Public Trust in Dentists among Arabic Populations

Objective To investigate public trust in dentists, fear of dentists, factors related to trust, and the impact of the COVID-19 pandemic on the trust in dentists. Materials and Methods We used an Arabic online anonymous survey to collect data from a random population of 838 adults to investigate public trust in dentists, the factors they perceive to affect trust, their perception of key factors in the dentist-patient relationship, fear of dentists, and the impact of the COVID-19 pandemic on the level of their trust in the dentists. Results Eight hundred thirty-eight subjects with a mean age of 28.5 responded to the survey (595 (71%) females, 235 (28%) males, and 8 (1%) did not specify their gender). More than half trust their dentist. The COVID-19 pandemic did not decrease trust in dentists according to 62.2%. There were significant gender differences in reporting fear of dentists (p < 0.001) and in the perception of factors affecting trust (p=0.028). Honesty was chosen by 583 (69.6%), competence by 549 (65.5), and dentist's reputation by 443 (52.9%). Conclusions The findings of this study show that the majority of the public trust dentists, more females reported fear of dentists, and the majority perceived honesty, competence, and reputation as key factors affecting trust in the dentist-patient relationship. The majority reported that the COVID-19 pandemic did not have a negative impact on their trust in dentists.


Introduction
Trust in dentists is a key pillar of the dentist-patient relationship. Without trust, patients would not seek dental treatment or visit dentists to seek dental care nor would they reveal the details of their illness or submit to treatment [1]. Te result would be aggravated dental problems and deterioration of patients' dental and oral health, which would likely cause unnecessary pain and sufering. Te outcome of not seeking dental care would likely impact the patient's health and could afect the quality of their life and predispose them to medical complications. In spite of the importance of patients' trust in dentists and the role it plays in the dentistpatient relationship, it has not been adequately investigated, at least in Arabic regions or Arabic speaking populations. Furthermore, although the public health message, which has focused on the dental clinic as a high risk-aerosol-inducing environment, may have afected the public trust in dentists, the impact of coronavirus disease (COVID-19) pandemic on patients' trust in dentists is not well understood despite the fact that it is now known to most populations that the novel virus that causes COVID-19, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is transmitted by droplets and aerosols that are highly infectious and produced during most dental procedures. A recent study found that 19% of Italians reported that they have little trust in their dentists' infection control practices during the pandemic, and 48% of the study population reported extreme trust in their dentists and their sanitization and sterilization procedures [2].
Tough many miscellaneous attempts in the literature clearly defne the meaning and interpretation of the term "Trust," Hall et al. [1] defned the term simply as "the optimistic acceptance of a vulnerable situation" in which the truster believes the trustee will care for the truster's interests. Studies that investigated trust in the patientphysician context showed that trust is a keystone in the physician-patient relationship as gaining patients' trust is a fundamental trait of a good clinician [3]. Trust is infuenced by the clinician's technical competency [3,4] and their communication skills [5,6]. However, as a result of trusting the physician, patients were more likely to adhere to the treatment provided to them by their respective physician [5]. It was also provided that a patient's doubt in their dentist can provoke dental anxiety owing to the fear of the unknown as patients are reluctant to trust a dentist that is unwilling to answer their questions, thereby stressing the importance of trust in the dentistpatient relationship [7]. Te issue of trust (or lack thereof ) has gained more interest in recent publications, and a certain trend of mistrust in physicians is emerging as reported by recent studies from China and India whose authors point to a worldwide mistrust in healthcare [8,9], although according to a previous study, a decline in patients' trust in their physicians became salient in the 1990s [10]. Although rare, reports about trust and mistrust in dentists indicate that mistrusting the dentist's ability can aggravate patients' fear and anxiety, especially when the patient does not comprehend what the dentist is doing in their mouth [7].
Research on trust in dentists has recently garnered attention for its importance in promoting oral health and as a key factor in the dentist-patient relationship [11]. Despite the importance of trust, there was, until recently, little research and guidance to dentists on how to build trust or how to be trustworthy [12]. One of the previous studies on trust in dentists was carried out in Australia; it showed that the majority of the adult population had trust in their dentists [12,13].
COVID-19 is a new source of concern and fear for both dentists and patients [14]. Tis recent challenge may also strain the patient-dentist relationship and could have an everlasting impact on patients' trust in dentists. Tis impact is not fully understood, not only because the virus that causes COVID-19 is novel but because the concept of trust in dentists is not fully investigated and understood as we have mentioned previously. Furthermore, although the public health message which has focused on the dental clinic as a high risk-aerosol-inducing environment may have affected the public trust in dentists, the gap in knowledge about trust in dentists in the COVID-19 era is worthy of investigation.
Terefore, the objectives of this study were as follows: (1) to investigate subjects' trust in dentists and fear of dentists, (2) identify which trust-related factors are perceived to be important by the public, and (3) explore if COVID-19 had any impact on public trust in dentists.

