Background: Dentists and dental auxiliaries are considered at high risk for the spread of COVID-19 due to their direct contact with the patient’s oral cavity. The stress of being infected with the virus was high during the pandemic. This research aims to estimate the psychological impact of COVID-19 on dental assistants in Saudi Arabia during this pandemic.
Methodology: This questionnaire-based cross-sectional study used a pre-validated Depression, Anxiety, Stress Scale with 21 Items (DASS-21) to assess the psychological impact on the mental health of dental assistants during the COVID-19 pandemic. The questionnaire was sent to the participants through the mail using Google Forms. One reminder email was sent after a week to fill out and submit the form. Data were entered using Microsoft Excel and later analyzed by the Statistical Package for the Social Sciences software.
Results: The response rate was 75% (210 out of 280). Most participants were 20–40 years old and only 10 were above 50. Most participants were females (180) and were of non-Saudi origin. The results of a comparison of DASS scores between males and females were statistically significant (p = 0.001), with a higher mean total DASS score noted in males (20.03) compared to females (13.68).
Conclusion: Healthcare workers in direct contact with patients, such as dental assistants, have a higher risk of contracting the infection, which increases their psychological stress and anxiety.
Key words: Coronavirus disease-2019, dental professionals, anxiety, stress
*Corresponding author: Sunil Babu Kotha, Preventive Dentistry Department, Pediatric Dentistry Division, College of Dentistry, Riyadh Elm University (REU), Riyadh, Saudi Arabia; Department of Pediatric and Preventive Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, India. Email: sunil.babu@riyadh.edu.sa
Submitted: 21 June 2022. Accepted: 16 November 2022. Published: 25 January 2023.
©2023 Kotha SB et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). License (http://creativecommons.org/licenses/by-nc/4.0/)
In December 2019, Wuhan, China, had an outbreak of pneumonia of unknown cause. This led to a grave condition, in not only China but also globally.1 By January 7, 2020, Chinese scientists successfully isolated a novel coronavirus (nCoV) from patients in Wuhan. However, the rapid spread of this deadly virus forced World Health Organization (WHO) to declare COVID-19 or SARS-CoV-2 as a public health emergency of international concern (PHEIC).2 The coronavirus pandemic placed a burden on the healthcare system and affected healthcare services globally. It spread worldwide and created panic among everyone, nationally and internationally, as there was no cure for it during the initial times, and it spread quickly. There is a dire need to comprehend the effect of COVID-19 on various healthcare professionals in different parts of the country.
According to the Occupational Safety and Health Administration (OSHA) guidelines, dentists and dental workers are considered at high risk for the spread of COVID-19.3 The spread of viruses in a dental setting may be due to the distance that bioaerosols travel during dental management. The infectious microorganisms can spread through different courses like direct/indirect contact with salivary and nasopharyngeal drops from the affected patients, contact with debased instruments or dental water supply framework, and cross-pollutions from lifeless surfaces inside the dental settings.4 Health authorities have instructed the dental professionals to provide only emergency dental treatment for patients with suspected/confirmed COVID-19 subjects and to suspend routine procedures to control the spread of the COVID-19 infection. The role of dentists in preventing the spread of COVID-19 is therefore critically important. Dental assistants are focused on ensuring patient security and are also among the experts most in danger of any infectious disease, given the nearby contact with patients.
Dental colleges are important places for dental students, technicians, dental assistants, and faculty members to learn and grow together as a team, to provide the best treatment in routine dental practice to patients. With dental students, professors, and dental assistants, along with the patients, being involved in routine, the chances of being infected with COVID-19 are always present, and this needs further exploration. The COVID-19 pandemic has created chaos among the academia, particularly in healthcare, which has increased the levels of stress and anxiety.5 During this emergency, all the healthcare workers (HCWs), including medical caretakers, doctors, paramedical staff, and nursing and medical students, have been under a high level of stress and anxiety, both psychologically and physically.5,6,7,8
Even though most dental clinical settings were suspended in nations experiencing the COVID-19 pandemic, dental care experts are facing tremendous psychological pressure, knowing the reality of being in a higher-hazard group.9 While there are many studies10,11 in Saudi Arabia regarding stress levels, none concerned dental assistants who are equally exposed to COVID-19 as dentists. This research aims to assess the psychological impact of COVID-19 on dental assistants in Saudi Arabia during this pandemic.
