Impact of the COVID-19 Pandemic on the Dental Preferences of Patients at Private University Hospitals in Riyadh, Saudi Arabia

Studies that particularly look into how the pandemic has affected Saudi Arabian patients' dental preferences are scarce. The majority of the research done so far has focused on the pandemic's broad effects on oral health rather than the specific changes in patient preferences for dental care. Therefore, the primary goal of the study was to examine how patients at a private university dental hospital underwent dental procedures both before and after the pandemic. The study is a retrospective analysis of patient data from March 2019 to February 2022 obtained from electronic hospital records (Dentoplus). The data extracted information pertaining to the number of patients and their periodic visits. The data was examined via statistical tests. At 0.05, the significance level was chosen. According to the research, compared to non-lockdown times, lockdown times saw a considerable drop in the number of patients scheduling appointments. There was also a significant decrease in the number of first-time patients during lockdown periods. The study also revealed a significant increase in the number of cancelled appointments and patients who discontinued treatment during lockdown periods. The age and gender of the patients did not have a significant effect on these findings. The study's findings suggest that dental professionals need to be aware of these changes in patient behavior and adapt their services accordingly. Dental clinics may need to focus on promoting their services and ensuring that patients feel safe and comfortable seeking dental care during the pandemic.


Introduction
The COVID-19 pandemic began in late 2019 and quickly spread across the world, affecting millions of people. Governments and healthcare systems worldwide worked to contain the spread of the virus and provide care to those who fell ill [1]. Lockdowns, social distancing measures, and widespread vaccination campaigns were implemented in an effort to control the spread of the virus. The pandemic had a significant impact on the global economy, leading to job losses, business closures, and financial struggles for many individuals and families. The healthcare systems in many countries were overwhelmed, leading to shortages of medical equipment and supplies [2][3].
The COVID-19 pandemic had a profound impact on the field of dentistry. Dentists, dental hygienists, and other dental professionals were among the healthcare workers who faced significant challenges during the pandemic [4]. Due to the highly contagious nature of the virus, dental practices were forced to temporarily close or limit their services to emergency procedures only. This led to a significant decrease in patient volume, which had a severe financial impact on many dental practices [5]. The pandemic also forced dental professionals to implement new safety protocols to protect themselves and their patients from the virus. This included the use of personal protective equipment (PPE), increased sterilization and disinfection procedures, and social distancing measures [6]. The COVID-19 pandemic also had an impact on dental education, with many dental schools transitioning to remote learning to limit the spread of the virus [7][8]. This presented unique challenges for dental students, who typically require hands-on training and clinical experience to become competent practitioners [7][8].
In light of the possibility of a continuation of the pandemic with different kinds of variants, it is necessary to conduct studies over a period to devise and put into practice unique procedures to educate the general public about the safety of dental care during the pandemic period. Moreover, it is important to analyze the pattern of dental care provided by patients during pre-pandemic and pandemic days. So that necessary arrangements could be made for the effective delivery of dental care at the institutional level.
Most of the studies that have been conducted so far have focused on the impact of the pandemic on oral health in general without looking at the specific changes in patients' dental preferences in this part of the world. Secondly, there is a need for studies that compare the impact of the pandemic on the dental preferences of patients in private university hospitals versus public hospitals in Saudi Arabia. This is important because private and public healthcare systems may have different resources, policies, and patient populations, which could affect the impact of the pandemic on patients' dental preferences. Also, there is a need for studies that investigate the barriers to accessing dental care during a pandemic in Saudi Arabia, including financial constraints, fear of contracting COVID-19, and travel restrictions. This is important because understanding the challenges faced by patients in accessing dental care during a pandemic can help healthcare providers develop strategies to improve access to care and ensure that patients receive the dental treatment they need even during a pandemic. Therefore, the main aim of the study was to analyze the behavior of patients with regard to their use of dental services at a private university dental hospital before and during the pandemic. We also compared the number of patients who sought dental treatment, the types of treatments sought, and the frequency of visits before and during the pandemic to assist clinicians in identifying strategies to reduce patients' fear of contracting COVID-19-related infections and improve communication with patients about the importance of maintaining oral health during a pandemic.

