Dental practice closure during COVID-19 and associated professional, practice and structural determinants: a multi-country survey

doi:10.21203/rs.3.rs-97390/v1

Download PDF

Research article

Dental practice closure during COVID-19 and associated professional, practice and structural determinants: a multi-country survey

https://doi.org/10.21203/rs.3.rs-97390/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: The outbreak of the novel coronavirus disease (COVID-19) in China has influenced every aspect of life worldwide. Due to the characteristics of dental settings, the risk of cross-infection is high between dental practitioners and patients and dentists may develop severe anxiety about the current pandemic. In addition, the limited provision of services and closure of dental practices raised concerns among dental professionals about the financial consequences of this closure. This study assessed the frequency of dental practice closure in several countries, the factors associated with this closure and whether closure and associated factors differed between private and non-private sectors.

Methods: From April to May 2020, an electronic survey was sent to dentists in several countries. The survey assessed professional factors, practice factors and country-level structural factors. Multilevel logistic regression was used to assess the association between practice closure and these factors. Effect modification by type of sector was also assessed.

Results: Dentists (n= 3243) participated from 29 countries. The majority (75.9%) reported practice closure with significantly higher percentage in the private sector than the non-private sector. Pandemic- related fears were associated with significantly higher likelihood of practice closure in private (OR= 1.54, 95%CI= 1.24, 1.92) and non-private sectors (OR= 1.38, 95%CI= 1.04, 1.82). Dentists in non-private, governmental sector (OR= 0.54, 95%CI= 0.31, 0.94), those in rural areas (OR= 0.58, 95%CI= 0.42, 0.81) and those in hospitals (overall OR= 0.60, 95%CI= 0.36, 0.99) reported low likelihood of closure. High likelihood of closure was reported by those in academia (OR= 2.13, 95%CI= 1.23, 3.71). More hospital beds at country-level were associated with lower likelihood of closure in the non-private sector (OR= 0.65, 95%CI= 0.46, 0.91). Private sector dentists in high income countries (HICs) reported less closure than in non-HICs (OR= 0.55, 95%= 0.15, 1.93).

Conclusions: Most dentists reported practice closure because of COVID-19 with greater impact in the private than non-private sectors. Closure was associated with factors at professional, practice, and country-level.

Dentistry

COVID-19

dentists

dental clinics

private practice

hospital bed capacity

fear

On January 8th 2020, the Chinese Center for Disease Control and Prevention declared that a novel coronavirus caused COVID-19 ¹. Since that time, COVID-19 has become a major public health problem in all countries globally, changing all aspects of life ². As of 19 June, COVID-19 cases have been reported in 47 countries in Africa, 15 countries in the Western Pacific region, 53 countries in Europe, 10 countries in South East Asia, 21 countries in the Eastern Mediterranean region and 35 countries in the region of Americas with a total of 8.7 million laboratory-confirmed cases and about half a million deaths ³.

Transmission of COVID-19 occurs interpersonally via respiratory droplets ⁴, inhalation, ingestion, or direct mucous contact with saliva droplets ⁵. The virus can survive on hands, objects, or surfaces previously exposed to infected saliva ⁵. COVID-19 incubation period is reported to range from 5 to 14 days ^1,6. The clinical manifestations may present as mild, flu-like symptoms, including fever (98%) and dry cough (76%). Patients may develop respiratory failure and multiple organ failure leading to death. Lymphocytopenia is observed, and chest CT examination usually shows ground-glass appearance of the lungs. No vaccine or specific antiviral therapy is available and supportive treatment, with organ support in intensive care units, remain the clinical management strategies ⁷.

Healthcare professionals are at the forefront of the fight against COVID-19 with number of infected cases and fatalities varying between countries ⁸. Due to the unique nature of dental practice, the risk of cross-infection is higher among dentists than other healthcare professionals ^9,10. In addition, the virus was identified in the saliva of infected patients ¹¹. These factors increase COVID-19 related fear and anxiety among dentists compared to the general public ¹².

During the pandemic, routine dental services were restricted to help flatten the curve and protect patients and dental personnel against infection. Urgent care was delivered using personal protective equipment (PPE) with additional precautions including taking patients’ recent travel history, recording patients’ body temperature, using 1% hydrogen peroxide as pre-procedural mouth rinse, using a rubber dam and high volume suction and frequent cleaning and disinfection of public contact areas including door handles, chairs and washrooms ¹³. The reduced availability of dental care might have increased the demand on the already burdened emergency departments in hospitals ¹⁴, with potential impact on oral health and quality of life. In addition, the closure of dental practices raised concerns among dentists about the financial consequences of this closure ¹⁵. Reports showed that the economy of the dental and other health care sectors was at a virtual standstill because of the pandemic ^15,16.

