Biosafety in public and private dental services in southern Brazil in the first COVID-19 pandemic year

Abstract

Objective  To compare the adoption of biosafety measures in the first year of the pandemic by public and private sector dentists in southern Brazil.

Methods  Cross-sectional study, with data collected using an online form, from August to October 2020. Exploratory Factor Analysis was used to define the dimensions and hypothesis tests were used to compare the sectors.

Results  1,721 professionals took part, the majority from the public service (50.6%) and female (n = 673; 77.4%). Four dimensions were obtained: I) availability and use of personal protective equipment; II) organization of the service; III) care; and IV) biosafety in the office. Public-sector dentists suspended elective procedures, avoided generating aerosols and intraoral X-rays, and worked four-handed more often than those in the private sector (p < 0.001). In the private sector, there was a higher frequency of reports of participation in decision-making; use of sterile handpieces, high-powered suckers, rubber dams, and tele-orientation/telemonitoring (p ≤ 0.001).

Conclusion  In the private sector, conventional attitudes to procedures and adherence to cleaning/disinfection measures for equipment and environments were more frequent. In the public sector, there was greater adherence to biosafety measures in care, and less adherence to those dependent on equipment, materials, and technologies.

Keywords:
COVID-19; Containment of Biohazards; Dentists; Occupational Health

Resumo

Objetivo  Comparar a adoção de medidas de biossegurança no primeiro ano da pandemia por cirurgiões-dentistas dos setores públicos e privados do Sul do Brasil.

Métodos  Estudo transversal, com dados coletados por formulário on-line, de agosto a outubro de 2020. Utilizou-se Análise Fatorial Exploratória para definição das dimensões e testes de hipóteses para a comparação entre os setores.

Resultados  Participaram 1.721 profissionais, a maioria do serviço público (50,6%) e do sexo feminino (n = 673; 77,4%). Obtiveram-se quatro dimensões: I) disponibilidade e uso de equipamentos de proteção individual; II) organização do serviço; III) atendimento; e IV) biossegurança no consultório. Cirurgiões-dentistas dos serviços públicos suspenderam procedimentos eletivos, evitaram geração de aerossóis e radiografias intraorais, e trabalharam a quatro mãos com maior frequência do que aqueles do setor privado (p < 0,001). Nos serviços privados, houve maior frequência de relato de participação na tomada de decisões; utilização de peças de mão esterilizadas, sugadores de alta potência, dique de borracha, e teleorientação/telemonitoramento (p ≤ 0,001).

Conclusão  No setor privado, foram mais frequentes atitudes convencionais nos procedimentos e adesão às medidas de limpeza/desinfecção de equipamentos e ambientes. No setor público, houve maior adesão às medidas de biossegurança no atendimento, e menor adesão àquelas dependentes de equipamentos, materiais e tecnologias.

Palavras-chave:
Covid-19; Contenção de Riscos Biológicos; Cirurgião-Dentista; Saúde do Trabalhador

Introduction

According to the World Health Organization (WHO), around 775 million cases of coronavirus disease 2019 (COVID-19) have been reported globally by June 2024¹. In 2021, Brazil was ranked among the four countries with the most COVID-19 cases and deaths¹, and the southern region was severely affected, with high incidence and mortality².

The COVID-19 pandemic has changed many aspects of daily life, creating a social, economic, and health crisis³. The situation has impacted health systems and demanded rapid, effective, and well-coordinated responses from the public and private sectors to meet emerging needs⁴.

Given this scenario, government agencies, professional councils, and dental institutions have formulated and published guidelines containing recommendations on biosafety in the context of dental services, for infection control during dental care⁵. In summary, the recommendations found most frequently in the protocols provided guidance on the use of N95 masks or similar, the use of a face shield, safe distancing, the use of high-power suction, the use of absolute isolation, and assisted work⁵. Considering the readjustment and challenges of professional practice, dental surgeons have faced psychological⁶ and financial⁷ impacts, as well as difficulties in managing the practice of services, in infection control, in diagnostic methods, and in identifying the oral manifestations of COVID-19⁸.

In response to the progression of the pandemic, the federal government has had to make decisions on measures to contain the spread of the pandemic, such as adopting personal hygiene practices, guidance on social distancing, wearing masks, and vaccinations; as well as on social protection measures and funding for coping actions⁹. Due to the complexity of the pandemic, there were divergences between decisions at the federal level, the federal entities and the other branches of government⁹, which possibly had an impact on the adoption of biosafety measures in the public and private sectors.

