IMPACT OF COVID 19 IN SEEKING DENTAL CARE

Authors:
Adapang, Graille Sarra
Agbanlog, Roa Joy
Ahmed, Ruba
Alfonso, Joshua Benjamin
Barte, Kiara Dominique
Guibone, Rodrigo
Mendoza, Lara Andrea
Santos, Charmaine Abigail
Udaundo, May-An

INTRODUCTION

Coronavirus (COVID-19) is an illness caused by the virus, SARS-CoV-2, that can be

spread from person to person. It mainly affects the upper and lower respiratory system which
could then lead to pneumonia, respiratory failure, septic shock, and death. This virus was first
discovered in Wuhan, China and was first thought to have jumped from an animal host to
humans. Before the declaration of the pandemic, most cases were only seen within China, people
who have traveled there, and those traveler’s close contact. As the total number of infected
individuals rose, the spread of the virus was growing rapidly and extended outside of China and
to almost all countries worldwide. This outbreak was announced as a pandemic on March 11,
2020. A lot of establishments and offices temporarily or even permanently closed due to the
protocol that was imposed and mandated by the government. It resulted in an increase in the
number of unemployed individuals in our country that created obstacles in accessing oral health
care.
The Philippine government announced that the entire country will be placed under state
of calamity until September 2021 and that home quarantines are to be implemented due to the
increasing number of Covid-19 cases. Multiple cities in the Philippines have been placed on
lockdown to prevent the virus from spreading further. The lock down inhibits people from going
outside unless absolutely necessary, this greatly affects the lives and most especially work or
sources of income of the Filipino people causing a decline in the economy. One of the areas that
has been under strict lockdown is Luzon. With it making up 57.2% of the country’s population,
the country’s economy has been terribly affected.
The unemployment rate at the start of the year (January 2020) has increased substantially
due to the coronavirus pandemic. Unemployment rate in the Philippines has reached a very high
percentage of 17.7% (April 2020) due to the COVID-19 pandemic, with around 7.3 million jobs
lost, as stated by Philippine Statistics Authority (PSA).
The COVID-19 pandemic forced itself into the lives of people and put the economy of
the world into recession. Since it is utmost important to impede the spread of the virus, many
businesses were forced to reduce operations or shut down, and an increasing number of people
were expected to lose their jobs. The crisis highlights the need for urgent action to cushion the
pandemic’s health and economic consequences, protect vulnerable populations, and set the stage
for a lasting recovery.
The economic damage is mounting across all countries, with alarming speed, causing far
greater challenges for the already-weak economic growth of the Philippines. Due to the
pandemic, millions of Filipinos became unemployed causing the Philippines’ GDP to plummet
by 16.5% from April 1 to June 30. In the face of this disquieting outlook, the immediate priority
for policymakers is to address the health crisis and to rebuild both for the short term and long
term by strengthening health services and concocting measures for economic growth.
The dental industry as part of the service sector of the Philippine economy has had
unprecedented revenue decline due to the dental office closures, whether temporary or
permanent, home quarantines, the patient’s hesitance and many interrelated factors. As the
economic survival of the dental industry is continually challenged, a greater concern relating to
the public’s dental health is just as alarming as the devastating socio-economic effects of current
pandemic such that a severely decayed tooth, impacted 3rd molars and other oral health issues can
worsen over time, and sometimes, become irreversible if no proper intervention and actions are
taken.
Fear and anxiety could be some of the main reasons why people are not seeking dental
care during these times. Mild anxiety is known to foster preventive behavior. At this rate, people
with persistent anxiety are more likely to make the decision to shelter themselves form any
situation that could cause them any increased stress. Consequently, we want to find out if the
dental clinics’ standard universal precautions (e.g., Assessing signs and symptoms of patients;
recording patients’ body temperature; taking patients’ recent travel history before scheduling
their procedures; as well as frequently cleaning and disinfecting public contact areas), would
make people feel safer and therefore be more courageous about visiting the dental clinic or fear
only play a small part in why people are reluctant to do so. The bigger issue could be that people
can no longer afford dental care services.
We have chosen this study to know if people will still seek oral health care during this
trying time where recession is felt by many. We chose Maslow’s Hierarchy of Needs to identify
the level in where the dental care belongs and to know also if the target respondents will
prioritize dental care after knowing that it is one of the necessities of people.
This research records the findings of a study conducted to establish whether
unemployment and the effects of COVID-19 on the country’s economy will impact working
individuals in prioritizing dental care. For the time being, the little money or decreased salary of
people are being spent on basic necessities, such as food, medicine and other expenses which
include gadgets or WIFI needed for online classes. We hope that by the end of our study, we can
finally pinpoint the main reasons why there is such a decline in dental care services demand.

