Archives of Academic Emergency Medicine. 2023; 11(1): e40 OR I G I N A L RE S E A RC H Dental Students’ Perceptions Regarding Bioterrorism; a Cross-Sectional Study Lina Bahanan1∗, Maha Alsharif2, Omar Al Qhtani3, Ahmad Al Juhani3, Meyassara Samman1 1. Department of Dental Public Health, King Abdulaziz University, Faculty of Dentistry, Jeddah, Saudi Arabia. 2. Department of Oral Diagnostic Sciences, King Abdulaziz University, Faculty of Dentistry, Jeddah, Saudi Arabia. 3. King Abdulaziz University, Faculty of Dentistry, Jeddah, Saudi Arabia. Received: March 2023; Accepted: April 2023; Published online: 22 May 2023 Abstract: Introduction: During the COVID-19 outbreak, dental professionals have demonstrated their importance in combating mass casualty incidents. This study aimed to understand dental students’ perceptions of their potential roles in a bioter- rorism attack. Methods: This cross-sectional study used a self-administered anonymous questionnaire, which was sent to all dental students and interns at King Abdulaziz University, Saudi Arabia. Bivariate and multiple linear regression analyses were conducted to assess dental students’ willingness to provide care during a bioterrorism attack, knowledge regarding bioterrorism and total number of roles a dentist should play during an attack. Results: This study included 472 dental students and interns. The mean knowledge score regarding bioterrorism was 3.3 ± 1.9 out of 5. A large ma- jority of the respondents (83.8%) were willing to provide care during a bioterrorism attack. Students with a cumulative grade point average (GPA) of 4.5–5 were more likely to indicate that a dental professional should take on more roles dur- ing a bioterrorism attack than those with a GPA of 2.5–2.99. Fourth- and fifth-year dental students had lower knowledge scores regarding bioterrorism than dental interns (B: -0.71; SE: 0.30; 95% CI: -1.3—0.1 and B: -0.68; SE: 0.30; 95% CI: -1.3– -0.1, respectively). Conclusion: Despite the fact that dental curricula do not cover topics related to bioterrorism, most students would be willing to provide care under bioterrorism conditions. There is wide agreement among the students regarding the need to add bioterrorism-related educations to dental curricula. Keywords: COVID-19; Dentistry; Disaster planning; Education, dental Cite this article as: Bahanan L, Alsharif M, Al Qhtani O, Al Juhani A, Samman M. Dental Students’ Perceptions Regarding Bioterrorism; a Cross-Sectional Study. Arch Acad Emerg Med. 2023; 11(1): e40. https://doi.org/10.22037/aaem.v11i1.2018. 1. Introduction Bioterrorism can be defined as a terrorist attack via a biolog- ical agent or the intentional use of a harmful biological agent that causes a civil illness, physical dysfunction or death (1, 2). Appropriate interventions must be implemented as soon as a threat is identified to limit the morbidity and mortality caused by the attack (3). With the increased incidence of bi- ological weapon use worldwide, healthcare personnel are an indispensable factor in facing such threats (3). There have been many claims and conspiracy theories that the COVID- 19 global pandemic was a result of deliberate bioterrorism Dentists are considered vital members of the healthcare community as they play a significant role in combating ∗Corresponding Author: Lina Bahanan; King Abdulaziz University, Faculty of Dentistry, Department of Dental Public Health, Jeddah, Saudi Arabia. Email: Lbahanan@kau.edu.sa. Tel: +966126403443, ORCID: https://orcid.org/0000- 0001-6508-5939. bioterrorism attacks (4–6). The role of the dental profession- als in bioterrorism attacks was defined by the American Den- tal Association (ADA) in 2002 (7). Dentists may be called upon to fill a range of roles in the event of a bioterrorism attack, including but not limited to education, sample col- lection, diagnosis, providing first aid and Cardiopulmonary Resuscitation (CPR), starting IV lines, suturing, vaccination, distribution of medications, and decontamination (7,8). The role of dentists in the COVID-19 outbreak has revealed their importance in combating any mass casualty incident that may arise from natural or human-caused circumstances. Licensed dental professionals were able to perform nasopha- ryngeal and oropharyngeal swabs for COVID-19 diagnoses (8). Moreover, COVID-19 screening capacity was increased through the use of dental clinics with negative pressure and high-volume excavators (8). It is, therefore, important for dental schools to expand their curricula to include prepared- ness skills for pandemics and natural catastrophes (8). Dental personnel, however, may face challenges during This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index L. Bahanan et al. 2 bioterrorist attacks due to a lack of