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Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 267-271
Assessment of biological risk among dentists during the COVID-19 Pandemic—A cross-sectional study

1 Department of Oral Medicine and Radiology, Government Dental College, Thrissur, Kerala, India
2 Department of Oral and Maxillofacial Surgery, Government Dental College, Thrissur, Kerala, India
3 Department of Transfusion Medicine, Malabar Cancer Centre, Thalassery, Kerala, India

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Date of Submission13-Mar-2022
Date of Decision24-Aug-2022
Date of Acceptance13-Sep-2022
Date of Web Publication17-Jan-2023


Background: The health and life of a healthcare worker are repeatedly under threat due to the rising number of epidemics and pandemics. The COVID-19 pandemic is said to be fatal in people with a risky biological, demographic profile and working environment. This study is the first of its kind carried out on the dentist population from India, who were most affected during the COVID-19 pandemic. Aims and Objective: The present study aims to assess the biological risk of dentists based on the objective risk stratification (ORS) tool developed by Strain et al. Materials and Methods: This was a cross-sectional study of dentists in government dental colleges of Kerala using the online form of the ORS tool consisting of questions which included certain demographic characteristics and comorbid conditions of the individual. An additional question was added to the tool, to categorise the work of the dentist depending on the exposure to aerosol (non-aerosol, minimal aerosol and aerosol). Results: Out of the 74 dentists, 48.6% reported high aerosol and 31% with minimal aerosol. The median score of the study participants was 2 (ranging from 1 to 12). Using the ORS tool, 16.2% had medium risk and only 2.7% had high risk. When the ORS tool was stratified with the aerosol generation, 5.4% had minimal and 6.7% had significant with medium-risk scores. Also, 2.7% with a high-risk score had minimal aerosol generation. Conclusion: Identifying the high-risk category to allocate duties accordingly and decrease the morbidity and mortality among dentists has to be kept a top priority in the event of a pandemic.

Keywords: Biological risk, COVID-19, dentist

How to cite this article:
Devaraj DK, Hussain Alikunju SK, Murugesan M. Assessment of biological risk among dentists during the COVID-19 Pandemic—A cross-sectional study. Indian J Dent Res 2022;33:267-71

How to cite this URL:
Devaraj DK, Hussain Alikunju SK, Murugesan M. Assessment of biological risk among dentists during the COVID-19 Pandemic—A cross-sectional study. Indian J Dent Res [serial online] 2022 [cited 2023 Mar 21];33:267-71. Available from:

   Introduction Top

Healthcare workers especially dental professionals have an increased risk of contracting an infection from the patients because of close contact occurring during the dental procedures. All healthcare workers are dutifully bound to render the services risking their own life as well as their kith and kin. The health and life of a healthcare worker are repeatedly under threat due to the rising number of epidemics and pandemics. The 21st century has witnessed a large number of epidemics like SARS, Chikungunya, Zika virus, Cholera, H1NI, Measles, MERS, and Ebola causing varying degrees of morbidity and mortality among the people. The disease, according to the World Health Organization (WHO) is said to be fatal in people with a risky biological and demographic profile and working environment.

The National Institute of Occupational Health-ICMR has put forth the guidelines to be followed in the workplace and has asked people with comorbidities and age greater than 60 years to refrain from physical appearance in the workplace and do 'work from home'. The WHO has been issuing strict guidelines from time to time for the safety of occupational health workers. The Ministry of Health and Family Welfare (MoHFW), Government of India (GoI), and National Guidelines for Infection Prevention and Control in healthcare facilities put forth in January 2020 had asked all healthcare workers to strictly adhere to the guidelines to prevent infection.[1] There is a need to do an occupational risk assessment in dental professionals based on their risk profile and make a protective allocation to those who have a higher level of risk. A study by Strain et al.[2] in the United Kingdom has been designed to formulate an empiric risk assessment tool known as the objective risk stratification (ORS) tool.

