COVID-19 Associated Stress Among Dental Students

Abstract

Background
The COVID-19 pandemic has exposed the global population to a high risk of infection that constitutes a major stress factor, especially for vulnerable groups such as dental students.

Objective
To assess levels of COVID-19 related stress and anxiety, changes in hygienic and social habits, as well as subjective worries regarding the dental profession among dental students.

Methods
A self-structured questionnaire was sent to students at the College of Dentistry, Umm Al-Qura University. It included demographic data, questions about the level of change in personal hygiene and social habits, students’ perception about the sufficiency of information received during the outbreak and its source, subjective worries regarding the dental profession, and the Generalized Anxiety Disorder 7-item (GAD-7) scale. Two hundred fifty-eight responses were received.

Results
Moderate and severe anxiety were reported in 17% and 4% of students, respectively, with non-significant associations between anxiety and gender or level of study. A high percentage of students (46.5% to 62.4%) reported great change in most hygienic and social habits with a highly significant association between change in buying more sanitizers and anxiety levels. Forty-six percent agreed that their job performance was not at its best, and 31% reported a possible intention to change profession, with the latter reported more by male students (63.8%).

Conclusion
A considerable percentage of dental students in our college are anxious and changed their hygienic and social habits due to COVID-19. This anxiety reflects worries about the dental profession in one-third of participants that necessitate counselling services and psychological support.

Full text

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554
DOI: 10.2174/1874210602014010554, 2020, 14, 554-562
The Open Dentistry Journal
Content list available at: https://opendentistryjournal.com
RESEARCH ARTICLE
COVID-19 Associated Stress Among Dental Students
Hanadi S. Lingawi1,* and Ibtesam K. Afifi2,3
1Department of Preventive Dentistry , College of Dentistry, Umm Al-Qura University, Makkah 22915, Saudi Arabia
2Department of Basic and Clinical Oral Sciences, College of Dentistry, Umm Al-Qura University, Makkah 22915, Saudi Arabia
3Department of Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
Abstract:
Background:
The COVID-19 pandemic has exposed the global population to a high risk of infection that constitutes a major stress factor, especially for
vulnerable groups such as dental students.
Objective:
To assess levels of COVID-19 related stress and anxiety, changes in hygienic and social habits, as well as subjective worries regarding the dental
profession among dental students.
Methods:
A self-structured questionnaire was sent to students at the College of Dentistry, Umm Al-Qura University. It included demographic data, questions
about the level of change in personal hygiene and social habits, students’ perception about the sufficiency of information received during the
outbreak and its source, subjective worries regarding the dental profession, and the Generalized Anxiety Disorder 7-item (GAD-7) scale. Two
hundred fifty-eight responses were received.
Results:
Moderate and severe anxiety were reported in 17% and 4% of students, respectively, with non-significant associations between anxiety and gender
or level of study. A high percentage of students (46.5% to 62.4%) reported great change in most hygienic and social habits with a highly significant
association between change in buying more sanitizers and anxiety levels. Forty-six percent agreed that their job performance was not at its best,
and 31% reported a possible intention to change profession, with the latter reported more by male students (63.8%).
Conclusion:
A considerable percentage of dental students in our college are anxious and changed their hygienic and social habits due to COVID-19. This
anxiety reflects worries about the dental profession in one-third of participants that necessitate counselling services and psychological support.
Keywords: COVID-19, Stress, Anxiety, Dentistry, Dental students, GAD-7, Saudi Arabia.
Article History Received: July 29, 2020 Revised: September 13, 2020 Accepted: September 13, 2020
1. INTRODUCTION
Human coronaviruses are a family of viruses that can cause
human diseases ranging from the common cold to Severe
Acute Respiratory Syndrome (SARS) and Middle East
Respiratory Syndrome (MERS-CoV). Both SARS and MERS-
CoV caused global epidemics with high mortality and morbidi-
* Address correspondence to this author at the Department of Preventive
Dentistry, College of Dentistry, Umm Al-Qura University, P.O. Box 14405,
Makkah 22915, Saudi Arabia; Tel: +966 505682076;
E-mail: hslingawi@uqu.edu.sa
ty rates in 2003 and 2012, respectively [1]. In December 2019,
an outbreak of a novel virus from the beta-coronavirus family
was identified in Wuhan, China, causing coronavirus disease
2019 (COVID-19) [2, 3]. On March 11, 2020, the World
Health Organization (WHO) declared the COVID-19 outbreak
a global pandemic [4].