knowledge and experi- ence (4). A study by Bhoopathi et al. revealed that den- tists both exposed and unexposed to a bioterrorism event showed low levels of perceived bioterrorism attack prepared- ness (9). Another study showed that less than 15% of den- tists were able to identify a bioterrorism event, and less than 10% were confident that they could respond effectively in a bioterrorist attack (10). To lower morbidity and improve out- comes during such malicious events, dental schools should incorporate pandemic and disaster preparedness skills into their curricula. Moreover, this would allow dental students to recognise and effectively respond to any catastrophic event and bioterrorist attack (8,11.) Thus, this study aimed to un- derstand dental students’ perceptions of their potential roles in a bioterrorism attack, self-perceived knowledge and self- perceived need for education. 2. Methods 2.1. Study design and setting This cross-sectional study was conducted between Septem- ber 2021 and May 2022, with participants recruited between November 2021 and January 2022 using a self-administered anonymous questionnaire regarding the students’ percep- tions about bioterrorism attack, which was sent to all den- tal students and interns at King Abdulaziz University, Saudi Arabia. The study was reviewed and approved by the Institu- tional Review Board at King Abdulaziz University Faculty of Dentistry (#364-12-21). All participants provided informed consent. This study was performed in accordance with the principles of the Declaration of Helsinki. 2.2. Study participants The inclusion criteria for the study included undergraduate dental students (second through sixth year) and dental in- terns at King Abdulaziz University Faculty of Dentistry. Sam- ple size calculation was performed using Raosoft sample size calculator with a population size of 861 students and interns, response distribution of 50%, confidence level of 95% and er- ror margin of 5% (12). This study required a minimum sam- ple size of 266 participants. 2.3. Data gathering A self-administered anonymous questionnaire was adapted from previous studies (9,13–15). To ensure the validity and reliability of the questionnaire, it was evaluated by two aca- demic dentists. In addition, a pilot test was conducted on 12 participants from the target population (two students from each year). The pilot test aimed to identify any potential issues with the questionnaire, such as vague or confusing questions, and to assess the clarity and comprehensibility of the questionnaire. Based on the results of the pilot test, the questionnaire was modified and finalized for use in the main data collection. Moreover, the internal consistency and reli- ability of the questionnaire were assessed using Cronbach’s alpha coefficient, which was > 0.7 indicating an acceptable level of reliability and consistency. It was distributed in En- glish using Question Pro forms. Every student received an email with the survey link and detailed instructions regard- ing the study. Two reminders were sent, two weeks and one month after the first email. Participation was completely voluntary and informed con- sent was obtained from each participant. The questionnaire consisted of five main sections. The first section comprised personal questions, including on gen- der (male or female), year of study (second, third, fourth, fifth, sixth, interns), grade point average (GPA) (4.5–5, 4–4.49, 3.5–3.99, 3–3.49, 2.5–2.99 and less than 2.5) and marital sta- tus (single or married). The second section included a yes–no question about the students’ willingness to provide care dur- ing a bioterrorist attack. It also included 5-point Likert scale questions about students’ opinions regarding the following topics: “1) bioterrorism is a national security concern, 2) lo- cal community at risk of bioterrorism attack, 3) first respon- der team should include dental professionals”. In the third section, respondents were asked to choose from 10 potential roles that a dental professional could play during a bioter- rorism attack, as recommended by the ADA. The fourth sec- tion consisted of yes–no questions to assess students’ self- perceived knowledge regarding whether they “1) would be able to identify signs and symptoms of an attack, 2) know who to contact in case of an attack, 3) know how to get infor- mation about an attack, 4) know how to get clinical informa- tion about a bioterrorism-related disease, 5) know the cur- rent state of bioterrorism and how to manage it”. The level of knowledge was then categorised according to the number of affirmative responses (good: 4–5, fair: 3, poor: 0–2). The final section comprised five questions about the self- perceived need for education and training on bioterrorism: ‘1) the need for more education regarding bioterrorism, 2) knowledge of a bioterrorism-related continuing education course, 3) previous training in bioterrorism, 4) incorporating bioterrorism preparedness into dental curricula, 5) willing- ness to attend a continuing education course on bioterror- ism’. The questionnaire is attached as Appendix A. Omar Al Qhtani and Ahmad Al Juhani were responsible for data gathering. 