The disruption of dental care delivery may affect dentists, other healthcare personnel, and the general public. Assessing the extent of dental practice closure and its determinants is important to help mitigate its impact and plan supportive measures. The present study assessed the extent of dental practice closure as reported by dentists from countries all over the world, the factors associated with this closure and whether closure, and associated factors differed between the private and non-private sectors. The null hypothesis of the study was that dental practice closure was affected by neither professional attributes of dentists (COVID-19 knowledge and fears), dental practice attributes (private or non-private sectors, in urban or rural areas and solo or group practices) nor country attributes (country-level number of hospital beds representing a country’s ability to mobilize resources to control the disease and country-level income indicating the potentially available financial support for dentists in case of practice closure).

Design

A cross-sectional, multi-country, electronic survey was conducted from April to May 2020. The Ethics Review Committee of the Faculty of Dentistry, Alexandria University approved the study, and it was carried out in agreement with the Declaration of Helsinki.

Participants and sample size

The target population was dentists of various specialties across the globe. The study recruited specialists and non-specialists who were practicing in various sectors during the study period. Dental students and interns were excluded. The sample size was estimated based on a conservative estimate that 50% of dentists at a global level would report practice closure. Thus, based on a margin of error= 5% and a 95% confidence level, the sample size was calculated ¹⁷ to be 377 dentists. A greater number of participants was included because of the multi-country nature of the study and because it was not possible to limit the number of participants on social media once the link was posted.

Questionnaire design and pilot testing

The questionnaire (Additional file 1) was designed based on information in the websites of the World Health Organization (WHO), American Dental Association, and Center for Disease Control about dental settings and considerations for treatment during the COVID-19 outbreak in addition to existing literature ¹⁸. A group of experts evaluated the original English questionnaire and confirmed its content validity and the logical structure of the questions. The questionnaire was further tested among 15 dentists, and few modifications for clarification were done. In addition, the survey was translated into German and Italian by two independent bilingual dentists. Using back translation, the translated questionnaires were compared with the original English version to identify discrepancies and resolve vagueness. The German version was pilot-tested by 14 dentists and 11 dentists tested the Italian version. Pilot testing results were not included in the analysis.

At the beginning of the survey, a short introduction described the study purpose and assured participants of the confidentiality of their responses. There were 31 close-ended questions in three sections. Section 1 was about the sociodemographic and practice characteristics of participants, including age, gender, country of practice, specialty, area of practice (rural or urban), and type of practice (private, governmental or academic sectors, solo, group or hospital practices). Section 2 included 8 items assessing dentists’ fears regarding COVID-19, with responses on a 5-point Likert scale ranging from strongly agree (code 5) to strongly disagree (code 1). Section 3 consisted of 15 questions assessing knowledge about measures to control the transmission of COVID-19 with possible responses being yes, no and do not know. The last question asked whether dental practice was closed at the time of the survey.

Data collection

A link to the electronic survey was created using the online survey platform "Survey Monkey". Respondents were allowed to change their responses before submission and no duplicate entries were allowed. The questionnaire took 5-7 minutes. The link was sent to collaborators and convenience and snowball sampling were used to promote the link via dentists’ groups on Facebook, Instagram, LinkedIn, Twitter and WhatsApp. Participants were asked to share the survey with their dental contacts.

Statistical Analysis

The overall score of fears and threats was the average of the 8 items’ scores and it ranged from 1 to 5. The overall knowledge score was created by assigning one point for each correct answer and adding the points of the 15 items and it ranged from zero to 15. Cronbach's alpha was used to assess the internal consistency of the items about fears and those about knowledge ¹⁹.