This questionnaire tool was developed based on the demographic and biological risk factors faced by the general population, and hospital data regarding morbidity and mortality among them. This tool evaluates the biological risk of an individual to advise mitigation of the latter by stratifying individuals to lower, medium and higher risk.[2] The present study aims to assess the biological risk of dentists based on this pre-validated questionnaire tool developed by Strain et al.[2] Individuals thought to be at a particularly high risk of infection can be given suggestions to modify their practice. This study is the first of its kind done on healthcare workers in India and assessed only the dentist population who were most affected during the COVID-19 pandemic.

   Materials and Methods Top

This was a cross-sectional study among dentists, and the study was conducted after obtaining institutional research committee and institutional ethics committee approval (Ref no: 13/IEC/GDCTSR/2021 dated: 05-03-2021). The ORS tool consisted of nine questions and its sub-questions.[2] The first three questions were framed to extract the demographic data such as age, sex, and ethnicity of the individual. The following six questions collected data on the comorbid condition of the individual such as diabetes and obesity, cardiovascular disease, pulmonary disease, malignant neoplasm, rheumatological conditions and immunosuppressant therapy. An additional question was added to the tool to categorise the work of the dentist depending on the exposure to an aerosol. (non-aerosol, minimal aerosol and aerosol).

After its development, the questionnaire was uploaded onto Google Forms. An online consent was obtained from the participants who were willing to participate in the study, and their email ID was recorded for future communications, if any. The questionnaire was shared through email of 200 dentists working in six government dental colleges of Kerala during the COVID-19 pandemic and a follow-up email was sent 2 weeks and 1 month later.

The response was analysed, and the risk factors were scored based on the risk stratification tool published [Table 1] and classified as low risk, medium risk and high risk.
Table 1: Objective risk stratification tool from Strain et al.[2]

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Statistical analysis

The online data sheet was structured into an Excel file. The categorical data was expressed as frequency and percentage. The continuous data was expressed as median (range). The data was analysed using IBM Statistical Package for the Social Sciences (SPSS) version 20.

As there were no previous studies from an Indian setting, the convenience sampling of dental professionals who consented to the study from the government dental colleges across Kerala was included.

   Results Top

Out of 200 dentists, only 74 (37%) responded to the online survey and were included in the study. Predominant participants were young (age <50 years; 77%) and female (60.8%) [Table 2]. Only four participants gave a positive history of diabetes; among them, only one had complicated diabetes. Obesity as a risk factor was reported in 6.8% of participants.
Table 2: Biological risk factors among dentists during the COVID-19 pandemic

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The cardiovascular risk factor was present in two participants; among them, one had heart failure. Asthma history was reported in 8.1% of participants, with three individuals requiring oral corticosteroid therapy in the previous year. None of the participants gave a history of malignancy. Rheumatology disease history was given by 5.4% of participants; of them, 2.7% were on active treatment and 1.4% were on immunosuppressant therapy. Around half of the participants (48.6%) reported aerosol generation during work and 31% with minimal aerosol generation.

Risk grading

The median score of the study participants was 2 (range: 1 to 12). Using the ORS tool, the low risk was graded in 60 (81.1%) of the participants. Twelve (16.2%) participants had medium risk, and only two (2.7%) participants were classified as high risk by this tool [Table 3].
Table 3: Relationship between aerosol generation and objective risk stratification grade among dentists

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Upon stratifying the ORS tool with aerosol generation during work, 4 (5.4%) participants had minimal and 5 (6.7%) participants with significant aerosol generation had medium-risk scores. Also, two (2.7%) participants with a high-risk score had minimal aerosol generation during work.