COVID-19 has the potential to cause a severe acute
respiratory tract infection in infected humans. It is commonly
transmitted from person-to-person via respiratory droplets,
hands, saliva, and surface contact [5, 6]. The average

COVID-19 Associated Stress The Open Dentistry Journal, 2020, Volume 14 555
incubation period for COVID-19 ranges between 4 and 14 days
after exposure. The infected person usually presents with an
acute upper respiratory tract infection and symptoms, including
fever, dry cough, and tiredness. The severity of symptoms
ranges from very mild to severe. Elderly people and those who
have existing chronic medical conditions are the most
vulnerable groups. Since COVID-19 is highly contagious, the
rate of case detection rapidly became very high. Many
organizational bodies launched web-based systems (dashboard)
where the number of infected people could be tracked in almost
real-time. On July 20, 2020, 19:55 hours (GMT), the number of
confirmed cases worldwide was 14,567,109 and reported
deaths were 607,187, with 8,804,227 recovered patients [7]. In
Saudi Arabia, the number of confirmed cases was 253,349 and
reported deaths were 2,523 cases with 203,259 recovered
patients [8].
The first case of a dentist testing positive for COVID-19
was reported on January 23rd, 2020, in the Dental Hospital of
Wuhan University, China. This was shortly followed by the
identification of the transmission of disease to a further eight
oral healthcare professionals [9]. Since then, more health care
workers have tested positive for COVID-19 worldwide [10].
This has made the healthcare community more distressed as
they are subjected to the highest risk of infection.
The rapid spread of COVID-19, that is difficult to control,
compelled most governments worldwide to take serious
measures in an attempt to slow down and control the epidemic.
Curfews, home isolation measures, social distancing, closure of
schools and universities, and shifts in the existing educational
system to E-learning/distance learning systems were all
implemented. Although these measures play a great role in
controlling the spread of the epidemic, they are expected to put
significant psychological stress on the students and may
negatively affect their learning outcomes and overall
psychological health. In particular, the nature of dental clinical
training, the characteristics of dental settings, and the high risk
of cross-infection between dental students undergoing their
clinical training and patients could all contribute to provoking
stress and anxiety among dental students and increase their
worries about the future of their profession.
Previous published works have studied the psychological
impact of infectious disease outbreaks, such as MERS and
SARS, on students. One such study reported that almost one-
quarter of medical students in Saudi Arabia recorded mild to
moderate anxiety levels during MERS and SARS outbreaks
[11]. Another study in Hong Kong reported that anxiety levels
were found to be significantly higher among medical students
than non-medical students [12]. Since the COVID-19 outbreak,
very few studies have been conducted to estimate the effect of
this pandemic on the psychological health of students [13, 14],
but none has been carried out on dental students in Saudi
Arabia.
The aim of this study was to evaluate the level of stress and
anxiety associated with COVID-19 among dental students at
the College of Dentistry, Umm Al-Qura University and to
explore the level of change in their personal hygiene and social
habits in response to COVID-19 as well as their subjective
worries regarding the dental profession.
2. MATERIALS AND METHODS
2.1. Study Design and Ethical Considerations
This study utilized a descriptive cross-sectional design and
was conducted at the College of Dentistry, Umm Al-Qura
University, Makkah, Saudi Arabia, between May 27 and June
10, 2020. Makkah was selected for the study as it is the only
city that had total lockdown restrictions during the spread of
COVID-19 in Saudi Arabia and has only one college of
dentistry.
The study protocol was approved by the Institutional
Review Board (IRB) of the college (No. 175-2). Questionnaire
submission by the students was considered as consent from
their side to participate in this study.
2.2. Study Population
Undergraduate dental education in Saudi Arabia provides
basic training to students over a period of 5 years, starting from
Grade 2 after passing preparatory year for medical colleges.
