Impact of COVID-19 on Dental Care in New York State and Georgia

DOI: https://doi.org/10.21203/rs.3.rs-1865186/v1

Abstract

Introduction:

During the COVID-19 pandemic, there was an unprecedented, forced closure of dental offices worldwide. As American state recommendations differed considerably during this period, this research strives to better define the effects of this pause on dental care.

Materials & Methods:

A 16-question Qualtrics survey was sent to the membership of the New York State Dental Association (NYSDA) and Georgia Dental Association (GDA). Licensed, actively practicing dental members of the NYSDA and GDA (n = 680) answered questions about their practice demographics, appointment cancellations, reopening times, and the volume of individual dental procedures performed from March 1 through August 1, 2020, compared to the same 5-month period in 2019.

Results:

Demographic characteristics of respondent NYSDA and GDA members were statistically similar. Nonetheless, NYSDA members reported significantly larger decreases in provision of all types of dental procedures except for antibiotic prescription, including prophylaxis, elective care, emergent care, and specialty procedures.

Discussion & Conclusions:

All dental procedures declined significantly during the COVID-19 pandemic, with greater decrease in New York than in Georgia. This study raises concern about the negative impact of the pandemic on oral public health, and mandates both further research and clinical strategies to mitigate against this future risk.

Introduction

During the onset of the 2020 SARS-CoV-2 (COVID-19) pandemic, there was an unprecedented, forced closure of dental offices in the United States (US) mandated by state governors in all states except North Dakota and Wyoming (1). While much of the current dental research in relation to the COVID-19 pandemic pertains to infection control and guidance on dental precautions, the specific dental care provided in the United States during the COVID-19 pandemic has yet to be quantified (2).

State government officials and the American Dental Association (ADA) recommended that state licensed dentists and dental facilities should postpone elective procedures, surgeries, and non-urgent dental visits, solely prioritizing urgent and emergency visits (3). The duration of this recommendation and subsequent permission for dental practices to reopen to their full scope of services varied state by state. As the first author of this research is from Georgia and attends dental school in New York, those two states with varying COVID-19 experiences were primarily analyzed. Governor Kemp of Georgia permitted the full reopening of dental offices on May 1, 2020 with adherence to the ADA’s guidelines of transmission minimization and personal protective equipment. In comparison, Governor Cuomo of New York State announced approval of statewide opening of dental offices for regular dental care one month later, on June 1, 2020 (1).

These state guidelines and national recommendations were widely communicated, but the degree to which dentists interpreted and complied with the recommendations remains unknown. Furthermore, there exists no publicly accessible database tracking this information.

Beyond state regulation of dental practice reopening dates, fear of COVID-19 exposure had a significant impact on patients’ willingness to seek dental care and dentists’ willingness to reopen practices to non-emergent care. Similarly, during the 2003 SARS epidemic, patients’ access to quality care was seriously compromised by their diminished care-seeking behavior due to fear of SARS (4). The present study investigated the shift in care-seeking behavior during the COVID-19 pandemic, as was seen previously in the SARS epidemic.

The objective of this research was to quantify dental procedures provided in the states of New York and Georgia during the COVID-19 pandemic compared to the year prior, and to investigate how fear of virus exposure contributed to appointment cancellations and deferrals when dental practices were reopened.

Coincident with present research, a similar survey of dental practitioners in Brazil was recently published (5). The web-based survey sent to Brazilian dentists via WhatsApp Messenger (WhatsApp Inc., California, United States) found that despite the lockdown recommendations, 83.8% of the dentists reported their patients continued to seek elective dental care, including prophylaxis and preventive procedures during the designated 2-week response time between May 5th -20th, 2020 (5). To our knowledge, our study is the first to attempt to quantitate the impact of the COVID-19 pandemic on specific dental procedures provided during the peak 5-month period of the pandemic in the United States.

Materials & Methods

A 16 question Qualtrics® survey (Qualtrics Software Company, Provo, UT, USA) was designed and tested with a mixed pilot group of 13 dentists in the New York State Dental Association (NYSDA) and Georgia Dental Association (GDA) who provided feedback on the survey. The survey instrument and its planned administration were reviewed by the Institutional Review Board and approved as exempt. The revised Qualtrics survey was emailed to the membership of the New York State Dental Association (NYSDA) and Georgia Dental Association (GDA) from the respective association headquarters, emphasizing the voluntary and anonymous nature of the survey with no sensitive or identifiable information. NY- and GA-based dentists were invited to participate in the survey if they were members of the NYSDA or GDA and licensed, actively practicing dentists of any dental specialty. In total, 10,005 NYSDA members received an invitation to participate in the survey on September 16, 2020, while 3,559 GDA members received an invitation to participate in the survey on September 28, 2020. As 506 NYSDA members and 174 GDA members responded, the response rates were 5.06% and 4.89%, respectively.

