IMPACT OF PAST EPIDEMICS ON MENTAL HEALTH

It is essential to consider the impact of past epidemics on psychological well-being. Data from the last epidemics showed that quarantined patients developed psychiatric symptoms. Due to its high mortality and infection rate, the severe acute respiratory syndrome (SARS) epidemic caused anxiety and panic in the affected countries, ^{Reference Sim, Chong, Chan and Soon11} and patients infected with Middle East respiratory syndrome coronavirus (MERS-CoV) had a significant impact on their mental health during quarantine. ^{Reference Kim, Yoo and Lee12}

COVID-19 was initially detected in 2019 in Wuhan city, Hubei Province, China. ¹³ The rapid increase of contagions and fast-spreading virus caused the WHO to raise the disease to pandemic status in March 2020. ² This quarantine has produced many stressful life events: the loss of freedom, separation from relatives and loved ones, and the inability to work has harmed mental health. ^{Reference Fiorillo and Gorwood4,Reference Brooks, Webster and Smith14}

IMPACT OF COVID-19 PANDEMIC ON THE DENTIST’S LIFE

General measures have been established for all, including HCWs, but, in addition to social distancing and mobility restriction measures, HCWs have to wear stricter personal protective equipment (PPE) at work. ^{Reference Spagnuolo, De Vito, Rengo and Tatullo3,Reference Guo, Xie, Liang and Wu15} Regrettably, with the lack of PPE for health care personnel, COVID-19 has revealed epidemiological and governmental deficiencies to prevent the spread of the disease. ^{Reference Petrovski, Lumi and Znaor16}

The COVID-19 outbreak has negatively impacted the activity of dentists. ^{Reference Consolo, Bellini and Bencivenni17} Routine dental procedures have been suspended because of the risk of cross-infection during dental care. ^{Reference Meng, Hua and Bian18,Reference Ahmed, Jouhar and Ahmed19} Moreover, oral mucosa has been recognized as an entry route of infection, limiting dental activities to treat urgent and emergency procedures to minimize the production of drops or sprays. ^{Reference Peng, Xu and Li20} Additionally, dental companies and industries have decided to suspend part of their staff. ^{Reference Proffitt21} Dentists feel a moral duty to reduce regular work to avoid spreading the infection among their relatives and patients. However, they also have a great concern about the financial consequences of a lockdown. ^{Reference Coulthard10,Reference El-Hage, Hingray and Lemogne22} Consolo et al. ^{Reference Consolo, Bellini and Bencivenni17} reported that almost 85% of dentists in a province of Italy reported being worried about contracting the infection during dental procedures. Shacham et al. ^{Reference Shacham, Hamama-Raz and Kolerman23} identified psychological distress among dentists and found that the fear of getting infected with COVID-19 from a patient provides high psychological tension. On the other hand, a high number of patients have been canceling their previous appointments, ^{Reference Consolo, Bellini and Bencivenni17} and others have perceived vulnerability to infection during dental practice. ^{Reference González-Olmo, Ortega-Martínez and Delgado-Ramos24}

A point often overlooked is the lack of inclusion of dental personnel in the public health emergency management system. In most countries, dentists do not participate in the direct care of patients infected with COVID-19. ^{Reference Coulthard10} It has been reported that medical staff unable to work in clinical areas or not posted directly on the front lines may feel guilty. ^{Reference Maunder, Hunter and Vincent25}

Meanwhile, the suspension of educational institutions has also affected dental education. ^{Reference Villa, Sankar and Shiboski26} Dental students have been required to stay at home and learn online during this pandemic. ^{Reference Meng, Hua and Bian18} However, it has been previously reported that the suspension of educational and research activities can lead to frustration. ^{Reference Clark27}