Multilevel logistic regression analysis was used to assess the association between the dependent variable (practice closure with yes/ no responses) and the independent variables that were introduced as fixed effects. These were level 1 dentist and practice factors obtained from the survey in addition to level 2 country-level structural factors. The latter factors included the country-level number of beds per 1000 population obtained from the World Bank Databank ²⁰. In the absence of multi-country data about the number of intensive care units needed to care for patients with COVID-19 complications, we used the number of beds per 1000 population as an indicator of the availability of inpatient services ²¹. Country-level factors also included income level based on the World Bank classification into high income countries (HICs) with gross national income (GNI) > 12,375 US$, upper middle income countries (UMICs) with GNI between 3,996 and 12,375 US$, lower middle income countries (LMICs) with GNI between 1,026 and 3,995 US$ and low income countries (LICs) with GNI<1,026 US$ ²². These were recoded into HICs and non-HICs. Country was included as random effect factor. Robust estimation was used to handle violations of model assumptions. A model was developed for the whole sample and two additional models were developed for participants working in the private sector and those working in the non-private sector. Odds ratios and 95% confidence intervals (CIs) were calculated. Effect modification by sector (private and non-private) was assessed and p values were computed for interaction. Significance level was set at 5%. SPSS version 23.0 ²³ was used for statistical analysis.

A total of 3243 dentists responded from 29 countries (Additional file 2). Of these, 49.2% were 20–30 years old, 56.8% were females and 70.6% were specialists. Also, 65.6% worked in the private sector, 52.3% were in group practice and 81.8% worked in urban locations. The mean (SD) number of beds/ 1000 population was 1.70 (0.99) and 71.7% of dentists were from non-HICs. Most participants (75.9%) reported that their practices were closed because of the pandemic (Table 1). Significantly higher percentage of dentists working in the private sector than non- private sector reported practice closure (78.3% and 71.3%, P < 0.0001).

Table 1

Distribution of personal, professional and practice and structural factors among the study participants (n = 3243)
Factors		N (%)
Personal
Age	20–30	1597 (49.2)
	31–40	986 (30.4)
	41–50	420 (13)
	51–60	193 (6.0)
	61+	47 (1.4)
Gender	Males	1401 (43.2)
Gender	Females	1842 (56.8)
Professional and Practice
Specialty	Specialists	2290 (70.6)
Specialty	General practitioners	953 (29.4)
Practice characteristic	Private sector	2123 (65.6)
	Governmental clinic	1263 (38.9)
	Clinics in an academic institution	528 (16.3)
	Solo practice	1129 (34.8)
	Group practice	1697 (52.3)
	Hospital	998 (30.8)
	Urban location	2653 (81.8)
	Rural location	590 (18.2)
Structural
Number of beds/ 1000 population	Mean (SD)	1.70 (0.99)
High income countries	Yes	917 (28.3%)
High income countries	No	2326 (71.7%)
Practice closed because of the pandemic	Yes	2461 (75.9)
Practice closed because of the pandemic	No	782 (24.1)

Table 2 shows the underlying causes of fear due to COVID-19. The greatest fear was of family members catching infection (mean = 4.36) and the high infection risk among healthcare personnel (mean = 4.21). Cronbach alpha for the internal consistency of fear items was 0.70. The mean fear score was 4.14 out of 5, SD = 0.54. Figure 1 shows that > 95% of dentists had correct knowledge about COVID-19 symptoms, transmission through respiratory secretions, specific training being needed to prevent infection and precautions needed against droplet, contact and airborne infections. Cronbach alpha for the internal consistency of knowledge items was 0.62. The mean knowledge score was 13.08 out of 15, SD = 1.89.

Table 2

Levels of fears and perceived threat because of the COVID-19 pandemic reported by participating dentists
Item	Mean (SD)
I am afraid of working in places where patients suspected of COVID-19 infection are treated.	4.08 (0.99)
I am afraid of providing dental care for patients infected with/ suspected of COVID-19.	4.14 (1.00)
In spite of PPE and infection prevention precautions, the risk of COVID-19 infection is high among health care personnel.	4.21 (0.89)
Equipment and facilities required to protect HCP from COVID-19 infection are not adequately provided in healthcare facilities	4.13 (0.92)
Healthcare personnel should be paid more when treating patients infected with/ suspected of COVID-19 infection	3.91 (1.13)
I am afraid that a family member may be affected by COVID-19 infection	4.36 (0.90)
I am worried that my patients will not be receiving adequate care because of the outbreak.	4.08 (0.79)
I am worried that my practice income would be affected because of the outbreak	4.16 (0.92)

Table 3 shows the factors associated with practice closure and how they differed between the private and non-private sectors. Regarding dentist factors, greater fear was associated with significantly higher likelihood of reporting closure by dentists in the private sector (OR = 154, 95%CI = 1.24, 1.92) and not in the private sector (OR = 1.38, 95%CI = 1.04, 1.82) with no significant difference between groups (P = 0.21). There was a significant difference between private sector and non-private sector dentists (P = 0.03) in the association between practice closure and specialization. In the private sector, there was a significantly greater likelihood of reporting closure by general practitioners than specialists (OR = 1.38, 95%CI = 1.04, 1.95). This association was not statistically significant in the non-private sector (OR = 1.08, 95%CI = 0.77, 1.53).