The dental profession is exposed to the pathogens of airborne infectious diseases, due to carrying out procedures with close, prolonged, and direct contact with the oral cavity, an environment characterized as a reservoir and exit/entry point for the virus¹⁰. Moreover, given the nature of dental procedures, there is a large generation of aerosols that are possibly contaminated with saliva and blood¹⁰.

Although there is no consensus on the higher incidence of COVID-19 and the occupational risk among health professionals¹¹, it is understood that those who have been exposed to oronasal secretions are at high risk of contamination¹². In this sense, the use of appropriate protective equipment and adherence to infection control and prevention measures can reduce the risk of COVID-19 infection¹¹.

In Brazil, the National Health Surveillance Agency (Anvisa) issued Technical Note GVIMS/GGTES/Anvisa No. 04/2020 (NT04/2020) on January 30, 2020, aimed at defining biosafety protocols in the face of the pandemic¹³. A new version, from March 2020, included guidelines for dental practices, aimed at preventing and controlling COVID-19. Over the course of the pandemic, the first version of this guideline underwent 11 updates up to June 24, 2024¹³. From the most recent versions of this standard, with the progress of vaccination and greater control of contamination, a gradual return to activities was recommended, with prioritization of care. Adherence to current biosafety measures was essential to mitigate the disease¹⁴ and to avoid or reduce transmission of the virus as much as possible.

To support policies to deal with the crisis, monitoring and detecting differences in the work process between public and private dental services during the pandemic is essential⁷. However, despite the existence of some studies on biosafety measures in the face of COVID-19 in dentistry, to date, few studies have evaluated the differences between the practices of dental surgeons in the public and private spheres¹⁵,¹⁶. Most articles have focused on the study of the oral health team¹⁷,¹⁸,¹⁴, socioeconomic profile¹⁹, and the impact of COVID-19 on the practice of dental surgeons⁷.

In view of the above, the aim of this article was to compare the adoption of biosafety measures during the first year of the COVID-19 pandemic by dental surgeons in the public and private sectors in southern Brazil.

Methods

Study design

This is a cross-sectional study, carried out with data from a multicenter study²⁰, whose data was collected using an online form, from August to October 2020, when the contagion curve of the first wave of COVID-19 was decreasing nationally. The study followed the guidelines for reporting observational studies (STROBE)²¹and websurveys (Checklist for Reporting Results of Internet E-Surveys - CHERRIES)²².

Population and sample

The multicenter study was carried out with the participation of oral health professionals (oral health assistants, oral health technicians, and dental surgeons). The non-probabilistic sample consisted of professionals from the three southern states who accepted the invitation and volunteered to take part in the study.

In Brazil, the Federal Council of Dentistry (Conselho Federal de Odontologia [CFO]) and the Regional Councils of Dentistry (Conselho Regional de Odontologia [CRO]) regulate professional registration. The number of professionals in their different states is updated daily in the CFO’s public database. In April 2020, according to the records, there were 55,147 dentists in the Southern Region, of which 21,037 (38.2%) were in Paraná, 14,136 (25.6%) in Santa Catarina, and 19,972 (36.2%) in Rio Grande do Sul²⁰.

Eligibility criteria

This study included dental surgeons from the three southern states who reported working in the public outpatient services of the Brazilian Unified Health System (Sistema Único de Saúde [SUS]) (basic health units, specialty centers, and emergency care services) and in private sector practices and clinics.

Those who had not worked in clinics since the beginning of the pandemic and those who worked in other areas (teaching, hospitals, management, armed forces, Sistema S, and health residencies) were excluded.

Research instrument

The data collection instrument was developed by the research team and was subjected to face validation by eight experts in the field and a pilot test with 35 oral health professionals not working in the southern region of Brazil. Specifics on the construction and face validation of the form, as well as the reproducibility and validation tests of the instrument can be found in previous publications²⁰,²³.

The final version contained three blocks: (1) Sociodemographic, training, and work profile; (2) Availability of supplies and biosafety measures; and (3) Professional practice, management, education, and teamwork. In total, the questionnaire had 47 closed questions, as well as two open questions about work difficulties and emotional and mental suffering of oral health professionals during the pandemic.

This study used data from the second block, which consisted of 37 questions based on Anvisa Technical Note No. 04/2020 and aimed to measure the level of compliance of dental services with the recommended measures, with an instrument that had been previously validated by the study’s authors²³. The items had five-point Likert scale response options (1 - never, 2 - rarely, 3 - sometimes, 4 - almost always, 5 - always), as well as the “don’t know” response option. The closed questions were compulsory. The response time was around 10 to 15 minutes.

