Open access peer-reviewed chapter
Abstract
Since March 2020, the COVID-19 disease has declared a pandemic producing a worldwide containment. For months, many people were subjected to strict social isolation away from family and loved ones to prevent disease transmission, leading to anxiety, fear, and depression. On the other hand, many had to close down their businesses and stop working, resulting in financial issues. Previous studies have reported that pandemics, epidemics, and some diseases can lead to mental disorders such as fear, anxiety, stress, and depression. Among those most affected, healthcare workers (HCWs), especially those on the front line, often develop mental health problems. Although there is data available on the management and care of HCWs, little attention has been paid to the mental health and well-being of dentists during the COVID-19 pandemic. Therefore, this chapter aims to review the impact of the COVID-19 pandemic on dentists’ mental health and mental health-related symptoms. Finally, to recommend specific measures to avoid consequent potential implications for dentists, dental students, and dental patients.
Keywords
- Anxiety
- COVID-19
- Dentistry
- Fear
- Mental health
- SARS-CoV-2
1. Introduction
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an airborne virus that has caused the Coronavirus Disease 2019 (COVID-19) [1]. Like other respiratory diseases, COVID-19 is transmitted mainly by droplets and contact with infected people [2]. Therefore, many governments declared quarantine to contain the rapid spread of the SARS-CoV-2 [3] and specific measures were applied to limit viral transmission, including isolation, the use of respirators, and handwashing [4, 5].
In the face of this, the mental health of the general population was compromised. Strict isolation, loss of freedom, separation from family and loved ones, and working incapacity led to different people developing anxiety, fear, and depression [3]. Moreover, quarantine produced a general perception of job insecurity [6] and a serious concern about family and friends contagion [7].
From previous epidemics, it is known that health care workers (HCWs), have a higher probability of developing anxiety and depressive symptoms [8]. Nevertheless, little attention has been paid to the mental health and burnout that dentists may suffer [9, 10, 11]. During the lockdown, dental activities were limited to treat only emergencies and urgent procedures and use strict biosecurity measures during dental procedures [12, 13]. Many routine dental practices were suspended because of cross-infection risk during dental care [14], affecting the economy of dentists and consequently their mental health [15, 16, 17]. Not to mention dental students and dental patients who had to suspend classes and dental treatments during lockdown [18, 19].
Thus, this chapter aims to review the impact of the COVID-19 pandemic on dentists’ mental health and mental health-related symptoms. Finally, recommend specific measures to avoid consequent potential implications for dentists, dental students, and dental patients.
2. Mental health problems in other epidemics and diseases
In 2008, the World Health Organization (WHO) ranked major depression as the third leading cause of global disease burden, making it a significant health concern [20]. It has been reported that different diseases and infections can lead to an increased prevalence of mental health problems and substance use disorders, including infectious, neonatal, and non-communicable diseases such as HIV [21, 22, 23].
Isolation during disease management is believed to affect mental health, but the actual effects are still unknown [24]. Quarantine and isolation measures have not only occurred in this pandemic; they were also imposed in Canada and China during the SARS outbreak in 2003 and many African countries for the Ebola outbreak in 2014 [7].
Data on past epidemics have indicated that HCWs are at risk for anxiety and depressive symptoms in the same manner as during the COVID-19 pandemic. Concerning other coronavirus outbreaks, it has been reported that HCWs were related to a substantial psychiatric burden during and after them [25]. Moreover, it has been shown that quarantined people in hospitals could develop mental health symptoms [26]. Patients infected with MERS-CoV had a considerable effect on mental health during quarantine. Common symptoms related were depression, anxiety, impaired concentration and memory, and insomnia [25].
Although the SARS epidemic was contained rapidly, it had a high human cost. Many HCWs reported mental symptoms and posttraumatic morbidities [26].
It was found that having been quarantined during the SARS outbreak and previous experience of other traumatic events increased the probability of having elevated levels of depressive symptoms three years later [27]. However, some authors do not consider the SARS epidemic as a mental health catastrophe; follow-up studies reported that these symptoms could be associated with the stress of daily life rather than with the SARS crisis [28, 29, 30].
