Abstract
Objectives
During the COVID-19 pandemic, dental appointments were cancelled or postponed by both patients and dentists. This study investigated the associations between German dentists’ concerns on cross infection and their emotional burden due to personal economic impact on dentist-initiated appointment cancellations.
Methods
Data were collected using an anonymous cross-sectional online survey of outpatient physicians in Germany from March through April 2020. Dental treatments were divided into 3 treatment categories (plannable treatments, acute treatments without COVID-19–like symptoms, and acute treatments with COVID-19–like symptoms). Descriptive analyses and multivariate logistic regression models were performed.
Results
A sample of 269 self-employed dentists was considered. Cancellations of prophylaxis appointments were reported by 82% of dentists, whilst 49% reported cancellations of appointments for acute complaints with simultaneous patient-side COVID-19–like symptoms. Further, 58% of respondents stated high or very high concerns about COVID-19 self-infection; 81% stated to be emotionally burdened by the personal economic impact. Dentists’ concern of infecting themselves significantly decreased the likelihood of maintaining appointments, with odds ratios of 0.635 (95% confidence interval [CI], 0.426 to 0.932) for plannable treatments and 0.587 (95% CI, 0.367 to 0.916) for treatments of patients with acute complaints and simultaneous COVID-19–like symptoms. In addition, there was a significant negative association between dentists who reported emotional distress due to personal economic impact and the likelihood to maintain appointments, with odds ratios of 0.291 (95% CI, 0.123 to 0.695) for plannable treatments and 0.231 (95% CI, 0.053; 0.706) for treatments of patients without acute complaints and simultaneous COVID-19–like symptoms.
Conclusion
Dentists’ fear of infecting themselves with COVID-19 played a role in terms of practice-related appointment cancellations. Dentists differentiated their appointment cancellations according to different treatment categories and patient needs. If dental care is to be maintained in pandemic times, physicians’ personal factors such as concerns about infection and perceived pandemic-related personal economic impact need to be considered.
Key words: COVID-19, Outpatient, Dentistry, Fear of infection, Economic burden, Appointment cancellations
Introduction
The SARS-CoV-2 virus was first discovered in Wuhan, China, in December 2019. As the virus spread rapidly worldwide, the World Health Organization consequently declared a global emergency on 11 March 2020, calling it a pandemic.1 At the end of January 2020, the first COVID-19 case was confirmed in Germany, and from then on the number of cases rose steadily.2 As a result, all restaurants, shops, schools, and kindergartens across Germany were closed in mid-March 2020. In addition, contact restrictions were imposed. In health care, planned operations and treatments were postponed to support the treatment of patients with COVID-19.3
Accordingly, dentistry was severely affected by the pandemic and the implemented countermeasures. During the first lockdown from mid-March to April 2020, the representatives of dentists in Germany, the National Association of Statutory Health Insurance Dentists (Kassenzahnärztliche Bundesvereinigung) and the German Dental Association (Bundeszahnärztekammer), presented a plan to maintain dental care during the pandemic.4 Patients with COVID-19 as well as those who were in quarantine were to be treated in dental clinics in the event of dental emergencies. The aim of these measures was to prevent the spread of SARS-CoV-2 and to minimise the risk of contagion for patients and the practice staff.2 These measures were especially important in the dental field because dentists were exposed to a greater risk of SARS-CoV-2 virus infection due to their work in the oral cavities and respiratory tracts.5 Because of the close contact with patients,5 their blood, and body fluids6—such as saliva7—and aerosol—which is produced during treatment—there is a possible avenue for contagion and consequently a risk of infection with SARS-CoV-2.1 During the first lockdown, dentists were advised by the government to perform only acute and pain treatment.1,4 Dentists should decide which treatment was necessary and which should be postponed or cancelled.1,8
Dentists worldwide closed their practices5,9 or reduced their activities at the beginning of the pandemic due to fear of infecting themselves10 or their families and relatives.9 Overall, there was a significant decline in the supply and utilisation of dental services in Germany during the first lockdown.11 The psychosocial burden of dentists during the pandemic has been studied for Germany as a function of sociodemographic factors.12 So far, however, the potential impact of a dentist's own infection fear on the cancellation of appointments has not been considered.