Data collection

A Google Forms^® form was used for data collection from August 10 to October 7, 2020. The participation link was sent by e-mail by the CROs in each state. This procedure was repeated 15 and 45 days apart.

Considering the General Data Protection Regulation (Lei Geral de Proteção de Dados [LGPD]), the rounds of the survey were sent out by the CROs and, therefore, there was no guarantee of access due to outdated data or spam. Therefore, from the start of the study, it was planned to disseminate the study concurrently with the collaboration of health departments, educational institutions, trade associations, and through social media²⁰. Although this has the advantage of ensuring greater visibility and adherence by those eligible, there is a greater chance of duplicates, since no form of identification was requested, such as: name, council registration number, or e-mail). However, through the answers in Block 1 (sociodemographic, training, and work profile) of the questionnaire, especially state, municipality, age, and type of service, duplicate answers were analyzed and removed.

Data analysis

The Statistical Package for the Social Sciences (Version 25.0 – IBM SPSS Statistics) was used. To enable the extraction and understanding of relevant factors that comprised the work process during the pandemic, Exploratory Factor Analysis (EFA) of the dependent variables was performed.

The Principal Component Analysis command was used, selecting the Varimax rotation technique. The suitability of the data for the application of EFA was assessed using the Kaiser-Meyer-Olkin (KMO) and Bartlett’s sphericity test. The assumption of normality was verified using the Shapiro-Wilk test, and it was found that the items had a non-normal distribution even after logarithmic transformation²⁴.

The chi-square test, adjusted by the Z and Bonferroni tests, and the Mann-Whitney U test (p ≤ 0.05) were used to identify differences between groups of dentists in the public and private sectors regarding the frequencies of the variables of interest.

Missing data were disregarded in the analysis; therefore, the number of valid observations was included for each variable.

Ethical aspects

The research was approved by the Research Ethics Committees (CEP) of the educational institutions involved: State University of Ponta Grossa (CAAE: 31720920.5.1001.0105 - May 13, 2020), Federal University of Paraná (CAAE: 31720920.5.3001.0102 - October 1^o, 2020), Federal University of Santa Catarina (CAAE: 31720920.5.2001.0121 - August 20, 2020), and Federal University of Rio Grande do Sul (CAAE: 31720920.5.2002.5530 - June 4, 2020). The Free and Informed Consent Form (FICF), which was made available before the questionnaire was filled in, was used to include only those who consented and agreed to take part in the research. To ensure the privacy of the participants and the confidentiality of the database, access to the information was restricted and controlled, and the anonymity of the respondents was maintained.

Results

A total of 2,862 responses were obtained during the data collection period. Of these, 11 were excluded for not agreeing to participate, one for not being from an oral health professional, and 290 were automatically duplicated by the Google Forms® platform. The final sample included 2,560 valid responses from oral health professionals. However, 1,941 responses were from dental surgeons, of which 1,721 met the inclusion criteria for this study (Figure 1).

Figure 1
Flowchart of the sample of oral health professionals for the states of the Southern Region and final sample of dental surgeons from public and private services, from August to October 2020.

CD: Dental surgeon; TSB: Oral Health Technician; ASB: Oral Health Assistant; UBS: Basic Health Unit; ESF: Family Health Estrategy; CEO: Dental Specialty Centre; UPA: Emergency Care Unit.

Others: dentists who did not work in clinics during the pandemic, and those who worked in other areas (teaching, hospitals, management, armed forces, Sistema S, and health residency programs).

Of the total of 1,721 participants, the majority were from the public service (50.6%), female (77.4%), aged up to 39 (52.6%). The comparison between the sectors revealed that a higher proportion of public service dentists had not taken time off from work in a dental clinic during the period of data collection (42.6%), and these professionals also had the highest percentage of COVID-19 tests (72.3%) and time off work due to this disease (17.3%) (p < 0.001). The highest proportion of dentists who did not have access to any guidelines (from government bodies or professional associations) for the prevention and control of COVID-19 (7.3%) and who did not have access to technical note GVIMS/GGTES/Anvisa No. 04/2020 (56.8%) were from private services (p < 0.001) (Table 1).

