Evaluation of Knowledge, Awareness, Preparedness, and Measures among Dental Technicians Attending COVID-19 in Jordan

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INTRODUCTION
In early 2020, a pandemic of the 2019 coronavirus disease  began, and a virus originating from China started to blow out worldwide. The rapid increase in confirmed cases made the prevention and control of COVID-19 extremely seri-reduced effectiveness of treatment which result in high fatalities around the world [1]. Most recently, the virus has spread worldwide as an Omicron variant; this is a heavily mutated variant of SARS-COV-2 with a high transmissibility rate but reduced severity of the disease [2].
In dental practice, many reports concluded that dental team members are at high risk of transmitting microbes and pathogens due to frequent contact with the patient's blood and saliva during different dental procedures [3]. Regarding COVID-19, direct contact with human saliva means contact with salivary gland excretions, food residues, serum components, microorganisms and their metabolites, and epithelial and white blood cell residues. According to some studies, the main targets of SARS-CoV-2 are cells expressing the angiotensin-converting enzyme 2 (ACE 2). Salivary gland epithelial cells express ACE2.5. Thus, after the entry of the virus into the body, the salivary gland can get infected, and the saliva produced by these glands can be an important source of cross-infection [4].
Moreover, indirect contact between dental team members and patients through contaminated sharp instruments, acrylic debris, dental impressions, gypsum models, restorations, and non-disinfected dental appliances was reported as crosscontamination vehicles in dental clinics and dental laboratories, which oppose health hazards to members of the dental team and patients [5,6].
Awareness of cross-infection is very important to the dental team; it is also necessary for dentists and dental technicians to adapt their knowledge and adherence to infection control [7]. However, there are practical guidelines recommended for dentists and dental staff by the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), and the World Health Organization to control the spread of COVID-19 [8,9] Measures practiced by healthcare personnel to reduce the risks of transmission of infectious agents to patients and the healthcare staff generally include proper hand hygiene, scrupulous work practices, and the use of personal protective equipment (PPE). The personal protective equipment (PPE) at dental clinics includes disposable caps, gowns, gloves, face masks and the use of protective eyewear. They are recommended to be used at all times when treating patients or dealing with patients' impressions and restorations [10]. During the Pandemic, some studies concluded more specific measures where they highlighted the importance of using Na5type masks which allow <0.3 µm particles to pass, rather than ordinary surgical face masks [11]. Also, using face shield to protect the whole face from aerosol and debris rather than using eyewear only was recommended [12].
Various studies in the field of dentistry are in progress, but there are few studies on dental laboratories and dental technicians [13,14]. In Jordan and up to the best of our knowledge, there is no studies assessing the knowledge, awareness, and measures of dental technicians attending the COVID-19 pandemic. Therefore, the aim of the current survey is to assess the level of knowledge among dental technicians in Jordan in regard to COVID-19, to assess the awareness of cross-infection control, and the precautions among dental technicians in Jordan in regard to . Also, to investigate the measures and attitudes that help in protecting dental technicians while dealing with cases throughout the COVID-19 pandemic.

Study Population
The study population consisted of dental technicians who work in public and private dental laboratories in Jordan. Participants were contacted using social media applications such as Facebook and WhatsApp. Only actively registered dental technicians in the Jordanian Dental Technology Association were contacted through the official WhatsApp and Facebook groups, and their responses were considered. In order to achieve a national survey, the participants were selected from the north, middle and south parts of Jordan.

QUESTIONNAIRE DEVELOPMENT, ADMINISTRA-TION, AND DESIGN
A questionnaire consists of six sections and 40 questions overall. It's self-designed to evaluate the knowledge, preparedness, awareness, and infection control measures regarding COVID-19 and practicing dental laboratory procedures during the pandemic amongst the population of the study. Participants in this survey involve dental technicians who are currently working in public and private dental laboratories in Jordan.
The tool utilized for data collection was specifically designed as an online Google Forms questionnaire. Forty close and open-ended questions were divided into six main categories.
The questionnaire was validated, and a consent form was sent to participants. Participants should be legally registered dental technicians. The questionnaire was validated by several experts in the field and pre-tested by 10 dental technicians, which were not included in the analysis.

ETHICAL APPROVAL
The questionnaire was anonymous to maintain the privacy and confidentiality of all information collected in the study. All procedures performed in the study were in accordance with the ethical standards of the institutional research committee. The ethics approval for conducting this study was granted by the Institutional Review Board (IRB) committee at the Jordan University of Science and Technology.