Table 3

Factors associated with practice closure because of COVID-19 in multilevel regression in private and non-private sectors
Factors	Private sector N = 2123	Non-private sector N = 1120	All participants N = 3243	P of interaction
Factors	OR (95% CI)			P of interaction
Professional factors
GP vs specialist	1.38 (1.04, 1.85)*	1.08 (0.77, 1.53)	1.14 (0.82, 1.59)	0.03*
Fear score	1.54 (1.24, 1.92)*	1.38 (1.04, 1.82)*	1.28 (0.97, 1.67)	0.21
Knowledge score	1.05 (0.98, 1.12)	1.03 (0.96, 1.11)	1.01 (0.94, 1.09)	0.21
Practice factors
Clinic in an academic institution	1.37 (0.93, 2.03)	1.81 (1.04, 3.15)*	2.13 (1.23, 3.71)*	0.13
Solo practice	1.45 (1.00, 2.10)	1.14 (0.66, 1.97)	1.13 (0.65, 1.94)	0.50
Group practice	0.88 (0.60, 1.29)	0.79 (0.49, 1.28)	0.80 (0.49, 1.29)	0.85
Hospital	0.55 (0.41, 0.75)*	0.58 (0.35, 0.97)*	0.60 (0.36, 0.99)*	0.64
Rural vs urban	1.29 (0.91, 1.82)	0.58 (0.42, 0.81)*	0.58 (0.42, 0.81)*	0.001*
Structural factors
Beds/ 1000 population	1.01 (0.72, 1.41)	0.65 (0.46, 0.91)*	0.94 (0.65, 1.37)	0.96
HICs vs non- HICs	0.55 (0.15, 1.93)	2.00 (0.60, 6.69)	0.60 (0.19, 1.90)	0.64
The models are adjusted for gender and age. OR: odds ratio, CI: confidence interval, GP: general practitioner, HICs: high income countries
Figure

Regarding practice factors, working in hospitals was associated with significantly lower likelihood of closure in the private (OR = 0.55, 95%CI = 0.41, 0.75) and non-private sectors (OR = 0.58, 95%CI = 0.35, 0.97) with no significant difference between groups (P = 0.64). Also, in both groups alike (P = 0.13), there was a significantly higher likelihood of reporting closure by dentists working in academia (OR = 2.13, 95%CI = 1.23, 3.71). On the other hand, there was a significant difference between private and non-private sectors (P = 0.001) in the association between practice closure and practice location (urban or rural). Dentists in the private sector reported non significantly higher likelihood of practice closure in rural than urban locations (OR = 1.29, 95%CI = 0.91, 1.82). However, dentists in the non-private sector reported significantly lower likelihood of practice closure in rural than in urban areas (OR = 0.58, 95%CI = 0.42, 0.81). Overall, dentists in solo practice were more likely to report practice closure than those not in solo practice (OR = 1.13, 95%CI = 0.65, 1.94) with no significant difference between groups (P = 0.50). On the other hand, dentists in group practice were less likely to report practice closure than those not in group practice (OR = 0.80, 95%CI = 0.49, 1.29) with no significant difference between groups (P = 0.85).

Regarding country-level structural factors, there were no significant differences between private and non-private sectors in the association between practice closure and the number of hospital beds (P = 0.96) or country high income (P = 0.64). More hospital beds were associated with significantly lower likelihood of practice closure among dentists in the non-private sector (OR = 0.65, 95%CI = 0.46, 0.91). Dentists in the private sector who practiced in HICs were non-significantly less likely to report practice closure than those from non-HICs (OR = 0.55, 95%CI = 0.15, 1.93).

The study showed that from April to May 2020, 75.9% of dentists reported practice closure with a higher percentage in the private than the non-private 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 were also associated with practice closure: better-prepared healthcare systems were associated with less closure in the non-private sector while the private sector was less likely to close in rich countries than in less affluent countries. The null hypothesis was, 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 for programs to maintain oral health for the public.

