1 PROBLEM

What responses are needed when a public health crisis, the COVID-19 pandemic, disrupts continuity of care in a dental school clinic? To what extent do fears regarding safety during treatment deter patients from attending appointments in dental school clinics and can the school control these factors to ensure educational experiences? Much attention has been paid to the precautions for protecting students, faculty, staff, and patients during treatment, including triage and procedures and barriers that ensure safe distancing.1-3 The University of the Pacific, Arthur A. Dugoni School of Dentistry has adhered to strict state and county guidelines and informed patients of these protocols as shown in Table 1. Nevertheless, we observed a 40% disruption in mid-treatment for endodontic, fixed, and removable prosthodontic care. We asked patients how receiving dental care under these circumstances appeared from their point of view.

TABLE 1. Measures taken to improve communication with patients regarding COVID-19 protocols during the pandemic Communication initiatives Date implemented Updated patient website March 2020–Present Group practice virtual huddles on patient communication April 2020–Present Patient information letters from student providers May 2020–August 2020 Patient information video added to website August 2020 Community outreach to patients via social media August–October 2020 Student/receptionist script regarding COVID-19 testing July 2020 PPE video displayed on patient waiting room monitors October 2020 2 SOLUTION

This project received IRB exempt approval 2020-15. The first author attempted to contact the 16 patients who had not attended a scheduled mid-treatment appointment during the first week of June 2020. Twelve were reached by phone after up to three attempts and gave verbal consent to be interviewed in English or Spanish for approximately 10 min each. Semi-structured guided interviews were conducted with the only standardized question being “Describe where you are in your dental treatment.” All subsequent discussion consisted of follow-up on patients’ comments. Patients were not asked about perceived barriers to care, although they all mentioned some. Interviews were not recorded, but notes were taken and transcribed and coded for themes.

3 RESULTS

Perceived value of the care and trust in the school remained high. No respondent expressed fear of contracting coronavirus during dental treatment.

Factors outside of the dental clinic were blocking care seeking. These included uncertainty regarding protocol for testing by the county and fear of contracting COVID-19 on public transportation on the way to dental appointments. Other personal concerns assumed greater salience than completing nonemergency oral care. “I'm 87 years old. I get out of the apartment once every two weeks, and that is for food. I don't understand what all I have to do now for dentistry. New hassle. I will wait until things get easier. A phone reminder isn't going to make any difference. The temporary crown is good.”

This project highlighted the fact that patients place oral health care behavior in the context of their other needs, some of which may not be directly influenced by information or protocol under the control of dentists. Stanford's Albert Bandura4 called this a self-efficacy mechanism, which influences thought patterns, actions, and emotional arousal on the patients’ part. Harvard Business School Professor Michael Porter5 argues that health care professionals tend to define care in terms of what happens between putting on and taking off the gloves or what staff do to encourage patient attendance. Patients, by contrast, define health in the entire context of their personal daily lives. The pandemic has shown that improvements in the former may have limited influence when the latter becomes larger problems.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

REFERENCES

1Wang C, Miao L, Wang Z, Xiong Y, Jiao Y, Liu H. Emergency management in dental clinic during the coronavirus disease 2019 (COVID-19) epidemic in Beijing. Int Dent J. 2021;71:32-39. 2Manuballa S, Abdelmaseh M, Tasgaonkar N, et al. Managing the oral health of cancer patients during the COVID-19 pandemic: perspective of a dental clinic in a cancer center. J Clin Med. 2020; 9(10): 3138. 3Long RH, Ward TD, Pruett ME, Coleman JF. Modifications of emergency dental clinic protocols to combat COVID-19 transmission. Spec Care Dentist. 2020; 40(3): 219- 226. 4Bandura A. Self-efficacy mechanism in human agency. Am Psychol. 1982; 37(2): 122- 147. 5Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press; 2006.