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Working Title Exploring the Impact of COVID 19 on Dental Office Staffing in Indiana Keywords Dental Care Dental Workforce COVID 19

Abstract Introduction The COVID 19 pandemic resulted in a massive deceleration of many dental care procedures The impact of COVID 19 on dental practices has been examined at a national level through sample surveys administered by the American Dental Association However minimal information was available on the specific impact on Indiana dentists and dental office staffing Methods In July 2020 the Indiana Dental Association IDA distributed a survey to all Indianalicensed dentists to understand operational and employment characteristics of dental practices Dentists IDA survey responses were merged with demographic and practice information collected during dentist 2020 license renewal Descriptive statistics were conducted using chisquare analysis Multivariate logistic regression was conducted to assess dentists characteristics associated being staffed at full capacity or having clinical staff leave their practice because of COVID 19 Qualitative analysis was also conducted to identify emerging themes from openended questions Results A total of 403 respondents were successfully matched to license renewal data and had complete data for study variables A slight majority of dentists reported their practice was staffed at full capacity 59 8 and over a third of dentists 37 2 reported staff departures related to COVID 19 Dentists were less likely to report being fully staffed if they were non White accept new Medicaid patients and work in a group practice Dentists accepting new Medicaid patients were more likely to report staff departures due to COVID 19 Emerging themes from the qualitative analysis included clinical challenges n 90 financial challenges n 46 or increased

costs due to supply of personal protective equipment and disinfection protocols n 51 Discussion These results demonstrate that COVID 19 has had a major impact on Indiana dental practices and related staffing National data collected by the ADA also validate these state level findings Recent guidance documents for dental settings provided by the Centers for Disease Control and Prevention may indefinitely impact clinic flow staffing needs and general costs for equipment that are necessary to accommodate these new protocols Implications As Indiana dental offices respond to policies associated with the pandemic there is a need to examine and monitor the impact of these changes on the future of the dental workforce As new protocols have implications for access to COVID 19 vaccines and dental safety nets monitoring dental workforce supply and demand will be critical to ensure an oral health workforce is available to serve Indiana s oral health needs

Introduction The coronavirus disease COVID 19 has had an unprecedented impact on oral health care delivery in the United States Agency for Healthcare Research and Quality 2020 Skinner 2020 1 On March 11 2020 as COVID 19 cases began to surge the World Health Organization declared a global pandemic Cucinotta Vanelli 2020 2 Many governors issued executive orders related to the postponement of elective dental procedures and the American Dental Association ADA called upon all dentists to do the same American Dental Association ADA 2020 3 In response most dental offices across the United States closed their doors to all but emergency appointments Dental care delivery was at a standstill until late April to early May 2020 depending upon the location and state local regulations Skinner 2020 1 As executive orders regarding elective dental procedures were lifted and dental offices reopened new challenges such as the availability of personal protective equipment PPE staffing changes and lower patient volumes emerged ADA 2020d Kranz et al 2021 4 Assessing the initial and ongoing impacts of COVID 19 on the delivery of dental care has been a priority of dental health services researchers Amato et al 2021 Bekes 2021 Diab et al 2021 dos Santos et al 2021 Gurenlian 2021 Kranz et al 2021 5 Much of the early research published about COVID 19 and dental care focused on transmission risks and other implications for clinical dental care and dental education Ather et al 2020 Elangovan et al 2020 Estrich et al 2020 Iyer et al 2020 Ren et al 2020 6 To date few studies have examined the impact of COVID 19 on dental care and dental practices in the United States Existing studies are national in nature and have relatively small samples Amato et al 2021 Baracco et al 2021 Bekes 2021 Diab et al 2021 dos Santos et al 2021