Table 1
Distribution of sociodemographic, training, work, and health characteristics of professionals in public and private dental services. Dental surgeons in the Southern Region, Brazil, from August to October 2020 (n = 1,721)

	Public service	Private service	p-value	Total sample
	n (%)	n (%)		n (%)
Sex (n = 1,720) §			0.001
Female	673 (77.4)	594 (69.9)		1,267 (73.7)
Male	197 (22.6)	256 (30.1)		453 (26.3)
Age* (n = 1,721)			0.268
Up to 39 years old	470 (54.0)	436 (51.3)		906 (52.6)
40 years or older	401 (46.0)	414 (48.7)		815 (47.4)
Length of professional training (n = 1,721)			0.33
Up to 10 years	335 (38.5)	343 (40.3)		678 (39.4)
11 to 20 years	248 (28.5)	215 (25.3)		463 (26.9)
Over 20 years old	288 (33.0)	292 (34.4)		580 (33.7)
Has a postgraduate degree (n = 1,721)			0.364
No	177 (20.3)	158 (18.6)		335 (19.5)
Yes	694 (79.7)	692 (81.4)		1386 (80.5)
Presents risk condition for severe forms of COVID-19 (n = 1,719) §			0.218
No	779 (89.6)	746 (87.8)		1,525 (88.7)
Yes	90 (10.4)	104 (12.2)		194 (11.3)
Absence from work in a dental clinic at some point during the pandemic (n = 1,721)			< 0.001
No	371 (42.6)	134 (15.8)		505 (29.3)
Yes, due to suspicion/treatment of COVID-19	151 (17.3)	51 (6.0)		202 (11.8)
Yes, for other reasons	349 (40.1)	665 (78.2)		1,014 (58.9)
Was tested for COVID-19 (n= 1,721)			< 0.001
No	241 (27.7)	585 (68.8)		826 (48.0)
Yes	630 (72.3)	265 (31.2)		895 (52.0)
Had access to the Ministry of Health guideline for the prevention and control of COVID-19 (NT 04/2020)** (n = 1,721)			< 0.001
No	252 (28.9)	483 (56.8)		735 (42.7)
Yes	619 (71.1)	367 (43.2)		986 (57.3)
Had access to any guidelines (from government bodies or professional councils) for the prevention and control of COVID-19 (n = 1,721)			< 0.001
No	13 (1.5)	62 (7.3)		75 (4.4)
Yes	858 (98.5)	788 (92.7)		1,646 (95.6)
Received guidance in the workplace on measures to be taken during the COVID-19 pandemic** (n = 1,721)			0.016
No	173 (19.9)	210 (24.7)		383 (22.3)
Yes	698 (80.1)	640 (75.3)		1,338 (77.7)

• ^a Chi-square test, with Bonferroni correction, for differences between public and private (p < 0.05)
• * Categorized by median; **Technical Note GVIMS/GGTES/ANVISA No. 04/2020;
• *** Yes: totally agree/partially agree; No: neither agree nor disagree/partially disagree/completely disagree;
• ^§ Some variables have missing data.

The dimensions shown in Table 2 were defined as a result of exploratory factor analysis (EFA). Eight factors were identified with Eigenvalues > 1.0, which explained a significant part (55.7%) of the total variance in the data. The factor with the greatest explanatory power was related to the availability and use of personal protective equipment (PPE) considered conventional - procedure gloves, caps, goggles, and surgical masks (dimension 1), with the N95/PFF2 mask (dimension 5) and waterproof apron (dimension 6) constituting individual factors. The organization of health services (dimension 2) and dental care (dimension 3), and biosafety in the office (dimension 4) complement the factors with the greatest share in the variance of the data. The factors related to the care of contaminated PPE, and the reception and screening of suspected cases played a lesser role in the model (dimensions 7 and 8).

Table 2
Exploratory Factor Analysis (EFA) regarding the work process and biosafety measures to control the spread of COVID-19, in a sample of dentists from the public and private sectors in the South of Brazil, from August to October 2020 (n = 1,721)

