Chair-Side Medical Screening for Every Dental Patient: Attitude & Awareness Among 104 Dental Professionals Working in Rural India During the COVID-19 Pandemic

INTRODUCTION

According to a report by the Washington State Department of Health dated 17 March 2020, the virus causing COVID-19 emerged in December 2019 and has since spread around the world causing a global pandemic. Health experts are concerned that increasing transmission in India will limit the ability of our healthcare system to provide urgent care to all who require it. What we have seen in the past year is the excessive pressure on the Indian healthcare system, which has implications in the professional as well as personal spheres of life of health professionals. This extreme stress on the healthcare system may lead to subsequent long-term failures.

In what is the biggest patient recall in the UK’s medical history, over 22,000 people have been asked to return to a clinic for tests to see if they have been infected with blood-borne viruses, including HIV and Hepatitis C. All these patients were screened for HIV or Hepatitis infection. This was after June 2014, when NHS England was contacted by a whistleblower who had concerns about the standard of clinical care being given to patients.

According to a report published in the Times of India on 17 November 2014, dental clinics are considered ‘Hotbeds of Infection.’^[1] According to the Dental Council of India, dental clinics have to be more careful about infection control than even operation theatres, as most walk-in patients are undergoing invasive procedures.^[1] In a recent study^[2] on people aged 40 years or older, none had risk factors for cardiovascular disease (CVD) and had not visited a physician for more than a year. However, they had visited the dentist, and a screening test was carried out. It revealed that 17-18% of individuals were at increased risk of developing a cardiovascular disease (CVD) events.^[2] In such cases, CVS screening tests like echocardiogram (ECG) and Echocardiogram (ECHO) should be included in routine screening. Systemic screening for medical diseases is still not done by many dental professionals. The reasons for this may be the taboo of the additional cost needed to be spent by the patient, as well as the additional time spent on screening. The people employed for the purpose of sterilization and disposal of waste have not undergone any formal training in most of the clinics.

In conventional dental practice across India, screening for medical diseases is done at a separate pathology laboratory. This practice is not only time-consuming but also cumbersome & costly for patients, leading to fewer patients wanting to access the clinic. To eliminate this problem, a simple, cost-effective, and safe screening kit [Table 1] must be available in each dental clinic. The kit should include provisions to check complete blood count (CBC), random blood sugar (RBS), and Triple H diseases. Such kits can be made dentist-friendly to submit samples & procure results. The prevalence of HIV has increased by 11% according to the data from 2003 to 2006.^[3] Study results have revealed that transmission rates are 3.5 times greater in those who are unaware than in those who are aware of it.^[4] Many studies are conducted on HIV testing in outpatient departments and hospitals.^[5,6] But such studies have not been done in dental settings.

MATERIAL AND METHODS

This study is approved by the Institutional Review Board and was conducted in full accordance with the World Medical Association Declaration of Helsinki. The study was conducted over 11 months, starting from June 2022 to May 2023. A questionnaire comprising seven questions was formulated & validated [Table 2]. Questions were framed to understand the factors that may be considered while screening patients systemically. The response to the question can be given on a scale of 5, i.e., Likert scale. This was a clinic-based study. All clinic-based practitioners gave the option to opt out of the study, and those willing to participate were included in this study. Written informed consent was taken from all participants. Explanation of the questions was provided if asked by the practitioner. Translation of the questionnaire in the local language was provided wherever asked for. Questions not attempted were considered as no response during data analysis. All data was tabulated in terms of percentage of responses on the Likert scale. Nonparametric analysis of variance was used to compare response items within each question. The data is also tabulated according to the distribution of responses and mean ranks. The data was subjected to a nonparametric ANOVA test.

RESULTS

Rural dentists selected via Cluster Random Sampling were surveyed using a standardized scale questionnaire comprising questions with answers graded on a point Likert scale. The study was conducted in offline mode by distributing the printed questionnaires to all participants. A total of 683 dental professionals responded to this survey. Mostly, the respondents were male practitioners (486) as compared to female practitioners (97). The data collected was tabulated in terms of Likert Scores [Graph 1]. Of the total respondents, most dentists (73%) agree to the fact that it is important to screen the patient for any medical conditions before commencement of treatment. Only 3% felt that it was somewhat unimportant to do such tests, and 21% were not sure about the importance of screening patients for hepatitis. Regarding methods of screening, most professionals (82%) chose referring to a physician as the most suitable way. As many as 56% thought it was very unimportant to conduct chair-side screening & to send samples to the laboratory [Graph 2]. Around 33% of professionals were not sure about discussing screening results with the patient. Regarding the collection of samples or data chair-side, 64% considered it very important to check blood pressure, but simultaneously, 51% found it somewhat important to send oral fluids to the laboratory. Height & weight measurement was considered important by only 14% professionals; 41% dentists were reluctant to collect & send blood samples. When asked about factors considered at the priority level for deciding chairside screening, 86% professionals selected patient willingness without considering the patient’s education & awareness. Additionally, 88% of professionals considered the cost of tests as the most important factor, whereas 86% thought that the time for the results was an important factor. When asked about their opinion of including COVID-19 screening at chairside aid in their setup, most dentists asked about the cost of the screening assembly.

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Graph 1:

Mean rank value of importance of conducting medical screening.

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Graph 2:

Mean rank value of willingness to perform action.

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DISCUSSION

In dental treatments, various procedures can easily transmit the infection from one patient to another, like extraction or root canal treatment, when proper precautions are not taken.

This was one of the unique chairside screenings for medical conditions by dental professionals in western Maharashtra. Previous studies were conducted in a non-Asian population. The walk-in patient in a private dental setup isn’t always aware of their medical status. The problem is more severe in the rural population, as the effect of systemic conditions on dental treatment is beyond the patient’s ability to understand. This may be due to greater levels of illiteracy and a lack of oral health awareness. This increases the responsibility of dental professionals handling the unaware patients in such high numbers routinely. The concept of a dentist screen for medical disease was proposed as early as 1926 in the Gies report ^[7] and retained as recently as 2002.^[8] One of the studies done showed that one-third of diabetes mellitus and cardiovascular diseases are undiagnosed^.[9]

We have searched the pharmaceutical store to find out the exact amount & time required for these tests. The product details with time & cost have been elaborated in Table 1. We want to mention that the various screenings, like hepatitis, haemoglobin, HIV, and blood sugar, are cost-effective and not very time-consuming.

This revealed that even though the dentists are willing to conduct chairside investigations, it has not been practiced routinely in most dental clinics. The ratio is still lower when it comes to the rural dental setups. Cost and time are the most important factors considered by the dentist. However, the cost and time required are not much compared to the cost of routine dental treatments. Unwillingness of dental professionals to collect samples may be attributed to the lack of training & involvement of risk according to them. This should be added to the training schedule of the dental curriculum, or can be implemented via additional training programs through other association platforms.

CONCLUSION

These screening tests should be put into practice. This would be beneficial to the dentist to take proper precautions before treatment, and it would be more beneficial to the patients as they would become aware of the disease, which, in the long run, prevents chronic complications due to lack of treatment.