Conceptual Framework/ Theoretical Framework

Human motivation is the force that guides behavior which can be fulfilled by attaining
various needs which can encompass human desires ranging from basic, tangible needs of
survival to a more complex, emotional need that involves the psychological well-being of an
individual. Abraham Maslow defined need as a physiological or psychological deficiency that a
person feels the compulsion to satisfy, and so he derived a theory of hierarchy in a pyramidal
form, which means that a need at any level only comes into play after a lower ‐level need has
been satisfied. The base of the pyramid is perceived as the most important need, while the apex
of the pyramid shows the least need for survival, rather it is self-fulfillment that varies from
person to person.
The first to be satisfied is the Physiological or biological needs; these are bodily needs
that are necessary for our physical bodies to survive. The second level is the safety or security
needs, wherein the feeling of being free from danger, threats, or deprivation is achieved. The
third tier presents the need for love and belongingness, Maslow realized the need to interact with
friends, family or those whom you share similar beliefs and give you a sense of connection as
reinforcement to continue social relationships. Esteem needs come in fourth; it comprises things
that boost people’s self-esteem from being able to achieve goals and accomplishments, the self-
satisfaction you receive from accomplishing these goals provide an impetus to establish new
goals and begin the cycle again. The top tier satisfies a person’s self-actualization; to achieve this
level, people must be relatively free of illness, sufficiently satisfied in their basic needs,
positively using their capacities, and motivated by some existing or sought-after personal values.
A person at this level often wants to help others achieve their goals by teaching from experience,
lessons he or she learned in earlier stages.
“In times of extreme uncertainty, people are first attracted to whatever will provide
security and safety before they will attend to the higher up needs.” (Keeping Your Dental
Practice Successful During COVID-19 Part , Square Practice, Apr 9, 2020 ) In Maslow’s
Hierarchy of Needs, we are reminded that physiological needs such as food, water, warmth and
rest must be met before they can consider pursuing higher up needs. Personal safety and security
are on the second level. During a pandemic, when someone loses a job, the first thing they will
secure is basic survival. People don’t have easy access to foods and cash and personal comforts
that they once took for granted. Above all, there are risks that currently challenge our personal
safety and routine habits.
Figure 1. Maslow's hierarchy of needs comprising a five-tier model of human needs, often
depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the
needs are: physiological, safety, love and belonging needs, esteem, and self-actualization.

Note. From “Maslow's Hierarchy of Needs,” by Saul McLeod, 2020,

https://www.simplypsychology.org/maslow.html

In Maslow’s hierarchy of needs, dental care falls more specifically on “Safety needs” as
it is a part of the overall health of the person. The oral cavity is a small portion of the human
being, but the meaning of health does not exclude one because every part affects the whole. The
importance of knowing about the hierarchy of needs in relation to dentistry is to remind us that it
is essential to get to know our patients and respect their individual choices and situations. We
chose this theory to help us understand that patients have priorities that are far more important
such as basic necessities for everyday living. This would help us recognize the reasons of the
patients in delaying oral health care during the pandemic.

Employment
Securing payment plans for a patient often exposes a conflict of needs. A person must
ensure that basic needs of food, housing, and clothing are met first, yet there may be a desire to
meet social needs by improving appearance with some form of dental treatment. The problem
arises in the decision-making process when the patient is confronted with conflict on how to
satisfy all these needs with a specified income. In order to know the reason for delay, we must
determine the patient’s needs and realize the potential conflict. An individual makes choices
voluntarily, although basic physiological and environmental needs have a strong influence.
In March of 2020, the people of the Philippines were asked to stay at home to help
prevent the spread of the virus. Many establishments and businesses temporarily or even
permanently closed amidst the Covid-19 pandemic crisis causing thousands of people to go
unemployed and face financial struggles. With the tight budget, most families prioritize their
basic needs, paying bills and also gadgets and WIFI for online classes. People spend less on
things they considered as privileges rather than needs (e.g., buying clothes, transport, eating out
and even dental services.). This crisis has changed the way people prioritize and access health
care due to financial constraints (not everyone is financially capable to spend for dental services;
Majority of Filipino families live under the poverty line) and the mindset that dental fees are
expensive and that it is better to spend on essential things.