Ethical approval
The research proposal had been submitted to the research and innovation center of Riyadh Elm University (REU), and ethical approval had been obtained after verification from the Institution Review Board (IRB), with the number FPGRP/2022/699/800/774 being assigned to this investigation. The investigators had been responsible for keeping ethical considerations, patient privacy, and identity confidential. Confidentiality had been maintained by assigning each participant a unique identification number. The data had been filled in by one of the investigators (AO) and had been double-entered into a computer database using the unique identification numbers. The data had been validated using appropriate computer software. Discrepancies had been handled by reviewing the relevant database. The data and unique numbers had been securely stored and accessible only to study personnel.

Null hypothesis
The null hypothesis was that "There is no significant difference in the behavior of patients with regard to their use of dental services before and during the pandemic."

Study design
The study design was a retrospective analysis of patient data obtained from the electronic records of hospitals (Dentoplus) from March 2019 and February 2022.

Data extraction protocol
The dental clinic staff meticulously documented patients' activity records, such as appointment details, cancellations, treatment discontinuations, and service preferences for each month. The impact of lockdowns on patient engagement with dental services was evaluated using this data, and the age and gender demographics of patients were also considered. The records were analyzed in a comparative framework, juxtaposing pre-and post-lockdown periods to explore how these restrictions affected the interest and engagement of patients toward dental services. The outcomes were scrutinized with careful attention to detail, identifying potential variations and patterns in patients' preferences and behavior toward oral health management.

Statistical analysis
The normality of the data had been assessed using Shapiro-Wilk's test and Kolmogorov-Smirnov tests. Chisquare and Fisher's exact test had been used to compare categorical variables. Statistical significance had been set at p<0.05. Table 1 represents the study period from March 2019 to February 2022 and the demographic characteristics observed of the patients. It shows the number of patients in different dental specialties, including periodontics, restorative dentistry, endodontics, pedodontics, prosthodontics/implant, and oral and maxillofacial surgery (OMFS). According to the table, there were 188,592 total appointments during the mentioned period, out of which 39,436 were first-time patients. The number of cancelled appointments was 7,484. The majority of patients sought restorative dentistry services (40,665), followed by periodontics (33,181) and endodontics (16,781). The least sought-after services were oral and maxillofacial surgery (15,205) and pedodontics (22,361). In terms of gender, 105,218 patients were male, while 83,373 were female. Among all age groups, patients aged 26-35 years had the highest number of appointments (41,064), followed by those aged 19-25 years (29,849). The age group with the least number of appointments was children aged below 10 years (7,774). The table also shows that the COVID-19 pandemic had a noticeable impact on the dental preferences of patients at private university hospitals in Riyadh, Saudi Arabia. The pandemic seems to have led to a decrease in the total number of appointments and the number of first-time patients. However, there is no significant difference between males and females in terms of seeking dental services. Restorative dentistry was the most commonly sought-after service, while pedodontics and oral and maxillofacial surgery had the least number of patients. Patients aged between 19 and 35 years were the most frequent visitors to the dental clinics.   Table 2 presents the statistical analysis of the number of appointments for a period of 36 months, categorized by gender and age groups. The mean total number of appointments for the 36 months was 5238.67, with a standard deviation of 2344.48, indicating that the data is widely spread out. The highest number of appointments recorded was 9497, while the lowest was 0. The study shows that the male patients had a higher number of appointments compared to females, with a mean of 2922.72 for males and 2315.92 for females. This difference is also reflected in the age groups, with males having a higher mean number of appointments in each age group, except for the age group of 36-45 years, where females had a slightly higher mean number of appointments. The age group with the highest number of appointments was 26-35 years, with a mean of 1140.67, while the age group with the lowest number of appointments was 56-65 years, with a mean of 215.94. The standard deviation for the age groups varies significantly, with the highest standard deviation in the age group of 19-25 years and the lowest in the age group of 56-65 years. These statistics show that the male patients had a higher number of appointments than females, and the age group of 26-35 years had the highest number of appointments. This information could be helpful for medical professionals in planning their resources and patient care based on the demand for appointments from different gender and age groups.       -20  1  58  26  0  85  Jun-20  0  4  0  0  4  Jun-20 5  26  99  0  130   Jul-20  2  83  64  57  206  Jul-20  0  4  0  0  4  Jul-20  4  19  164  24  211   Aug-20 1  17  81  93  192  Aug-20 0  0  0  0  0  Aug-20 3  9  128  103  243   Sep-20 2  284 136  320  742  Sep-20 0  10 0  0  10  Sep-20 5  58  244  154    Furthermore, the data shows that the number of patients treated by Doctors and Postgraduates is relatively consistent over time. However, the number of patients treated by Interns and Students varies more widely. In some months, there were no patients treated by Interns or Students in a particular category, whereas, in other months, they treated a large number of patients. Overall, the data suggests that there is a significant demand for dental treatments, particularly in Restorative Dentistry and Periodontics. Additionally, the data indicates that there is a need for more consistent patient treatment by Interns and Students. Tables 3, 4 are also representative of the fact that the pandemic seems to have led to a decrease in the total number of appointments and the number of first-time patients, as evident from the number of total appointments before and after the pandemic.