In the present study, 75% of dentists reported practice closure. International guidelines about the provision of dental care during the pandemic varied from allowing only public dental and general hospitals to deal with emergency cases in China ²⁴, urging practitioners to shut their practices in California, USA ²⁵; decreasing the number of examined patients in the UK ²⁶ to no guidance ²⁷. The frequency of dental practice closure in the present study was higher than that reported for other, non- dental specialties in a WHO survey of 155 countries where 53% of participating countries reported disruption of treatment for hypertension, 49% for diabetes, 42% for cancer and 31% for cardiovascular emergencies ²⁸. However, the frequency of closure was similar to that reported in the USA where 79% of dental practices were closed except for emergency care ²⁹. The impact of practice closure and the suspension of dental care on oral health is yet to be quantified.

In the present study, fear of income reduction because of COVID-19 was among the three top fears reported by dentists. Similarly, reports showed lower patient volume attributed to avoidance of healthcare facilities due to fear of COVID-19 with 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 continued to September 2020, 46% of dentists may need to file for bankruptcy ²⁹. This financial crisis is not likely to end in the coming period with a potentially huge impact on the profession. In addition, the present study showed that fear of infection was one of the factors associated with practice closure among dentists in the private sector which agrees with a study reporting that a high level of anxiety was associated with more dentists indicating a desire to close their practices ³².

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 ³⁰. The present 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, hospitals are more likely than other healthcare facilities to be equipped with high-level PPE to protect against aerosol-generating dental procedures, ^33,34 to have 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. Group practices may be more resilient at times of financial hardship than solo practices because they are more likely to have reserves and can afford to pool resources to bridge crises. On the other hand, small-scale health care providers tend to be less profitable which may increase their vulnerability to financial threats ³⁷.

The current study showed that compared to urban practices, practices in rural areas had more closure if they were in the private sector but less closure if they were in the non-private sector. Private sector rural healthcare facilities usually operate on thin profit margins and have a small number of staff which puts 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 lower likelihood of closure.

The present study showed that practice closure was also associated with country-level determinants. More hospital beds were associated with less closure in the non-private sector. Countries with high- resources and well-prepared healthcare systems are likely to have better capacity to manage COVID-19 complications resulting in lower mortality rates, panic and anxiety with less 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 provided financial support for dental practices to avoid closure due to economic losses; offering funds, loans and credits to help with payment of salaries and supplies ^31,43−46. In addition, dentists in HICs would have higher per capita income ensuring financial stability in spite of decreased revenues and reducing the need for practice closure. No such measures were reported in less affluent countries where no economic support plans were made to help the dental industry despite their needs.

The study is limited by its cross-sectional design which cannot prove causality and by 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 backgrounds and healthcare systems characteristics and this increases the generalizability of findings. The study estimated the frequency of practice closure which is important to assess the pandemic impact on oral health with implications for dental education. Providing support to dentists in the private sector may help retain skillful personnel and reduce the devastating impact of the pandemic on dental services. Future studies are needed to assess the long-term impact of practice closure on the financial, psychologic, and professional outcomes of dentists.

COVID-19 had a considerable impact on dental practice around the globe. Most dentists reported practice closure because of COVID-19 with greater impact in the private sector than in the non-private sector. Personal, professional, and country-level factors were associated with practice closure. The findings help provide a profile of dentists with practices at greater risk of closure to plan for support packages.

PPE

Personal Protective Equipment

WHO

World Health Organization

HICs

High Income Countries

GNI

Gross National Income

UMICs

Upper Middle Income Countries

LMICs

Lower Middle Income Countries

LICs

Lower Income Countries

CIs

Confidence Intervals

SPSS

Statistical Package for Social Sciences

Standard Deviation

Odds Ratio

Ethics approval and consent to participate

The Ethics Review Committee of the Faculty of Dentistry, Alexandria, Egypt approved the study (IRB No: 00010556-IORG 0008839) which was conducted in agreement with the Declaration of Helsinki. In the introduction to the survey, the purpose of the study was explained and participants were assured of the confidentiality and anonymity of their responses. They were invited to respond to the survey and their consent was implicitly assumed when their answers were submitted.

Consent for publication

Not applicable.

Availability of data and materials

The dataset used during the current study is available from the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

HA, SA, MI and MET conceptualized and designed the study, coordinated data collection in Egypt, conducted the analysis, interpreted the results and drafted the original version of the manuscript. MN, DAM, AR, MS, KS, SB, AS and LB contributed to data collection in their respective countries and reviewed the manuscript. All authors contributed to the final approval of the paper.