This questionnaire-based cross-sectional study was carried out from March 2022 to June 2022 after getting approval from the Institutional Review Board (IRB) at Riyadh Elm University, Saudi Arabia. The study included dental assistants working in various dental clinics and hospitals in Saudi Arabia. Other dental auxiliaries were excluded from this study. The psychological behavior of the dental assistants was assessed during the COVID-19 pandemic through a pre-validated Depression, Anxiety, Stress Scale with 21 Items (DASS-21) questionnaire.12 This survey consisted of two sections:
The first section included questions related to demographic details including age, gender, nationality, and marital status.
The second section included questions related to depression, anxiety, and stress. Each section consisted of seven items, related to depression, anxiety, and stress. The scoring was calculated on a four-point scale of “did not apply to me at all,” “applied to me to some degree,” “applied to me to a considerable degree,” and “applied to me very much.” The scores were calculated by adding the individual scores for the relevant items and interpreted as normal, mild, moderate, severe, and extremely severe as provided in Table 1.
TABLE 1. Scoring system for DASS-21 scale.
Scoring | Depression | Anxiety | Stress |
---|---|---|---|
Normal | 0–4 | 0–3 | 0–7 |
Mild | 5–6 | 4–5 | 8–9 |
Moderate | 7–10 | 6–7 | 10–12 |
Severe | 11–13 | 8–9 | 13–16 |
Extremely Severe | 14+ | 10+ | 17+ |
Data (emails) from dental assistants were obtained from the dental assistant society. A total of 280 questionnaires were sent to the dental assistants via email using Google Forms. One reminder email was sent after a week to fill out and submit the form. The completed questionnaire was considered as their consent to participate in the study. No information revealed the identity of the study participants.
Data were tabulated in Microsoft Office Excel 2019, and the analysis was performed using Statistical Package for the Social Sciences (SPSS) (IBM, New York City, USA) Version 23.0. Descriptive statistical measures were employed to summarize the data.
The response rate was 75% (210 out of 280). Figure 1 depicts the demographics of the study subjects. Most assistants were 20–40 years old and only 10 were above 50 years of age. Most participants were females (180) and were of non-Saudi origin.
FIG 1. Demographic characteristics of the study sample.
Tables 2, 3, and 4 display the response of the study participants to the questions on the DASS questionnaire. Of the participants, 49.04% did not experience any positive feeling to some degree and 41.42% of the dental assistants found it challenging to work during the pandemic to some degree. Out of 210 participants, 117 did not feel that they did not have anything to look forward to. In the fourth question related to depression, 41.43% of subjects felt downhearted and blue to some degree during the COVID pandemic. Only 10 participants could not become enthusiastic about anything; but this was true for 42.38% of subjects to some degree. Eight subjects chose the “Applied to me very much” option for the question, “During the COVID-19 pandemic period, I felt I was not worth much as a person.” Around 62 people felt that life was meaningless during the COVID-19 pandemic.
TABLE 2. Response of DASS questionnaire (Depression) by the study participants (n = 210).
Question | Options | N | Percentage |
---|---|---|---|
DEPRESSION—SEVEN ITEMS | |||
1. During the COVID-19 pandemic period, I could not seem to experience any positive feeling at all | Applied to me to a considerable degree | 30 | 14.29 |
Applied to me to some degree | 103 | 49.04 | |
Applied to me very much | 13 | 6.19 | |
Did not apply to me at all | 64 | 30.48 | |
2.During the COVID-19 pandemic period, I found it difficult to work up the initiative to do things | Applied to me to a considerable degree | 34 | 16.20 |
Applied to me to some degree | 87 | 41.42 | |
Applied to me very much | 16 | 7.61 | |
Did not apply to me at all | 73 | 34.76 | |
3.During the COVID-19 pandemic period, I felt that I had nothing to look forward to | Applied to me to a considerable degree | 15 | 7.14 |
Applied to me to some degree | 70 | 33.33 | |
Applied to me very much | 8 | 3.81 | |
Did not apply to me at all | 117 | 55.71 | |
4.During the COVID-19 pandemic period, I felt downhearted and blue | Applied to me to a considerable degree | 33 | 15.71 |
Applied to me to some degree | 87 | 41.43 | |
Applied to me very much | 14 | 6.67 | |
Did not apply to me at all | 76 | 36.19 | |
5.During the COVID-19 pandemic period, I was unable to become enthusiastic about anything | Applied to me to a considerable degree | 27 | 12.86 |
Applied to me to some degree | 89 | 42.38 | |
Applied to me very much | 10 | 4.76 | |
Did not apply to me at all | 84 | 40 | |
6.During the COVID-19 pandemic period, I felt I was not worth much as a person | Applied to me to a considerable degree | 13 | 6.19 |
Applied to me to some degree | 42 | 20 | |
Applied to me very much | 8 | 3.81 | |
Did not apply to me at all | 147 | 70 | |
7.During the COVID-19 pandemic period, I felt that life was meaningless | Applied to me to a considerable degree | 12 | 5.71 |
Applied to me to some degree | 41 | 19.52 | |
Applied to me very much | 9 | 4.29 | |
Did not apply to me at all | 148 | 70.48 |
TABLE 3. Response of DASS questionnaire (Anxiety) by the study participants (n = 210).
