A descriptive pilot study of the immediate impacts of COVID-19 on dental and dental hygiene students’ readiness and wellness.

Abstract

Background:

The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has impacted dental students training across the U.S. academic dental institutions by moving classroom instruction to an online modality, limiting patient care, canceling external rotations, and rescheduling of licensure examinations.

Objective:

The aim of this study was to assess the immediate impacts of COVID-19 on students’ readiness to enter clinical practice or residency and its association with well-being (anxiety, perceived stress, coping and social support, and resilience).

Methods:

An online REDCap survey was distributed to 407 D1-D4 year dental students and 29 DH3-DH4 year dental hygiene students enrolled at a U.S. dental school. The survey consisted of readiness and wellness measures as well as socio-demographic variables.

Results:

Overall response rate was 58% (N=252) ranging from 40% among D4 students to 72% among D1 students. About half (55%) of the respondents were White, a third (34%) Asians and 5% were African Americans. Ninety-two percent were non-Hispanics while 62% were female. Overall mean (SD) anxiety score was 6.5 (5.3) and 26% of respondents reported moderate or severe levels of anxiety. Anxiety score differed significantly by gender with females reporting higher anxiety levels, mean (SD)=7.3 (5.5) vs. 5.2 (4.7) for males; p=0.002). Further, mean anxiety score differed significantly among the dental school classes, ranging from 5.5 (5.3) among D2 students to 11.8 (6.2) in DH4 students (p=0.02).

Conclusion:

Academic dental institutions need to be responsive to the heightened anxiety and uncertainly levels of students and provide responsive training and support to mitigate its effects.

BACKGROUND

Dental schools are competitive, rigorous, and demanding learning environments.^1–3 They differ fundamentally from medical education with respect to instruction in technique and education in scientific and critical thinking. Dentistry as a profession demands both intellectual and technical skills that depend on clinically relevant education in the basic sciences and scientifically informed education in clinical care.⁴ Within the U.S. context, dental schools have a two-year preclinical and a two-year clinical sciences curriculum designed to prepare students for licensure and practice after graduation.

The onset of the ongoing novel coronavirus disease 2019 (COVID-19) pandemic has direct implications for the practice of dentistry and student training. Dental providers including trainees are at high risk of infection given the mode of transmission of SARS-CoV-2 — the causative agent of COVID-19 — through respiratory droplets. Indeed, the occupational safety and health administration (OSHA) classified dentists as very high-risk category because of the potential for exposure to the novel coronavirus through aerosol-generating procedures.⁵ This presents a unique challenge for the dental profession due to the nature of the working environment, where high aerosols and droplets are generated during routine dental procedures. To date, standard infection control precautions appear inadequate to prevent the spread of the novel coronavirus.⁶

Academic dental institutions across the U.S. have actively responded to the COVID-19 pandemic according to their institutional setting, resources, and state and federal guidelines. Student training has specifically been impacted given the implementation of various response strategies including but not limited to moving classroom instructions online, limiting patient care, canceling external rotations, professional meetings and rescheduling of licensure examinations.⁷ In the Commonwealth of Virginia, the Governor issued a shelter in place order on March 12, 2020 to curtail the spread of the virus. This led to a halt in all elective procedures to alleviate concerns surrounding insufficient personal protective equipment for frontline healthcare workers. The resulting postponement of direct patient care, a key component of the dental curriculum,⁸ has been the biggest challenge to dental schools and to dentistry in general. While clear that academic dental institutions have had to modify dental/dental hygiene students’ training in response to COVID-19, less clear is the impact of such changes on students’ wellness. Factors historically reported as stress inducing for dental/dental hygiene students include grades,^9,10 financial pressure for dental students, and meeting graduation requirements.^3,10 Elevated stress in particular has been shown to adversely affect dental students’ health and well-being.¹¹ On the contrary, dental hygiene students reported high psychological well-being scores despite reporting similar levels of stress to that of dental students.¹² The temporary closure of the dental school and postponement of elective dental care per the Governor’s executive order, likely represent an additional source of stress to dental/dental hygiene students, especially those in their last year of clinical training yet to complete their graduation requirements. Furthermore, fourth year dental students may also face heightened anxiety and stress levels when compared to dental hygiene students due to the associated concerns of potentially heading up businesses upon graduation.¹³