Health
We also need to look out for our own mental health and wellbeing, and that of each other.
Fear and anxiety about a new disease and what could happen can be overwhelming and cause
strong emotions in adults and children. Public health actions, such as social distancing, can make
people feel isolated and lonely which can affect their mental state. In connection to dental health,
people fear going outside and would rather live through the pain than to seek dental services and
receive treatment. (CDC, 2020)
Even if a patient is strong and healthy, that does not make them immune to COVID-19.
This being said, patients steer away from the dental clinic during these times, because of the
increased risk of not only contracting the virus, but possibly passing the virus onto a family
member. Among adults, the risk for severe illness from COVID-19 increases with age, with
older adults at highest risk, often in people who are older than 60 years. Furthermore, people of
any age with some conditions (e.g., cancer, chronic kidney disease, COPD, obesity) are at
increased risk of severe illness from COVID-19.

Personal Security
 Communications concerning patient and provider safety are critical. Surveillance and
monitoring are needed to confirm whether transmission of COVID-19 occurs in the dental office.
According to the WHO, non-essential dental care should be delayed during the pandemic so not
all dental procedures are available. It is recommended that only priority be given to urgent or
emergency oral cases and in the treatment of patients. Dental workers should avoid or minimize
procedures that may generate aerosols, which could easily spread the infection and prioritize the
use of hand instruments in dental cases.
The dental profession will need to consider a number of unanswered questions; for
example, whether the workflow and layout of dental clinics should be permanently reorganized,
and whether expanded PPE is warranted for care of all dental patients as part of Standard
Precautions. Dental care providers should be prepared to assist patients in understanding their
dental insurance benefits, which may have changed due to the pandemic. Dental care providers
are also enforcing the highest infection control standards in the dental clinic because the patient's
health and safety are always prioritized. With the ongoing pandemic situation, they maintain the
strict disinfection and sterilization protocols to help the patient feel and be secure in returning to
the dental clinic.
In the patient's perspective, most of them assume that they might put themselves at risk
by going to the dentist due to the pandemic. Remember, delaying care is not advisable, and
preventive care is crucial. Delaying dental treatment may progress the oral problem and end up
as an emergency dental case that will cost even more.

Resources
Accessibility in seeking dental health care has become almost impossible due to the
overwhelming fear brought by the virus. Dental officer in WHO’s Department of
Noncommunicable Diseases, Benoit Varenne, says 75% of survey respondents reported dental
services have been completely or partially disrupted because of the COVID-19. He says the
high-level of disruption is linked to the nature of the work provided by the oral health care
personnel.
As the dental clinics were advised to close at the increasing cases of coronavirus infection
in the country as with the resumption of routine dental care, issues regarding dental care services
were deemed at a high-risk of transmission due to the nature of the profession which requires
close-proximity to the patient’s oropharyngeal region with procedures generating droplets and
aerosol which are the established modes of transmission of this infection(Aldahlawi, Afifi, 2020)
possibly leading to the nosocomial spread in the dental health care setting(Kochhar A., Bhasin,
Kochhar G., 2020).

Equipment
Risks in Dental Materials
Transmission of the virus is increased in the dental setting due to the close interpersonal
contact between individuals involved and by nature of the procedures performed during the
delivery of dental care. “As you know, dentists, dental nurses, hygienists, and dental assistants
work in close contact with patients and are exposed to saliva and blood, and as so, they are using,
what we call, spray-generating equipment and all this equipment are generating, what we call,
airborne particles or aerosol," said Varenne. Airborne contamination during dental procedures
may come from a variety of sources. Foremost among these are: dental instrumentation, salivary,
and respiratory sources. Dental handpieces, ultrasonic scalers, and the air-water syringes used in
common dental practice can produce aerosols, which are usually a mix of air and water derived
from these devices and the patient’s saliva. Dental instruments, surfaces within the dental
operatory, and dental equipment, when improperly cleaned, sterilized, and stored, or disinfected
can also serve as fomites and contribute to cross-infection (Geisinger, 2020). The risk of self-
contamination and cross-contamination to both the patients and the dentist through dental
instruments, devices, handpieces, contact surfaces and equipment wherein there is an inadequate
preparation for the current situation and an inadequate precaution taken such as failure in
environmental infection control and isolation gowns are not changed for every patient seen in the
dental setting is of urgent concern (PDA, 2020).
Due to some deeply evolved responses to disease, fears of contagion lead us to become
more conformist and tribalistic, and less accepting of eccentricity. Our moral judgments become
harsher and our social attitudes more conservative.
These reasons may explain why many oral health care providers are anxious about
returning to work, and many patients may be hesitant and reluctant in seeking dental care. (Brian,
2020)
Paradigm of the study

Independent variable:
(a)COVID-19 pandemic & Dependent variable:
(b) lockdowns (c) Seeking dental care

Moderator:
(d) Filipinos with or without family
who are currently employed and
living here in the Philippines
particularly in Luzon.

