key: cord-0871553-6jekldst
authors: Moharrami, Mohammad; Bohlouli, Babak; Amin, Maryam
title: Frequency and Pattern of Outpatient Dental Visits during the COVID-19 Pandemic at Hospital and Community Clinics
date: 2021-09-30
journal: J Am Dent Assoc
DOI: 10.1016/j.adaj.2021.09.007
sha: 550d9f1c47acc7cde0339d2f133e0b1fc0bdff67
doc_id: 871553
cord_uid: 6jekldst

Background This study aimed to measure the frequency of dental visits before and during the COVID-19 pandemic and to evaluate if dental visits can be predicted from demographics, socioeconomic status, oral problem diagnoses, and received dental services. Methods Participants for this retrospective study were patients visiting dental providers at the hospital- and community-based outpatient clinics in Alberta, Canada. Data were retrieved from electronic databases from March 12th to the end of September 2020 and the same period for 2018 and 2019. Also, the lockdown was declared for March 12 to May 14, 2020. Data were analyzed using ANOVA test and multiple logistic regression at α=0.05. Results From a total of 14,319 dental visits, 5,671, 5,036, and 3612 occurred in 2018, 2019, and 2020. The mean (SD) frequency of daily visits was 36.69 (15.64), 32.09 (15.51), and 24.24 (14.78) respectively (P<0.001). Despite the overall decrease, the frequency of visits for infections, salivary problems, and temporomandibular disorders increased during the pandemic. The dental visits during the pandemic were associated with increased oral problems, complicated dental procedures, and higher economic status. Conclusion During the pandemic, the frequency of dental visits decreased specifically during the lockdown. Patients with complicated problems needing urgent treatments mainly visited dental clinics. Reduced access to care was observed primarily among socially disadvantaged groups. Practical Implications Although the current guidelines and related recommendations have been effective during the pandemic in restoring the compromised dental system, further modifications are needed to promote in-person visits to improve oral health status of patients.

COVID-19 infection that affects the upper airways. (1) Fever, cough, fatigue, loss of smell and taste are the main clinical symptoms of the infection. (2) The COVID-19, a major health crisis worldwide, was declared a pandemic by the World Health Organization (WHO). The healthcare workers are in extreme danger of being exposed to the virus and constitute 9% of all the infected individuals. (3) Similarly, dental practitioners have a higher likelihood of exposure to the coronavirus due to direct exposure to saliva and blood and a variety of aerosol-generating dental procedures. (3, 4) As such, numerous countries have issued restrictions for the prevention and spread of coronavirus.

Consequently, dentists have been advised by the WHO to provide only emergency treatments that are essential for preserving a patients' oral function, managing severe pain, or maintaining the patients' quality of life. It is advised that non-urgent procedures such as check-ups, dental cleanings, preventive care, and aesthetic treatments are delayed until a significant reduction in COVID-19 community transmission. (5) Following the WHO's advice, dentists have implemented strict measures developed by their local health authorities to prevent the transmission of the virus. To minimize occupational hazards, dentists have adapted new triage, evaluation, and treatment systems alongside teledentistry. Through this approach, a real emergency should be first identified, and if possible, pharmacotherapy should be followed immediately. (6) In case, a patient requires hands-on dental treatment, dentists should ask a series of screening questions and check for clinical symptoms of COVID-19. Only patients who meet the negative COVID-19 screening criteria and can be treated with low-aerosol-generating procedures, shall be seen in private clinics equipped with level 1 personal protective equipment (PPE). In case of the presence of a symptom or need for aerosol-J o u r n a l P r e -p r o o f generating procedures, patients must be seen in hospital clinics with adequate infrastructure and level 2 PPE implementation. (6) Due to the current restrictions imposed on the delivery of dental treatments and considering financial and psychological burdens secondary to the COVID-19 pandemic, many individuals are likely to avoid non-emergency dental treatments. (7) (8) (9) It was reported that patients' anxiety level increase during the COVID-19 pandemic, and there was a strong relationship between the perception of the patients about the COVID-19 pandemic and the motivation to attend a dental appointment. Except for those patients who receive regular treatments, such as orthodontics, others would only visit in case of emergency. (10, 11) Since March 11, 2020, marked by the beginning of the COVID-19 pandemic, Alberta dentists started using teledentistry more broadly and were allowed to prescribe medications. Also, similar to many other regions, a system of triage was implemented starting with a patient phone call for symptoms and risk factors which followed by remote and pharmaceutical management, physical assessment in the office, referrals, and finally non-aerosol vs. aerosol-generating procedures. However, lack of direct patient examination means that the cause of a dental problem cannot be properly assessed and addressed in a timely manner Data on the pattern and frequency of dental visits, dental services, oral problems, and patient characteristics before and during the pandemic is lacking. Therefore, in this study, we aimed to 1. measure the frequency of dental patients' visits before and during the pandemic and also during and after lockdown 2. determine if dental visits during the pandemic can be predicted based on demographics, socioeconomic status, service providers, and oral problem diagnoses.