   Discussion Top

Healthcare professionals had to face a series of known and unknown infectious agents in the 21st century. In December 2019, the city of Wuhan, in the province of Hubei in China, became the epicentre of an outbreak of pneumonia of unknown aetiology in 2020. The International Committee on Taxonomy of Viruses named it “severe acute respiratory syndrome coronavirus 2” (SARS CoV-2) in February. In March, the WHO named the disease the coronavirus disease 2019 (COVID-19).[3] Initially, the SARS CoV-2 epidemic remained limited to China and later spread globally and was declared a pandemic. SARS CoV-2 was identified as a single-stranded RNA virus, and this type of virus tends to mutate more easily, which accounts for its increased contagiousness and infectivity. The varying symptom profile and higher infectivity of the virus summed up with the increasing mortality rate and the lack of efficient measures of prevention or treatment made it dreadful.

Maintaining an adequate healthcare workforce in this crisis requires not only an adequate number of physicians and supporting personnel but also boosting the morale of the healthcare workforce is of prime importance so that healthcare professionals are well equipped physically as well as mentally to provide care for their patients and communities.[4] India is the third worst affected country in the world with more than 4 million confirmed cases and over 515,850 deaths attributed to COVID-19.[5] The decreasing doctor–patient ratio and increasing mortality among doctors worsen the already compromised healthcare system. Doctors face multiple challenges while dealing with this pandemic, especially limited personal protective equipment (PPE), training, rest, and rotation, but worst of all, loss of life due to coronavirus infection.[6] Fear and anxiety of contracting the infection and cross-infecting the family; the subsequent complications of the disease like “long COVID” have questioned the morality of the healthcare professionals and remain a barrier to practising professional ethics. This scenario made them ask themselves what they would do if they were personally at risk. Henceforth, it becomes important to implement a proper risk assessment among the healthcare professionals and assessing the biological risk and the risk faced by the work environment becomes equally important.

Strain et al.[2] have discussed the three types of risk faced by healthcare professionals. The first relates to their biology, the second to their environment and the third to their exposure. The risk stratification tool was based on the findings like the increased mortality observed in men and mortality risk doubling in individuals of the 50–59 age group and quadruples in the 60–79 age group. Similarly, people of Indian Asian descent showed 50% increased hospitalisation and the presence of comorbidities had a synergistic effect.

The COVID-19 case fatality rate has also been higher in individuals with a previous chronic disease, which corresponds to more than half of the countries reaching 90% of the cases of infection.[7] Most COVID-19 confirmed cases have been in patients older than 30 years of age, with more than 90% being older than 45 years of age; the estimated age-specific infection fatality rate is low for children and younger adults (e.g. 0.002% at age 10 and 0.01% at age 25) and increases progressively to 0.4% at age 55, 1.4% at age 65, 4.6% at age 75, and 15% at age 85.[8],[9] A study conducted in Ethiopia showed that healthcare workers whose age was 25–34 years were 80 times less likely affected than the age group of 18–24 years.[10] All healthcare workers and doctors should screen for tuberculosis and major comorbidity such as diabetes before starting practising or doing COVID-19 duties. The history of latent or active tuberculosis is an important risk factor for acquiring COVID-19 infection.[6]

COVID-19 has reshaped the working environment for dentists and a 'new normal' has come into being since the pandemic. Dentists are among the group in the high-risk category of contracting the infection because they perform their duties in close contact with the infection being transmitted via respiratory droplets, by direct contact with infected people, or by contact with contaminated surfaces and objects.[11] The use of high-speed rotary handpieces in surgical as well as restorative procedures generates large quantities of aerosol mixed with saliva and blood into the environment.

A study by Ahmed et al.,[11] 2020, assessed 650 participants from 30 countries for their fear or anxiety levels and practice modification due to COVID-19. While treating a patient suspected to be infected with COVID-19, 90% were anxious. More than 72% of participants felt nervous when talking to patients in close vicinity, 92% were afraid of carrying the infection from dental practice to their families, and 77% were afraid of getting quarantined if they got infected. The anxiety rate concerning the cost of treatment if they got infected was 73%, whereas 86% felt afraid when they learnt about mortalities because of COVID-19. A considerable number of dentists (66%) wanted to close their dental practices until the number of COVID-19 cases start to decline. Psychological coping mechanisms and strategies have to be implemented to remain calm and function efficiently.

