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Knowledge, stress levels, and clinical practice modifications of Turkish dentists due to COVID-19: a survey study

Abstract:

Dentists are exposed to the highest risk of occupational respiratory and droplet infections by working face-to-face with patients. The aim of this study was to investigate the knowledge of symptoms and modes of transmission of COVID-19, stress levels and clinical practice modifications of Turkish dentists during the COVID-19 pandemic. An online survey (15 questions) was sent to Turkish dentists from May 5 to 12 May, 2020. The survey comprised questions about dentists’ demographic characteristics, their knowledge about COVID-19, stress levels and the measures taken in dental clinics against COVID-19. This study included a total of 1,095 Turkish dentists. The data were expressed as frequency with percentage values for overall variables. Dentists were most familiar with high fever among the symptoms of COVID-19 (99.4%) and 99.2% of them reported that COVID-19 was transmitted with eye, mouth and nasal mucosa contact on surfaces contaminated with the droplets of infected persons. While the stress levels of females were higher than males, the stress levels of dentists with more than 20 years of professional experience were found to be lower. Regarding the precautions to be taken as a preventive measure when working again, 86.6% of the dentists took precautions by increasing daily patient care intervals and only 38.4% of the dentists wore an N95 mask. During this pandemic, knowing the conditions about when the treatments can be applied and the precautions to be taken will shed light on dentistry staff. Current recommendations of national authorities about the coronavirus should be followed.

Keywords:
COVID-19; Coronavirus; Dentistry; Dentists

Introduction

An epidemic viral pneumonia of unknown etiology emerged in Wuhan, China by the end of 2019. The pathogen causing the condition was called as the 2019 novel coronavirus (2019-nCoV), and the disease caused by this pathogen the 2019 coronavirus infectious disease (COVID-19). The human-to-human transmission rate of this virus increased significantly since mid-January 2020 and the disease spread rapidly throughout the world.11. World Health Organization – WHO. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance. 2020 Mar 20 [cited 2020 May 20]. Available from: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
https://www.who.int/publications-detail/...

On March 10, 2020, one day after the first coronavirus case was reported in Turkey, a global epidemic (pandemic) was declared by the World Health Organization (WHO) in the presence of 118,319 diagnosed cases and 4,292 deaths. In Turkey, all schools, including universities, were closed by March 13. All meetings, social gatherings, and indoor and outdoor public activities were restricted. Home isolation for individuals over the age of 65 and under 20 was enforced. All elective surgeries, including minimally invasive procedures, were postponed (excluding emergency cases). As of May 26, of this year, 157,814 coronavirus cases have been reported, with 4,369 deaths and 121,507 recoveries in Turkey.22. World Health Organization – WHO. Coronavirus disease (COVID-19): situation report-127. 2020 [cited 2020 May 20]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200526-covid-19-sitrep-127.pdf?sfvrsn=7b6655ab_8
https://www.who.int/docs/default-source/...

When a patient coughs, sneezes, talks or breathes, pathogen-laden droplets are released.33. Wang J, Chow TT. Numerical investigation of influence of human walking on dispersion and deposition of expiratory droplets in airborne infection isolation room. Build Environ. 2011;46(10):1993-2002. https://doi.org/10.1016/j.buildenv.2011.04.008
https://doi.org/10.1016/j.buildenv.2011....
It is widely known that the novel coronavirus can be transmitted mainly through direct contact and droplets.4 5 COVID-19 is also likely to spread through high concentrations of aerosols in a relatively closed environment. The use of high-speed dental equipments such as drills and aerators are currently considered to be aerosol generating procedures. This aerosol is potentially able to carry the virus causing COVID -19.66. Liyanage S, Ramasamy P, Elhaddad O, Darcy K, Hudson A, Keller J. Assessing visible aerosol generation during vitrectomy in the era of Covid-19. Eye (Lond). 2020 Jun; https://doi.org/10.1038/s41433-020-1052-4 Epub ahead of print.
https://doi.org/10.1038/s41433-020-1052-...
The dentist, staff, and patients are under a potential threat during routine dental treatments due to the aerosols formed.44. Ge ZY, Yang LM, Xia JJ, Fu XH, Zhang YZ. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci B. 2020 May;21(5):361-8. https://doi.org/10.1631/jzus.B2010010
https://doi.org/10.1631/jzus.B2010010...
Dentists are at risk of contracting COVID-19 due to one-on-one communication with patients (entailing exposure to saliva, blood, and other body fluids) and the use of sharp instruments. In fact, it is has been reported that dentists are more likely to be infected by the novel coronavirus disease than doctors and nurses.77. Gamio L. The workers who face the greatest Coronavirus risk. New York Times, 2020 Mar 15 [cited 2020 May 20]. Available from: https://www.nytimes.com/interactive/2020/03/15/business/economy/coronavirus-worker-risk.html
https://www.nytimes.com/interactive/2020...
Dentists can also be carriers of the disease. Although there has not yet been a report of the disease being transmitted from a dental treatment environment, given its high contagiousness, dental care teams should be cautious and provide a safe environment for both patients and themselves. In this critical process, understanding aerosol propagation and its importance in dentistry raises the necessity to apply some special measures in addition to those that are already standard. Due to aerosol production and exposure to saliva and blood, dental clinicians are at high risk of transmission during their routine dental treatments.88. 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 May;17(10):E3459. https://doi.org/10.3390/ijerph17103459
https://doi.org/10.3390/ijerph17103459...
Therefore, this situation can create anxiety and stress on dentists.