This study was reviewed and approved by the Health Research Ethics Board of the University of X (ID: Pro00095759).

Participants for this retrospective cohort study were patients visiting dental providers at hospitaland community-based outpatient clinics in Alberta, Canada. Data was retrieved for participants who visited dental clinics from March 12 th (beginning of the pandemic declared by WHO) to the end of September 2020 and the same period for 2018 and 2019. Linkage of all extracted information defined two main cohorts namely: 1) dental patients during the pandemic, and 2) dental patients before the pandemic in 2018 and 2019. Further, the pandemic period was divided into lockdown phase from March 12 to May 14, 2020 in which private dental offices were closed and from May 14 onwards in which dentists were permitted to return to full provision of services as part of the stage 1 relaunch strategy in Alberta.

The National Ambulatory Care Reporting System (NARS) was the source of our data which exists in all provinces in Canada. The de-identified electronic health records processed by the Canadian Institute for Health Information (CIHI) are available to researchers upon their request and after they obtain the ethics approval and sign the data disclosure agreement with the provincial health.

The dataset contains information for all hospital-and community-based ambulatory care, such as day surgery, emergency departments, outpatient, and community-based affiliated clinics and contains demographics, socioeconomic status, service providers, diagnosis, and procedure interventions. Up to ten diagnoses/conditions/problems/circumstances are coded using the This medical classification system is used to code and classify diseases, signs or symptoms, and procedures associated with hospital utilization. (12) The codes used to retrieve data in this study can be found in Appendix 1.

The Statistical Package for the Social Sciences (SPSS, IBM Corp. Version 25.0, NY, USA) was used to perform the analyses. The descriptive analysis was reported for the continuous data by mean and standard deviation and for the discrete data by frequency and percentage. The frequency of dental visits was calculated before and during the pandemic and also during and after lockdown on a yearly, monthly, and daily basis.

The Kolmogorov-Smirnov was used to verify the normality of the collected data. The one-way ANOVA and Bonferroni post hoc tests were used to measure the differences in dental visits between the three years. Moreover, to determine the factors important in predicting dental visits during the pandemic, the pandemic status (outcome measure) was dichotomized into pre-pandemic vs. pandemic and the following predictors were used in the binary logistic regression analysis. Service providers: dentists, pediatric dentists, oral surgeons, dental hygienists 6. Oral diagnosis: caries and dental problems, periodontal problems, infections and lesions, cleft and fractures, temporomandibular disorders (TMD), orthodontic problems, cysts, salivary problems, examination.

In the first model age and sex were included. Residential zone and economic status were added to the second model. Finally, service providers and oral diagnosis were incorporated into the third model. Akaike Information Criterion (AIC) was applied to compare the models and to determine which one is the best fit for data, and the Nagelkerke R Square was reported for the final model.

A 95% confidence interval and P value of less than 0.05 were considered to be statistically significant.

From the 14,319 dental visits, females and males constitute 47.1% and 52.9% of patients with a mean (SD) age of 29.30 (24.31) and 29.30 (24.91) respectively.

Overall, records of 14,319 dental visits were evaluated from which 5,671, 5,036, and 3612 occurred in 2018, 2019, and 2020 respectively. The distribution of frequency of dental visits in each month is depicted in Figure 1 . Also, the frequency of dental visits before and during the pandemic based on included factors namely admission type, age, sex, residential zone, economic status, service providers, and oral problems is presented in Table 1 . The noteworthy finding was that even the frequency of dental visits decreased during the pandemic, from all the variables, the 

Except for admission type, since there were less than 1% of emergency patients, and 99.7% were outpatients, all other predictors entered into the multiple logistic regression models.

The results of multiple logistic regression regarding pre-pandemic and pandemic periods are shown in Table 3 . Age and sex did not associate with dental visits during the pandemic. On the J o u r n a l P r e -p r o o f While visits to pediatric dentists (CI: 2.47 to 3.65, OR=3.00) and oral surgeons (CI: 2.72 to 3.37, OR=3.03) were three times higher during the pandemic, the visits to dental hygienists significantly decreased (CI:0.05 to 0.28, OR=0.12).

Oral problems had the strongest association with the pandemic period, and all the diagnoses were increased compared with dental examination. The detailed analysis and related ORs and confidence intervals are shown in Table 3 .