DATA ANALYSIS
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 20 (SPSS ® : Inc., Chicago, IL, USA). Data were described using means, standard deviations (SD), and percentages.

RESULTS
This study included a total of 90 dental technicians (31 females and 59 males), forming a response rate of about 26%.
Their age ranged from 22-60 years old, with 62% of them being younger than 40 years old. More demographic characteristics of the current study population are shown in Table 1.
A big majority of the participants were able to identify common symptoms of COVID-19. Most participants reported shortness of breath, coughing, and fever as the most common symptoms of the infection. These were followed by sore throat, muscle and joint pain. More than half (86.7%) of participants reported that COVID-19 may not present any symptoms.
Knowledge about very well-known general vehicles like touching surfaces, coughing, and handshaking was reported by more than 95% of participants. However, transmission ways related to dental clinics and dental laboratories, like impression tray handles, handpieces, and contaminated instruments, were also highly reported by participants (>90%) ( Table 2).

Measures should be taken to Prevent Transmission from known or Suspected COVID-19 Patients
Frequently clean hands by using alcohol-based hand rub or soap and water 90 100.0 Put facemask all the time during work 88 97.8 Change face masks and gloves between cases 81 90.0 All dental laboratory staff members wear protective clothing 85 94.4 Avoid sharing instruments between dental laboratory staff members 83 92.2 Routinely clean and disinfect surfaces in contact with impression, models and restorations 87 96.7 Accept impressions that sustain delay pouring 57 63.3 Encourage dentist to send digital impressions 80 88.9 Accept only approved sterilized impressions, restorations and prosthesis from clinic 80 88.9 Prevent any patient from entering the laboratory premises 87 96.7 Disinfect impressions by immersion in recommended 88 97.8  Most of the participants were aware of the protective measures that should be taken to protect themselves from the infection. The majority of participants (88.9%) reported encouraging dentists to use digital impressions and accepting only approved sterilized impressions as a key protractive measure among dental staff in particular. However, accepting impressions that sustain delayed pouring was only reported by 63% of participants.

Sources of Information
The majority of participants, 80 (94.8%), had up-to-date information about COVID-19; when the participants were asked about the source of information regarding the virus, 87 (96.7%) reported that government organizations, such as the Ministry of Health, were the main source of information. Social media platforms were reported by 90% of participants as their second trusted source of information and statistics about COVID-19.
Almost half the participants (51%) declared that they had received training regarding infection control in dental laboratories, but only 10% had attended the training or received lectures about COVID-19 in specific.
More than half the participants (61.1) considered themselves prepared to work after the COVID-19 outbreak. Less than half of the dental technicians reported that they could receive impressions for suspected patients (32.2%) or from suspected dentists (30%). So, the majority of the participants (90%) believe that asking dentists to send digital impressions instead of conventional impressions is necessary and will significantly reduce the possible transmission of the COVID-19 virus. Nevertheless, 73 (81.1%) dental technicians knew who to contact in case of unprotected exposure; also, 93.3% knew how to act if they felt any symptoms of the virus ( Table 3).
More than half of the participants, 59 (65.6%), perceived COVID-19 as very dangerous, while only 1 dental technician considered COVID-19 as non-dangerous. In regard to the transmission risk to dentists and dental technicians, 68.9% found that it is a high risk for dentists, and 42.2% stated that there is a very high risk of transmission to dental technicians.  In terms of dealing with impressions, restorations and dentures for confirmed cases/suspects of COVID-19 at dental laboratories, 22-27% of dental technicians considered themselves not confident at all in dealing with such cases. Most dental technicians, 81 (90%), reported that they perceived the importance of changing both masks and gloves to decrease the possibility of transmitting the virus to patients and to themselves ( Table 4).
Despite the general behaviors and cross-infection control protocols, which include washing hands, wearing face masks, using disinfectants, and other measures which were reported by almost all the participants. Special measures were adopted to reduce the transmission/spread of the infection at dental laboratories, as well as between the dental clinic and dental laboratory, such as; using sterilized instruments 96.7%, routinely disinfecting the surfaces in contact with the impressions 97.8%, and reduce the staff members working in the laboratory at the same time to be maximum 3 persons 98.9% ( Table 5).