Traumatic events can decrease people’s feeling of security, remind them of the reality of death and have adverse effects on their mental health. Many factors including can adversely affect stress levels and mental health of the people, some of them are: questions with no definite answers such as the end date of the epidemic and the appropriate methods of treatment, constant exposure to a flow of information about the epidemic and its effects, decreased social relationships and recommendations/prohibitions such as staying at home as much as possible. COVID-19 pandemic has led an increase in the frequency of symptoms such as anxiety, depression, fear, stress, and sleep problems.99. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health [published Online First: 2020/04/03]. Int J Soc Psychiatry. 2020 Jun;66(4):317-20. https://doi.org/10.1177/0020764020915212
https://doi.org/10.1177/0020764020915212...
Family income stability and living with parents were found to be shielding from anxiety symptoms.1010. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res. 2020 May;287:112934. https://doi.org/10.1016/j.psychres.2020.112934
https://doi.org/10.1016/j.psychres.2020....
Variables such as occupation, education, and gender affected the symptoms of anxiety and depression tend to be developed during the epidemic in different ways.1111. 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. Psychol Health Med. 2021 Jan;26(1):13-22. https://doi.org/10.1080/13548506.2020.1746817
https://doi.org/10.1080/13548506.2020.17...

To the best knowledge, psychological stress due to COVID-19 has not been assessed among Turkish dentists although it has done in other countries.88. 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 May;17(10):E3459. https://doi.org/10.3390/ijerph17103459
https://doi.org/10.3390/ijerph17103459...
,1212. 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 Apr;17(8):E2821. https://doi.org/10.3390/ijerph17082821
https://doi.org/10.3390/ijerph17082821...
The present study aimed to assess the anxiety and stress levels surrounding the threat of infection among dentists working during the current viral outbreak. In addition, dentists’ knowledge about various practice modifications to combat the novel coronavirus disease (COVID-19) has been evaluated.

Methodology

All procedures conducted were approved by the Ethical Committee of Bezmialem Vakif University (06/107,05.05.2020).

Our study population consisted of dentists working in Turkey. At the time of the survey, dentists were not actively taking care of patients. Informed consent was obtained electronically before data were collected from the participants.

At the present time, most countries around the world are in lockdown conditions; therefore, it was not feasible to conduct physical interviews during this critical period. Instead, we decided to use an online platform to collect the necessary data. A new survey about COVID-19 was formed for our study. First, we carried out a PubMed search in English and Turkish for COVID-19-related content and guidelines by using the keywords “COVID-19,” “coronavirus”, “dentistry,” “dental treatment,” and “stress level” with and without Boolean operators. Survey questions were formed after reviewing the pertinent literature and the international guidelines.1313. Centers for Disease Control and Prevention – CDC. Developing guidance regarding responding to COVID-19 in dental settings. Centers for Disease Control and Prevention; 2020.,1414. World Health Organization – WHO. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance. Geneva: World Health Organization; 2020.,1515. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
https://doi.org/10.1177/0022034520914246...

The questionnaire was designed in Turkish. Following Zhong et al.,1616. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020 Mar;16(10):1745-52. https://doi.org/10.7150/ijbs.45221
https://doi.org/10.7150/ijbs.45221...
who studied the knowledge, attitudes, and practices of COVID-19 infected areas in China, and Ahmed et al.,1212. 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 Apr;17(8):E2821. https://doi.org/10.3390/ijerph17082821
https://doi.org/10.3390/ijerph17082821...
who investigated the presence of fear and practice modifications among dentists, we prepared a structured questionnaire with a combination of 20 multiple choice, open-ended, and Likert-type questions. The content adequacy of the survey was examined by experts to assess the clarity the wording of the items prior to the main study. The questions were sent to five experts (two restorative dentists, one endodontist, one general dentist, and one biostatistician). Based on their comments, five questions were removed. Then, the final 15 questions were tested in a pilot study with 10 participants. Based on the feedback from the pilot study, we finalized the questionnaire with 15 questions. The final questionnaire was sent to a Turkish language expert for validation and it was concluded at this stage. The questionnaire had four parts: a) dentist’s demographic and professional characteristics (five questions); b) knowledge of COVID-19 and dentist’s awareness of the incubation period, the symptoms of the disease, the mode of transmission, and preventive infection control measures (four questions); c) stress level (four questions); and d) adjustments in the clinical practice and attitude in the treatment of patients after the COVID-19 pandemic (two questions).

This self-reportable, online questionnaire form was designed using Google Forms (Alphabet Co., Mountain View, USA), and the link was shared among all Turkish dentists through several dentist-specific closed social media forums, email, WhatsApp, Facebook, Instagram, etc. We received responses through online survey submission. Anonymity was ensured, and no personal identification, such as IP address, email address, or user ID, were collected. A total of 1,095 Turkish dentists, all volunteers, answered the questionnaire. Participation was voluntary, and participants could withdraw from survey at any time. All participants provided informed consent prior to completing the survey. The form was posted on May 5, 2020 at 22:00, and the survey was closed on May 12, 2020 at 22:00.

