Assessment of the Economic and Health-Care Impact of COVID-19 (SARS-CoV-2) on Public and Private Dental Surgeries in Spain: A Pilot Study

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle Assessmen o he Economic and Heal h-Ca e Impac o COVID-19 (SARS-CoV-2) on Public and P i a e Den al Su ge ies in Spain: A Pilo S udy Cin ia Chamo o-Pe onacci 1,2, Ca men Ma in Ca e as-P esas 3, Ad iana Sanz-Ma chena 4, Ma ía A Rod íguez-Fe nández 5, JoséMa ía Suá ez-Quin anilla 6, Be a Ri as-Mundiña 7, Juan Suá ez-Quin anilla 8and Ma io Pé ez-Sayáns 1,2,* 1Uni o O al Medicine, Facul y o Medicine and Den is y, Uni e si y o San iago de Compos ela, 15705 San iago de Compos ela, Spain; cin ia.chamo o.pe [email p o ec ed] 2Heal h Resea ch Ins i u e o San iago de Compos ela (IDIS), 15706 San iago de Compos ela, Spain 3P o essional Associa ion o Den is s and S oma ologis s o Mad id, 28046 Mad id, Spain; [email p o ec ed] 4P esidency o he P o essional Associa ion o Den is s and S oma ologis s o Pon e ed a-Ou ense, 36003 Pon e ed a, Spain; [email p o ec ed] 5Depa men o p e en i e medicine and public heal h, Uni e si y o San iago de Compos ela, 15705 San iago de Compos ela, Spain; [email p o ec ed] 6P esidency o he P o essional Associa ion o Den is s and S oma ologis s o A Co uña-Lugo, 15011 A Co uña, Spain; josema ia.sua [email p o ec ed] 7 Pa hology and The apeu ic Uni y, Facul y o Medicine and Den is y, Uni e si y o San iago de Compos ela, 15705 San iago de Compos ela, Spain; [email p o ec ed] 8Galician Public Heal h Se ice (SERGAS), Den is y and P ima y Heal h Ca e o he Heal h Dis ic o San iago de Compos ela, 15705 San iago de Compos ela, Spain; juanan onisua ez.sua [email p o ec ed] *Co espondence: ma io.pe [email p o ec ed] Recei ed: 18 June 2020; Accep ed: 15 July 2020; Published: 17 July 2020   Abs ac : Objec i es: The COVID-19 (SARS-CoV-2) pandemic is an ongoing public heal h challenge, also o he den is y communi y. The main objec i e o his pape was o de e mine he economic and heal h-ca e impac o COVID-19 on den is s in he Au onomous Region o Galicia (Spain). Me hods: This was a desc ip i e obse a ional s udy in which he da a was collec ed by means o a sel -adminis e ed su ey ( om 1 Ap il 2020 o 30 Ap il 2020). Resul s: A o al o 400 den is s om Galicia esponded o he su ey. Only 12.3% o he pa icipan s could ob ain pe sonal p o ec i e equipmen (PPE) including FFP2 masks. O he male esponden s, 33.1% su e ed losses > € 15,000 compa ed o 19.4% o emale esponden s (OR =3.121, p<0.001). Economic losses seem o ha e con ibu ed o he applica ions o economic help as 29.5% o he esponden s who applied o his measu e eco ded losses in excess o € 15,000 (p=0.03). Pa ien s complained mo e abou he ac ha only eme gency ca e was a ailable du ing he S a e o Ala m, in den al su ge ies ha do no wo k wi h insu ance companies o anchises. Only 4 p o essionals es ed posi i e, 50% o whom wo ked exclusi ely in p i a e p ac ice and he o he 50% who p ac ised in bo h p i a e and public su ge ies. Den is s who p ac ise in he public sec o saw mo e u gen pa ien s pe week han hose p ac ising in p i a e su ge ies (p=0.013). Conclusions: The COVID-19 pandemic has had economic epe cussions in den is y as only u gen ea men was a ailable du ing he S a e o Ala m. These epe cussions seem o be