3. Risk factors and possible stressors
There are different risk factors of Mental Health problems, such as previous history of depression or anxiety, but the best known are female gender and current medical history [8]. Risk factors for experiencing anxiety and anger after MERS infection included isolation, inadequate supplies (food, shelter, clothing), history of psychiatric illness, and financial loss [24]. Similarly, it has been shown that psychiatric impact during the COVID-19 pandemic may be more significant in females. Anxiety and depressive disorders were higher in women than in men during the COVID-19 pandemic, indicating that female gender has been identified as the strongest predictor of posttraumatic stress disorder symptoms after pandemics [31, 32, 33]. Additionally, the COVID-19 pandemic adds other essential aspects such as isolation and quarantine that produce a psychological impact on individuals [7].
Likewise, dentists, dental staff, and dental patients have faced specific problems. For instance, Dentists have also changed their priorities. Their schedules may not be sufficient to handle all emergencies and emergencies during quarantine because of the need to add time for strict disinfection [3]. At the same time, there is great difficulty in acquiring supplies needed for dental care. Many governments did not have clear guidelines in place at the onset of the pandemic leading to work disruption and economic losses [7].
4. COVID-19 consequences in healthcare workers
Mental health symptoms such as stress, depression, anxiety, and sleep problems have been reported during the COVID-19 pandemic [34]. Likewise, exacerbation of fear, depression, and anxiety [3].
Studies have reported posttraumatic stress symptoms between HCW during the pandemic [8] and one month after the COVID-19 outbreak [35].
HCW may experience evasion by their family or friends due to stigma or fear of contracting the disease from them [36]. Isolation, reduced social relations, and loneliness are well-recognized risk factors for several mental disorders, including major depression and schizophrenia [3]. During quarantine, the medical staff was more likely to develop fatigue, anxiety, insomnia, irritability, poor concentration, and resistance to work, resulting in decreased work performance [7].
Vindegaard et al. reported a high level of posttraumatic stress symptoms and found a 29% prevalence of depression among 57 newly recovered COVID-19 patients and 9.8% in quarantined participants (9.8%) [8]. Panagioti et al. [37] reported that physicians with burnout are twice as likely to be involved in patient safety incidents, provide inadequate patient care, and three times more likely to receive a low patient satisfaction rating. In the same way, a study revealed that quarantined staff in a hospital show signs of acute stress disorder nine days after the end of isolation, indicating that being quarantined in a hospital could be a predictor of posttraumatic stress [7].
On the other hand, the Covid-19 pandemic has affected health systems around the world [11]. Many institutions have to deal with the limited availability of personal protective equipment (PPE) in some facilities and the increasing need for trained medical personnel [38]. Besides, it was difficult to import medical equipment and supplies at the peak of the COVID-19 crisis due to government restrictions prohibiting their medical industry from selling outside their own countries [39].
5. COVID-19 consequences in dentists and dental staff
As in other HCWs, the mental health of dental workers could also be affected by this pandemic context. The SARS-CoV-2 pandemic has led to several mental health issues among doctors and nurses, and dentists are no exception due to the nature of their work [40]. Anxiety and mental disorders due to COVID-19 in dentists have been reported. The prevalence of symptoms related to anxiety was 71%, 60% with depression, and stress was 92% [41, 42].
Isolation and social distancing could have a detrimental impact on the mental health of patients and dental workers. It has been reported that the psychosocial consequences of the COVID-19 pandemic may be particularly severe for health professionals with a higher level of exposure [3]. An association was found between higher fear of COVID-19, job insecurity, and depressive symptoms [6]. It was also found that dentists working in the private sector presented fewer psychological symptoms than the independent ones [42].
Khader et al. [43] reported that 71.7% of 368 interviewed dentists perceived COVID-19 as a moderately dangerous disease, and 17.7% like very dangerous. A recent study about happiness among dentists highlighted that inadequate stress management and not achieving professional satisfaction could influence the quality of delivered treatment and patients compliance, revealing the urgency among dentists to be trained in this matter [44].
Managers and team leaders may experience extra pressure concerning their roles and responsibilities [36]. Understanding the risks associated with SARS-CoV-2 transmission during dental treatment and assessing strategies for its prevention in dental offices is critical to ensure patient safety and access to oral health care [45].