We also included a section for rating the average perceived stress level experienced by dentists during the pandemic in Turkey. A 10-point Likert scale with four questions, where 0 referred to “not at all stressful,” 5 referred to “moderately stressful,” and 10 referred to “extremely stressful”,1717. Korre M, Farioli A, Varvarigou V, Sato S, Kales SN. A survey of stress levels and time spent across law enforcement duties: police chief and officer agreement. Policing. 2014 May;8(2):109-22. https://doi.org/10.1093/police/pau001
https://doi.org/10.1093/police/pau001...
was developed to evaluate the stress levels induced by the COVID-19 outbreak; this section asked questions about the suggested sources of stress emotions (e.g., “I am worried about getting infected”). A psychometric analysis for the scale was finally conducted. Factor analysis was applied to determine the sub-dimensions of the “stress scale” within the scope of the Validity-Reliability. Cronbach’s Alpha coefficients were calculated within the scope of reliability analysis of the scale questions. The statistical significance level (α) was taken as 5% in calculations. Cronbach’s Alpha value for “stress scale questions” was found to be 0.782 (78.2%). Accordingly, the Cronbach’s Alpha value of these scale questions exceeding 75% indicates that the reliability of these questions (items) is high.

The sample size required for the study was calculated by a statician. The power analysis estimated that survey with 380 or more individuals were needed to have a 95% confidence interval, a population size of 30,128 dentists, with the real value within ± 5% of the surveyed value. However, 1,095 dentists who answered the web-based survey completely during the survey application period were included to increase the reliability of the findings. Based on the stratified random sampling method, the minimum number required was determined by considering the targeted sample size.

Data were analyzed using IBM SPSS Statistics for Windows, version 22.0. To handle missing data, direct deletion method was used and all surveys with invalid data were discarded from further analysis and statistical analysis were conducted based on a complete dataset. While evaluating the study data, the appropriateness of the parameters to normal distribution was evaluated with the Shapiro–Wilk test. Frequencies and percentages were used to describe the categorical data. Mann Whitney test was used to compare stress items between gender and institution groups. A Kruskal Wallis test was used to test differences of stress ratings between professional experience groups. Dunn’s test was used as post hoc procedure after a significant effect. Significance was evaluated at the level of p < 0.05.

Results

Frequency distribution of the 1,095 dentists’ demographic characteristics were presented in Table 1.

Table 1
Frequency distribution of dentists’ demographic characteristics.

When evaluating the knowledge of the dentists about COVID-19 symptoms, it was seen that high fever is known with the highest rate (99.4%) among all other symptoms. Regarding the mode of transmission of COVID-19, 99.2% (1,086) of the dentists thought that the disease was transmitted through eye, mouth, and nasal mucosa contact with contaminated surfaces. Of the participants, 100% (1095) thought that they could prevent infection by washing their hands with soap and water for at least 20 seconds. While 4.4% (48) of the dentists thought that a COVID-19 positive patient could be treated when the Reverse Transcription- Polymerase Chain Reaction (RT-PCR) test result was negative, 63.1% (691) thought treatment could be done 14 days after the RT-PCR test result was negative (Table 2).

Table 2
Dentists’ awareness about symptoms, mode of transmission, measures for prevention and dental treatment time of the COVID-19 (+) patient.

The levels of stress about being infected ranged from 1 to 10 and the scores given by the participants were shown in Figure 1. The results showed that the dentists had the “extremely stress” from infecting their families (28.4%, 311) and they had concerns regarding current or future financial and organizational difficulties (27.3%, 299). The results of the comparative evaluation of the responses to the stress scale items according to gender, professional experience and the type of institution were shown in Figures2, 3 and 4. The level of stress related to family and patient safeties of dentists with 0–10 years and 11-20 years of professional experience were found to be statistically similar (p > 0.05), while the level of stress was found to decrease statistically in dentists with more than 20 years of professional experience (p < 0.05) (Figure 3). Post-hoc analyses showed that increases in stress regarding professional practice were significantly associated with the type of institution (p < 0.001) (Figure 4). Although the level of stress was higher among females than males (Figure 2), there was no statistical difference between females and males regarding their professional practice (concerns regarding current or future financial) (p = 0.074).

Figure 1
Distribution of perceived stress levels of dentists during the COVID-19 pandemic.
Figure 2
Box-plot representing the statistical relation of gender and stress scale responses. [Data represented as median (horizontal bars inside the box) and range (Y-error bars). *** = represents significant difference (p < 0.001). NS= Non-significant (p > 0.05).
Figure 3
Box-plot representing the statistical relation of professional experience and stress scale responses. [Data represented as median (horizontal bars inside the box) and range (Y-error bars). * = represents significant difference (p < 0.05). NS = Non-significant (p > 0.05).
Figure 4
Box-plot representing the statistical relation of type of institution and stress scale responses. [Data represented as median (horizontal bars inside the box) and range (Y-error bars). *** = represents significant difference (p < 0.001). NS = Non-significant (p > 0.05).