Gurenlian 2021 7 However the ADA Health Policy Institute HPI has been tracking the economic impact of COVID 19 on dental practices since March 2020 by administering surveys to a national panel of dentists ADA n d 8 In April 2020 97 of dentists who responded to the ADA survey reported that their practices were either closed completely or closed except for emergency patients ADA n d 8 As states lifted restrictions on elective dental procedures the majority of dentists reported that their practices were open by mid August however almost half of them reported lower than normal patient volumes ADA n d 8 This trend of dentists reporting lower patient volumes persisted throughout the remainder of 2020 and has continued into 2021 demonstrating the ongoing impact of COVID 19 on dental care in the United States Dental office staffing emerged as a challenge during the pandemic The ADA s ongoing survey gathers information regarding a dentist s ability to pay staff but no additional information regarding staffing has been reported ADA n d 8 Most reports on dental office staffing challenges associated with COVID 19 are either anecdotal or discussed in the context of previous research Burger 2020 Hunter 2020 Lanthier 2021 Randall 2020 Tepichin 2020 9 However a recent collaborative study of the ADA and the American Dental Hygiene Association ADHA examined dental hygiene employment during the pandemic in the United States and identified reductions in the workforce capacity associated with dental hygienists voluntarily leaving practice being furloughed or being terminated from their positions Gurenlian 2021 10 Among the top issues contributing to the decision to not return to work dental hygienists reported a desire to wait until after the pandemic is under control and concerns regarding workplace safety Gurenlian 2021 10 Although this important study contributes to research on the impact of COVID 19 on dental office staffing in the United States it is unclear whether these findings apply at the state level Gurenlian 2021 10 Additionally no studies

have examined the impact of COVID 19 on other dental office staff such as dental assistants or front office personnel or whether staffing challenges are a global issue or one that disproportionately affects certain dental practices with similar characteristics National studies are helpful for producing national estimates and monitoring trends but may not account for state level variations in policy that may impact dental care Such variations may be due to executive orders impacting dental care delivery during the pandemic and occupational regulation of dental professionals As a result state level studies are needed to contextualize national findings and generate information reflective of a state s dental care environment In this context the Indiana Dental Association IDA conducted a statewide survey of the impact of COVID 19 on Indiana dentists in the fall of 2020 The objectives of this study were to determine the extent to which COVID 19 impacted dental office staffing and whether dentist characteristics were associated with a greater likelihood of staffing challenges This information is critical for informing state level policy and planning

Methods A mixed methods approach was used for this observational study In July 2020 the IDA developed and administered a survey to gather quantitative and qualitative information from Indiana dentists on the operational and employment characteristics of their dental practices The survey was administered electronically through SurveyMonkey An email invitation to complete the survey was sent to 3 093 dentists for whom the IDA maintained contact information The survey remained open for a period of four weeks after which the collected survey data were exported into Excel and formatted for descriptive and statistical analyses The survey data also contained the unique Indiana license number for each IDA affiliated dentist Using the unique license number IDA survey data were merged with license and supplemental data collected by the Indiana Professional Licensing Agency PLA from Indiana dentists during the 2020 state license renewal period December 2 2019 March 1 2020 just prior to the COVID 19 pandemic Vaughn 2020 11 This data served as the source of information on characteristics of dentists who provide direct patient care to Indiana residents Dentists in the merged study dataset were included in the study sample if they had completed IDA and PLA data Two outcomes associated with dentists self reported staffing experiences were analyzed 1 whether dental practices were fully staffed at the time they completed the survey and 2 whether dentists reported that staff resigned or retired due to COVID 19 To assess the relationship between characteristics of dentists and their practices and dental office staffing several covariates were included in the analyses which are listed in Table 1 Dentists demographic characteristics explored in the analyses included age gender and race Practice characteristics were dental specialty practice type Medicaid participation status whether a Medicaid participating dentist was accepting new Medicaid patients sliding fee scale

participation practice geography and whether the practice was located in a dental Health Professional Shortage Area dental HPSA Health Resources and Services Administration n d 12 Additional information on study variables from the supplemental survey administered during the biennial license renewal period for dentists is available in the 2020 Indiana Oral Health Workforce Data Report Vaughn 2020 11 Table 1 Summary of reclassification for study variables Variable Age Race Medicaid Acceptance Status Medicaid Service Status Sliding Fee Scale Status Dental Specialty Practice Type Rurality Dental HPSA Study Variable Classes Under 35 35 44 45 54 55 64 65 and older White Other Native Hawaiian Pacific Islander Black or African American Asian Other Two or More Races Not accepting new Medicaid patients Accepting new Medicaid patients Not serving Medicaid patients Serving Medicaid patients Not offering a sliding fee scale Offering a sliding fee scale General dental practice Other Dental public health Oral and maxillofacial surgery Orthodontics and dentofacial orthopedics Other pediatric dentistry Periodontics Prosthodontics Not applicable Dental office practice solo practice Dental office practice partnership Dental office practice group practice Other setting Hospital Clinic Federal government hospital clinic includes military Health center CHC FQHC FQHC look alike Other public health community health setting School health service Other setting Urban Rural Dental Health Professional Shortage Area HPSA Not dental Health Professional Shortage Area HPSA Descriptive analyses were generated across all covariates by each outcome variable using the chi square analysis Multivariate logistic regression was conducted to determine the demographic and practice characteristics that were associated with the likelihood that dentists were staffed at full capacity or clinical staff left their practice due to COVID 19 This method enables estimates of the direction and magnitude of the relationship between each covariate and