At the same time, the restriction of dental care led to a reduction in working hours10 and thus in a reduced income2,13 and a loss of revenue of 1.5 billion euros.13 Previous studies, such as the one by Schwendicke et al,14 aimed to investigate the economic impact of COVID-19 on dental practices in Germany14 but not with regard to the decision on appointment cancellations.
This study contributes to better dental preparedness for future respiratory infection pandemics by understanding reasons for practice-related treatment cancellations. In particular, the differentiation by treatment reasons aids in identifying possible undersupply and thus indicates starting points for improvements in future pandemics. Overall, by providing insight into the COVID-19 pandemic from a dentist's perspective, improved measures can be implemented for future pandemics to avoid numerous appointment cancellations and to ensure patient care and well-being.
Methods
Study design and survey method
The analysis was based on data collected as part of the COVID-GAMS project (“The COVID-19 Crisis and Its Impact on the German Ambulatory Sector—the Physicians’ View”). The project was approved by the Ethics Committee of the Medical Faculty of the University of Cologne (20-1169_1) and funded by the German Federal Ministry of Education and Research (BMBF 01KI2099, https://www.bmbf.de/bmbf/en/).
In total, the project included 3 separate anonymous online surveys (conducted with LimeSurvey) of physicians in private practice. Data for the analysis presented here are derived from the first survey, which took place between June and September 2020 and refers to the period of March and April 2020 retrospectively (the first lockdown in Germany). The invitation to participate in the online survey and reminders were sent by email and fax to a total of 18,000 practising physicians in the outpatient sector. Amongst them were general practitioners (n = 6,500), paediatricians (n = 2,000), dentists (n = 4,000), otolaryngologists (n = 500), cardiologists (n = 1,000), gastroenterologists (n = 2,000), and gynaecologists (n = 500). The contact data for the study sample was randomly selected in collaboration with the National Association of Statutory Health Insurance Physicians. The invitations were followed by 3 reminders at 2-week intervals. In addition, physicians were invited to participate in the survey via the project homepage (www.covid-gams.de) and various specialist associations. Therefore, the study sample consisted of 2 groups with different access to the survey: one group addressed personally via email and fax and another group recruited via an open survey link. During conception and development of the questionnaire, preliminary interviews were conducted with different representatives of the listed group of specialists, including one dentist. The questionnaire was subsequently tested by several physicians from different specialty groups, who were not involved in the design. Participation in the online survey was voluntary and anonymous.
Measurements
Dependent variables
The questions on the main outcome variables of the types of appointments referred to 7 types of treatments. For each response item, it was possible to indicate whether the examination was “cancelled”, “continued to be offered”, or “generally not offered”. For the statistical analysis, answers were dichotomised (“cancelled” = 0; “continued to be offered” = 1). Treatment types were grouped into 3 categories (Table 1). The preventive dental checkups, prophylaxis, and prosthodontics appointments were summarised as “plannable treatments”. The acute reasons for seeking care without simultaneous COVID-19–like symptoms and root canal treatment were summarised as “acute treatment without COVID-19–like symptoms”. The acute reasons for seeking care with simultaneous COVID-19–like symptoms (e.g. fever, body aches, cough, and diarrhoea) were categorised as “acute treatment with COVID-19/COVID-19–like symptoms”. The response item “orthodontics” was excluded from examination because this treatment is only offered by very few specialised practices in Germany. If the response “cancelled” was selected at least once within a category for the respective response items, the category was coded as cancelled.
Table 1.