After this basic training, students undergo a 1-year internship
before being eligible to receive a Bachelor's Degree in Dental
Science (BDS) and a license to practice. Convenience and
snowball sampling (students were asked to forward the
questionnaire to their colleagues) were used to ensure maximal
participation. Two hundred fifty-eight (258) study subjects out
of a total of 300 students in the college responded to the
questionnaire. The study was performed during the summer
holiday before registration of the next academic year Grade 2
students and, therefore, the study included junior students of
the 3rd and 4th academic year as well as senior students of 5th
and 6th academic years together with dental interns.
2.3. Study Questionnaire
A detailed, anonymous, structured questionnaire designed
by authors as an online Google form of 27 items in six sections
was posted to study participants along with its link via the
WhatsApp platform. The first section included an introduction
to the research that emphasized the confidentiality of the
questionnaire. The second section included four questions
related to demographic data (age, gender, study level, and
university name). The third section of eight questions focused
on the level of change in personal hygiene and social habits in
response to COVID-19 on a 5-point Likert scale (did not know,
did not change, changed a little, moderately changed, and
greatly changed). The fourth section contained two questions
about students’ perception of the sufficiency of information
they received about COVID-19 during the outbreak on a 5-
point Likert scale (excellent, good, fair, poor, and very poor)
and source of that information (college and university
announcement, ministry of health, World Health Organization,
media [TV and news], and social media). The fifth section had
six questions focused on subjective worries regarding the
dental profession with a Yes or No option and its rate on a
scale from 1 to 10. Lastly, the sixth section of the Generalized
Anxiety Disorder 7-item (GAD-7) scale included seven
questions about the level of anxiety they felt over the preceding
two weeks due to the COVID-19 outbreak. Each question in
the scale was graded on 4- point scale (not sure, for 2-3 days,

556 The Open Dentistry Journal, 2020, Volume 14 Lingawi and Afifi
more than half of the days and nearly every day) scored from 0
(not sure) to 4 (nearly every day). Total scores of 5, 10, and 15
were taken as the cut-off points for mild, moderate, and severe
anxiety, respectively, where 0-4 was considered as none to
minimal anxiety, 5-9 as mild anxiety, 10-14 as moderate
anxiety, and 15-21 as severe anxiety [15].
2.4. Validity and Reliability of the Questionnaire
A pilot study to test the precision of survey questions was
conducted with 10 participants. Based on their responses, three
survey questions were modified, and the format was edited for
clarity and comprehensibility. A second pilot study was
conducted with another 10 participants to confirm the
feasibility, validity, and reliability of the questionnaire. To
avoid questionnaires’ bias, google form was designed to accept
the submission of completely answered questionnaires only.
Each participant was allowed a single submission only.
2.5. Statistical Analysis
Data was entered and analyzed using the Statistical
Package for Social Sciences (SPSS 20, IBM, Armonk, NY,
United States of America). Descriptive statistics were used to
describe the data where frequency and percentage for
categorical variables were determined. The subjective worries
regarding the dental profession and total GAD-7 score were
described by the mean and standard deviation. Pearson's Chi-
square test was used to assess the association between anxiety
level and gender, level of study, personal hygiene, and social
habits, as well as the subjective worries regarding the dental
profession. A Chi-square test was also used to study the
association between the possible intention to choose another
profession and gender and study level. A critical probability
value (P-value) of <0.05 was used as the cut-off level for
statistical significance.
3. RESULTS
3.1. Demographic Data
The responders were 258 students out of 300 total students
from the College of Dentistry, Umm Al-Qura University,
giving a response rate of 86%, with 104 (40.3%) males and 154
(59.7%) females, and an age range of 18-26 years. The
participants included 53 (20.5%) third grade, 45 (17.4%) fourth
grade, 49 (19%) fifth grade, and 47 (18.2%) sixth grade
students, and 64 (24.8%) dental interns.