highe in male pa icipan s, as he majo i y o he pa icipan s ha e e ealed highe economic losses han emales. The le el o assis ance has also been a ec ed, educing he numbe o ea ed pa ien s, al hough his quan i y has been di e en in p i a e and public su ge ies. By p esen ing hese indings we look o highligh he ole ha den is s play in socie y in ea ing den al eme gencies in ou su ge ies, and his mus be ecognised and add essed by he ele an au ho i ies, who mus p o ide PPEs as a p io i y o his g oup as well as p o iding special economic aid in acco dance wi h he losses incu ed by he sec o . In . J. En i on. Res. Public Heal h 2020,17, 5139; doi:10.3390/ije ph17145139 www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2020,17, 5139 2 o 9 Keywo ds: COVID-19; SARS-CoV-2; economic impac ; den al o ice managemen 1. In oduc ion On he 11 h o Ma ch, 2020, COVID-19 (SARS-CoV-2) was decla ed as a pandemic by he Wo ld Heal h O ganiza ion (WHO), and i has been an ongoing public heal h challenge in mo e han one hund ed coun ies [ 1 ]. The i s case in Spain was de ec ed a he end o Janua y 2020, howe e , he S a e o Ala m (Spanish Royal Dec ee 14/3/2020) was no decla ed un il he 14 h o Ma ch. In o de o ace his heal h eme gency, he popula ion’s eedom o mo emen was limi ed and all ac i i ies in he comme cial, ec ea ional and hospi ali y sec o s we e suspended. Den al su ge ies we e no o ced o close, ne e heless, hei ac i i y was limi ed exclusi ely o eme gency ea men s by he Spanish O de SND/310/2020 (Minis y o Heal h), issued on he 31s Ma ch. Acco ding o ins i u ions and p o essional associa ions, his new si ua ion has been he causal ac o o he economic and heal h ca e- ela ed di icul ies which ha e a ec ed he den al sec o . The di icul ies which his sec o has aced a e he esul o he limi ed access o pe sonal p o ec i e equipmen (PPE), gi en ha his equipmen was exclusi ely alloca ed o public ins i u ions, and he complexi y in managing he inancial aid as app o ed by he new legisla ion, which was passed du ing he S a e o Ala m. Den is s a e one o he p o essional g oups ha wo k in e y equen con ac wi h pa ien s, and i is no possible o hem o main ain a sa e dis ance while pe o ming den al ea men s, as a esul , his collec i e has a highe p obabili y o being in ec ed by di e en mic o-o ganisms, such as COVID-19 [ 2 ]. The majo i y o he guidelines and p o ocols o ac ion es ablished o den al p ac ices o he COVID-19 pandemic emphasise he high isk o ansmission o he i us du ing den al ea men , mainly due o he equen p oduc ion o ae osol and di ec con ac wi h he pa ien ’s sali a [ 3 – 6 ]. Den al p o essionals, like all o he heal h wo ke s, also ha e an e hical and deon ological du y o a end o si ua ions which a e ca ego ised as u gen , as by doing so, hey can p e en mo e s ain om being pu on he hospi al eme gency se ices and s op heal hy pa ien s om being in ec ed while wai ing o hei den al ea men in he hospi al [7]. Conside ing he delay in decla ing he S a e o Ala m (a mon h and a hal a e he i s posi i e case was con i med), we conside he si ua ion o den al su ge ies du ing he COVID-19 c isis o be o g ea in e es . Fu he mo e, he equipmen p o ocols o ou ine den al p ac ice do no include he use o FFP2 masks (masks wi h 92% minimum il a ion e iciency) which seem o be