Figure 2. (a)COVID-19 pandemic – Coronavirus (COVID-19) is an illness caused by the virus,

SARS-CoV-2, that can be transmitted from person to person. It has spread worldwide;
(b)lockdown - a temporary condition imposed by governmental authorities in which people are
required to stay in their homes and refrain from or limit activities outside the home involving
public contact; (c)Seeking dental care – visit to the dentist for a dental treatment; (d)Filipinos
who are currently employed and living here in the Philippines particularly in Luzon.

Significance of the Study

Oral health is an integral and core component of overall health and well-being
(Heilmann, Tsakos, Watt, 2015). This is one of the reasons why we want to highlight the
importance of oral health care’s role in reinforcing good health and boost the people’s
confidence in health care provision in this time of adversity as the people’s fears continually
grow. Moreover, the impacts of disregarding oral health care and seeking dental services also
affects a person’s self-esteem, reduced productivity, general health problems, and in the long run
could lead to expensive treatment costs and discomfort.

Objectives of the study

● To determine the association of the respondent's frequency of visit to the dentist or dental
facility and respondent's civil status.
● To determine the level of impact of COVID19 in seeking dental treatment along the areas
of health, resources, and equipment.   
● To compare the level of priorities according to the respondent’s priorities in relation to
their dental visits before and during the pandemic.
METHOD

Research Design
This study will make use of descriptive survey research design since our study is about a
current issue and it describes a population as our respondents and affected citizens, present
situation which is the pandemic, and the phenomenon that shows the effects of the pandemic as
to why people do not prioritize seeking dental treatment. It focuses on answering the how, what,
when, and where questions If a research problem, rather than the why. This design is used to
report the way things are at a specific point in time. In this case our research takes place during a
global pandemic and is only valid during this time. The descriptive-survey is intended to
describe/explain the reasons behind the delay in seeking dental care and services to the
employees with or without family through a Modified Impact Scale in a form of questionnaires
as data-gathering tool to suit our problem. The reason for carrying out descriptive research is to
describe the data and characteristics and find out the cause of something that is considered very
important. The research tool is designed to bring out the features embedded in the research
problems using quantitative approach.

Sample/ Population of the Study

Our target population are the employed Filipinos with family (married and with child/ren)
and those without family (single). Both groups have common characteristics of being employed
with the financial capability of regular dental check-ups even before the pandemic
Sample size is determined in 2 steps:
1. Calculate the sample size for infinite populations.
2. Adjust the sample size to the required population.

S= Z2 x P x (1- P) / M2
S= sample size for infinite population
Z= Z score
P= population proportion (assumed to be 50% = 0.5
M= margin of error

Z score is determined based on confidence level

Confidence level: the probability that the value of a perimeter falls within a specified range of
values

Table 1

Computation of Confidence level

Confidence level Z- Value

90% 1.645

95% 1.960

99% 2.576

Note. Adapted from “My Easy Statistics: How to Determine Sample Size,” by G. N. Kumar,
2017, https://m.youtube.com/watch?v=51NS0cGjBlk.

*Confidence level = 1.645

*Z- score = 1.645
Margin of error = small amount that is allowed for in case of miscalculation or change of
circumstances.
Generally, we take margin of error as 5%
*M = 0.05

● Z-score = 1.645
● P = 0.5
● M = 0.05

STEP 1
S = ( Z-score)2 x p ( 1- p) / ( margin of error)2
= (1.645)2 x 0.5 x (1- 0.5) / (0.05)2
= 2.706025 x 0.5 x 0.5 / 0.0025
= 0.67650625 / 0.0025
S = 270.6

Thus, sample size for infinite population is 270.6

Adjust the sample size to the required population

Total population of Luzon: 63,075,303
Employment rate: 72.7%
Population = 72.7% of 63,075,303
= 45,855,745
Then, use the following formula for adjusted sample size
Adjusted sample size = (5) / 1+ [(S-1) / population]

STEP 2
Adjusted S= (S) / 1+ [(S-1) / population]
= 270.6 / 1+ [(270.6-1) / 45,855,745]
= 270.6 / 1.00000588
 Adjusted S= 270.5984088813558
= 271
Thus, sample size for 45,855,745 is 271.

