COVID-19 Pandemic Onset and its Impact on a Pediatric Dental Outpatient Clinic: A University-Based StudyABSTRACT
Objective: To evaluate the impact of the COVID-19 pandemic on dental care provided at a university-based pediatric dental outpatient clinic.
Material and Methods: This was an observational. The monthly numbers of dental procedures were obtained from clinical records. For comparison purposes, three intervals were set: pre-pandemic (March 2019 to February 2020), first year (March 2020 to February 2021), and second year (March 2021 to February 2022) after the COVID-19 pandemic onset (n = 12 in each). The significance level was set at 5%.
Results: 1,813 patients were treated, and 6,457 dental procedures were performed. There was no productivity between April 2020 and February 2021. When comparing the pre-pandemic interval and the second year, it was observed that there was a lower monthly number of dental procedures, estimated at -71% (95%CI = -43%, -85%). This reduction was observed in preventive, restorative, endodontic, surgical, and orthodontic/orthopedic dental procedures. However, there was a reduction in the ratio between restorative and surgical (-41%, 95%CI = -4%, -65%) and preventive and surgical (-43%, 95%CI = -4%, -66%), as well as an increase in the ratio between surgical and endodontic (130%, 95%CI = 38%, 291%) dental procedures.
Conclusion: The performance of dental procedures at this oral health service was significantly reduced after the COVID-19 pandemic onset.
Keywords:
Dental Care for Children; Pediatric Dentistry; COVID-19
Introduction
In March 2020, the World Health Organization (WHO) declared the COVID-19 pandemic globally. The outbreak began in China in December 2019 in the city of Wuhan. Due to the transmissibility potential of the virus (SARS-CoV-2), the other countries were quickly reached [1,2]. In the field of health, the COVID-19 pandemic onset significantly increased the pressure on health systems and services; considering the high demand for hospitalizations to deal with the disease and the need to temporarily reorganize the health care assistance, recommending urgent actions to face the pandemic setting [3,4].
In Dentistry, the provision of dental care was significantly affected by the COVID-19 outbreak. In the first instance, the risk of transmission and viral infection related to the dental environment was assessed, considering its routines and procedures. Then, urgent dental care was prioritized, and interventions and elective procedures were postponed [5,6]. Furthermore, the population faced the fear of the disease and the need to comply with sanitary measures that involved social distancing, which negatively influenced the demand for health services, including those related to oral health [7,8].
Considering the COVID-19 and Dentistry interface, the scientific community was concerned about the impact of the pandemic context on children’s oral health worldwide, as well as the provision of dental care for this age group. It was observed that there could be a significant limitation in the capacity of health services to provide adequate oral care for children in the context of restrictions imposed by the COVID-19 outbreak, as well as a delay in the search for these services by avoiding seeking these services when there were demands to be addressed, which can negatively affect oral health in the short and long term [9-11].
Moreover, concern about children's oral health, in addition to issues related to oral health services, was driven by the negative impact of the COVID-19 pandemic on the routine and habits of eating and oral hygiene during the lockdown. The evidence differed between populations and study methods, but an increase in the consumption of ultra-processed foods with high sugar content and a reduction in the amount of daily tooth brushing was observed [12,13]. Consequently, added to the limitations of oral health services, children may have a greater need for dental treatments in the future, especially those who have not received adequate dental care or are in socioeconomic vulnerability and depend on public health services [14,15].
Therefore, it is reasonable to understand that there is a need to investigate the impact of the COVID-19 pandemic on dental care for children in different oral health services, seeking to describe and measure the changes caused by the pandemic context in the performance of dental procedures and children’s oral health needs. Then, this study aimed to evaluate the impact of the COVID-19 pandemic on dental care provided at a university-based pediatric dental outpatient clinic. It was hypothesized that (H1) there was a reduction in the monthly number of dental procedures carried out in the first and second year after the COVID-19 pandemic onset, as well as (H2) a decrease in the ratio between preventive and therapeutic dental procedures (restorative, endodontic and surgical).