3.2. Source of Students’ Information about COVID-19 and
their Perception of the Sufficiency of the Information
Provided
The Saudi Ministry of Health was the main source of
information to the greatest number of students (n = 136
[52.7%]), followed by social media (60 [23.3%]), then the
WHO (43 [16.7%]), followed by the media, including TV news
(16 [6.2%]), and finally college and university announcements
(3 [1.2%]). Most of the students (120 [46.5%]) reported that
the information they received was excellent and 111 students
(43.0%) considered it as good, 25 students (9.7%) thought it
was fair and only one student thought it was poor.
3.3. Level of Anxiety Felt in the Preceding 2 Weeks Due to
COVID-19 Outbreak
The level of anxiety felt over the preceding 2 weeks due to
COVID-19 varied between dental students. From Fig. (1), it
can be observed that 40% of the students had no or minimal
symptoms of anxiety, while 4% reported severe anxiety.
Fig. (1). Percentages of anxiety levels among dental students according to the GAD-7 scale.
40% 39%
17%
4%
0
20
40
60
80
100
120
None/ Minimal Mild Moderate Severe
Number of students
Anxiety level according to total GAD-7 scale
None/ Minimal Mild Moderate Severe

COVID-19 Associated Stress The Open Dentistry Journal, 2020, Volume 14 557
The mean values of responses to each item of the GAD-7
score are shown in Fig. (2). Here, the lowest percentages of
students reported anxiety nearly every day. The mean total
GAD-7 score was 6.20 ± 4.38.
There was no significant association detected between
anxiety level and gender or level of study (Table 1).
3.4. Level of Change in Personal Hygiene and Social Habits
in Response to COVID-19 and its Association with Anxiety
Level
Table 2 shows that the highest percentages of students
(46.5-62.4%) reported that they had greatly changed in all
personal hygiene measures and social habits except for
handwashing technique, buying more sanitizers, and avoidance
of social gathering, where the greatest percentages of them
(31.8-60.9%) were moderately changed. A highly significant
association was observed between changes in the behavior of
buying more sanitizers and anxiety level, where percentages of
students with greatly changed habits increased with increased
levels of anxiety while in compliance with standard
precautions, the association with anxiety level was significant.
Fig. (2). Comparison between different GAD-7 scale items among dental students.
Table 1. Association between anxiety level and gender and level of study.
Variables
Anxiety level Chi-square
None/Minimal
(n = 103)
Mild
(n = 101)
Moderate
(n = 45)
Severe
(n = 9) X2P-value
Gender Male 43 (41.7%) 35 (34.7%) 22 (48.9%) 4 (44.4%) 2.872 0.412
Female 60 (58.3%) 66 (65.3%) 23 (51.1%) 5 (55.6%)
Level of study
3rd 25 (24.3%) 23 (22.8%) 5 (11.1%) 0 (.0%)
7.829 0.798
4th 16 (15.5%) 18 (17.8%) 8 (17.8%) 3 (33.3%)
5th 19 (18.4%) 19 (18.8%) 9 (20.0%) 2 (22.2%)
6th 17 (16.5%) 19 (18.8%) 9 (20.0%) 2 (22.2%)
Dental Interns 26 (25.2%) 22 (21.8%) 14 (31.1%) 2 (22.2%)
Table 2. Level of change in personal hygiene and social habits in response to COVID-19 among students and its association
with anxiety.