Regarding the precautions to be taken as a preventive measure in the clinic when working again, 86.6% (948) of the dentists took precautions by increasing daily patient care intervals, 73.1% (800) reported that they would measure the fever of each patient coming into the clinic, 49.2% (539) would sterilize the clinical environment with UV systems, and 55.9% (612) would use aerosol absorber machine. It was revealed that 90.9% (995) would wear special protective masks, 88% (964) would wear protective goggles, and 60.6% (664) would wear overalls, while 1.6% (18) were not considering taking extra measures (Table 3).

Table 3
Personal protective equipment used by dentists and additional precautions to take as preventive measures against infection in clinics.

Discussion

The study aimed to provide an insight into the changes in Turkish dentists’ clinics in the preparation period of returning to routine dental treatment practices after the peak of the COVID-19 epidemic in Turkey in May 2020. The first official COVID-19 case in Turkey was detected on March 10, 2020. The number of cases increased day by day and peaked in May. This study was carried out using a web-based survey made available between May 5 and 12, 2020.

Dentists have been shown to have a high risk of becoming infected with COVID-19 due to the aerosol spread when performing especially prosthetic, restorative, and endodontic treatments in their working conditions.1515. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
https://doi.org/10.1177/0022034520914246...
The identification of such symptoms can help dentists to recognize the threat as early as possible and take the necessary precautions, which is a critical step in the management1818. Gaffar BO, El Tantawi M, Al-Ansari AA, AlAgl AS, Farooqi FA, Almas KM. Knowledge and practices of dentists regarding MERS-CoV: a cross-sectional survey in Saudi Arabia. Saudi Med J. 2019 Jul;40(7):714-20. https://doi.org/10.15537/smj.2019.7.24304
https://doi.org/10.15537/smj.2019.7.2430...
and control of the spread of the disease 1515. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
https://doi.org/10.1177/0022034520914246...
. Similar to the results of a study in the literature,1919. 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 ınfection control: cross-sectional study among jordanian dentists. JMIR Public Health Surveill. 2020 Apr;6(2):e18798. https://doi.org/10.2196/18798
https://doi.org/10.2196/18798...
Turkish dentists were able to identify the main symptoms of COVID-19, such as high fever (99.4%), shortness of breath (98.8%), dry cough (98%), and fatigue (92.2%) (Table 2).

The Depression Anxiety Stress (DASS) scale consists of 42 questions. The high number of questions in the scale complicates the process of data collection and analysis. According to some authors, as the number of items on the scale increases, it tires the participants and provides less reliable answers.2020. Burisch M. Test length and validity revisited. Eur J Pers. 1997;11(4):303-15. https://doi.org/10.1002/(SICI)1099-0984(199711)11:4<303::AID-PER292>3.0.CO;2-#
https://doi.org/10.1002/(SICI)1099-0984(...
,2121. Gosling SD, Rentfrow PJ, Swann WB Jr. A very brief measure of the Big-Five personality domains. J Res Pers. 2003;37(6):504-28. https://doi.org/10.1016/S0092-6566(03)00046-1
https://doi.org/10.1016/S0092-6566(03)00...
At the same time, frequently asking similar questions to measure a particular dimension can be both tiring and disappointing, whereas measuring a dimension with less substance has the opposite effect.2222. Robins RW, Tracy JL, Trzesniewski K, Potter J, Gosling SD. Personality correlates of self-esteem. J Res Pers. 2001;35(4):463-82. https://doi.org/10.1006/jrpe.2001.2324
https://doi.org/10.1006/jrpe.2001.2324...
Therefore, in our study, we created our own stress scale (four questions) to determine the stress levels of dentists in relation to the COVID-19 pandemic.

