1 Volume 22 2023 e237812 Original Article Braz J Oral Sci. 2023;22:e237812http://dx.doi.org/10.20396/bjos.v22i00.8667812 1 Graduate Program Teaching in Health, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. 2 Department of Dentistry and Oral Health, Section for Periodontology, Aarhus University, Aarhus, Denmark. 3 Department of Public Health, Graduate Program Teaching in Health, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. 4 Department of Dentistry of State University of Ponta Grossa. Ponta Grossa, PR, Brazil. 5 Department of Public Health, Federal University of Santa Catarina, Florianópolis, SC, Brazil. 6 Professor and Head of Graduate Program Teaching in Health, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. Corresponding author: Fernando Valentim Bitencourt fvbitencourt@dent.au.dk (+45 25770902) Department of Dentistry and Oral Health, Section for Periodontology Aarhus University Vennelyst Boulevard 9, building 1610, office 2.76 8000 Aarhus C, Denmark Editor: Altair A. Del Bel Cury Received: December 07, 2021 Accepted: July 11, 2022 How Brazilian oral health care workers face COVID-19: surveillance, biosafety, and education strategies Luciana Zambillo Palma1 , Fernando Valentim Bitencourt2,* , Gabriel Ricardo Velho1 , Fabiana Schneider Pires3 , Márcia Helena Baldani4 , Claudia Flemming Colussi5 , Cristine Maria Warmling6 Aim: To investigate surveillance, biosafety, and education strategies of Brazilian oral health care workers (OHCWs) during the first wave of the COVID-19 outbreak. Methods: This was a cross-sectional study covering OHCWs from a single multicenter research centre. A self-administered and validated online questionnaire was used for data collection, including the following variables: sociodemographic, medical history, biosafety, professional experience, surveillance, and education. Results: The sample consisted of 644 OHCWs (82.5% dentists, 13.2% dental assistants and 4.3% technicians), most without comorbidities (84.8%), from the public (51.7%) and private (48.3%) health systems, in 140 cities of a southern state. The most prominent measures of surveillance were waiting room distancing and visual alerts, symptom assessment, and availability of guidelines on COVID-19. Regarding biosafety measures, the lowest adherence was related to intraoral radiographs (2.7±1.4; 95%CI: 2.6–2.9), use of dental dams (2.1±1.4; 95%CI: 2.0–2.2), and availability of high-power suction systems (2.5±1.7; 95%CI: 2.3–2.6). Among OHCWs, 52.6% received guidance on measures to take during dental care in the workplace. Continuing education was mainly through documents from non-governmental health authorities (77.4%). Conclusion: Surveillance and biosafety measures were adopted, but activities that reduce the spread of aerosols had less adherence. These findings underscore the importance of considering dental practices, and surveillance and education strategies to formulate policies and relevant support to address health system challenges during the COVID-19 pandemic. A coordinated action of permanent education by policymakers is necessary. Keywords: SARS-CoV-2. COVID-19. Health workforce. Education, dental. Public health dentistry. https://orcid.org/0000-0003-1187-0784 https://orcid.org/0000-0002-7310-2767 https://orcid.org/0000-0002-4155-6801 https://orcid.org/0000-0001-6545-524X https://orcid.org/0000-0003-1310-6771 https://orcid.org/0000-0002-3395-9125 https://orcid.org/0000-0003-2259-4199 2 Palma et al. Braz J Oral Sci. 2023;22:e237812 Introduction With the worldwide spread of the COVID-19 pandemic caused by the SARS-CoV-2 virus, the policies adopted by Brazil to contain the disease have had no positive effect. The mismanagement of the public health system, the delay in vaccine acquisition, and the lack of tests, combined with political instability, worsened the country’s han- dling of COVID-19. Brazil was an epicenter of the spread of COVID-19, considered the third most-affected country globally, with excessive cases and deaths1. In this challenging scenario for health systems, oral health care workers (OHCWs) in particular have been part of the frontline struggle against COVID-19. Dental care requires proximity to the