Questionnaire items**				Dimension (factor loadings)*
	1	2		3	4	5	6	7	8	Total
1 - Availability and use of PPE
Procedure gloves available	0.810
Wears procedure glove	0.805
Cap available	0.773
Wears cap	0.747
Goggles available	0.666
Surgical mask available	0.646
Face shield available	0.556
Wears goggles	0.541
Wears face shield	0.515
Wears surgical mask	0.513
2 - Organization of the health service
In the waiting room, a minimum distance of one meter was respected between each person		0.692
Participated in decision-making about changes at work during the pandemic		0.677
Use of digital tools for teleorientation or telemonitoring		0.535
Investigation of respiratory infection symptoms when scheduling appointments		0.533
There was a reduction in the workload or turnover of professionals to minimize the risk of contamination		0.524
Patients with symptoms of respiratory tract infection were immediately isolated		0.479
Interaction with other health professionals during the pandemic		0.411
3 - Organization of dental care
Elective procedures were suspended, care restricted to urgencies and emergencies			0.781
Procedures that generate aerosols were avoided			0.759
Intraoral radiographic exams were avoided and/or requested			0.695
Definition of urgency is based on previously established clinical protocols			0.558
Four-handed dental procedures			0.482
4 - Biosafety in the dental office
Wears a rubber dam when using high-rotation pens					0.667
Uses high-powered suction system (vacuum pump)					0.657
Use sterile handpieces at every dental appointment					0.599
Cleaning/disinfection of suction hoses at each service					0.571
Cleaning/disinfection of the environment carried out by a trained professional using appropriate PPE					0.410
5 - Availability and use of the N95 mask
Wears N95/PFF2S mask/or equivalent						0.758
Reuse of N95/PFF2 mask with safety criteria						0.683
N95/PFF2S mask/or equivalent available						0.652
6 - Availability and use of waterproof aprons
Wears a waterproof apron							0.858
Waterproof apron available							0.840
7 - Care of contaminated PPE
Cleaning and disinfecting the face shield after each visit								0.719
Visual alerts are available in the health service								0.454
Dismounting is carried out in the recommended sequence								0.453
8 - Reception and screening of suspected cases
Works on COVID-19 reception/screening/fast track actions									0.491
Oral health professional advises patients on COVID-19									0.433
Eigenvalues	7.18	3.86	2.98		1.74	1.29	1.23	1.19	1.15	20.62
Variance (%)	19.41	10.43	8.05		4.69	3.49	3.32	3.22	3.12	55.74

• * Rotation method: Varimax with Kaiser normalization, convergent rotation in nine iterations; KMO test = 0.850/Bartlett’s sphericity (Chi-square) = 17830.87 (p < 0.001).
• ** Likert scale responses: 1 - never, 2 - rarely, 3 - sometimes, 4 - almost always, 5 - always; “don’t know” responses were considered missing.
• PPE: Personal protective equipment.

The results regarding the work process and good practice measures to control the spread of COVID-19 in public and private services are shown in Table 3 and Figure 2, according to the dimensions.

Table 3
Distribution of professionals regarding the work process and adoption of biosafety measures to control the spread of COVID-19 in public and private practices, in a sample of dental surgeons from the Southern Region of Brazil, from August to October 2020 (n = 1,721)

	Public service (n= 871)	Private service (n= 850)	p-valuea	Total sample (n= 1721)
	M(d) (IQR)*	M(d) (IQR)*		M(d) (IQR)*
1 - Availability and use of PPE
Sufficient PPE available:
Cap	5 (5-5)	5 (5-5)	0.032	5 (5-5)
Procedure gloves	5 (5-5)	5 (5-5)	0.007	5 (5-5)
Goggles	5 (5-5)	5 (5-5)	0.463	5 (5-5)
Surgical mask	5 (5-5)	5 (5-5)	< 0.001	5 (5-5)
Face shield	5 (5-5)	5 (5-5)	0.787	5 (5-5)
PPE used in patient care:
Cap	5 (5-5)	5 (5-5)	0.235	5 (5-5)
Procedure gloves	5 (5-5)	5 (5-5)	0.011	5 (5-5)
Goggles	5 (5-5)	5 (5-5)	0.468	5 (5-5)
Surgical mask	5 (5-5)	5 (5-5)	0.004	5 (5-5)
Face shield	5 (5-5)	5 (4-5)	< 0.001	5 (5-5)
2 - Organization of the health service
In the waiting room, a minimum distance of one meter was respected between each person	5 (4-5)	5 (5-5)	< 0.001	5 (4-5)
Participated in decision-making about changes at work during the pandemic	2 (1-4)	5 (4-5)	< 0.001	4 (1-5)
Use of digital tools for teleorientation or telemonitoring	2 (1-3)	3 (2-5)	< 0.001	3 (1-5)
Investigation of respiratory infection symptoms when scheduling appointments	5 (4-5)	5 (4-5)	< 0.001	5 (4-5)
There was a reduction in the workload or turnover of professionals to minimize the risk of contamination	2 (1-4)	4 (2-5)	< 0.001	3 (1-5)
Patients with symptoms of respiratory tract infection were immediately isolated	5 (4-5)	5 (4-5)	0.007	5 (4-5)
Interaction with other health professionals during the pandemic	4 (3-5)	4 (3-5)	< 0.001	4 (3-5)
3 - Organization of dental care
Elective procedures were suspended, care restricted to urgencies and emergencies	5 (4-5)	3 (2-4)	< 0.001	4 (3-5)
Procedures that generate aerosols were avoided	4 (3-5)	2 (1-3)	< 0.001	3 (2-4)
Intraoral radiographic exams were avoided and/or requested	4 (3-4)	2 (1-3)	< 0.001	3 (1-4)
Definition of urgency is based on previously established clinical protocols	5 (4-5)	4 (3-5)	< 0.001	5 (4-5)
Four-handed dental procedures	5 (3-5)	2 (1-4)	< 0.001	4 (2-5)
4 - Biosafety in the dental office
Wears a rubber dam when using high-rotation pens	1 (1-3)	3 (2-4)	< 0.001	2 (1-3)
Uses high-powered suction system (vacuum pump)	1 (1-5)	5 (3-5)	< 0.001	4 (1-5)
Use sterile handpieces at every dental appointment	3 (1-5)	3 (2-5)	0.001	3 (1-5)
Cleaning/disinfection of suction hoses at each service	3 (2-5)	5 (3-5)	< 0.001	4 (2-5)
Cleaning/disinfection of the environment carried out by a trained professional using appropriate PPE	4 (2-5)	5 (4-5)	< 0.001	5 (3-5)
5 - Availability and use of N95 masks
Wears N95/PFF2S mask/or equivalent	5 (4-5)	5 (3-5)	0.003	5 (4-5)
Reuse of N95/PFF2 mask with safety criteria	5 (4-5)	5 (3-5)	< 0.001	5 (3-5)
N95/PFF2 mask or equivalent available in sufficient quantity	5 (4-5)	5 (3-5)	0.174	5 (4-5)
6 - Availability and use of waterproof apron
Wears a waterproof apron	5 (3-5)	5 (3-5)	0.416	5 (3-5)
Waterproof apron available	5 (2-5)	5 (3-5)	0.006	5 (3-5)
7 - Care of contaminated PPE
Cleaning and disinfecting the face shield after each visit	5 (5-5)	5 (5-5)	0.43	5 (5-5)
Visual alerts are available in the health service	4 (2)	5 (3-5)	0.124	5 (3-5)
Dismounting is carried out in the recommended sequence	4 (2)	5 (3-5)	0.063	4 (3-5)
8 - Reception and screening of suspected cases
Works in COVID-19 reception/screening/fast track actions	2 (1-3)	1 (1-3)	< 0.001	1 (1-3)
Oral health professional advises patients on COVID-19	4 (3-5)	5 (3-5)	0.226	4 (3-5)