Turkish dentists were found to be very concerned for their families and their stress levels exceeded the average stress value (Figure 1). Dentists were expected to be worried about getting infected with 2019-nCoV and transmitting it to their close family members.1212. 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 Apr;17(8):E2821. https://doi.org/10.3390/ijerph17082821
https://doi.org/10.3390/ijerph17082821...
Additionally, incompatible with our results, Duruk et al.,2323. Duruk G, Gümüşboğa ZS, Çolak C. Investigation of Turkish dentists’ clinical attitudes and behaviors towards the COVID-19 pandemic: a survey study. Braz Oral Res. 2020;34:e054. https://doi.org/10.1590/1807-3107bor-2020.vol34.0054
https://doi.org/10.1590/1807-3107bor-202...
reported that facing COVID-19 contraction threat, most of dentists were concerned about their families and about themselves. The severity of psychological symptoms depends on age, gender, occupation, and proximity to the infected patient.2424. Bohlken J, Schömig F, Lemke MR, Pumberger M, Riedel-Heller SG. [COVID-19 pandemic: stress experience of healthcare workers:a short current review]. Psychiatr Prax. 2020 May;47(4):190-7. German. https://doi.org/10.1055/a-1159-5551
https://doi.org/10.1055/a-1159-5551...
Females were correlated to higher risk of experiencing anxiety and stress which may be due to the already reported gender difference for anxious and depressive symptoms.2525. Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci. 2015 Jul;40(4):219-21. https://doi.org/10.1503/jpn.150205
https://doi.org/10.1503/jpn.150205...
Previous studies claimed that females had higher depression and anxiety levels than male during the pandemic of COVID-19.26 27 However, it was also reported in a study that gender was not associated with anxiety and depression during the COVID-19 pandemic.2828. Chen Y, Zhou H, Zhou Y, Zhou F. Prevalence of self-reported depression and anxiety among pediatric medical staff members during the COVID-19 outbreak in Guiyang, China. Psychiatry Res. 2020 Jun;288:113005. https://doi.org/10.1016/j.psychres.2020.113005
https://doi.org/10.1016/j.psychres.2020....
Although our study revealed that female gender was associated with higher self reported anxiety and stress levels, there was no significant difference between females and males regarding current or future financial and organizational difficulties. Older people, city residents, and people with stable income present with low anxiety and depression.2929. González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020 Jul;87:172-6. https://doi.org/10.1016/j.bbi.2020.05.040
https://doi.org/10.1016/j.bbi.2020.05.04...
Educated young people are more likely to follow pandemic related news that increases the anxiety and stress levels.3030. Ahmad AR, Murad HR. The impact of social media on panic during the COVID-19 pandemic in Iraqi Kurdistan: online questionnaire study. J Med Internet Res. 2020 May;22(5):e19556. https://doi.org/10.2196/19556
https://doi.org/10.2196/19556...
Current study showed that older dentists with more than 20 years of professional experience have lower stress levels than less experienced colleagues. Among dental staffs, being young and having less professional experience usually means low monthly income, lacking experience, and knowledge in dealing with terrible infectious diseases.

Researchers have revealed that the new type of coronavirus (SARS-CoV-2) that causes COVID-19 can live on different surfaces, such as metal, glass, or plastic, for hours and even up to nine days.3131. Suman R, Javaid M, Haleem A, Vaishya R, Bahl S, Nandan D. Sustainability of Coronavirus on different surfaces. J Clin Exp Hepatol. 2020 Jul-Aug;10(4):386-90. https://doi.org/10.1016/j.jceh.2020.04.020
https://doi.org/10.1016/j.jceh.2020.04.0...
Luckily, the virus can be efficiently inactivated within one minute by using surface disinfection products with 62–71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite.3232. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020 Mar;104(3):246-51. https://doi.org/10.1016/j.jhin.2020.01.022
https://doi.org/10.1016/j.jhin.2020.01.0...
If soap and water are not available and hands are not visibly dirty, an alcohol-based hand sanitizer containing at least 60% alcohol can be used. However, visibly dirty hands should always be washed with soap and water.1313. Centers for Disease Control and Prevention – CDC. Developing guidance regarding responding to COVID-19 in dental settings. Centers for Disease Control and Prevention; 2020. In our study, dentists considered that the most important measures for prevention against COVID-19 were “washing hands with soap and water for at least 20 seconds (sec) (100%)” and “avoiding contact of the hands with mouth, nose, and eyes (99.2%)” (Table 2). It is now confirmed that COVID-19 is transmitted through human contact and in the form of droplets, but airborne transmission is not rejected yet.3333. Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020 Dec;15(4):564-7. https://doi.org/10.1016/j.jds.2020.02.002
https://doi.org/10.1016/j.jds.2020.02.00...
,3434. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel Coronavirus-ınfected pneumonia. N Engl J Med. 2020 Mar;382(13):1199-207. https://doi.org/10.1056/NEJMoa2001316
https://doi.org/10.1056/NEJMoa2001316...
Authorities recommended people to abstain from crowded places, including hospitals and dental clinics, as much as possible to guard against cross-infection resulting from the rapid transmission of COVID-19 since the end of January 2020. Similarly, in our study, avoiding crowded places (98.9%) and wearing masks in public areas (96.1%) were found to be the most effective protective measures to take by Turkish dentists (Table 2).

Of the dentists participated in this survey, at least 38.4% wore an N95 mask (Table 3). The reason behind such an unexpected low rate could be the limited number of the masks and their high cost throughout the world.3535. Mukerji S, MacIntyre CR, Seale H, Wang Q, Yang P, Wang X, et al. Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections. BMC Infect Dis. 2017 Jul;17(1):464. https://doi.org/10.1186/s12879-017-2564-9
https://doi.org/10.1186/s12879-017-2564-...
. Similarly, Khader et al. found 92.9% of dentists to wear personal protective equipment such as masks, gloves, and goggles, and 96.2% to frequently clean their hands using alcohol-based antiseptics along with soap and water.2020. Burisch M. Test length and validity revisited. Eur J Pers. 1997;11(4):303-15. https://doi.org/10.1002/(SICI)1099-0984(199711)11:4<303::AID-PER292>3.0.CO;2-#
https://doi.org/10.1002/(SICI)1099-0984(...
Furthermore, Khader et al.1919. 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 ınfection control: cross-sectional study among jordanian dentists. JMIR Public Health Surveill. 2020 Apr;6(2):e18798. https://doi.org/10.2196/18798
https://doi.org/10.2196/18798...
reported that although Jordanian dentists were beware of COVID-19 symptoms, its mode of transmission, infection control, and measures in dental clinics; they had limited comprehension of additional precautionary measures to protect the dental staff and patients from COVID-19. However, there were no “local” cases in Jordan at the time of data collection.

