The Knowledge, Awareness, and Attitude Regarding COVID-19 among Trinidad and Tobago Dentists. A Cross-Sectional Survey

: The COVID-19 virus is highly infectious, and it places both patients and dental health care providers at high risk for contracting the disease. Therefore, it is crucial for dental teams to practice preventative measures against COVID-19 by wearing personal protective equipment (PPE), handwashing, ensuring adequate ventilation and sticking to strict protocols when conducting aerosol-generating procedures. Methods: A cross-sectional survey using an online platform was conducted to assess dentists’ knowledge, attitude and awareness of COVID-19 in Trinidad and Tobago. Descriptive statistics, Pearson’s chi-square and Fisher exact test were performed. Results: One hundred and ninety-two dentists participated in the survey. The age group, 30–39, comprised 40.6% of the respondents. General dentists comprised 80.7% of the sample. The majority of the respondents evaluated their awareness of COVID-19 as above average. There was no difference in knowledge between dentists and specialists regarding routes of transmission and preventative techniques. More female dentists reported feeling anxious and fearful. Conclusions: There was a high level of agreement between different professionals about the preventative measures, routes of transmission and incubation period. There was a lot of variation in knowledge about the survivability of the virus on innate objects. More education campaigns, seminars, and rehabilitation services targeting dentists in Trinidad and Tobago are required.


Introduction
In December 2019, the COVID-19 outbreak was observed for the first time in Wuhan, the capital of Hubei province, China [1]. This breakout was declared a pandemic on 30 January 2020 by the World Health Organization [2]. On 12 March, Trinidad and Tobago had its first case of SARS-CoV-2 (COVID-19) infection [3].
Common clinical symptoms include dry cough, fever, muscle pain, exhaustion, and irregular chest scan. Less common symptoms reported are headache, diarrhea, sputum development and hemoptysis [4,5]. Studies have revealed that transmission can occur directly (droplet inhalation, sneezing, and coughing) and by contact transmission (eye, oral and nasal mucous membranes) [6].
Due to the nature of COVID-19 and dentistry, it places both patients and dental health care providers at high risk for contracting the disease. Airborne microorganisms can stay locked in the air for long periods. These microorganisms can be transmitted in the dental setting through inhalation [7], patient materials, contact with oral fluids, or blood [8]. Transmission can also occur through aerosols from an infected person without a mask through talking, coughing, contact with the oral mucosa, nasal fluids and conjunctiva [9,10]. Dental equipment that generates aerosols such as ultrasonic scalers and high-pressure handpieces have also been implicated [11].
Therefore, it is crucial for dental teams to practice preventative measures against COVID-19 by wearing personal protective equipment (PPE), regular handwashing, en-

Demographic Results
Almost half, 40.6% (n = 78), of the participants, were aged 30-39 years, 20.3% were 40-49 years, 17.2% were 50-59 years and 5.7% were 60 years and over. Males represented 46.4% (n = 89), while females represented more than half, 53.6% (n = 103) of the representative sample. The highest number of respondents were general dentists (80.7%), while only 19.3% were specialists. Most of the respondents graduated from the local dental school (85.9%). A large number of dentists worked in the private sector (82.8%) and had been practicing dentistry for an average of 11-20 years. The participants' demographic data are found in Table 1.

Knowledge, Awareness and Attitude Regarding COVID-19
When evaluating the participants' level of awareness of COVID-19, most respondents rated themselves to be above average (see Figure 1).