Personal hygiene and social habits Response Total
n. (%)
Anxiety level Chi-square
None/Minimal
n. (%)
Mild
n. (%)
Moderate
n. (%)
Severe
n. (%)
X2P-value
0
10
20
30
40
50
60
Feeling
nervous,
anxious, or on
edge
Not being able
to stop or
control
worrying
Worrying too
much about
different
things
Finding it
difficult to
relax
Being so
restless that
it's hard to sit
still
Becoming
easily annoyed
or irritable
Feeling afraid
as if something
bad might
happen
Percentage of students
(%)
Generalized Anxiety Disorder 7- item (GAD-7) scale
Not sure 2 - 3 days > half of the days Nearly every day

558 The Open Dentistry Journal, 2020, Volume 14 Lingawi and Afifi
Handwashing technique R1 3 (1.2) 0 (0.0) 3 (3.0) 0 (0.0) 0 (0.0) 18.149 0.111
R2 24 (9.3) 12 (11.7) 7 (6.9) 4 (8.9) 1 (11.1)
R3 34 (13.2) 19 (18.4) 9 (8.9) 5 (11.1) 1 (11.1)
R4 100 (38.8) 42 (40.8) 43 (42.6) 14 (31.1) 1 (11.1)
R5 97 (37.6) 30 (29.1) 39 (38.6) 22 (48.9) 6 (66.7)
Buying more sanitizers R1 2 (0.8) 0 (0.0) 0 (0.0) 2 (4.4) 0 (0.0) 32.043 0.001**
R2 24 (9.3) 11 (10.7) 11 (10.9) 2 (4.4) 0 (0.0)
R3 75 (29.1) 39 (37.9) 31 (30.7) 3 (6.7) 2 (22.2)
R4 82 (31.8) 26 (25.2) 29 (28.7) 24 (53.3) 3 (33.3)
R5 75 (29.1) 27 (26.2) 30 (29.7) 14 (31.1) 4 (44.4)
Wearing surgical masks and gloves outdoor R1 5 (1.9) 2 (1.9) 3 (3.0) 0 (0.0) 0 (0.0) 15.004 0.241
R2 22 (8.5) 11 (10.7) 4 (4.0) 6 (13.3) 1 (11.1)
R3 42 (16.3) 18 (17.5) 20 (19.8) 3 (6.7) 1 (11.1)
R4 59 (22.9) 23 (22.3) 28 (27.7) 7 (15.6) 1 (11.1)
R5 130 (50.4) 49 (47.6) 46 (45.5) 29 (64.4) 6 (66.7)
Following social distancing (2m apart) R1 3 (1.2) 1 (1.0) 2 (2.0) 0 (0.0) 0 (0.0) 13.685 0.321
R2 14 (5.4) 6 (5.8) 8 (7.9) 0 (0.0) 0 (0.0)
R3 47 (18.2) 20 (19.4) 17 (16.8) 10 (22.2) 0 (0.0)
R4 74 (28.7) 36 (35.0) 25 (24.8) 11 (24.4) 2 (22.2)
R5 120 (46.5) 40 (38.8) 49 (48.5) 24 (53.3) 7 (77.8)
Avoid social gathering R1 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 14.540 0.104
R2 6 (2.3) 3 (2.9) 3 (3.0) 0 (0.0) 0 (0.0)
R3 32 (12.4) 7 (6.8) 20 (19.8) 5 (11.1) 0 (0.0)
R4 63 (24.4) 22 (21.4) 23 (22.8) 14 (31.1) 4 (44.4)
R5 157 (60.9) 71 (68.9) 55 (54.5) 26 (57.8) 5 (55.6)
Avoid hand shaking R1 1 (0.4) 1 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 10.655 0.559
R2 10 (3.9) 3 (2.9) 4 (4.0) 3 (6.7) 0 (0.0)
R3 33 (12.8) 13 (12.6) 18 (17.8) 2 (4.4) 0 (0.0)
R4 57 (22.1) 26 (25.2) 18 (17.8) 11 (24.4) 2 (22.2)
R5 157 (60.9) 60 (58.3) 61 (60.4) 29 (64.4) 7 (77.8)
Avoid using public utilities R1 6 (2.3) 3 (2.9) 3 (3.0) 0 (0.0) 0 (0.0) 6.294 0.901
R2 6 (2.3) 3 (2.9) 2 (2.0) 1 (2.2) 0 (0.0)
R3 36 (14.0) 14 (13.6) 16 (15.8) 6 (13.3) 0 (0.0)
R4 49 (19.0) 19 (18.4) 21 (20.8) 6 (13.3) 3 (33.3)
R5 161 (62.4) 64 (62.1) 59 (58.4) 32 (71.1) 6 (66.7)
Compliance with standard precautions R1 9 (3.5) 5 (4.9) 3 (3.0) 1 (2.2) 0 (0.0%) 25.972 0.011*
R2 8 (3.1) 4 (3.9) 1 (1.0) 1 (2.2) 2 (22.2)
R3 35 (13.6) 17 (16.5) 10 (9.9) 7 (15.6) 1 (11.1)
R4 77 (29.8) 34 (33.0) 36 (35.6) 6 (13.3) 1 (11.1)
R5 129 (50.0) 43 (41.7) 51 (50.5) 30 (66.7) 5 (55.6)
R1:Do not Know, R2: Did not change, R3: Changed a little, R4: Moderately changed, R5: Greatly changed.