necessa y o p e en he i us om sp eading [8]. Social dis ancing and hygiene measu es seem o be he mos e ec i e me hods o con olling he isk o COVID-19 c oss-in ec ion. Gi en he speci ic cha ac e is ics o he COVID-19 i us (a as -mu a ing RNA), he need o u he lockdowns in he u u e, which would lead o a decline in economic ac i i y, canno be uled ou [9]. Al hough he majo i y o he publica ions, ins i u ions, guidelines and public o ganiza ions acknowledge ha he COVID-19 pandemic has an economic and heal h-ca e impac on he den al sec o [ 10 ], ne e heless, he majo i y o s udies on his pandemic add ess ac o s such as he ea o con agion, knowledge abou he pa icula aspec s o he i us o p e en ion p o ocols [2,11,12]. In o de o be able o p opose sa e guidelines and p ocedu es o bo h pa ien s and p o essionals, we mus i s ly be awa e o how den al su ge ies ha e been a ec ed by COVID-19, and o his eason, he main objec i e o his pape was o de e mine he economic and heal h-ca e impac ha he COVID-19 pandemic has had on den is s in he Au onomous Region o Galicia. In . J. En i on. Res. Public Heal h 2020,17, 5139 3 o 9 2. Ma e ials and Me hods This is a desc ip i e obse a ional s udy o which he da a was collec ed by means o a sel -adminis e ed su ey. The s udy was aimed a p ac icing den is s who we e wo king when he S a e o Ala m was decla ed (Royal Deg ee 14/0/2020, no m wi h ank o law) in Spain. This s udy was conduc ed ollowing he STROBE (S eng hening he Repo ing o Obse a ional s udies in Epidemiology) guidelines o obse a ional s udies [ 13 ] and was e alua ed by he Galician E hics Commi ee (Re . IDIS/2020/COVID19-ODONTO). The ques ions o his s udy we e d awn up a e e ising he ele an li e a u e on COVID-19 [14–16]. The ques ionnai e was conduc ed in Spanish and was ini ially es ed by 20 p o essionals in o de o e alua e he esponden s’ unde s anding o he ques ions and o de e mine how long i ook hem o comple e he ques ionnai e. The ques ionnai es we e dis ibu ed ( om 1 Ap il 2020 o 30 Ap il 2020) by he P o essional Associa ions o he egions o A Co uña, Lugo, Ou ense and Pon e ed a o den is s who wo ked in Galicia Communi y (Region o No hwes o Spain) h ough newsle e s and pos s on hei espec i e websi es. The po en ial o ou s udy was calcula ed using Epida 4.2 so wa e (SERGAS, Galicia, Spain). Ou o a o al sample o 2020 den is s, he esponse a e was 19.95%, wi h a 50% he e ogenei y and a 5% ma gin o e o , he e o e a 97% con idence le el was ob ained. The da a was s a is ically analysed using he SPSS .24.0 (IBM, S a is ics, A monk, NY, USA) p og am. The ca ego ised a iables we e desc ibed using equencies and pe cen ages. Con ingency ables we e es ablished in o de o s udy he ela ionship be ween he ca ego ical a iables using he Chi-squa e es , and he deg ee o associa ion was de e mined using C ame ’s V. In o de o assess he isk (OR) o he p incipal a iables, mul inomial logis ic eg ession was used and his was done by ecoding and g ouping he a iables. The signi icance alue was es ablished as p≤0.05. 