• * Md (IQR) - median (interquartile range) of answers on a Likert scale of frequency: 1 - never, 2 - rarely, 3 - sometimes, 4 - almost always, 5 - always; ‘don’t know’ answers were considered missing.
• ^aMann-Whitney U-test for differences between public and private (p< 0.05).
• PPE: Personal Protective Equipment.

Figure 2
Distribution of professionals regarding the high availability and use of personal protective equipment in public and private practices, in a sample of dental surgeons in the South Region, Brazil, from August to October 2020 (n = 1,721).

Likert frequency scale score 5 (always); ‘don’t know’ answers were considered missing data. Chi-square test for differences between public and private (p < 0.05).

PPE: Personal protective equipment.

As for dimension 1, conventional PPE and face shields were reported as being available and used, with more than 75% of participants reporting that they were always available and used (Table 3). According to Figure 2, the private sector had the highest availability of caps, procedure gloves and surgical masks (p≤ 0.05).

Regarding dimension 2, there was a lower frequency of reduced working hours or turnover of professionals, use of digital tools, and interaction with other health professionals. The greatest amplitude, with an interquartile range varying between scores of 1 (never) and 5 (always), was identified for participation in decision-making, reduction in working hours and the use of digital tools. Dentists in private practice adopted measures related to this dimension more frequently (p < 0.001) (Table 3).

Regarding dimension 3, the greatest amplitude was identified for avoiding intraoral radiographs and carrying out four-handed procedures, which were also the least frequently adopted measures. Dental surgeons in public services reported adopting the rules more frequently than those in private services (p < 0.001) (Table 3).

On the other hand, regarding dimension 4, private practice dentists reported more frequent use of rubber dams, high-power systems and sterilized handpieces at each dental appointment, as well as more frequent cleaning/disinfection of suction hoses and the environment by trained professionals using appropriate PPE (p ≤ 0.001) (Table 3).

Two items of PPE that were added to the routine due to the COVID-19 pandemic, N95/PFF2 masks and waterproof aprons, showed a lower frequency of availability and use than conventional PPE. Dimension 5 included the variables related to the N95/PFF2 mask (Table 3). The private sector showed greater availability of the N95/PFF2 mask and waterproof apron (p ≤ 0.003), while the public sector showed greater use of the mask (p = 0.013) (Figure 2). Regarding dimension 8, professionals in the public sector had the highest frequency of working in COVID-19 reception/screening/fast track actions (p < 0.001) (Table 3).