the outcome while simultaneously controlling for the impact of other covariates All statistical analyses were conducted using SAS 9 4 with a significance level of 0 05 In addition to quantitative data the IDA survey also collected qualitative information using an open ended question about how COVID 19 has affected the respondent s practice Qualitative analysis was conducted by two researchers using a code to theory method Saldana 2015 12 Each researcher independently reviewed and assigned one or more categories to each open ended response Both researchers then reviewed all categories together and finalized categories through consensus The final categories were then grouped into emerging themes based on common concepts identified by the researchers

Results Descriptive Results Figure 1 provides a summary of the study sample selection process Of the 3 093 dentists who received the IDA survey 427 13 8 responded to it Of these 407 were successfully matched to the 2020 Indiana PLA data Of those 403 had complete data for the study variables and were included in the study sample analysis A summary of the results of the descriptive statistics is provided in Tables 2 and 3 Of the dentists in the study sample 241 59 8 reported their practice as being staffed at full capacity

and 150 37 2 reported staff departures related to COVID 19 Demographically the highest percentage of the study sample were between ages 35 and 44 25 31 male 67 74 and White 90 82 Professionally the highest percentage of dentists reported practicing in general dentistry 84 37 and in a solo practice 63 77 Additionally most dentists reported not serving Medicaid patients in their practice 59 31 not accepting new Medicaid patients 68 49 and not offering a sliding fee scale 90 57 Finally most dentists reported practicing in an urban county 80 89 and a county with a federal designation as a dental HPSA 66 00 There were statistically significant differences for the two study outcomes based on several covariates In terms of being staffed at full capacity statistically significant differences were found with regards to dentists reported race p 0 0013 practice type p 0 0056 and acceptance of new Medicaid patients p 0 0002 Table 2 A greater percentage of those who reported being staffed at full capacity reported being White practicing in a solo practice not accepting new Medicaid patients and not serving Medicaid patients in their practice In terms of clinical staff leaving because of COVID 19 statistically significant differences were found with regards to dentists reported race p 0 0262 practice type p 0 0343 and acceptance of new Medicaid patients p 0 0173 Table 3 A greater percentage of those who reported their clinical staff departing because of COVID 19 reported being White practicing in a group practice and accepting new Medicaid patients

Table 2 Descriptive statistics for full staffing capacity N Total Age Group Under 35 35 44 45 54 55 64 65 and older Gender Female Male Race White Other Dental Specialty General dental practice Other Practice Type Dental office practice solo practice Dental office practice partnership Dental office practice group practice Other setting Medicaid Acceptance Not accepting new Medicaid patients Accepting new Medicaid patients Medicaid Service Status Not serving Medicaid patients Serving Medicaid patients Sliding Fee Scale Status Not offering a sliding fee scale Offering a sliding fee scale Rurality Rural Urban Dental HSPA Dental HPSA Not dental HPSA Full Staffing Capacity Yes No N 241 162 Total N P value 403 0 7999 34 62 53 62 30 14 11 25 73 21 99 25 73 12 45 21 40 38 48 15 12 96 24 69 23 46 29 63 9 26 55 102 91 110 45 13 7 25 3 22 6 27 3 11 2 70 171 29 05 70 95 60 102 37 04 62 96 130 273 32 3 67 7 228 13 94 61 5 39 138 24 85 19 14 81 366 37 90 8 9 18 205 36 85 06 14 94 135 27 83 33 16 67 340 63 84 4 15 6 0 0924 0 0013 0 6394 0 0056 163 41 32 5 67 63 17 01 13 28 2 07 94 20 39 9 58 02 12 35 24 07 5 56 257 61 71 14 63 8 15 1 17 6 3 47 182 59 75 52 24 48 94 68 58 02 41 98 276 127 68 5 31 5 156 85 64 73 35 27 83 79 51 23 48 77 239 164 59 3 40 7 0 0002 0 0069 0 6575 217 24 90 04 9 96 148 14 91 36 8 64 365 38 90 6 9 43 0 124 52 189 21 58 78 42 25 137 15 43 84 57 77 326 19 1 80 9 162 79 67 22 32 78 104 58 64 2 35 8 266 137 66 00 34 00 0 53

