The contrasting short‐term effects of COVID‐19 on dental care practices in the United States

Abstract Objectives The study utilized a cross‐sectional survey to determine the short‐term effects of the COVID‐19 pandemic on dental care practices. The authors hypothesized that the effects of the pandemic would indicate differences based on the ethnicity of the participating dentist. Materials and Methods The survey was available online between June 1, 2020 and July 10, 2020, a period when many dental offices remained closed, and for the most part, unable to provide non‐emergency dental care. The link to the survey was made available to dentists through outreach to several national dental organizations. Descriptive statistics summarized the characteristics of the entire sample and Fisher's exact test was used to examine respondents' answers stratified by ethnicity using frequencies and percentages. Results All ethnic groups reported decreased revenue and African American dentists were the least likely to report a decrease in revenue compared to White and Other ethnic groups (84.2%, 87.2% and 92.9%). African American dentists were the most likely to report willingness to contribute to a task force to address the new challenges resulting from COVID‐19 when compared to White and Other ethnic groups (46.4%, 18.8%, and 29.6%, respectively). African American dentists were more likely to indicate a need for a stronger connection to academic programs as compared to White or Other dentists in order to address current and future challenges (12.3%, 0.0%, and 9.1%). Conclusion The COVID‐19 pandemic has affected dental practices differently, highlighting racial disparities, and strategies that factor in the race or ethnicity of the dentist and the communities in which they practice need to be considered to ensure that underserved communities receive needed resources.


| MATERIAL AND METHODS
Prior to its conduct, this project was reviewed and approved by the net. The board considered this project exempt and therefore did not require informed consent.
The DPPPQ was designed as a cross-sectional survey aimed at collecting information from dentists on the impact of the COVID-19 pandemic on different aspects of their practice and existing preparedness plans to face future pandemics. Dentists were asked to provide their demographic information and respond to questions about the effect COVID-19 had on practice revenue and operations, ability to navigate through the pandemic, preparations for future challenges and willingness to join a network that could provide early notification of regions where COVID-19 incidence may be increasing. The survey was available online between June 1, 2020 and July 10, 2020, a period when many dental offices remained closed and for the most part unable to provide non-emergency dental care. The link to the survey was made available to dentists through outreach to several national dental organizations. We also shared the survey with the appropriate contact person for the dental society for each state in the United States. We specifically targeted national dental organizations that have higher numbers of minority dentists. The study protocol and the survey were approved by the Institutional Review Board at Medstar Health Research Institute.
A checklist of 24 questions with various response options were initially developed by the study team in collaboration with dental experts.
In day 2 after the survey was sent out, the checklist was updated with additional questions based on respondents' feedback. The final checklist was completed by the subsequent participant (N = 183), excluding the first 10 participants who provided their feedback for the initial pool of questions. For the analysis phase, questions asking participating dentists to what extent they agree with the answer options presented, the responses "Very Much" and "Somewhat" were collapsed into one category, "Not Much" and "Not at all" into a second category, and the response "Neutral" created a separate category. For the analyses stratified by ethnicity, we collapsed dentists other than "African American" or "Whites" into one category defined as "Other" due to the small numbers in each of the remaining ethnic groups.
Descriptive statistics summarized the characteristics of the entire sample and Fisher's exact test was used to examine respondents' answers stratified by ethnicity using frequencies and percentages. All analyses were performed with R software with statistical significance set at p ≤ 0.05. Though our survey was disseminated nation-wide, responses collected anonymously, and statistical analysis was blinded, the potential for self-selection bias of those who completed the survey is possible.

