Impact of COVID-19 on Dentistry

Anders Bjork, MBA, is vice president of strategic intelligence and analytics for the California Dental Association. In this role, he performs a variety of primary and secondary quantitative and qualitative research projects to help inform CDA’s leadership in decisions regarding the organization’s strategy. Conflict of Interest Disclosure: None reported.

Many superlatives have been used to describe the global impact of COVID-19. [1] Suffice it to say that probably no entity was able to avoid at least some impact from the pandemic; and of course for many, it has fundamentally and permanently changed their lives and businesses. The ongoing economic impact of COVID-19 will undoubtedly be felt for years — if not decades — to come. Some types of businesses benefited during this time, perhaps from unexpected demand for their products or a unique distribution feature that was deemed safer during the pandemic versus traditional offerings. [2] However, the vast majority of companies that depend on direct interaction with customers suffered tremendous and longlasting economic damage. Health care was especially impacted for obvious reasons; most care is provided personally, clinician to patient, and many patient-provider care interactions increase the possibility of viral transmission. As experts began to evaluate the transmission mechanism of the COVID-19 virus, an early focus was to determine which medical procedures and disciplines had higher risk factors so as to be able to advise clinicians and their patients as to what nonemergent care could still be provided during the pandemic. As virologists studied SARS- CoV-2, they determined that the spread was principally through aerosolized droplets emitted by an infected person’s respiration, coughing, sneezing and/ or touch. [3] Therefore, much of the focus of risk categorization then turned to an understanding and mitigation of risk in understanding aerosol-generating procedures. [4] Those involved in dentistry and the support of the dental profession immediately understood that the impacts to patient care would be high given the frequent and widespread use of dental equipment known to create aerosols in the dental practice including but not limited to ultrasonic scalers, high-speed dental handpieces, air/water syringes, air polishing and air abrasion. [5] The subsequent focus was to understand what personal protective equipment (PPE) could be used to allow patient care to continue while minimizing risk of transmission between staff and patients. [6] For dentists, understanding how to safely treat patients during the pandemic — and indeed have patients feel safe about getting routine care — was the highest priority to address.

Economic Impacts

As the timeline of COVID-19-related events covered elsewhere in this issue describes, the guidance given to dentists by the American Dental Association (ADA) in mid-March 2020 was to postpone elective dental procedures and only see emergency patients. [7] The ADA’s guidance was based on and developed from information from the Centers for Disease Control and Prevention (CDC) evidence-based recommendations. [8] Similarly, on March 19, the California Department of Public Health (CDPH) expanded the shelter-in-place order for California residents and directed that dentists should not schedule patients for nonemergency care until the order was lifted. [9] CDA joined with the recommendations of the CDC, the ADA and the CDPH and urged all members to only treat emergency patients at that time. A week after issuing that guidance, the ADA’s Health Policy Institute (HPI) surveyed and found that almost 95% of dental practices had complied with that recommendation. Two weeks later, during the week of April 6, the ADA’s HPI found that more than 97% of dental practices surveyed across the country were either closed and seeing emergency patients only (79.5%) or fully closed and not treating any patients (17.6%) [9] (FIGURE 1).

Within a month, dental practices began to address some of the challenges and issues associated with treating patients during the pandemic, and dental practices began to make steady gains toward seeing patients at least on an emergent basis but also resuming routine care to the extent safely possible. Two principal factors limited patient care at this point in the pandemic: PPE (both the availability and confusion over the standards) and patient willingness/uncertainty about whether receiving dental care as a patient was safe at that time.

Trying to determine the precise economic cost to the profession of dentistry is difficult, but we can begin to get some perspective using the U.S. Department of Commerce Bureau of Economic Analysis (BEA) 2019 data [10] (TABLE 1).

2019 provides a good baseline from which to measure the impact of COVID-19 on dental practices. For simplicity’s sake, this analysis makes several assumptions:

■ Expenditures are spread evenly through the year or approximately $11.23 billion dollars are spent on dental services each month.

■ Over the prior seven years, dental services grew at a compound annual growth rate of 3.33%, so without the pandemic, it is assumed that dental services would have increased by this amount and been worth $139.3 billion in 2020 or $11.61 billion per month (TABLE 2).