SIGNS AND SYMPTOMS

Previous studies have described the effects of isolation on mental health in HCWs. ^{Reference Fiorillo and Gorwood4,Reference Brooks, Webster and Smith14} Acute stress reactions included physical, cognitive, social, and emotional reactions or a combination of these. ^{Reference Walton, Murray and Christian28} Lee et al. ^{Reference Lee, Chan and Chau29} have reported irritability, low mood, insomnia, and posttraumatic stress symptoms among residents and hospital staff after quarantine. Burnout can be shown as a reduced sense of accomplishment, emotional exhaustion, or depersonalization. These phenomena have a direct negative impact on anxiety, stress, fatigue, mood disorders, depression, poor patient quality care, and, in worst cases, substance abuse and suicides. ^{Reference Brooks, Webster and Smith14,Reference Patel, Bachu and Adikey30} During the SARS epidemic, being in contact with infected patients was a predictor of developing anxiety, exhaustion, poor concentration, detachment from others, and deteriorating work performance. ^{Reference Bai, Lin and Lin31}

During this pandemic, medical workers have been dealing with the risk of infection, isolation from their families, discrimination, and overworking with inadequate protection, developing frustration, and exhaustion. ^{Reference Torales, O’Higgins, Castaldelli-Maia and Ventriglio32} Fear of the unknown can cause anxiety to develop in healthy people as well as in those with previous mental health problems. ^{Reference Mowbray33} In dentists, the appearance of psychological symptoms has been related to the fear of contracting COVID-19, especially when having a background disease or a higher subjective overload. ^{Reference Shacham, Hamama-Raz and Kolerman23}

STRATEGIES AND RECOMMENDATIONS

Well-being is not only the absence of emotional distress, but also it implies a positive mental, social, and physical condition. ^{Reference Lopez, Perez-Rojo and Noriega34} Self-care and psychological flexibility are essential aspects of psychological health. ^{Reference Coyne, Gould and Grimaldi35} Experts recommend being self-compassionate, staying active, and having time for leisure activities. ^{Reference Peteet6,36} Additionally, they encourage healthy sleeping, eating, drinking, and exercising, and trying to focus on the positives. ^{Reference Walton, Murray and Christian28}

The importance of maintaining physical activity is well understood. There is a risk that a vulnerable sector of the population falls short of staying active, affecting immunity that directly influences the probability of infection. ^{Reference Burtscher, Burtscher and Millet37}

Taking care of ourselves, keeping in touch with family and friends, and finding sources of inspiration and joy are strongly recommended. ^{Reference Peteet6,36} Social media can assist in communication with relatives, allowing isolated people to receive updates about the situation of loved ones. ^{Reference Brooks, Webster and Smith14}

Some protocols have been established for doctors but not for dentists. Many health professionals working in health institutions are not qualified to provide mental health assistance during pandemics. ^{Reference Xiang, Yang and Li38} In hospitals and dental clinics, surveys should be used to measure the physical, emotional, and mental exhaustion of the staff, and counseling services should be established using digital technologies. ^{Reference Xiang, Yang and Li38} According to Torales et al., ^{Reference Torales, O’Higgins, Castaldelli-Maia and Ventriglio32} mental health support should be provided even at 6 months after the end of isolation in people with vulnerable mental health.

Remote psychological support should be implemented. Daily free text messages, phone calls, and video calls with supportive tips may be performed to support the mental health of those in isolation or lockdown. ^{Reference Walton, Murray and Christian28,Reference Agyapong39} The creation of programs has been suggested to provide economic support during quarantine to those families with lower incomes and those whose family members cannot work. ^{Reference Manuell and Cukor40} On the other hand, it is time to see this situation as a forced opportunity to review and restructure our businesses. ^{Reference Proffitt21} Consider proactive approaches at home to avoid financial loss and avoid boredom. ^{Reference Manuell and Cukor40} An alternative approach to maintain the dentist-patient relationship is by using the Internet along with technology such as apps or software to facilitate communication via chat, telemedicine, and/or videoconference. ^{Reference Guo, Xie, Liang and Wu15,Reference Wright and Caudill41}