Material and Methods
Study Design and Ethical Clearance
This was an observational, longitudinal, retrospective, and quantitative study [16]. The STROBE checklist was used to structure the study report [17]. The study protocol was approved by the Research Ethics Committee (Opinion No. 6.205.629) and was carried out in accordance with research guidelines applicable to studies involving humans.
Data Collection
Data were collected from clinical charts of patients treated at the Pediatric Dentistry Clinic of the School of Dentistry of Ribeirão Preto, University of São Paulo. In this public oral health service, all dental care in pediatric dentistry and special needs dentistry specialties were considered, including undergraduate and postgraduate clinics. These clinics receive patients referred from other healthcare services (both public and private) or through walk-ins. To assess the impact of the COVID-19 pandemic, a control pre-pandemic interval (March 2019 to February 2020) was designed to be compared with the first (March 2020 to February 2021) and the second (March 2021 to February 2022) year after the COVID-19 pandemic onset. Given the short timeframe, the intervals were evaluated by months (n = 12 per interval), similar to other approaches [18].
The main outcome (primary variable) was the monthly number of dental procedures. In addition to the quantitative, as a secondary outcome, the dental procedures were characterized according to the type as preventive, restorative, endodontic, surgical, orthodontic/orthopedic, prosthodontic, or others. In addition, the number of patients, their age, and the number of dental procedures per patient were recorded and whether they lived in the same city where the University was located (resident). Moreover, the ratio between the types of dental procedures was also examined to investigate changes between COVID-19 pre-pandemic and pandemic intervals.
Considering data collection from clinical charts, those not presenting all the variables listed will not be eligible for the study. The data was collected through the researchers' access to the patient management system, applying filters to reach the clinical charts of patients. A systematic procedure was adopted in each clinical chart to record the variables, transporting the data to a spreadsheet for tabulation and processing prior to data analysis.
Data Analysis
Statistical analysis of the data was carried out using the Jamovi, version 2.3.15 (Sydney, Australia) statistical package, adjusting the significance level at 5% (α = 0.05), as well as considering P <0.05 as statistically significant. The variables were expressed by medians and their interquartile ranges (IQR), in addition to absolute and relative frequencies and 95% confidence intervals (95%CI). In addition to the descriptive analysis, a negative binomial regression (generalized linear model) was used to compare the number of dental procedures between the COVID-19 pre-pandemic (reference level) and pandemic intervals, considering Quasi-Poisson distributions (overdispersion) and the maximum likelihood estimation in the logarithmic link-function (Log-likelihood ratio).
Results
Overall, 1,813 patients were treated during the study timeframe, 1,315 (72.5%) in the pre-pandemic interval and 498 (27.5%) in the second year after the COVID-19 pandemic onset. There was no productivity between April 2020 and February 2021 (first year). For this timeframe, the median of the patient's age was 7 years (IQR = 4). However, considering the pre-pandemic interval, it was 8 years (IQR = 4), decreasing to 7 (IQR = 4) in the second year after the COVID-19 onset. In addition, regarding the number of dental procedures per patient, the median was 3 (IQR = 3). However, considering the pre-pandemic interval, it was 3 (IQR = 3), decreasing to 2 (IQR = 3) in the second year after the COVID-19 onset.
Table 1 shows the frequency of age groups and the number of dental procedures per patient and residence. The age group 5-9 years was the most frequent in both intervals, and the performance of 0-3 dental procedures per patient and patients residing in the same city where the University is located. It is also worth noting the increase in the frequency of age groups 10-14 and 15 or more years, as well as the decline in the frequency of patients who underwent 4-9 and 10 or more dental procedures when comparing the pre-pandemic interval and the second year after the COVID-19 pandemic onset.