Question | Options | N | Percentage |
---|---|---|---|
ANXIETY—SEVEN ITEMS | |||
1.During the COVID-19 pandemic period, I was aware of dryness of my mouth | Applied to me to a considerable degree | 25 | 11.91 |
Applied to me to some degree | 66 | 31.42 | |
Applied to me very much | 14 | 6.67 | |
Did not apply to me at all | 105 | 50 | |
2.During the COVID-19 pandemic period, I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion) | Applied to me to a considerable degree | 14 | 6.67 |
Applied to me to some degree | 42 | 20 | |
Applied to me very much | 8 | 3.81 | |
Did not apply to me at all | 146 | 69.52 | |
3.During the COVID-19 pandemic period, I experienced trembling (e.g., in the hands) | Applied to me to a considerable degree | 10 | 4.76 |
Applied to me to some degree | 34 | 16.19 | |
Applied to me very much | 9 | 4.29 | |
Did not apply to me at all | 157 | 74.76 | |
4.During the COVID-19 pandemic period, I was worried about situations in which I might panic and make a fool of myself | Applied to me to a considerable degree | 12 | 5.71 |
Applied to me to some degree | 75 | 35.71 | |
Applied to me very much | 14 | 6.67 | |
Did not apply to me at all | 109 | 51.90 | |
5.During the COVID-19 pandemic period, I felt I was close to panic | Applied to me to a considerable degree | 12 | 5.71 |
Applied to me to some degree | 66 | 31.43 | |
Applied to me very much | 14 | 6.67 | |
Did not apply to me at all | 118 | 56.19 | |
6.During the COVID-19 pandemic period, I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat) | Applied to me to a considerable degree | 15 | 7.14 |
Applied to me to some degree | 51 | 24.28 | |
Applied to me very much | 13 | 6.19 | |
Did not apply to me at all | 131 | 62.38 | |
7.During the COVID-19 pandemic period, I felt scared without any good reason | Applied to me to a considerable degree | 19 | 9.04 |
Applied to me to some degree | 79 | 37.61 | |
Applied to me very much | 13 | 6.19 | |
Did not apply to me at all | 99 | 47.14 |
TABLE 4. Response of DASS questionnaire (Stress) by the study participants (n = 210).
Question | Options | N | Percentage |
---|---|---|---|
STRESS—SEVEN ITEMS | |||
1.During the COVID-19 pandemic period, I found it hard to wind down (relax) | Applied to me to a considerable degree | 19 | 9.05 |
Applied to me to some degree | 81 | 38.57 | |
Applied to me very much | 13 | 6.19 | |
Did not apply to me at all | 97 | 46.19 | |
2.During the COVID-19 pandemic period, I tended to overreact to situations | Applied to me to a considerable degree | 18 | 8.57 |
Applied to me to some degree | 95 | 45.24 | |
Applied to me very much | 12 | 5.71 | |
Did not apply to me at all | 85 | 40.47 | |
3.During the COVID-19 pandemic period, I felt that I was using a lot of nervous energy | Applied to me to a considerable degree | 12 | 5.71 |
Applied to me to some degree | 72 | 34.29 | |
Applied to me very much | 16 | 7.62 | |
Did not apply to me at all | 110 | 52.38 | |
4.During the COVID-19 pandemic period, I found myself getting agitated (upset) | Applied to me to a considerable degree | 30 | 14.29 |
Applied to me to some degree | 89 | 42.38 | |
Applied to me very much | 7 | 3.33 | |
Did not apply to me at all | 84 | 40 | |
5.During the COVID-19 pandemic period, I found it difficult to relax | Applied to me to a considerable degree | 23 | 10.95 |
Applied to me to some degree | 83 | 39.52 | |
Applied to me very much | 9 | 4.28 | |
Did not apply to me at all | 95 | 45.24 | |
6.During the COVID-19 pandemic period, I was intolerant of anything that kept me from getting on with what I was doing | Applied to me to a considerable degree | 21 | 10 |
Applied to me to some degree | 79 | 37.62 | |
Applied to me very much | 7 | 3.33 | |
Did not apply to me at all | 103 | 49.05 | |
7.During the COVID-19 pandemic period, I felt that I was rather touchy (oversensitive) | Applied to me to a considerable degree | 28 | 13.33 |
Applied to me to some degree | 84 | 40 | |
Applied to me very much | 8 | 3.81 | |
Did not apply to me at all | 90 | 42.86 |
Most subjects (69.52%) did not experience breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion) during the COVID-19 pandemic. Only nine (“Applied to me very much” category) subjects experienced trembling in their hands. Less than half of the subjects were worried about situations in which they might panic and make a fool of themselves during the pandemic. Around 111 dental assistants felt scared without any good reason.