Treatment categories.
| Category I Plannable treatment |
Category II Acute/pain treatment without COVID-19–like symptoms |
Category III Acute/pain treatment with COVID-19–like symptoms |
|---|---|---|
| Preventive dental checkups; prophylaxis; prosthodontics appointments | Acute complaint treatment without simultaneous COVID-19–like infection symptoms; root canal treatment | Acute complaint treatment with simultaneous COVID-19–like infection symptoms (e.g. fever, body aches, cough, and diarrhoea) |
Endodontic treatment, in this case, means a treatment that cannot be postponed in case of pain. If the patient has pulpitis pain (eg, night pain, pulsating continuous pain, and/or swelling), dental treatment must be carried out immediately. Otherwise, an abscess may develop, which can be life-threatening because the inflammation can spread to other parts of the body. In addition, in some cases the second session, that is, the medicinal insertion, may still be associated with pain if residual tissue remains. The last session in the endodontic treatment, that is, the root canal filling, is not associated with pain and the dentist can postpone it. Since pain is the focus of acute inflammation during root canal treatment, we have grouped it together with dental pain treatments. With regard to acute treatment with COVID-19–like symptoms, we treated the response “generally not offered” as meaning the appointment type was cancelled unless dentists did indicate that they generally did not offer acute treatment even without COVID-19–like symptoms.
Independent variables
Dentists’ own concern about infection (CAI) was recorded by means of a 4-point Likert scale (1 = “very low”; 4 = “very high”). In addition, participants could choose to provide no information about their CAI. Those answers were treated as missing data. The emotional burden of the personal economic impact (EBPEI) was queried dichotomously (“no” = 0; “yes” = 1), where the answer “does not apply” was treated as missing data. Questions and response options (German original and English translation) can be accessed at https://osf.io/evnx2/?view_only=31c6d0e64a124cada5915b38f3d4f90d.
Control variables
The demographic control variables age and gender have been used. In the survey, age was divided into 5 age groups: 30 years and younger, 31 to 40, 41 to 50, 51 to 60, and older than 60 years. Male gender was coded as 0, female as 1, and diverse as 2.
Statistical analysis
To analyse the relationship between the independent and dependent variables, binary logistic regressions with odds ratios (ORs) and robust standard errors were conducted using the statistical program R (version 4.1.3) and R Studio (version 2023.06.1 +524) with the packages gtsummary (1.7.0), ggthemes (4.2.4), gt (0.8.0), modelsummary (1.3.0), and tidyverse (2.0.0). To investigate the relationship of dentists’ CAI and EBPEI on appointment cancellations, 3 examination models each with sociodemographic control variables were performed. All data used and the R code can be found at https://osf.io/evnx2/?view_only=31c6d0e64a124cada5915b38f3d4f90d.
Results
In the first survey wave, 293 dentists completed the questionnaire, 135 via personalised invitation by email/fax and 158 via an open survey link. Employed dentists (n = 24) were excluded because, as employees, they may not have had autonomy over appointment cancellations. Hence, 269 dentists were included for further analysis (Table 2). From that sample, 97 were female (36%), 169 were male (63%), and one person was gender-diverse (0%). Most dentists were between 41 and 50 years (27%) and 51 and 60 years (38%) old. The majority of the dentists surveyed (71%) were running single practices. Participating dentists’ practices were from various areas of Germany, with most practices located in small towns (32%) and large cities (30%). The average length of work experience was 25 years.
Table 2.
Demographic data of self-employed dentists (N = 269).
| Characteristic | N | N = 269* |
|---|---|---|
| Gender | 267 | |
| Male | 169 (63.3%) | |
| Female | 97 (36.3%) | |
| Diverse† | 1 (0.4%) | |
| Missing | 2 | |
| Age | 267 | |
| 30 years and younger | 0 (0.0%) | |
| 31 to 40 years | 29 (10.9%) | |
| 41 to 50 years | 71 (26.6%) | |
| 51 to 60 years | 101 (37.8%) | |
| 60 years and older | 66 (24.7%) | |
| Missing | 2 | |
| Type of practice | 266 | |
| Single practice | 189 (71.1%) | |
| Joint practice | 77 (28.9%) | |
| Missing | 3 | |
| Practice location | 266 | |
| Rural community | 44 (16.5%) | |
| Small city | 84 (31.6%) | |
| Medium-sized city | 59 (22.2%) | |
| Large city | 79 (29.7%) | |
| Missing | 3 | |
| Years of professional experience | 267 | 24.6 (9.4) |
| Missing | 2 |
n (%) or mean (SD).