(**) Highly significant P≤ 0.001, (*) Significant P< 0.05.
3.5. Subjective Worries Regarding the Dental Profession
and its Association to Level of Anxiety
The mean rate of worries reported was 7.67 ± 1.91 on a
scale from 1 to 10 (where 1 is not worried at all and 10 is
extremely worried) regarding contracting COVID-19. Table 3
shows that a higher percentage of students (53.9%) disagreed
with the idea that they would not be able to perform their job to
the best of their ability post COVID-19, with a highly
significant association with the level of anxiety (P = 0.001).
Correspondingly, 69.0% of students do not wish to change
their profession if given a chance, and this was significantly
associated with the anxiety level (0.011). Moreover, there was
a highly significant association between the level of anxiety
and response of students to their need for extra precautions
during dental training, even after the number of COVID-19
cases declined (P = 0.001).
3.6. Association Between the Possible Intention to Choose
Another Profession and Gender and Level of Study
The results of this study showed a highly significant
difference between both genders regarding their intention to
change their dental profession (P = 0.001), with a higher
percentage among male students (63.8%). On the other hand,
there was a non-significant difference among students in
different study levels for their possible intention to choose
another profession (Table 4).
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COVID-19 Associated Stress The Open Dentistry Journal, 2020, Volume 14 559
Table 3. Subjective worries regarding the dental profession and its association with anxiety level.
Subjective Worries Questions Total
n. (%)
Anxiety level Chi-square
None/ Minimal
n. (%)
Mild
n. (%)
Moderate n. (%) Severe
n. (%)
X2P-value
Will your profession be risky post COVID-19? Yes 211 (81.8) 79 (76.7) 87 (86.1) 37 (82.2) 8 (88.9) 3.384 0.336
No 47 (18.2) 24 (23.3) 14 (13.9) 8 (17.8) 1(11.1)
Will your ability to perform your job to the best, be
jeopardized post COVID-19?
Yes 119 (46.1) 28 (27.2) 52 (51.5) 33 (73.3) 6 (66.7) 30.971 0.001**
No 139 (53.9) 75 (72.8) 49 (48.5) 12 (26.7) 3 (33.3)
Would you choose another profession if given a
chance?
Yes 80 (31.0) 21 (20.4) 35 (34.7) 21 (46.7) 3 (33.3) 11.238 0.011*
No 178 (69.0) 82 (79.6) 66 (65.3) 24 (53.3) 6 (66.7)
Do you prefer to postpone your training until
COVID-19 cases decline/ vaccine is available?
Yes 193 (74.8) 69 (67.0) 79 (78.2) 37 (82.2) 8 (88.9) 6.223 0.101
No 65 (25.2) 34 (33.0) 22 (21.8) 8 (17.8) 1 (11.1)
Will there be a need for extra precautions in clinical
training after COVID-19 cases decline?
Yes 217 (84.1) 76 (73.8) 91(90.1) 41 (91.1) 9 (100.0) 14.274 0.003*
No 41 (15.9) 27 (26.2) 10 (9.9) 4 (8.9) 0 (.0)
(**) Highly significant P≤0.001, (*) Significant P < 0.05.
Table 4. Association between the possible intention to choose another profession and gender and level of study.
Variables Would you choose another profession if given a chance? Chi-square
Yes (n = 80) No (n = 178) X2P-value
Gender Male 51 (63.8%) 53 (29.8%) 26.478 0.001**
Female 29 (36.3%) 125 (70.2%)
Level of study
3rd 16 (20.0%) 37 (20.8%) 4.727 0.316
4th 12 (15.0%) 33 (18.5%)
5th 21 (26.3%) 28 (15.7%)
6th 15 (18.8%) 32 (18.0%)
Dental Interns 16 (20.0%) 48 (27.0%)
(**) Highly significant P ≤0.001.