Most assistants (113, 53.8%) managed to relax during the COVID-19 pandemic with varying severity. Of the subjects, 45.24% chose (“Applied to me to some degree” category) on questions about overreacting to a situation and 52.38% did not feel nervous during the COVID-19 pandemic. Around 120 subjects felt oversensitive during the pandemic period (Tables 2, 3, and 4).
Depression score was more in the age group of 20–30 years (5.281), which was slightly lower than in the age group of 41–50 (5.29) years and above 50 years (6.00) and more than the age group of 31–40 years. The comparison was statistically nonsignificant. Anxiety score was highest among 20–30 years old (4.978) and minimum in the age group of 41–50 years (2.83) and the difference was not statistically significant. Similarly, the stress scores among the different age groups were not statistically significant (p = 0.731). The details are summarized in Table 5.
TABLE 5. Comparison of DASS scores based on age groups.
N | Mean | SD | Standard Error | 95% Confidence Interval for Mean | Minimum | Maximum | p | |||
---|---|---|---|---|---|---|---|---|---|---|
Lower Bound | Upper Bound | |||||||||
Depression | 20–30 | 89 | 5.281 | 4.5352 | 0.4807 | 4.326 | 6.236 | 0 | 18.0 | 0.845 |
31–40 | 87 | 4.874 | 4.5233 | 0.4850 | 3.910 | 5.838 | 0 | 21.0 | ||
41–50 | 24 | 5.292 | 3.1962 | 0.6524 | 3.942 | 6.641 | 0 | 13.0 | ||
Above 50 | 10 | 6.000 | 4.5216 | 1.4298 | 2.765 | 9.235 | 0 | 15.0 | ||
Total | 210 | 5.148 | 4.3772 | 0.3021 | 4.552 | 5.743 | 0 | 21.0 | ||
Anxiety | 20–30 | 89 | 4.978 | 5.0811 | 0.5386 | 3.907 | 6.048 | 0 | 21.0 | 0.150 |
31–40 | 87 | 3.793 | 4.4958 | 0.4820 | 2.835 | 4.751 | 0 | 21.0 | ||
41–50 | 24 | 2.833 | 3.5098 | 0.7164 | 1.351 | 4.315 | 0 | 16.0 | ||
Above 50 | 10 | 4.100 | 2.2336 | 0.7063 | 2.502 | 5.698 | 0 | 7.0 | ||
Total | 210 | 4.200 | 4.6151 | 0.3185 | 3.572 | 4.828 | 0 | 21.0 | ||
Stress | 20–30 | 89 | 5.494 | 4.8760 | 0.5169 | 4.467 | 6.522 | 0 | 19.0 | 0.731 |
31–40 | 87 | 5.195 | 5.0528 | 0.5417 | 4.118 | 6.272 | 0 | 21.0 | ||
41–50 | 24 | 4.292 | 3.3164 | 0.6769 | 2.891 | 5.692 | 0 | 14.0 | ||
Above 50 | 10 | 5.700 | 4.3982 | 1.3908 | 2.554 | 8.846 | 0 | 16.0 | ||
Total | 210 | 5.243 | 4.7646 | 0.3288 | 4.595 | 5.891 | 0 | 21.0 | ||
Total score | 20–30 | 89 | 15.75 | 13.285 | 1.408 | 12.95 | 18.55 | 0 | 56 | 0.613 |
31–40 | 87 | 13.86 | 13.301 | 1.426 | 11.03 | 16.70 | 0 | 63 | ||
41–50 | 24 | 12.42 | 8.787 | 1.794 | 8.71 | 16.13 | 1 | 43 | ||
Above 50 | 10 | 15.80 | 10.401 | 3.289 | 8.36 | 23.24 | 0 | 38 | ||
Total | 210 | 14.59 | 12.715 | 0.877 | 12.86 | 16.32 | 0 | 63 |
SD, standard deviation.
The results were statistically significant (p = 0.001) in the comparison of the DASS scores between males and females. The mean total DASS score was higher in males (20.03) compared to females (13.68) as summarized in Table 6.