Prior research on disruption to the clinical learning environment was reported to have minimal impact on students’ assessment performance when students had time to adapt to the disruption.¹⁴ However, this has not been the case for the COVID-19 outbreak, which represents an unexpected/abrupt disruption of training with no immediate return to normalcy. Even with anticipated disruption, lack of knowledge on the extent of the disruption can negatively impact clinical dental training. For instance, disruption created by a dental building redevelopment work was reported to be correlated with students experiencing high levels of stress due to interruptions in their clinical training.¹⁵ Nevertheless, a sense of resilience was found to be correlated with better outlook and the ability of students to cope and manage the stress induced by the disruption.¹⁵

Alternative methods such as the ADEX simulation examination are being explored as an option for students to complete their remaining clinical requirements and potentially also for state licensing board examinations in the Commonwealth of Virginia. Given the unprecedented nature of the ongoing COVID-19 pandemic, students’ feelings and perceptions surrounding this mode of assessment of their clinical competency is unknown. In addition, the impacts of the COVID-19 pandemic on dental/dental hygiene students’ levels of stress and readiness for the dental workforce vis-a-vis infection control, tele-dentistry and job prospects are unknown. To address this gap in the literature, this study seeks to assess students’ readiness to enter clinical practice or residency after the COVID-19 pandemic and its association with well-being operationalized using anxiety, perceived stress, coping, social support, and resilience measures. We hypothesize that clinical year students yet to complete all clinical requirements prior to the shelter in place order will self-report lower confidence in entering clinical practice or residency compared to their counterparts who have completed their requirements. Furthermore, lower self-reported readiness to enter clinical practice or residency will be associated with higher anxiety and stress scores and lower social support and resilience scores.

METHODS

Study population

Dental and dental hygiene students at a U.S. Dental School were invited to participate in a 10-minute anonymous online REDCap (Research Electronic Data Capture) survey hosted at Virginia Commonwealth University.^16,17 REDCap is a secure, web-based software platform designed to support data capture for research studies. Data collection was conducted in the 3-week period between April 27^th and May 17^th, 2020, while the stay-at-home orders were still in place throughout the Commonwealth. Students received an invitation to complete the survey with an individualized link that allowed the survey to be taken only once. Survey participation was voluntary and informed consent was obtained electronically. Each survey responder with complete responses received a $10 incentive for participation, in the form of an amazon e-gift card. This study was reviewed and approved by the Institutional Review Board at VCU as exempt (IRB: #HM20019288).

Wellness measures

Perceived stress scale (PSS-10):

The PSS is the most widely used psychological instrument for measuring the perception of stress,¹⁸ and has been reported to have very good psychometric properties in a group of suicide survivors.¹⁹ This instrument measures the degree to which situations in one’s life are appraised as stressful, including queries about current levels of experienced stress. We reversed positively worded items (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 & 4 = 0) and summed across all items to obtain a total PSS-10 score that can range anywhere from 0 to 40 with higher scores indicating higher levels of perceived stress.

Resilience scale:

We used the brief resilience scale (BRS) developed and tested by Smith et al²⁰ to assess the ability to bounce back or recover from stress. This scale was found to have reliable psychometric properties in a variety of samples including in a sample of students.²⁰ With total possible scores ranging from 1 to 30, items 2, 4, and 6 on the BRS that are negatively worded were reverse coded such that higher mean score indicates higher/greater levels of resilience.