Under German law, diverse can be stated as a third category in the gender indication.
Dental treatments
Supply of dental services
The Figure shows the practice-related dental examinations, which were either continued to be offered, cancelled, or generally not offered in the period of March and April 2020. The majority of dentists reported to have cancelled plannable treatments like preventive dental checkups (51%), prophylaxis appointments (82%), and prosthodontics appointments (56%). With regard to the second treatment category, acute treatment without COVID-19–like symptoms, 79% of dentists continued root canal treatments whilst 92% of dentists continued to offer appointments for acute complaints without simultaneous COVID-19–like symptoms. Finally, for the third treatment category, 49% of dentists reported cancelling appointments for acute complaints with simultaneous COVID-19–like symptoms and 37% reported not offering those appointments in general.
Fig.
Supply of dental services in March/April 2020.
CAI
Of the 259 dentists who provided information on their CAI, 34% had rather high and 24% very high concerns about contracting SARS-CoV-2, whereas 31% had rather low concerns about their own infection. Twelve percent reported very low concerns (Figure S1).
EBPEI
In all, 261 self-employed dentists provided information on their EBPEI: 81% reported feeling distressed by the economic impact during the first lockdown and 19% reported not feeling personally distressed (Figure S2).
Logistic regression models
Individuals with no information on CAI, EBPEI, age, and gender or categories with fewer than 3 individuals per group were excluded from further investigation for statistical reasons. Hence, 256 dentists remained. For the 3 developed treatment categories (plannable treatment, acute treatment without COVID-19–like symptoms, and acute treatment with COVID-19–like symptoms) we excluded all individuals with no information in one or more of the three treatment categories (n = 50). Hence, we arrived at 206 dentists for further analysis. Consequently, there could have been no appointments for acute treatment with COVID-19–like symptoms before the COVID-19 pandemic. Hence, we assigned all “generally not offered” responses to “cancelled” (n = 78). Only for dentists who regularly did not offer acute treatment (n = 6), this classification was omitted altogether. Accordingly, 200 dentists were included for the analysis of acute treatment with COVID-19–like symptoms.
CAI
In the first logistic regression analysis (Table 3), the association between dentists’ own concern about infection and the 3 treatment categories was investigated. In model 1, there was a significant negative association between dentists’ CAI and the continuation of plannable treatments. Dentists with higher CAI were less likely to maintain appointments, with an OR of 0.635 (95% CI, 0.426 to 0.932). In model 2, the results showed no significant association between CAI and acute complaints without simultaneous COVID-19–like symptoms. In model 3, the results showed a significant negative correlation between dentists’ CAI and appointments with acute complaints with simultaneous COVID-19–like symptoms. Dentists with greater CAI were less likely to maintain appointments, with an OR of 0.587 (95% CI, 0.367 to 0.916). All 3 models performed significantly better than a crude intercept model (omnibus test <.05).
Table 3.
Binary logistic regression analysis between concern about own infection and 3 treatment types.