2.4. Statistical analysis Statistical analyses were conducted using the Statistical Pack- age for the Social Sciences (SPSS), Version 20. We used Cron- bach’s alpha to determine the internal consistency of the opinion domain. Descriptive statistics, such as frequencies This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 3 Archives of Academic Emergency Medicine. 2023; 11(1): e40 Table 1: Characteristics of studied dental students (n=472) Characteristic Value Gender Male 248 (53.0) Female 220 (47.0) Age (year) Mean ± SD 21.6 ± 1.7 Year of study 2nd 64 (13.6) 3rd 81 (17.3) 4th 80 (17.1) 5th 85 (18.1) 6th 73 (15.6) Dental intern 86 (18.3) Cumulative GPA 4.5-5 188 (40.1) 4-4.49 207 (44.1) 3.5-3.99 58 (12.4) 3-3.49 12 (2.6) 2.5-2.99 4 (0.9) Marital status Single 457 (98.9) Married 5 (1.1) Willing to provide care Yes 393 (83.8) No 76 (16.2) Total score of self-perceived knowledge (out of 5) Mean ± SD 3.3±1.9 Total number of roles during a bioterrorism at- tack (out of 10) Mean ± SD 8.3±2.4 Data are presented as mean ± standard deviation (SD) or frequency (%). Some variables do not add up to the total, as not all participants answered every question. GPA: grade point average. and percentages, were used to report the sample characteris- tics. Bivariate analysis was used to assess students’ opinions and self-perceived need for education against the sample characteristics. Using a multivariate linear regression anal- ysis, the dependent variable dental students’ need for bioter- rorism education and training was determined based on the following predictors: gender, year of study, GPA, and marital status. We chose to handle the missing data using the pair- wise deletion method, which involves excluding cases with missing data on a particular variable from the analysis for that variable only. The significance level was set at p < 0.05. 3. Results A total of 472 participants with the mean age of 21.6 ± 1.7 (range: 19 - 24) years were included in the study, which cor- responds to a response rate of 54.8%. The response rate may indicate that students were overburdened with requirements and exams or that awareness of the topic was partially un- derdeveloped. More than half of the respondents were male (53.0%). The majority of participants were single (98.9%), had a cumulative GPA ≥ 4 (84.2%) and were willing to provide care during a bioterrorist attack (83.8%) (Figure 1). The mean total score of self-perceived knowledge regarding bioterror- ism was 3.3 ± 1.9 out of 5. Moreover, the mean total number of roles that participants perceived that a dentist should play during a bioterrorism attack was 8.3 ± 2.4 out of 10 (Table 1). Table 2 shows students’ perceptions regarding bioterrorism preparedness and management. Most of the respondents (78.2%) believed that bioterrorism is a national concern, and a substantial majority (71.7%) believed that the local com- munity is at risk of bioterrorism. Additionally, 68.6% of the participants believed that one of the first responder teams should be dental professionals. Most of the responders agreed with the roles given by the ADA regarding bioterror- ism, with the majority believing they should provide first aid and CPR (90.5%) and a smaller majority considering that they should diagnose a possible bioterrorist attack (76.4%). According to 75.2% of the respondents, the dental curricu- lum should include bioterrorism, and 76.3% were willing to attend a continuing education course on the topic (Figure 1). Overall, participants showed willingness to provide care dur- ing a bioterrorism event, though none of the results were sta- tistically significant. Females (85.9%) showed slightly more willingness than males (82.1%). Dental interns were the most willing to provide care (88.1%), and students in the fifth year were the least willing to provide it (81.2%). Respondents with a GPA of 3–3.49 were the most willing to provide care (91.7%). Single dental students (84%) were slightly more likely to pro- vide care than married dental students (80%) (Table 3). Most participants from both genders (males 71.4% and fe- males 75.8%) had excellent knowledge of bioterrorism. There was also an almost equal gender distribution of poor knowl- edge (males 8.2% and females 9.0%). Dental interns had the highest proportion of excellent knowledge regarding bioter- rorism (83.9%), whereas second- and