Compared to the expected growth in dentistry in 2020, it is estimated that the sector lost approximately 33.4% of revenue. Even if there was no growth in 2020 (using the 2019 dental services value), the dental sector lost approximately 31.1%. The ADA’s HPI also performed an economic analysis of the impact of COVID-19 on dentistry focusing on dentist net earnings. The HPI’s conclusion was that general practitioner dentists saw an average 17.9% drop in net income in 2020 compared to 2019. [11]

PPE

Dentists are accustomed to the routine use of PPE in the dental practice. As the COVID-19 pandemic hit, many were quick to point out that dentistry had to adjust to the realities of the AIDS/ HIV epidemic that struck in the early 1980s and could apply learnings from that experience. Given the frequency of bloodborne pathogen contact in dentistry, it was vital that dentists adjust their PPE practices to avoid exposure. [12] The first challenge was to obtain clear guidance from a credible source as to what PPE protocols should be adopted. [13] Understandably, as researchers were working to determine the method and severity of transmission for the SARS- CoV-2 virus, there was initially much confusion over the proper level of PPE, to whom it should apply within a dental practice and even which governing entity (local, state, federal) should be issuing that recommendation. The CDC, 5 the Occupational Safety and Health Administration (OSHA), [14] the CDPH [15] and the California Department of Health Care Services (DHCS) [16] all issued infection control and PPE guidance, which was subsequently used by CDA to provide guidance for dental practices. [17] Many practices undertook even more conservative methods of infection control, such as making physical modifications to their practices, including adding physical barriers to protect patients and staff (e.g., plexiglass separating work spaces and/or reception areas) and special ventilation equipment to create a more sterile office, and implementing numerous patient protocols such as having patients wait in their vehicles prior to treatment to avoid risking contamination in the waiting room. However, having experience using PPE and an understanding of PPE protocols proved to be only part of the problem for multiple sectors reliant upon PPE for their work. As the pandemic had a broad global impact on manufacturing and supply chain logistics, even being able to acquire the desired PPE equipment became a challenge. Numerous factors contributed to the situation including a demand shock triggered by an acute need in health care and a panicked marketplace buying behavior that depleted domestic PPE inventories. There were even instances of PPE hoarding by speculators looking for arbitrage opportunities. [18] The lack of effective action on the part of the federal government to maintain and distribute domestic inventories as well as severe disruptions to the PPE global supply chain amplified the problem. Analysis of trade data shows that the U.S. is the world’s largest importer of face masks, eye protection and medical gloves, making it highly vulnerable to disruptions in exports of medical supplies. [19] The global supply chain had become accustomed to the practice of “Just-in-Time” (JIT) manufacturing inventory control, which has the desirable feature of minimizing standing inventories and therefore the costs associated with them. [20,21] Governments and large corporations were able to disproportionately influence supply chain activities, oftentimes leaving smaller entities unable to compete financially directly (the rising cost of supplies) or indirectly (existing or future partnerships of strong economic value). At particular disadvantage were small businesses without excess resources and/or influence on supply channels — like many dental offices.

Employment

As the COVID-19 pandemic commenced, most businesses began an immediate triage of what impacts they would need to account for as many employers realized that they would need to drastically reevaluate the way they provide their services in a pandemic economy. Hit particularly hard were employers in the service sector, notably restaurants, hotels and travel as normal behaviors and activities quickly ground to a halt (FIGURE 2).

As demonstrated earlier in this article, almost all dental offices closed for at least some period of time early in the pandemic as they awaited more information about how the COVID-19 virus was transmitted and therefore clearer guidance on how to safely treat patients (and for patients to feel comfortable returning to the dentist). During the first weeks of closure, dental practices also struggled with employment decisions, especially in light of confusing information about government grants and loans. [22] Dentist employers grappled with whether to lay off employees, furlough them or retain them as employees but with reduced pay.