Moreover, during this timeframe, 6,457 dental procedures were carried out between March 2019 and February 2020, considering 4,848 (75.1%) in the pre-pandemic interval, 196 (3%) during the first year, and 1,413 (21.9%) in the second year after the COVID-19 pandemic onset. Among the types of dental procedures, 2,628 (40.8%) were preventive, 1,688 (26.1%) were restorative, 564 (8.7%) were surgical, 236 (3.6%) were endodontic, 124 (1.9%) were orthodontic/orthopedic and 16 (0.2%) were prosthodontic, as well as 1,201 (18.6%) were classified as "others." Table 2 presents the monthly average numbers of dental procedures, and Table 3 presents the comparison between the pre-pandemic interval and the second year after the COVID-19 pandemic onset, considering the types of dental procedures. The first year was excluded from this analysis, and the 196 dental procedures reported were carried out in March 2020, before the onset.
(): Interquartile Range.
Regardless of the interval, there was a marked variability in the monthly numbers. The months of July, December, and January had lower numbers in both intervals. It was possible to observe that only the performance of prosthodontic dental procedures did not reduce in the second year after the COVID-19 pandemic onset. Reductions were estimated at -71% (95%CI = -43%, -85%) for all types of dental procedures, -68% (95%CI = -34%, -85%) for restorative, -76% (95%CI = -59%, -86%) for endodontic, -51% (95%CI = -6%, -75%) for surgical, -92% (95%CI = -73%, -98%) for orthodontic/orthopedic, -71% (95%CI = -32%, -87%) for preventive, and -79% (95%CI = -61%, -89%) for others types of dental procedures.
At last, Table 4 also shows the comparison of the monthly numbers of dental procedures, now considering the ratio between types of dental procedures, patient’s age, number of dental procedures per patient, and residence. It was observed that, when comparing the pre-pandemic interval and the second year after the COVID-19 pandemic onset, there was a significant reduction in the ratio between restorative and surgical (-41%, 95%CI = -4%, -65%) and between preventive and surgical dental procedures (-43%, 95%CI = -4%, -66%), as well as an increase in the ratio between surgical and endodontic dental procedures (130%, 95%CI = 38%, 291%). Moreover, there was a decrease in the number of dental procedures per patient (-24%, 95%CI = -18%, -30%) and an increase in the patient’s age (15%, 95%CI = 9%, 22%). It is important to highlight that extractions were the majority among surgical and dental procedures, corresponding to 354 (96.2%) in the pre-pandemic period and 168 (93.3%) in the second year after the COVID-19 pandemic onset.
Discussion
This study evaluated the impact of the COVID-19 pandemic on dental care provided at a university-based pediatric dental outpatient clinic. Returning to the hypotheses, H1 was accepted since dental procedures were suspended during the first year, and a significantly lower monthly number of dental procedures was carried out in the second year after the COVID-19 pandemic onset compared to the pre-pandemic interval. Among the types of dental procedures, this difference was not observed among prosthodontic ones (due to the low monthly numbers in both intervals), affecting the other types.
However, H2 was partially accepted since only the ratio between preventive and surgical dental procedures was reduced in the second year compared to the pre-pandemic interval (indicating that the numbers of the first have decreased in relation to the second). In addition, there was a reduction in restorative over surgical and an increase in surgical over endodontic dental procedures. Despite significance, the decrease in surgical dental treatments occurred at a lower magnitude than the others (which can be seen in the reduction estimates as the lowest among the types of dental procedures). Furthermore, as expected, the number of dental procedures per patient reduced after the COVID-19 pandemic onset (accompanying the general reduction). However, there was a slight increase in the age of patients treated (especially in the age groups 10-14 and 15 or more).
The suspension of dental care during the first year of the COVID-19 pandemic resulted from guidelines directed at higher education institutions, including dental schools, considering the exposure and protection of students and lecturers to COVID-19-related risks. Once academic activities were suspended, dental care provided by undergraduate and postgraduate students was suspended in all specialties [19]. In addition to dental education, this suspension directly affected the population's access to dental specialties through university-based dental services, which often allows access to dental treatments not reached in other services, especially by underserved populations [9,20]. The importance of these specialized dental services for the population can also be seen by the number of patients who do not live in the city where the University is located, considering both intervals (almost ⅓ of them).