Knowledge, Awareness and Attitude Regarding COVID-19
When evaluating the participants' level of awareness of COVID-19, most respondents rated themselves to be above average (see Figure 1).  The majority of respondents believed that the incubation period of COVID-19 is 5-14 days, and the virus can survive on an inanimate object for 72 h (Figures 2 and 3).
Regarding the level of awareness, the proportion of participants who attended seminars and rated their knowledge as above average and excellent was 73%. Therefore, those who attended seminars considered themselves more aware than those who did not. The majority of respondents believed that the incubation period of COVID-19 is 5-14 days, and the virus can survive on an inanimate object for 72 h (Figures 2 and 3).  Regarding the level of awareness, the proportion of participants who attended seminars and rated their knowledge as above average and excellent was 73%. Therefore, those who attended seminars considered themselves more aware than those who did not.
Of the participants who rated themselves above average, 69.9% attended seminars. Noteworthy is that only one participant gave themself a rating of below average. This respondent also reported that they did not attend any seminars and stated that the COVID-19 is not caused by a dangerous virus. Moreover, 30.8% of respondents who assessed their level of awareness as excellent did not attend seminars on COVID-19. Additionally, 7.7% of participants who regarded their level of awareness as excellent did not agree that a dangerous virus causes COVID-19. Of the respondents who believed they had an above-average or excellent level of awareness, 69.6% correctly identified the incubation period of 5-14 days.
Regarding common signs and symptoms of COVID-19 virus infection, 91.1% (n = 179) of participants identified fever, 79.7% (n = 153) a dry cough and 66.7% (n = 128) tiredness. The responses for the remaining signs and symptoms were 66.7% (n = 128) for sore throat, 18.8% (n = 36) for sneezing, 5.7% (n = 11) conjunctivitis and 4.7% (n = 9) skin rash.  The majority of respondents believed that the incubation period of COVID-19 is 5-14 days, and the virus can survive on an inanimate object for 72 h (Figures 2 and 3).  Regarding the level of awareness, the proportion of participants who attended seminars and rated their knowledge as above average and excellent was 73%. Therefore, those who attended seminars considered themselves more aware than those who did not.
Of the participants who rated themselves above average, 69.9% attended seminars. Noteworthy is that only one participant gave themself a rating of below average. This respondent also reported that they did not attend any seminars and stated that the COVID-19 is not caused by a dangerous virus. Moreover, 30.8% of respondents who assessed their level of awareness as excellent did not attend seminars on COVID-19. Additionally, 7.7% of participants who regarded their level of awareness as excellent did not agree that a dangerous virus causes COVID-19. Of the respondents who believed they had an above-average or excellent level of awareness, 69.6% correctly identified the incubation period of 5-14 days.
Regarding common signs and symptoms of COVID-19 virus infection, 91.1% (n = 179) of participants identified fever, 79.7% (n = 153) a dry cough and 66.7% (n = 128) tiredness. The responses for the remaining signs and symptoms were 66.7% (n = 128) for sore throat, 18.8% (n = 36) for sneezing, 5.7% (n = 11) conjunctivitis and 4.7% (n = 9) skin rash. Of the participants who rated themselves above average, 69.9% attended seminars. Noteworthy is that only one participant gave themself a rating of below average. This respondent also reported that they did not attend any seminars and stated that the COVID-19 is not caused by a dangerous virus. Moreover, 30.8% of respondents who assessed their level of awareness as excellent did not attend seminars on COVID-19. Additionally, 7.7% of participants who regarded their level of awareness as excellent did not agree that a dangerous virus causes COVID-19. Of the respondents who believed they had an above-average or excellent level of awareness, 69.6% correctly identified the incubation period of 5-14 days.
Fever was the only sign and symptom where there was a difference in knowledge between a general dentist and a specialist p < 0.05 ( Table 2).
The majority of the respondents (n = 180, 93.8%) believed that the implemented protocols were effective. A total of 69.3% (n = 133) of respondents reported suspending their practice at the beginning of the pandemic, and the difference between the genders was statistically significant, p < 0.05.