3. Resul s A o al o 400 den is s om Galicia esponded o he su ey. The dis ibu ion o he esponses is shown in Table 1. The majo i y o he pa icipan s we e women (64.5%), and hal o ou sample g oup was 45 yea s old o younge . Table 1. Responses dis ibu ion. Ques ionnai e I ems No. (%) Sex Male 142 (35.5) Female 258 (64.5) Age 4 (1) Be ween 22–25 108 (27) Be ween 26–35 138 (34.5) Be ween 26–35 79 (19.8) Be ween 56–65 67 (16.8) 65 and olde 4 (1) Type o su ge y whe e you wo k: Exclusi ely p i a e p ac ice 359 (89.9) Exclusi ely public p ac ice 13 (3.3) Public and p i a e p ac ice 28 (7) Do you wo k in mo e han one su ge y? No 218 (54.5) Yes 182 (45.5) How many? 2 98 (24.5) 3-4 58 (14.5) Mo e han 4 24 (6) In . J. En i on. Res. Public Heal h 2020,17, 5139 4 o 9 Table 1. Con . Ques ionnai e I ems No. (%) A e any o hese su ge ies anchises o den al insu ance companies? No 351 (37.8) Yes 49 (12.3) A e age numbe o pa ien s seen pe week: 1–20 25 (6.3) 21–40 98 (24.5) 41–60 140 (35) Mo e han 60 pa ien s 137 (34.3) Speciali y: O al Su ge y and Implan ology 76 (19) Endodon ics 24 (6) Gene al Den is y 241 (60.3) Paedodon ics 12 (3) O hodon ics 37 (9.3) P os hodon ics 10 (2.5) Be o e he S a e o Ala m was decla ed (14 h Ma ch) did you use FFP2 masks in ou ine den al p ac ice? No 383 (95.8) Yes 17 (4.3) Did you manage o p ocu e PPE (Pe sonal P o ec i e Equipmen ) o you sel and you colleagues once he S a e o Ala m had been decla ed? I was unable o p ocu e any PPE 243 (60.8) Yes, I managed o p ocu e caps, FFP2 masks and disposable gowns 44 (11) Yes, I managed o p ocu e caps and masks 26 (6.5) Yes, I managed o p ocu e caps o masks 38 (9.5) Yes, I managed o p ocu e caps, FFP2 masks and disposable gowns. 49 (12.3) Rega ding COVID-19 es : I was no es ed 385 (96.3) I es ed nega i e 11 (2.8) I es ed posi i e 4 (1) I you es ed posi i e, wha ype o symp oms did you ha e? Mild symp oms 8 (2) Se ious symp oms ( equi ed hospi alisa ion) 0 Did any o you employees o non-den is colleagues ( ecep ionis s, den al hygienis s o clinic assis an s) es posi i e o COVID-19? Some o hose who we e es ed came back posi i e 9 (2.3) No one es ed posi i e 18 (4.5) No one was es ed 373 (93.3) Do you know any den is who es ed posi i e o COVID19? No 300 (75) Yes 100 (25) Do you know any den is who died om COVID19? No Yes 390 (97.5) 10 (2.5) Wha pe cen age o pa ien s called o cancel o in o med o hei in en ion o cancel p e iously scheduled appoin men s a e he S a e o Ala m was decla ed on he 14 h o Ma ch? Less han 10% 344 (86) 10–40% 41 (10.3) 40–70% 12 (3) Mo e han 70% 3 (0.8) In . J. En i on. Res. Public Heal h 2020,17, 5139 5 o 9 Table 1. Con . Ques ionnai e I ems No. (%) How many pa ien s did you see pe week du ing he S a e o Ala m? 1–5 pa ien s/week 342 (85.5) 6–10 pa ien s/week 45 (11.3) Mo e han 11 pa ien s/week 13 (3.3) Did any o he pa ien s eques ea men o a si ua ion which hey conside ed o be a medical eme gency bu ha you did no conside as such? No, o less han 10% 254 (63.5) Yes, be ween 10–30% 112 (28) Yes, be ween 31 and 60% 22 (5.5) Mo e han 60% 12 (3) Wha pe cen age o pa ien s exp essed hei dissa is ac ion ega ding he p o ision o den al ca e exclusi ely o eme gency cases? Less han 10% 344 (86) 10–40% 41 (10.3) 40–70% 12 (3) Mo e han 70% 3 (0.8) I you a e he owne o he den al su ge y, did you apply o a TERF ( empo a y employmen egula ion ile) o any o he den al su ge y’s s a ? No 43 (10.8) Yes 219 (54.8) I am no he owne 138 (34.4) I you applied o a TERF, was i app o ed by he go e nmen ? No 19 (4.8) Yes 225 (56.3) I did no apply o i 156 (39) I you wo k a a p i a e su ge y, wha economic losses ha e been caused by he COVID-19 pandemic in e ms o mon hly income? 