Indeed, the impact of the COVID-19 pandemic onset on this Brazilian university-based dental service must be added to the other oral health services. For example, a reduction in pediatric outpatient dental procedures in the Brazilian Unified Health System (SUS) has already been demonstrated. It is essential to consider that dental care provided during the first year of the COVID-19 pandemic was not suspended [21], which differs from this education-linked oral health service. Despite providing free oral health care, the evaluated university-based dental service is not managed by the SUS (Ministry of Health), although the teaching and learning environments involving health care adhere to its sanitary standards (e.g., COVID-19-related aspects in dental settings) [19]. Therefore, it is reasonable to understand that the educational context has introduced a distinct perspective.
However, a reduction in restorations and endodontic and surgical treatments in primary teeth was observed within SUS [21], similar to the outcomes of this study. In addition, another study demonstrated that the number of dental procedures in the SUS reduced after the COVID-19 pandemic onset. However, it was observed that surgical and dental procedures showed the most minor reduction, while aerosol generators and preventive procedures showed the most significant [22], similar to this study's outcomes. Both studies point to worsening oral health conditions in the future [21,22].
This context can be even more worrying for children with disabilities, as they already face limitations in accessing oral health services and receiving effective dental care. Since public health systems and services were already facing highly increased demand due to the COVID-19 pandemic, meeting other demands was challenging, and those related to individuals with disabilities were neglected in some contexts, including oral health. Unmet demands during the COVID-19 pandemic will undoubtedly be difficult in the coming years [23,24]. The inclusion of Special Needs Dentistry clinics in this study considered the frequency of disabled pediatric patients at this university-based outpatient clinic, a specialized service for people with disabilities.
Moreover, when dental care resumed in 2021, this Brazilian university-based dental service observed significantly lower monthly dental procedures. Among the hypotheses that may justify this outcome, it is imperative to consider the changes caused by the COVID-19 pandemic in the dental routine for pediatric patients, such as new biosafety trends in dental settings to enhance the protection of students and lectures (more rigorous) and new workflows to schedule the pediatric patients, including prior health status assessment (signs and symptoms of contagious diseases) and other requirements [20,25]. In addition, since the suspension lasted a year, it is reasonable to hypothesize that referrals from other oral health services were progressively redirected, which reduced demand. This hypothesis needs further investigation.
Nevertheless, the COVID-19-related concern about the worsening of the oral health status of pediatric patients, among other factors, is subsidized by the pandemic impacts on oral health services [21,25]. In this university-based pediatric outpatient clinic, the increase in the ratio of surgical and dental procedures (especially tooth extractions) may be related to this concern, as it was observed concerning preventive, restorative, and endodontic dental procedures, acting as preliminary evidence that before-and-after clinical studies must confirm.
As an important limitation, once secondary data were evaluated, it is important to point out that there was no influence or control over the completion of clinical charts, as an information bias. In addition, no distinction was made between children with and without special needs. Then, the students and lecturers recorded the dental procedures for each pediatric patient exclusively during their clinical activities. Furthermore, the performance of dental procedures acted as a proxy measure for oral health needs, and primary data may help address the oral health status of pediatric patients in the post-COVID-19 pandemic interval.
Conclusion
Dental procedures performed significantly less well after the onset of the COVID-19 pandemic in this university-based pediatric dental outpatient clinic, affecting most types of dental procedures. This reduction occurred immediately (first year) and late at the COVID-19 outbreak (second year). However, there was an increase in surgical and dental procedures compared to preventive, restorative, and endodontic ones in the second year.