COVID-19 transmission can occur between humans who are in close contact (within about two meters) of each other. Additionally, the infected people who are infected but show no symptoms of the disease are also likely to play a role in the spread of COVID-19.3636. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Surveill. 2020 Feb;25(5): https://doi.org/10.2807/1560-7917.ES.2020.25.5.2000062
https://doi.org/10.2807/1560-7917.ES.202...
People can spread the virus before they become aware of their sickness. Therefore, it is crucial to avoid contact with other people whether they show any symptoms or not. Social distancing can help to limit the contact with infected people and contaminated surfaces. There should be a distance of at least two meters between people and gathering in groups should be avoided to practice social or physical distancing. Social distancing is particularly important for people who carry higher risk due to their health conditions.3737. Centers for Disease Control and Prevention – CDC. Coronavirus disease 2019 (COVID-19): Social distancing. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
https://www.cdc.gov/coronavirus/2019-nco...
Similar to a study in the literature,2323. Duruk G, Gümüşboğa ZS, Çolak C. Investigation of Turkish dentists’ clinical attitudes and behaviors towards the COVID-19 pandemic: a survey study. Braz Oral Res. 2020;34:e054. https://doi.org/10.1590/1807-3107bor-2020.vol34.0054
https://doi.org/10.1590/1807-3107bor-202...
our results showed that Turkish dentists believed in the importance of social distancing in mitigating the spread of the virus, and most of the dentists (86%) thought that there should be at least one meter of distance from others who may be infected (Table 2).

Due to the possibility of COVID-19 recusancy and the fact that some viruses can be present in saliva for as long as 29 days after recovery 3838. Zuanazzi D, Arts EJ, Jorge PK, Mulyar Y, Gibson R, Xiao Y, et al. Postnatal Identification of Zika virus peptides from saliva. J Dent Res. 2017 Sep;96(10):1078-84. https://doi.org/10.1177/0022034517723325
https://doi.org/10.1177/0022034517723325...
, it is important to be cautious when deciding upon the timing of non-emergency elective dental treatments of a COVID-19 (+) patient. A recovery is confirmed if the patient has been asymptomatic for at least 30 days after the last negative laboratory test.3939. Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020 May;32(4):181-6. https://doi.org/10.1016/j.sdentj.2020.04.001
https://doi.org/10.1016/j.sdentj.2020.04...
Knowing the dental treatment time of COVID-19 (+) patients can help in reducing and preventing new outbreaks. In our study, dentists mostly responded to the question on this topic by suggesting that procedures could be done 14 days after the rRT-PCR test result turned out to be negative (63.1%) (Table 2). The lack of information on this issue may be due to the time it takes for symptoms to appear after confrontation with the virus, and the period within which symptoms appear can be extended up to 14 days. Also, the time that the virus stays in the saliva may not be known by dentists.

The main limitation of this study was the use of an adapted stress scale. Future studies should, if possible, employ other more objective questionnaire using a stress scale which has been proven to be reliable and valid. According to our findings, dentists’ stress and anxiety levels related to COVID-19 had increased. Although the results here are similar to other studies in the literature,4040. 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 Apr;17(8):E2900. https://doi.org/10.3390/ijerph17082900
https://doi.org/10.3390/ijerph17082900...
,4141. Tran TT, Nguyen NB, Luong MA, Bui TH, Phan TD, Tran VO, et al. Stress, anxiety and depression in clinical nurses in Vietnam: a cross-sectional survey and cluster analysis. Int J Ment Health Syst. 2019 Jan;13(1):3. https://doi.org/10.1186/s13033-018-0257-4
https://doi.org/10.1186/s13033-018-0257-...
it still may not be possible to generalize on this issue, since we do not use all the questions of the perceived stress scale.

Another limitation of this study was the survey was conducted only with dentists in Turkey and not included all the dentists in Turkey. The results will likely vary according to the general conditions of each country and the degree of exposure to COVID-19. Therefore, the results of our study should be interpreted carefully and not be globalized. Even though the survey was sent to dentists all over Turkey, there was a lack of response and resultant small sample size. The reason for this could be that not all dentists use Internet and social media. It is aimed to carry out a study in which higher number of dentists are involved.

Conclusion

There has been a significant increase in stress levels due to the uncertainty of the working conditions of Turkish dentists during the COVID-19 pandemic period, as can be said to be the case with dentists all over the world. Accordingly, there will likely be an increase in the personal and professional protective measures that they will take when they return to their routine clinical practices. Further studies with more participants and longer follow-up term are needed to achieve more precise results.

Acknowledgements

The authors thank all participants for their valuable contribution to this study and all healthcare workers who devoted themselves to the coronavirus pandemic. The authors also would like to thank Ebru Osmanoglu from Variance Statistical Consultancy, who carried out statistical analysis.