1,000–4,999 €108 (27) 5,000-9,999 €102 (25.5) 10,000–14,999 €79 (19.8) Mo e han 15,000 €97 (24.3) I do no wo k a a p i a e su ge y 14 (3.5) Ha e any o he su ge ies whe e you wo k closed down? No 348 (87) Yes 52 (13) Economic losses seem o ha e con ibu ed o he applica ions o TERF ( empo a y employmen egula ion ile), as 29.5% o he esponden s who applied o his measu e eco ded losses in excess o € 15,000 (Chi 2 =10.744, C ame ’s V=0.116, p=0.03). Fo losses exceeding € 15,000, he OR o applying o a TERF was 3.248 (CI95% 0.976–10.805, p=0.05) compa ed wi h an OR o no applying o a TERF o 1.895 (CI95% 0.189–19.039, p=0.587). Wi h ega ds o he app o al o he TERF, he OR o su ge ies which did no apply o his measu e, o whose eques was ejec ed, was highe in he cases o su ge ies wi h losses o less han € 15,000 (OR =4.545, CI95% 1.425–14.504, p=0.011), compa ed o hose wi h highe losses, in which he OR o being ejec ed was lowe (OR =3.433, CI95% 2.024–5.822, p<0.001). 33.1% o he male esponden s su e ed losses > € 15,000 compa ed o 19.4% o emale esponden s (OR =3.121, CI95% 1.715–5.679, p<0.001). In he lowe income anges ( € 1000–4999), 32.2% o he emale esponden s su e ed hese losses compa ed wi h 17.6% o he male esponden s (Chi 2 =16.938, C ame ’s V =0.206, p=0.002) (Figu e 1). No signi ican di e ences we e e ealed in ou analysis o economic losses acco ding o special y. In . J. En i on. Res. Public Heal h 2020,17, 5139 6 o 9 Figu e 1. Economics o emale and male losses. The pe cen age o pa ien s ha complained abou he ac ha only eme gency ca e was a ailable du ing he S a e o Ala m (>10% o he pa ien s as he e e ence alue) was highe in den al su ge ies ha do no wo k wi h insu ance companies o anchises, 75% s 25% in anchise su ge ies, (Chi 2 =9.848, C ame ’s V =0.157, p=0.002). The OR o high pa ien complain s (>10%) in non- anchise su ge ies was 2.943 (CI95% 1.463–5.918, p=0.002). Only 4 p o essionals es ed posi i e, 50% o whom wo ked exclusi ely in p i a e p ac ice and he o he 50% who p ac iced in bo h p i a e and public su ge ies. The esponden s who we e no es ed o who es ed nega i e, mainly wo ked exclusi ely in p i a e p ac ice, 90.2% (Chi 2 =6.940, C ame ’s V=0.132, p=0.008). The OR o es ing nega i e o COVID-19 among hose wo king exclusi ely in p i a e p ac ice was 9.154 (CI95% 1.254–66.808, p=0.029). Den is s who p ac ice in he public sec o saw mo e u gen pa ien s pe week han hose p ac icing in p i a e su ge ies (Chi 2 =12.749, C ame ’s V =0.126, p=0.013) (Figu e 2). The OR o seeing mo e han 11 u gen pa ien s pe week was 6.270 o public su ge ies (CI95% 1.933–20.339, p=0.002). Figu e 2. Pa ien s pe week du ing he S a e o Ala m in public and/o p i a e su ge y. 4. Discussion A o al o 400 den is s esponded o his su ey, he majo i y o whom (64.5%) we e women, wi h he highes le els o pa icipa ion om he 36–45 age ange (27%). The esponse a e was low, howe e , his was p obably due o a lack o mo i a ion amongs p o essionals gi en he ha shness o he si ua ion. In e ms o gende , ou pa icipa ion esul s a e simila o p e ious emo e and/o physical su eys, whe e he pe cen age o emale pa icipa ion anges om 66–75% [ 17 , 18 ]. The majo i y o ou esponden s (89.9%) ca y ou hei ac