key: cord-0866147-bsdpkqtj authors: Nosrat, Ali; Yu, Peter; Dianat, Omid; Verma, Prashant; Taheri, Sahar; Wu, Di; Fouad, Ashraf F. title: Endodontic Specialists’ Practice During the COVID-19 Pandemic One Year After the Initial Outbreak date: 2022-03-17 journal: J Endod DOI: 10.1016/j.joen.2022.03.004 sha: d5417f2ea5bf5e9e6083c813f7a63d464e4ae97d doc_id: 866147 cord_uid: bsdpkqtj Introduction The aims of this observational study were to: 1) Determine if Endodontists’ practice in early 2021 experienced changes in patients’ characteristics compared to a comparable pre-pandemic period; 2) Determine whether the changes reported during the initial outbreak of COVID-19 in 2020 were reversed one year later. Methods Demographic, diagnostic, and procedural data of 2657 patient visits from two endodontist private offices, from March-16 to May-31 in 2019, 2020, and 2021 were included. Bivariate analyses and multiple logistic regression models were used to examine the impact of ongoing COVID-19 pandemic on patient data. Results Bivariate analyses showed that patients’ self-reported pain levels and number of visits with irreversible pulpitis in 2021 were higher than 2019 (P<.05). Patient’s self-reported pain, percussion pain, and palpation pain levels in 2021were less than 2020 (P<.05). Multiple logistic regression analyses showed that Endodontists’ practice in 2021 had an increase in the number of non-surgical root canal treatments (Odds ratio [OR], 1.482; 95% Confidence interval [CI], 1.102-1.992), and apicoectomies (OR, 2.662; 95% CI, 1.416-5.004) compared to 2019. Compared to the initial outbreak in 2020, endodontists’ practice in 2021 had visits with older patients (OR, 1.288; 95% CI, 1.045-1.588), less females (OR, 0.781; 95% CI, 0.635-.960), more molars (OR, 1.389; 95% CI, 1.065-1.811), and less pain on percussion (OR, 0.438; 95% CI, 0.339-0.566). Conclusions Ongoing COVID-19 pandemic was associated with an increase in the number of non-surgical root canal treatments. Some of the changes observed during the initial outbreak in 2020, including objective pain parameters, returned to normal levels one year later. The emergence of corona virus disease 2019 (COVID-19) pandemic (1, 2) initially resulted in a nation-wide lockdowns and disruption in dental healthcare services in countries around the world, including the United States. This period lasted ~ 2.5 months, from March-16 to May-31, 2020. In a previous study, on the characteristics of patients seen during the lockdown period, our group showed that the initial COVID-19 outbreak was associated with having younger patients, who had higher levels of pain, and received more primary root canal treatments and apicoectomies than in the same period a year before (3) . Following the initial outbreak period, most dental offices resumed their services and there was a consensus that a gradual return to normalcy will ensue (4) . The assumption was that many of changes in patient characteristics during the initial outbreak of COVID-19 were due to the nation-wide lockdown and lack of access to dental care. Therefore, the changes would reverse overtime, as dental offices reopened, and with the advent of vaccination and more effective treatment of the disease. However, the change in public's behavior towards dental care during the COVID-19 pandemic has been a multi-factorial phenomenon. For example, the hesitancy among older patients to attend dental visits could have been partly associated with their higher risk of morbidity and mortality with COVID-19 infection (5) . Studies showed that worsened socioeconomic conditions led to an increase in dental pain and deterioration in dental health during the initial outbreak of COVID-19 (6) . Given the continued prevalence of disease and societal disruption, some of the factors associated with changes in patients' characteristics during the initial outbreak of COVID-19 in 2020 continued to be present in 2021. In addition, emergence of new variants, as well as vaccine hesitancy, have caused and will likely continue to cause surges in the number of cases, hospitalizations, and deaths (https://coronavirus.jhu.edu/us-J o u r n a l P r e -p r o o f map). Nevertheless, the fluctuating trends in COVID-19 case numbers (https://coronavirus.jhu.edu/us-map), vaccinations (https://www.mayoclinic.org/coronaviruscovid-19/vaccine-tracker), and other societal responses in 2021 might have helped with reversal of changes observed during the initial COVID-19 outbreak. There is lack of data on how all these pandemic related factors may have changed the endodontic patients' characteristics and the practice of Endodontists. Therefore, the aims of this observational study, which is follow up analysis on our previous study (3), were to: 1) Determine if endodontists' practice in early 2021 saw changes in patients' demographic, diagnostic, and procedural characteristics compared to a similar period pre-pandemic period in 2019; 2) Determine whether the changes reported during the initial outbreak of COVID-19 in 2020 were reversed one year later in 2021. The present study builds on the results of our previous study (3) . The study protocol was reviewed by the Institutional Review