| Model I: plannable treatment (OR [95% CI]) | Model II: acute treatment without CoV (OR [95% CI]) | Model III: acute treatment with CoV (OR [95% CI]) | |
|---|---|---|---|
| Intercept | 0.83 [0.177 to 3.42] | 7.835** [2.049 to 35.154] | 0.773 [0.131 to 3.748] |
| Reg. coefficient | −0.186 | 2.059 | −0.258 |
| SE (P value) | 0.715 (.829) | 5.626 (.004) | 0.656 (.761) |
| Concern about own infection (1 = very low to 4 = very high) | 0.635* [0.426 to 0.932] | 0.862 [0.606 to 1.215] | 0.587* [0.367 to 0.916] |
| Reg. coefficient | −0.454 | −0.148 | −0.533 |
| SE (P value) | 0.146 (.049) | 0.159 (.422) | 0.154 (.042) |
| Gender (0 = male/1 = female) | 0.462 [0.172 to 1.111] | 0.51+ [0.244 to 1.057] | 0.313* [0.099 to 0.829] |
| Reg. coefficient | −0.772 | −0.673 | −1.163 |
| SE (P value) | 0.228 (.118) | 0.198 (.082) | 0.17 (.032) |
| Age (0 = 31 to 40 years/1 = 41 to 50 years) | 0.381 [0.08 to 1.795] | 1.332 [0.364 to 4.475] | 1.015 [0.242 to 5.255] |
| Reg. coefficient | −0.966 | 0.287 | 0.015 |
| SE (P value) | 0.32 (.251) | 0.872 (.661) | 0.846 (.986) |
| Age (0 = 31 to 40 years/1 = 51 to 60 years) | 1.224 [0.377 to 4.793] | 1.286 [0.37 to 3.965] | 1.72 [0.474 to 8.292] |
| Reg. coefficient | 0.202 | 0.252 | 0.542 |
| SE (P value) | 0.831 (.766) | 0.787 (.68) | 1.359 (.492) |
| Age (0 = 31 to 40 years/1 = 60 years and older) | 1.255 [0.357 to 5.168] | 0.411 [0.116 to 1.265] | 0.536 [0.103 to 3.049] |
| Reg. coefficient | 0.227 | −0.888 | −0.623 |
| SE (P value) | 0.894 (.75) | 0.244 (.135) | 0.477 (.484) |
| No. of observations | 206 | 206 | 200 |
| AIC | 182.2 | 216.8 | 158.9 |
| BIC | 202.1 | 236.8 | 178.7 |
| Log-likelihood | −85.087 | -102.408 | -73.463 |
| F | 1.298 | 1.821 | 1.975 |
| Omnibus test | 0.013 | 0.043 | 0.010 |
| Robust SE | HC3 | HC3 | HC3 |
+ P < 0.1, * P < .05, ** P < .01, *** P < .001.
AIC, akaike information criterion; BIC, bayesian information criterion; CoV, COVID-19–like symptoms; HC3, heteroskedasticity-consistent 3.
EBPEI
In the second logistic regression analysis (Table 4), the association between the emotional burden due to the personal economic impact and the 3 treatment categories was investigated. In model 1, the results showed a significant negative association between the EBPEI and the continuation of plannable treatment. Dentists who reported to feel emotionally burdened were less likely to maintain appointments for plannable treatments with OR of 0.291 (95% CI, 0.123 to 0.695). In model 2, the results showed a significant negative association between the EBPEI and the continuation of acute treatments without simultaneous COVID-19–like symptoms. Dentists who reported to feel emotionally burdened were 0.231 (95% CI, 0.053 to 0.706) less likely to maintain appointments for acute treatments without simultaneous COVID-19–like symptoms. In model III, the results showed no significant associations between the EBPEI and continuation of acute treatment with COVID-19–associated symptoms. In all 3 examination models, female dentists showed a significantly negative association with appointment continuation, reflecting in lower ORs. Models 1 and 2 performed significantly better than a crude intercept model (omnibus test < .05), and model 3 showed no significant benefit (omnibus test = .063).
Table 4.
Binary logistic regression analysis between emotional burden due to personal economic impact and 3 treatment types.