-
Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
References
-
[1] Umakanthan S, Sahu P, Ranade AV, Bukelo MM, Rao JS, Abrahao-Machado LF, et al. Origin, transmission, diagnosis and management of coronavirus disease 2019 (COVID-19). Postgrad Med J 2020; 96(1142):753-758. https://doi.org/10.1136/postgradmedj-2020-138234
» https://doi.org/10.1136/postgradmedj-2020-138234 -
[2] Yüce M, Filiztekin E, Özkaya KG. COVID-19 diagnosis - A review of current methods. Biosens Bioelectron 2021; 172:112752. https://doi.org/10.1016/j.bios.2020.112752
» https://doi.org/10.1016/j.bios.2020.112752 -
[3] Andrade CLT, Pereira CCA, Martins M, Lima SML, Portela MC. COVID-19 hospitalizations in Brazil's Unified Health System (SUS). PLoS One 2020; 15(12):e0243126. https://doi.org/10.1371/journal.pone.0243126
» https://doi.org/10.1371/journal.pone.0243126 -
[4] Vervoort D, Ma X, Luc JGY. COVID-19 pandemic: A time for collaboration and a unified global health front. Int J Qual Health Care 2021; 33(1):e065. https://doi.org/10.1093/intqhc/mzaa065
» https://doi.org/10.1093/intqhc/mzaa065 -
[5] COVIDental Collaboration Group. The COVID-19 pandemic and its global effects on dental practice. An international survey. J Dent 2021; 114:103749. https://doi.org/10.1016/j.jdent.2021.103749
» https://doi.org/10.1016/j.jdent.2021.103749 -
[6] Villani FA, Aiuto R, Paglia L, Re D. COVID-19 and Dentistry: Prevention in dental practice, a literature review. Int J Environ Res Public Health 2020; 17(12):4609. https://doi.org/10.3390/ijerph17124609
» https://doi.org/10.3390/ijerph17124609 -
[7] Anderson KM, Stockman JK. Fear of COVID-19 and prevention behaviors: Cross-lagged panel analysis. JMIR Form Res 2022; 6(11):e35730. https://doi.org/10.2196/35730
» https://doi.org/10.2196/35730 -
[8] Johnson V, Brondani M, von Bergmann H, Grossman S, Donnelly L. Dental service and resource needs during COVID-19 among underserved populations. JDR Clin Trans Res 2022; 7(3):315-325. https://doi.org/10.1177/23800844221083965
» https://doi.org/10.1177/23800844221083965 -
[9] Lyons-Coleman M, O'Sullivan E, Thompson W. The impact of COVID-19 on paediatric dental services and tips for patient management. Prim Dent J 2021; 10(4):88-94. https://doi.org/10.1177/20501684211066526
» https://doi.org/10.1177/20501684211066526 -
[10] Luzzi V, Ierardo G, Bossù M, Polimeni A. Paediatric oral health during and after the COVID-19 pandemic. Int J Paediatr Dent 2021; 31(1):20-26. https://doi.org/10.1111/ipd.12737
» https://doi.org/10.1111/ipd.12737 -
[11] Vuković A, Mandić-Rajčević S, Sava-Rosianu R, Betancourt MD, Xhajanka E, Hysenaj N, et al. Pediatric dentists' service provisions in South-East Europe during the first wave of COVID-19 epidemic: Lessons learned about preventive measures and personal protective equipment use. Int J Environ Res Public Health 2021; 18(22):11795. https://doi.org/10.3390/ijerph182211795
» https://doi.org/10.3390/ijerph182211795 -
[12] Costa AL, Pereira JL, Franco L, Guinot F. COVID-19 Lockdown: Impact on oral health-related behaviors and practices of Portuguese and Spanish children. Int J Environ Res Public Health 2022; 19(23):16004. https://doi.org/10.3390/ijerph192316004
» https://doi.org/10.3390/ijerph192316004 -
