**1. Introduction**

Since March 2020, when the World Health Organization (WHO) declared infection with COVID-19 as a pandemic [1] dentists have had to deal with many challenges: the COVID-19 pandemic has influenced the physical and mental health of dentists and impacted their family relationships and financial status, and has led to changes in professional practice [2–5].

From the beginning of the COVID-19 pandemic, doctors have been considered a hotspot for infection, with a high risk of bidirectional transmission—from doctor to patient and vice versa. The risk of contagion was extremely high, especially in the context of dental medical services: blood droplets and saliva that are deposited on the surfaces or aerosol inhalation generated by rotating instruments and ultrasound hand pieces put both doctors and patients at high risk [2,3].

Tysi ˛ac-Mi´sta and Dziedzic [4] showed that one of the most important challenges for Polish dentists was that of medical protective equipment. Their study pointed out that 71.2% of dentists decided to suspend their clinical practice during the onset of the pandemic. Dentists who continued their clinical work during the first months of the

**Citation:** Iorga, M.; Iurcov, R.; Pop, L.-M. The Relationship between Fear of Infection and Insomnia among Dentists from Oradea Metropolitan Area during the Outbreak of Sars-CoV-2 Pandemic. *J. Clin. Med.* **2021**, *10*, 2494. https://doi.org/ 10.3390/jcm10112494

Academic Editor: Michele Roccella

Received: 10 April 2021 Accepted: 29 May 2021 Published: 4 June 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

pandemic were four and a half times more likely to have access to PPE than those who closed their dental offices. The same results were highlighted by Chamorro-Petronacci et al. [5] among Spanish dentists. The authors found that only 12.3% of participants could obtain personal protective equipment (PPE) including FFP2 masks, and dentists registered important economic losses due to the interruption of their activity. Casillas Santana et al. [6] showed that only a small percentage of Mexican dentists used protective masks and a large majority had to change disinfection rules between appointments to ensure a safe environment for patients. Consolo et al. [7] found that dentists from northern Italy reported feelings of concern (70.2%), anxiety (46.4%) and fear (42.4%) and most of them (89.6%) mentioned increased concerns about their professional future. Ahmed et al. [8] conducted a survey among dentists from thirty countries and found that 90% were anxious while treating a coughing patient or a patient suspected of being infected with COVID-19. More than 72% of the participants felt nervous when talking to patients in close proximity, and most of them (92%) were afraid of carrying the virus from workplace to their families. The authors also found that 73% were anxious about the cost of the treatment if they got infected, and 86% about the mortality rates presented by the media. More than half of the dentists recommended the closure of private and public dental clinics until the number of COVID-19 cases started to decline [8].

Shacham et al. [9] conducted a cross-sectional survey among Israeli dentists and dental hygienists and found higher psychological distress among those with history of illness, with an increased level of fear of contracting COVID-19 from their patients, and with those who self-rated their work as overloaded. Vergara-Buenaventura et al. [10] showed that there were important health consequences of the coronavirus disease 2019 pandemic in dentistry, including physical and psychological pressure, depression, social anxiety, and other mental health concerns. Sarialioglu Gungor et al. [11] highlighted that Turkish dentists had to deal with a high risk of infection, isolation from their families, discrimination, and overwork with inadequate protection, developing frustration and exhaustion. In Egypt, Hanafy identified that 75.1% of dentists reported difficulties in finding Personal Protective Equipment and 97.6% of the questioned doctors reported worry about acquiring COVID-19 while working. When questioned about it, 44% of participants reported anxiety, 28.7% concern, and 16.4% fear [12]. In a study conducted by Moraes et al. [13] of Brazilian dentists it was shown that there were three major impacts of the pandemic on dentistry: increasing inequalities due to health coverage differences between public and private clinics, the adoption of new clinical daily practices (correlated with an economic burden for dentists), and associations of regional COVID-19 incidence/mortality with fear of contracting the disease in the working environment. All these studies revealed that the Coronavirus-19 pandemic has had, since the beginning, a great impact on dentists' personal and professional lives, with important psychological consequences. Fear, anxiety and stress should be further investigated, due to their consequences regarding general health status.