| Model I: plannable treatment (OR [95% CI]) | Model II: acute treatment without CoV (OR [95% CI]) | Model III: acute treatment with CoV (OR [95% CI]) | |
|---|---|---|---|
| Intercept | 0.752 [0.179 to 2.691] | 19.638⁎⁎⁎ [4.584 to 116.215] | 0.319 [0.06 to 1.296] |
| Reg. coefficient | −0.285 | 2.977 | −1.141 |
| SE (P value) | 0.536 (.69) | 17.639 (.001) | 0.243 (.134) |
| Emotional burden due to personal economic impact (0 = no/1 = yes) | 0.291** [0.123 to 0.695] | 0.231* [0.053 to 0.706] | 0.616 [0.239 to 1.732] |
| Reg. coefficient | −1.234 | −1.464 | −0.484 |
| SE (P value) | 0.137 (.009) | 0.16 (.034) | 0.308 (.332) |
| Gender (0 = male/1 = female) | 0.391* [0.144 to 0.948] | 0.45* [0.213 to 0.937] | 0.284* [0.09 to 0.742] |
| Reg. coefficient | −0.938 | −0.799 | −1.259 |
| SE (P value) | 0.182 (.044) | 0.174 (.039) | 0.153 (.019) |
| Age (0 = 31 to 40 years/1 = 41 to 50 years) | 0.369 [0.078 to 1.743] | 1.335 [0.361 to 4.544] | 1.034 [0.252 to 5.25] |
| Reg. coefficient | −0.996 | 0.289 | 0.033 |
| SE (P value) | 0.29 (.205) | 0.886 (.663) | 0.827 (.967) |
| Age (0 = 31 to 40 years/1 = 51 to 60 years) | 1.102 [0.337 to 4.319] | 1.313 [0.374 to 4.115] | 1.569 [0.441 to 7.43] |
| Reg. coefficient | 0.097 | 0.272 | 0.45 |
| SE (P value) | 0.707 (.88) | 0.838 (.669) | 1.157 (.541) |
| Age (0 = 31 to 40 years/1 = 60 years and older) | 1.107 [0.314 to 4.553] | 0.389 [0.109 to 1.211] | 0.494 [0.097 to 2.752] |
| Reg. coefficient | 0.102 | −0.943 | −0.706 |
| SE (P value) | 0.759 (.882) | 0.236 (.12) | 0.422 (.409) |
| No. of observations | 206 | 206 | 200 |
| AIC | 180.0 | 210.5 | 163.6 |
| BIC | 200.0 | 230.4 | 183.3 |
| Log-likelihood | −84.000 | −99.228 | −75.776 |
| F | 2.925 | 2.514 | 1.813 |
| Omnibus test | 0.005 | 0.003 | 0.063 |
| Robust SE | HC3 | HC3 | HC3 |
+P < .1, * P < .05, ** P < .01, *** P < .001.
AIC, akaike information criterion; BIC, bayesian information criterion; CoV, COVID-19–like symptoms; HC3, heteroskedasticity-consistent 3.
Discussion
German dentists faced major challenges during the first lockdown in 2020.2 Amongst other challenges, there were numerous dental appointment cancellations by dentists and patients.11 Our study showed that mainly prophylaxis appointments were cancelled by dentists, whilst appointments for acute complaints without simultaneous COVID-19–associated symptoms continued to be offered in March and April 2020. These results showed that dentists consciously distinguished between time-critical and less time-critical treatment reasons. Non-acute treatments were advised to be cancelled, whilst appointments for patients with acute care needs were advised to be continued.4 When COVID-19–associated symptoms were present, there was a shift in the behaviour of dentists in terms of willingness to provide care. Whilst patients with confirmed COVID-19 infection could be referred to special dental clinics by dentists,2 those without a positive test result who still had COVID-19–like symptoms needed to be treated as well.
Around the world, dentists were afraid of becoming infected with COVID-199 and closed their practices or reduced their office hours.5 However, in Germany dentists are obligated under the Social Code (SGB V § 95 para. 3 sentence 1) to fulfil their mandate to provide care and cannot simply close their practice.2 Possible uncertainty during treatment of patients with COVID-19–like symptoms could have increased dentists’ anxiety9 and thus led to an unmet medical need for those patients who had COVID-19-like symptoms (but no documented COVID-19 infection).15
Overall, those dentists with greater CAI were more likely to cancel appointments for acute treatment for patients with COVID-19–like symptoms and plannable treatments. Notably, there was no significant change in behaviour for acute treatment for patients without COVID-19–like symptoms. This indicates the assumption that dentists balanced their personal needs (i.e., CAI) with their medical obligations to patients.
CAI may have been increased by the fact that there was a shortage of personal protective equipment even for medical professionals in Germany at the beginning of the pandemic.15 Our study showed that 58% of dentists were highly or very highly concerned about getting infected themselves. It remains unclear how well or inadequately equipped these dentists were to protect themselves. If personal protective equipment would decrease CAI, better stockpiling and distribution of such equipment would be an adequate strategy for future pandemics.
