Effects of COVID-19 Lockdown on Clinical Practice among Undergraduate Dental Students in Tamil Nadu- A Survey

1. Junior Resident, Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India. 2. Junior Resident, Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India. 3. Professor, Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India.

Abstract

Introduction: The Coronavirus Disease-2019 (COVID-19) pandemic had not only developed as a key challenge to public health all around the world but also instigated physical and mental constraints on the healthcare professionals especially on the education of dental students with the sudden switch from traditional teaching methods to e-learning platforms thereby shutting all means of clinical experiences.

Aim: To assess the effects of lockdown on clinical practice among undergraduate dental students in Tamil Nadu, India.

Materials and Methods: A cross-sectional observational study was done among undergraduate dental students in Tamil Nadu, India, from June 1, 2021 to July 1, 2021, using convenience sampling method to yield a total of 510 responses for a self-administered online questionnaire that aimed at evaluating the consequence of lockdown on clinical practice. Statistical Package for the Social Sciences (SPSS) version 19.0 was used to analyse the data.

Results: A total of 510 responses (mean age: 21.72±2.2827 years; 323 female and 187 male) were analysed in the present study. Majority of the students felt that COVID-19 lockdown had a negative impact on clinical exposure. Inspite of following infection control measures, only 35.1% of students felt imperative to practice during pandemic. With over 82.7% of patient flow reduced due to fear of disease spread. 85.1% revealed being stressed in completing clinical quota in a short duration. Further questions on prospects in improvising their clinical knowledge; showed 45% recommending e-workshops, 29.4% opting for video demonstration followed by 22.2% on exposure to Objective Structured Clinical Examination (OSCE) to compensate for the loss of clinical practice.

Conclusion: New teaching protocols have to be adopted taking into account the changing aspects of the pandemic to improve their wellbeing, overcome mental stress and to enhance the sustainability of dental education. Focus on video demonstrations, lectures provoking their clinical reasoning, simulations on phantom heads and conducting workshops enhancing preclinical skills as well as following appropriate safety protocols must be implemented.

Coronavirus disease-2019, Dentists, Education, Infection control, Online system, Pandemic

Novel Coronavirus disease (COVID-19) is a highly contagious viral infection caused by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) first observed at Wuhan City, China in December 2019 that caused significant economic and social breakdown across the world (1). Later, World Health Organisation (WHO) declared COVID-19 outbreak a global pandemic threat that can seriously increase morbidity and mortality over a wide geographic area on 11th March 2020 (2). It was recognised that this highly infective virus spreads through direct and indirect modes such as respiratory droplets, nasal droplets, direct contact of surfaces or indirect contact (fomites) or even through saliva (3).

Among various healthcare professionals, it is evident that dentists are at a higher risk of acquiring and spreading the disease due to close exposure to aerosols and infected droplets from patient’s oral cavity (4),(5). The swift spread of the COVID-19 pandemic disease forced several countries to impose overnight restrictions, lockdowns, curfews; home isolation measures and protocols, social distancing norms, closure of schools, universities and shifts in the existing educational system to e-learning and distance learning systems (6). Hattar S et al., reinforces that the sudden shift from traditional methods of teaching to e-learning and distant learning has created a greater challenge among the dental students especially at the undergraduate level (7). Although new technologies with simulation and virtual reality techniques are gaining more interest, still the direct in person experience is one that cannot be simply replaced by virtual teaching platforms (7). Consequently, COVID-19 outbreak has negatively impacted the activity of dental professional as well as dental educational institutions on a larger scale and several routine dental clinical practice have been suspended owing to the risk of cross-infection during dental treatment (8).

Valekar SS et al., had shown that undergraduate dental students constantly undergo academic and professional stress such as fear of inability to understand the desired knowledge in due time, fear of infection, burden of increased content of curriculum, clinical anxiety, fear of making poor choice of profession, lack of professional growth, fear of helplessness to be paid (9). Subsequently, Loch C et al., stated that undergraduate students also fears that online e-learning platforms along with closure of dental practices would cause extreme impacts on all these factors and impair their clinical competence due to pandemic (10).

Several studies have been published in the recent years eliciting the psychological status of students during pandemic but this study illustrates the struggles faced by students during clinical practice resuming after attending e-teaching modes for months with loss of clinical exposure due to lockdown [8-10]. The present study aimed at assessing the effects of lockdown on clinical practice among undergraduate dental students in Tamil Nadu and the ability to apply the theoretical knowledge gained in online platform while dealing with patients.