Discussion
It was essential to conduct this study, because the Centre for Disease Control (CDC) labelled dentists as high risk for SARS-CoV-2 virus exposure; this was attributed to the SARS-CoV-2 virus being identified in infected patients' saliva, and further research concluded that the SARS-CoV-2 virus could also be transmitted by saliva directly or indirectly [12,13]. In addition, dentists and their patients are usually in close proximity to facilitate dental treatment. The World Health Organization prescribed maintaining an inter-personal distance of 6 feet (1.83 m) from each other to minimize the risk. However, new research concluded that virus transmission can occur over a distance of 2 m from an infected person [14]. The COVID-19 pandemic has placed all dental and health professionals at risk. Thus, dentists must be more cautious against the infectious disease spread.
This study was a representative sample, since it consisted of 192 dentists from all areas of Trinidad and Tobago. This represented an even distribution of the workforce around the Oral 2021, 1 256 country. The gender distribution was also representative. In the local dental workforce, according to the Trinidad and Tobago Dental Council, males comprise 43.8% (n = 257) and females represent 56.2% (n = 330) of the local workforce. In this study, males represented 46.4% (n = 89), while females represented 53.6% (n = 103). The study sample, therefore, had a similar distribution to the local workforce.
The study was conducted when Trinidad and Tobago was undergoing their second wave of the COVID-19 infection. This cross-sectional survey assessed the degree of knowledge, awareness and the attitude of dentists on the Caribbean Island. The majority of participants believed that their knowledge of the COVID-19 virus was above average to excellent, and most reported attending seminars on COVID-19. In order to control the spread of this virus, education about the virus is essential; therefore, we should continue to encourage dentists to attend seminars, workshops and online courses to update their knowledge on this novel coronavirus. New research is being published weekly as the world seeks information in our fight against this deadly virus. Over 4.3 million deaths have been recorded, and the mortality rate is 2% [15]. Hence, there is a need for dentists to remain vigilant in obtaining knowledge about the COVID-19. All dentists in Trinidad and Tobago who reported their knowledge as below average also stated that SARS-CoV-2 was not a dangerous virus.
Overall knowledge about the preventative measures and use of personal protective equipment, routes of transmission and incubation period of the SARS-CoV-2 virus was consistent across the dental profession. COVID-19 transmission has been reported through droplets, human contact and airborne transmission [16].
There was significant disagreement among dental professionals regarding the question of COVID-19 virus survivability on innate objects. However, this difference was not statistically significant. The survivability of the virus on innate objects was believed to be 24-48 h by 43.3% of respondents. This was probably due to conflicting times published for different surfaces [6]. Therefore, the dental working environment needs to be adequately disinfected, as there can be many different types of surfaces.
Only a small number (17.7%, n = 34) of participants had poor knowledge about the COVID-19 virus incubation period. This was in contrast to dentists in Jordan, where only 36.1% of dentists reported that the incubation period was 1-14 days [17].
Knowledge of transmission routes was generally good. However, a small percentage believed that transmission could occur through food (1.7%). Most respondents believed that the common modes of transmission of COVID-19 were respiratory droplets, surface contact and airborne viral particles.
Knowledge on preventative measures was also good, except for a few who incorrectly reported water as a disinfectant (n = 7) and inhaling disinfectant (n = 1) as preventative measures. This positive response was probably due to community-based education programs, social media, seminars and the government introducing laws about wearing face masks, social distancing and hand hygiene as preventive strategies to prevent infection with the COVID-19 virus. In contrast, in the Telangana state of India, a high level of knowledge was exhibited by only 29.9% of dentists [18].
Whereas symptomatic COVID-19 patients are the primary transmission source, new research indicates that asymptomatic patients and patients in the incubation period are also carriers of the SARS-CoV-2 virus [19]. This is due to some COVID-19 positive patients not exhibiting any common signs and symptoms and thus being oblivious to their status. Inevitably, some dentists will be unaware that they are treating COVID-19-positive patients [20].
The majority of participants (69.3%) suspended their practice during the pandemic. This was similar to findings in Switzerland (69.9%) and Poland (71.2%), where dentists also reduced their dental practice activity due to the pandemic [21,22]. It was found that at the beginning of the COVID-19 pandemic, 38% fewer patients visited the dental office. This suggests that COVID-19 impacted dentists and dental patients' behavior [23].
A total of 44.8% of participants reduced the number of aerosol-generating procedures, which indicated a certain level of trepidation. This is similar to dentists in Turkey, where 49.95% avoided aerosol-generating procedures [24]. It is well documented that aerosolgenerating procedures can spread bacteria and viruses (including the COVID-19 virus) to people in dental clinics, including staff [9]. In addition, research conducted by Wax et al. 2020 [25] indicated that the COVID-19 virus may become airborne by aerosols produced during medical treatments. Routine dental treatments produce aerosols which increase the risk for contracting COVID-19 for both dental staff and patients [2]. Candeiro (2021) reported that Brazilian dentists demonstrated a good knowledge of COVID-19's main symptoms [26]. Similarly, in this study, participants identified fever, dry cough and tiredness as the common symptoms of COVID-19. This indicates that dentists in Trinidad and Tobago also have good knowledge. Of note is that almost every establishment and business in our country installed temperature checks and hand sanitizer use.