4. DISCUSSION
Stress is a general response or reaction of a person to a
difficult physical or psychological situation. It could predispose
anxiety, which has a negative impact on mental and physical
health, with a sense of uncontrollability and unpredictability
over potentially unpleasant life events [16, 17]. Undergraduate
dental education is usually considered a stressful environment,
and one of the reported stressors facing dental students is the
fear of infection, which can lead to clinical anxiety [18, 19].
The hypothesis tested here was that dental students would have
elevated stress and anxiety during the COVID-19 outbreak,
which may have an impact on personal hygiene behaviors and
social habits as well as subjective worries about the dental
profession.
In this study, the mean total GAD-7 score reflects that the
majority of students have mild anxiety, while a few
percentages of them have moderate to severe anxiety. The
same anxiety scale (GAD-7) was used to assess anxiety during
the COVID-19 pandemic among dental students in the United
Arab Emirates and reported a higher percentage of moderate to
severe anxiety levels in almost half of their students [14].
However, much lower percentages of moderate (2.7%) to
severe anxiety (0.9%) were found in medical students in China
[13]. The percentages were nearly the same among dental
practitioners in Italy, whether in the mean GAD-7 score (6.56)
or in the recorded levels of moderate (15.2%) and severe
(8.7%) anxiety [20]. On the other hand, using other scales for
psychological distress, such as Kessler’s K6, on dentists and
dental hygienists in Israel found that 11.5% of their study
sample reported distress due to COVID-19 [21]. A self-
designed questionnaire, which included a section focused on
the fear of getting infected with COVID-19, was given to
dentists from 30 countries with 50% of participants from
Pakistan, Saudi Arabia, and the United Arab Emirates, and
concluded that more than two-thirds of the general dental
practitioners (78%) were anxious and scared [22].
According to study levels, the present work showed a non-
significant difference in anxiety levels among students in
different grades, with no students reported severe anxiety in the
3rd year. This could be attributed to their theoretical study and
lack of experience in facing infected patients in clinical
situations and being less acquainted with the clinic
environment. A higher percentage of females reported anxiety
in comparison to males, with a non-significant difference
between both genders. This could be explained by the higher
number of females participating in the study (154 vs. 104
males) as well as the assumption of Muhammad and Rajan
(2020) that “females are more prone to get emotional and
neurotic problems because of their metacognitive beliefs and

560 The Open Dentistry Journal, 2020, Volume 14 Lingawi and Afifi
thought control strategies” [23]. However, the response of any
person to a potential stressor could be changeable according to
their personality make-up [24].
With regards to changes in personal hygiene and social
habits in response to COVID-19, students in the present study
reported that they were changed with moderate to great levels
and significant association between a change in behavior of
buying more sanitizers as well as a change in standard
precautions with anxiety level was reported. The study by
Saddik et al. [14] on 719 medical and 323 dental students
reported an increase in hand hygiene (46.7%) compliance to
standard precautions (29.3%), an increase in the use of hand
sanitizers (60.6%), a decrease in social visits (34.8%), a
decrease in handshaking (27.5%), and a decrease in the use of
public facilities (39%) [14]. This difference in the percentage
of change could be attributed to the higher total number of
students in their study and the involvement of medical students
in addition to dental students.
Most students reported that the information they received
about COVID-19 during the outbreak ranged from good to
excellent. The Saudi Ministry of Health (MOH) was the main
source of information for the greatest percentage of them,
followed by social media. The least number of students got
their information from college and university announcements.
In comparison, Saddik et al. [14] reported social media as the
main source of information for 46.7% of their medical/dental
study group, with the second source the Ministry of Health
(39.8%), while 31.3% got their information from university
announcements [14]. Reporting the MOH as the main source of
information in the present study could be explained by the
daily messages sent to all cell phones with information about
modes of infection, warnings, and preventive measures against
COVID-19.
Owing to the high likelihood of dental healthcare providers
acquiring infections during dental practice, the dental
profession has been considered a hazardous job [18]. This
hazard is expected to increase among undergraduate students
because of early exposure to patients in dental clinics while
training in practical sessions with the possibility of exposure to
many respiratory viruses [14]. This expectation tends to be
more during the COVID-19 pandemic, as confirmed by the
high percentages of students who agreed that the dental
profession would be more risky post COVID-19.