Material and Methods

The present cross-sectional observational study was done among undergraduate dental students in Tamil Nadu from June 1, 2021 to July 1, 2021. This study utilised non probability convenience sampling method that yielded information from 510 individuals. All the respondents provided informed consent, and the data were collected anonymously. Ethical clearance for the study was obtained from the Institutional Review Board at Dr.M.G.R. Educational and Research Institute, Chennai, (certificate no. Dr.MGRERI/TMDCH/EC/2020-21/009 dated 22/04/2021) prior to the circulation of survey questionnaires to the candidates. An informed consent was obtained via Google forms in accordance to the protocols and principles under the purview of Helsinki Declaration (1964 and later) before the respondents volunteered to participate in the survey. The participants were assured that their e-mail ids and personal details will be maintained under complete confidentiality by the researcher.

Inclusion criteria: Undergraduate dental students who had recently passed out/currently studying in any dental college in Tamil Nadu, those of third year, final year and current intern batch, recently passed out batch of interns of academic year 2019-2020, who were able to understand and respond in English language were included in the study.

Exclusion criteria: Subjects who are not willing to participate and those who had not filled the questionnaire survey completely were excluded from the study.

Sample size calculation: A preliminary survey was conducted among 30 subjects and the estimated sample size was 498 with margin of error at 5% and 95% confidence level. Non probability, convenience sampling technique was employed that yielded responses from 510 dental practitioners out of 700 survey forms sent across various online platforms for this observational study with a cross-sectional design.

Questionnaire

The required information was collected through published scientific articles pertaining to the objective of the study using thorough search in electronic database like PubMed, EMBASE, Cochrane Library and Google Scholar by the authors independently (7),(9),(10),(11),(12),(13),(14),(15),(16),(17),(18),(19),(20),(21),(22),(23),(24),(25). Self-administered structured questionnaire comprising 40 questions (Table/Fig 1) in English language was prepared and evaluated by a panel consisting of professors of various clinical specialties in dentistry belonging to the institute and a statistician. The questionnaire had a combination of close ended questions (Yes/No) followed by questions of linear rating scale as well as open ended questions eliciting the mental status, physical constraints as well as economical hurdles faced on account of pandemic during their clinical practice after the lockdown. The survey was done through Google forms ensuring that all the participants were informed about the purpose of the study. The questionnaire was validated and standardised using a test study among 30 samples showing adequate internal consistency with a Cronbach’s alpha value of 0.7.

Statistical Analysis

Responses recorded among the selected population group were evaluated by frequency distribution and descriptive analysis using Microsoft Excel. On statistical evaluation, it was observed that 42.2all 510 samples were valid for the study with Cronbach’s alpha reliability score being 0.861 (Significant score). Statistical Package for the Social Sciences version 19.0 (SPSS Inc., Chicago, IL, USA) was used to analyse the data.

Results

On analysis of the given data the mean age of the study population was observed to be 21.72±2.2827 years of age ranging between 18-27 years of age. On evaluation, a total of 323 female (63.3%) and 187 male (36.7%) respondents were present.

In the present study, as described in (Table/Fig 2), depicts the frequency and percentage of each response for questions of Section A (Yes/No) questioning the steps taken by the institute and individual in the safety measure followed and the aspects related to patient flow. Section B (Linear Rating Scale) elicits the perception and degree of acceptance of undergraduate students towards the pandemic scenario as was observed that the majority of the participants (99%) feel COVID-19 lockdown had an impact on clinical practice exposure. The measures taken by their respective institutes on account of pandemic had been questioned revealing that 80.8% maintain a record of the temperature and oxygen saturation for all individuals including workers entering the campus on a daily basis. About 65.9% of institutions have conducted COVID-19 infection control protocol awareness programs and encouraged students in taking up certified courses in reinforcement of clinical practice during COVID-19.

(Table/Fig 3) illustrates the responses to open-ended questions that demanded the reasons behind various hurdles faced in treating patients, completion of quota and applying the theoretical knowledge into practical use. Fear of exposure to COVID-19 (30%) was the response by most when questioned regarding the problem faced in clinical practice due to COVID-19. A 35.5% of the students felt that conducting free dental camps can increase the patient flow and thus compensate the loss in clinical experience, while 24.11% felt that reducing the treatment charges to benefit the people from various social strata could help.