Routine calls have been suspended during the pandemic period and appropriate measures to prevent infection taken while attending dental emergencies. Only emergency dental care was provided with advice on strict personal protection, and measures to reduce and avoid the production of droplets and aerosols were adopted, with the use of high-volume aspiration. Dentists are concerned about the safety of patients as well as of themselves when so little is known about the treatment of COVID-19 infections, contamination, and possible recontamination.[12],[13]

According to the WHO, oral health is an indicator of overall health, well-being, and quality of life. Postponing dental procedures can have significant consequences on the oral health of the population. According to the Global Burden of Disease Report of WHO (2017), oral diseases affect close to 3.5 billion people worldwide, with caries of permanent teeth being the most common condition.[14] Due to COVID-19, the delayed approach to dental healthcare delivery has resulted in an increased oral health burden. According to research conducted by the ADA Health Policy Institute in March, around 76% of dentists in the United States have closed their offices to elective procedures except for dental emergencies during the COVID-19 pandemic, whereas 19% ceased their services to the public in general. With regard to the economic consequences, 82% of respondents have declared that the volume of earnings was reduced fourfold in comparison with previous years.[13]

Therefore, a risk assessment policy to mitigate the health risk of dentists is equally warranted as in other realms of the medical profession. For the protective allocation of the duties in the best interest of the dentist as well as the society, the risk assessment has to be done in all workplaces. The primary purpose of risk assessments is to identify health and safety hazards, evaluate the risks presented within the workplace, and evaluate the effectiveness and suitability of existing control measures. A multidisciplinary approach is essential in developing risk assessment approaches and precautionary guidelines. The FDI World Dental Federation (the global voice of the dental profession that represents over one million dentists worldwide) supports developing evidence-based recommendations, guidelines, and regulations based on international best practices in consultation with the dental profession.[14]

The assessment of biological risk based on the ORS tool developed by Strain et al. was tested in the Saudi population.[2] It revealed that more than three-quarters of the respondents were Saudi (86.9%) and 31.3% were physicians, 21.9% were health-associated professionals, and 19.5% were nurses. Furthermore, 36.7% of healthcare workers reported that they have health-related risk factors for severe COVID-19 and the risk level of COVID-19 was found to be high in 0.3% of participants, medium in 12.5%, and low in 87.2%. Males had a higher risk level than females and participants aged between 70 and 79 years had a higher risk level compared to the other age groups. Non-Saudis and Black African participants had a higher risk level when compared with other ethnicities. Participants who had health-related risk factors for severe COVID-19 had a higher risk level when compared with their counterparts.[15]

The WHO, CDC, and BMA have suggested a risk stratification approach that comprised time, distance, PPE etc., to help combat the infectivity rate among healthcare professionals. Paulo Melo et al.[16] has recommended triage and guidance to all patients before scheduling a dental appointment; guidance on personnel preventive measures and health literacy; additional precautionary measures for the waiting room, reception area, and dental operatory; and disinfection procedures before, during, and after each patient visit.

Identifying and implementing strategies and approaches to reduce the chances of infection among healthcare workers is a priority for any healthcare facility, especially during a pandemic. In addition to existing infection control standards, there is an urgent need for incorporating recent information and advancements to reduce the contamination of healthcare workers, including dentists.[14]

The limitation of the study was the biological risk assessment tool was prepared from the studies done on the Western population and also on Indians inhabiting that place. Hence, more studies are warranted to be done on the Indian population to explore the possibility of more risk factors which might alter the biological risk score.