Table 3 Descriptive statistics for clinical staff departing because of COVID 19 Total Age Group Under 35 35 44 45 54 55 64 65 and older Gender Female Male Race White Other Dental Specialty General dental practice Other Practice Type Dental office practice solo practice Dental office practice partnership Dental office practice group practice Other setting Medicaid Acceptance Not accepting new Medicaid patients Accepting new Medicaid patients Medicaid Service Status Not serving Medicaid patients Serving Medicaid patients Sliding Fee Scale Status Not offering a sliding fee scale Offering a sliding fee scale Rurality Rural Urban Dental HPSA Dental HPSA Not dental HPSA Staff Departing Because of COVID 19 Yes No N N 150 253 Total N P value 403 0 247 20 42 39 38 11 13 33 28 00 26 00 25 33 7 33 35 60 52 72 34 13 83 23 72 20 55 28 46 13 44 55 102 91 110 45 13 7 25 3 22 6 27 3 11 2 56 94 37 33 62 67 74 179 29 25 70 75 130 273 32 3 67 7 130 20 86 67 13 33 236 17 93 28 6 72 366 37 90 8 9 18 130 20 86 67 13 33 210 43 83 00 17 00 340 63 84 4 15 6 0 0933 0 0262 0 3277 0 0343 85 23 37 5 56 67 15 33 24 67 3 33 172 38 34 9 67 98 15 02 13 44 3 56 257 61 71 14 63 8 15 1 17 6 3 47 92 58 61 33 38 67 184 69 72 73 27 27 276 127 68 5 31 5 84 66 56 00 44 00 155 98 61 26 38 74 239 164 59 3 40 7 0 0173 0 2984 0 7627 135 15 90 00 10 00 230 23 90 91 9 09 365 38 90 6 9 43 0 0232 20 130 13 33 86 67 57 196 22 53 77 47 77 326 19 1 80 9 97 53 64 67 35 33 169 84 66 80 33 20 266 137 66 34 0 6623

Logistic Regression Results Multivariate logistic regression analysis results are summarized in Table 4 Dentists were less likely to report their practice being fully staffed if they reported being non White OR 0 442 95 CI 0 208 0 904 accepting new Medicaid patients OR 0 418 95 CI 0 191 0 914 and practicing in a group practice OR 0 462 95 CI 0 216 0 990 Dentists who reported accepting new Medicaid patients were more likely OR 2 464 95 CI 1 088 5 582 to report staff departures due to COVID 19 No other statistically significant relationships were found between the variables and likelihood of a dentist reporting staff departures due to COVID 19 Table 4 Multivariable logistic regression analysis results Variables Age Category ref 45 54 Under 35 35 44 55 64 65 and older Gender ref Male Female Race ref White Non White Medicaid Acceptance Status ref Not accepting new Medicaid patients Accepting new Medicaid patients Medicaid Service Status ref Not serving Medicaid patients Serving Medicaid patients Sliding Fee Scale Status ref Not offering a sliding fee scale Offering a sliding fee scale Dental Specialty ref Other practice type General dental practice Practice Type ref Dental Office Practice solo practice Dental office practice group practice Dental office practice partnership Other setting Rurality ref Urban Rural Dental HPSA ref Not dental HPSA Dental HPSA Likelihood of Reporting Practice Fully Staffed OR 95 CI Likelihood of Reporting Staff Departures Due to COVID OR 95 CI 1 574 1 340 0 839 1 140 0 553 0 568 0 366 0 378 4 480 3 161 1 920 3 437 0 651 0 858 0 788 0 535 0 232 0 371 0 344 0 169 1 826 1 983 1 804 1 692 0 748 0 468 1 195 1 269 0 797 2 021 0 442 0 208 0 940 1 528 0 737 3 166 0 418 0 191 0 914 2 464 1 088 5 582 1 142 0 550 2 372 0 663 0 308 1 427 2 221 0 953 5 174 0 935 0 423 2 067 0 822 0 444 1 522 1 664 0 885 3 129 0 462 1 022 0 241 0 216 0 456 0 042 0 990 2 293 1 379 2 035 1 288 1 058 0 956 0 584 0 187 4 329 2 840 5 969 1 424 0 809 2 505 0 568 0 316 1 021 1 268 0 810 1 985 0 877 0 559 1 374