Discussion

Coronavirus Disease-2019 transmissions are associated with the release of respiratory droplets by coughing, sneezing, and through aerosol route. Due to the nature of dental procedures and the large number of droplets and aerosols generated during dental treatment associated with close contact with patients, several standard protective measures and guidelines have been adopted in daily dental clinical work to prevent the spread of COVID-19 (11),(12). (Table/Fig 4) illustrates the comparison of the responses attained in the present study with other studies (7),(9),(10),(13),(14),(15),(17), (19),(20),(21).

About 65.9% of institutions conducted COVID-19 Infection Control Protocol awareness programs, 71.8% follow adequate safety measures during the radiographic examinations and 55.7% prefer separate rooms for performing aerosol generated procedures in institutions similar to those of Loch C et al., Meng L et al., and Ge ZY et al., as mentioned in (Table/Fig 4) (10),(15),(16). Coulthard P believe that the use of the PPE kits can be useful during dental practice to limit the spread of aerosol and aerogenic infections caused during dental practice (17).

Apart from the restraints of cross-infection, another hurdle faced during clinical practice was the restrictions in transport facilitation. Deshmukh SV and Iosif L et al., observed that limited transportation due to the lockdown enforced in most countries to control the spread of the pandemic created a negative impact on the patient flow as well as the difficulty in mobilisation of dental professionals across the city for work (18),(19).

As a solution for reduced transmission of disease, Personal Protective Equipment (PPE), head caps, protective goggles, double surgical masks or N95, disposable surgical gowns, special foot-wears, and protective screens are essential while working in dental teaching and clinical environment (20),(21). Apart from the health-related issues, 85.1% feared the completion of clinical quota in a short duration and recommend (90.6%) supplementary workshops to gain better hands on clinical practice. This was similar to the study by Kharma MY et al., illustrating as high as 85% of the individuals with stress level (>7 in a score of 0-10) attributed to concerns about clinical experiences and research experience, and other factors such as employment predictions (22).

On evaluation of their perception on a linear rating scale about 56.9% of the students had rated 3 out of 5 when questioned if confident while approaching a clinical case at present when compared to prelockdown period by applying the knowledge gained from online classes during practice efficiently. In order to improve the clinical practice and gain knowledge, about 45% recommend organising webinars, 29.4% opted for video demonstration followed by 22.2% on exposure to OSCE to compensate for the loss of clinical practice and also suggests frequent workshops and hand-on exercises (35.5%) for better clinical practice. Coulthard P, Jiang Z et al., Chang TY et al., and Hung M et al., in their respective studies observed that students were experiencing higher levels of stress and feel their clinical education has impacted on a larger scale (17),(23),(24),(25). From these observations, it is evident that proper protocols should be established for the safety of students at institutions and to overcome the problems which could be created due to travel restrictions for both students and patients seeking dental treatment. Thus, adapting adequate precautionary measures as per government and WHO, Centers for Disease Control and Prevention(CDC), Americans with Disabilities Act (ADA) guidelines will protect the dentist as well as prevent cross contamination of the infection.

Limitation(s)

This study was done on an online platform using self-administered structured questionnaires on account of the pandemic situation leading to the lack of accountability and veracity of the response due to absence of an interviewer.

Conclusion

Coronavirus Disease-2019 has had a deleterious impact on the clinical practice among undergraduate students as well as their intellect in applying their theoretical knowledge practically. The pandemic has trained every professional to cope with restraints and hurdles, lest the field of education has had the necessity to utilise newer teaching programs. Majority of the participants (99%) felt COVID-19 lockdown had an impact on clinical practice exposure.

Most of the students felt that conducting free dental camps can increase the patient flow and thus compensate the loss in clinical experience. Video demonstrations live clinical training programs, workshops on infection control protocols, practice on simulations like phantom heads alongside psychological counselling and motivational therapies at regular intervals will aid in improving their clinical application as well as to overcome mental stress and fear to enhance the sustainability of dental education.

It is the responsibility of the institute to follow strict safety protocols by the provision of necessary equipment to the practitioners as well as avoid demanding increased treatment charges on account of pandemic, which inadvertently prevents the patients from availing dental services. Further studies must be taken up to evaluate newer teaching methods and incorporating counselling sessions regularly in the curriculum to encourage the students to cope with the inevitable impacts of COVID-19 successfully.

DOI and Others

DOI: 10.7860/JCDR/2022/52893.16230

Date of Submission: Oct 16, 2021
Date of Peer Review: Jan 03, 2022
Date of Acceptance: Jan 18, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 19, 2021
• Manual Googling: Jan 17, 2022
• iThenticate Software: Feb 02, 2022 (12%)

ETYMOLOGY: Author Origin