Study Population and
Methodology. An anonymous online Arabic questionnaire was created by the authors using a Google Form. Te questionnaire was used to evaluate the public's trust in dentists and whether the COVID-19 pandemic had any impact on the trust in dentists. Te questionnaire was divided into four sections. Te frst section was a description of the purpose of the study and an informed consent. Invitees were asked to fll in the questionnaire if they would consent to participate. Te second section included questions about demographic characteristics of participants. Te third section included questions investigating how much respondents agreed with statements about trust in dentists following Te Dentist Trust Scale [13] and questions to investigate the association between trust and fear. Te fourth section included a question on whether the COVID-19 pandemic had any impact on subjects' trust in dentists and questions on the factors that afect trust in dentists and which factor was perceived as the factor most afecting trust in dentists. Te study was approved by the Institutional Review Board (IRB) of King Abdullah University Hospital (KAUH)-Irbid-Jordan (Ref. 85/136/2020). Te questionnaire was validated and piloted before inviting subjects to participate. Ten, the Google Form questionnaire's link was posted on Facebook (group and personal accounts) and sent via WhatsApp. To minimize selection bias by the authors, we asked potential respondents to share the questionnaire's link with their families and friends and those who live in other countries. Descriptive statistics were used to analyze the data. To examine diferences between genders, Pearson's chi-square test or Fisher's exact test were used. A p value less than 0.05 was considered statistically signifcant.

Results
From December 11, 2020 to February 4, 2021, eight hundred thirty-eight subjects responded to the survey (595 (71%) females, 235 (28%) males, and 8 (1%) did not specify their gender). Seven hundred forty-fve (89%) were from Jordan, and 11% were from other countries. Table 1 shows the demographic characteristics of the respondents. Answering all questions on demographics was not required to ensure voluntariness and eliminate untrue answers. Table 2 shows the responses to questions about subjects' agreement with statements indicating their perception of important factors of the dentist-patient relationship. 44.7% (n � 375) agreed and 22.6% (n � 189) strongly agreed that they had no worries about putting their oral health in the hands of the dentist. Te majority (46.1% (n � 386) and 23.6% (n � 198)) agreed and strongly agreed that they completely trust dentists' decisions about which dental treatments are best. More than half (53%) agreed or strongly agreed with the statement "in general, you completely trust your dentist," 29.8% were neutral, and 16.4% reported that they disagreed or strongly disagreed with this statement. Tere was a statistically signifcant association between the responses to "in general, you completely trust dentists" and "do you fear dentists" X 2 (12, N � 838) � 37.9, p < 0.001.
Regarding the pandemic impact on subjects' trust in dentists, Figure 1 shows the percentage of responses to "do you fear dentists" by gender.
Regarding the perception of subjects about the factors afecting their trust in dentists, subjects could choose more than one factor: honesty was chosen by 583 (69.6%), competence was perceived to be an important factor by 549 (65.5), and dentist's reputation was an important factor according to 443 (52.9%). Te cost of treatment was reported to be important by 255 (30.4%). Figure 2 shows the most important factor that can afect trust as perceived by gender. Tere were statistically signifcant diferences between gender and age groups in responding to a question about the most important factor afecting trust [X 2 (10, N � 838) � 20, p � 0.028; X 2 (25, N � 838) � 49, p � 0.003], respectively. Honesty was perceived to be the most important factor, followed by competency, dentist's reputation, and only 14 (1.7%) reported that the university the dentist attended (alma mater) was the most important trust factor. On the other hand, there was no signifcant diference between genders; the majority perceived the dentist's treatment decisions to be in the patient's best interest. 62.2% reported that the COVID-19 pandemic did not afect their trust in dentists, while 18.9% reported that the pandemic negatively impacted their trust in dentists.

