key: cord-0996854-3l8xjhko
authors: Motevasel, Hengameh; Helms, Lana R.; Eckert, George J.; Stewart, Kelton T.; Albright, David A.
title: The impact of the COVID-19 pandemic on US orthodontic practices in 2020
date: 2021-10-04
journal: Am J Orthod Dentofacial Orthop
DOI: 10.1016/j.ajodo.2020.11.040
sha: 0b37b86efe8ca6bb1aab17e7d026565094598886
doc_id: 996854
cord_uid: 3l8xjhko

Introduction This study aimed to investigate the immediate impact and longer-term implications that the SARS-CoV-2 virus has had on the orthodontic practices in the United States in 2020. Methods A 35-item survey was developed and validated to investigate the impact of the COVID-19 pandemic on the orthodontic profession. The survey contained five domains including respondent demographic information, COVID-19 information acquisition, practice ramifications of the COVID-19 pandemic, financial implications of the COVID-19 pandemic, and patient management strategies during the COVID-19 pandemic. This voluntary survey acquired responses from active orthodontists in the U.S. Associations of demographic and practice characteristics with items related to COVID-19 were assessed using chi-square tests, with a 5% significance level. Results The survey was disseminated to 5,694 individuals and 507 complete surveys were obtained (response rate of 8.9%). Respondents indicated that they obtained the most useful information regarding the COVID-19 pandemic through professional associations and internet/online news resources. However, 30% of the orthodontists believed information regarding personal financial guidelines was lacking. Most respondents identified delayed treatment progress and temporary staff layoffs as the two most negative ramifications of mandated office closures. Approximately 93% of practices applied for and utilized some sort of stimulus funding offered through the CARES Act. Respondents indicated that the COVID-19 related office closures resulted in an average of 50% decrease in net revenue. Conclusions The survey found that the COVID-19 pandemic had a broad and significant impact on patient care and financial aspects of US orthodontic practices in 2020. Though generally accepting of the federal and state recommendations, respondents appeared to desire more guidance during the early phase of the pandemic.

Cross-species virus transmission and emergence of viral pandemics are immense threats to public health. Unrecognized viruses that affect both humans and animals have been responsible for the emergence of epidemics and pandemics such as Severe Acute Respiratory Syndrome (SARS), Ebola, Acquired Immunodeficiency Syndrome (AIDS), and Swine flu. [1] [2] [3] [4] [5] The most recent examples of these epidemics are the SARS-CoV virus of 2003 and H1N1 influenza outbreak in 2009 that resulted in hundreds of deaths and economic disruption. 3, 6, 7 SARS-CoV-2 belongs to the coronavirus family of viruses and is responsible for the "coronavirus disease 2019", also known as the COVID-19 pandemic. COVID-19 is a singlestranded RNA virus that is extremely contagious, with confirmed cases in nearly every region of the globe. 8 Due to the significant impact of COVID-19 on all aspects of life, various mandates have been imposed on communities across the world that encourage public social distancing and self-isolation to help prevent the spread of this deadly virus. 9 Social distancing and self-isolation practices have obvious ramifications on businesses and medical professions, including dental/orthodontic offices.

Considering the association between exposure to disease, the physical proximity to others, and high patient volume in an orthodontic practice make orthodontists one of the professionals at greatest risk in the United States. 10, 11 On March 16, 2020, the American Dental Association (ADA) recommended dentists postpone elective procedures for three weeks, nationwide. 12 On April 1, 2020, the ADA issued an interim recommendation that "dentists keep their offices closed to all but urgent and emergency procedures until April 30 at the earliest". 12 As a result, many orthodontists closed their offices and discontinued seeing non-emergency patients on a daily basis.

These unprecedented and extraordinary circumstances have raised many questions regarding office closures, business survival, patient care, and employee management. Because of the tremendous impact that the COVID-19 pandemic has had on the orthodontic community, it is critical that the immediate and projected impact of this pandemic on orthodontic private practices be investigated. Understanding the driving factors of the profession's real-time decision-making process in a period of crisis will give insight into whether the decisions made were prudent and how similar crises might be handled in the future.

The aim of this study was to evaluate the resources and entities that best aided orthodontists to remain informed on the COVID-19 situation, the strategies orthodontists used to help their businesses survive, the methods used to manage active and future orthodontic patients, as well as the effect of the pandemic on orthodontic practice employees in 2020.