The schedule of health professionals could be challenging. Time schedules could be insufficient to handle all treatments, adding the disinfection time as efficiently as before [3]. Not to mention the stress and difficulty in needed supply acquisition and the inadequate and insufficient information from governments and public health authorities on what measures to take to combat the pandemic [7].
Dentistry could be a hazardous and stressful profession [46, 47, 48]. It is well known to be associated with health concerns, including psychological stress, burnout, physical tiredness, pressure, and emotional exhaustion, directly affecting general and mental health, leading to poor work performance [49, 50]. In addition, HCW and dentists had to wear a mask for long periods throughout the pandemic with concerns about its correct use [51]. The adverse effects of this pandemic appear to be long-lasting [7]. Clinics and dental practices need to be modified to guarantee care and a safe environment [3].
6. Dental patient’s concern about dental treatment in the context of COVID-19 pandemic
A significant association was found between patients’ feelings about COVID-19 infection and attendance at their dental appointments. Patients, especially women, reported feeling anxious and worried during their treatments and others about prolonged orthodontic treatments [19, 52]. Similarly, patients who were going to undergo oral surgeries presented a higher increase in anxiety than before the pandemic [53]. Among the main concerns of the patients was the risk of infection and possible transmission to their families. On the other hand, worsening their oral health was also reported, and others considered that treatment outcomes could be affected [52, 54].
In the same way, there is concern about the dental treatment of children. Thirty-three percent of parents described the dental office as more dangerous than public areas. The majority of surveyed parents felt that their children could become infected more easily during dental treatment [55].
Peloso et al. [52] recommended that dentists should use technology for patient counseling about appointments and treatment to decrease their anxiety. Finally, it is necessary to share consistent information about biosafety protocols during dental care to reduce fear and anxiety in patients [56].
7. COVID-19 pandemic and the mental health of dental students
Numerous studies have informed that university students are at high risk for mental health problems that are exacerbated by the COVID-19 pandemic [57]. Ma et al. [58] reported that of 746,217 students surveyed, 45% presented mental health problems, 34.9% signs of acute stress, 21.1% depression, and 11% anxiety. The main factors that could influence the mental health of university students are social isolation, inability to meet with friends, concern about personal health, fear of someone in the family becoming infected, and lack of certainty about the future [59, 60]. In addition, 83% of the students showed anxiety and concern about losing their manual dexterity, and others reported fear of the new way examination process [60].
Again, an association was found with female gender and depressive symptoms [60, 61] and with having infected family members or friends [58].
In terms of clinical education, students reported that they had to adapt to changes and didactic learning; others indicated that at least one of their courses moved to virtual mode. Although 51.8% perceived some difficulties during virtual education, 48.3% perceived that faculty were prepared for the online transition [62]. Some students reported feeling stress about the risk of infection and returning to clinical classes and patient contact [63].
In this matter, faculty support is needed to help in the transition and concerns about academic progress and stress levels [62].
8. Recommendations and considerations to improve mental health
First, if you notice any changes that concern you regarding your mental health, seek professional help [3]
It is essential to implement and conduct psychological workshops to reinforce the moral of dentists and the correct instruction in the use of personal protective equipment [41].
Make time to communicate frequently with family and friends; whenever you can opt for video chat to see people’s expressions [36].
If you do not have a social group, contact with a trained person such as a social worker or a psychologist [5].
It is healthy to focus on the thought that we voluntarily stay home to care for ourselves and others and not see it as mandatory [7].
If you have any questions about people infected with COVID, inform yourself and avoid prejudice and stigmatization. Make an effort to show empathy [36].
Limit stressful sources or news about COVID-19 to minimize the access to exacerbated information. Look for objective data in trusted sites [3, 36].
Attempts to use technology to reduce anxiety levels by counseling patients about their treatment, appointments, and oral health [52].
Concerning patients, an important aspect is to inform them about the safety of dental office visits. Communication about biosafety is a crucial aspect of reducing fear and anxiety in patients [56]. It is also essential to minimize care time and reduce the intervals between patient appointments [19].