[13] Garcés-Elías MC, Beltrán JA, Del Castillo-López CE, Agudelo-Suárez AA, León-Manco RA. Peruvian children toothbrushing during the COVID-19 pandemic. F1000Res 2022; 11:760. https://doi.org/10.12688/f1000research.122504.2
» https://doi.org/10.12688/f1000research.122504.2 -
[14] Lyu W, Wehby GL. Effects of the COVID-19 pandemic on children's oral health and oral health care use. J Am Dent Assoc 2022; 153(8):787-796.e2. https://doi.org/10.1016/j.adaj.2022.02.008
» https://doi.org/10.1016/j.adaj.2022.02.008 -
[15] Kalash DA, Ramos-Gomez F. Public utilities during COVID-19 are critical for child health, oral health, and equity. J Am Dent Assoc 2022; 153(7):598-600. https://doi.org/10.1016/j.adaj.2022.01.009
» https://doi.org/10.1016/j.adaj.2022.01.009 -
[16] Merchán-Hamann E, Tauil PL. Proposal for classifying the different types of descriptive epidemiological studies. Epidemiol Serv Saude 2021; 30(1):e2018126. https://doi.org/10.1590/s1679-49742021000100026
» https://doi.org/10.1590/s1679-49742021000100026 - [17] Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução n. 466 de 12, de dezembro de 2012. Diretrizes e Normas Regulamentadoras de Pesquisas com Seres Humanos. Brasília: Diário Oficial da União; 2012. [In Portuguese].
-
[18] Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: Guidelines on reporting observational studies. Rev Saude Publica 2010; 44(3):559-565. https://doi.org/10.1590/s0034-89102010000300021
» https://doi.org/10.1590/s0034-89102010000300021 -
[19] Gurgel BCV, Borges SB, Borges REA, Calderon PDS. COVID-19: Perspectives for the management of dental care and education. J Appl Oral Sci 2020; 28(1):e20200358. https://doi.org/10.1590/1678-7757-2020-0358
» https://doi.org/10.1590/1678-7757-2020-0358 -
[20] Farrokhi F, Mohebbi SZ, Farrokhi F, Khami MR. Impact of COVID-19 on dental education - A scoping review. BMC Med Educ 2021; 21(1):587. https://doi.org/10.1186/s12909-021-03017-8
» https://doi.org/10.1186/s12909-021-03017-8 -
[21] Chisini LA, Costa FDS, Demarco GT, da Silveira ER, Demarco FF. COVID-19 pandemic impact on paediatric dentistry treatments in the Brazilian Public Health System. Int J Paediatr Dent 2021; 31(1):31-34. https://doi.org/10.1111/ipd.12741
» https://doi.org/10.1111/ipd.12741 -
[22] Chisini LA, Costa FDS, Sartori LRM, Corrêa MB, D'Avila OP, Demarco FF. COVID-19 pandemic impact on Brazil's Public Dental System. Braz Oral Res 2021; 35(1):e082. https://doi.org/10.1590/1807-3107bor-2021.vol35.0082
» https://doi.org/10.1590/1807-3107bor-2021.vol35.0082 -
[23] Kavanagh A, Dickinson H, Carey G, Llewellyn G, Emerson E, Disney G, et al. Improving health care for disabled people in COVID-19 and beyond: Lessons from Australia and England. Disabil Health J 2021; 14(2):101050. https://doi.org/10.1016/j.dhjo.2020.101050
» https://doi.org/10.1016/j.dhjo.2020.101050 -
[24] Sabbagh HJ, Aljehani SA, Abdulaziz BM, Alshehri NZ, Bajkhaif MO, Alrosini SK, et al. Oral health needs and barriers among children in Saudi Arabia. Int J Environ Res Public Health 2022; 19(20):13584. https://doi.org/10.3390/ijerph192013584
» https://doi.org/10.3390/ijerph192013584 -
[25] Luzzi V, Ierardo G, Bossù M, Polimeni A. Paediatric oral health during and after the COVID-19 pandemic. Int J Paediatr Dent 2021; 31(1):20-26. https://doi.org/10.1111/ipd.12737
» https://doi.org/10.1111/ipd.12737