Qualitative Analysis Results from the qualitative analysis are summarized in Table 5 Several themes emerged from dentists responses to the open ended question regarding how COVID 19 affected their practices Themes included clinical challenges financial challenges and other non specific effects The most commonly reported clinical challenges were resuming clinical operations upon reopening n 90 and workforce challenges n 34 This was reflected in one dentist s response The biggest effects were during the shutdown period on both practice cash flow and staff payroll In having no steady collections both were adversely affected Less commonly reported challenges were negative effects on patients oral health n 8 and reduced demand n 18 Once dentist explained Some patients do not want to return for routine procedures until there is a vaccine Among financial challenges dentists reported having either a general loss of income in their practice n 46 or increased costs due to PPE and new disinfection protocols n 51 One dentist explained Additional PPE and protocols have increased costs Protocols are increasing the length of treatment and thus limiting the number of procedures that can be done in the same amount of time Other non specific responses included experiencing an unexpected positive effect n 8 general negative effect n 7 or not observing any effect n 8 One dentist commented on the unexpected benefits of the pandemic I feel very lucky relative to most I didn t lose any staff and none came back to the practice with unrealistic fears or concerns My patient base

has almost fully returned and we are almost back up to a normal schedule So aside from the time I was shut down 7 weeks the time it has taken to ramp up and the increased PPE cost I have had little effect from COVID 19 Table 5 Qualitative Analysis Results Themes and Categories Clinical Challenges N Post COVID clinical operation challenges 90 Workforce challenges 34 Patient fear Reduced demand 18 Negative effect on patient oral health Financial Challenges 8 Cost Supply of PPE 51 General loss of income 46 Example s Difficult to get production up due to extra disinfection time Reduced schedules Protocols are increasing the length of treatment and thus limiting the number of procedures that can be done in the same amount of time Staff did not want to return even with significant costs spent on PPE and safety equipment Lost a staff member Our staff mainly hygienists are fearful of returning to work 2 of my team won t return because they earn more sitting at home In the last week there have been several patients that have cancelled appointments because now MDs are telling patients to avoid dental treatment Patient fear has hindered work productivity Some patients do not want to return for routine procedures until there is a vaccine delayed care for those in need Delayed patient treatment has resulted in more extensive and costly treatment for patients Increased PPE costs Higher PPE costs Additional PPE and protocols have increased costs Decreased income decrease in patients being cared for more work on remaining staff Certainly being off for 7 weeks mattered financially Two months of lost revenue for the year Loss of income due to needs of extra equipment on backorder for weeks Other Types of Impact Unexpected positive effect 8 No effect 8 General impact 7 It has caused us to improve our protocols for nearly every aspect of our procedures We turned a tragedy into opportunity It has actually helped Since shutdown I am busier than normal I have been fortunate in that staffing has not been an issue Just trying to get caught up from the mandated shut down in April Created turmoil Created instability

Discussion This analysis provides evidence of the impact of COVID 19 on Indiana dental practice staffing after the reopening of dental offices in the state At the time of the survey more than two out of every five Indiana dentists reported that their practices were not fully staffed and just slightly less than that reported permanent staff departures due to COVID 19 The findings largely suggest that COVID 19 has had an indiscriminate impact on Indiana dentists and their practices but the results also provide limited evidence that certain dentists may have been slightly more likely to experience staffing challenges Dentists race and practice type were significantly associated with the likelihood of reporting their practice not being fully staffed and dentists who accepted new Medicaid patients were more likely to report both staffing shortages and permanent staff departures due to COVID 19 Data collected by national organizations provide context for these findings ADA n d 8 The ADA s reports on the ongoing economic impact of COVID 19 on dental practices provide insight into key factors that may influence dental office staffing Beginning in March and continuing throughout much of 2020 the ADA surveyed dentists including some in Indiana on a biweekly basis to gather information on their dental practice ADA 2020c 9 Data on Indiana dentists self reported practice status and ability to pay staff that were collected by the ADA during the week of July 27 2020 correspond to the time period in which this study took place July 2020 enabling a temporal comparison of findings ADA n d Comparisons are limited to contextual purposes as the breakdown of Indiana dentists in the ADA survey for that date is not provided At the end of July 2020 the ADA reported that nearly 40 or two out of every five dentists of the survey respondents reported that their practice was open but with lower patient