Acknowledgements

The authors are grateful for the dentists who responded to the survey and for their time.

Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382(13):1199-1207. doi:10.1056/NEJMoa2001316
Phelan AL, Katz R, Gostin LO. The Novel Coronavirus Originating in Wuhan, China: Challenges for Global Health Governance. JAMA - J Am Med Assoc. 2020;323(8):709-710. doi:10.1001/jama.2020.1097
Mahase E. China coronavirus: WHO declares international emergency as death toll exceeds 200. BMJ. 2020;368:m408. doi:10.1136/bmj.m408
Coronavirus Disease (COVID-19) Situation Reports. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports; 2020 Accessed 20 July 2020.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):1-6. doi:10.1038/s41368-020-0075-9.
Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019- nCoV) infections among travellers from Wuhan, China, 20 28 January 2020. Eurosurveillance. 2020;25(5):2000062. doi:10.2807/1560-7917.ES.2020.25.5.2000062
Pan Y, Guan H. Imaging changes in patients with 2019-nCov. Eur Radiol. 2020;30(7):3612-3613. doi:10.1007/s00330-020-06713-z
Ng K, Poon BH, Kiat Puar TH, et al. COVID-19 and the Risk to Health Care Workers: A Case Report. Ann Intern Med. 2020;172(11):766-767. doi:10.7326/L20-0175
The Workers Who Face the Greatest Coronavirus Risk - The New York Times. https://www.nytimes.com/interactive/2020/03/15/ business/economy/coronavirus-worker-risk.html; 2020 Accessed 20 July, 2020.
Malik YS, Sircar S, Bhat S, et al. Emerging novel coronavirus (2019-nCoV)—current scenario, evolutionary perspective based on genome analysis and recent developments. Vet Q. 2020;40(1):68-76. doi:10.1080/01652176.2020.1727993
To KK-W, Tsang OT-Y, Yip CC-Y, et al. Consistent Detection of 2019 Novel Coronavirus in Saliva. Clin Infect Dis. 2020. doi:10.1093/cid/ciaa149
Fazel M, Hoagwood K, Stephan S, Ford T. Mental health interventions in schools in high-income countries. The Lancet Psychiatry. 2014;1(5):377-387. doi:10.1016/S2215-0366(14)70312-8
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care. J Endod. 2020;46(5):584-595. doi:10.1016/j.joen.2020.03.008
Wu M, Chang YC. COVID-19 and its implications in the management of resource infrastructure. J Dent Sci. 2020;15(2):225. doi:10.1016/j.jds.2020.04.008
Coulthard P. Dentistry and coronavirus (COVID-19) - moral decision-making. Br Dent J. 2020;228(7):503-505. doi:10.1038/s41415-020-1482-1
COVID Survey — The Larry A. Green Center. https://www.green-center.org/covid-survey. Accessed 20 July 2020.
Sample Size Calculator by Raosoft, Inc. http://www.raosoft.com/samplesize.html. Accessed 20 July 2020.
Abdollahi M, Ghahramanian A, Shahbazi S, Rezaei F, Naghili B, Asghari-Jafarabadi M. Developing a questionnaire to assess Iranian nurses’ knowledge of and attitude to Middle East respiratory syndrome. East Mediterr Health J. 2020;26(5):506-516. doi:10.26719/emhj.19.065
Ursachi G, Horodnic IA, Zait A. How Reliable are Measurement Scales? External Factors with Indirect Influence on Reliability Estimators. Procedia Econ Financ. 2015;20:679-686. doi:10.1016/s2212-5671(15)00123-9
The World Bank. Hospital beds (per 1,000 people) | Data. The World Bank. https://data.worldbank.org/indicator/SH.MED.BEDS.ZS; 2018 Accessed 20 July 2020.
Mark Landry. Hospital beds (per 1,000 people). World Health Organisation. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3119; 2019 Accessed 20 July 2020.
Prydz EB, Wadhwa D. Classifying countries by income. The World Bank. https://datatopics.worldbank.org/world-development-indicators/stories/theclassification-of-countries-by-income.html; 2019 Accessed 20 July 2020.
IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.