fourth-year dental stu- dents had the highest proportion of poor knowledge regard- ing bioterrorism (13.1% and 13.3%, respectively) (Table 4). A linear regression model to predict the score of knowledge regarding bioterrorism and the number of roles that a dentist should play during a bioterrorism attack included the follow- ing: gender, year of study, cumulative GPA, and marital status (Table 5). According to our findings, fourth- and fifth-year dental stu- dents had significantly less knowledge of bioterrorism than dental interns. Furthermore, dental interns reported a sig- nificantly higher number of roles that a dental professional should play during a bioterrorism attack than dental stu- dents from the second to fifth years. Moreover, participants with a cumulative GPA of 4.5–5 and 4–4.49 were significantly more likely to indicate that a dental professional should take on more roles during a bioterrorism attack than those with a This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index L. Bahanan et al. 4 Table 2: Students’ perception regarding bioterrorism preparedness and management Variable of interest Number (%) Students’ opinion regarding bioterrorism (affirmative response) Bioterrorism is a national security concern 366 (78.2) Local community at risk of bioterrorism attack 324 (71.7) First responder team should include dental professionals 310 (68.6) Students’ perception regarding the roles during a bioterrorism event (affirmative response) Report a possible bioterrorism infection 394 (85.7) Identify and triage victims 373 (81.8) Provide information and guidance to the public during an attack 384 (82.9) Diagnose a possible bioterrorism infection 350 (76.4) Keep dental records for forensic identification 402 (87.2) Provide first aid and cardiopulmonary resuscitation 420 (90.5) Perform forensic dentistry 380 (82.1) Provide assistance to medical personnel (e.g., physician, nurse) 388 (84.2) Create an alternative medical site by providing clinic space 403 (86.7) Give vaccines and medications under supervision 405 (87.7) Table 3: Bivariate analysis of demographic characteristics and willing to provide care during a bioterrorism attack Characteristic Willing to provide care during a bioterrorism attack P-value Yes n (%) No n (%) Gender Male 202 (82.1) 44 (17.9) 0.3 Female 189 (85.9) 31 (14.1) Year of study 2nd 53 (82.8) 11 (17.2) 3rd 66 (81.5) 15 (18.5) 4th 68 (85.0) 12 (15.0) 0.8 5th 69 (81.2) 16 (18.8) 6th 61 (83.6) 12 (16.4) Dental intern 74 (88.1) 10 (11.9) Cumulative GPA 4.5-5 156 (83.0) 32 (17.0) 4-4.49 176 (85.0) 31 (15.0) 3.5-3.99 46 (82.1) 10 (17.9) 0.8 3-3.49 11 (91.7) 1 (8.3) 2.5-2.99 3 (75.0) 1 (25.0) Marital status Single 382 (84.0) 73 (16.0) 0.6 Married 4 (80.0) 1 (20.0) Data are presented as frequency (%). GPA: grade point average. GPA of 2.5–2.99 (Table 5). 4. Discussion The purpose of this cross-sectional study was to exam- ine dental students’ perceptions of their potential roles in a bioterrorism attack, self-perceived knowledge and self- perceived need for education. This study found that dental interns had a higher level of knowledge about bioterrorism than fourth- and fifth-year dental students. The majority of dental students believed that dental professionals should be part of the first responder team. Furthermore, most dental students were willing to assist during a bioterrorist attack. They also recommended including bioterrorism prepared- ness in dental curricula. Our findings regarding high willingness of dental students and interns to provide care during a bioterrorism attack were in line with those of previous studies. Bhatt et al., who eval- uated Indian students’ knowledge and willingness to assist in a bioterrorist attack, found that 96.6% of undergraduate dental students were willing to provide care during an attack (13). In Boston in 2005, the majority (92.0%) of the dental students, assistants and hygienists attending the Yankee den- tal conference expressed willingness to assist during an at- tack (14). Similarly, Katz et al. revealed that 73.8% of Hawai- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 5 Archives of Academic Emergency Medicine. 