DISCUSSION
Dental health professionals, including dentists, dental hygienists, dental assistants, and dental technicians, are more likely at high risk of having COVID-19. Dental procedures used for dental treatment in dental office and dental laboratories increase the risk of transmission between dental professionals and patients [14].
This study aimed to assess Jordanian dental technicians' knowledge about COVID-19, awareness about infection control protocols relating to COVID-19, and infection management measures that help them while dealing with cases during the pandemic.
The current survey included a sample of Jordanian dental technicians. Males were predominant in this sample, which might be explained by the number of male dental technicians in Jordan being higher than the number of female dental technicians based on The Jordanian Dental Technician Association. A similar observation was noted in a study conducted among Libyan clinical dental technicians [15].
The majority of Jordanian dental technicians reported most of the COVID-19 symptoms. Many participants reported fever, cough, and respiratory problems as the main symptoms of COVID-19, which reflect the ability to recognize the suspected cases and take the required precautions and follow the guidelines that lessen the spread of the disease [1, 10]. The ability of dental health professionals to report most of the COVID-19 symptoms was in agreement with previous studies [15 -17]. However, the most known COVID-19 symptom, according to Jordanian dental technicians in the current study, was shortness of breath, which disagrees with Mansour et al. (2021), where sore throat was the most common symptom reported by Libyan clinical dental technicians [15]. Also disagrees with Khader et.al, where Jordanian dentists stated that fever was the most common symptom of .
The most known mode of COVID-19 transmission as reported by Jordanian dental technicians, was touching surfaces. This is contrary to a study conducted among Libyan clinical dental technicians, where handshaking was the most reported mode of transmission [15]. Consequently, these professionals are less likely to increase the transmission risk for others due to their solid knowledge of COVID-19 transmission modes. Thus, dental technicians are capable of controlling the spread of the disease to help in shrinking the possibility of having new cases of COVID-19.
The most reported protective measure among Jordanian dental technicians was washing hands using alcohol-based hand rub or soap and water regularly. However, the most reported measures employed in the dental lab were cleaning and disinfecting surfaces in contact with the impression, models, and restorations regularly. These results agree with the review study conducted two years ago in China stating the prevention measures employed in Chinese dental institutions [18]. Furthermore, similar results were reported recently by Indian dental technicians working in armed forces hospitals where the same common measures were mentioned [19].
Regarding the source of information, government organizations were the main source. This might be explained because the Jordanian Ministry of Health was actively working toward preventing and controlling COVID-19 spreading via training courses, educational videos, and brochures for both healthcare professionals and the general population [20]. However, evidence-based guidelines, training, or treatment specifically in dental settings worldwide have not been provided until late 2020 [7]. According to the Australian Dental Association, the first risk management principles for dentistry during the COVID-19 pandemic were published on 22 October 2021 [21]. Preventing and controlling the spread of the disease was via controlling the source of infection, using prevention measures, isolation, and providing supportive care for patients [22].
Social media was the second source of information regarding COVID-19. According to Sahni & Sharma 2020, social media during the COVID-19 pandemic has different roles; beneficial, destructive, or reconstructive. Social media has positive and negative impacts on the general population and health professionals [23,24]. Social media has a significant role in disseminating information, increasing awareness, education, and health care during the COVID-19 crisis with preserving social distancing [24]. On the other hand, the negative impact of social media should not be neglected, which includes sharing inaccurate medical information and fake material without professional supervision that enables users to distinguish between true and false information. However, "if used wisely and prudently, social media serves as a powerful tool for changing people's behavior and to promote the well-being of individual and public health." [23].
Several dental technicians reported preparedness to work attending COVID-19, which might be explained since about half of the participants in this study received general training in infection control in dental laboratories and some focused training sessions regarding COVID-19. However, the majority would prefer to avoid working with suspected COVID-19 cases; this might be explained by the 95.6% of the dental technicians in the current study listed the risk of COVID-19 transmission as high to very high and the perceived seriousness of COVID-19 as very dangerous. A different observation was noted in a previous study where participants perceived COVID-19 as moderately dangerous. However, most of the Jordanian dental technicians prefer not to work with suspected cases to reduce the risk of having COVID-19 which is in agreement with previous findings By Mansour et al. 2020 [15].
The perception of the disease's seriousness was reflected by the response of dental technicians to dealing with impressions, restorations, and dentures. The participants perceived low confidence in dealing with COVID-19 cases/suspected cases. This perception of this disease is not surprising due to its threat; there were many cases of COVID-19 in Jordan at the time of data collection.