References

  • 1
    World Health Organization – WHO. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance. 2020 Mar 20 [cited 2020 May 20]. Available from: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
    » https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
  • 2
    World Health Organization – WHO. Coronavirus disease (COVID-19): situation report-127. 2020 [cited 2020 May 20]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200526-covid-19-sitrep-127.pdf?sfvrsn=7b6655ab_8
    » https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200526-covid-19-sitrep-127.pdf?sfvrsn=7b6655ab_8
  • 3
    Wang J, Chow TT. Numerical investigation of influence of human walking on dispersion and deposition of expiratory droplets in airborne infection isolation room. Build Environ. 2011;46(10):1993-2002. https://doi.org/10.1016/j.buildenv.2011.04.008
    » https://doi.org/10.1016/j.buildenv.2011.04.008
  • 4
    Ge ZY, Yang LM, Xia JJ, Fu XH, Zhang YZ. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci B. 2020 May;21(5):361-8. https://doi.org/10.1631/jzus.B2010010
    » https://doi.org/10.1631/jzus.B2010010
  • 5
    Smither SJ, Eastaugh LS, Findlay JS, Lever MS. Experimental aerosol survival of SARS-CoV-2 in artificial saliva and tissue culture media at medium and high humidity. Emerg Microbes Infect. 2020 Dec;9(1):1415-7. https://doi.org/10.1080/22221751.2020.1777906
    » https://doi.org/10.1080/22221751.2020.1777906
  • 6
    Liyanage S, Ramasamy P, Elhaddad O, Darcy K, Hudson A, Keller J. Assessing visible aerosol generation during vitrectomy in the era of Covid-19. Eye (Lond). 2020 Jun; https://doi.org/10.1038/s41433-020-1052-4 Epub ahead of print.
    » https://doi.org/10.1038/s41433-020-1052-4
  • 7
    Gamio L. The workers who face the greatest Coronavirus risk. New York Times, 2020 Mar 15 [cited 2020 May 20]. Available from: https://www.nytimes.com/interactive/2020/03/15/business/economy/coronavirus-worker-risk.html
    » https://www.nytimes.com/interactive/2020/03/15/business/economy/coronavirus-worker-risk.html
  • 8
    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 May;17(10):E3459. https://doi.org/10.3390/ijerph17103459
    » https://doi.org/10.3390/ijerph17103459
  • 9
    Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health [published Online First: 2020/04/03]. Int J Soc Psychiatry. 2020 Jun;66(4):317-20. https://doi.org/10.1177/0020764020915212
    » https://doi.org/10.1177/0020764020915212
  • 10
    Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res. 2020 May;287:112934. https://doi.org/10.1016/j.psychres.2020.112934
    » https://doi.org/10.1016/j.psychres.2020.112934
  • 11
    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. Psychol Health Med. 2021 Jan;26(1):13-22. https://doi.org/10.1080/13548506.2020.1746817
    » https://doi.org/10.1080/13548506.2020.1746817
  • 12
    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 Apr;17(8):E2821. https://doi.org/10.3390/ijerph17082821
    » https://doi.org/10.3390/ijerph17082821
  • 13
    Centers for Disease Control and Prevention – CDC. Developing guidance regarding responding to COVID-19 in dental settings. Centers for Disease Control and Prevention; 2020.
  • 14
    World Health Organization – WHO. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance. Geneva: World Health Organization; 2020.
  • 15
    Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
    » https://doi.org/10.1177/0022034520914246
  • 16
    Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020 Mar;16(10):1745-52. https://doi.org/10.7150/ijbs.45221
    » https://doi.org/10.7150/ijbs.45221
  • 17
    Korre M, Farioli A, Varvarigou V, Sato S, Kales SN. A survey of stress levels and time spent across law enforcement duties: police chief and officer agreement. Policing. 2014 May;8(2):109-22. https://doi.org/10.1093/police/pau001
    » https://doi.org/10.1093/police/pau001
  • 18
    Gaffar BO, El Tantawi M, Al-Ansari AA, AlAgl AS, Farooqi FA, Almas KM. Knowledge and practices of dentists regarding MERS-CoV: a cross-sectional survey in Saudi Arabia. Saudi Med J. 2019 Jul;40(7):714-20. https://doi.org/10.15537/smj.2019.7.24304
    » https://doi.org/10.15537/smj.2019.7.24304
  • 19
    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 ınfection control: cross-sectional study among jordanian dentists. JMIR Public Health Surveill. 2020 Apr;6(2):e18798. https://doi.org/10.2196/18798
    » https://doi.org/10.2196/18798
  • 20
    Burisch M. Test length and validity revisited. Eur J Pers. 1997;11(4):303-15. https://doi.org/10.1002/(SICI)1099-0984(199711)11:4<303::AID-PER292>3.0.CO;2-#
    » https://doi.org/10.1002/(SICI)1099-0984(199711)11:4<303::AID-PER292>3.0.CO;2-#
  • 21
    Gosling SD, Rentfrow PJ, Swann WB Jr. A very brief measure of the Big-Five personality domains. J Res Pers. 2003;37(6):504-28. https://doi.org/10.1016/S0092-6566(03)00046-1