2023; 11(1): e40 Table 4: Bivariate analysis of demographic characteristics and level of knowledge regarding bioterrorism Characteristic Level of knowledge regarding bioterrorism P-value Excellent Fair Poor Gender Male 105 (71.4) 30 (20.4) 12 (8.2) 0.5† Female 100 (75.8) 20 (15.2) 12 (9.0) Year of study 2nd 24 (63.2) 9 (23.7) 5 (13.1) 3rd 35 (72.9) 10 (20.8) 3 (6.3) 4th 30 (66.7) 9 (20.0) 6 (13.3) 0.4‡ 5th 32 (69.6) 10 (21.7) 4 (8.7) 6th 36 (78.2) 5 (10.9) 5 (10.9) Dental intern 47 (83.9) 7 (12.5) 2 (3.6) Cumulative GPA 4.5-5 80 (70.8) 24 (21.2) 9 (8.0) 4-4.49 95 (76.0) 16 (12.8) 14 (11.0) 0.3‡ 3.5-3.99 22 (66.7) 9 (27.3) 2 (6.0) 3-3.49 8 (100.0) 0 (0.0) 0 (0.0) 2.5-2.99 1 (50.0) 1 (50.0) 0 (0.0) Marital status Single 201 (73.9) 48 (17.7) 23 (8.4) 0.2¥ Married 0 (0.0) 1 (100.0) 0 (0.0) Data are presented as frequency (%). GPA: grade point average, †Chi-square test, ‡Fisher exact test with Monte Carlo simulation, ¥fisher exact test. Table 5: Linear regression model predicting students’ total knowledge score regarding bioterrorism and total number of roles a dentist should play during a bioterrorism attack Total knowledge score Total number of roles Variables Estimate SE 95% CI Estimate SE 95% CI Gender Male Ref Ref Ref Ref Ref Ref Female -0.04 0.19 -0.4 – 0.3 0.09 0.22 -0.4 – 0.5 Year of study 2nd -0.51 0.34 -1.2 – 0.2 -1.9 0.40 -2.7 – -1.1* 3rd -0.56 0.30 -1.1 – 0.03 -1.9 0.36 -2.6 – -1.2* 4th 0.71 0.30 -1.3 – -0.1* -1.1 0.36 -1.8 – -0.3* 5th -0.68 0.30 -1.3 – -0.1* -0.9 0.36 -1.6 – -0.2* 6th -0.18 0.31 -0.8 – 0.4 -0.6 0.37 -1.3 – 0.1 Dental intern Ref Ref Ref Ref Ref Ref Cumulative GPA 4.5-5 1.18 1.16 -1.1– 3.5 3.2 1.38 0.5 – 5.9* 4-4.49 0.97 1.15 -1.3 – 3.2 2.9 1.38 0.2 – 5.6* 3.5-3.99 0.66 1.17 - 1.6 – 3.0 2.2 1.40 -0.5 – 5.0 3-3.49 1.19 1.28 -1.3 – 3.7 2.7 1.50 -0.3 – 5.7 2.5-2.99 Ref Ref Ref Ref Ref Ref Marital status Single -2.4 0.89 -1.1 – 1.5 0.4 1.06 -1.7 – 2.5 Married Ref Ref Ref Ref Ref Ref * Statistically significant; p <0.05. ER: Standard error; CI: confidence interval; GPA: grade point average; Ref: reference. ian dentists were willing to assist during a bioterrorism event (10). Our findings were also consistent with a cross-sectional study conducted among healthcare professionals in three emergency departments and poison control centres/clinical laboratories in Riyadh, Saudi Arabia, which found that 68.7% of respondents were willing to provide care during an attack (15). Among the respondents, only 23.1% had received bioterror- ism training. Similarly, a study of physicians and nurses in Riyadh found that 20.6% were trained in bioterrorism (15). In comparison, two previous studies showed that only 4.5% of dental students in India and 5.5% of dental professionals in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index L. Bahanan et al. 6 Figure 1: Dental students’ perceived need for education and willingness to provide care during bioterrorism attacks. New England had attended a course on bioterrorism (13,14). In light of the increase in bioterrorism incidents worldwide, these percentages are considered low, especially because the literature has demonstrated that dentists have been effective in handling catastrophic events (7). In a study by Nofal et al., the percentage of respondents who reported knowing where to take a bioterrorism course was higher than in our study (55.5% vs. 37.0%, respectively) (15). Another study of a sample of family physicians with an active membership in the American Academy of Family Physicians revealed that 56% of the respondents knew where to obtain bioterrorism training (16). This may be due to the fact that the study included physicians, nurses and other members of the emergency department team, whereas our study in- cluded undergraduate dental students and interns. Our study showed that the mean total number of roles that students perceived that a dentist should play during a bioter- rorism event was 8.3 ± 2.4 out of 10. This was consistent with a study of Indian undergraduate dental students, which re- ported the mean number of roles as 8.73 ± 2.1 (13). How- ever, a study conducted on New England dental profession- als showed a slightly lower mean total number of roles at 5.9 ± 2.7 (14). The higher mean total number of roles among the Indian undergraduate students and in our findings might be attributed to the fact that these studies were conducted after the COVID-19 pandemic, when students had become more aware of the importance of dental professionals’ involvement and assistance during a catastrophic disaster. In agreement with previous studies, we found that more education about bioterrorism is needed (7,11,13–15,17). Dental interns had significantly higher scores on self- perceived knowledge of bioterrorism than undergraduate students. Dental interns also reported a higher number of roles for dentists in a bioterrorist attack than undergradu- ates, which is consistent with a previous study, which found that postgraduate dental students scored higher than under- graduate dental students on this topic (13). This may be due to the postgraduate students’ and interns’ clinical experience and greater community awareness than the undergraduates. However, we could not compare the overall score in our study with those of previous studies because the method of calcu- lation was different. Our sample of dental students indicated that CPR, vaccina- tions, and record-keeping were some of the most commonly mentioned roles they could perform during a bioterrorism event. The survey sample of New England dental profes- sionals showed that 46.3% believed that dentists could help administer vaccines (14), compared to 87.7% of our respon- dents. The difference may be explained by our study be- ing conducted after the COVID-19 pandemic, during which some dental professionals were involved in administering vaccines through the Ministry of Health (18). In 2003, at a workshop on bioterrorism preparedness, the ADA and the American Dental Education Association con- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 7 Archives of Academic Emergency Medicine. 