**4. Discussion**

Numerous studies conducted during the first year of the pandemic triggered by the Coronavirus infection have shown that there are vulnerable groups: women, people with minimal education, the unemployed, low-income individuals, and people living in the environment with high risk of infection [9–11,15]. Applied to the general population, the tool used to measure fear of Coronavirus infection scored highly, with most studies showing higher cutoff levels than the 16.5 score [16,22,23].

Dental offices had been closed for a long time, in terms of weeks, or months. Similarly, the number of patients had decreased considerably, with most patients showing that both patients and dentists preferred to intervene soon in case of urgent dental problems. However, although the financial impact had been significant, this was not crucial in increasing the fear of Coronavirus-19 infection. Similar results were highlighted by Gasparro et al. [35]. Researchers indicated that perceived job insecurity and fear of COVID-19 had negative impact on mental health, both variables being positively associated with depressive symptoms. The authors found that the effect of perceived job insecurity on depressive symptoms was weaker among those with a low fear of COVID-19. In a study conducted on Italian dentists, De Stefani et al. [36] also showed that more than half of the respondents declared that they were afraid because they were not sufficiently trained to restart work after the lockdown. They considered the virus infection highly dangerous, and they were concerned about the future economic situation of their clinical practices.

The scale proposed by Ahorsu et al. has been taken up by many researchers. Many published studies have validated the scale for use in various languages and in various countries [22,23,26]. The scale has also identified the level of fear of COVID-19 in populations in different countries. Some authors have argued that a weak point of the scale is that it did not propose cutoff scores, which made it impossible to make comparisons between populations, cultures, or ethnic groups [27,29–31]. Other research identified that different scores were highlighted by using the scale at various times during the first year after the onset of the pandemic. This showed that a high level was identified at the initial peak of the pandemic, after which the population became accustomed to the new preventive rules imposed to limit the spread of the virus. This peak in scores for fear of COVID-19 infection was also explained by the fact that little scientific information was available during the first months of the state of emergency.

The scale was applied to various populations of different countries but also on specific groups: students, doctors, medical professionals. The scale is useful for identifying the level of fear of infection and the results are useful for identifying people at risk (vulnerable populations, people from low socio-economic backgrounds, professions at risk of illness, patients with chronic diseases, etc.), but cannot be used for clinical purposes [16,18,22]. Some researchers have used the scale to provide a cutoff score, which is important when using a psychological tool. As Nikopoulou et al. [16] sustained, establishing a cutoff score is a common and useful practice in the psychiatry and psychology research fields to enable classification of respondents into either cases or non-cases. The authors proposed a cutoff score of 16.5 to separate both categories after having studied the Greek population.

In our study, the total score was 14.56 ± 6.90, lower than in other studies conducted on general healthcare professionals or dentists. Compared to other studies, the total score for FCV-19S was similar to those obtained by other investigations focusing on health professionals [27–34]. Firstly, this research was conducted on dentists and the respondents had more knowledge about infection, the spread of a virus and the implementation of protective practices. Secondly, this low score could be related to the period when the research was conducted, seven months from the beginning of pandemic. Compared to other studies, it is possible that the scores were lower compared to studies that measured the fear of COVID-19 during the peak of the pandemic [31–34]. Thirdly, the low score could also be related to easier access to medical supplies (a source of anxiety and fear during the first seven months of the pandemic). The fourth explanation could be related to the epidemiologic context, because in Romania the number of cases was not so high compared to other European countries (such as Italy, or Spain, where the number of cases and deaths increased considerably during the first seven months of pandemic).

Consolo et al. [7] identified similar results regarding the lower score compared to the general population. Their survey found that fear, anxiety, concern, sadness, and anger were commonly reported by dentists, but fortunately only a minority group reported a mild level of anxiety (10.3%), while 8.7% showed a score indicative of a severe level of anxiety. When thinking about COVID-19, only 4.2% of the questioned doctors reported an intense experience of fear. These results are similar to another survey conducted in Israel by Shacham et al. [9], in which elevated psychological distress was found in 11.5% of dentists. Similar to our study, anxiety was related to the level of fear of being infected by the patients. However, in our study we did not identify differences according to gender in terms of fear of contagion, these results being congruent with many others identified in the literature [21].

We found a positive correlation between the level of fear and the practice of some protective behaviors, results that were congruent with some studies conducted during the MERS or Ebola pandemics that proved the positive effect of fear on adopting preventive measures [37,38]. Therefore, normal fear of infection was associated with the adoption of recommended protection measures. Moreover, the implication of institutions, medical organizations, governments, and social entities was found to increase public compliance. Media, as well as social networks have the power to rapidly spread the information. When people have trust in medical institutions and policy makers, the power of fake news is lower, and compliance is higher [37]. In the case of the pandemic, the line between fear and anxiety will become less strong. Fear is related to a known or impending threat, whereas anxiety is mainly related to an imprecise or unknown threat [39]. So, the line will be created by the amount of knowledge that scientists, doctors, policy makers, media, or educators transmit about the virus. The higher the trust, the stronger the compliance. When these actors are missing, when they are undecided, when they do not transmit information or they transmit information which is contradictory, anxiety arise. The results of several studies indicated that public compliance with preventive behaviors like social distance, wearing masks, or vaccination during the health crisis required the development of social and institutional trust [40]. In our research, we found that breaking news about the pandemic had a negative impact on the mental state of dentists. We found a positive and strong relationship between the self-rated fear when dentists watched TV news about infection and scores for both fear of COVID-19 and insomnia. This result was due to the information related to the impact of the pandemic on health, financial incomes, food supplies or daily