The scores for depression (5.966), anxiety (5.494), and stress (6.034) were more in Saudi-origin dental assistants when compared to non-Saudi subjects and the results were also statistically significant as mentioned in Table 7.
TABLE 6. Comparison of DASS scores based on gender.
Sex | N | Mean | SD | Standard Error Mean | p | |
---|---|---|---|---|---|---|
Depression | Male | 30 | 5.933 | 5.6198 | 1.0260 | 0.019* |
Female | 180 | 5.017 | 4.1393 | 0.3085 | ||
Anxiety | Male | 30 | 6.833 | 6.5447 | 1.1949 | 0.001* |
Female | 180 | 3.761 | 4.0711 | 0.3034 | ||
Stress | Male | 30 | 7.267 | 6.0226 | 1.0996 | 0.011* |
Female | 180 | 4.906 | 4.4530 | 0.3319 | ||
Total score | Male | 30 | 20.03 | 17.139 | 3.129 | 0.001* |
Female | 180 | 13.68 | 11.635 | 0.867 |
*Denotes significant values. SD, standard deviation.
TABLE 7. Comparison of DASS scores based on nationality.
Nationality | N | Mean | SD | Standard Error Mean | p | |
---|---|---|---|---|---|---|
Depression | Saudi | 89 | 5.966 | 4.9416 | 0.5238 | 0.004* |
Non-Saudi | 121 | 4.545 | 3.8210 | 0.3474 | ||
Anxiety | Saudi | 89 | 5.494 | 5.4212 | 0.5746 | 0.000* |
Non-Saudi | 121 | 3.248 | 3.6590 | 0.3326 | ||
Stress | Saudi | 89 | 6.034 | 5.3692 | 0.5691 | 0.016* |
Non-Saudi | 121 | 4.661 | 4.1943 | 0.3813 | ||
Total score | Saudi | 89 | 17.49 | 14.595 | 1.547 | 0.001* |
Non-Saudi | 121 | 12.45 | 10.701 | 0.973 |
*Denotes significant values. SD, standard deviation.
As shown in Table 8, there was no statistical difference in total and individual DASS scores between married and unmarried dental assistants.
TABLE 8. Comparison of DASS scores based on marital status.
Marital Status | N | Mean | SD | Standard Error Mean | p | |
---|---|---|---|---|---|---|
Depression | Married | 82 | 5.183 | 4.5600 | 0.5036 | 0.534 |
Not married | 128 | 5.125 | 4.2741 | 0.3778 | ||
Anxiety | Married | 82 | 3.927 | 4.7682 | 0.5266 | 0.738 |
Not married | 128 | 4.375 | 4.5246 | 0.3999 | ||
Stress | Married | 82 | 5.537 | 5.1333 | 0.5669 | 0.652 |
Not married | 128 | 5.055 | 4.5234 | 0.3998 | ||
Total score | Married | 82 | 14.65 | 13.539 | 1.495 | 0.926 |
Not married | 128 | 14.55 | 12.212 | 1.079 |
SD, standard deviation.
Dentistry involves close contact with patients, which can lead to the transmission of the coronavirus to the dentist and the other dental staff. The people infected with the coronavirus may not show symptoms during the initial stages of infection, making them a possible source of virus transmission to the dental HCWs (dentists and assistants) while seeking treatment. As a result, dentists and their assistants are at risk of contamination while carrying out routine dental procedures.13 The current guidelines on the COVID-19 outbreak recommend delaying all nonemergency dental treatment, and only patients with acute pain, swelling, or trauma are advised to visit a dentist.14 The COVID-19 pandemic has caused a lot of psychological pressure on HCWs, which has affected the health of HCWs, such as doctors, nurses, and dentists. This study focused on the psychological impact of COVID-19 on dental assistants in Saudi Arabia.