The complete 16-question Qualtrics survey is in the online appendix. Demographic questions requested zip code of the primary office location, how many years the respondent dentist has been in practice, the number of dentists practicing at the primary site, and whether the dentist(s) accept(s) Medicaid. Subsequent questions inquired into how the dental practice’s cancellation rates changed during the COVID-19 pandemic compared to the year prior, and an estimate of how much of that change was accounted for by cancellations due to fear of COVID-19 exposure. The final questions of the survey sought to quantify the change in the amount of individual dental procedures provided for patients during the COVID-19 pandemic, including dental prophylaxis, direct restorations, crowns, implants, extractions, endodontic treatment, orthodontic treatment, periodontal treatment, and antibiotic prescriptions.

Statistical analysis of responses was conducted in Excel (Microsoft, Redmond, WA). Survey responses from zip codes outside NY and GA, from dentists that chose not to share their zip code and whose state could not be determined, and from retired dentists who were not in practice during the COVID-19 pandemic were excluded from data analysis. Two-way t-tests were used to determine significant differences between the means of the NYSDA and GDA groups, and chi-square tests were applied to assess differences between categorical variables. Both analyses set statistical significance at 0.05. Due to differences in respondents’ specialties, not all respondents answered all questions (Fig. 1).

Results

Participant characteristics

The response rates of members of the NYSDA and GDA were remarkably similar, at 5.06% and 4.89%. Most respondents had been in dental practice for > 20 years (range, < 5 years - >20 years). Nearly half of respondents from both NYSDA and GDA reported practicing in a solo dentist practice, with less than 3% of respondents in each association practicing in offices shared by 10 + dentists (Fig. 2). Chi square analysis determined that time of reopening was not a function of years in practice nor of the number of dentists in each practice. Medicaid was accepted by 15.81% of NYSDA respondents’ practices and 17.24% of GDA respondents’ practices (p = 0.51).

Reopening non-emergent care

Georgia formally permitted the full reopening of dental offices on May 1, 2020, and 75.3% of Georgian dental respondents reopened their practice in May 2020 for non-emergent care (Table 1). However, 13.2% of surveyed Georgian dentists waited until June to reopen, and some reported opening prior to the permitted full reopening time or never fully closing their dental practice. Interestingly, a nearly identical proportion of NYSDA (4.95%) and GDA (5.17%) respondents stated that their dental practice was never closed during the COVID-19 pandemic. New York formally permitted the full reopening of dental offices on June 1, 2020, and 79% of New York dental respondents reported reopening their practices in June 2020 for non-emergent care. Like Georgia, 8.3% of New York dentists hesitated to reopen until July 2020, a month later. But while nearly 2% of surveyed New York dentists had not yet started accepting routine non-emergent procedures at the time of their survey response in September of 2020, all Georgian dentists that responded had reopened their practice for routine non-emergent procedures by that time.

Appointment cancellations

A key section of the survey assessed COVID-19’s impact on dental appointment cancellation rates and to what degree the patients’ fear of COVID-19 exposure factored into their practice’s cancellations. The dentists’ opinion of how the cancellation rate changed from March to August of 2020 was compared to the same 5-month period in 2019. The change in cancellation rates showed a wide distribution, ranging from half as many cancellations compared to the year prior to twice as many cancellations. As a result, the average percent change for both states fell closer to 0% change. Nonetheless, on average New York dental respondents felt 37% of cancellations were due to COVID-19 exposure fear, while Georgia dental respondents felt 52% of cancellations were due to COVID-19 exposure fear.

Dental procedures provided

The primary goal of this research was to quantify and document what specific dental procedures were provided relative to “normal” volumes during the hiatus in dental care enforced during the COVID-19 pandemic from March to August 2020 (Fig. 3).

Dental prophylaxis during the COVID-19 pandemic from March to August 2020 decreased by 29% in Georgia and 44% in New York compared to the prior year. t-tests confirmed a statistically significant difference between New York and Georgia respondents (p < .001).

