness regarding COVID-19 during the pandemic has been highlighted by previous studies and current research. Our findings are similar to those of Indu et al. (12) Their study included interns and residents, but our study focused on graduates in the dental profession working in dental clinics.
Our findings are consistent with Huynh et al. (13) In line with our study, just over two-thirds of participants had sufficient knowledge about COVID-19. Furthermore, Huynh et al. showed that almost three-quarters of participants took suitable measures to prevent COVID-19, which indicates a correlation between knowledge level and compliance with preventive measures. It is worth noting that in Huynh's study, those who had sufficient knowledge about the disease were 1.24 times more likely to take proper measures. This highlights the importance of training healthcare personnel and dental professionals about adhering to health protocols during the COVID-19 pandemic. Ultimately leads to better adherence to health guidelines and a decrease in virus transmission.
In a previous study on the MERS epidemic, Gaffar et al. (14) demonstrated better management measures to prevent MERS-CoV transmission among dentists correlated with higher awareness about the transmission modes and patient identification. A sound management system that enhances the knowledge of dental professionals and staff can lead to better adherence to health protocols and a reduction in the transmission cycle. Our ultimate goal was to examine adherence to health protocols during the COVID-19 pandemic to evaluate the performance and knowledge of healthcare personnel and dentists, improve the quality of management in dental clinics, and increase awareness about the transmission modes and prevention of this disease. One of the main challenges in combating COVID-19 is its higher transmissibility compared to other strains of the virus, which underscores the need for greater adherence to preventive protocols to break the transmission cycle (15).
Another topic that was examined in our checklist was social distancing in dental clinics. Four questions in the checklist evaluated the proper distancing between patients in the waiting or reception room. Only about one-third of dental clinics completely obeyed this requirement. Nearly half of the clinics took complete measures to prevent the presence of patients' companions. Regarding the importance of maintaining social distancing between patients and staff, only slightly more than one-third paid full attention to this issue.
Regarding the importance of maintaining social distancing in interrupting or reducing the transmission cycle during the pandemic, in this study, less than half of the clinics paid full attention to this issue. Nearly half of the clinics in our study took complete measures to prevent the presence of patients' companions. Maintaining social distancing has been highlighted in many studies. It is highly essential to have an enforceable system for these requirements. This matter was confirmed by Afrahshteh et al. (16) Their study focused on the necessity of social distancing and examined its various dimensions. Additionally, their results showed that only slightly more than one-quarter of the clinics examined had phone and online appointment scheduling, and patient triage and screening were done through tele-screening. As previously mentioned, the lack of the possibility of non-face-to-face appointments can increase the number of visitors to medical clinics and reduce social distancing, leading to an increase in the transmission chain, which must also be considered in future follow-ups.
The study by Yu Y et al. emphasized the importance of proper ventilation during the COVID-19 pandemic (17). In our study, in one-third of dental clinics, strong and appropriate ventilation was present in the entire treatment area, especially in the waiting area and treatment section. Also, observing a one-hour interval between patient appointments for optimal ventilation and disinfection was fully complied with in almost half of the dental clinics examined, highlighting the importance of proper ventilation and creating an enforceable system for these requirements.
Our results also showed that in two-thirds of the dental clinics, staff used isolating goggles or shields to cover their eyes, surroundings, and face. Results of a systematic review by Byambasuren et al. demonstrated that the use of protective shields or goggles significantly reduced SARS-CoV-2 infection (18). Therefore, compliance with clause 27 of the executive guidelines seems promising for shortening the transmission cycle.
In the study by Atanu Kumar et al., the importance of solid waste management during the pandemic based on World Health Organization (WHO) guidelines was emphasized (19). This issue was also highlighted in our study. The results showed that only in two-thirds of the clinics examined, the collection and disposal of infectious and sharp waste were entirely compliant with infection control standards, which is not very satisfactory. However, fortunately, contracts for waste management exist in three-quarters of dental clinics.
In this study, we also investigated the frequency of adherence and non-adherence of dental clinics in Karaj to the contents of the "COVID-19 Dental Service Delivery Checklist" based on their establishment history. Results showed that adherence in recognized clinics was slightly higher than in new clinics, but it was not statistically significant. Therefore, there is no correlation between the establishment history of dental clinics and their adherence to protocols. No similar study was found in this regard for comparison with our results.
Furthermore, our study showed that out of 76 dental clinics, seven were Specialty based, and 69 were general. Our findings indicated that all Specialty clinics adhered to the guidelines, but ten general clinics did not adhere to the guidelines. This issue may be related to an increase in the level of knowledge and awareness among dentists.
Previously, in the article by Huynh et al., the relationship between the level of knowledge and sufficient awareness about COVID-19 and the level of adherence to preventive measures was reported to be significant (13).
The Ministry of Health's law from 2009 regarding the prohibition of naming clinics as "Specialty clinics" can justify this significant difference between the statistics of Specialty and general clinics.
Moreover, out of 76 clinics studied, 73 were private, and only three were public. All public clinics and 63 privates adhered to the guidelines. It seems that a higher level of adherence in public clinics may be due to better education, stricter enforcement measures, and greater executive guarantees in the government sector and may impact the different results between public and private clinics. We suggest that the adherence of all dental clinics be evaluated to make major management decisions in the future.