Concerning dental students, it is essential to provide psychological and social help to students, especially those with associated risk factors [58].
Institutions and universities should take preventive measures to support students and manage factors that could influence their mental health and crisis management [61, 64].
Dental schools must adapt quickly and customize changes primarily for those students who may not practice their clinical or laboratory skills [60].
Although most dentists are knowledgeable and aware of COVID-19, specific gaps require more efficient training programs, proper guidelines, and improved treatment protocols [65]. Authorities should support dentists if they have to stop their professional activities without prior planning by providing them with appropriate policies and monetary support [40].
9. Conclusions
As HCW and human beings, dental workers are coping with the consequences and effects of this pandemic. The pandemic will be over, but its impact on mental health and well-being will remain for a long time. Our call is for our colleagues to take measures to decrease those adverse effects in mental health and seek professional help in the case is needed. In addition, within our healthcare workers’ position, spread this knowledge and refer any patient who could need psychological or psychiatric attention. Mental health problems after release from isolation could be prevented by providing mental health support to vulnerable individuals and providing accurate information and appropriate supplies, including food, clothing, and shelter.
Acknowledgments
The authors want to thank the Periocientifica research team for comments to improve this paper.
Conflict of interest
The authors declare no conflict of interest.
References
- 1.
Zheng J. SARS-CoV-2: an Emerging Coronavirus that Causes a Global Threat. International journal of biological sciences. 2020;16:1678-1685. doi: 10.7150/ijbs.45053. - 2.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. International journal of oral science. 2020;12:9. doi: 10.1038/s41368-020-0075-9. - 3.
Fiorillo A, Gorwood P. The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. European psychiatry : the journal of the Association of European Psychiatrists. 2020;63:e32. doi: 10.1192/j.eurpsy.2020.35. - 4.
World Health O. Advice on the use of masks in the context of COVID-19: interim guidance, 5 June 2020. Geneva: World Health Organization; 2020. - 5.
World Health O. Infection prevention and control during health care when COVID-19 is suspected: interim guidance, 19 March 2020. Geneva: World Health Organization; 2020. - 6.
Gasparro R, Scandurra C, Maldonato NM, Dolce P, Bochicchio V, Valletta A, et al. Perceived Job Insecurity and Depressive Symptoms among Italian Dentists: The Moderating Role of Fear of COVID-19. International journal of environmental research and public health. 2020;17. doi: 10.3390/ijerph17155338. - 7.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 2020;395:912-920. doi: https://doi.org/10.1016/S0140-6736(20)30460-8 . - 8.
Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain, behavior, and immunity. 2020;89:531-542. doi: 10.1016/j.bbi.2020.05.048. - 9.
Vergara-Buenaventura A, Chavez-Tunon M, Castro-Ruiz C. The Mental Health Consequences of Coronavirus Disease 2019 Pandemic in Dentistry. Disaster Med Public Health Prep. 2020:1-4. doi: 10.1017/dmp.2020.190. - 10.
Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Journal of the American Academy of Child and Adolescent Psychiatry. 2020;59:1218-1239.e1213. doi: 10.1016/j.jaac.2020.05.009. - 11.
Muller AE, Hafstad EV, Himmels JPW, Smedslund G, Flottorp S, Stensland S, et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review. Psychiatry research. 2020;293:113441. doi: 10.1016/j.psychres.2020.113441. - 12.
Mupparapu M. Editorial: Aerosol reduction urgency in post-COVID-19 dental practice. Quintessence international (Berlin, Germany : 1985). 2020;51:525-526. doi: 10.3290/j.qi.a44705. - 13.
Bizzoca ME, Campisi G, Muzio LL. Covid-19 Pandemic: What Changes for Dentists and Oral Medicine Experts? A Narrative Review and Novel Approaches to Infection Containment. International journal of environmental research and public health. 2020;17. doi: 10.3390/ijerph17113793. - 14.
Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and Practice Modifications among Dentists to Combat Novel Coronavirus Disease (COVID-19) Outbreak. Int J Environ Res Public Health. 2020;17. doi: 10.3390/ijerph17082821. - 15.
Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 Outbreak: An Overview on Dentistry. Int J Environ Res Public Health. 2020;17. doi: 10.3390/ijerph17062094. - 16.
Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. Journal of dental research. 2020;99:481-487. doi: 10.1177/0022034520914246. - 17.
Farooq SM, Sachwani SAA, Haider SI, Iqbal SA, Parpio YN, Saeed H. Mental Health Challenges and Psycho-social Interventions amid COVID-19 Pandemic: A Call to Action for Pakistan. J Coll Physicians Surg Pak. 2020;30:59-62. doi: 10.29271/jcpsp.2020.Supp1.S59. - 18.
Hakami Z, Khanagar SB, Vishwanathaiah S, Hakami A, Bokhari AM, Jabali AH, et al. Psychological impact of the coronavirus disease 2019 (COVID-19) pandemic on dental students: A nationwide study. Journal of dental education. 2021;85:494-503. doi: 10.1002/jdd.12470. - 19.
Xiong X, Wu Y, Fang X, Sun W, Ding Q, Yi Y, et al. Mental distress in orthodontic patients during the coronavirus disease 2019 pandemic. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2020;158:824-833.e821. doi: 10.1016/j.ajodo.2020.07.005. - 20.
WHO. The global burden of disease: 2004 update. World Health Organization; 2008. - 21.
Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS (London, England). 2019;33:1411-1420. doi: 10.1097/qad.0000000000002227. - 22.
Metrics IfH, Evaluation. GBD compare data visualization. 2017. - 23.
Douglas PK, Douglas DB, Harrigan DC, Douglas KM. Preparing for pandemic influenza and its aftermath: mental health issues considered. International journal of emergency mental health. 2009;11:137-144. - 24.
Jeong H, Yim HW, Song YJ, Ki M, Min JA, Cho J, et al. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and health. 2016;38:e2016048. doi: 10.4178/epih.e2016048. - 25.
Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The lancet Psychiatry. 2020;7:611-627. doi: 10.1016/s2215-0366(20)30203-0. - 26.
Sim K, Chong PN, Chan YH, Soon WS. Severe acute respiratory syndrome-related psychiatric and posttraumatic morbidities and coping responses in medical staff within a primary health care setting in Singapore. The Journal of clinical psychiatry. 2004;65:1120-1127. doi: 10.4088/jcp.v65n0815. - 27.
Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, et al. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Comprehensive psychiatry. 2012;53:15-23. doi: 10.1016/j.comppsych.2011.02.003. - 28.
Lung FW, Lu YC, Chang YY, Shu BC. Mental Symptoms in Different Health Professionals During the SARS Attack: A Follow-up Study. The Psychiatric quarterly. 2009;80:107-116. doi: 10.1007/s11126-009-9095-5. - 29.
Maunder RG. Was SARS a mental health catastrophe? General hospital psychiatry. 2009;31:316-317. doi: 10.1016/j.genhosppsych.2009.04.004. - 30.
Anderson RM, Fraser C, Ghani AC, Donnelly CA, Riley S, Ferguson NM, et al. Epidemiology, transmission dynamics and control of SARS: the 2002-2003 epidemic. Philosophical transactions of the Royal Society of London Series B, Biological sciences. 2004;359:1091-1105. doi: 10.1098/rstb.2004.1490. - 31.
Özdin S, Bayrak Özdin Ş. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. The International journal of social psychiatry. 2020;66:504-511. doi: 10.1177/0020764020927051. - 32.
Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet (London, England). 2020;395:470-473. doi: 10.1016/s0140-6736(20)30185-9. - 33.
Wang Y, Di Y, Ye J, Wei W. Study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (COVID-19) in some regions of China. Psychology, health & medicine. 2021;26:13-22. doi: 10.1080/13548506.2020.1746817. - 34.
Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. The International journal of social psychiatry. 2020;66:317-320. doi: 10.1177/0020764020915212. - 35.
Zhang Y, Ma ZF. Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study. International journal of environmental research and public health. 2020;17. doi: 10.3390/ijerph17072381. - 36.