Pandemic-related changes in the practice and appointment management had an impact not only on provision of dental care but on an economic level as well.14 Our study showed that 81% of dentists reported to be emotionally burdened by the personal economic impact during the first lockdown. The Free Association of German Dentists investigated the reduction of working hours of dentists during the pandemic in Germany in June 2020. This survey found that amongst the respondents, of which more than 87.5% were self-employed, two-thirds experienced a 50% reduction in practice activity compared to before the pandemic.2 A further study found a significant decline of about 45% to 50% in the provision of services in March and April 2020,16 with an estimated loss of sales worth 1.5 billion euros in German dental practices.13 At the same time, the financial losses were at least partially compensated by government payments.13 More than two-thirds (69.8%) of dental practices registered short-time work.17 Hence, many dental practices adjusted their opening hours and consequently reduced their office hours for patients.17 As a result, some practices reduced their number of employees for financial reasons.12
Given that many dentists experienced severe financial turmoil during the survey period, it is not surprising that 82% of surveyed dentists complained about EBPEI. We saw a significant association between EBPEI and the cancellation of appointments. As the response alternatives for the question “The pandemic has been emotionally challenging for many people. Did you yourself feel emotionally burdened by the pandemic during the months of March/April due to the following factors? Personal economic effects” were “yes” and “no,” it remains unclear whether the dentist had financial resources available or not. Depending on whether the dentist was financially secure, they might perceive the same personal economic impact different. Therefore, the amount of economic impact alone was an insufficient measurement. What remains unexplained is the cause–effect relationship: Did the dentists feel emotionally burdened in their personal economic situation by the circumstances of the pandemic and the measures initiated, or was it the practice-wide appointment cancellations that led to the economic impact and thus were the self-inflicted cause of the emotional distress? Furthermore, the association for appointments with possible COVID-19–infected patients may not have been significant, because there were only a few cases of patients with COVID-19–like symptoms in the first lockdown and, thus, those cases had no major economic impact in quantitative terms.
Limitations
As this is a cross-sectional survey, causal relationships cannot be inferred. Because this was an anonymous survey, participants may have responded to the survey more than once or nondentists may have participated. As participation in the survey was possible via an open online survey, there may have been a selection bias.
The investigation took place in the months of June to September 2020, referring retrospectively to the months of the first lockdown in March and April 2020. For the entire study, a total sample of 269 self-employed dentists were considered in comparison to about 75,000 dentists working in Germany in 2020.18 Due to the low response rate and the different recruitment methods, the representativeness of the sample was limited. Nonetheless, the sociodemographic data did not show any major deviations from the overall population of German dentists.19 Overall, the logistic regressions explain a small proportion of the variance, indicating that other confounding factors need to be identified.
Conclusions
Our analysis indicated that dentists’ own CAI was a reason for practice-related appointment cancellations. To reduce the risk of deterioration of patients’ state of health, it is important to know how to reduce dentists’ CAI.
Conflict of Interest
None disclosed.
Acknowledgments
Acknowledgments
The authors express their gratitude to all participating dentists. Although they remain anonymous, this study would not have been possible without their participation.
Author contributions
Morena Santamaria: conceptualisation, methodology, software, validation, formal analysis, writing–original draft; Arno Stöcker: conceptualisation, methodology, software, validation, formal analysis, investigation, data curation, writing–review and editing, visualisation, project administration, funding acquisition; Jan Hoffmann: investigation, writing–review and editing; Laura Mause: investigation, writing–review and editing; Tim Ohnhäuser: investigation, writing–review and editing, project administration, funding acquisition; Nadine Scholten: conceptualisation, methodology, investigation, writing–review and editing, supervision, funding acquisition. SM and AS contributed equally to this work.
Funding
This article was written within the COVID-GAMS project. COVID-GAMS was funded by the Federal Ministry of Education and Research (BMBF 01KI2099, https://www.bmbf.de/bmbf/en/). The funding body played no role in the design of the study nor of the collection, analysis, interpretation, or writing of the manuscript. All stages of the study were entirely performed by the authors.
Footnotes
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.identj.2023.09.004.
Appendix. Supplementary materials
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