Anxiety scale:

The 7-item Generalized Anxiety Disorder Scale (GAD-7), a widely used and validated instrument was used to screen anxiety levels surrounding the COVID-19 pandemic. The GAD-7 includes seven items based on core anxiety symptoms and inquires the frequency to which respondents suffered from these symptoms within the last two weeks using a 4-item Likert scale rating ranging from 0 (not at all) to 3 (almost every day), with total possible score ranging from 0 to 21.²¹ We reported mean GAD-7 and also categorized the total score into minimal (0-4); mild (5-9); moderate (10-14); and severe (15-21) anxiety.²¹

Social support:

The three-item Oslo-3 social support (OSS-3) scale was used to evaluate social support, defined as a psychosocial resource that is accessible in the context of interpersonal contacts, and one’s social network.²² Due to the brevity of the scale, it was found to have an acceptable internal consistency of 0.64 in a general population survey.²² This scale comprises both the functional (obtaining support from family, friends and neighbors) and structural domains of social support (size and type of the social support network and frequency of contact within it).²³ The sum of the OSS-3 score can range from 3 to 14, with high values indicating strong levels and low values representing poor levels of social support. We operationalized the sum of the OSSS-3 in terms of its mean value and categorized it into 3–8 poor social support; 9–11 moderate social support; 12–14 strong social support.

Coping:

refers to the cognitive, emotional, and behavioral methods of dealing with problems. We assessed this construct using the 13-item coping scale developed by Hamby, Grych, & Banyard,²⁴ that was found to be internally valid with estimates ranging from 0.88 to 0.91.²⁴ Total possible score can range from 13-52, with higher scores indicating higher/better levels of coping.

Readiness measures

We assessed readiness using the following question: “What is your level of confidence in entering clinical practice or residency” and collected responses on a 4-point Likert scale of very confident; somewhat confident; not too confident; not confident at all.

Covariates

Survey respondents indicated their sociodemographic characteristics which included: Race (Black/African American; Native Hawaiian/Pacific Islander; White; Asian; two or more races). Ethnicity (Hispanic or non-Hispanic). Gender (Male or Female). Marital status [married (including co-habiting), single, or divorced (including separated)]. Survey respondents also reported the amount of dental school debt incurred, which we categorized as $0-<50k, $51-200k, $201-350k and >$350k, and whether their graduation plans have changed since the COVID-19 outbreak (Yes or No). Other covariates include: year in the dental program [first (D1); second (D2); third (D3); fourth (D4); third (DH3); and fourth (DH4) year dental hygiene]; interest level in Tele-dentistry (very interested, somewhat interested, not too interested, not at all interested); confidence in developing an infection control manual for future work practice (very confident, somewhat confident, not too confident, not at all confident) and student’s confidence in simulated clinical experience as a substitute to live patient care to complete clinical requirements and/or to obtain licensure (very confident, somewhat confident, not too confident, not at all confident).

Statistical analysis

We summarized the demographic characteristics of respondents using frequencies and relative frequencies and the distribution of wellness scores (GAD-7, PSS, BRS, Coping) according to selected demographic variables and year in the dental program to determine if there are differences in wellness levels since the COVID-19 outbreak. Differences in wellness scores were assessed using ANOVA (analysis of variance) for mean scores or Fishers exact test for differences in proportions. Further, we cross-classified readiness, including interest levels in tele-dentistry, confidence in infection control protocol and summarized the results according to year in the dental program using fishers exact test to assess differences in proportions. Restricting to D3, D4, DH4 students, we compared self-reported confidence in entering clinical practice/residency for those who have and have not completed their requirements for graduation. And, assessed if lower self-reported readiness to enter clinical practice or residency is associated with higher anxiety and/or stress scores using ANOVA to test differences in mean anxiety and/or stress scores.