Identifying the level of fear has a dual scientific purpose. The positive aspect of fear is that it is an alarm signal; fear is a normal reaction and determines awareness about a situation, produces changes in behaviors, and stimulates adaptability [9]. In the early stages of previous pandemics, such as Ebola or MERS, fear was associated with increased vaccination rates and the practice of preventive behaviors like hand washing, distance, body hygiene, etc. [14]. The negative side of fear is that the presence of high scores for fear is associated with the appearance and persistence of psychological problems such as anxiety, depression, post-traumatic stress disorder, sleeping disorder, eating disorder, or somatization [9,10,14–16]. Authors have shown that a fear construct is expected to have a significant predictive power of posttraumatic stress symptomatology, anxiety, and insomnia, since the most common clinical manifestations of fear include these psychological problems [15]. Therefore, the presence of fear determines the sufferer to search for preventive behaviors but also has negative consequences on physical and mental health [8,14]. That is why, when analyzing fear in the context of COVID-19 pandemic, as Nikopoulou

et al. highlighted in their study [16], it is extremely important to discriminate between adults with extreme COVID-19-related fear and those with normal fear reactions, to prevent psychological consequences and to maintain mental health. In the context of the coronavirus-19 pandemic, the impact on mental health is just at the beginning. Studies have identified the influence of the pandemic on the psychological, physical, social, and financial status as an acute reaction [6,8,14].

Compared to other countries of the European Community, Romania registered a lower risk of community transmission and a considerably lower number of deaths. The first case of infection was identified on 26 February 2020. By Presidential Decree, on 16 March a state of alarm was imposed; on 21 March, by Military Decree, a lockdown was imposed till 15 May [17,18]. Dental offices had to close and only emergency dental offices from public institutions (hospitals or clinics) continued to provide dental services. Due to the small number of emergency dental care offices (less than 5%) private dental clinics could accept patients in compliance with two rules: to provide only a limited amount of dental care (emergency cases) and to have the approval of Territorial Health Departments (after checking that the clinics had respected all the preventive measures to limit the spread of the infection). Only a very small number of private clinics could follow the imposed rules, first because of the difficulty in finding protective suits or protective materials and, second, because of their costs that negatively impacted their financial balance. The third important reason is not to be ignored, that at the beginning of the pandemic, information on the ways of transmitting the virus was relatively limited, which determined both patients and dentists being careful in carrying out activities related to dental services.

A small number of articles were published during the first year of the pandemic about the practice of dental services in Romania and how the restrictions, fear of infection and the new adopted preventives rules impacted dental services. The study of Pituru et al. [19] conducted among Romanian dentists identified that 87.1% of the respondents preferred a full set of personal protective equipment, including gloves, goggles, N95 mask, face shield, head cover, gown and shoe cover while treating asymptomatic patients with positive travel/contact history. Moreover, Petrescu et al. [20] showed that certain pathologies provided in emergency dental rooms in Romania considerably increased during 2020, compared to 2019. In April 2019, 160 patients had visited the Emergency Department of County General Hospital whereas in April 2020, one month after the State of Alarm, 2131 patients sought dental treatment in this department, as other dental emergency centers and private practices were closed by the State of Emergency dispositions. The number of patients increased more than 13 times. The main causes of attendance at emergency dental offices were acute apical periodontitis and acute pulpitis. However, no studies evaluated the impact of the COVID-19 pandemic on the mental health of Romanian dentists.

The goal of the present research is to evaluate the mental status of dentists after the first wave of the COVID-19 pandemic (November–December 2020) by identifying the presence of fear of Covid-19 and insomnia, and their relationship with dentists' preventive behaviors. As secondary purpose, we wanted to highlight the correlation analysis between fear and the practice of preventive behaviors (as a health-protective consequence of fear) and fear and insomnia (as a negative consequence on health status) among dentists during the first months of the pandemic. This study is part of a larger investigation among dentists; previous results have evaluated preventive behaviors and new preventive practices in dental clinics, adopted by dentists to diminish the risk of infection from and to their patients, and the impact of the pandemic on their family life and financial status [21].

## **2. Materials and Methods**

This cross-sectional study was conducted in Oradea department situated in the northwestern part of the country, one of the regions that immediately applied restrictive rules even before the imposed State of Alarm, decided by Presidential Ordinance on 15 March 2020, especially due to its closeness to the Romanian border. The data for the present

research was collected between 18 November and 5 December 2020, after the first wave of the pandemic, thus covering the first seven months of the pandemic.