i i y in a p i a e den al su ge y, and his is simila o he esul s In . J. En i on. Res. Public Heal h 2020,17, 5139 7 o 9 ob ained in o he consul ed su eys abou COVID-19 (74%) [ 18 ]. The signi ican link be ween gende and specializa ion can be seen in o al su ge y (29.6% men s 13.2% women) and in paedodon ics (4.3% women s 0.7% men) and o hodon ics (11.2% women and 5.6% men). This is in line wi h he esul s o o he s udies ha e eal ce ain p e e ences among men and women o specializa ions [19]. Despi e equali y policies, he loss o pu chasing powe amongs he emale gende , seems o be pe pe ua ed o e ime [ 20 ]. Some s udies sugges ha women educe hei wo king hou s when hey ha e child en. Gi en hese economic epe cussions, i seems easonable ha he di e ence in loss should be signi ican be ween he wo g oups [21]. 1% o esponden s con i med ha hey had es ed posi i e o COVID-19. Conside ing he high isk in ol ed in adminis e ing any den al ea men , i seems ha Spanish den is s ha e ollowed he guidelines and ecommenda ions o he di e en ins i u ions wi h sound judgemen [ 22 ]. I is e iden ha he e has been a dec ease in he numbe o pa ien s seen du ing he S a e o Ala m, wi h he majo i y o he esponden s (85.5%) seeing be ween 1–5 pa ien s pe week ollowing he ecommenda ions o ea only u gen si ua ions [6,23]. PPEs seem o be essen ial in o de o be able o p o ide ca e in a sa e manne and o con ol c oss-in ec ion [ 24 ]. Acco ding o ou da a, mo e han 60% o he esponden s we e unable o ob ain any ype o p o ec i e ma e ial, and only 12.3% we e able o ob ain his ma e ial including FFP2 masks. This da a coincides wi h he su ey ca ied ou by he SESPO (Spanish Socie y o O al Public Heal h) [ 25 ]. In ou case, he e we e no di e ences be ween hose su eyed in he i s hal o Ap il and in he second hal o he same mon h (p=0.506) ega ding he acquisi ion o PPEs, he e o e showing ha he e we e no imp o emen s in e ms o he p o ision o his ma e ial o e he cou se o he mon h. We belie e ha his was due o he ac ha public heal h ca e uni s had p io i y o ecei e PPEs. The Spanish Go e nmen has aken some measu es o educe he economic impac o COVID-19 in he mos a ec ed sec o s. The economic losses o he esponden s we e, o he mos pa , (27%) be ween 1000–4999 eu os, ollowed by 5000–9999 eu os (25.5%). The compa a i e analysis e lec s a highe a e o TERFs eques ed in he cases in which he economic loss was g ea e (p<0.01) , as well as he a o able esponse o said eques s (p<0.01). In o de o educe he economic c isis, hose companies o ced o close down o educe hei wo king hou s could bene i om he TERF, jus i ied h ough echnical, o ganiza ional o p oduc ion easons. Du ing his si ua ion, e en hough he wo ke does no wo k o educed he o his wo king day, he pay oll and he con ibu ion is assumed by he S a e. Al hough we ha e ound pape s ha eco ded he loss o pa ien s and e enue in den al su ge ies due o he impac o SARS CoV-1 (16%) [ 26 ], speci ically in he Taiwan a ea, we ha e no ye ound any pape s ha add ess he economic impac o COVID-19. Wi h ega ds o he pa ien s’ a i ude o he implemen a ion o he S a e o Ala m and special den al ca e si ua ion, he majo i y o he esponden s (86%) s a ed ha none o hei pa ien s o less han 10% had complained abou i , al hough 10% o he esponden s s a ed ha 10–40% o hei pa ien s had