The percent change in each elective procedure during the COVID-19 pandemic compared to the baseline 2019 “normal” remained nearly consistent for direct restorations, crowns, and implants. New York dental respondents reported a decrease of 40% for direct restorations and crowns and a decrease of 47% for implants compared to the same timeframe in 2019. Georgia dental respondents reported a decrease of ~ 25% for direct restorations, crowns, and implants alike. Each of these interstate comparisons were statistically significant for direct restorations (p < .001), crowns (p < .001), and implants (p < .001).

Emergency procedures, including extractions and endodontic treatment, declined to a lesser extent across both states. New York dental respondents reported a decrease of 20% and 21% for extractions and endodontic treatment, respectively. Georgia dental respondents reported a decrease of 4% and 6% for extractions and endodontic treatment, respectively. Again, interstate comparisons were statistically significant for both extractions (p < .001) and endodontic treatment (p < .001).

Other specialty procedures generally considered slightly less urgent, including orthodontic and periodontal treatment, decreased to a greater extent across both states. New York dental respondents reported a decrease of 33% and 35% for orthodontic and periodontal treatment, respectively. Georgia dental respondents reported a decrease of 16% and 20% for orthodontic and periodontal treatment, respectively. P-values were significant for both interstate comparisons (p = .0011 for orthodontic treatment and p < .001 for periodontal treatment).

Antibiotic prescription compared to “normal” increased by 6.5% according to New York dentists and 7.7% according to Georgia dentists. Antibiotic prescription was the only dental care service whose change from baseline was not significantly different between New York State and Georgia (p = 0.75).

Discussion

This study is the first to our knowledge to quantify the individual dental procedures provided during the forced hiatus in dental care associated with the coronavirus pandemic from March to August 2020 compared to the same period the year prior in the states of New York and Georgia. Dentists in both states reported a statistically significant decrease in all dental procedures, in particular dental prophylaxis, during the COVID-19 pandemic. These findings in the United States differ from the reported 83.8% of Brazilian dentists who reported that their patients sought out elective care (prophylaxis and preventive procedures) during the pandemic (5). This contrast highlights the international inconsistencies in attitudes and management of the COVID-19 pandemic.

Despite NYSDA and GDA members having no statistically significant differences in the demographic makeup of respondents in this study, NYSDA members had a significantly larger decrease in prophylaxis, elective care, emergent care, and specialty procedures.

New York dentists were advised to reopen non-emergent dental care a month later than Georgia dentists, but the consistently greater decrease in dental care in New York over the 5-month period suggests other external factors at play. These results might reflect the increased general fear and COVID-19 impact felt by citizens and dental practitioners in New York, and New York City in particular, during the Spring of 2020. The CDC COVID-19 Response Team’s report of the cases, deaths, and incidences of COVID-19 across the United States from February 12th to April 7th showed that New York City and secondly New York State held the highest cumulative number of reported COVID-19 cases, the highest cumulative incidence, and the highest number of reported COVID-19-related deaths, while these metrics were much lower in Georgia (6). Such significant differences in the COVID-19 experience in New York State and Georgia may explain the consistently greater decline in dental care in New York. These findings may suggest an increased fear of reopening dental offices in New York for dentists and patients alike.

Dentists’ number of years of practice experience had no statistically significant impact on time of reopening in NY and GA. One could speculate that increased confidence gained through years of experience might have been counterbalanced by an increased fear of age-related COVID-19 morbidity and mortality among older, more experienced dentists. This finding differs from Faccini’s survey of dental care in Brazil in which a higher percentage of younger dentists continued routine dental treatment with less concern compared to older dentists (5). Further, the number of dentists in a group practice also had no significant impact on time of reopening in this study.

The only dental procedure that did not significantly differ from baseline 2019 levels or between New York State and Georgia was antibiotic prescription. It might have been anticipated that New York dentists, who had a greater decrease in in-person care, would prescribe more antibiotics to treat patients remotely, but the findings of this survey demonstrated a similar increase in antibiotic prescription to Georgia dentists. The explanation remains unknown, but New York patients’ readiness to reach out remotely for dental care due to COVID-19 fear could be a contributing factor.

Study Limitations:

The survey response rate of 5.06% for NYSDA and 4.89% for GDA raises the possibility that respondents may differ from nonrespondent dentists, diminishing the generalizability of these results. Correction and stratification of potential respondent bias could not be easily resolved, as the data was collected anonymously through the professional associations. Neither the New York State nor the Georgia Dental Association collects information on their membership’s years in practice, number of dentists per practice, nor whether they accept Medicaid. Without this baseline demographic information, the extent to which respondent dentists represent the broader membership of the dental associations is unknown. While this study’s results found 16% and 17% of NYSDA and GDA respondents’ practices accept Medicaid, respectively, the Health Policy Institute’s statistics found that 36.5% of dentists in New York State participate in Medicaid while 27.5% of dentists in Georgia participate in Medicaid (7). It is possible that Medicaid-accepting dentists are less likely to become members of these dental associations, but because this information is not collected by either dental association, respondent bias cannot be ruled out.