RESULTS

The overall response rate was 58% ranging from 40% among D4 students to 72% among D1 students. The response rates among third- and fourth-year dental hygiene students were 88% and 69% respectively. A little more than half (55%) were white, 34% were Asians and African Americans comprised 5% of the respondents. Ninety-two percent were non-Hispanics and 8% identify as Hispanics. Two-thirds (62%) of the respondents were female, majority (69%) were single and 34% have dental school debt of more than $200 thousand (Table 1).

Table 1.

Demographic distribution of survey respondents

Variables	Frequency	Percent
Race
American Indian/Alaskan Native	1	0.4
Black/African American	13	5.2
White	140	55.6
Asian	87	34.5
Two or more races	11	4.4
Ethnicity
Hispanic	21	8.3
Non-Hispanic	231	91.7
Gender
Male	95	37.7
Female	157	62.3
Marital status
Married	74	29.4
Single	173	68.6
other	5	2.0
Dental School class
D1	71	28.2
D2	50	19.8
D3	67	26.6
D4	41	16.3
DH3	14	5.6
DH4	9	3.6
Dental school debt
$0-<50k	69	27.4
$51-200k	96	38.1
$201-350k	51	20.2
>$350k	36	14.3
Funding for dental school
Gifts/Grants/scholarships	36	14.2
Savings/Part-time employment/other	15	6.0
Student loans	201	79.8
Has graduation plans changed since the COVID-19 outbreak?
No	223	88.5
Yes	29	11.5

Table 2 reports the mean wellness scores for selected demographic factors. Reported anxiety, resilience and social support scores differ significantly between males and females with females reporting higher anxiety levels, mean (SD)=7.3 (5.5) vs. 5.2 (4.7) for males; p=0.002); higher stress scores, mean (SD)=18.2 (6.3) vs. 14.4 (6.4) for males; p <0.001) and lower resilience score, 20 (4.0) vs. 22 (4.4); p=0.0006. Similarly, respondents whose graduation plans had changed since the COVID-19 outbreak were more like to report higher anxiety scores, mean (SD)=9.2 (5.9) vs. 6.2 (5.1), p=0.004; higher perceived stress, mean (SD)=20.1 (5.2) vs. 16.3 (6.6), p=0.003; and lower resilience scores, mean (SD)=18.9 (3.4) vs. 20.9 (4.3), p=0.01. There was however no significant difference in reported wellness measures according to ethnicity or dental school debt amount (Table 2).

Table 2.

Mean wellness scores according selected demographic characteristics

Variables		GAD-7		PSS-10		BRS		OSS-3		Coping
	N	Mean (SD)	p-value	Mean (SD)	p-value	Mean (SD)	p-value	Mean (SD)	p-value	Mean (SD)	p-value
Race			0.7		0.1		0.001		0.04		0.4
American Indian/Alaskan Native	1	9.0		21.0		23.0		12.0		47.0
Black/African American	13	5.9 (4.8)		17.9 (4.1)		19.6 (3.8)		10.7 (2.7)		40 (2.5)
White	140	6.2 (5.5)		15.8 (6.8)		21.7 (4.2)		11.3 (1.9)		39.3 (6.2)
Asian	87	6.9 (5.0)		17.9 (6.4)		19.2 (4.2)		10.6 (2.3)		38.4 (5.8)
Two or more races	11	8.0 (5.5)		18.3 (5.9)		20.6 (3.7)		9.8 (2.1)		38.8 (5.3)
Ethnicity			0.9		0.9		0.3		0.8		0.3
Non-Hispanic	21	6.4 (4.9)		16.8 (7.1)		21.6 (3.6)		10.9 (2.0)		40.4 (6.4)
Hispanic	231	6.5 (5.4)		16.8 (6.6)		20.6 (4.3)		11.0 (2.2)		39.0 (5.9)
Gender			0.002		<0.001		0.0006		0.08		0.09
Male	95	5.2 (4.7)		14.4 (6.4)		21.9 (4.4)		10.7 (2.5)		39.9 (6.2)
Female	157	7.3 (5.5)		18.2 (6.3)		20.0 (4.0)		11.2 (2.0)		38.6 (5.7)
Marital status			0.1		0.2		0.02		0.2		0.7
Married	74	5.7 (5.1)		15.7 (6.8)		21.9 (4.4)		10.7 (2.3)		38.9 (6.5)
Single	173	6.8 (5.4)		17.1 (6.5)		20.2 (4.2)		11.1 (2.1)		39.1 (5.7)
Other	5	9.2 (3.5)		19.4 (5.9)		20.0 (3.6)		10.0 (1.6)		41.0 (3.1)
Dental school debt			0.1		0.3		0.7		0.9		0.2
$0-<50k	69	7.2 (5.9)		16.8 (6.8)		20.9 (4.6)		11.1 (2.1)		40.1 (5.6)
$51-200k	96	5.5 (4.5)		15.9 (6.2)		20.7 (4.1)		10.9 (2.2)		38.5 (5.5)
$201-350k	51	7.4 (5.5)		18.1 (6.6)		20.1 (4.0)		10.9 (1.9)		38.3 (6.3)
>$350k	36	6.9 (5.4)		17.0 (7.2)		21.0 (4.5)		11.0 (2.6)		39.9 (6.7)
Graduation plans changed since COVID-19 outbreak			0.004		0.003		0.01		0.08		0.7
No	223	6.2 (5.1)		16.3 (6.6)		20.9 (4.3)		11.1 (2.1)		39.1 (5.8)
Yes	29	9.2 (5.9)		20.1 (5.2)		18.9 (3.4)		10.3 (2.5)		38.8 (7.0)