After establishing five desired survey domains, the principal investigators developed questions that would aid in the acquisition of information to understanding these thematic areas.

The questionnaire was divided into the following five sections/domains: Orthodontics and Oral Facial Genetics. The devised questions were then presented to a panel of 14 orthodontists from across the United States to assess the survey and provide input. This process was conducted to garner feedback regarding the survey length, relevance of domains and questions, question sequence, and appropriateness of answer choices. These reviews served to establish the construct, content, and face validity of the survey and to ensure the information gathered would be pertinent to developing a greater understanding of the immediate and potential long-term effects the COVID-19 pandemic has had on orthodontists and orthodontic practices.

Using the collected feedback, the investigators made changes to the survey to address identified deficiencies and reduce potential biases. The survey was then entered into SurveyMonkey ® , an online surveying platform, and prepared for dissemination. After the online survey was formatted, the orthodontist review panel completed an additional survey review. This A 5% statistical significance level was used for all tests. Analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

The study utilized a cross-sectional design and disseminated a validated survey instrument to obtain relevant information regarding the COVID-19 pandemic and orthodontic business survival, models of sustained patient care, and employee management by orthodontists in the United States. The survey was distributed to 5,694 orthodontists and 586 accessed the survey. Survey submissions that either answered only Domain 1 (Demographic Information) questions or failed to answer sufficient demographic information questions for the examiners to draw the desired correlations were excluded. Using these parameters, 79 respondents were excluded, yielding a total sample size of 507 and a response rate of 8.9%. Table I lists the practice locations of the survey respondents by state. For some of the statistical analysis, states were combined according to their AAO constituent society groups to enhance group numbers (Table II) . The data shows that some states had zero representation, while Indiana was over-represented within the sample set.

The respondents consisted of 250 females (50%) and 252 males (50%) with 3 (1%) individuals preferring not to disclose their gender. The age distribution of the respondents was broken down into 10-year increments. The largest groups were 30-39 year-old orthodontists at 40% (n=202) and 40-49 year-olds at 32% (n=161). Orthodontists age 50-59 years old represented 18% (n=90) of the respondents, while only 9% were found to be over the age of 60 (n=44).

Regarding the respondents' practice information (level of experience, practice type, and practice setting), the majority of responding orthodontists indicated they maintained a solo private practice (53%, n=266). Twenty percent reported being associates in either private practices (11%, n=57) or corporate practices (9%, n=43). The remainder were practice owners practicing with an associate (10%, n=48), practitioners in group practices (12%, n=60), or orthodontists in academia or hospital practices (3%, n=13). Most orthodontists in the survey claimed to practice in suburban areas (70%, n=355), while 19% (n=96) practice in urban areas, and only 11% (n=56) in rural practices. Levels of experience were grouped into five-year increments. The largest group of participants was the under 5 years in practice group at 26% (n=132). Each subsequent five-year span decreased in participation from 22% (n=111) of 5-10 years in practice, 18% (n=93) 11-16 years in practice, and 10% (n=49) 16-20 years in practice.

The most senior orthodontists were grouped into a 20+ years in practice group, and they represented nearly one quarter of the respondents (n=121).

Office size prior to the COVID-19 pandemic was estimated by the number of employees within the practice. Most of the offices included in the sample (38%, n=194) had 5-10 employees. The next most common practice size was offices employing 11-15 people, which represented 22% of responses (n=110). The smallest offices, with a staff of less than 5 employees, represented 16% (n=81) of the sample, and the largest practices in the survey employed 16-20 staff members or had over 20 employees, and represented 8% and 16% of the sample, respectively (n=41 and 81).

After collecting the above demographic information, the next subset of questions sought to gauge orthodontists' opinions on the initial federal and local responses to the emerging pandemic. These Likert scale questions were used to measure the level of satisfaction of the respondents to the federal and state/regional responses to the COVID-19 pandemic. The majority of the respondents (67%, n=340) rated the federal response as fair to poor, while there were J o u r n a l P r e -p r o o f slightly more that were satisfied with their state/regional response, which yielded fair to good assessment from 74% of respondents (n=375).