Board (IRB) at the University of Alabama at Birmingham and received an IRB Exempt approval (IRB-300006461). This observational study followed the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Data from all patient visits that took place in two private Endodontic practices, Centreville Endodontics and Capitol Endodontics, during March-16 to May-31 in 2021 (ongoing COVID-19 pandemic), 2020 (initial COVID-19 outbreak) and 2019 (normal Pre-COVID-19) were included in the present study. The two private practices are in the Northern Virginia and Washington DC area, operated by the same team of Endodontists, administrative and clinical staff, and serve a similar population of patients. The two practices stayed fully operational, without any limitation for patients who needed endodontic care, during the lockdown phase in 2020 and thereafter during COVID-19 pandemic throughout 2021. The staffing in the practices was also stable with no changes throughout the periods studied. When patients contacted the offices, the administrative staff filled out a "call-sheet" during the phone call. They collected some of patients' demographic data, including gender, address, tooth number, and pain level. They used a 4-point Verbal Rating System (no, mild, moderate, severe) to determine patients' self-reported pain level. An electronic chart was created for each patient in a secure electronic record software, PBS Endo Enterprise (https://pbsendo.com/), and a copy of this call sheet was scanned and saved into the chart documents. After arrival at the clinic, the J o u r n a l P r e -p r o o f endodontists recorded patients' chief complaint and performed a series of examinations on tooth/teeth associated with the chief complaint. These exams included percussion, palpation, bite test, thermal tests (cold and/or hot), periodontal probing, and mobility. Pain level on percussion and palpation was objectively recorded using the 4-point Verbal Rating System (no, mild, moderate, severe). Following the clinical exams, the clinical staff took a periapical radiograph of the tooth using XCP paralleling device (Dentsply Sirona, Charlotte, NC, USA) and Carestream digital sensors (Carestream Dental, Atlanta, GA, USA). Finally, a diagnosis was made, and treatment options were offered to the patient. After the treatment, the endodontist entered all diagnostic and procedural data into the patient's electronic chart. For data collection, daily schedules were reviewed, and patients' electronic charts were accessed manually. Three sets of data were collected for each patient visit as described previously (3): A) Demographic data-age; gender; tooth type (molar, premolar, anterior); self-reported pain level (using 4-point Verbal Rating System); self-reported systemic diseases (diabetes, liver disease, kidney disease); distance traveled to office which was the distance between patient's residential zip code and the office zip code determined using Google Maps Analyses were performed in two stages: for the first aim, we analyzed patient visit characteristics in mid-March to end of May 2021 (ongoing COVID-19 pandemic) with the same period in 2019 (normal Pre-COVID-19); and for the second aim, a comparison of patient visit characteristics in the same periods in 2021 and 2020 (initial COVID-19 outbreak) was performed. At each stage bivariate analyses and multivariable analyses were performed, as detailed below. Bivariate analyses were performed using two tests: Chi-square test for categorical data of demographic (gender, tooth type, medical history), diagnoses, and procedures; And logistic regression (each test only has one explanatory variable in the logistic regression with binary years being the response variable) (7) for continuous data of age, distance from the office, and pain levels (converted to numeric data: no and mild=0; moderate and severe=1). A logarithmic scale for distance from the office was used because this made the data distributed normally. The outliers (>100 miles) were excluded. Since a number of these variables may interact with one another and to control for potential confounders multivariable analyses were performed for each aim separately. We used a multiple logistic regression model where data from 2021 was the binary response variable, and all others were explanatory variables. Multiple logistic regression analyses were done to compare 2021 with 2019 (aim-1) and to compare 2021 with 2020 (aim-2). The following variables were excluded from multiple logistic regression analyses: patients' self-reported pain levels due to number of missing entries; incision for drainage, type of restoration, and single/multiple visits J o u r n a l P r e -p r o o f 8 because they were related to a subgroup of patient visits (i.e., those who received non-surgical root canal treatment, or retreatment, or pulpotomy) not all patient visits. All covariates were converted to binary variables in multiple logistic regression analyses. For categorical variables with multiple categories (i.e., tooth type, pulpal diagnosis, periapical diagnosis, and procedure) one category was defined as a reference group as described previously (3) . Pain levels were converted to 0 or 1 for