The concern raised here is about the dental assistants because of their crucial position in the smooth running of the dental clinic. They communicate with potentially infected patients and encounter patients’ noncompliance with hygiene instructions in the waiting area. Another factor contributing to stress is inadequate staffing during the COVID-19 pandemic.15,16 The DASS-21 questionnaire, a shorter version of the elaborated DASS-41, is often used in research17,18 related to mental health and practices. With the overall and individual subscales of Cronbach’s alpha (0.96) showing exceptional internal consistency for the DASS-21 instrument, this questionnaire was used in this study.19
A total of 210 dental assistants participated and completed the online DASS questionnaire, displaying a substantial study sample size. The socio--demographic data represent more female dental assistants participating in the survey than males, similar to the other study from Saudi by Ali et al.20 Most participants were in the age group of 20–40 years, similar to the discussed regular age and corresponding employment features in various studies in Germany and Saudi Arabia.20,21
The depression, anxiety, and stress scores were higher in males than females, with statistically significant differences. This could be due to fear in male participants of this survey and the low numbers of males employed in this profession. Similar results were obtained in previous studies where female participants did not show higher psychological stress scores than male colleagues.22,23,24 Marital status did not significantly affect the DASS scores. Parents and family members provide moral support for various problems, which boosts a person positively and gives strength to overcome mental distress.25,26 However, in other studies, subjects with no relationships displayed more sound mental health than the married participants, especially those with poor relationship quality.27
Depressive conditions, anxiety, and stress at the workplace are the most prominent reasons for mental problems worldwide. Previous literature showed that dentists and other HCWs face occupational stressors, such as the risk of infection, continuous pressure, anxiety about their capability to deliver satisfactory health services in the future, and financial burdens.28,29,30 These factors have aggravated anxiety among dental professionals all over the country during the COVID-19 pandemic. Pandemics bring about psychological consequences, such as fear and anxiety, mainly when the number of infected people and the mortality ratio are high.31 According to a study, around one-third of dental assistants preferred emergency dental treatment alone and reported significantly more anxiety regarding COVID-19 infection transmission than other groups (p < 0.05).32 Most dental practitioners feared contracting COVID infection from a patient, which was significantly related to high levels of psychological distress.33,34 Nurses (closest similarity to dental assistants) have reported increased pain levels than other frontline HCWs,35,36,37,38,39 while some studies reported no difference in the stress levels.39,40
Only one study highlighted a higher rate of stress in doctors.41 Dental health professionals are a significant part of the healthcare system.42 The adverse effect of COVID-19 on their mental health (psychological impact) must not be ignored, and preventive measures must be considered. Training and education regarding COVID-19 guidelines for controlling the transmission of the infection, followed by the execution of these measures for a safe working setting, will create room for the optimistic psychological minds of dental professionals treating patients during emergency times.
First, this is a cross-sectional study so no -follow-up could be performed. Further, the voluntary option to be part of this study must have led to a selection bias.
Frontline HCWs in direct contact with COVID-19 patients had higher distress symptoms. There was a significant difference in DASS scores in both gender and the origin of dental assistants. It is essential for the governments to be concerned about the mental health of the HCWs to avoid adverse psychological impacts on their health. The guidelines and restrictions measures implemented by different countries might also affect the practice and mental health of HCWs.
1. Yang, Y. et al. (2020) ‘Exuberant elevation of IP-10, MCP-3 and IL-1ra during SARS-CoV-2 infection is associated with disease severity and fatal outcome’, medRxiv, 2019 (December 2019), 2020.03.02.20029975. 10.1101/2020.03.02.20029975
2. Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727–733. 10.1056/NEJMoa2001017
3. Mixon B, Nain J. Complying with Occupational Safety and Health Administration regulations: a guide for compounding pharmacists. Int J Pharm Compd. 2013;17(3):182–190. PMid: 24046933.
4. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):9. Published 2020 Mar 3. 10.1038/s41368-020-0075-9
5. Ali S, Tauqir S, Farooqi FA, et al. Psychological Impact of the COVID-19 Pandemic on Students, Assistants, and Faculty of a Dental Institute of Saudi Arabia. Int J Environ Res Public Health. 2021;18(24):13366. Published 2021 Dec 19. 10.3390/ijerph182413366
6. Li JM, Wu R, Zhang T, et al. Psychological responses of medical staff during COVID-19 and the adjustment effect of brief mindfulness meditation. Complement Ther Clin Pract. 2022;48:101600. 10.1016/j.ctcp.2022.101600
7. Verma S, Mythily S, Chan YH, Deslypere JP, Teo EK, Chong SA. Post-SARS psychological morbidity and stigma among general practitioners and traditional Chinese medicine practitioners in Singapore. Ann Acad Med Singap. 2004;33(6): 743–748. PMid: 15608831
8. Kang L, Li Y, Hu S, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7(3):e14. 10.1016/S2215-0366(20)30047-X
9. Ahmed MA, Jouhar R, Ahmed N, et al. Fear and Practice Modifications among Dentists to Combat Novel Coronavirus Disease (COVID-19) Outbreak. Int J Environ Res Public Health. 2020;17(8):2821. Published 2020 Apr 19. 10.3390/ijerph17082821
10. Al-Rabiaah A, Temsah MH, Al-Eyadhy AA, et al. Middle East Respiratory Syndrome-Corona Virus (MERS-CoV) associated stress among medical students at a university teaching hospital in Saudi Arabia. J Infect Public Health. 2020;13(5):687–691. 10.1016/j.jiph.2020.01.005
11. Khanagar SB, Alfadley A. Psychological Impact of the COVID-19 Pandemic on Dental Interns in Riyadh, Saudi Arabia: A Cross-sectional Survey. Int J Clin Pediatr Dent. 2020;13(5):508–512. 10.5005/jp-journals-10005-1773
12. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995 Mar;33(3):335–343. 10.1016/0005-7967(94)00075-u
13. Olivieri JG, de España C, Encinas M, et al. General Anxiety in Dental Staff and Hemodynamic Changes over Endodontists’ Workday during the Coronavirus Disease 2019 Pandemic: A Prospective Longitudinal Study. J Endod. 2021;47(2):196–203. 10.1016/j.joen.2020.10.023
14. Mallineni SK, Nuvvula S, Bhumireddy JC, Ismail AF, Verma P, Sajja R, Alassaf A, Almulhim B, Alghamdi S, Saha A, Goyal V, Namineni S. Knowledge and Perceptions Regarding Coronavirus (COVID-19) among Pediatric Dentists during Lockdown Period. Int J Environ Res Public Health. 2021 Dec 25;19(1):209. 10.3390/ijerph19010209.