GAD-Generalized anxiety disorder; PSS-Perceived stress scale; BRS- Brief resilience scale; OSS-3- Oslo social support scale

^*p-values were based on ANOVA that assesses differences in mean scores; SD-standard deviation

Table 3 reports the mean wellness scores since the COVID-19 outbreak according to year in the dental program. The overall mean (SD) anxiety score was 6.51 (5.3). The mean anxiety score was significantly different among the dental school classes, ranging from 5.5 (5.3) among D2 students to 11.8 (6.2) in DH4 students (p=0.02). Further, a significant proportion (p=0.004) of the two dental hygiene classes had moderate or severe scores on the anxiety scale when compared to the dental classes. Specifically, 50% of the DH3 and 66% of the DH4 class had moderate or severe scores on the anxiety scale as compared to 29% of D3 and 24% of D4 students. Classes with the highest mean (SD) perceived stress scores were D1 at 17.2 (5.7); DH3 at 18.6 (7.4); and DH4 at 21.1 (7.6) while the D2 class had the lowest mean (SD) score at 15.7 (6.2), although these differences in score did not attain statistical significance (p=0.2). Although anxiety and stress scores differed between dental and dental hygiene classes, we found no meaningful difference in resilience, social support or coping scores (Table 3).

Table 3.

Bivariate distribution of wellness scores according to year in the dental or dental hygiene program