A large percentage of participants in the present study
agreed that their job performance will not be to the best of their
ability and that they have the possible intention to choose
another profession; these are both alarming responses. These
results are consistent with the conclusions of a study in Italy
that found anxiety from COVID-19 might prevent a new
generation of dental practitioners from entering the practice
[20]. In that study, 74.4% of the respondents mentioned that
COVID-19 had a highly negative impact on their professional
activity and that most of them (89.6%) were quite concerned
about their professional future, mostly due to the uncertainty
about the end of the emergency situation.
Most students in the present work, whatever their level of
anxiety, thought that they would prefer to postpone their
training until COVID-19 cases decline or a vaccine is
available, while there was a highly significant association
between level of anxiety and response of students to their need
to extra precautions on dental training even after the number of
COVID-19 cases declines. These results are in accordance with
a previous study by Ahmed et al. where 66% of their study
participants agreed to close their dental practice until the
number of COVID-19 cases starts to decline [22]. Similarly,
Consolo et al. reported that one-third of their study participants
were concerned by the need for further devices and adequate
new clinical guidelines to overcome the spread of COVID-19
in the near future [20].
Although there was a non-significant difference between
students in different study levels and their possible intention to
choose another profession, the highest percentages were
mentioned for the fifth-grade students and interns. The possible
explanation of higher percentages among students in the fifth
grade is that they have already passed one year of clinical
training and patient contact and they were on the way to
transitioning to a greater clinical contact in advanced dental
driplines, while interns are on the way to be licensed for actual
clinical practice without supervision.
The higher percentage of possible intention to change
profession among male students (63.8%) in the present study
highly recommends providing counselling services and
psychological support with continuous monitoring of stress
level to this recognized group. Moreover, as mentioned by
Bhanushali et al. [24], Ghai [26], and Varalakshmi et al. [27],
the college should urge faculty members to engage the students
academically through online courses for the benefit of their
career. Additionally, they recommended helping students to
attend webinars about COVID-19 and its risk of infection in
dental practice, aiming to understand the importance of its
preventive guidelines’ implementation.
CONCLUSION
In conclusion, COVID-19 created some degree of anxiety
among dental students at Umm Al-Qura University, ranging
from mild to severe. This anxiety was higher in females with a
non-significant difference between students in different grades.
A high percentage of participating students reported changes in
their personal hygiene and social habits with subjective worries
regarding the dental profession, where one-third of them
agreed that they would change their profession if they had the
chance. Therefore, efforts should be made to minimize student
anxiety in colleges through counselling and creating a
supportive learning environment. In addition, dental schools
should adequately prepare to face outbreaks of COVID-19 and
other emerging infectious diseases with the latest updated
information about its modes of infection and preventive
measures.
The present study has some limitations, such as being
confined to a single dental college, and consequently, the
results may not be applicable to other parts of Saudi Arabia.
Other COVID-19-related stressors, such as economic stressors,
effects on daily-life, and academic delays, were not addressed.
Thus, further study on a larger cohort of dental students is

COVID-19 Associated Stress The Open Dentistry Journal, 2020, Volume 14 561
recommended, together with investigations of other factors that
could lead to stress and anxiety during the COVID-19
pandemic.
ETHICS APPROVAL AND CONSENT TO PARTI-
CIPATE
The study received ethical approval from the Institutional
Review Board (IRB) at the College of Dentistry, Umm Al-
Qura University, Saudi Arabia (IRB No. 175-2).
HUMAN AND ANIMAL RIGHTS
Not applicable.
CONSENT FOR PUBLICATION
All participants in the study agreed on study publication by
answering the study questionnaire.
AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are
available from the corresponding author, [I,K,A], upon
reasonable request.
FUNDING
None.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or
otherwise.
ACKNOWLEDGEMENTS
The authors would like to thank Professor Omayma Afifi
for her help with statistical analysis.
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© 2020 The Author(s). Published by Bentham Open.
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