15. Maunder RG, Lancee WJ, Balderson KE, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006;12(12):1924–1932. 10.3201/eid1212.060584
16. Schlenz MA, Schmidt A, Wöstmann B, et al. Perspectives from Dentists, Dental Assistants, Students, and Patients on Dental Care Adapted to the COVID-19 Pandemic: A Cross-Sectional Survey. Int J Environ Res Public Health. 2021; 18(8):3940. Published 2021 Apr 9. 10.3390/ijerph18083940
17. Schlenz MA, Schmidt A, Wöstmann B, et al. Perspectives from Dentists, Dental Assistants, Students, and Patients on Dental Care Adapted to the COVID-19 Pandemic: A Cross-Sectional Survey. Int J Environ Res Public Health. 2021; 18(8):3940. Published 2021 Apr 9. 10.3390/ijerph18083940
18. Wong PTP, Mayer CH, Arslan G. Editorial: COVID-19 and Existential Positive Psychology (PP2.0): The New Science of Self-Transcendence. Front Psychol. 2021;12:800308. Published 2021 Dec 8. 10.3389/fpsyg.2021.800308
19. Thiyagarajan A, James TG, Marzo RR. Psychometric properties of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Malaysians during COVID-19: a methodological study. Humanit Soc Sci Commun. 2022;9(1):220. 10.1057/s41599-022-01229-x
20. Ali S, Tauqir S, Farooqi FA, et al. Psychological Impact of the COVID-19 Pandemic on Students, Assistants, and Faculty of a Dental Institute of Saudi Arabia. Int J Environ Res Public Health. 2021;18(24):13366. Published 2021 Dec 19. 10.3390/ijerph182413366
21. Mekhemar M, Attia S, Dörfer C, Conrad J. Dental Nurses’ Mental Health in Germany: A Nationwide Survey during the COVID-19 Pandemic. Int J Environ Res Public Health. 2021;18(15):8108. Published 2021 Jul 30. 10.3390/ijerph18158108
22. Conrad J, Retelsdorf J, Attia S, Dörfer C, Mekhemar M. German Dentists’ Preferences for the Treatment of Apical Periodontitis: A Cross-Sectional Survey. Int J Environ Res Public Health. 2020;17(20):7447. Published 2020 Oct 13. 10.3390/ijerph17207447
23. Elbay RY, Kurtulmuş A, Arpacıoğlu S, Karadere E. Depression, anxiety, stress levels of physicians and associated factors in Covid-19-pandemics. Psychiatry Res. 2020;290:113130. 10.1016/j.psychres.2020.113130
24. De Stefani A, Bruno G, Mutinelli S, Gracco A. COVID-19 Outbreak Perception in Italian Dentists. Int J Environ Res Public Health. 2020;17(11):3867. Published 2020 May 29. 10.3390/ijerph17113867
25. Thomas PA, Liu H, Umberson D. Family Relationships and Well-Being. Innov Aging. 2017; 1(3):igx025. 10.1093/geroni/igx025
26. Kowal M, Coll-Martín T, Ikizer G, et al. Who is the Most Stressed During the COVID-19 Pandemic? Data From 26 Countries and Areas. Appl Psychol Health Well Being. 2020;12(4):946–966. 10.1111/aphw.12234
27. Pieh C, O Rourke T, Budimir S, Probst T. Relationship quality and mental health during COVID-19 lockdown [published correction appears in PLoS One. 2021 Sep 1;16(9):e0257118]. PLoS One. 2020;15(9):e0238906. Published 2020 Sep 11. 10.1371/journal.pone.0238906
28. Shaikh SA, Aldhuwayhi S, Mallineni SK, Kumari VV, Thakare AA, Mustafa MZ. Stress perception among dental practitioners in Saudi Arabia during the COVID-19 pandemic: a cross-sectional survey. Signa Vitae. 2022. 10.22514/sv.2022.042
29. Aldhuwayhi S, Shaikh SA, Mallineni SK, et al. Occupational Stress and Stress Busters Used Among Saudi Dental Practitioners During the COVID-19 Pandemic Outbreak. Disaster Med Public Health Prep. 2022;16(5):1975–1981. 10.1017/dmp.2021.215