	Combined classes	D1 (N=71)	D2 (N=50)	D3 (N=67)	D4 (N=41)	DH3 (N=14)	DH4 (N=9)	p-value*
Wellness measures	N (%) or mean (SD)
GAD-7 (mean score, SD)	6.51 (5.3)	5.9 (5.0)	5.5 (5.3)	6.9 (5.2)	6.6 (5.2)	8.1 (5.8)	11.8 (6.2)	0.02
Minimal (0-4)	101 (40)	31 (44)	27 (54)	23 (34)	14 (34)	5 (36)	1 (11)
mild (5-9)	85 (34)	26 (37)	14 (28)	24 (36)	17 (41)	2 (14)	2 (22)	0.004
moderate (10-14)	46 (18)	10 (14)	4 (8)	15 (22)	7 (17)	6 (43)	4 (44)
severe (15-21)	20 (8)	4 (6)	5 (10)	5 (7)	3 (7)	1 (7)	2 (22)
PSS-10, (mean score, SD)	16.8 (6.6)	17.2 (5.7)	15.7 (6.2)	16.2 (7.0)	16.5 (7.2)	18.6 (7.4)	21.1 (7.6)	0.2
BRS, (mean score, SD)	20.7 (4.3)	20.0 (4.2)	21.0 (4.5)	20.5 (4.0)	21.9 (4.4)	20.9 (4.6)	20.0 (4.3)	0.3
OSS-3, (mean score, SD)	11.0 (2.2)	10.8 (2.1)	11.1 (2.3)	11.1 (2.1)	11.0 (2.4)	10.6 (1.5)	11.2 (2.4)	0.9
Poor (3-8)	33 (13.1)	9 (13)	6 (12)	11 (16)	5 (12)	1 (7)	1 (11)
Moderate (9-11)	105 (41.7)	32 (45)	20 (40)	24 (36)	16 (39)	9 (64)	4 (44)	0.9
Strong (12-14)	114 (45.2)	30 (42)	24 (48)	32 (48)	20 (49)	4 (29)	4 (44)
Coping, (mean score, SD)	39.1 (5.9)	37.7 (5.6)	39.9 (6.3)	38.9 (5.5)	40.3 (5.9)	40.8 (7.3)	39.0 (5.3)	0.2

GAD-Generalized anxiety disorder; PSS-Perceived stress scale; BRS- Brief resilience scale; OSS-3- Oslo social support scale

^*p-values were based on either ANOVA that assesses differences in mean scores or Fisher’s exact test that assesses differences in proportions; SD-standard deviation

Table 4 reports readiness for clinical practice or residency, interest level in tele-dentistry, infection control and confidence in ADEX as an alternative to live patient care for licensure. A higher proportion of students across all classes were very or somewhat interested in tele-dentistry as compared to those who were not while a significant proportion of D4 and DH4 students when compared to the other classes reported a higher level of confidence in developing an infection control manual for their future work practice (p=0.04). Overall, D3, D4, DH3 and DH4 students reported a high level of confidence in entering clinical practice or residency than D1 and D2 students (Table 4).

Table 4.

Bivariate analysis of readiness for clinical practice, interest level in tele-dentistry and confidence in infection control

	Combined classes	D1 (N=71)	D2 (N=50)	D3 (N=67)	D4 (N=41)	DH3 (N=14)	DH4 (N=9)	p-value*
	N (%)
With the current COVID-19 outbreak,
What is your level of interest in tele-dentistry								0.4
Very/somewhat interested	177 (70)	50 (70)	40 (80)	41 (61)	30 (73)	10 (71)	6 (67)
Not too/not interested	75 (30)	21 (30)	10 (26)	26 (39)	11 (27)	4 (29)	3 (33)
Do you feel competent in developing an infection control manual?								0.04
Very/somewhat competent	150 (60)	35 (49)	33 (66)	37 (55)	30 (73)	7 (50)	8 (89)
Not too/not competent	102 (40)	36 (51)	17 (34)	30 (45)	11 (27)	7 (50)	1 (11)
What is your confidence level in ADEX as an alternative to live patient care for licensure								0.0002
Very/somewhat confident	207 (82)	45 (63)	42 (84)	60 (90)	39 (95)	13 (93)	8 (89)
Not too/not confident	45 (18)	26 (37)	8 (16)	7 (10)	2 (5)	1 (7)	1 (11)
What is your level of confidence in entering clinical practice /residency								0.0003
Very/somewhat confident	174 (69)	37 (52)	32 (64)	48 (72)	36 (88)	13 (93)	8 (89)
Not too/not confident	78 (31)	34 (48)	18 (36)	19 (28)	5 (12)	1 (7)	1 (11)