The survey sample might also be subject to recall bias, as all parties were asked to recount procedures and cancellations from months prior.

Finally, limitations may include erroneous responses to question #6, “How did the cancellation/rescheduling rate compare to your dental practice's usual rate when your office reopened after the COVID-19 dental hiatus?”. Results for this question had a very wide distribution that averaged close to 0% change, diminishing confidence in the interpretation by respondents, despite apparent success in the pilot testing. While NYSDA and GDA members felt COVID-19 exposure fear contributed to 37% and 52% of dental appointment cancellations, respectively, it might have been anticipated that the cancellation rate compared to normal would be a clear increase. It is possible that the dentists and their patients were more affected by other factors, although this cannot be determined from the present data.

This survey was conducted to take the first step in understanding the impact on oral public health of the unprecedented hiatus in dental care during the COVID-19 pandemic. The sample groups of dentists from New York and Georgia who accepted the invitation to participate in this survey were similar in terms of years in practice, size of practice, and acceptance of Medicaid.

Across the states of New York and Georgia, the provision of all dental procedures declined significantly during the COVID-19 pandemic. This decrease was significantly greater in New York than in Georgia, particularly with dental prophylaxis, direct restorations, crowns, and implants.

Conclusions

In brief, the deferral of dental care during the COVID-19 pandemic that this study quantified is likely to cause a decline in oral public health. Dentists throughout the world should actively encourage their patients to resume routine dental prophylaxis to mitigate against this risk. It will be interesting to see if cities hit harder by the pandemic, who received significantly less dental care, will present with more advanced dental disease and worse dental prognosis in the aftermath of the COVID-19 pandemic. Future investigations can use this quantification of the dental care provided during the COVID-19 dental hiatus to assess the impact and repercussions of the COVID-19 pandemic on oral public health in the near and more distant future.

Declarations

Author Contributions:

Caroline Puskas: Conception and design of the study, acquisition of the data, analysis, and interpretation of the data; Drafting the manuscript

Stephen Morse: Contributing to design of the study, reviewing, and revising the manuscript; Approval of the final manuscript version to be submitted

Conflicts of Interest:

The authors declare no conflicts of interest.

Funding:

None

This research was ruled exempt by the Columbia University IRB.

Acknowledgments:

The authors thank the leadership and staff of the New York State and Georgia Dental Associations for distributing the questionnaire, and the immediate past presidents, Payam Goudarzi DDS and Evis Babo DMD for their support, without which this research could not have been performed.

References

  1. Association AD. COVID-19 State Mandates and Recommendations [Website]. 2020 [updated August 7, 2020. Available from: https://success.ada.org/en/practice-management/patients/covid-19-state-mandates-and-recommendations?utm_source=adaorg&utm_medium=covid-statement-200401&utm_content=stateaction&utm_campaign=covid-19).
  2. Lucaciu O, Tarczali D, Petrescu N. Oral healthcare during the COVID-19 pandemic. J Dent Sci. 2020;15(4):399–402.
  3. Prevention CfDCa. Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic [Website]. 2020 [cited 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#print.
  4. Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health. 2004;94(4):562–4.
  5. Faccini M, Ferruzzi F, Mori AA, Santin GC, Oliveira RC, Oliveira RCG, et al. Dental Care during COVID-19 Outbreak: A Web-Based Survey. Eur J Dent. 2020;14(S 01):S14-S9.
  6. Team CC-R. Geographic Differences in COVID-19 Cases, Deaths, and Incidence - United States, February 12-April 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):465–71.
  7. Association AD. Geographic Access to Dental Care. Health Policy Institute; 2015.

Table

Table 1. Dental Practice Full Reopening Times for NYSDA and GDA members

The study’s results are largely consistent with the state mandates of New York and Georgia to reopen dental practices for non-emergent care on June 1st and May 1st, respectively.


NYSDA

GDA

My dental practice was never closed

4.95%

5.17%

March

0.59%

0%

April

0.59%

5.17%

May

3.37%

75.29%

June

79.01%

13.22%

July

8.32%

0.57%

August

1.19%

0.57%

My dental practice has yet to accept routine non-emergent procedures 

1.98%

0.00%