social activity. Trnka and Lorencova (2020) showed also that pessimistic communications used by the mass media considerably increasing traumatic feelings, fears and psychological distress in the Czech population during the outbreak of the pandemic [41] and Ermolaev et al. (2020) revealed that news about the speed of the spread of the coronavirus in Russia influenced people not to go to hospitals with minor health problems, when infection with the virus was seen to be putting their lives in danger [42].

Our study showed that dentists changed their preventive behaviors due to fear of infection. The results are congruent with other studies. For example, in a study conducted in thirty countries, Ahmed et al. (2020) showed that, despite the high level of medical knowledge among dentists, important levels of anxiety and fear were identified while working. The authors identified that a number of dental practices had been modified according to the recommended guidelines for emergency treatment and many offices had closed for an uncertain period [8].

The correlation between the fear of infection and the practice of preventive behaviors was also discussed by Becker et al. [43] in a study that included experts in dentistry from 32 countries. The authors identified preventive measures that were adopted by dentists in different countries. For example, 80% of the experts included in the research recommended wearing protective masks by patients even if they were not (at that time when the research was developed) recommended by professional associations or the WHO. These preventive behaviors could be explained by the fact that dentists had knowledge of and experience with contagious disease in dental settings. On the other hand, the high risks and fear of infection during maneuvers determined doctors to adopt supplementary strategies to diminish the risk of spread, even if they were not (yet) recommended.

We identified that dentists obtained a high score for insomnia (11.37 ± 3.45). As Nikopoulouet et al. [16] showed when they evaluated insomnia in the Greek population, results similar to those published by Sirajudeen et al. [25], an increasing amount of evidence indicated that there was a bidirectional relationship between psychosomatic conditions and insomnia and that this relationship may have been exacerbated by stress. In our study, the fear of infection and the anxiety related to financial matters during the first seven months from the outbreak of pandemic were related to the increased level of insomnia among our respondents. Our study showed that there was a strong positive correlation between total score of AIS and total score for FCV-19S questionnaire, meaning that the more the dentists were afraid of COVID-19, the more they would suffer from insomnia. Our results are similar to the few studies conducted on front-line medical staff working with COVID-infected patients. Xiao et al. [44] found that sleep quality was negatively associated with the degree of anxiety and stress and the effect of stress and anxiety on sleep was pointed out by many researchers [45,46] who also proved the negative impact on physical and mental health and the risk of developing chronic diseases.

Similar to our results, Bohlken et al. [47] showed that 18% of German doctors (psychiatrists and neurologists) reported that the pandemic triggered anxiety, while 9% reported sleep problems and Lai et al. [48] conducted a study on Chinese health care workers exposed to COVID-19 and proved that front-line health care workers had a high risk of developing unfavorable mental health outcomes and may have needed psychological support or interventions. Mustafa et al. [49] also identified fear of infection among dentists in South-Arabia, the main cause being contagion from patients. The researchers showed an increased concern about their accessibility to materials provided by dental health care authorities, which was mentioned as the best and safest approach for dealing with patients during and after the outbreak of pandemic.

We found that men where more prone than women to have sleep-related problems and that there was a strong positive relationship between both fear of infection and insomnia with self-rated fear when watching media news. The results of our study are in congruence with those obtained by Léger et al. (2020) who conducted a study on a French population. The researchers showed that media overexposure was associated with sleeping disorders during the lockdown and men were more prone to be overexposed to media and social

media during lockdown [50]. Dai et al. (2020) identified that men had difficulties in maintaining sleep patterns and lifestyle during social distance restrictions and Sinha et al. (2020) showed that an increased digital media duration was evident in all age groups, mainly in males [51,52].

More studies should prove the effect of the pandemic on the physical and mental health of dentists Additionally, the long-term consequences of the fear of infection and of the application of measures to limit the disease need to be identified.

### *4.1. Reflections and Planning*

Sleep quality is an indicator of physical and mental health. For healthcare professionals, sleep is an indicator of stress and burnout and these factors are the main cause of professional mistakes especially among doctors who are working in the frontline and under permanent pressure. Many studies have proven that sleep quality was closely related to addictive behaviors, burnout, malpractice complaints, poor communication with patients, low level of medical practice and suicide [53–58]. Due to the fact that fear of infection is an important cause of stress for dentists that is added to the overloaded activity during the pandemic period, dentists 'mental health must be an extremely important priority for hospitals and clinics. Psychological counselling, individual psychotherapy or Balint meetings must be provided to medical staff in order to help dentists to cope with the stress determined by the COVID-19 pandemic.