As practices began to return to work through April and May, employers were met with a new set of challenges: How to bring their employees back to work amid competing priorities. As many schools began having their students participate in classes virtually, this created a challenge for parents’ ability to leave their homes for work. Many professional jobs were transitioned to remote work, but of course very few aspects of dentistry can be provided with clinicians working from home, so parents working with children learning at home needed to make a decision as to whether they could leave their children to participate in school unsupervised. The younger the children, the more difficult this decision became. And for the youngest children who were not yet in school, the impact was even more severe, as many day care centers were forced to close due to the risks associated with spreading the virus in those settings. [23] Another factor at play was whether employees felt safe to return to work for fear of contracting COVID-19. [24] This is especially relevant for dental practice employees, where the workplace environment could provide many potential exposures. Dental hygienists and dental assistants work very closely with patients’ mouths and therefore have a high probability of exposure to patient illnesses. The complications with PPE availability were also influencing behavior, as it was well-documented that having enough proper PPE was challenging in the earliest months of the pandemic. [25] Lastly, employees who had been furloughed or were laid off were now eligible to receive enhanced unemployment benefits offered by the government to help alleviate financial hardships created by the pandemic. For some members of the dental team, the value of these benefits potentially influenced some behaviors around whether to return to work or not (although this is difficult to prove because admission of that as a reason would be reason to terminate those same unemployment benefits). One study found that the enhanced unemployment insurance (UI) benefit supplement allowed 37% of the workforce to earn more with UI benefits than from working. [26]

As dental offices returned to work, the employment situation created a circular problem: Many offices were unable to maintain full patient schedules due to pandemic-related infection control protocols and therefore couldn’t hire back all of their staff. At the same time, having full staffing would allow the practices to generate enough practice revenue to hire back their staff. Without a clear understanding of how the pandemic would play out, many dentists faced difficult decisions on staffing (FIGURE 3).

Nonowner Dentists

As offices returned to work through the pandemic, among the hardest hit were nonowner dentists working as associates, employed and/or contract employees in dental practices. Several probable factors explain this trend. As previously discussed, as dental practices initially responded to the pandemic, it was commonplace for offices to furlough or terminate most or all of their employees even if only for a few weeks while determining how to proceed. Also as previously covered, as practices came back online, they were not able to see their full, normal, prepandemic volume of patients. So owner doctors — with their own income on the line — resumed their roles as the primary provider in the practice. This makes sense; owners typically hire associates to increase their volume either from a supply or demand standpoint. Unfortunately, associate dentists tend to be younger, often near the start of their careers and looking to gain experience, skill and procedural speed. Because of their relative newness to the profession, they are therefore more likely to be working to service substantial levels of educational debt, with their creditworthiness and debt service based on full employment in their chosen profession of dentistry. Yet through most of the pandemic, approximately one-quarter of associates were unable to work due to lack of demand for their services. Even as practices continued to increase their patient loads, the return to work for employed dentists stagnated. As dental offices worked through the summer surge of returning patients, that volume began to dwindle into the fall, further exacerbating the plight of associates (FIGURE 4).

The pandemic employment situation definitely affected the concerns of dentists with loans. Survey work done by the ADA’s HPI shows how poll respondents felt the pandemic contributed to their financial stress (FIGURE 5).

Fortunately, part of the overall federal relief package did specifically address the student loan situation. The U.S. Department of Education provided a suspension of loan payments, 0% interest rate and cessation of collection on defaulted loans. [27] It is too soon to know what the longer-term impacts to these associates will be. Some may have relocated to any place they could find jobs. It is also possible that there may be impacts on debt service for these dentists, especially if they were not able to secure government subsidies to offset their losses. Whether there could be a longer-term impact on the creditworthiness of dental students in general remains to be seen.

Patient and Staff Hesitancy

The issue of vaccine hesitancy has been covered extensively by news organizations. The focus of discussion here will be patient hesitancy in returning to the dentist and staff hesitancy in returning to work in the dental practice.