30. Ammar N, Aly NM, Folayan MO, et al. Behavior change due to COVID-19 among dental academics--The theory of planned behavior: Stresses, worries, training, and pandemic severity. PLoS One. 2020;15(9):e0239961. Published 2020 Sep 29. 10.1371/journal.pone.0239961
31. Golchha V, Sharma P, Gupta B D, Yadav N. Impact of Covid 19 Pandemic on Dentists: Psychological Evaluation using DASS 21. Indian Journal of Forensic Medicine & Toxicology, April–June 2021, 15(2). 10.37506/ijfmt.v15i2.14493
32. Schlenz MA, Schmidt A, Wöstmann B, et al. Perspectives from Dentists, Dental Assistants, Students, and Patients on Dental Care Adapted to the COVID-19 Pandemic: A Cross-Sectional Survey. Int J Environ Res Public Health. 2021; 18(8):3940. Published 2021 Apr 9. 10.3390/ijerph18083940
33. Consolo U, Bellini P, Bencivenni D, Iani C, Checchi V. Epidemiological Aspects and Psychological Reactions to COVID-19 of Dental Practitioners in the Northern Italy Districts of Modena and Reggio Emilia. Int J Environ Res Public Health. 2020;17(10):3459. Published 2020 May 15. 10.3390/ijerph17103459
34. Shacham M, Hamama-Raz Y, Kolerman R, Mijiritsky O, Ben-Ezra M, Mijiritsky E. COVID-19 Factors and Psychological Factors Associated with Elevated Psychological Distress among Dentists and Dental Hygienists in Israel. Int J Environ Res Public Health. 2020;17(8):2900. Published 2020 Apr 22. 10.3390/ijerph17082900
35. Shacham M, Hamama-Raz Y, Kolerman R, Mijiritsky O, Ben-Ezra M, Mijiritsky E. COVID-19 Factors and Psychological Factors Associated with Elevated Psychological Distress among Dentists and Dental Hygienists in Israel. Int J Environ Res Public Health. 2020;17(8):2900. Published 2020 Apr 22. 10.3390/ijerph17082900
36. Sanghera J, Pattani N, Hashmi Y, et al. The impact of SARS-CoV-2 on the mental health of healthcare workers in a hospital setting-A Systematic Review. J Occup Health. 2020;62(1):e12175. 10.1002/1348-9585.12175
37. Wang Y, Ma S, Yang C, et al. Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross--sectional study. Transl Psychiatry. 2020;10(1):348. Published 2020 Oct 13. 10.1038/s41398-020-01031-w
38. Lasalvia A, Bonetto C, Porru S, et al. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci. 2020;30:e1. Published 2020 Dec 17. 10.1017/S2045796020001158
39. Allan SM, Bealey R, Birch J, et al. The prevalence of common and stress-related mental health disorders in healthcare workers based in pandemic-affected hospitals: a rapid systematic review and meta-analysis. Eur J Psychotraumatol. 2020;11(1):1810903. Published 2020 Oct 16. 10.1080/20008198.2020.1810903
40. Xing J, Sun N, Xu J, Geng S, Li Y. Study of the mental health status of medical personnel dealing with new coronavirus pneumonia. PLoS One. 2020;15(5):e0233145. Published 2020 May 19. 10.1371/journal.pone.0233145
41. Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond). 2004;54(3):190–196. 10.1093/occmed/kqh027
42. Mallineni SK, Nuvvula S, Ismail AF, Aldhuwayhi S, Shaikh SA, Deeban Y, Kumar V, Almaz ME. Influence of information source regarding COVID-19 knowledge among the undergraduate dental students during the early lockdown: a multi-national study. Eur Rev Med Pharmacol Sci. 2022;26(23):9030–9039. 10.26355/eurrev_202212_30578