    » https://doi.org/10.1016/S0092-6566(03)00046-1
  • 22
    Robins RW, Tracy JL, Trzesniewski K, Potter J, Gosling SD. Personality correlates of self-esteem. J Res Pers. 2001;35(4):463-82. https://doi.org/10.1006/jrpe.2001.2324
    » https://doi.org/10.1006/jrpe.2001.2324
  • 23
    Duruk G, Gümüşboğa ZS, Çolak C. Investigation of Turkish dentists’ clinical attitudes and behaviors towards the COVID-19 pandemic: a survey study. Braz Oral Res. 2020;34:e054. https://doi.org/10.1590/1807-3107bor-2020.vol34.0054
    » https://doi.org/10.1590/1807-3107bor-2020.vol34.0054
  • 24
    Bohlken J, Schömig F, Lemke MR, Pumberger M, Riedel-Heller SG. [COVID-19 pandemic: stress experience of healthcare workers:a short current review]. Psychiatr Prax. 2020 May;47(4):190-7. German. https://doi.org/10.1055/a-1159-5551
    » https://doi.org/10.1055/a-1159-5551
  • 25
    Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci. 2015 Jul;40(4):219-21. https://doi.org/10.1503/jpn.150205
    » https://doi.org/10.1503/jpn.150205
  • 26
    Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 2020 Mar;17(5):6. https://doi.org/10.3390/ijerph17051729
    » https://doi.org/10.3390/ijerph17051729
  • 27
    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. Int J Soc Psychiatry. 2020 Aug;66(5):504-11. https://doi.org/10.1177/0020764020927051
    » https://doi.org/10.1177/0020764020927051
  • 28
    Chen Y, Zhou H, Zhou Y, Zhou F. Prevalence of self-reported depression and anxiety among pediatric medical staff members during the COVID-19 outbreak in Guiyang, China. Psychiatry Res. 2020 Jun;288:113005. https://doi.org/10.1016/j.psychres.2020.113005
    » https://doi.org/10.1016/j.psychres.2020.113005
  • 29
    González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020 Jul;87:172-6. https://doi.org/10.1016/j.bbi.2020.05.040
    » https://doi.org/10.1016/j.bbi.2020.05.040
  • 30
    Ahmad AR, Murad HR. The impact of social media on panic during the COVID-19 pandemic in Iraqi Kurdistan: online questionnaire study. J Med Internet Res. 2020 May;22(5):e19556. https://doi.org/10.2196/19556
    » https://doi.org/10.2196/19556
  • 31
    Suman R, Javaid M, Haleem A, Vaishya R, Bahl S, Nandan D. Sustainability of Coronavirus on different surfaces. J Clin Exp Hepatol. 2020 Jul-Aug;10(4):386-90. https://doi.org/10.1016/j.jceh.2020.04.020
    » https://doi.org/10.1016/j.jceh.2020.04.020
  • 32
    Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020 Mar;104(3):246-51. https://doi.org/10.1016/j.jhin.2020.01.022
    » https://doi.org/10.1016/j.jhin.2020.01.022
  • 33
    Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020 Dec;15(4):564-7. https://doi.org/10.1016/j.jds.2020.02.002
    » https://doi.org/10.1016/j.jds.2020.02.002
  • 34
    Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel Coronavirus-ınfected pneumonia. N Engl J Med. 2020 Mar;382(13):1199-207. https://doi.org/10.1056/NEJMoa2001316
    » https://doi.org/10.1056/NEJMoa2001316
  • 35
    Mukerji S, MacIntyre CR, Seale H, Wang Q, Yang P, Wang X, et al. Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections. BMC Infect Dis. 2017 Jul;17(1):464. https://doi.org/10.1186/s12879-017-2564-9
    » https://doi.org/10.1186/s12879-017-2564-9
  • 36
    Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Surveill. 2020 Feb;25(5): https://doi.org/10.2807/1560-7917.ES.2020.25.5.2000062
    » https://doi.org/10.2807/1560-7917.ES.2020.25.5.2000062
  • 37
    Centers for Disease Control and Prevention – CDC. Coronavirus disease 2019 (COVID-19): Social distancing. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
    » https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
  • 38
    Zuanazzi D, Arts EJ, Jorge PK, Mulyar Y, Gibson R, Xiao Y, et al. Postnatal Identification of Zika virus peptides from saliva. J Dent Res. 2017 Sep;96(10):1078-84. https://doi.org/10.1177/0022034517723325
    » https://doi.org/10.1177/0022034517723325
  • 39
    Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020 May;32(4):181-6. https://doi.org/10.1016/j.sdentj.2020.04.001
    » https://doi.org/10.1016/j.sdentj.2020.04.001
  • 40
    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 Apr;17(8):E2900. https://doi.org/10.3390/ijerph17082900
    » https://doi.org/10.3390/ijerph17082900
  • 41
    Tran TT, Nguyen NB, Luong MA, Bui TH, Phan TD, Tran VO, et al. Stress, anxiety and depression in clinical nurses in Vietnam: a cross-sectional survey and cluster analysis. Int J Ment Health Syst. 2019 Jan;13(1):3. https://doi.org/10.1186/s13033-018-0257-4
    » https://doi.org/10.1186/s13033-018-0257-4

Publication Dates

  • Publication in this collection
    12 Mar 2021
  • Date of issue
    2021

History

  • Received
    15 June 2020
  • Reviewed
    08 Feb 2021
  • Accepted
    12 Dec 2020
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