Discussion

This study reveals that there were differences in the implementation of measures to control the spread of COVID-19 between public and private dental surgeons. Despite the increased discussion about the pandemic as the number of cases evolved, little evidence regarding the implementation of biosafety measures in public and private dental services has been published¹⁵,¹⁶.

In the present study, data collection took place when Brazil was experiencing a decline in new cases and deaths in the first wave of the pandemic²⁵. Its results are influenced by the epidemiological context and regulations in force at that time¹, and the data should be interpreted with caution, considering this scenario.

Most participants in this study were professionals working in the public service, unlike another study carried out on COVID-19 in another country²⁶. This greater adherence may have been due to the different strategies used to publicize the study, since there was direct contact with health departments, live streams on the subject, and discussion of experience reports²⁰.

In the context of the pandemic, dental surgeons were forced to adopt new routines in the work process, such as: adherence to new PPE (N95 mask, face shield, and waterproof apron), decontamination protocols, and the organization of patient demand. In this sense, these factors had an impact on the variation in procedures and the increase in costs⁷,²⁷. The lower suspension of elective procedures in the private service, as in this study, may be influenced by economic issues, since many professionals depend on the flow of patients to meet their financial expenses²⁸. From this perspective, the instability and financial insecurity of the private sector seem to outweigh the insecurity related to the occupational risks and illness of COVID-19²⁹, similar findings were identified in a study carried out in Brazil in May 2020⁷. The negative financial effects for the private sector and insufficient biosafety for the public sector reinforce the existence of inequalities between the systems in which oral health professionals work³⁰.

The differences found between the public and private sectors in relation to the availability, use and/or reuse of some PPE, such as face shields, surgical masks, N95/PFF2 masks, and waterproof aprons, may reflect greater autonomy and less bureaucratization in the purchase of PPE in the private sector, while at the same time they may demonstrate a prioritization of the allocation of supplies to public health services and/or health professionals working on the front line⁷. It should be noted that in the early stages of the pandemic, PPE stocks became scarce, and some proposals suggested rationing and controlling the allocation of this equipment²⁷. However, the greater or equal availability of PPE was not reflected in the greater frequency of availability for some PPE, such as the use of face shields and N95/PFF2 masks, which were used more by public service dentists. Greater knowledge of and/or adherence to biosafety protocols regarding the measures to be taken during the pandemic may have contributed to the greater use of PPE by these professionals.

The fact that public dental surgeons have carried out a greater number of tests for SARS-CoV-2 and had a higher percentage of positives throughout the pandemic may have influenced the greater absence due to suspicion or treatment of COVID-19 in public services. In this sense, it is clear that Brazil has faced challenges in expanding its COVID-19 testing capacity, such as the supply and import of diagnostic components³¹. The Brazilian Ministry of Health has included in its planning the offer of COVID-19 tests for health professionals³². Despite this, many professionals have reported difficulties in accessing the tests and, consequently, not having them carried out³³. It is possible that public service professionals had easier access to testing for SARS-CoV-2 due to the possibility of their workplace being a testing point for the population.

In this study, there was a lower frequency of four-handed work in private services. With a view to reducing costs, depending on the complexity of the procedures, dental surgeons did not work with assistants. Unlike this logic, in the public sector, there is a prioritization of auxiliary work in dentistry, which may reflect the incentives for the implementation of the Oral Health Team in the SUS³⁴. The COVID-19 pandemic has alerted professionals to the occupational risks of individualized work, both during and after clinical care. Four-handed work respects the precepts of ergonomics and biosafety with greater quality and effectiveness, as well as reducing the time it takes to provide care and, therefore, making professionals and users less vulnerable to becoming ill³⁵.

Professionals in both sectors had low adherence to teleodontology, while the private service showed greater frequency in the use of digital tools for teleguidance or telemonitoring. Tele-dentistry has been highlighted as an important tool for increasing the effectiveness of primary health care and improving the quality of oral health care provided³⁶. In Brazil, this modality was regulated belatedly, so that the pandemic encouraged this process through CFO resolution No. 226/2020³⁷. In this sense, the decision to incorporate teleodontology in Brazil was a decisive measure for reducing occupational risk, but it was not effective due to these limiting factors. There are several challenges to the implementation of teleodontology, such as the lack of knowledge among professionals and patients about how to use technological equipment, the need for resources, infrastructure and technology³⁸. In view of this, there is an urgent need for continuous education and training to ensure the acceptability and applicability of this tool³⁹.