Regarding opinions about the specific, more locally directed mandates/recommendations, younger orthodontists tended to agree with the necessity of such guidelines, while their more senior colleagues did not (p = 0.038). In addition, significantly more females felt the mandates were necessary compared to males. Fifty-nine percent of females and only 45% of males felt the limitations placed on patient care within orthodontic practices were necessary (p = 0.006). Just over 50% of the participants felt that guidelines set by local and state governments regarding limitations to all but emergency and essential care in orthodontic practices were necessary overall, and the most critical subset of the sample to these mandates were practitioners in solo and group private practices (p = 0.044). Figure 1 illustrates the information sources survey respondents utilized most during the early stages of the pandemic. Approximately, three-quarters of the participants accessed information from professional associations, and 61% used internet/online news sources. The gathering of information from internet and online news sources was statistically significant with the youth of the respondent (p = 0.024), but the use of social media, specifically, was not similarly correlated with age. While obtaining information from vendors and print media was not selected by many participants, the orthodontists that selected this option were in the most senior age groups (p = 0.001 and 0.005, respectively) and practicing in suburban and rural areas (p = 0.034). Figure 2 illustrates which sources provided participants with the most helpful information. Roughly half of the respondents stated that the most helpful sources of information were state or local dental associations (53%) and the AAO (50%). According to the participants, the most helpful sources providing information regarding COVID-19 were the state or local dental associations, AAO, ADA and CDC, in descending order. The older the participants' age group, the more they utilized the AAO as a source for obtaining information (p = 0.004), and the larger the practice, the more likely the respondents were to select the AAO as a helpful information source (p = 0.003). The same trend held true regarding age and practice size and the attitudes toward the ADA as an information source (p = 0.038). Practitioners in rural and suburban practice settings and those in smaller practices also tended to rate professional associations highly as sources of helpful information (p = 0.018 and 0.007, respectively). Half of the respondents ranked COVID-19 mitigation, prevalence, and spread as the topics for which J o u r n a l P r e -p r o o f they were able to collect the most useful information. Information regarding practice business management, small business resources, and personal financial guidance were generally rated as lacking by about 1/3 of the participants (figure 3). It is interesting to note that while professional associations, such as the AAO and ADA, were listed as useful sites to glean information, when asked if guidelines set forth by these organizations were helpful in the early management of the pandemic, 55% of respondents felt the professional associations did not provide sufficient guidance in these critical early days. Two demographic groups responded counter to this trend.

Orthodontists practicing in rural settings and practitioners with smaller practices (10 employees or less) tended to believe that professional association guidelines were helpful in the early management of the pandemic (p = 0.003 and 0.022, respectively).

Among the 481 participants who volunteered their opinion on recommendations to limit practices to emergency or essential care in orthodontic practices, 252 (52%) believed that the guidelines set by local and state governments were necessary. Significantly more females (59%) than males (45%) thought that the guidelines were necessary (p = 0.006). Approximately twothirds (63%) of orthodontists under 30 years old agreed with the necessity of the guidelines, while only 43% of orthodontists older than 60 years old shared that perspective (p = 0.038).

When inquired about negative ramifications to orthodontic practices caused or anticipated by the various local lock-down orders, 95% of respondents selected delayed patient treatment as a primary concern. Seventy-one percent of participants were concerned about the potential need to temporarily furlough staff. Figure 4 highlights the response choices of survey participants in descending order for this question. These two top concerns were also listed as being negative ramifications that could have been lessened or avoided with more timely information and resources. At the time of taking the survey, 73% of practices stated they laid off more than 60% of their staff. Only one in four practices relayed that they did not release at least one employee permanently due to the effects on the business caused by the pandemic related shutdowns. A vast majority (87%) of practice owners encouraged their furloughed staff to apply for unemployment benefits.

Only practice owners or participants who managed the financial aspects of their practices answered financial related items within the survey. Within this subset of participants, 93%

(n=375) stated that they utilized at least some of the programs within the CARES Act, and a full 98% utilized the Payroll Protection Program. Just over half of these respondents (54%) utilized J o u r n a l P r e -p r o o f the Economic Disaster Loan. Only 26 participants decided to forego these programs, and of these individuals, 65% stated they did not need the support or were unsure of the financial ramifications of utilizing the programs (38%) or didn't have adequate knowledge to comfortably agree to them (15%). Most orthodontists (77%) consulted with a CPA prior to making these financial decisions for their practices. Other common sources of guidance for financial matters were consulting a colleague (43%) and professional associations (16%). Over one in five respondents stated they conducted their own research.