none-mild or moderate-severe, respectively. An "old" patient was defined as a patient who was older than the average age of the entire cohort of all three years (49.5 years). Patients who traveled more than average distance in the entire cohort Fig. 1 . Bivariate analyses showed significant differences in few variables (Table 1) . Patients reported higher levels of self-reported pain in 2021 (P<.05) but pain on percussion and palpation were not different than 2019 (P ≥.05) ( Table 2 ). There was a significant increase in the number of cases diagnosed with irreversible pulpitis and chronic apical abscess, and a significant decrease in the number of previously treated teeth (P<.05) ( Table 1) . Patient visits, in which non-surgical root canal treatment and apicoectomy were performed, were significantly higher in 2021 (P<.05). Patients had more multiple-visit treatments and received more permanent restorations in 2021 (P<.05). The rest of the variables did not show differences (Tables 1 and 2) . Multiple logistic regression analyses showed that, compared with 2019, the ongoing COVID-19 pandemic year 2021 was significantly associated with a decrease in the number of cases J o u r n a l P r e -p r o o f diagnosed with reversible pulpitis and previously initiated treatment; and with an increase in the number of non-surgical root canal treatments and apicoectomies (Table-3) . This analysis was performed to determine if there were any changes in endodontic practice characteristics, one year after the pandemic outbreak, and after other dental offices resumed their practice. Bivariate analyses showed significant changes in several variables ( Table 4 ). The number of patient visits for male patients increased in 2021 (P<.05). Pain levels in all three categories of self-report, percussion and palpation were significantly less in 2021(P<.05) ( Table 5 ). Patient visits associated with molar teeth increased in 2021 (P<.05) while visits associated with premolars decreased (P<.05). There were less visits for patients with kidney disease in 2021 (P<.05). There were more patient visits with pulpal diagnosis of irreversible pulpitis, and with periapical diagnoses of normal periapex and asymptomatic apical periodontitis in 2021 (P<.05). There were also fewer patient visits with pulpal diagnosis of pulp necrosis and periapical diagnosis of acute apical abscess in 2021 (P<.05). Permanent restorations were placed less frequently in 2021 and patients received multiple-visit treatments more frequently (P<.05) ( Table 4 ). Multiple logistic regression analyses showed that the ongoing COVID-19 pandemic year 2021 was significantly associated with older patients, less females, higher number of molars, and less pain on percussion when compared with the period of outbreak in 2020 (Table 6 ). Most research studies published after the initial outbreak of COVID-19 pandemic focused on changes in practices and patients' characteristics during the outbreak (8) (9) (10) (11) (12) (13) (14) . There is a lack of data regarding if and how these changes returned to normal following the outbreak. As far as we are aware, the present study is the first analysis of the longer-term impact of COVID-19 pandemic on characteristics of patients in need of endodontic treatments. The current study shows that some changes that took place during the initial outbreak of COVID-19 in 2020 returned to normal one year later in 2021, and some did not. It reveals how the COVID-19 pandemic may create ongoing changes in the characteristics of patients seen in Endodontics specialists' practices. Overall, the number of patient visits to the two offices had decreased by 16% during the initial outbreak of the pandemic, but increased by 38% a year later, compared with 2019 numbers. This shows a reasonable rebound in patient flow, similar to trends reported in other areas of dentistry (4) . Future studies would clarify how the patient flow has been affected by subsequent surges in COVID-19 infections, hospitalizations, and deaths due to the emergence of more transmissible variants and vaccine hesitancy. In the previous study we showed that the initial COVID-19 outbreak was associated with increased patients' self-reported pain, pain on percussion and pain on palpation (3). ). The present investigation showed that in 2021, the presence of pain on percussion and palpation returned to pre-pandemic 2019 levels. Percussion pain significantly decreased in 2021, compared to 2020. However, self-reported pain levels in 2021 stayed significantly higher than the norms of 2019. These findings may be due to patients' continued hesitancy to visit a dentist (15) until the pain becomes significant, coupled with the improved availability of general dental offices to J o u r n a l P r e -p r o o f address at least some of the acute dental pain. It is worth noting that the spike in the number of visits associated with acute apical abscesses that took place during the initial outbreak in 2020, returned to normal levels in 2021. In other words, patients do not wait too long to face the most severe consequences of pulpal pathosis, i.e., acute apical abscesses. Previous studies showed that the COVID-19 pandemic resulted