patient, and it demands procedures that generate aero- sols containing saliva, oral fluids, and blood. With the increase of COVID-19 cases combined with the high risk of transmission of SARS-CoV-2 and the intensification of healthcare work, especially in dental emergencies, strict biosecurity and infection control measures were recommended2,3. Given the need to maintain dental care, Brazil adopted restrictive measures and actions to prevent the spread of the virus. The Ministry of Health (MS) and the Federal Council of Dentistry (CFO) published guidelines with specific recommendations for clinical dental management to be followed by OHCWs. Among them, dental care was restricted to urgencies and emergencies with subsequent release of elective proce- dures. COVID-19 symptom investigation during anamnesis, education in the waiting room, appropriate use of personal protective equipment (PPE), and reduction of aero- sols to prevent the spread of the virus were emphasized4,5. The bleak context for Brazilian public health and particularly dental care, aggra- vated by the absence of a national emergency plan, prompted collaboration and research networks to face the challenges of COVID-19. This investigation is part of a broader multicenter study, carried out in three states in the southern region of Brazil between four universities, the CFO, and the Brazilian Dental Education Asso- ciation (ABENO). Thus, the study aimed to evaluate the surveillance, biosafety, and education strategies of Brazilian OHCWs in the context of the first wave of the COVID-19 pandemic. Materials and Methods Study design and population This study was descriptive and cross-sectional design using data on surveillance and biosafety measures and access to education activities among OHCWs (dentists, dental assistants, and technicians) from the public and private sectors. The study population corresponds to one of the states obtained from the multicenter research encompassing three states of the south of Brazil.   This investigation was conducted between August 2020 and October 2020. Ethi- cal approval for data collection in the state was obtained from the Research Ethics Committee, the Federal University of Rio Grande do Sul, Porto Alegre, Brazil (CAAE 3 Palma et al. Braz J Oral Sci. 2023;22:e237812 no. 31720920.5.2002.5530). All participants provided written informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemi- ology (STROBE) guidelines6. Selection of participants and eligibility criteria Participants were identified through the CFO registration of professionals at June 2020 in the state of Rio Grande do Sul. This record contained a total of 30,588 OHCWs. They were invited to participate by email to the address provided by the CFO. To maximize participation, before recruiting participants through email, Instagram social networking campaigns targeting OHWCs were held to promote this research. Informed consent for participation in the study was incorporated. After the first invitation, the response to the form was monitored. Two more invitations were made within 15 days. Data collection A structured, self-administered, unidentified, and validated questionnaire was applied via email using a Google Forms® (Appendix 1). Briefly, the instrument was submitted to eight experts with experience from the public health, biosafety, and education for evaluation to verify its performance and reliability. After modifications requested by the experts, the questionnaire was evaluated through a pilot study with 52 OHCWs in the three professional categories. This step aimed to ascertain the degree of understanding concerning the questions that were developed and the reproducibility of the instrument. The agreements obtained in the test retest ranged from 84% to 100%. The time to complete the instrument was approximately 20 minutes. It was com- posed of three thematic axes: (1) sociodemographic characteristics; (2) surveillance and biosafety measures; and (3) professional experience, management, education, work, and staff. The questionnaire had 47 closed questions with answer options on a 5-point Likert Scale (1: never, 2: rarely, 3: sometimes, 4: almost always, 5: always).  