| RESULTS
A total of 193 dentists completed the DPPPQ, Table 1 shows that respondents were evenly split between males and females (48.4% vs. 49.5%). White dentists made up 46.0% of the respondents, African Americans were at 30.5%, followed by Asians or Pacific Islanders (11.2%), and Hispanics or Latinos were at 2.7%. More than 60% of the respondents were 50 years of age or older or in practice for more than 20 years. General dentists made up 61.1% of the respondents, oral and maxillo-facial surgeons made up 7.3%, orthodontists, periodontists, and endodontists were at 5.8% respectively, and both Pediatrics Dentist and Prosthodontics composed 5.3% of the respondents, with the remaining 3.8% comprised of other dental specialties. Most of the respondents practiced in New York State (53.2%), followed by the District of Columbia (16.1%) and Maryland (10.2%). Dentists from Texas and Rhode Island combined made up 8.1% of the respondents with the few remaining participants from various other states. Table 2 shows the responses to selected questions stratified by ethnicity. Compared to White and Other dentists, African American dentists were more likely to agree that dental administrators in the state where they practiced had adequately considered the views of the dental community during the pandemic (62.5%, 54.8%, and 31.7%, respectively). However, compared to African American dentists, White and Other dentists were more likely to indicate that they did not agree that the state administrators had made the best decisions for dentistry based on available information at the time (12.8%, 33.7%, and 39.0%, respectively). Regardless of ethnicity, respondents were similarly prepared to work remotely during the pandemic with African American, White and Others reporting 33.3%, 27.4%, and 29.3%, respectively. As expected, all ethnic groups indicated that their practice showed decreased revenue with the ethnic group classified as Other having the largest percentage of respondents indicating a decrease (92.9%) and African American respondents the lowest (84.2%).
Dentists from all ethnic groups indicated a strong willingness to join a network that provides early notification of a COVID-19 incidence increase (73.2%, 68.6%, and 63.6%, respectively). African American dentists indicated a greater willingness to contribute to a task force created to address new challenges arising as a result of COVID-19 compared to White and Other ethnic groups (46.4%, 18.8%, and 29.6%, respectively). Finally, African American dentists were more likely to indicate a need for a stronger connection to academic programs in order to address current and future challenges as compared to White or Other dentists (12.3%, 0.0%, and 9.1%) and were more likely to indicate a need for specific training in response to pandemics (33.3%, 20.9%, and 20.5%). Some respondents did not answer all questions, these were considered not applicable and excluded from the analysis. The total number of complete answers are reflected in Tables 1 and 2

| DISCUSSION
This is one of the first studies to date that has compared the shortterm effects of the COVID-19 pandemic on dental practices and examined racial disparities in context of the effects of the pandemic on the ethnicity of participating dentists. In accordance with the study hypothesis, we observed that the pandemic effects on dental practices differed by ethnicity. The survey was developed and deployed for a limited period of time as part of a larger initiative by our research group to develop a network of dentists who are willing to take an active role in preparation for pandemic events. The study finding will inform our interactive technology development that will display real-time COVID-19 infection rates based on population density and social determinants of health at the census block level. This just-in-time approach will allow dentists to take early action in the event of actual or anticipated future localized COVID-19 or similar pandemic outbreaks, thus providing tools to better manage their patients including those who might be at higher risk given their demographic profiles.
The results of our study are similar to several studies showing the pandemic had unanticipated effects on dental practices (Al-Khalifa et al., 2020;Chamorro-Petronacci et al., 2020;Kinariwala et al., 2020;Tysiąc-Mi sta & Dziedzic, 2020). Studies in India, Spain and Poland, reported results that dentists were generally not prepared to provide patient care during the COVID-19 pandemic and that the pandemic has had economic repercussions contributing to increased challenges in providing optimal dental care. Our study findings suggest that African American dentists were affected differently by COVID-19 as compared to White and Other dentists in select regions in the United States. The results also show that a large number of participating dentists from all groups indicated a willingness to join a network for early notification of increased COVID-19 incidence and that African American dentists, in particular, were more interested in developing stronger connections to academic programs to address current and future challenges.
A strength of our study is the high representation of dentists who self-identified themselves as African American. In the United States, 3.7% of practicing dentists are of African descent (Solana, 2019), however African American dentists comprised 30.5% of our study population. African American dentists are significantly underrepresented among practicing dentists in the United States, yet they serve a disproportionate share of minority and underserved communities (Mertz et al., 2017). Another strength of the study is that we administered our survey during the period when dental offices were primarily closed throughout the United States, a unique period that may not occur again. Study limitations include the small sample size and the possibility that responding dentists may have been those more likely to have been adversely affected by the COVID-19 pandemic. Several state dental representatives we contacted indicated an unwillingness to share the survey with members due to survey fatigue from other COVID-19 surveys that had been shared with their members. Given the fact that our participants are from only a few states, any generalizations that apply the results of this study to the larger population of dentists practicing in the United States should be made with caution.
The COVID-19 pandemic has affected dental practices differently