The results of this study showed that, from April to May 2020, 75.9% of the 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 practice, in rural areas, and with greater COVID-19 fears were also more likely to report practice closure. Country-level determinants were associated with practice closure. For example, better-prepared healthcare systems were associated with fewer closures in the non-private sector, and private-sector practices in richer countries were less likely to close than those in less affluent countries. Thus, the null hypothesis was rejected.
This study provides compelling evidence of the impact of the first wave of COVID-19 on dental practice closures, which jeopardized the provision of dental care. In the second wave of the pandemic, fear and anxiety still exist due to the continued presence of the pandemic, the emergence of new variants with different patterns of infectivity and the cumulative health, social and economic impacts. Our findings provide an analysis of how various factors were associated with practice closure in the first wave and how they may shape countries’ or individuals’ decisions to close their practices in the second wave or in future crisis situations. The need for packages to support the profession and for programs to maintain oral health for the public assumes greater importance as the pandemic continues. This high level of practice closure seen in the first wave seems to be unrealistic and may be unneeded for future scenarios.
75% of the dentists who participated in this study reported practice closure. International guidelines on the provision of dental care during the pandemic vary from country to country. For instance, China only allows public dental and general hospitals to deal with emergency cases [33], the USA, California, in particular, urges practitioners to close their clinics [34], the UK prescribes decreasing the number of examined patients [35], and some countries offer no guidance whatsoever [36]. 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 [37]. However, the frequency of closure observed in this study was similar to that reported in the USA, where 79% of all dental practices except for those providing emergency care, were closed [38]. 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 and fear was associated with practice closure. This agrees with reports showing that there was lower patient volume due to avoidance of healthcare facilities and fear of COVID-19 which resulted in 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 [39, 40]. It was estimated that if the current lockdown continued, a large proportion of dentists and dental practices will face serious financial hardships [38]. A British survey also reported increasing risks of permanent closure of dental practices, especially in the primary care sector, as the pandemic continues with greater risks in the absence of support measures such as loans [41].
The financial crisis brought about by COVID-19 is not likely to end in the coming period, and a potentially massive impact on the dental profession may be expected. The present study showed that fear of infection is one of the factors associated with practice closure among dentists in the private sector. This finding agrees with a study reporting that a high level of anxiety is associated with more dentists indicating a desire to close their practice [42].
In the present study, dentists in the academia were more likely to report practice closure. This finding agrees with previous data from North America which indicated that dental care in teaching clinics was suspended and only emergency treatment was offered [39]. The present study also showed that dentists working in hospitals were less likely to report practice closure. This finding 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 for protection against aerosol-generating dental procedures [43, 44] and have strict infection control measures and more dental units to meet patients’ needs for emergency dental services [36, 45, 46].
This study showed fewer closures in group practices and more closures in solo practices. Group practices may be more resilient than solo practices in times of financial hardship because the former are more likely to have reserves and can afford to pool resources to bridge crises. Compared with larger practices, small-scale health care providers tend to be less profitable and are more vulnerable to financial threats [47].
The current study showed that practices in rural areas are more likely to close than urban practices if they are in the private sector but less likely to close if they are in the non-private sector. Rural healthcare facilities in the private sector usually operate on thin profit margins and have a small number of staff, which puts them at greater risk of closure compared to urban facilities to reduce financial and infection risks [48,49,50]. Consequently, rural practices in the non-private sector may be the only type of facility available to provide care for the local population, which could explain their lower likelihood of closure.
The present study showed that practice closure is also associated with country-level determinants. More hospital beds were associated with fewer closures in the non-private sector than in the private sector. Compared with less affluent countries, countries with high- resources and well-prepared healthcare systems are more likely to have better capacity to manage COVID-19 complications, resulting in lower mortality rates, panic, and anxiety as well as less chances of dental practice closure [51, 52]. This study found fewer private practice closures in HICs than in non-HICs. This finding agrees with reports that some HICs provide financial support for dental practices to avoid closure due to economic losses by offering funds, loans, and credit to help with the payment of salaries and supplies [40, 53,54,55,56]. In addition, dentists in HICs also generally have higher per capita income, which translates to better financial stability despite decreased revenues and reduced needs for practice closure. No such measures were reported in less- affluent countries, where no economic support plans were formulated to help the dental sector despite its needs.
This study has some limitations. First, its cross-sectional design cannot prove causality. Second, the convenience sample cannot support statistical representativeness. The study included a large number of dentists from many countries all over the world, with different professional backgrounds and healthcare system characteristics, and this increases the generalizability of findings. However, the number of participants per country varied widely and because of this and the convenience selection, the samples were not representative of the respective countries. We accounted for country level variation in the multilevel modeling but did not report estimates by countries for this reason. Also, some countries were under-represented, especially HIC, as the USA and some were not represented, such French speaking countries and China. We claim that traditional statistical representativeness cannot be achieved by random sampling for the present study targeting dentists in several countries for the following reasons: (1) not all countries have a comprehensive list/ archive of practicing dentists and (2) even in those where such records exist, the high non-response [57, 58] associated with COVID-19 studies would still pose a threat of selection bias. In addition, online surveys are known for their low response [59] which would yet add a further dimension for selection bias. The third limitation was because our study did not investigate the source of the decision to close dental practices and whether it was a political decision issued by governments or left to individual dentists’ choices. Fourth, we did not separately analyze complete closures and closures that allowed the management of emergency conditions and it would be useful to address this in future studies. Fifth, the dynamic nature of the pandemic and its spread were associated with changes in its knowledge base: some information that were believed to be correct in the initial stages may have failed the test of time and later became obsolete. It is important to consider the knowledge level of participants reported in this study within its time frame. The study estimated the frequency of practice closure which is important to assess the pandemic impact on oral health with implications for dental practice. Providing support to dentists in the private sector may help retain skilled 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, psychological, and professional outcomes of dentists.