2023; 11(1): e40 cluded that dental professionals should be knowledgeable about bioterrorism agents, trained to respond appropriately during an attack and capable of communicating surveillance data effectively (7,11). The role of dental schools in this pro- cess is crucial. However, adding bioterrorism training to the dental school curriculum can be challenging due to regional differences, core curriculum management, and financial re- strictions (11). Chmar et al. proposed three scenarios to im- prove students’ knowledge of bioterrorism: first, to create a new course that would provide bioterrorism training to stu- dents; second, to seamlessly integrate terrorism education into existing courses; and third, to combine the two previous scenarios by incorporating training into the existing curricu- lum as well as a culminating course (11). 5. Limitations To our knowledge, this is the first study to assess dental students’ preparedness to deal with a bioterrorism event in Saudi Arabia. This study has several limitations. First, the study design is cross-sectional, which precludes mak- ing causal inferences. Second, the sample consisted of stu- dents from one university, limiting the generalisability of the results. Third, the study is limited to undergraduate dental students and does not include postgraduate dental students, hygienists, or dental assistants. Since cross-sectional stud- ies are subject to selection bias, we attempted to minimize non-response bias by following up with non-responders. Al- though this study has limitations, its significance lies in iden- tifying the need for dental students to receive additional training and education in bioterrorism. There are many ways in which dental professionals can receive bioterrorism train- ing, including undergraduate courses, continuing education programmes, and online courses (15). Hence, future research should focus on training programmes aimed at improving dental professionals’ readiness for bioterrorism events. 6. Conclusion The increasing threat of bioterrorism worldwide necessitates the education and training of all healthcare professionals in bioterrorism. Regardless of whether dental students intend to participate in addressing bioterrorism attacks, they should be familiar with the necessary knowledge and control mea- sures to counter such attacks. This preparation could be achieved by incorporating bioterrorism education into den- tal curricula. 7. Declarations 7.1. Acknowledgments We acknowledge dental students and interns at King Abdu- laziz University who participated in this study. 7.2. Conflict of interest The authors declare that they have no competing interests. 7.3. Fundings and supports This study did not receive any funding. 7.4. Authors’ contribution LB conceived the project idea with MS. OA and AA collected the data and drafted the manuscript. LB analysed the data. LB, MS, and MA critically reviewed the manuscript. All au- thors read and approved the final manuscript. 7.5. Ethics approval This study was reviewed and approved by the Institutional Review Board at King Abdulaziz University Faculty of Den- tistry, Jeddah, Saudi Arabia (#364-12-21). All methods were performed in accordance with the princi- ples of the Declaration of Helsinki. 7.6. Consent for publication All participants provided written informed consent. 7.7. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reason- able request. References 1. Gupta V, Bankar N, Chandankhede M. The COVID-19 - an agent for bioterrorism?. J Pharm Res Int. 2021; 33(40B):279-284. 2. Prakash N, Sharada P, Pradeep G. Bioterrorism: Challenges and considerations. J Forensic Dent Sci. 2010;2(2):59. 3. Rathish B, Pillay R, Wilson A PV. Comprehensive Review Of Bioterrorism. In: StatPearls [Internet]. Treasure Is- land (FL): StatPearls Publishing; 2022. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29630269. 4. 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Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index Introduction Methods Results Discussion Limitations Conclusion Declarations References