The study showed that from April to May 2020, 75.9% of dentists reported closure with higher percentage in than outside the private sector. Dentists in the private sector, who were general practitioners, in solo practices, in rural areas and with greater COVID-19 fears were more likely to report practice closure. Country-level determinants also affected practice closure: better prepared health care systems were associated with less closure outside the private sector while the private sector in rich countries was less likely to close. The null hypothesis can, thus, be rejected. The study provides evidence of the impact of COVID-19 on dental practice closure which jeopardizes the provision of dental care. These findings have implications for planning support packages for the profession and the public.
In the present study, 75% of dentists reported practice closure. International guidelines related to provision of dental care during the pandemic ranged from allowing only public stomatological and general hospitals to deal with emergency cases in China , urging practitioners to shut their practices in California, USA ; decreasing the number of daily check-ups in the UK  to no guidance . The level of dental practice closure in the present study was higher than that reported for non- dental specialties in a WHO survey of 155 countries where 53% reported disruption of treatment services for hypertension, 49% for diabetes and related complications, 42% for cancer and 31% for cardiovascular emergencies . The level of practice closure in the present study was similar to that reported in the USA where 79% of dental of practices were closed except for emergency care . The impact of this suspension of dental care on the oral health of the population is yet to be quantified.
In the present study, fear of reduced income because of the pandemic was among the three top fears. Similarly, reports showed lower patient volume following the public’s avoidance of healthcare settings due to fear of COVID-19 which lead to financial losses in dental practices and reduced ability to pay employees. A US survey conducted in March 2020 reported that 28% of dentists were unable to pay their staff and 45% made partial payments [30, 31]. It was estimated that if the current lockdown continues to September 2020, 46% of dentists may need to file for bankruptcy . This financial crisis is not likely to end in the coming period with potentially huge impact on the profession in the future. In the present study, fear of infection was one of the strongest factors associated with practice closure among self-employed dentists in the private sector which agrees with a study reporting that high level of anxiety was associated with more dentists indicating a desire to close their practices .
In the present study, dentists in academia were more likely to report practice closure. This agrees with previous data from North America indicating that dental care in teaching clinics was suspended and only emergency treatment was offered . The study also showed that dentists working in hospitals were less likely to report practice closure. This may be attributed to the high level of preparedness of hospitals. For example, some hospitals designated for the care of COVID-19 patients were equipped with high level PPE for aerosol generating dental procedures [33, 34] with strict infection control measures and more dental units to meet patients’ need for emergency dental services [27, 35, 36].
The study showed less closure in group practices and more closure in solo practices. Large, group practices may be more resilient at times of financial hardship than small solo practices because they generally have more reserves and can pool resources to bridge the crisis. Small-scale health care providers tend to be less profitable which may increase their vulnerability to financial threats .
The study showed that compared to urban practices, there was more closure in private sector rural practices and less closure in non-private sector rural practices. Private sector rural healthcare facilities usually operate on thin profit margins, have small number of staff and less PPE against COVID-19 which put them at greater risk of closure to reduce financial and infection risks [38–40]. Consequently, non-private sector rural practices may be the only type of facility left to provide care for the local population and hence the reported less closure.
In the present study, practice closure was also associated with country-level determinants. More hospital beds were associated with less closure in the non-private sector. Countries with low- resources and underprepared healthcare systems may have less capacity to manage COVID-19 complications resulting in higher mortality rates, panic and anxiety that increase the chances of dental practice closure [41, 42]. In addition, the study showed less private practice closure in HICs. This agrees with reports that some HICs governments– such as Canada, Ireland and the UK- providing financial support for dental practices to avoid closure due to economic losses; offering funds, loans and credits to face issues of payment of salaries and supplies [31, 43–46]. In addition, the generally higher income in HICs may provide financial sustainability in spite of decreased revenues and reduce the need for practice closure. No such measures were reported from LICs, LMICs or UMICs where no economic response plans were made to support the dental industry despite their needs.
The study is limited by its cross-sectional design which cannot provide proof of causality and by the convenience sampling which cannot support statistical representativeness. However, it included a large number of dentists from many countries all over the world with different professional and healthcare systems background which increases the generalizability of findings. The findings provide estimates of practice closure in many countries around the world that can be used to assess COVID-19 impact on the oral health of the public with potential implications for dental education. Assisting the dental industry, especially self-employed dentists in the private sector, may help retain skillful personnel and avoid devastating impact on dental services. Future studies are needed to assess the long-term impact of closure on the financial, psychologic and professional outcomes of dentists.