Data analysis The data compilation, organization, and codification were performed using Micro- soft Excel TM (Microsoft Corp., Seattle, USA). Data were subsequently analyzed for inconsistencies and incomplete data. Missing data were excluded from the study. The statistical analysis was performed using IBM SPSS version 20.0 (IBM Corp, Armonk, USA). Absolute and percentage frequencies were measured for categorical variables and means (± standard deviations) for Likert Scale scores. Proportions and confi- dence intervals for the study population were estimated.  Results The study included 644 OHCWs in 140 cities of the state of Rio Grande do Sul. The sample was composed of 82.5% dentists, 13.2% dental assistants and 4.3% techni- cians, being 73.8% women. The length of professional experience was well-distributed 4 Palma et al. Braz J Oral Sci. 2023;22:e237812 in the sample, with the highest rates in the groups over 20 years (29.5%) and between 6 and 10 years (22.4%). Concerning the professional category of the participating den- tists, 47.5% were specialists, 19.1% of whom were in public health. Of the participants, 51.7% worked in the public sector, 46.5% worked in primary health care, and private clinics represented 36.6%. A total of 68.5% reported an absence from work in the first wave of the COVID-19 outbreak. Regarding health aspects, 84.8% of the participants reported no risk factors or conditions. Testing for COVID-19 was not performed by 43.0% (Table 1). Table 1. Sociodemographic, education, work, and health characteristics of the sample of oral health care workers from the Rio Grande do Sul, Brazil, August-October, 2020. Variables n % CI 95% Gender Female 475 73.8 70.3 – 77.1 Male 169 26.2 22.9 – 29.7 Age (years) 18-24 24 3.7 2.4 – 5.4 25-39 307 47.7 43.8 – 51.5 40-59 277 43.0 39.2 – 46.9 >60 36 5.6 4.0 – 7.5 Occupation Dentists 531 82.5 79.4 – 85.3 Dental Assistant 85 13.2 10.7 – 16.0 Technicians 28 4.3 3.0 – 6.1 Conclusion of professional training (years) Up to 5 131 20.3 17.4 – 23.6 6-10 144 22.4 19.3 – 25.7 11-15 95 14.8 12.2 – 17.6 16-20 84 13.0 10.6 – 15.8 >20 190 29.5 26.1 – 33.1 Higher graduate level* Specialization/Residency 306 47.5 43.7 – 51.4 Master 87 13.5 11.0 – 16.3 PhD 57 8.9 6.8 – 11.2 None 194 30.1 26.7 – 33.7 Postgraduate areas# Public Health 123 19.1 16.8 – 20.5 Clinical specialties# 327 69.9 67.2 – 72.5 None 194 11.0 9.8 – 14.2 Continue 5 Palma et al. Braz J Oral Sci. 2023;22:e237812 Continuation Workplace SUS¶ – Primary Health Care (PHC) 300 46.5 44.3 – 48.4 SUS¶ - Dental Specialty Centers (DSC) 32 5.0 3.9 – 7.4 SUS¶ – Urgency care 1 0.2 0.1 – 0.4 Private clinic 236 36.6 32.8 – 40.5 Dental teaching clinic 43 6.7 3.8 – 8.1 Corporate Entities Health System 11 1.7 0.7 – 2.6 Security forces (army, police, etc.) 4 0.6 0.3 – 0.8 Hospital 6 1.0 0.6 – 1.7 Management 4 0.6 0.3 – 0.8 Other 7 1.1 0.8 – 1.5 Risk factors for severe forms of COVID-19 Only age over 60 years old 25 3.8 3.0 – 4.5 Health condition only 62 9.7 6.8 – 11.2 Age over 60 and health condition 11 1.7 1.4 – 2.1 None 546 84.8 80.6 – 87.1 Absence from work during the pandemic Yes 441 68.5 65.4 – 71.4 No 203 31.5 28.0 – 35.2 Testing for COVID-19 No 277 43.0 39.2 – 46.9 Yes RT PCR 153 23.8 20.6 – 27.1 Rapid test 173 26.9 23.5 – 30.4 Serological test 41 6.4 4.7 – 8.4 * Only dentists included. # Most cited areas of dentistry: orthodontics, implantology, dental prosthesis, endodontics, periodontics, pediatric dentistry and dentistry. ¶ Brazilian National Health System. The COVID-19 preventive practices with the highest average responses were the avail- ability of guidelines (3.9±1.2) and visual alerts in the office (3.9±1.4), investigation of possible respiratory symptoms (4.1±1.3), and adoption of distancing in the waiting room (4.2±1.1). However, lower averages were registered for questions relating to innovative practices in dental care: working directly in COVID-19 fast-tracking proce- dures (2.2±1.4) or the use of tools for telemonitoring of patients (2.4±1.6; Table 2). 