exp essed hei dissa is ac ion. On he o he hand, 28% o he esponden s s a ed ha 10–30% o hei pa ien s eques ed an appoin men o wha he den is conside ed as non-eme gency ea men . Likewise, he esponden s who pe o m hei ac i i y in non- anchise den al su ge ies o do no wo k wi h den al insu ance companies epo ed signi ican ly di e en pa ien esponses (p=0.008). All he esponden s who claimed ha “mo e han 70% o he pa ien s had complained abou his new si ua ion”, wo k in non- anchise den al su ge ies. We hink ha hese esul s mus be in e p e ed cau iously. F anchise den al su ge ies ha e a di e en o ganiza ion whe e mos o he ime he e is a ecep ionis o an auxilia y ha deals wi h pa ien ’s complain s o iage, while in he non- anchise den al su ge ies (and aking in o accoun he possibili y ha he owne has sen mos o hei pe sonal s a o TERF) he den is can pe o m his ask. This means ha pa ien complain s may be simila bu , as we ha e only asked den is s, i is likely ha he wo k o egis e ing hem in some cases has been done by ano he s a membe . One o he limi a ions o his s udy was he exclusi e use o sel -adminis e ed online su eys. Ano he limi a ion was he ime in which his su ey was a ailable ( om 1 Ap il 2020 o 30 Ap il 2020), In . J. En i on. Res. Public Heal h 2020,17, 5139 8 o 9 and he ac ha when he su ey was comple ed, he S a e o Ala m was s ill in o ce in Spain, he e o e meaning ha he economic losses may be g ea e han hose assessed in his su ey. Ano he limi a ion o his s udy is ha i did no conside any economic aids o he han TERFs, and ha TERF has only been analyzed as an economic ac o , when i also has assis ance epe cussions, as he company has less wo ke s o pa ien ca e. This is a pilo s udy, and in u u e esea ch ou g oup in end o inc ease he sample size o he whole e i o y o Spain, add ques ions such as knowledge abou COVID-19 in he den is y communi y, isk pe cep ion and ea on ea ing pa ien s. Discussions abou u u e challenges in den is y include new si ua ions as den al ele assis ance, which should be limi ed scien i ically and deon ologically. Adjus men o his new eali y is una oidable and hese new aspec s equi e conside a ion o den al p o essionals and pa ien s. 5. Conclusions The COVID-19 pandemic has had economic epe cussions in den is y as only u gen ea men could be a ailable du ing he S a e o Ala m. These epe cussions seem o be highe in male pa icipan s, as he majo i y o hem ha e e ealed highe losses han emales. The le el o assis ance has also been a ec ed, educing he numbe o ea ed pa ien s, al hough his quan i y has been di e en in p i a e and public su ge ies. By p esen ing hese indings we highligh he ole ha den is s play in socie y in ea ing den al eme gencies in ou su ge ies, and his mus be ecognized and add essed by he ele an au ho i ies, who mus p o ide PPEs as a p io i y o his g oup as well as p o iding special economic aid in acco dance wi h he losses incu ed by he sec o . Au ho Con ibu ions: Concep ualiza ion, C.C.-P.; me hodology, M.P.-S.; J.S.-Q.; o mal analysis, B.R.-M.; in es iga ion, C.M.C.-P.; da a cu a ion, J.M.S.-Q.; w i ing—o iginal d a p epa a ion, M.A.R.-F.; w i ing— e iew and edi ing, A.S.-M. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch ecei ed no ex e nal unding. 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