Discussion
Trust is a keystone in the dentist-patient relationship. Building trust between dentists and their patients can be improved by understanding prospective patients' perception of the key factors that might afect trust [15]. It can be theorized that the COVID-19 pandemic and the public's attention to the risks entailed in the exposure to a deadly virus in a dental ofce may have negatively impacted the public trust in dentists. Te results of this investigation indicate that the majority of respondents trust their dentists and that the COVID-19 pandemic did not have a negative impact on their trust in dentists, although a minority reported that the pandemic decreased their trust in dentists. Tis fnding is in line with a recent investigation from Italy [2]. It is evident that the population of the present study believed their dentist would not mislead them and that the treatment decisions made by their dentists are in the patient's best interest. Furthermore, the majority reported having no worry in putting their oral health in the hands of their dentist.
Although 41.7% of the population agreed that "dentists only think about what is best for themselves," 69.7% reported to completely trust dentists' decisions about which dental treatments are best. Tese fndings suggest that if trust is to be defned by Hall et al. [1] as the belief that the trustee will care for the truster's interests, then the discrepancy may be attributed to the assumption that the patients believe that their dentist's interests align with the patient's own interests. Indeed, a strong argument would support the fact that building trust in the dentist-patient relationship is in the best interest of dentists, patients, and oral health systems [15].
Te results of this study show that 17-40% of the respondents' answers to the questions of the modifed Dentist's Trust Scale were "neutral" which can be understood to mean that a signifcant proportion of society is undecided about whether they can trust or distrust dentists. Tis fnding is important and can be used by dentists and dental associations to implement trust building strategies that enhance societal trust in the profession of dentistry.
Although the results of this study show that the majority of our population trust dentists, which is in alignment with the results of a similar study on an Australian population, both studies showed comparable results with means ranging from 3 to 3.9. However, a slight deviation between this study and the Australian study can be spotted when the participants were asked about whether they thought that "dentists think only about what is best for their patients," in this context, it seems that the Australian population has more trust in their dentists. A plausible explanation can be attributed to methodological and population diferences.
In agreement with a previous study [16], the results of this investigation showed signifcant gender diferences regarding fear of dentists, and more females reported to sometimes or always fear dentists. Findings of this study indicate that there might be a possible association between fear and trust. Te association between trust in dentists and the fear of dentists warrants further investigation as dental fear could lead to avoidance behavior and deterioration of dental health [17] and can revolve around many issues such as feelings of shame, fear of being judged by the dentist [18], fear of chocking, fear of blood, and lack of trust in the competency of dentist. Overall, good communication practices can mitigate fear of treatment [19] because patients who need to see a dentist are often frightened [20] and some feel uncomfortable expressing their fear of dentists or dental procedures [21].

Strongly agree N/(%)
A dentist would never mislead you about anything competency (females: 31.4%-males: 27.2%). Curiously, the dentist's alma mater was chosen by a few as the most important factor afecting trust. Previous and recent research has established that honesty is a fundamental characteristic of the best dentistpatient relationship [22]. Improving ethical practices and building trust in the dentist-patient relationship cannot be achieved without honesty and competency. Although receiving quality dental care by a competent dentist is the goal of each dental patient, misleading patients by dishonest dentists is a violation of the patient's rights and a trust eroding behavior. Consequently, behaviors that erode public trust in dentists would certainly harm the position of the profession of dentistry in society and violate the ethical principles of practicing dentistry [23,24].

3.1.
Limitations. Data used in this study were collected by using an online self-administered questionnaire; therefore, the fndings from this study are subject to some limitations. Te most important limitation is diferent sources of bias including recall bias and selection bias. Te majority of the respondents were females, although we could not determine the response rate, but the results show that most respondents were in the younger age group. Tis could be due to the fact that a signifcant percentage of seniors may not have access to smart phones or access to the Internet. Tus, the results may lack external validity; further research with other populations will determine the generalizability of the fndings of this study.

Conclusions
Te fndings of this study add to the current literature on the trust in dentists. Te results suggest an association between fear of dentists and trust in dentists, which should be considered in future research on the dentist-patient relationship. Findings provide evidence that honesty, although perceived to be the most important factor afecting trust, honesty, and competence, go hand in hand and are perceived to be the most important factors afecting trust in dentists among diferent genders and age groups. Tis study also highlights the need for further research on the relationship between trust and using dental services. Its fndings can be used to raise awareness about the importance of adopting trust building behaviors that enhance the societal perception of dentists and promote oral health and the need to avoid practices that could erode public trust in dentists.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon reasonable request.

Disclosure
Tis research was performed as part of the employment at Jordan University of Science and Technology.

Conflicts of Interest
Te authors declare that they have no conficts of interest. Prefer not to answer  International Journal of Dentistry 5