6 Palma et al. Braz J Oral Sci. 2023;22:e237812 Table 2. Sample distribution regarding the adoption of surveillance, planning and risk management measures to control the dissemination of COVID-19 in health services. Oral health care workers from the Rio Grande do Sul, Brazil, August-October, 2020. Organization of health services (surveillance, planning and management) Always (score 5) Often (score 4) Sometimes (score 3) Ever (score 2) Never (score 1) Do not know Mean (DP) CI 95% n (%) n (%) n (%) n (%) n (%) n (%) Suspended elective procedures and care restricted to urgency/emergency 213 (33.1) 198 (30.7) 124 (19.3) 64 (9.9) 42 (6.5) 3 (0.5) 3.7 (1.2) 3.6 – 3.8 Participation in decision-making about changes in work during the pandemic 238 (37.0) 69 (10.7) 96 (14.9) 59 (9.2) 178 (27.6) 4 (0.6) 3.1 (1.6) 3.0 – 3.3 Reduced workload or professional turnover to minimize the risk of contamination 165 (25.6) 74 (11.5) 100 (15.5) 63 (9.8) 236 (36.6) 6 (0.9) 2.7 (1.6) 2.6 – 2.9 Worked directly in COVID-19 reception/ sorting/fast track procedures 89 (13.8) 53 (8.2) 89 (13.8) 84 (13.0) 325 (50.5) 4 (0.6) 2.2 (1.4) 2.0 – 2.3 Investigation of respiratory infection symptoms in appointment scheduling 394 (61.2) 98 (15.2) 60 (9.3) 39 (6.1) 32 (5.0) 21 (3.3) 4.1 (1.3) 4.0 – 4.2 Patients with symptoms of respiratory tract infection immediately isolated 384 (59.6) 84 (13.0) 40 (6.2) 29 (4.5) 65 (10.1) 42 (6.5) 3.8 (1.6) 3.7 – 4.0 Waiting room respecting the minimum distance of 01 meter between people 386 (59.9) 125 (19.4) 72 (11.2) 34 (5.3) 16 (2.5) 11 (1.7) 4.2 (1.1) 4.1 – 4.3 Availability of visual alerts in the health service 346 (53.7) 110 (17.1) 61 (9.5) 47 (7.3) 63 (9.8) 17 (2.6) 3.9 (1.4) 3.7 – 4.0 Urgency based on pre-established clinical protocols 318 (49.4) 141 (21.9) 73 (11.3) 29 (4.5) 58 (9.0) 25 (3.9) 3.8 (1.4) 3.7 – 3.9 Orientation of patients about COVID-19 303 (47.0) 135 (21.0) 125 (19.4) 42 (6.5) 30 (4.7) 9 (1.4) 3.9 (1.2) 3.8 – 4.0 Use of digital tools for teleorientation or telemonitoring 121 (18.8) 62 (9.6) 102 (15.8) 81 (12.6) 255 (39.6) 23 (3.6) 2.4 (1.6) 2.3 – 2.5 Interaction with other health professionals 221 (34.3) 153 (23.8) 157 (24.4) 67 (10.4) 44 (6.8) 2 (0.3) 3.6 (1.2) 3.5 – 3.7 Regarding the adoption of biosafety measures by OHCWs, the highest averages were related to routine care with PPE and decontamination of environments: dis- infection of the face shield (4.7±0.9), proper removal of personal barrier protection (3.9±1.3), reuse of N95/PFF2 masks following appropriate criteria (3.8±1.5), and disinfection of environments (3.8±1.4). Lower averages were identified in practices to minimize the generation of aerosols and oral secretions: avoiding intraoral radio- 7 Palma et al. Braz J Oral Sci. 2023;22:e237812 graphs (2.7±1.4), use of dental dams in high-speed care (2.1±1.4) and availability of high-power suction systems (2.5±1.7; Table 3). Table 3. Sample distribution regarding the adoption of biosafety measures in health services. Oral health care workers from the Rio Grande do Sul, Brazil, August-October, 2020. Work biosafety Always (score 5) Often (score 4) Sometimes (score 3) Ever (score 2) Never (score 1) Do not know Mean (DP) CI 95% n (%) n (%) n (%) n (%) n (%) n (%) Disinfection of the environment by a trained professional with appropriate PPE 322 (50.0) 118 (18.3) 69 (10.7) 45 (7.0) 82 (12.7) 8 (1.2) 3.8 (1.4) 3.7 – 3.9 Disinfection of suction hoses 272 (42.2) 86 (13.4) 89 (13.8) 56 (8.7) 105 (16.3) 36 (5.6) 3.4 (1.7) 3.2 – 3.5 Use of sterile micromotors at every dental appointment 269 (41.8) 62 (9.6) 67 (10.4) 80 (12.4) 152 (23.6) 14 (2.2) 3.2 (1.7) 3.1 – 3.4 Intraoral radiographic examinations were avoided 75 (11.6) 159 (24.7) 160 (24.8) 75 (11.6) 156 (24.2) 19 (3.0) 2.7 (1.4) 2.6 – 2.9 Performing four- handed dental procedures 165 (25.6) 114 (17.7) 110 (17.1) 103 (16.0) 137 (21.3) 15 (2.3) 3.0 (1.5) 2.9 – 3.1 Use of the dental dam in high rotation services 68 (10.6) 77 (12.0) 98 (15.2) 84 (13.0) 278 (43.2) 39 (6.1) 2.1 (1.4) 2.0 – 2.2 Procedures that generate aerosols were avoided 135 (21.0) 176 (27.3) 135 (21.0) 86 (13.4) 98 (15.2) 14 (2.2) 3.1 (1.4) 3.0 – 3.3 Use of suction system (vacuum pump) 176 (27.3) 51 (7.9) 53 (8.2) 31 (4.8) 309 (48.0) 24 (3.7) 2.5 (1.7) 2.3 – 2.6 Proper removal of personal barrier protection 317 (49.2) 167 (25.9) 61 (9.5) 34 (5.3) 50 (7.8) 15 (2.3) 3.9 (1.3) 3.8 – 4.0 N95/PFF2 mask reuse with proper criteria 357 (55,4) 101 (15,7) 66 (10,2) 24 (3,7) 70 (10,9) 26 (4,0) 3,8 (1,5) 3.7 – 4.0 Disinfection of face shield 569 (88,4) 31 (4,8) 12 (1,9) 13 (2,0) 8 (1,2) 11 (1,7) 4,7 (0,9) 4.6 – 4.7 Table 4 shows how the participants accessed technical standards and recommenda- tions on dental care during the COVID-19 pandemic. Of the OHCWs, 77.4% searched for documents without identifying the agency responsible for the information accessed. The responses related to accessing official recommendations showed similar scores: 58.8% accessed CRO recommendations, and 58.0% accessed the Technical Note No. 04/2020 ANVISA. 8 Palma et al. Braz J Oral Sci. 2023;22:e237812 Table 4. Aspects related to access to technical standards and recommendations on dental care during COVID-19 pandemic. Oral health care workers from the Rio Grande do Sul, Brazil, August-October, 2020. Variables Total Dentists Dental Assistants Technicians n (%) n (%) n (%) n (%) Access to technical standards and recommendations Technical note GVIMS/GGTES/ANVISA Nº 04/2020 374 (58.0) 324 (50.3) 40 (6.2) 10 (1.5) Recommendations booklet of the Federal Council of Dentistry (CFO) 377 (58.5) 334 (51.8) 33 (5.1) 10 (1.5) Recommendations booklet of the Regional Council of Dentistry (CRO) from own state 361 (56.0) 303 (47.0) 44 (6.8) 14 (2.1) Recommendations booklet of the Regional Council of Dentistry (CRO) from other state 92 (14.2) 84 (13.0) 6 (0.9) 2 (0.3) Recommendations from the Municipal/ State Secretariat 341 (52.9) 270 (41.9) 51 (7.9) 20 (3.1) None 33 (5.1) 29 (4.5) 4 (0.6) 0 (0.0) Other documents * 499 (77.4) 405 (62.8) 70 (10.8) 24 (3.7) * Any source of information without identification of the agency responsible for the information accessed. The results related to continuing education show that 52.6% of the participants received guidance on measures to be taken during dental care in the workplace. However, 22.2% reported not having applied the acquired information, with no changes in dental practices. Clarity and security to work correctly in the pandemic were positive, with 41.3% of participants partially agreeing and 39.3% fully agreeing. However, 33.4% felt anxious or worried about working properly during the pandemic (Table 5). Table 5. Sample distribution regarding training/education during COVID-19 pandemic. Oral health professionals from the Rio Grande do Sul, Brazil, August-October, 2020. Training on COVID-19 Strongly Agree (score 5) Agree (score 4) Undecided (score 3) Disagree (score 2) Strongly Disagree (score 1) Do not know Mean (DP) CI 95% n (%) n (%) n (%) n (%) n (%) n (%) I consider that I received guidance at my workplace regarding measures to be taken during the COVID-19 pandemic 339 (52.6) 177 (27.5) 43 (6.7) 39 (6.1) 42 (6.5) 4 (0.6) 4.1 (1.2) 4.0 – 4.2 I was able to apply the knowledge acquired in training/education about COVID-19 to modify my practice 255 (39.6) 180 (28.0) 35 (5.4) 17 (2.6) 14 (2.2) 143 (22.2) 4.6 (1.1) 4.5 – 4.6 Continue 9 Palma et al. Braz J Oral Sci. 2023;22:e237812 Continuation I feel sufficiently enlightened and secure to work properly in dental practice during the COVID-19 pandemic 253 (39.3) 266 (41.3) 42 (6.5) 51 (7.9) 27 (4.2) 5 (0.8) 4.0 (1.1) 3.9 – 4.1 I feel anxious and concerned to work properly in dental practice during the COVID-19 pandemic 215 (33.4) 208 (32.3) 57 (8.9) 72 (11.2) 88 (13.7) 3 (0.5) 2.3 (1.4) 2.2 – 2.4 Discussion This study emphasizes the surveillance, biosafety and education strategies by OHCWs during the first wave of the COVID-19 outbreak in the south of Brazil. Although the pandemic’s effects on dentistry in Brazil have been discussed7-9, scarce information exists regarding actions to respond to the challenges facing OHWCs. The pandemic has amplified the need for instituting biosafety processes and actions and professional updating in the area. The context of the high risk of contagion faced by health professionals is one of the vulnerabilities of health sys- tems. In addition to human risks, the decrease in front-line workers can compromise the potential response of health services. Our findings demonstrate the adherence of OHCWs to COVID-19 procedures, guide- lines, and surveillance, especially for activities close to the dental office such as screening and fast-tracking - a rapid-flow tool for triage and care of COVID-19 cases. The results are consistent with studies indicating that dentists know about methods to investigate patients10 with suspected COVID-19 and inform the population about widespread disease issues11,12. Adherence to fast-tracking of OHCWs working in the SUS was low. This performance may have influenced oral health policies at the time of the pandemic, which induced a financing model based on the productivity of specific indicators for dentistry, that do not include activities such as fast-tracking13. The restrictions imposed by the pandemic impacted the offer of dental treatments, and dentistry mediated by remote technologies emerged as a possibility, but with con- troversies, especially in the regulation of this professional practice. Therefore, during the pandemic, a resolution has regulated the types of use of teledentistry: teleorien- tation (guidance by digital means or telephone) and telemonitoring (verification of health issues and clinical developments), prohibiting its use for consultation, diagno- sis, prescription, or preparation of a treatment plan14. In the present study, OHCWs demonstrated moderation in the use of digital tools in daily dental work. Obstacles to the use of teledentistry are related to the con- servatism of managers, clinical acceptance (willingness by professionals to use telehealth tools)15, the perception of its benefits by professionals, and demanding technological and personnel resources16. With teledentistry, the workflow and the 10 Palma et al. Braz J Oral Sci. 2023;22:e237812 participation of the patient can be streamlined in more personalized and accessible care7,17. In the resumption of activities during the pandemic, teledentistry was used to face the reduction of preventive procedures, allowing the monitoring of groups in health surveillance18. The highest scores in the biosafety themes were those related to the care of profes- sionals’ PPE. Specifically, cleaning and disinfection of the face shield were reported as always performed by 88.4% of the participants, and the appropriate reuse of N95/PFF2 masks was always performed by 55.4%. Additionally, 50.0% reported always cleaning the environments (Table 3). SARS-CoV-2 can be found in the saliva of COVID-19 patients in the pre-symptomatic period, which demands the correct use of PPE to avoid exposure to contaminated aerosols19,20. The survival of this virus on surfaces for many days can be considered one of the reasons for the care reported by OHCWs in the frequent cleaning of dental environments. These locations can be vehicles for indirect contact between patients and professionals2. Proper removal of personal barrier protection for OHCWs is essential. The operator’s body and arms, visors, glasses, and masks can become highly contaminated19. In this study, adequate removal was indicated as always performed by 49.2% of the partici- pants. Considering that one of the main ways of contamination of health profession- als is during the removal of PPE, all steps must be strictly followed. Health services must carry out training with teams to achieve mastery in these skills21. This study showed lower adherence to the recommendations associated with con- trolling the generation and spread of aerosols and oral secretions. Of the participants, 10.6% stated that they always used dental dams. Additionally, 27.3% reported adher- ence with high-power suction systems, and 11.6% always avoided intraoral radio- graphic examinations (Table 3). In the context of the COVID-19 pandemic, biosafety needs have made dental prac- tice more costly. In the SUS, the place of employment of half of the study partici- pants (51.7%) and many Brazilian dentists (around 58,000), adapting to guidelines and norms has implied a high investment economy22,23. The pandemic represented an unprecedented situation, a disease with high mor- bidity and mortality caused by an etiological agent that can be airborne, which caused fear and high demand for technical information24. An important finding of the study regarding access to technical standards and recommendations for dental care during the pandemic was that 77.4% of participants reported accessing pub- lications that did not identify the agency responsible, regardless of whether they also accessed materials from reputable agencies (Table 04). Much access to pub- lications via the media, the internet, or direct communication has been observed in other studies12,25,26. This reality, which presents difficulties in clinical practice is based on the best evidence during such times20,27. Searching without scientific cri- teria can lead to false information and corroborate inappropriate conduct in dealing with the pandemic26. As for continuing education, 52.6% of the participants stated that they had received guidance on the measures to be adopted in their workplaces, but 22.2% did not know how to answer this question (Table 5). Given the panorama of social iso- 11 Palma et al. Braz J Oral Sci. 2023;22:e237812 lation imposed by the pandemic, the privileged education strategies were elabo- rated online, lacking a foundation in the problematization of realities28. Digital tools (applications, online courses) allow for fast and constant updating. It is noteworthy that this type of pedagogical tool is an essential resource in the face of social isola- tion. However, it disfavors human interaction that facilitates learning and sociabil- ity28,29. Thus, coordinated actions based on a national education program for health professionals should be proposed with a broad scope, contributing to safety in work processes26. In this study, 33.4% strongly agreed and 32.3% agreed that they felt anxious or worried about working during the pandemic (Table 5). Fear and anxiety are natural in pandem- ics, especially with an increase in infected individuals and mortality rates11. The high- est scores for anxiety, depression, and stress were related to increased risk factors for contracting the disease30. The highest indices of fear and anxiety were associated with low searching for knowledge7,31, not following biosafety rules11,25 and receiving updates by social media26. Some strengths and weaknesses should be highlighted. The study was carried out in the context of the first wave of COVID-19. Therefore, the generalizability of the results must be extrapolated with caution. Considering the country’s regional inequalities, epidemiological differences, and subnational government response to the COVID-19 pandemic, the results may not fully reflect the Brazilian reality since the responses varied widely in terms of the type, timing, and rigor of policy imple- mentation in each state32. Nevertheless, our study was intended to be discussed at the moment of the first wave, as the pandemic impacts unfold around us daily. The results reveal for researchers and policymakers the evidence needed for planning and evaluating surveillance and biosafety measures in the context of the Brazilian political severe crisis. Our findings revealed that OHCWs adopted surveillance measures in dental environ- ments, such as providing COVID-19 guidelines and visual alerts in the office, investi- gating possible respiratory symptoms, and adopting distancing in the waiting room. Biosafety measures to reduce the generation or propagation of aerosols, including avoiding intraoral radiographs, using dental dams in high-speed care, and availabil- ity of high-power suction systems, had less adherence because they conflict with team management. However, disinfection of face shields, proper removal of personal barrier protection, and reuse of N95/PFF2 masks following appropriate criteria had greater compliance. The substantial access to information on dental care during the COVID-19 pandemic reflected awareness of the high risk of work exposure. Most access to technical stan- dards and recommendations was through non-governmental health authorities. Coor- dinated and purposeful action by policymakers for permanent education of the entire workforce is necessary. Conflict of interest None declared. 12 Palma et al. Braz J Oral Sci. 2023;22:e237812 Funding and Acknowledgements None declared. Ethical approval Ethical approval for data collection was obtained from the Research Ethics Com- mittee, the Federal University of Rio Grande do Sul, Porto Alegre, Brazil (CAAE no. 31720920.5.2002.5530) in accordance with the Helsinki Declaration of 1975 on experiments involving human subjects. Data availability Datasets related to this article will be available upon request to the corresponding author. Author Contribution All authors substantially contributed to the analysis and interpretation of the data; significantly contributed to the critical review of the content; and participated in the approval of the final version of this manuscript. 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Questions Categories Sociodemographic and health profile Gender Male Female Other Age Years Occupation Dentists Dental assistants Technicians Conclusion of professional training Years Higher graduation level Specialization/Residency Master PhD None Postgraduate area Specialty list City where you work Municipality Workplace SUS – Primary Health Care (PHC) SUS - Dental Specialty Centers (DSC) SUS – Urgency care Private clinic Dental teaching clinic Corporate Entities Health System Security forces (i.e., army, police) Hospital Management Other Risk group for COVID-19 Only age over 60 years old Health condition only Age over 60 and health condition None Absence from work during the pandemic Yes No Testing for COVID-19 No Yes, RT PCR Yes, rapid test Yes, serological test Continue 16 Palma et al. Braz J Oral Sci. 2023;22:e237812 Continuation Adoption of surveillance, planning and risk management measures to control the dissemination of COVID-19 in health services Answer options: 0 – do not know; 1 – never; 2 – ever; 3 – sometimes; 4 – often; 5 - always Suspended elective procedures and care restricted to urgency/emergency Participation in decision-making about changes in work during the pandemic Reduced workload or professional turnover to minimize the risk of contamination Worked directly in COVID-19 reception/sorting/fast track procedures Investigation of respiratory infection symptoms in appointment scheduling Patients with symptoms of respiratory tract infection immediately isolated Waiting room respecting the minimum distance of 01 meter between people Availability of visual alerts in the health service Urgency based on pre-established clinical protocols Orientation of patients about COVID-19 Use of digital tools for teleorientation or telemonitoring Interaction with other health professionals Adoption of biosafety measures in health services Answer options: 0 – do not know; 1 – never; 2 – ever; 3 – sometimes; 4 – often; 5 - always Disinfection of the environment by a trained professional with appropriate PPE Disinfection of suction hoses Use of sterile micromotors at every dental appointment Intraoral radiographic examinations were avoided Performing four-handed dental procedures Use of the dental dam in high rotation services Procedures that generate aerosols were avoided Use of suction system (vacuum pump) Proper removal of personal barrier protection N95/PFF2 mask reuse with proper criteria Disinfection of face shield Permanent health education Access to technical standards and recommendations on dental care Access to standards and recommendations on dental care during the COVID-19 pandemic Technical note GVIMS/GGTES/ANVISA Nº 04/2020 Recommendations booklet of the Federal Council of Dentistry (CFO) Recommendations booklet of the Regional Council of Dentistry (CRO) from own state Recommendations booklet of the Regional Council of Dentistry (CRO) from other state Recommendations from the Municipal / State Secretariat None Other documents Continue 17 Palma et al. Braz J Oral Sci. 2023;22:e237812 Continuation Training/education during COVID-19 pandemic Answer options: 0 – do not know; 1 – strongly disagree; 2 – disagree; 3 – undecided; 4 – agree; 5 – strongly agree I consider that I received guidance at my workplace regarding measures to be taken during the COVID-19 pandemic I was able to apply the knowledge acquired in training/education about COVID-19 to modify my practice I feel sufficiently enlightened and secure to work properly in dental practice during the COVID-19 pandemic I feel anxious and concerned to work properly in dental practice during the COVID-19 pandemic