WHO: Mental health and psychosocial considerations during the COVID-19 outbreak https://apps.who.int/iris/bitstream/handle/10665/331490/WHO-2019-nCoV-MentalHealth-2020.1-eng.pdf?sequence=1&isAllowed=y (2020). Accessed April 2021. - 37.
Panagioti M, Geraghty K, Johnson J, Zhou A, Panagopoulou E, Chew-Graham C, et al. Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis. JAMA internal medicine. 2018;178:1317-1331. doi: 10.1001/jamainternmed.2018.3713. - 38.
Cotton S, Zawaydeh Q, LeBlanc S, Husain A, Malhotra A. Proning during covid-19: Challenges and solutions. Heart & lung : the journal of critical care. 2020;49:686-687. doi: 10.1016/j.hrtlng.2020.08.006. - 39.
Pons-Òdena M, Valls A, Grifols J, Farré R, Cambra Lasosa FJ, Rubin BK. COVID-19 and respiratory support devices. Paediatric respiratory reviews. 2020;35:61-63. doi: 10.1016/j.prrv.2020.06.015. - 40.
Mishra S, Singh S, Tiwari V, Vanza B, Khare N, Bharadwaj P. Assessment of Level of Perceived Stress and Sources of Stress Among Dental Professionals Before and During the COVID -19 Outbreak. Journal of International Society of Preventive & Community Dentistry. 2020;10:794-802. doi: 10.4103/jispcd.JISPCD_340_20. - 41.
Salehiniya H, Abbaszadeh H. Prevalence of corona-associated anxiety and mental health disorder among dentists during the COVID-19 pandemic. Neuropsychopharmacology reports. 2021. doi: 10.1002/npr2.12179. - 42.
Ranka MS, Ranka SR. Survey of Mental Health of Dentists in the COVID-19 Pandemic in the UK. Journal of International Society of Preventive & Community Dentistry. 2021;11:104-108. doi: 10.4103/jispcd.JISPCD_401_20. - 43.
Khader Y, Al Nsour M, Al-Batayneh OB, Saadeh R, Bashier H, Alfaqih M, et al. Dentists' Awareness, Perception, and Attitude Regarding COVID-19 and Infection Control: Cross-Sectional Study Among Jordanian Dentists. JMIR public health and surveillance. 2020;6:e18798. doi: 10.2196/18798. - 44.
Alhajj MN, Omar R, Khader Y, Celebić A, El Tantawi M, Folayan MO, et al. Happiness among dentists: a multi-scale, multi-national study from 21 countries. International dental journal. 2020;70:328-339. doi: 10.1111/idj.12579. - 45.
Estrich CG, Mikkelsen M, Morrissey R, Geisinger ML, Ioannidou E, Vujicic M, et al. Estimating COVID-19 prevalence and infection control practices among US dentists. Journal of the American Dental Association (1939). 2020;151:815-824. doi: 10.1016/j.adaj.2020.09.005. - 46.
Al-Khatib IA, Ishtayeh M, Barghouty H, Akkawi B. Dentists' perceptions of occupational hazards and preventive measures in East Jerusalem. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit. 2006;12:153-160. - 47.
Moore R, Brødsgaard I. Dentists' perceived stress and its relation to perceptions about anxious patients. Community dentistry and oral epidemiology. 2001;29:73-80. - 48.
Galginaitis C, Gift H. Occupational hazards. Is dentistry hazardous to your health? The New dentist : the official journal of the American Student Dental Association. 1980;10:24-27. - 49.
Hill KB, Burke FJ, Brown J, Macdonald EB, Morris AJ, White DA, et al. Dental practitioners and ill health retirement: a qualitative investigation into the causes and effects. British dental journal. 2010;209:E8. doi: 10.1038/sj.bdj.2010.814. - 50.
Lo Sasso AT, Starkel RL, Warren MN, Guay AH, Vujicic M. Practice settings and dentists' job satisfaction. Journal of the American Dental Association (1939). 2015;146:600-609. doi: 10.1016/j.adaj.2015.03.001. - 51.
Vergara-Buenaventura A. Comfort and compliance with the use of facemasks during COVID -19 infection. International journal of oral and maxillofacial surgery. 2020;49:1523. doi: 10.1016/j.ijom.2020.06.019. - 52.