in substantial decrease in procedure volume for patients covered by public insurances in the United States (16) . There are other socioeconomic factors that could contribute to patients' behavior in this regard. A study by Matsuyama et al (6) showed that dental pain was associated with household income reduction, work reduction, and job loss during the outbreak of COVID-19. These worsened socioeconomic conditions continued beyond lockdown period for millions of households in the United States. More clinical studies on different populations in different geographical areas and different settings are needed to assess and compare the pain levels of endodontic patients before and after the COVID-19 pandemic and to investigate other related factors. Our previous study revealed that the odds for performing non-surgical root canal treatments significantly increased during the initial COVID-19 outbreak in 2020 (3). The present study showed that the same trend continued in 2021 and it did not return to the norms of 2019. This is an important finding that implies that the public's need for non-surgical root canal treatment has increased. Also, it is worth noting that non-surgical root canal treatments constitute most of the emergency visits in Endodontic offices. Therefore, our findings indirectly show that the trend of more emergency visits in 2020 compared to 2019, has persisted into 2021. This is consistent with the persistent increase in the level of self-reported pain among patients. We observed a significant increase in the number of visits with the diagnosis of irreversible pulpitis and a significant decline in the number of visits with the diagnosis of previously treated J o u r n a l P r e -p r o o f in 2021 as compared to 2019. This finding is a key contributing factor to increased likelihood of non-surgical root canal treatments but not non-surgical retreatments in 2021. The shift in public's attitude towards their dental health, pain being the motive for dental visits, might be one of the factors that has led to this change. Taken together these findings may indicate that despite the return of general dentists to full-time practice, they were less likely to perform emergency or definitive non-surgical root canal treatment, perhaps related to busyness with other dental procedures. Another aspect related to this finding, that is yet to be studied, is the etiologies of pulpal pathosis related to these patient visits. An investigation on the etiology of pulpal disease before and after COVID-19 pandemic could potentially explain the reasons behind the trend for more non-surgical root canal treatments after COVID-19 pandemic. The present study shows that some of the changes observed during the initial COVID-19 outbreak in 2020 returned to normal levels in 2021. The patients seen during the initial outbreak This finding may indicate that the overall fear and hesitancy about dental visits among these patients is less than that seen during the period of the initial outbreak, specifically among older patients. Vaccinations, effectiveness of preventative measures such as masking and social distancing, and the availability of more effective treatment strategies for COVID-19 may all play a role in this finding. We observed procedural changes during the initial outbreak of COVID-19 in 2020 that seemed to be related to changes in operators', patients' and referring dentists' preferences. These procedural changes included-increased number of apicoectomies performed, increased number of permanent fillings placed, and reduced number of visits with diagnosis of previously initiated therapy (3). These trends persisted into 2021. Also, even though the number of cases where patients received permanent fillings was reduced in 2021 compared to 2020 (probably because the general dentists were available to restore these teeth), the patients still received significantly more permanent fillings in 2021 compared to 2019. Patients', operators', and referring dentists' preferences in limiting the number of patient visits could be a factor associated with these changes. The present study showed a significant rise in the percentage of molar cases in 2021 compared to 2020. It may be that general dentists are treating more anterior and premolars in their practice now that they are available. The present study showed a significant decline in the number of visits for female patients. The reasons for this change in sex distribution are not clear. Other similar studies are needed to determine if these findings are consistent. The gender-specific impacts of socioeconomic fluctuations due to COVID-19 pandemic and the gender-specific changes in the public's behavior towards their dental health have not been adequately studied. However, it is generally known that the pandemic has affected women in the workforce more than men. It is worth noting that the data from this study is limited to two endodontist offices located in the Washington DC and Northern Virginia area. More clinical studies are recommended to determine the genderspecific changes of patients' attitude towards their dental health around the nation. 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