This research has some limitations. The data cannot be extrapolated to the context of Brazil, as the results reflect the characteristics of respondents from the southern region of the country, and may not represent the particularities of all regions of the national territory. There are limitations and challenges to the development and implementation of websurveys. There is no space for participants to ask questions; the population that accesses the Internet is heterogeneous. Furthermore, the messages that researchers send to respondents may not reach their intended destination⁴⁰, and selection bias may occur. To minimize these limitations, a great effort was made to reach and raise awareness among as many professionals as possible, by widely publicizing the survey; as well as controlling the responses and making three attempts to send the e-mails. This research followed a rigorous method in its planning and development of an instrument that would reliably address the subject under study. The identification, in this article, of the differences in the work process between dental services can provide subsidies for directing policies to deal with future crises similar to this one.

Conclusion

In conclusion, this study analyzed four dimensions related to biosafety for controlling the spread of COVID-19: availability and use of PPE; organization of the health service; organization of dental care; and biosafety in the dental office. It was possible to identify that dental surgeons in public and private services in southern Brazil showed differences in the adoption of these measures. In the private sector, there was greater adherence to measures related to biosafety in the dental office, and greater frequency of cleaning and disinfecting equipment (suction hoses and the use of face shields) and environments, as well as greater maintenance of conventional attitudes (those commonly used before the pandemic) in relation to clinical procedures. In the public sector, there was greater adherence to biosafety measures for dental care, such as assisted work and the reduction of elective and aerosol-generating procedures, but less adherence to the service’s organizational measures, and less use of measures dependent on equipment and materials and technologies.

It should be noted that whether certain biosafety measures are adhered to depends on the availability of adequate materials, supplies and infrastructure. With this in mind, this study only assessed the availability of PPE; for the other biosafety measures, availability was not assessed. It should be emphasized that the public sector has also been affected by financial problems during the pandemic, which may influence the proper implementation of biosafety measures. The SUS has been facing structural challenges that have been exacerbated by fiscal austerity measures and policies adopted by the federal government⁴¹. These factors, coupled with the underfunding of the public health system, may be related to the lower resilience that Brazil has had to face the pandemic⁴². In a post-pandemic scenario, strengthening the SUS and improving its management should be on the agenda of health and other sectors of society⁴².

This study points to risks not only for patients, but also imminent occupational risks for dental surgeons in both sectors, considering that during the first phase of the COVID-19 pandemic they did not have access to biosafety standards to deal with the pandemic, did not suspend elective care, did not always have PPE available to minimize the risks of contamination, or did not use it when available. The treatments analyzed in this study were mainly urgent and the benefits outweighed the risks. It should not be overlooked that the dentists faced ethical dilemmas and suffering⁴³. It should be noted that the work process under pandemic conditions can lead to difficulties in understanding elective care and prioritization of emergencies; access to services; and implementation of biosafety protocols⁴³. All these aspects can have an impact on workers, resulting in anguish due to the demands of the population, fear due to the pandemic, exhaustion at work and neglect by management⁴³. In this sense, it is important to provide more publicity and training for access to and application of biosafety standards and their updates, psychological support and monitoring for professionals in both sectors, as well as greater awareness and enforcement to mitigate occupational risks during dental care.

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• Information on academic work:
  The authors inform that the work was based on the doctoral thesis of Renata Cristina Soares Fornazari, entitled “Análise das diretrizes de biossegurança frente à covid-19 e implementação no ensino e nos serviços odontológicos no Brasil (Analysis of biosafety guidelines in the face of covid-19 and implementation in teaching and dental services in Brazil)”, presented in 2024 to the Postgraduate Program in Dentistry at the State University of Ponta Grossa.
• Data availability:
  The entire data set supporting the results of this study is in the SciELO Data repository, available from: https://data.scielo.org/dataset.xhtml?persistentId=doi%3A10.48331%2FSCIELODATA.KFHUZ7&version=DRAFT
• Presentation at a scientific event:
  The authors inform that the study was presented at a scientific event: 38Meeting of the Brazilian Society of Dental Research, held in 2021.
• Funding:
  The authors declare that the study was not subsidized.

Edited by

• Editor-in-chief:
  Leila Posenato Garcia

Data availability

The entire data set supporting the results of this study is in the SciELO Data repository, available from: https://data.scielo.org/dataset.xhtml?persistentId=doi%3A10.48331%2FSCIELODATA.KFHUZ7&version=DRAFT

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2025

History

• Received
  18 Mar 2025
• Reviewed
  23 June 2025
• Accepted
  24 June 2025