Guo J, Xie H, Liang M, Wu H. COVID-19: a novel coronavirus and a novel challenge for oral healthcare. Clin Oral Investig. 2020;24(6):2137-2138. doi:10.1007/s00784-020-03291-8
CDA Presents. https://www.cda.org/Home/News-and-Events/CDA-Presents. Accessed 20 July 2020.
The Scottish Government - gov.scot. https://www.gov.scot/. Accessed 20 July 2020.
Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-186. doi:10.1016/j.sdentj.2020.04.001
WHO. COVID-19 significantly impacts health services for noncommunicable diseases. World Health Organisation. https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases; 2020 Accessed 20 July 2020.
Nasseh K, Vujicic M. Modeling the Impact of COVID-19 on U.S. Dental Spending. https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0420_1.pdf?la=en ;2020 Accessed 20 July, 2020.
Wu KY, Wu DT, Nguyen TT, Tran SD. COVID‐19’s impact on private practice and academic dentistry in North America. Oral Dis. June 2020:odi.13444. doi:10.1111/odi.13444
Farooq I, Ali S. COVID-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers. Postgrad Med J. 2020. doi:10.1136/postgradmedj-2020-137781
Ahmed MA, Jouhar R, Ahmed N, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17(8). doi:10.3390/ijerph17082821
Jirka GP, Thompson W. Personal protective equipment. In: The A3 Workbook: Unlock Your Problem-Solving Mind. ; 2009:493-508. doi:10.1201/9781420071825-29
Chamorro-Petronacci C, Martin Carreras-Presas C, Sanz-Marchena A, et al. Assessment of the Economic and Health-Care Impact of COVID-19 (SARS-CoV-2) on Public and Private Dental Surgeries in Spain: A Pilot Study. Int J Environ Res Public Health. 2020;17(14):5139. doi:10.3390/ijerph17145139
Dave M, Seoudi N, Coulthard P. Urgent dental care for patients during the COVID-19 pandemic. Lancet. 2020;395(10232):1257. doi:10.1016/S0140-6736(20)30806-0
Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. March 2020. doi:10.1016/j.jds.2020.02.002
Kruse FM. For-Profit Hospitals Out of Business? Financial Sustainability During the COVID-19 Epidemic Emergency Response. Int J Heal Policy Manag. May 2020. doi:10.34172/ijhpm.2020.67
Kumar A, Rajasekharan Nayar K, Koya SF. COVID-19: Challenges and its consequences for rural health care in India. Public Heal Pract. 2020;1:100009. doi:10.1016/j.puhip.2020.100009
RURAL_HEALTH_CARE_AND_HEALTH_INSURANCE. https://journalistsresource.org/studies/government/health-care/rural-health-care-covid-19-research/; 2020 Accessed 20 July 2020.
Rural Health and COVID-19.; 2020. https://files.asprtracie.hhs.gov/documents/aspr-tracie-rural-health-and-covid-19.pdf. Accessed 20 July 2020.
Elhadi M, Msherghi A, Alkeelani M, et al. Concerns for low-resource countries, with under-prepared intensive care units, facing the COVID-19 pandemic. Infect Dis Heal. June 2020. doi:10.1016/j.idh.2020.05.008
Kasozi KI, Mujinya R, Bogere P, et al. Pandemic panic and anxiety in developing countries. Embracing One Health offers practical strategies in management of COVID-19 for Africa. Pan Afr Med J. 2020;35(Suppl 2):3. doi:10.11604/pamj.2020.35.3.22637
Canada government of. Canada’s COVID-19 Economic Response Plan. CanadaCa.. https://www.canada.ca/en/department-finance/economic-response-plan.html; 2020 Accessed 20 July 2020.
Evans S. Coronavirus – what’s the financial impact on dentistry?. https://www.dentistry.co.uk/2020/03/19/coronavirus-financial-impact-dentistry/; 2020 Accessed 20 July 2020.
COVID-19 Updates & Support | IDA Ireland. https://www.idaireland.com/how-we-help/covid19-support-and-updates. Accessed 20 July 2020.
COVID-19 Business Loan. https://microfinanceireland.ie/loan-packages-2/covid19/. Accessed 20 July 2020.