Participants were asked to estimate the net financial impact of the lost time in practice, Another potential financial impact explored in the survey was whether a planned practice transition was affected, including the hiring of an associate. Around 60% of practices stated they were at some stage of planning a practice transition. Of those practices, just over 50% stated the COVID-19 pandemic negatively impacted those plans.

The final aspect of orthodontic practice that the instrument surveyed was the management of patients during the shutdown. This section collected input from 463 respondents. The choices given were Tele-orthodontics (65%, n=299), phone calls to patients (72%, n=332), emails to patients (67%, n=310), and texts to patients (64%, n=298). Nearly a quarter (24%) of respondents (n=111) reported that they limited patient contact strictly to handling emergencies.

The orthodontists who utilized Tele-orthodontics did so for a variety of situations. A significant majority (82%) used it to assist with emergency patient management, but 79% used it for patients in active aligner treatment, 78% used it for patients in active fixed appliances, and 47% used it for retention checks. A number of practitioners used Tele-orthodontics for new patient consults (58%) and for monitoring patients between phases for future treatment (43%).

A number of questions allowed participants to submit other thoughts and concerns regarding the issues related to the pandemic. A word cloud (Figure 7) was generated from these free-form responses. While not statistically measured, these comments were very instructive about attitudes and opinions of the survey respondents.

The demographic data from this survey was compared to demographic data available from the AAO 13 to determine the representative caliber of our sample. Overall, our sample compares favorably to national demographics of practice geography, practice location (urban/suburban/rural), and practice type (large percentage of solo private practice owners).

Seventy-five percent of the survey participants were private practice owners, while 20% were associates in either private practices or corporate practices. When considering the national distribution of orthodontists, our sample was slightly over-weighted geographically to Indiana practices. While this is not unexpected, given the survey originated from the only Indiana state dental school, we do not believe the numbers are so severely disproportionate as to overly skew the nationwide intent of the survey, as evidenced by the strong participation of all AAO constituent society group regions. Regarding respondent gender, our sample was split nearly 50/50 male to female. This ratio is not as well aligned with national data for gender distribution in the orthodontic profession, which is closer to a 70/30 male to female distribution. Our sample also trended a bit younger than the AAO demographic data might suggest. Two important considerations should be noted regarding these relationships. First, it has been demonstrated that females are more likely to participate in surveys compared to males. 14, 15 Additionally, in the attempt to disseminate the survey as broadly as possible to a nationwide audience, the decision was made to approach the Women in Orthodontics Facebook™ group. While realizing this could create a gender bias in the survey, we believed the need for obtaining a large number of responses as quickly as possible due to the time-sensitive, fluid nature of the pandemic, outweighed any potential risks of bias. This could also explain the slight tilt of our sample towards younger orthodontists (40% of our participants were between the ages of 30-39), as the ratio of male to female orthodontists in the under-35 age range is roughly 50/50.

Another potential impact of the of the gender distribution of our sample was the slightly positive sentiment of the respondents to the imposed mandates. Considering our sample is likely J o u r n a l P r e -p r o o f over-represented by younger, female orthodontists, conclusions about the entire sample opinion might skew toward a more favorable response to the mandates, given the strong predilection for women orthodontists to have responded in support of them. A sample with greater male representation could shift the trend to a less favorable response to the mandates.

When participants were asked to express how they felt about the federal and state/regional response to COVID -19 pandemic, the Likert scale question responses were offered (poor, fair, good, excellent). The federal response was recorded to be mainly poor to fair, while the majority of the participants rated the state/regional response to be fair to good. Even though the federal response was not highly regarded in general, a vast majority of respondents took advantage of at least some of the available resources offered through the CARES Act.

Between 94-100% of practice owners utilized at least some of the benefits. Regardless of time in practice, size of staff, or age of practitioner, the Paycheck Protection Program was overwhelmingly utilized. In addition, over 60% of practices within the MASO, MSO, NESO, and PCSO accessed Economic Injury Disaster Loans.