In the first weeks of the pandemic, there was frequent media coverage on what were considered safe and unsafe activities during the pandemic. Dentistry — along with routine/preventive medical care — was a common question and concern. To better understand patient concerns about visiting the dentist during COVID-19, CDA commissioned a research study to determine whether a media campaign to reinforce the importance and safety of visiting the dentist during the pandemic would be of benefit. The initial wave of the consumer survey was fielded June 15, 2020, to June 18, 2020, to establish a baseline measure, with a follow-on survey fielded Aug. 10, 2020, to Aug. 17, 2020, to measure change. There was initial concern that patients were reluctant to return for dental procedures during COVID-19, but the baseline study indicated that patients were returning to their dental appointments at a greater rate than was expected.

More than half the sample had been to the dentist within the past six months (three months of which were during the pandemic), and more than 10% of the sample had been within the past month. Most encouragingly, almost 8 in 10 respondents indicated that they planned to keep their scheduled/upcoming appointments. As the pandemic worsened through the summer of 2020, the followon research indicated that the population’s feelings about going to the dentist were stable. Again, slightly more than half the population had been to the dentist within the prior six months, and there was a significant increase among those who said they had been in the last month. There was also a slight increase in those signaling that they intended to keep their upcoming scheduled appointment with more than 8 in 10 respondents agreeing.

These findings are consistent with other studies, specifically similar research that the ADA performed with Engagious, a consumer research firm, and its “Back to Normal Barometer,” which measures consumer sentiment across a broad range of economic activities. [28] The ADA included several questions about returning to the dentist and saw similar results (FIGURE 6).

Within CDA’s research, there were some interesting trends related to the geography of California. Notably, there were measurable differences in how consumers responded to whether they intended to keep their upcoming dental appointment. In urban and suburban areas, intention to keep an upcoming appointment increased, while in rural areas, it decreased slightly overall, with a very large drop in the northeast portion of California. The general demography of the area provides a plausible explanation: The population skews older (more susceptible to COVID-19) and more politically conservative (the pandemic became increasingly politicized as 2020 progressed [29] ), and some notable nursing home incidents related to COVID-19 outbreaks were newsworthy locally in Northern California, to which this population could relate [30] (FIGURE 7).

The study provided additional findings regarding communication and expected patient behavior. With regard to communications, the survey tested several potential messages around dental offices and infection control protocols to determine what resonated most positively with patients. With media focus on PPE, it was not surprising to learn that patients wanted to know that dentists and their staff were using PPE. The survey also found that confirmation of routine dental office staff testing for COVID-19 and reminding the public that dentists have always had strict infection control protocols and routinely disinfect their work areas were important (FIGURE 8).

In the second wave of the research, the respondent sample was split to measure contrasting response on one question, with half the recipients asked what their response to keeping their upcoming appointment would be if they learned that someone at the practice was exposed. About a third of those respondents indicated that they would cancel their appointment. However, the other half of the sample received additional information about the exposed practice employee. Specifically, that extensive safety protocols were being employed to quarantine that employee at home, test other employees who might have been exposed and thoroughly disinfect workstations between all patients. This additional messaging decreased the cancel rate by almost 50%, indicating the importance of proactively managing not only messaging but also any incidence of COVID-19 exposure in the practice (FIGURE 9).

The last important finding from the research is consistent with several other studies regarding consumer sentiment during the time of COVID-19. With regard to returning to the dentist during COVID-19, the population seems to divide into categories of those who are generally unconcerned, those who will return but are anxious about it and those who are anxious enough to avoid returning until they are sure it is safe to do so (generally defined as having an approved vaccine) (FIGURE 10).

Again, the ADA’s research with Engagious showed a directionally similar result with regard to patient sentiment on COVID-19 exposure in a dentist’s office and willingness to return (FIGURE 11).

