DENTAL PROFESSIONALS KNOWLEDGE, ATTITUDE, AND PRACTICE TOWARDS TO COVID-19: SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Dental professions are at high risk of contracting novel corona virus (COVID-19) infections during the dental procedure due to the droplets and aerosols generated during various dental procedures on infected patients. To prevent and avoid the cross-infection of the infection to dental professionals or the patients attending the dental clinic, good knowledge of the infection and its prevention mechanisms is mandatory among the professionals. Until to date, there is no pooled estimate on the knowledge,attitude and practice (KAP) of dental professionals Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 18 September 2020 doi:10.20944/preprints202009.0439.v1 © 2020 by the author(s). Distributed under a Creative Commons CC BY license. 2 to COVID-19 in the globe. Hence, this study aimed to determine the pooled estimate of KAP of dental professionals in this pandemic disease. Methods: Article search was done electronically using Medline, Scopus, Web of Science, EMBASE, SciELO and Google Scholar from June 1, 2020 to August 20, 2020. All studies that assessed the KAP of dental professionals to COVID-19 were searched and included in this review after passing the inclusion criteria. The pooled analysis of their knowledge (sign and symptom, mode of transmission and prevention mechanisms), attitude (their concern, intention to treat suspected patients) and practice (face mask usage, hand washing and alcohol based hand rub usage, handshaking practice, deferred procedures and checkup of patients temperature) was computed using RevMan 5.3 and random effect model was used. The presence of publication bias was assessed using the funnel plot. Results: Twelve articles with a total of 5,362 study participants were included in this study. The pooled estimate revealed that 59.91% of the dental professionals had good knowledge of the signs and symptoms of COVID-19. Two-third of dental professionals know the prevention mechanisms of the infection, and 70.13% had enough knowledge of the transmission modalities of the infection. The professional attitude revealed that only 36.43% of the participants had intention to treat a patient with cough or suspected COVID-19 (36.43%, 95%CI: 8.57, 64.29). Moreover, 47.85% of the dentists were concerned about their life, and the fate of their profession due to this pandemic disease (47.85%, 95%CI: 26.74, 68.97). The pooled analysis showed only 50.86% (95%CI: 18.64, 83.09) of the study participants worn face mask and 52.63% (95%CI: 10.54, 94.71) had avoided handshaking practice during this pandemic period. Non-emergency dental procedures were canceled by 83.98%. Conclusion: The dental professional KAP is not optimal. Thus, dental professionals should be aware of the recently updated knowledge about COVID-19 and practice according to the standards of treatment guidelines, and the recommended infection control measures in dental settings. Moreover, as saliva and droplets are the major sources of infection, dentists should follow essential protocols to regulate droplet and aerosol contamination in the dental practice.

to COVID-19 in the globe. Hence, this study aimed to determine the pooled estimate of KAP of dental professionals in this pandemic disease. Methods: Article search was done electronically using Medline, Scopus, Web of Science, EMBASE, SciELO and Google Scholar from June 1, 2020 to August 20, 2020. All studies that assessed the KAP of dental professionals to COVID-19 were searched and included in this review after passing the inclusion criteria. The pooled analysis of their knowledge (sign and symptom, mode of transmission and prevention mechanisms), attitude (their concern, intention to treat suspected patients) and practice (face mask usage, hand washing and alcohol based hand rub usage, handshaking practice, deferred procedures and checkup of patients temperature) was computed using RevMan 5.3 and random effect model was used. The presence of publication bias was assessed using the funnel plot. Results: Twelve articles with a total of 5,362 study participants were included in this study. The pooled estimate revealed that 59.91% of the dental professionals had good knowledge of the signs and symptoms of COVID-19. Two-third of dental professionals know the prevention mechanisms of the infection, and 70.13% had enough knowledge of the transmission modalities of the infection. The professional attitude revealed that only 36.43% of the participants had intention to treat a patient with cough or suspected COVID- 19

Conclusion:
The dental professional KAP is not optimal. Thus, dental professionals should be aware of the recently updated knowledge about COVID-19 and practice according to the standards of treatment guidelines, and the recommended infection control measures in dental settings. Moreover, as saliva and droplets are the major sources of infection, dentists should follow essential protocols to regulate droplet and aerosol contamination in the dental practice.