Peloso RM, Pini NIP, Sundfeld Neto D, Mori AA, Oliveira RCG, Valarelli FP, et al. How does the quarantine resulting from COVID-19 impact dental appointments and patient anxiety levels? Brazilian oral research. 2020;34:e84. doi: 10.1590/1807-3107bor-2020.vol34.0084. - 53.
Pylińska-Dąbrowska D, Starzyńska A, Cubała WJ, Ragin K, Alterio D, Jereczek-Fossa BA. Psychological Functioning of Patients Undergoing Oral Surgery Procedures during the Regime Related with SARS-CoV-2 Pandemic. Journal of clinical medicine. 2020;9. doi: 10.3390/jcm9103344. - 54.
Cotrin P, Peloso RM, Oliveira RC, de Oliveira RCG, Pini NIP, Valarelli FP, et al. Impact of coronavirus pandemic in appointments and anxiety/concerns of patients regarding orthodontic treatment. Orthodontics & craniofacial research. 2020;23:455-461. doi: 10.1111/ocr.12395. - 55.
Sun J, Xu Y, Qu Q, Luo W. Knowledge of and attitudes toward COVID-19 among parents of child dental patients during the outbreak. Brazilian oral research. 2020;34:e066. doi: 10.1590/1807-3107BOR-2020.vol34.0066. - 56.
Moffat RC, Yentes CT, Crookston BT, West JH. Patient Perceptions about Professional Dental Services during the COVID-19 Pandemic. JDR clinical and translational research. 2021;6:15-23. doi: 10.1177/2380084420969116. - 57.
Luo W, Zhong BL, Chiu HF. Prevalence of depressive symptoms among Chinese university students amid the COVID-19 pandemic: a systematic review and meta-analysis. Epidemiology and psychiatric sciences. 2021;30:e31. doi: 10.1017/s2045796021000202. - 58.
Ma Z, Zhao J, Li Y, Chen D, Wang T, Zhang Z, et al. Mental health problems and correlates among 746 217 college students during the coronavirus disease 2019 outbreak in China. Epidemiology and psychiatric sciences. 2020;29:e181. doi: 10.1017/s2045796020000931. - 59.
Romeo A, Benfante A, Castelli L, Di Tella M. Psychological Distress among Italian University Students Compared to General Workers during the COVID-19 Pandemic. International journal of environmental research and public health. 2021;18. doi: 10.3390/ijerph18052503. - 60.
Agius AM, Gatt G, Vento Zahra E, Busuttil A, Gainza-Cirauqui ML, Cortes ARG, et al. Self-reported dental student stressors and experiences during the COVID-19 pandemic. Journal of dental education. 2021;85:208-215. doi: 10.1002/jdd.12409. - 61.
Volken T, Zysset A, Amendola S, Klein Swormink A, Huber M, von Wyl A, et al. Depressive Symptoms in Swiss University Students during the COVID-19 Pandemic and Its Correlates. International journal of environmental research and public health. 2021;18. doi: 10.3390/ijerph18041458. - 62.
Klaassen H, Ashida S, Comnick CL, Xie XJ, Smith BM, Tabrizi M, et al. COVID-19 pandemic and its impact on dental students: A multi-institutional survey. Journal of dental education. 2021. doi: 10.1002/jdd.12597. - 63.
Zarzecka J, Zarzecka-Francica E, Gala A, Gębczyński K, Pihut M. Dental environmental stress during the COVID-19 pandemic at the Jagiellonian University Medical College, Kraków, Poland. International journal of occupational medicine and environmental health. 2021. doi: 10.13075/ijomeh.1896.01773. - 64.
Ataş O, Talo Yildirim T. Evaluation of knowledge, attitudes, and clinical education of dental students about COVID-19 pandemic. PeerJ. 2020;8:e9575. doi: 10.7717/peerj.9575. - 65.
Khanal N, Singh AK. Knowledge, Attitude and Practice Regarding COVID-19 and its Impact on Dentistry: A Cross-sectional Survey among Nepalese Dentists. Kathmandu University medical journal (KUMJ). 2020;18:3-9.