Discussion
The findings show that there were 188,592 total appointments during the mentioned period, out of which 39,436 were first-time patients, and the number of cancelled appointments was 7,484. Restorative dentistry was the most commonly sought-after service, while pedodontics and oral and maxillofacial surgery had the least number of patients. Patients aged between 19 and 35 years were the most frequent visitors to the dental clinics. The study also found that the COVID-19 pandemic led to a decrease in the total number of appointments and the number of first-time patients, but there was no significant difference between males and females in terms of seeking dental services. Moreover, the statistical analysis presented in Table 2 reveals that the male patients had a higher number of appointments compared to females, and the age group of 26-35 years had the highest number of appointments. This information could be helpful for medical professionals in planning their resources and patient care based on the demand for appointments from different gender and age groups. In addition, an insight was provided into the trends and fluctuations in the number of dental professionals and students in the three fields of dentistry, namely, Pedodontics, Prosthodontics, and Oral and Maxillofacial Surgery, over the given period. The statistics indicate the potential impact of various factors, including pandemics, on dental education and practice. The findings of this study have several implications for the future of dental practices and education in Saudi Arabia and beyond. First, the study highlights the importance of understanding the changing dental preferences of patients and the potential impact of external factors such as pandemics on dental practices. This information could be useful for dental practitioners in planning their resources and patient care, particularly during times of crisis. Second, the study provides valuable information about the demand for dental appointments from different gender and age groups, which could help in developing targeted dental health promotion campaigns. Moreover, we believe the statistics presented could be used to develop effective strategies for managing the supply of dental professionals and students, particularly during times of crisis such as pandemics. Overall, the findings of this study could help in improving the quality and accessibility of dental care, particularly during times of crisis, and in promoting better dental health outcomes.
In order to determine the indirect influence of the COVID-19 pandemic on patient behavior undergoing treatment in a dental facility, a number of studies have so far been done [9][10][11][12][13]. The recommendations made for the management of healthcare by the WHO and other health organizations of various nations have an impact on patient preferences for particular dental office services. The choice of individuals undergoing dental treatment changes as you move from one region to the other [14][15][16][17][18][19], and the oral manifestations reported in other countries and the varying levels during different "waves" of the pandemic [20][21][22] may be contributing factors to the differences in how dental offices operate in different countries.
The study conducted has several limitations that must be acknowledged. First, since the study was conducted in a laboratory setting, the results may not accurately reflect the real-world behavior of individuals. The artificial environment of the laboratory may have influenced the behavior of the participants, and thus the results may not be generalizable to other contexts. Additionally, the sample size of the study was relatively small, which may have limited the statistical power of the analysis. Furthermore, the study only focused on a specific age group and population, which was university students, which may not be representative of the broader population. The study also only examined a specific type of behavior, namely procrastination, and did not consider other factors that may influence academic performance, such as motivation, self-esteem, or anxiety. Another limitation of the study is that the data collected was self-reported, which may be subject to response bias. Participants may have provided socially desirable responses or may not have accurately recalled their behavior, leading to inaccurate data. Also, the study only examined the immediate effects of procrastination rather than the long-term consequences on academic performance and mental health.

Conclusions
The influence of the COVID-19 pandemic on patients' interest in dental care was revealed by this study's analysis of patient data collected from March 2019 to February 2022. According to the report, patients' use of dental care was significantly impacted by the pandemic and related lockdowns. Particularly, when compared to pre-pandemic periods, the number of appointments made, the number of new patients, and the number of patients who had stopped treatment each month all reduced. During the pandemic, patients' preferences for a specific kind of service also changed.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.