Due to the fear of high-risk transmission, dental technicians perceived the importance of using new masks and gloves between patients to lower the risk of disease transmission. The use of personal protective equipment and changing the masks and gloves is recommended by WHO to prevent infection when COVID-19 is suspected. The COVID-19 virus remains on hard surfaces, including dental devices and benches, for hours and days and then can be transferred to the hands and faces of the dental team members [25]. Dental health professionals are recommended to follow these guidelines to reduce the risk of transmission and decrease dental procedures that may increase dental aerosols and droplets.
Dental technicians in this study have reported different behaviors that are considered, from their perspective, necessary to control and manage the spread of the disease. Regarding Jordanian dental technicians' behavior toward protective measures, the majority reported that conventional personal protective equipment (PPE), such as masks, gloves, safety glasses, and lab coats, are needed to prevent the transmission of COVID-19. Disinfection, sanitation, and social distance procedures were reported by the participants to reduce the risk of disease transmission [22]. A similar observation was noted in a study conducted among Poland dental practitioners who considered these behaviors as necessities in dental practices during . Chu et al. analyzed 172 studies' results regarding protective measures against COVID-19; all 172 studies confirmed that physical distancing of 1m or more and wearing face masks by healthcare workers and people in the community were very effective in reducing transmission of the virus and eye protection added benefit [12]. These results are similar to previous studies where dentists and dental technicians changed their patient protocol to reduce the risk of transmission [14,26].
Although, a few dental technicians in the current study reported that they thoroughly disinfect the conventional dental impressions, which, as in a previous study by Meng et al. 2020 [14]. Extra protective measures should be adopted to minimize the risk of COVID-19 transmission through conventional impressions and non-sterilized dental appliances and restorations. Subsequently, digital dentistry employment was highly recommended by Jordanian dental technicians to reduce the risk of virus transmission.
A scoped review by Markarian et al. (2020) on the clinical relevance of digital dentistry during the COVID-19 pandemic has identified many advantages of digital workflows in different fields of dentistry compared to the conventional techniques in treating patients during the COVID-19 pandemic. For example, in prosthodontics, the field of study, using CAD-CAM procedures result in a reduction in chairside time and the number of appointments. Another example is implant dentistry, in which using prosthetically-driven guided surgery results in decreasing surgical time and the number of appointments. This review emphasizes the importance of using digital dentistry to increase safety and reduce COVID-19 transmission [27].
Furthermore, dental technicians are encouraged to use digital dentistry, such as using digital impressions and avoiding conventional impressions that have biological materials that might increase the risk of disease transmission [28]. Additionally, dental laboratory workflow consumes less time and a smaller number of workers [27].
According to Stoeva et al., the implantation of such protective measures provides a safe environment and safe care to the staff in dental offices and laboratories [28]. According to CDC, these actions might reflect on the participants' understanding of how the transmission of COVID-19 occurs; through direct contact between contaminated hands and mucus membranes [10]. In addition, it might reflect an awareness of the evidence-based guidelines and recommendations which were established by the CDC to guide infection prevention and control of COVID-19 transmission. A well-informed dental health professional on COVID-19 might be a good source to disseminate the correct knowledge and information in the community to create a safe environment for patients and the dental team.
Despite the valuable information gathered, the current study had a few limitations. The validity and reliability of this study may be affected by the following: the response rate was relatively low, which resulted in a relatively smaller sample size than expected; therefore, findings may be generalized only to similar populations; the study results were self-reported responses and may have participant bias; active participants on social media had the chance to be part in this study, which might be resulting in a selection bias that effects generalizability of the study results.

CONCLUSION
In conclusion, within the limitations of the current study, most Jordanian dental technicians have sufficient knowledge about COVID-19 and showed knowledge of the disease in terms of symptoms, mode of transmission and preventive measures to deal with infected or suspected cases. However, most of them were found not confident or prepared to deal with impressions, restorations, and dentures of suspected cases. Educational and training programs regarding COVID-19 among dental technicians are significantly needed.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The ethics approval for conducting this study was granted by the Institutional Review Board (IRB) committee at the Jordan University of Science and Technology.

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committees and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION
The questionnaire was validated, and a consent form was sent to participants. Participants should be legally registered dental technicians.

STANDARDS OF REPORTING
STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of the article is available in the Zenodo repository at https://zenodo.org/deposit/7940 292, reference number 95636ecbde2c46a0461a3561cdf3d1e.