While professional associations, such as the AAO and ADA, were listed as useful sites to glean information, when asked if guidelines set forth by these organizations were helpful in the early management of the pandemic, 55% of respondents felt the professional associations did not provide sufficient guidance in these critical early days. The two groups that responded counter to this trend were practitioners in rural settings and those in smaller practices with 10 employees or less. A possible explanation for these findings could be that rural and smaller practices are more likely subject to a single orthodontist's decisions regarding how to implement the given guidelines. Practices in suburban and urban settings and larger practices have more stakeholders and are subject to competitive pressures that are more closely tied to how others are interpreting the guidelines. If guidelines are not similarly implemented across a competitive field, differences in interpretations and implementation could alter the competitive balance.

Many who are involved in organized dentistry can take heart in the fact that a significant majority of the membership still looks to their professional associations for guidance and direction, especially in a time of crisis. It would appear from our data that outreach efforts to younger orthodontists could be a fruitful area of effort and that online platforms would be the best means to reach them. In addition, while it might be concerning that a majority of respondents seemed critical of the quality and timing of the information provided early in the J o u r n a l P r e -p r o o f pandemic, the fact that organizations such as the AAO are still considered a "go-to" resource is a net positive. It could be interpreted that members appreciated what was presented, but were disappointed that there was not more.

Regarding net revenue loss, the average percentage loss over all demographic categories was around 50%. Financial ramifications were also examined relative to AAO Constituency geographic regions and some interesting findings were seen. The hardest hit regions were geographic areas where the reported virus outbreaks were equally devastating. The NESO, MASO, PCSO, and SAO constituencies were particularly ravaged, as evidenced by fewer practices that experienced "minimal" losses and the higher percentage of practices that reported loss estimates in the 41-80% range. RMSO practices were the only region to have over 50% of practices report losses in the lowest two range possibilities (0-40%). The ADA Health Policy Institute has published survey data from the dental community at large on a bi-weekly basis since 3/23/20. 16 Examining these results against the ADA Health Policy Institute survey numbers, the percentage of dental practices reporting greater than 50% decrease in volume of collections for the weeks of 5/18 and 6/1 (the time periods within the scope of our survey) were 76.9% and 59.7%, respectively. Some mitigating factors that could impact general dental practices differently than orthodontic practices is the fact that while treatments are suspended within an orthodontic practice, active patients are still under contract and possibly making payments.

Emergency visits, on the other hand, are likely more billable in a general dental practice than they would be in an orthodontic practice.

While not directly examined by our instrument, free-form responses yielded insights into concerns among respondents that were not specifically queried in the survey. A concern that was brought up in a number of ways was recommendations, utilization, and availability of personal protective equipment (PPE). In a recent article published by Suri et al., a summary was presented regarding the clinical management of patients during the COVID-19 pandemic. 17 At the time of their writing, the CDC guidelines for PPE use were using a fit-tested N95 mask, eyewear with side shields or full-face shields, hair covers, over gowns, fluid-impermeable shoes, and double gloving. While these recommendations will likely change with time, they highlight the increased demands in cost, supply, and compliance that are being placed on orthodontic practices. In a recent ADA "Morning Huddle" email blast, articles by ABC News and Bloomberg were highlighted, reporting the looming threat of increasing PPE shortages for healthcare workers.

The ADA Health Policy Institute survey also questioned dentists regarding PPE supply. Roughly 20% of dental offices reported having less than 8-day supply of N95 masks and over one fourth of practices have similar limited inventory of gowns. The issues surrounding PPE availability will likely be the most immediate threat to workplace safety and the return to whatever the new normal post-COVID-19 operations will look like. 17 Our survey comments loudly echo these concerns.

The survey found that the COVID-19 pandemic has made a broad and significant impact on the patient care and financial aspects of US orthodontic practices. Though generally accepting of the federal and state recommendations, respondents appeared to desire more guidance during the early phase of the pandemic, and as the reopening proceeded, our respondents sought better guidance in obtaining PPE and making definitive recommendations on PPE usage and reopening protocols.

Crises present challenges, but also afford opportunities. Respondents to this survey continue to look to our professional associations for help and guidance. Providing orthodontists robust and timely information and resources is both a challenge and an opportunity. Examining our responses to the difficult and fluid circumstances surrounding the COVID-19 pandemic can help our profession meet the challenges and seize the opportunities both now and into the future. 

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The authors thank the orthodontists who helped in the review and revision of the survey.We would also like to recognize the various groups that allowed us to sample their members: AAO Partners in Research Program, Women in Orthodontics Facebook group, Orthodontic