Speculated Impacts to Dentistry

PERMANENT OF INCREASED PATIENT AND STAFF SAFETY PROTOCOLS

As has been presented previously, all practices adopted new safety protocols to mitigate the risk of viral transmission to and from the dentist, the staff and the patient. Many practices took measures beyond PPE and included physical and technological modifications to their practices. Some of the more advanced modifications to practices were possible during the period the practice was closed in the first weeks of the pandemic, as the work could be done without impact to patient care. For dentists with foresight, stimulus grants and loan funds, empty offices and contractors looking for work combined to create an opportunity to make these modifications. These changes are likely to become permanent for several reasons. For anything beyond PPE, these changes can often represent capital investments in the practice, and leaving them in place has financial/tax advantages to the practice. Furthermore, most scientists agree that we are unfortunately likely to see more pandemics in the future. [31–35] As such, dentists who made the investments in these technologies and trained their staff to work with high levels of respiratory protection will not only be safer from less harmful illnesses in the near term, but they will also be better prepared to serve patients without disruption in the future event of another pandemic. In the meantime, these physical modifications are easily visible to nervous patients who may be reassured by their dentist’s proactive attention to their safety. Also, as removing many of these physical modifications would impact patient care, dentists would likely be reluctant to disrupt their schedules long enough to remove them, especially if paying a contractor to do so would be required.

GENERAL PRACTICE DENTISTS AND SPECIALISTS

During the 2008-2011 recession, there was an observable trend toward general practice (GP) dentists referring less work outside of their practices, preferring to keep that work in-house for revenue reasons, but also to increase their own clinical skill and retain their patients. [36] It is reasonable to expect that this trend will continue following COVID-19, as many GPs seek to recover losses incurred during the pandemic. However, several specialties will likely be less affected. Pediatric dentistry will progress with less impact as parents — especially those with means — continue to spend on their children’s health. Periodontists, oral surgeons and endodontists may find an increase in patient needs due to delayed preventive and routine care. And similarly for orthodontists with clear aligners, technology will assist these specialists in offering new and less-invasive methods of treatment for patients (although the digital nature of design in clear aligners also benefits GPs). An unexpected side effect of the virtual work environment was people’s sudden awareness of their teeth and smiles as so many employees were relegated to having their heads appear in a box on a screen. This has been dubbed “Zoom dysmorphia” or more simply “The Zoom Effect.” [37] That, combined with increased discretionary funds from a lack of ability to travel, created a situation that drove unexpected demand for clear aligner treatments. [38]

DENTAL SUPPORT ORGANIZATIONS (DSOs)

DSOs continue to grow their share of patient care through economies of scale and active marketing/recruitment practices to new dentists seeking employment. The ADA’s HPI polling data through the pandemic showed that DSOs were somewhat slower to recover versus private practices, likely due to their reliance upon associate/employed dentists who were more likely to be furloughed or laid off at the start of the pandemic and perhaps seek other practice settings. DSOs are also oftentimes reliant upon venture capital (VC) and private equity (PE) investors for capital infusions. Depending on how those investing entities have diversified their holdings, it is possible that some may find themselves overleveraged through the pandemic and find the need to liquidate some assets. It is unclear if dental holdings might be impacted or to what extent. To that end, it is plausible that there might be more consolidation in the profession, as smaller DSOs seek to “roll up” to larger DSOs as an exit strategy, and that some PE/VC firms may seek to sell their dental interests as they adjust their portfolios in a post-pandemic economy. This could have the effect of reducing the flow of capital into this practice model, which would in turn likely curtail some of the growth in this care segment.

MEDICAL/DENTAL INTEGRATION

Although society accepts without question that visits to a physician and a dentist are handled quite differently, not much recognition is given to why this is the case and the history that created the separation that still exists today. [39] Patients see physicians for all medical needs through more complex health system structures, medical groups and physician organizations, often booking their appointments through centralized call centers and/or app-based/ online appointment systems. Physician encounters are also oftentimes paid for through true risk-based medical insurance. However, when it comes to teeth, patients typically call their local dentist’s office and make the appointment with a live individual working in that office. And the payment for treatment might be fully or partially covered through a dental benefits plan, which is quite dissimilar to health insurance and better described as a savings plan with negotiated provider discounts. Again, we accept that this one feature of our anatomy/health should be carved out and handled differently with regard to care and payment. With greater focus on integrated health and systemic approaches to care, there are increasing discussions and focus on whether this separation still makes clinical sense for the patient. [40] Some influential health care entities such as Kaiser Permanente — which integrates dental care into their business model in the Pacific Northwest — are no doubt discussing whether there is a patient case to combine these disciplines on a broader scale across their substantial national footprint. [41] The COVID-19 pandemic has cast more positive light on the role of dentistry in the health care continuum. Dentist and physician needs for PPE, infection protocols and patient safety have all combined to create more of an acceptance of dentists as “essential health care providers,” a phrase frequently heard through the pandemic. Unfortunately, a reduction in patient flow to dental offices and the resulting reduction in profitability may also contribute to exploration of and innovation with new partnerships and care delivery models that could achieve economic efficiencies.