   Conclusion Top

The safety of healthcare workers including dentists is of paramount importance during the pandemic. Developing and updating a biological risk tool and implementing it to protect dentists has to be advocated by all workplaces which helps to boost the morality of the working population. Our study identified 6.7% medium-risk and 2.7% high-risk dentists who need practice modifications. Identifying the high-risk category to allocate duties accordingly and decrease the morbidity and mortality among dentists has to be kept a top priority in the event of a pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

National Guidelines For Infection Prevention And Control In Healthcare Facilities Infection Prevention And Control Programmes Workload, Staffing And Bed Occupancy. Vol. January, National Centre for Disease Control, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. 2020. Available from: Guidelines for IPC in HCF-final%281%29.pdf. [Last accessed on 2022 Aug 24].  Back to cited text no. 1
Strain WD, Jankowski J, Davies AP, English P, Friedman E, McKeown H, et al. Development and presentation of an objective risk stratification tool for healthcare workers when dealing with the COVID-19 pandemic in the UK: Risk modelling based on hospitalisation and mortality statistics compared with epidemiological data. BMJ Open 2021;11:e042225.  Back to cited text no. 2
World Health Organization (WHO). Novel coronavirus (2019-nCoV)-situation report-22. Available from:  Back to cited text no. 3
Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-4.  Back to cited text no. 4
COVID-19 India. Available from:  Back to cited text no. 5
Iyengar KP, Ish P, Kumar G, Malhotra N. COVID-19 and mortality in doctors. Diabetes Metab Syndr Clin Res Rev 2020;14:1743-6.  Back to cited text no. 6
Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 outbreak: What we know. Int J Infect Dis 2020;94:44-8.  Back to cited text no. 7
Levin AT, Hanage WP, Owusu-Boaitey N, Cochran KB, Walsh SP, Meyerowitz-Katz G. Assessing the age specificity of infection fatality rates for COVID-19: Systematic review, meta-analysis, and public policy implications. Eur J Epidemiol 2020;35:1123-38.  Back to cited text no. 8
Melo P, Barbosa JM, Jardim L, Carrilho E, Portugal J. COVID-19 Management in clinical dental care. Part I: Epidemiology, public health implications, and risk assessment. Int Dent J 2021;71:251-62.  Back to cited text no. 9
Atnafie SA, Anteneh DA, Yimenu DK, Kifle ZD. Assessment of exposure risks to COVID-19 among frontline health care workers in Amhara Region, Ethiopia: A cross-sectional survey. PLoS One 2021;16:e0251000. doi: 10.1371/journal.pone.0251000.  Back to cited text no. 10
Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health 2020;17:2821. doi: 10.3390/ijerph17082821.  Back to cited text no. 11
Indian Dental Association's Preventive Guidelines for Dental Professionals on the Coronavirus Threat. Indian Dental Association; 2020. Available from: [Last accessed on 2022 Aug 24].  Back to cited text no. 12
Gambarini E, Galli M, di Nardo D, Miccoli G, Patil S, Bhandi S, et al. A survey on perceived covid-19 risk in dentistry and the possible use of rapid tests. J Contemp Dent Pract 2020;21:718-22.  Back to cited text no. 13
Alsaegh A, Belova E, Vasil'ev Y, Zabroda N, Severova L, Timofeeva M, et al. Covid-19 in dental settings: Novel risk assessment approach. Int J Environ Res Public Health 2021;18:1-10.  Back to cited text no. 14
Latif R, Alali S, AlNujaidi R, Alotaibi L, Alghamdi N, Alblaies M. COVID-19: Risk stratification of healthcare workers in the eastern province of saudi arabia and their knowledge, attitude, and fears. Cureus 2021;13e19652. doi: 10.7759/cureus. 19652.  Back to cited text no. 15
Melo P, Manarte-Monteiro P, Veiga N, de Almeida AB, Mesquita P. COVID-19 management in clinical dental care part III: Patients and the dental office. Int Dent J 2021;71:271-7.  Back to cited text no. 16

Correspondence Address:
Dr. Divya K Devaraj
Department of Oral Medicine and Radiology, Government Dental College, Thrissur, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.ijdr_227_22

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