^*Fishers exact test p-value

When we restricted our analytic sample to D3, D4, DH4 students, we found that those who reported in the affirmative to have completed their graduation requirements prior to the shelter in place order were more likely to report a higher confidence in entering clinical practice or residency compared to their counterparts who have not completed their graduation requirements (97% vs. 72%). They also had lower mean (SD) anxiety score, 6.4 (5.6) as compared to their counterparts yet to complete their graduation requirements, 7.4 (5.4). While the overall mean stress scores were high, it was not meaningfully different between these groups (16.2 (7.3) and 16.8 (7.2) respectively while the stress score for those who reported ‘unsure’ to the question about completion of graduation requirements was higher [19.3 (5.5)], although the difference in scores was not statistically significant. D3, D4, DH4 students who reported being very or somewhat confident in entering clinical practice or residency had on average lower anxiety score [6.7, (5.2)] and stress scores16.2 (7.1) compared to their counterparts who reported that they were not too or not at all confident in entering clinical practice or residency, [8.8, (5.8) and 18.8 (7.3) for mean (SD) anxiety and mean stress (SD) scores respectively (Table 5).

Table 5.

Mean wellness scores for clinical year students according to completion of clinical requirements for graduation (n=117)

	Completed graduation requirements				Confidence in entering clinical practice or residency
	Yes (n=30)	No (n=84)	Unsure (n=3)	p-value	Very confident* (n=89)	Not confident** (n=25)	p-value
Level of confidence in entering clinical practice/residency				0.01
Very/somewhat confident	29 (97)	60 (72)	3 (100)
Not confident	1 (3)	24 (28)	0
GAD-7, mean score (SD)	6.4 (5.6)	7.4 (5.4)	7.7 (4.0)	0.6	6.7 (5.2)	8.8 (5.8)	0.09
PSS-7, mean score (SD)	16.2 (7.3)	16.8 (7.2)	19.3 (5.5)	0.7	16.2 (7.1)	18.8 (7.3)	0.1

Restricted to D3, D4 and DH4 students

^*very or somewhat confident;

^**not too or not at all confident

DISCUSSION

This descriptive pilot study on the immediate impacts of COVID-19 on dental/dental hygiene students’ readiness and wellness showed a heightened level of anxiety that differed according to year in the dental program. Indeed, clinical year students closer to graduation were more likely to report anxiety than preclinical students. These findings highlight the likely impacts of the abrupt and unexpected disruption caused by the ongoing COVID-19 pandemic on the psychological well-being of dental and dental hygiene students. Further, we observed no meaningful difference in ability to bounce back (operationalized using measures of social support, coping and resilience) according to dental school class. This lack of difference suggests that the heightened anxiety levels are unlikely due to lacking support or differences in the ability to cope. Nevertheless, significant differences in wellness measures according to gender, race and reporting changed graduation plans since the COVID-19 outbreak warrant further study and targeted interventions to these groups.

Previous studies indicate that clinical year students tend to be more concerned about their professional future while preclinical students tend to be more concerned about grades.² Our findings of increased anxiety levels irrespective of dental school class further support the likely role of the ongoing pandemic on reported levels of anxiety with direct implications for academic dental institutions and the broader workforce.

Dentistry is an inherently stressful profession.²⁵ Burnout, anxiety and depression may result from such stress with consequent negative effects on dental practice, personal and professional relationships.²⁶ The dental education community is in a prime position to modify the high anxiety levels the future workforce may exhibit by curricular changes that incorporate protective factors for anxiety and mental health challenges such as resilience and wellness.²⁷ The National Academy of Medicine Actional Collaborative on Clinician Well-being and Resilience²⁸ recently published a set of strategies for healthcare leaders and managers to support the well-being of clinicians that can be adapted for dental trainees. COVID-19 and the disruption it has caused while initially perceived negatively, could also be harnessed for innovations in artificial intelligence technology in pre-clinical education,^29,30 virtual recruitment and retention efforts particularly for historically underrepresented groups, and new teaching modalities. Furthermore, incorporating emergency preparedness protocols into the dental curriculum may prove helpful for new dentists in practice for years to come.