The COVID-19 pandemic has cast more positive light on the role of dentistry in the health care continuum.

THIRD-PARTY PAYER DISRUPTION

Prior to the pandemic, dental benefits plan reimbursements were a frequent source of concern for dentists. Even prepandemic, most participating providers cited that the payments strained their practices’ ability to cover the costs of providing care. Costs of providing care have increased through the pandemic, as requirements for PPE and the cost associated with acquiring it have increased dramatically. [42] But dentists are often seeing fewer patients due to many of the factors discussed in this article: Increased duration between patients allows fewer patients to be seen versus prior to the pandemic; many offices cannot hire enough staff to see the patient volumes they experienced — and on which their practice economics were based — prior to the pandemic; and some offices are experiencing patient relocations for their own jobs, often voluntary but far enough away to disrupt the patient relationship. The combined effect is that practices are working harder to see fewer patients and cannot spread the financial risk of dental benefits plans across the same number of patients as they previously did before the pandemic. A reimbursement that may have been 60% to 80% of the dentist’s actual charges before the pandemic might be less than the overhead cost of providing care now. This is causing providers to take a critical look at the economics of benefit plans and determine if they can indeed afford to continue accepting them. It seems unlikely that benefit plans would increase their reimbursement levels without some financial incentive or necessity to do so. A more integrated approach to health care as described previously could also shift the payment mechanisms in dentistry, specifically if dental work could be covered through traditional risk-based health insurance plans.

ACCESS TO CARE ISSUES

Government dental benefits through Medicaid (the Medi-Cal Dental Program in California) are generally perceived to offer lower reimbursements. As provider offices evaluate all their payer sources per the above, it is expected that there will be a greater exodus of offices accepting these plans. Dentists often cite their participation in government plans such as Medicaid as a societal and/or professional obligation to help care for populations that have limited access to care. When their practice success permits, many choose to take on additional un- and undercompensated care as a way to “give back.” Also, a focus on improved oral health can improve patients’ overall health and reduce costly care in other areas, giving dentists a compelling reason to help these patients live healthier — and potentially less expensive — lives. Many accept the losses in this area with the intention of recouping those losses through higher commercial payments and/or cash-paying patients and/or they chalk up the losses to obligatory participation in the care continuum. However, overall increases in practice costs may prove this model is no longer feasible. Indeed, the ADA’s HPI polling shows more practices disenrolling from these programs through the pandemic. When the ADA’s HPI initially asked this question of their poll participants, 6% nationally had already disenrolled in the pandemic and another 16% were planning to disenroll from Medicaid. In California, where CDA has successfully advocated for Medi-Cal reimbursements for dentists through Proposition 56, the likelihood of disenrolling from the program is much lower: Only 1% had already disenrolled with 4% planning to disenroll. A future ADA HPI poll on this subject found that 20% of respondents also said their ability to accept Medicaid patients had decreased during the pandemic. These data taken together indicate a likely reduction in care capacity and therefore access in the near future (FIGURE 12).

RETIREMENT AND TURNOVER

Dentists over the age of 60, and especially those over 65, will likely be weighing the effort of recovering from the pandemic against the cost of winding up their careers. Those who suffered through the last economic downturn may not have the energy — or time left in their careers — to do it again. The ADA’s HPI polling data do indicate an increasing number of later-career dentists considering their options of selling or closing and retiring 43 (FIGURE 13).

On the positive side, there have not been great opportunities for younger dentists to buy private practices over the past five to seven years. Strong economic recovery after the last downturn has kept many older dentists practicing, likely to offset losses they incurred during said downturn. However, younger dentists have struggled to find practices available for sale and experienced more competition for those practices especially in desirable living areas. This situation could provide some balance in practice transfers, although dentist-buyers will be competing with each other and also with cash from VC and PE firms.