volumes and approximately 98 reported that they were able to fully pay their staff ADA n d 8 Theoretically there is a correlation between patient volumes and staffing needs higher patient volumes generally require more staff whereas lower patient volumes require less staff Unfortunately without information on whether dentists were experiencing staffing challenges it is unclear whether the ADA survey respondents had the same number of staff working in their practice as they had pre pandemic It is possible that those with lower patient volumes had less staff return to work but they were able to pay those that did This study s survey largely focused on collecting information on staffing challenges experienced by Indiana dentists The finding that approximately two out of every five Indiana dentists reported that their practices were not fully staffed and or reported permanent staff departures is similar in magnitude to the ADA s finding that two out of five dentists reported lower patient volumes ADA n d Although some respondents to the open ended question in this study reported other issues that were monitored by the ADA i e lower patient volumes this information was not collected from every respondent Together the ADA and IDA surveys contribute important information to understanding the impact of COVID 19 on dental care in Indiana To enhance more robust analyses economic and workforce indicators should be incorporated into future surveys In addition to staffing issues clinical operations challenges a general loss of income and increased costs related to PPE and new disinfection protocols were common themes that emerged from dentists response to the open ended question on the impact of COVID 19 on their practice These findings are not surprising and likely interrelated The Centers for Disease Control and Prevention released COVID 19 related guidance for infection prevention and control for dental settings Centers for Disease Control and Prevention 2020 To implement

these recommendations many dental offices had to alter staffing arrangements and develop new protocols for patient scheduling and appointments Although additional research is needed to determine the specific impact of COVID 19 related protocols and procedures on staffing needs they have likely resulted in prolonged patient visits decreased patient appointments and increased costs to the dental practice Although this study focused on exploring dental staffing challenges associated with COVID 19 the findings also highlight potential oral health care access challenges A greater proportion of Indiana dentists who self reported accepting new Medicaid patients during license renewal before the start of the pandemic also reported experiencing staffing shortages and departures The reasons for this finding are unknown and thus additional research is needed to identify contributing factors This finding suggests that COVID 19 related staffing issues may have disproportionately impacted Indiana s dental care capacity for Medicaid recipients The number of dental assistants and hygienists at a practice is directly related to the number of dental visits per week the larger the staff the greater the number of visits Conrad et al 2010 Therefore staffing shortages at practices accepting new Medicaid patients likely impact the number of visits available to these individuals Commitment to diversity is a strategic priority for dentistry ADA 2020a American Dental Education Association n d 12 Recent national studies have highlighted the gap that exists between diversity in the population and in the dentist workforce E Mertz et al 2016 E A Mertz et al 2016 13 Similarly this study found that dentists who identify as non White reported experiencing significantly greater staffing shortages than their White colleagues although the specific reasons are unknown Indeed very little is known about the staffing practices of underrepresented minority dentists with the exception of research focusing on the

types of staff they employ such as the expanded function of dental assistants Mertz et al 2017 14 Further studies have demonstrated that underrepresented minority dentists typically incur more debt to finance their education and earn lower incomes than their non minority colleagues E Mertz et al 2016 13 Recent reports from the business sector suggest that minority owned businesses in the United States have been disproportionately impacted by the COVID 19 pandemic Fairlie 2020 U S Chamber of Commerce 2020 14 The majority of dentists in Indiana are solo practitioner and business owners Solo practitioners were not identified as being more likely to report staffing challenges than those in partnership or group practices Unfortunately the underrepresentation of non White dentists in this study limits analyses that might explore the relationship between race practice type and staffing challenges Thus additional research is needed to better understand this finding The finding that non White dentists reported greater staffing challenges may also have implications for oral health care access in Indiana Recent data demonstrate that dentists from underrepresented minority groups are also more likely than other dentists to provide care to a greater proportion of patients from a similar population group and are more likely to engage in the dental safety net Logan et al 2014 Maxey et al 2018 E A Mertz et al 2016 15 Therefore similar to the prior discussion regarding access for Medicaid recipients the reporting of staffing issues among non White dentists in Indiana may also signal potential access issues among certain populations Mechanisms for monitoring access to oral health care in Indiana will be important especially for underrepresented and underserved populations moving past the COVID 19 pandemic and forward Limitations