Background
The novel coronavirus (COVID-19) was first observed in the city of Wuhan, China in December 2019, and become a global public health problem, promoting the world health organization (WHO) to declare it as a pandemic disease on March 11, 2020(1,2). The newly occurred virus was initially named "new coronavirus" (nCoV) (3), and finally, the pathogen has been called SARS-CoV-2 (3,4).
The virus is transmitted from human to human through air droplets of the respiratory secretions from the infected patients and direct contact with contaminated surfaces or individuals (5).COVID-19 can live on the surface of materials or skin for a few hours to days (6). Even if peoples of all age groups are affected by this infectious disease, individuals who are in close contact with COVID-19 patients, health care staff, and other patients in hospitals are at higher risk of acquiring the infection (7). Due to the nature of the dental treatment, procedures that produce aerosols and flashes that containing a large amount of blood and saliva from the patients increase the risk of transmission of the virus to the dentist (8). Dentists may be unknowingly providing direct dental care to infected patients that are not yet diagnosed COVID-19 or considered to be suspected cases for surveillance (9).
Many ongoing clinical trials are going to search the vaccine for this fatal virus since its occurrence. However, there is no confirmed antiviral drug or vaccine to date. As a mater of fact, preventive measures such as; applying a face mask, hand washing, maintain social distance, and several other measures were applied by WHO and different countries in the world (10,11). The disease is managed with a symptomatic treatment such as analgesics and antipyretics and supportive care. Avoiding exposure to the virus is the best prevention (12). in China found that 29% of the cases were health care workers (14).
Health care professionals, including nurses, physicians, Dentists, and other hospital staffs are playing a critical role in combating, preventing, and managing patients affected by COVID-19 (12). In the last months, multiple reports of COVID-19 infection have been reported throughout the globe, which is of grave concern(12). Of the total health care workers death report 8% were dentists (15). Due to the reported infection rates, it was hypothesized that the KAP of healthcare professionals towards COVID-19 will be poor. To decrease COVID-19 infection among the health care professional, the first step should be to increase their KAP to the infection. Therefore the present systematic review and meta-analysis focused to estimate the pooled effect on KAP of dental professionals on COVID-19.

METHODS
This systematic review and meta-analysis were conducted according to the preferred reporting items for systematic review and meta-analysis guidelines (PRISMA) (16). August 20, 2020. The following key terms were used to search all the relevant articles; KAP of dental professionals to COVID-19, perception of dental professionals to COVID-19.

ARTICLE SELECTION
Five authors (KD, BG, AT, AA and AM) searched the studies electronically using four databases and manually using Google scholar. Papers identified in the initial article search were exported to Endnote and duplicates were removed by one reviewer (AT). After the duplicates were removed, the remaining articles were screened based on the abstract and titles and then, the full text of the screened articles was evaluated thoroughly and papers that didn't meet the inclusion criteria would be excluded from the study. Finally, eligibility and availability of all the necessary data were evaluated by two reviewers independently. Any disagreement between these two reviewers was solved by the involvement of a 3 rd reviewer.

DATA EXTRACTION
All relevant data were extracted by three reviewers using the pre-designed checklist. The following variables would be extracted from the selected articles; first author's name, study country, study year, study design, sample size, qualification, experience, and the outcome of the study (knowledge, attitude, and practice).

RISK OF BIAS ASSESSMENT
The quality of the included studies was assessed using the Joanna Briggs institute reviewers manual (JBI) tools for a systematic review of prevalence and incidence studies (17). Two reviewers critically appraised the quality of the studies based on sample representativeness, participants recruitment, sample size estimation, reliability of the measurement, and the analysis of the outcomes. Accordingly, articles were given scores and the studies that scored 7 and 8 were considered as very good quality, 4-6 as good, and below four were designed as poor quality. All studies with a quality of >50% would be included in the review.

STATISTICAL ANALYSIS
The primary outcome of the study was the KAP of dental professionals towards COVID-19. The pooled analysis was done using RevMan 5.3 software. The heterogeneity between the selected articles was assessed using the I 2 test. Moreover, the publication bias was evaluated using the funnel plot.