LONGER-TERM WORKFORCE CHALLENGES

Although the workforce issue was discussed previously in this article, as the pandemic wears on, it has become increasingly apparent that the dental profession — among many others — has not seen a full recovery and it may take some period of time to achieve that. The ADA’s HPI has continued to survey member-dentists on their staffing challenges, and they report that the problem has actually been somewhat exacerbated through the pandemic. Dentists are facing even greater challenges in recruiting dental team members than they were in October 2020. About 4 in 10 have recently or are currently seeking dental assistants and roughly one-third have recently or are currently hiring dental hygienists. [44] Among those recruiting, 90% considered recruitment of dental hygienists extremely or very challenging. [44] Open staff positions are the most common limiting factor for practices that want to see more patients (FIGURE 14).

It seems that the tail of the COVID-19 pandemic may be long when it comes to employment and workforce recovery. The portion of the population that has become solidified in their resistance to getting vaccinated has contributed to the spread of COVID-19 variants in the population, especially the delta variant. Vaccineresistant people often cite that vaccinated individuals can still transmit the virus and can in some cases still become sick from COVID-19. Their contention is that the vaccine seems pointless in this regard. However, as many individual employers take increasingly stronger stances on requiring proof of vaccine to remain employed, [45,46] this will of course have the unintended consequence of shrinking the overall employment pool. The U.S. Census Bureau finds that approximately 3 million adults are not working due to concerns about “getting or spreading the coronavirus.” [26] This portion of the population may not feel comfortable returning to the workforce until the virus has been all but eradicated, if that is even possible. Some health researchers are beginning to introduce the concept of the endemicity of COVID-19, which means that the virus would become another illness to be treated like a flu or other routine illness. [47] These factors combine to create a complicated employment situation. Through the summer of 2021, there were a record nearly 10 million job openings in the labor market. [26] For dentistry, where most work cannot be conducted remotely and there is a high probability of exposure, this may have the ultimate effect of changing the dental office employment structure in some way that has yet to be seen. Some researchers expect that the pandemic will foster an environment of greater workplace automation. [26] Prior research has shown that workplace automation increases following recessions as employers choose to invest in new technology instead of rehiring workers. [26] It might be difficult to create more automation within dental offices, but a McKinsey study projects that 73% of activities in accommodation and food service industries could be automated. [48] This could have the indirect effect of transitioning those displaced employees into new occupations and could create a pool of potential dental office support employees.

Conclusions

Throughout this article, COVID-19- related impacts to the dental profession have been presented. The pandemic was (and remains in many regards) clearly a tumultuous time for any business, sometimes increasing demand and improving revenue (with challenges), but oftentimes having a more negative effect as is noted in the profession of dentistry. As the pandemic began, it was unclear how long it would last and how long dental practices would be unable to see patients or to see patients at a reduced capacity. With the benefit of hindsight, it appears that the recovery curve was shorter and steeper than expected; truly, many practices were closed for a few weeks to a month at most before mounting an encouraging comeback. [49] As depicted in FIGURE 1, in the first weeks of April 2020, more than 97% of dental offices were completely closed or only seeing emergency patients. By the end of June, that same number — more than 97% — of dental offices were open and reporting business as usual or open with lower patient volume. Anecdotally, some offices reported having record patient volumes during June and so busy as to have to push patients into July and even August to be seen. However steep the curve, it does also appear that the tail will be long. Indeed, a year later, the needle moved barely 2% to just over 99% (FIGURE 15). As the pandemic began, some predicted that some practices might not be able to recover from the closure and will cease to operate. Although no formal research was done to support this, some speculated that the number of permanently closed practices could approach 10%. In fact, the number of offices closed during the pandemic generally hovered around 2%, and according to the ADA HPI data, a year later, the number remaining closed as a result of the pandemic nationally is less than 1%.

Dentistry continues to emerge from the pandemic battered but recovering and getting back to work. Certainly, this was a learning experience for all involved, and dental offices will be better prepared for the next pandemic. Until then, dentists are taking this opportunity to refocus on patient care and their practices.

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THE AUTHOR, Anders Bjork, MBA, can be reached at anders.bjork@cda.org.