Table 1: Distribution of personal, professional and practice and structural factors among the study participants (n= 3243)

Factors		N (%)
Personal
Age	20-30	1597 (49.2)
	31-40	986 (30.4)
	41-50	420 (13)
	51-60	193 (6.0)
	61+	47 (1.4)
Gender	Males	1401 (43.2)
Gender	Females	1842 (56.8)
Professional and Practice
Specialty	Specialists	2290 (70.6)
Specialty	General practitioners	953 (29.4)
Practice characteristic	Private sector	2123 (65.6)
	Governmental clinic	1263 (38.9)
	Clinics in an academic institution	528 (16.3)
	Solo practice	1129 (34.8)
	Group practice	1697 (52.3)
	Hospital	998 (30.8)
	Urban location	2653 (81.8)
	Rural location	590 (18.2)
Structural
Number of beds/ 1000 population	Mean (SD)	1.70 (0.99)
High income countries	Yes	917 (28.3%)
High income countries	No	2326 (71.7%)
Practice closed because of the pandemic	Yes	2461 (75.9)
Practice closed because of the pandemic	No	782 (24.1)

Table 2: Levels of fears and perceived threat because of the COVID-19 pandemic reported by participating dentists

Item	Mean (SD)
I am afraid of working in places where patients suspected of COVID-19 infection are treated.	4.08 (0.99)
I am afraid of providing dental care for patients infected with/ suspected of COVID-19.	4.14 (1.00)
In spite of PPE and infection prevention precautions, the risk of COVID-19 infection is high among health care personnel.	4.21 (0.89)
Equipment and facilities required to protect HCP from COVID-19 infection are not adequately provided in healthcare facilities	4.13 (0.92)
Healthcare personnel should be paid more when treating patients infected with/ suspected of COVID-19 infection	3.91 (1.13)
I am afraid that a family member may be affected by COVID-19 infection	4.36 (0.90)
I am worried that my patients will not be receiving adequate care because of the outbreak.	4.08 (0.79)
I am worried that my practice income would be affected because of the outbreak	4.16 (0.92)

Table 3: Factors associated with practice closure because of COVID-19 in multilevel regression in private and non-private sectors

Factors	Private sector N= 2123	Non-private sector N= 1120	All participants N= 3243	P of interaction
Factors	OR (95% CI)			P of interaction
Professional factors
GP vs specialist	1.38 (1.04, 1.85)*	1.08 (0.77, 1.53)	1.14 (0.82, 1.59)	0.03*
Fear score	1.54 (1.24, 1.92)*	1.38 (1.04, 1.82)*	1.28 (0.97, 1.67)	0.21
Knowledge score	1.05 (0.98, 1.12)	1.03 (0.96, 1.11)	1.01 (0.94, 1.09)	0.21
Practice factors
Clinic in an academic institution	1.37 (0.93, 2.03)	1.81 (1.04, 3.15)*	2.13 (1.23, 3.71)*	0.13
Solo practice	1.45 (1.00, 2.10)	1.14 (0.66, 1.97)	1.13 (0.65, 1.94)	0.50
Group practice	0.88 (0.60, 1.29)	0.79 (0.49, 1.28)	0.80 (0.49, 1.29)	0.85
Hospital	0.55 (0.41, 0.75)*	0.58 (0.35, 0.97)*	0.60 (0.36, 0.99)*	0.64
Rural vs urban	1.29 (0.91, 1.82)	0.58 (0.42, 0.81)*	0.58 (0.42, 0.81)*	0.001*
Structural factors
Beds/ 1000 population	1.01 (0.72, 1.41)	0.65 (0.46, 0.91)*	0.94 (0.65, 1.37)	0.96
HICs vs non- HICs	0.55 (0.15, 1.93)	2.00 (0.60, 6.69)	0.60 (0.19, 1.90)	0.64

The models are adjusted for gender and age. OR: odds ratio, CI: confidence interval, GP: general practitioner, HICs: high income countries

Appendix.docx

Download PDF

Review #4 received at journal
10 Jan, 2021
Editorial decision: Major revision
10 Jan, 2021
Reviewer #4 agreed at journal
16 Dec, 2020
Reviewer #3 agreed at journal
13 Dec, 2020
Review #2 received at journal
13 Dec, 2020
Review #3 received at journal
13 Dec, 2020
Review #1 received at journal
21 Nov, 2020
Reviewer #2 agreed at journal
17 Nov, 2020
Reviewers invited by journal
23 Oct, 2020
Reviewer #1 agreed at journal
23 Oct, 2020
Editor assigned by journal
15 Oct, 2020
First submitted to journal
14 Oct, 2020
Submission checks completed at journal
14 Oct, 2020
Editor invited by journal
14 Oct, 2020

You are reading this latest preprint version

Dental practice closure during COVID-19 and associated professional, practice and structural determinants: a multi-country survey

Status:

Version 1

Abstract

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Supplementary Files

Status:

Version 1