Data Gathering Tools

Quota sampling under non-random sampling will be utilized as sampling technique; the
reason is that we have an important characteristic that must be followed or met which is the
participants must be employed.
We will utilize questionnaires as our data gathering tool. (Questionnaires through google
form). A modified scale that we constructed will be used as our guide.
 
Table 2

Impact Scale in the Delay of Seeking Dental Treatment

SCALE DESCRIPTION
High Impact
Strongly agree describes that the
respondent is always in favor of the
particular statement presented in
STRONGLY AGREE the given questionnaire . The dental
health is important; there is a delay
in seeking dental treatment.

Moderate Impact
Agree describes that the respondent
is in favor of the particular
statement presented in the given
AGREE questionnaire; dental health is
moderately important and there is a
slight delay.
 Low Impact
Disagree describes that the respondent
DISAGREE is not in favor of the particular
statement presented in the given
questionnaire. dental health is not
important; delay is irrelevant

Note. Adapted from “An enhanced multi-objective optimization approach for risk allocation in
public-private partnership projects: A case study of Malaysia” by A. Valipour, Y.
Mohammadreza, R. Mohamad zin, N. Yahaya, N. Noor, 2014, p.25.

Data Gathering Procedure

In our data gathering procedure, 271 employed individuals from Luzon were chosen,
classifying them into two categories: with family and with no family. These people will represent
the population. We will determine it through calculating the sample size for infinite populations
and adjusting the sample size to required population.
Since the researchers are from Luzon, sampling was done to focus on people from this
area, and given the pandemic, we are more confident in reaching participants at a nearer vicinity.
Survey questions were formulated in relation to the impact of Covid-19 in the delay of seeking
dental treatment. These survey questionnaires will first be subjected to validity and reliability
tests, and then are distributed through google forms to be sent to qualified participants.
For our study, we will be using both Electronic processing and manual processing. Then,
the collected data in research is processed and analyzed to come to some conclusions or to verify
the hypothesis made. In processing our data, we will be doing:1. Editing of the data; 2. Coding of
data; 3. Classification of data; 4. Tabulation of data.

Treatment of data

We will be using the Chi-square test as the statistical treatment. This will be utilized to
compare the frequency of dental visits of the two groups. Our two groups are Employed Filipino
citizens with family(Married and with children) and Employed citizens without family(Single).
Chi-square test in the SPSS trial version will be used to determine if there is a significant
difference in the dental visits of the two classifications.

Ethical consideration
The supreme goal of any profession is to provide quality and standard services to people.
Professions are governed by a set of rules and ethical principles to achieve these goals. Ethics is
a belief that determines people's behavior and resides in the realm of human values, morals,
individual culture interpersonal belief, and faith.
The researchers must strictly follow the safe and ethical manner in conducting the study
while observing any possible violations and consequences of those actions. These violations can
arise in any parts of the research from the statement of the problem, objectives/hypothesis,
review of the literature, research design, questionnaire design, data collection procedures, data
editing, statistical methods, analysis of data, conclusions, and even as simple as the references
used. Ethics are to be applied throughout the phases of the research. There is no clear moral
compass that perfectly meets the requirements of a certain study, places and individuals to guide
the researchers when facing the problems regarding what is good and bad but through applying
the ethics guidelines in the research will greatly help in keeping the participant’s welfare interest
in the research and the benefits it will provide.
Given this situation, the dentist should be knowledgeable and be able to analyze and
attempt to resolve any issues arising in delaying of seeking dental care. The goal in mind is to
give a safe dental service amidst the COVID-19 pandemic for the patient to have the security
they need from the fear of infection and the dental care they deserve.
Hence, the present study was conducted to assess the ethical challenges in dental practice
and to determine the possible probabilities of the cause of delay. Dental professionals felt a
moral duty to reduce routine care for fear of spreading COVID-19 among their patients and
beyond but were understandably concerned about the financial consequences and shouldn’t
launch personal attacks against any individual, as ethics as it also lies in the fact that it can
develop shared feelings with others and makes one committed to one’s own personal
responsibilities and actions. 
 In practice, these ethical principles mean that, it needs to obtain informed consent from
potential research participants; minimize the risk of harm to participants; protect their anonymity
and confidentiality; avoid using deceptive practices; and give participants the right to withdraw
from our research. While getting information or data, we should keep it confidential and
anonymous. Our goal is to successfully do our research on the impact of Covid-19 pandemic on
the delay to seeking dental care without bringing harm, threat, or any discomfort to our
respondents.

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