To the best of our knowledge, this is the first study that comprehensively evaluated the frequency of dental visits before and during the pandemic and also during and after the lockdown. Based on our results, the number of days, as well as frequency of dental visits, decreased during the pandemic. These findings are important since only visits to community and hospital-based dental clinics, which were open and providing dental services to the patients during the pandemic, were included in this study.

Several factors could have contributed to the lower frequency of dental visits during the pandemic. First, at the beginning of the pandemic, the information on COVID-19 was scarce, and the fear of exposure in dental settings and consequent morbidities discouraged many people from routine visits and checkups. Even professional organizations such as the American Dental Association (ADA) recommended on April 1, 2020 "dentists keep their offices closed to all but J o u r n a l P r e -p r o o f urgent and emergency procedures until April 30 at the earliest." Moreover, the public and professional guidelines for the work environment had not been developed fully. For example, it was only on April 27 that ADA's Task Force on Dental Practice Recovery developed the Return to Work Interim Guidance Toolkit to assist dentists to protect themselves, staff, and patients while practicing dentistry. Moreover, the CDC's interim infection prevention and control guidance for dental settings during COVID-19 was first published on May 19. (13) There were also some other limitations for patients to visit dental offices even when they were open and functional. Access to dental clinics has become challenging for certain individuals and groups whose main commuting route was public transport. Due to safety concerns, the primary reason for travel changed, and there was also a shift from public to private and community transport. (14) In lieu of in-person visits, teledentistry and new triage protocols were developed; based on CDC's guidelines, all patients need to be screened for symptoms of COVID-19; if symptoms exist, non-emergent dental care should be delayed, and relevant instructions are provided. (15) Moreover, it is recommended that, whenever possible, aerosol-generating procedures including but not limited to the use of high-speed dental handpieces, air/water syringes, and ultrasonic scalers be limited. In case of necessity, the four-handed dentistry technique should be adapted using high evacuation suction as well as dental rubber dams to reduce the generated aerosol. (15, 16) Based on our results, not only the frequency of dental visits decreased but also the pattern of visits has changed dramatically. More patients visited oral surgeons and pediatric dentists compared to general dentists but less sought service from dental hygienists which is in line with guidelines and policies persuading individuals to schedule urgent treatments. Moreover, in the pandemic period, all types of oral health problems increased compared to oral examinations. More It seems that although current recommendations such as teledentistry have been effective in restoring the compromised dental system and bridging the gap between oral health care providers and patients, (17) (18) (19) further modifications are needed to safely and efficiently provide dental services to individuals in a timely manner.

Another important finding of this study was that individuals with better economic status visited dental clinics more frequently than socially disadvantaged groups during the pandemic.

Overall, visits to dental clinics in Edmonton, which is the capital city of the province of Alberta, were higher than in other residential zones. Therefore, special focus should be given to access to care of disadvantaged groups and remote communities, and efforts should be made to eliminate barriers to receive timely dental services and to provide education on visiting dental clinics during the pandemic period.

While administrative data are collected for non-research purposes, they can provide large, demographically diverse cohorts at a fraction of the time and cost. However, there is some skepticism regarding the validity of administrative databases including the accuracy of billing codes used to categorize diagnoses and procedures. Administrative data can also be unwieldy to work with as data are often stored raw and not in analysis-ready format, which requires data cleaning and management. Therefore, the administrative data should be used in research with caution and an understanding of its limitations. 20 In this study, we only had access to hospital-and community-based outpatient clinics. Data on private clinics, which were closed during the J o u r n a l P r e -p r o o f lockdown, were not available. Future studies need to evaluate if the patterns for community and outpatient clinics also apply to private clinics.

During the pandemic, the frequency of dental visits decreased specifically during the lockdown.

Patients with complicated problems needing urgent treatments mainly visited dental clinics.

Reduced access to care was observed among socially disadvantaged groups. Although the current guidelines and related recommendations were effective during the pandemic in managing dental visits, further modifications are needed to promote in-person visits to improve the oral health status of patients. A. Frequency of dental visits before and during the pandemic for different age categories B. Frequency of dental visits before and during pandemic for different residential zones C. Frequency of dental visits before and during pandemic for different economic status (1=best, 5=worst) D. Frequency of dental visits before and during pandemic for different service providers E. Frequency of dental visits before and during pandemic for different oral problems 

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6%) 417 (2.9%) 148 (1.0%) 1213 (8.6%) Calgary 2732 (19.3%) 2477 (17.5%) 1272 (9.0%) 6481 (45.8%) Central 350 (2.5%) 343 (2.4%) 291 (2.1%) 984 (6.9%) North

Table 2. The Bonferroni post hoc tests to compare the frequency of dental visits between pre-pandemic