A total of 59.9% of respondents reported they were worried about their personal safety, and 77.1% reported being worried about family safety. This showed that dentists were more concerned for their families than themselves. Getting infected with COVID-19 and transmitting it to their family is a typical concern of dentists. As documented in Wuhan, China, out of 138 hospitalized COVID-19 patients, 29% were members of a health care team [4].
More females reported feeling anxious and fearful. This was consistent with findings in a study in Italy [27]. This can be attributed to cultural, social and biological factors that affect women's mental health [28].
Insufficient PPE was reported by 31.8% of respondents; this was slightly higher than in a report of Turkish dentists, where 21.85% reported a shortage of PPE [24]. Unfortunately, this is due to the worldwide demand for PPE during this pandemic.
To prevent COVID-19 infection, some respondents reported alcohol consumption and gargling with saltwater. This demonstrates a deficit in knowledge among some dentists and the need for more campaigns and seminars to increase health care providers' knowledge.
This highlights that there is a need for rehabilitation services and courses for dentists to be able to function in their clinics. There is a need to have refresher courses for practicing dentists on new and improved infection control strategies. For example, hand hygiene, the donning and doffing of adequate additional PPE, the sterilization of instruments and devices, the disinfection of workplaces, workflow patterns and the re-configuration of their clinic layouts.
The Dental Council can appoint taskforces to develop protocols and appropriate courses for dental practitioners [29].
Several guidelines have been published to assist dentists by the Centers for Disease Control and Prevention (CDC) in the US. [30] and the National Health Service (NHS) in the UK [31]. Current literature on precautions and recommendations for providing dental care during the current pandemic is readily available online; these could be disseminated to dentists in Trinidad and Tobago via online platforms and webinars.
For example, the American Dental Association (ADA) has released recommendations for dentists returning to work: • Implement a pre-appointment screening process via text, telephone, or email to ensure that patients with symptoms consistent with COVID-19-or recent exposure to infected individuals-do not travel to the dental office; • Staff protection strategies may include recommendations for in-office clothing (emphasizing that clinical attire should only be worn in the dental practice, and not back to staff members' homes or other community settings); • Limit the number of patients in the waiting room simultaneously, as part of social distancing.
One author has also suggested that dentists lessen their work hours to reduce virus spread [32].
The COVID-19 pandemic and the resultant lockdown practices worldwide have created a stressful environment globally. Such stressful situations have been shown to lead to poor oral health [33,34]. Dentists should consider developing online platforms to provide information on the prevention of oral diseases, such as oral hygiene and diet advice.
In addition, digitalized dental services can be implemented with qualified dentists being available online to provide reliable oral health care solutions in an accessible, affordable and appropriate manner. Tele-dentistry is "a combination of telecommunications and dentistry, involving the exchange of clinical information and images over remote distances for dental consultation and treatment planning" [35]. Tele-dentistry such as real-time video consultations can determine if a patient's oral health needs can be handled remotely [36]. During the pandemic, these remote dental consultations should be considered for non-emergency patients [37].
Dentists in the United Kingdom felt that their stress and anxiety levels had increased since the pandemic [38]. This corroborates with data in Trinidad and Tobago of increased levels of anxiety among dentists. One author's solution to alleviate the anxiety of dentists is to delay non-emergency treatment until the end of the pandemic [39]. This may not be practical for all dentists.
Psychological support services should be offered to the dental professionals in Trinidad and Tobago to help them cope with increased stress, anxiety and burnout.
The United Kingdom has arranged for the following to help their dentists [40]: The Dentists' Health Support Trust, providing specialized mental health services; • Counselling for mental health and wellbeing support.
The dental council of Trinidad can attempt to recreate some of these services for our local dentists struggling with anxiety.

Limitations
Due to the severity of different waves of the virus, the government initiated lockdowns, curfews and a state of emergency at different times. Thus, the validity of the responses may only be for a single point in time. In addition, factors such as religion and ethnicity were not assessed in this survey. Detailed demographics of dentists during this pandemic are necessary. The limited period for collection and the cross-sectional nature could result in a sampling error, which would affect the accuracy of results.
This survey was on a convenience sample, and therefore, the results may not be generalized to all dentists in this country. There may have been under or overrepresentation of some groups of dentists. Some dentists could be biased, which may be the underlying reason for them choosing not to participate.
The difference between dentists using recommended PPE and those that do not could not be proven. Due to the anonymity of this survey, future studies will not be able to contact the same participants.

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Awareness was consistent regarding preventative measures, routes of transmission and the incubation period for the SARS-CoV-2 virus; Rehabilitation services and courses should be offered to allow dentists to function in their clinics in Trinidad and Tobago.

Informed Consent Statement:
Informed consent was obtained from all subjects in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest.