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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 168-175

Assessment of challenges faced by dental interns and their psychological health during the COVID-19 pandemic in South Indian State of Kerala

1 Department of Periodontics, Government Dental College, Kozhikode, Kerala, India
2 Department of Public Health Dentistry, Government Dental College, Kozhikode, Kerala, India

Date of Submission04-Apr-2021
Date of Acceptance21-May-2021
Date of Web Publication23-Aug-2021

Correspondence Address:
Thayyil Sivaraman Hrishi
Department of Periodontology, Government Dental College, Kozhikode - 673 008, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_54_21

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Context: The dental universities were shut or partially operating amidst the lockdown imposed by the coronavirus disease 2019 (COVID-19) pandemic. Dental interns because of reduced opportunities for clinical training and recruitment for COVID-19 containment activities can be faced with many challenges. Aims: To assess the various challenges faced by the dental interns during the COVID-19 pandemic and to evaluate their psychological health. Materials and Methods: A cross-sectional study was conducted using an online questionnaire among dental interns of ten randomly selected dental colleges in Kerala. The questionnaire comprised of questions about demographic information, questions to assess various challenges the interns faced during the COVID-19 pandemic, and a Patient Health Questionnaire-4 tool to screen for anxiety and depression. Statistical Analysis Used: The data were analyzed using SPSS 21 software; descriptive statistics were used to describe the demographic characteristics and challenges faced by interns. The Chi-square test was used to analyze the association of psychological health with different parameters. Results: A total of 283 interns, 154 (54.4%) from private colleges and 129 (45.6%) from government colleges completed the questionnaire. About 86% of the interns opined that they did not receive the expected clinical training and 71.7% of interns were not confident to practice with the training they received. Almost 58% of the respondents were frontline workers in managing the pandemic with a majority of them being from government colleges. A high prevalence of psychological distress (73.1%), depression (36%), and anxiety (28%) was observed among interns. The lack of adequate training influenced the psychological health of interns significantly. Conclusions: The dental interns did not receive adequate clinical training during the pandemic; this had severely affected their confidence to practice and mental health. Measures should be implemented by institutions and governing bodies to address these problems immediately.

Keywords: Challenges, coronavirus disease 2019, dental interns, psychological health

How to cite this article:
Hrishi TS, Sanara PP, Vadakkekuttical RJ, Soumya Mohanan T V. Assessment of challenges faced by dental interns and their psychological health during the COVID-19 pandemic in South Indian State of Kerala. J Dent Res Rev 2021;8:168-75

How to cite this URL:
Hrishi TS, Sanara PP, Vadakkekuttical RJ, Soumya Mohanan T V. Assessment of challenges faced by dental interns and their psychological health during the COVID-19 pandemic in South Indian State of Kerala. J Dent Res Rev [serial online] 2021 [cited 2022 Nov 27];8:168-75. Available from: https://www.jdrr.org/text.asp?2021/8/3/168/324418

  Introduction Top

The novel coronavirus disease 2019 (COVID-19) which originated in China in the latter part of 2019 attained a proportion of global pandemic by January 2020.[1] The World Health Organization had put forward a series of stringent measures to contain the spread of the virus. Most countries complied with these recommendations and introduced nationwide lockdowns, leading to suspension of attendance at schools, universities, and workplaces.[2],[3] Dentists have been classified in the very high-risk category because of the potential of exposure to coronavirus through aerosol-generating procedures. Most dental schools throughout the world suspended clinical activities except for dental emergencies during the lockdown.[4] Students were banned from coming to the universities and online teaching replaced the physical classrooms. The clinical teachings were limited to online case discussions and videos.[5]

Dental education in India includes 4½ years of learning and 1 year of compulsory rotatory internship. It is during the internship, the dental undergraduates will have maximum exposure to various clinical scenarios and are independently allowed to work. Whatever skills they acquire during the internship would define their future in the profession. With more than 2.7 lakh registered dentists and a dentist ratio of 1 for 5000 which is higher than WHO recommended ratio of 1:7500, the opportunities for fresh graduates have dwindled.[6] There had been previous reports of a high prevalence of depression and stress among dental students.[7],[8]

India is one of the most affected countries by pandemic and the first case of COVID-19 patient in India was reported in Kerala. The dental colleges in Kerala in both government and private sectors had restricted the academic activities to online teaching and were operating only on emergency basis.[9] The number of patients visiting dental colleges has drastically reduced following the fear among the public of colleges being a potential contagion site.[10] Moreover, with an acute shortage of health-care personnel, the interns have been deployed in the frontline for combating the COVID-19 pandemic, which might have further reduced their clinical training hours during the internship. The dental interns like any other health care workers deployed in COVID-19 pandemic management will be subjected to immense psychological stress. In addition to this, the concerns about their future due to limited clinical training in dental subjects during the pandemic could jeopardize their mental health. The ill effect of the COVID-19 pandemic on the psychological health of general population, health university students, dentists, and health workers has been documented.[11],[12],[13] However, to our knowledge, no studies have focused on the challenges faced by dental interns during the COVID-19 pandemic. Our study aimed to assess various challenges faced by dental interns and their psychological health during the COVID-19 pandemic.

  Materials and Methods Top

A cross-sectional study was conducted among interns from dental colleges in Kerala. The time period of the study was from January 15, 2021–March 30, 2021. The study was reviewed and approved by the Institutional Ethics Committee (IEC no 194/2020/DCC, Dated: 21-12-2020). Dental colleges in Kerala were grouped into two groups: Private and Government and five colleges were randomly selected from each group by drawing lots. The sample size was calculated as 267 with a 95% confidence interval (95% CI) for a prevalence of 50% and with a margin of error of 6%.

An online questionnaire was drafted using google forms (https://docs.google.com/forms/). The validated questionnaire was circulated through E-mails and other social media platforms to the interns. The first page of the questionnaire consisted of information about the study and informed consent which the participants have to accept before proceeding to the next section. This section comprised of a total of 19 questions which included five questions regarding demographic information, 11 questions to assess various challenges interns faced during the COVID19 pandemic and a Patient Health Questionnaire-4 (PHQ-4) tool to screen for anxiety and depression among interns [Table 1].
Table 1: Sample questionnaire

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PHQ-4 tool consisted of four questions and is a reliable and valid tool for screening depression and anxiety disorders.[14] The first two questions screened for anxiety (Generalized Anxiety Disorder-2 scale or GAD-2) and the last two questions screened for depression (PHQ-2). The response options for questions are as follows: Not at all (score = 0), several days (score = 1), more than half the days (score = 2), and nearly every day (score = 3). Total score is determined by adding together the scores of each of the 4 questions and total possible scores ranged from 0 to 12. Scores are rated as none or minimal (0–2), mild (3–5), moderate (6–8), and severe (9–12) amount of psychological distress.[14]

Data were analyzed using the SPSS software version 21 (IBM Corp., Armonk, NY, USA) computer software; descriptive statistics were used to describe the demographic characteristics and various challenges the subjects faced. The association of stress and anxiety with various demographic parameters was assessed by the Chi-square test with post hoc. The difference in psychological status and the challenges between the interns of the government and private institute was assessed by the Chi-square test.

  Results Top

Demographic distribution

A total of 283 interns completed the questionnaire. The mean age of interns was 24.43 years (±1.07) and a majority of respondents were females (81.6%). Among the participants, 154 (54.4%) were from private institutions and 129 (45.6%) from government institutions. For a higher proportion of respondents (67.8%), dentistry was not the first choice, they took up dentistry because they got through state entrance examinations and only 22.3% selected dentistry by choice. The majority of interns (60.4%) were planning to prepare for postgraduate examinations, 28.3% wanted to join as an associate dentist and only 8.8% percentage of the interns wanted to start their own practice [Figure 1] and [Table 2].
Figure 1: Distribution of Plans of Interns after completion of Internship. *Expressed in percentage

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Table 2: Background data of participants

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Challenges faced by interns

A high proportion of interns (86%) are of the opinion that they did not receive the expected clinical training irrespective of the type of institution they are studying and 71.7% of interns are not confident to practice with the training they received [Figure 2]. In order to compensate for the inadequate amount of clinical training during the pandemic, 46% (64.3% in government colleges and 31.2% from private colleges) of interns wanted to do voluntary internship in their college again. Almost 43% of the interns wanted to join an experienced dentist to gain clinical expertise, majority from the private dental institutes preferred this measure compared to interns from the govt. institute. Only 4% of respondents opined that no additional measures were needed. The majority wanted (62%) the current internship pattern to be changed [Figure 2], 35% of the interns wanted practice management workshop to be introduced and another 34% opined that additional training in managing medical emergencies was required. The interns of government institutes favored more for practice management workshop, whereas the majority of interns from the private colleges wanted training in medical emergencies [Table 3].
Figure 2: Distribution of Challenges Faced By Interns. *Expressed in percentage

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Table 3: Challenges faced by interns

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Impact of coronavirus disease 2019 pandemic

About 58% of respondents were frontline workers in managing the pandemic and a majority of them were from government institutes [Figure 3]. Only 33.5% of the interns who took COVID-19 duties believed that they were sufficiently trained to take COVID-19 duties. Almost 40% of interns responded that they gained positive inputs by taking up COVID-19 duties. The majority of interns' perception of continuing dentistry as a profession has not changed due to the pandemic [Table 4].
Figure 3: Distribution of coronavirus disease 2019 duties among interns of Government and Private Colleges. *Expressed in percentage

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Table 4: Challenges faced by interns due to coronavirus disease 2019 pandemic postings

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Psychological status of interns

A high prevalence of psychological distress was observed among interns. The majority of interns (43.8%) showed mild distress, 19.8% moderate and 9.5% severe distress. Severe distress among interns was more prevalent in the private institutes (14.9%) as compared to government institutes (3.9%), and the difference was significant statistically. Mild distress among the interns from government institutes was significantly higher than those from private institutes. The prevalence of anxiety and depression among interns was 28.6% and 36%, respectively, and 44.2% of interns either suffered from anxiety or depression [Figure 4], no significant difference was observed between government and private institute [Table 5].
Figure 4: Distribution of prevalence of anxiety or depression among Interns

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Table 5: Psychological status of interns (evaluated by patient health questionnaire 4 tool)

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On assessing the association of psychological status and various factors, it was observed that the type of institution studying and receiving the expected clinical training had a significant impact on psychological distress. Severe distress was significantly higher in interns from the private colleges, whereas mild distress was more among the interns of government institutes. Interns who feel they received adequate training was found to have no distress and those who did not receive training showed significant levels of mild distress. The confidence to start practice was significantly linked with levels of depression, the interns who are not confident to practice showed high levels of depression. The factors such as gender, place of residence, and COVID-19 duty did not show significant levels of association with the psychological status of subjects [Table 6].
Table 6: Association of various factors with psychological parameters*

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  Discussion Top

This study, to our knowledge, is the first of its kind which attempted to evaluate various challenges faced by the dental interns during the COVID-19 pandemic and the psychological burden on interns. COVID-19 pandemic had forced a temporary shutdown of medical and dental universities throughout the world. Hence, the amount of academic and clinical training of the medical and dental students was compromised.[5] In the dental curriculum, 1 year of rotatory internship is a crucial period for an undergraduate student. During this period, they get maximum exposure in clinical cases and this will make them competent to practice the profession.

In our study, majority of the interns responded that they did not receive adequate training during the internship, and they were not confident to practice independently, this can be attributed to the lack of training received during the pandemic. The interns were planning to compensate for the lack of training by doing voluntary internship in their institute or by working with an experienced dentist. A common trend among dental graduates is to join postgraduate courses rather than starting their practice.[15],[16] This study also showed similar results with 60.4% of them wanting to prepare for the national entrance test for postgraduate courses. The opportunities for a fresh dental graduate are limited in India because of a large number of dental schools and increased dentist population ratio; therefore, fresh graduates are of the notion that by joining postgraduation they can gain more skills and increase their job prospects. The respondents think that current internship programs should incorporate practice management workshops, training in the management of medical emergencies, and posting in the emergency rooms of hospitals. Practice management workshop will be helpful for fresh graduates to build their own practice and to survive in the current scenario. The emergency room postings and training in the management of medical emergencies will make them better prepared for any untoward event in the dental office, and they can complement the medical fraternity during the time of an emergency or a pandemic.

The first COVID-19 case in India was reported in Kerala, to date, the total number of cases has reached 1.1 million. Medical, paramedical, and health-care students were deployed in the frontline to contain the COVID-19 pandemic. Dental interns along with other health-care workers were deployed in COVID-19 wards, swab collection centers, and for screening people who are entering the state.[17],[18] In our study, 57.2% of the total respondents were involved in COVID-19 containment duties. The interns from government colleges were mandatorily posted for COVID-19 duties while postings for the interns from private colleges were optional. About 39.9% of total respondents opined that their perceptions of taking dentistry as a profession had changed following the pandemic. A similar observation was made in Jordan before that pandemic in which 33.3% of final year students wanted to change their career.[19] The reasons behind this decision were limited employment opportunities, stress, lack of social interaction, and difficult coursework in dentistry. In the current scenario, the pandemic had affected the dental profession adversely, many dental professionals were concerned about the lack of patients, increasing establishment charges, the safety of self and family and the availability of protective gear.[20],[21] These challenges which dental professionals are facing would have influenced the decision of dental interns to rethink their career choice.

The current study assessed the psychological health of dental interns by utilizing a PHQ-4 tool. The PHQ-4 is a valid and reliable brief tool to screen for depression and anxiety which had been tested in previous studies.[14],[22] In the present study, the dental interns showed a high percentage of psychological distress with almost 36% showing depression and 28% showing anxiety. Raghunathan et al. in 2019 observed that the prevalence of depression among students of a dental tertiary care center in Kerala was 26.9%.[7] Studies from India, Germany, and United States showed the prevalence of depression among dental students ranging from 49% to 56%.[7],[8],[23],[24] Similarly, a higher level of anxiety was observed among dental students by previous studies.[25],[26] The presence of high levels of depression and anxiety can be attributed to the extensive curriculum of dental education, stressful clinical hours, and concerns about the future.

Recent literature reveals that COVID-19 had adversely affected the psychological health of all strata of society.[11],[12],[13] The dental professionals and dental students showed high levels of psychological distress during the pandemic in the different parts of the world.[26],[27],[28],[29] A recent study from Saudi Arabia which assessed the psychosocial impact of the COVID-19 pandemic on dental interns showed low levels of depression (11.9%) and anxiety (7.3%) as opposed to our study.[30] The possible explanations given by authors were period of collection of data was during the end of the academic year and during the lockdown period when interns were not attending the college and also due to reporting bias. In the current study, during the data collection period, the interns were attending the clinics and were posted for COVID-19 duties. Apart from this, the interns were concerned about the lack of training they received and about their future in dentistry, which possibly could explain the difference in findings. A significant level of mild distress was seen among dental interns of the government colleges, this can be because the government colleges in Kerala were functioning in limited capacity compared to private colleges which were shut during the lockdown period. Interns were also posted in triage, for swab duties and in the screening of COVID-19 patients which would have affected their mental health. There were significant levels of severe distress among interns of private college which we were not able to correlate to any of the factors assessed in our study; this group requires further evaluation of underlying reason and professional help. The COVID-19 duties were not found to significantly impact the mental health of interns in our study, this might be because the majority of the interns who took COVID-19 duty believe that they gained positive inputs from the duties and also many voluntarily opted for the duties.


The study was based on a self-reported online questionnaire; hence, chances of reporting bias are present. The study was conducted among interns of a limited geographical area, a nationwide or a worldwide study is recommended for future research. The psychological health was assessed by an ultra-short tool, a more comprehensive tool could have been ideal.

  Conclusions Top

Dental interns did not receive adequate clinical training due to reduced patient inflow to the dental colleges during the ongoing COVID-19 pandemic because of this many of them are not confident enough to practice. The additional COVID-19 duties also reduced their opportunities for clinical training. The prevalence of psychological distress, depression, and anxiety is alarmingly high among dental interns, this requires immediate attention by the teaching institutions. The education institution should include mental health programs in the dental curriculum. Inadequate clinical training received during the internship was observed to be the major factor affecting the mental health of interns adversely, whereas the COVID-19 duties had limited influence. The dental internship program may be modified by introducing practice management workshops and optional preparatory classes for the national postgraduate entrance test for those who aspire to pursue postgraduation.

Ethical clearance

The study was reviewed and approved by the Institutional Ethics Committee (IEC no 194/2020/DCC, Dated: 21-12-2020).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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