The vast majority of respondents reported a high level of interest in tele-dentistry, which is an expected finding given the presumed high risk of COVID-19 transmission in the dental care setting. Instruction in tele-dentistry is not part of the current dental curriculum and the ongoing COVID-19 pandemic has made the introduction of non-traditional methods for oral health care vital in an effort to mitigate the spread of the virus and conserve limited PPEs. From triaging emergency patients to preventing interruptions in orthodontic treatment, tele-dentistry is proving beneficial both now and into the future. As states implement tele-dentistry practice laws and regulations and third-party payers increase the coverage of tele-dentistry for specific procedures, it will be imperative to provide training in tele-dentistry for students. Likely concerns surrounding implementation of tele-dentistry and patient compliance were addressed in a recent pilot study of tele-dentistry during the COVID-19 pandemic that reported high patient compliance with instructions and care and a better provider-patient relationship.³¹

Transmission of the SARS-CoV-2 virus occurs primarily through respiratory droplets and aerosolization. Most dental procedures including preparing cavities for fillings, use of rotary instruments for root canal treatment, scaling and polishing of teeth generate aerosols. Four categories of transmission of SARS-CoV-2 has been described: symptomatic transmission; pre-symptomatic transmission; asymptomatic transmission; and environmental transmission³² Hence, patients cared for in the dental care setting during the COVID-19 pandemic need be presumed infectious and necessary precautions taken to protect students and faculty. While graduating D4 and DH4 students were more likely to report being very or somewhat confident in developing an infection control manual for their future work practice, many preclinical students were not. The ongoing pandemic and modifications that are needed to protect the dental work force further underscore the need to develop and teach students COVID-19 specific infection control protocols and engineering controls to reduce the levels of dental aerosols. For instance, using high-velocity air evacuation, advanced filtration, purification and decontamination systems³³ and, where appropriate, minimally invasive treatments for dental disease as an alternative to traditional restorative treatment.

LIMITATIONS/STRENGTHS

A major limitation was our small sample size that prevented multivariable adjustment and limited the power to detect statistically significant differences in wellness measures. Nevertheless, lack of statistical significance does not necessarily imply a lack of clinical meaningfulness. Wellness measures were assessed at a single timepoint thus, we were unable to determine if there were changes from the pre-COVID-19 levels. Our findings are unique to a single dental school surveyed and do not necessarily generalize broadly. Future studies assessing the psychosocial impact of COVID-19 on dental and dental hygiene students in the U.S. and elsewhere are needed. Study strengths include the high survey response rate of 58% relative to other studies of dental school students,^27,34 which highlights dental students desire to share their thoughts during emergency situations.

CONCLUSIONS

The ongoing COVID-19 pandemic and its impacts on educational institutions, curriculum and clinical practice is arguably unprecedented. This study indicates that dental and dental hygiene students are not immune to the effects of COVID-19 especially as it relates to their psychological wellbeing, uncertainty and concerns related to training. Increased anxiety and stress levels could suggest that the abrupt disruption caused by the pandemic may also be influenced by the high-risks that dentists face in providing care during the COVID-19 pandemic. Our findings have implications for classroom instruction, advising and clinical practice. Given that a “new normal” needs to be established certainly until a vaccine is widely available, dental education need to be responsive, adaptive and must include a focus on the psychological well-being including efforts to reduce anxiety levels of its students and workforce. This study highlights an opportunity for dental educators to enhance the curriculum to more specifically focus on strategies for practicing in the “new normal.” Regular, transparent and compassionate communication with students are needed to address concerns related to an adaptive and/or expanded curriculum as this may relieve some of the anxiety and stress they experience. This study findings represents an initial step in quantifying the immediate impacts of COVID-19 on the psychological well-being of dental/dental hygiene students. More studies on the long-term impacts of the pandemic on student’s well-being are warranted.