Article Search
A total of 53 studies was retrieved from the databases and during a manual search for the analysis. During title and abstract screening for duplicates and non-relevant studies, 27 articles excluded. Twenty six articles were screened for full text review and 14 studies were excluded as they did not meet the inclusion criteria. Finally, 12 studies meet the inclusion criteria and included in the systematic review and meta-analysis (Figure 1).

STUDY CHARACTERISTICS
All the selected 12 studies in this review were cross-sectional studies collected using online questionaries' and self-administered questionnaire conducted in India  The study includes dental, dental students, general dental practitioners and dental specialists both in governmental and private practice. A total of 5,362 study participants was involved in the studies included in this systematic review and meta-analysis.

RESULTS OF INDIVIDUAL STUDIES
A cross-sectional study done in Turkey on dental students on their KAP to COVID-19 revealed that 45% had enough knowledge of the spread and the protection mechanism of the infection.
While only 35.2% of them have intention to treat the Covid patient. The study also showed only 40.5% of the study participants had trust on personal protective equipments on dental procedures (28). A similar study in India on Dentists found only 29.9% of the dental professionals had higher knowledge (23).
Singh and his colleagues revealed that the use of face masks among the dental professionals in

Risk of Bias within Studies
The quality of the included studies for the systematic review and meta-analysis was assessed by JBI critical appraisal checklist and studies with a quality assessment score of 50% and above were included in the review (Table 2).

Dental professional's knowledge about COVID-19
This pooled analysis tried to show the knowledge of dental professionals to the mode of transmission, sign and symptoms and prevention mechanism of the infection. The pooled analysis showed that dental professional knowledge of the prevention mechanisms of COVID-19 was 64.37% (95%CI: 44.14, 84.61; p<0.00001) with a heterogeneity of (I 2 ) 100% (Figure 2).

Attitude of dental professionals to COVID-19
The study showed only 36.43% of the dental professionals involved have intention to treat a patient with cough or suspected COVID-19 (36.43%, 95%CI: 8.57, 64.29) (Figure 5). Almost half of the study participants were bothered by the pandemic of the infection and the fate of their profession (47.85%, 95%CI: 26.74, 68.97; P<0.00001) (Figure 6). The study also revealed that 70.41% of the study participants fear the risk of acquiring infection during dental procedures (Figure 7).

Practice of dental professionals during COVID-19
The pooled estimate revealed that 50.86% of the study participants had worn face mask during their dental procedure ( Besides, 62.82% of the study participants washed their hand after each procedure (Figure 12).
The funnel plot demonstrated there was no publication bias in any of the 12 studies analyzed (Figure 13).

DISCUSSION
This review aimed to assess the KAP of dental professionals towards COVID-19. To the best of our knowledge, this is the first systematic review and meta-analysis on the topic.
A present meta-analysis on the KAP of health professionals on COVID-19 showed more than half of (56.6% (95%CI: 45.9-67%) the health care workers (HCWs) had poor knowledge about . This study supports the present meta-analysis of KAP of dental professionals to This service limitation results in a significant economic loss for the dental sector and affects the oral health-related quality of the patients (30).
There is an obvious probability that dental professionals and members of the dental team are having a high risk of contracting and/or transmitting the novel coronavirus infection due to their contact with a high number of patients that require close contact with the patient and also the examination is taken place intra-orally (31)(32)(33). The present study found 47.85% (95%CI: 26.74, 68.97) of the study participants were concerned with the pandemic, and 70.41% of dental professionals fear the risk of acquiring COVID-19 infections during dental procedures. Dental professionals should take urgent action to protect the patients and the dental health care team from infection. The American Dental Association (ADA) and Centers for Disease Control and Prevention (CDC) have urged all dental professionals to defeer, or at least postpone all elective procedures (34) and timely reassessment of the dental professionals involved in the dental emergencies is necessary (27,35).

CONCLUSION
The KAP of dental professionals is not optimal. Thus, dental professionals should be aware of the recently updated knowledge about COVID-19 and practice according to the standards of treatment guidelines and the recommended infection control measures in dental settings.
Moreover, as saliva and droplets are the major sources of infection, dentists should follow nominal management protocols to regulate droplet and aerosol contamination in the dental clinic.