This study has several limitations First the data was collected from self reported surveys which introduces the possibility of response bias Second the IDA survey was sent to Indiana dentists regardless of where they were located Therefore multiple dentists located at one practice could have responded to the survey increasing the possibility of overrepresentation in the sample Finally the sample only included dentists licensed to practice in Indiana which limits the generalizability of the results Implications As the response to COVID 19 continues dental offices will need to re visit practice protocols such as staffing roles ratios and clinic flow In addition with the continuation of vaccine deployment efforts practices may need to respond flexibly Some states are passing legislation to permit dentists to administer the COVID 19 vaccine ADA 2020b 16 If vaccination is an additional service line that will be offered at dental offices implications for office staffing e g vaccination registration and clinic flow will need to be considered Furthermore COVID 19 has implications for the future dental workforce Based on a recent survey administered to 436 dental and dental hygiene students enrolled in U S dental programs more than 11 of these students reported that COVID 19 changed their career plans Garc a et al 2021 17 Students reporting changes to career plans also reported higher levels of stress and anxiety as well as concerns regarding employment opportunities the long term sustainability of the dental profession interruptions to clinical education and licensure examination consequences Garc a et al 2021 17 Although this study represents a relatively small proportion of students in the United States these findings suggest that COVID 19 may have an impact on the future dental workforce Garc a et al 2021 17 Given current staffing challenges planning may be needed to ensure a sufficient pipeline of dental professionals

Medicaid participating dentists are the largest component of the dental safety net in Indiana and across the nation Bailit et al 2006 18 Dentists who are accepting new Medicaid patients represent critical additional capacity in the dental safety net The number of people enrolled in Indiana Medicaid increased substantially between March and June 2020 but it is uncertain whether these increases will endure Brian 2020 Frenier et al 2020 19 However it is certain that Indiana Medicaid recipients will need access to dental care in the coming months and years and when they do they will need a dental practice to visit Finally there is a paucity of literature that examines the impact of COVID 19 on staffing at dental offices Data reported by the HPI of the ADA have been vital for assessing the economic impact of COVID 19 on dental care in the United States These data have enabled monitoring of national trends and supported state level comparisons however representation of data at the state level is unclear and community level analyses are not possible Although the ADA s survey reports on dentists ability to pay staff which is an important indicator for measuring the economic health of a dental practice it does not provide insight into staffing challenges and changes that have emerged as a result of the pandemic In the future indicators of dental staffing should be included in the ADA s surveys to enable more robust analyses of the dental workforce

References Agency for Healthcare Research and Quality 2020 COVID 19 and Destistry Challenges and Opportunities for Providing Safe Care https psnet ahrq gov primer covid 19 and dentistrychallenges and opportunities providing safe care Amato A Ciacci C Martina S Caggiano M Amato M 2021 COVID 19 The Dentists Perceived Impact on the Dental Practice Eur J Dent https doi org 10 1055 s 0040 1721910 American Dental Association 2020a ADA s Commitment to Diversity and Inclusion https www ada org en about the ada diversity and inclusion American Dental Association 2020b COVID 19 Vaccine Regulations for Dentists Map https success ada org en practice management patients covid 19 vaccine regulations fordentists map American Dental Association 2020c HPI poll examines impact of COVID 19 on dental practices https www ada org en publications ada news 2020 archive april hpi poll examines impactof covid 19 on dental practices American Dental Association 2020d HPI Poll Urban dentists reporting lower patient volume than rural dentists https www ada org en publications ada news 2020 archive october urban dentistsreporting lower patient volume than ruraldentists utm_source cpsorg utm_medium covid main lp utm_content cv hpi covidlp utm_campaign covid 19 American Dental Association n d COVID 19 Economic Impact on Dental Practices https www ada org en science research health policy institute covid 19 dentists economicimpact survey results American Dental Association ADA 2020 ADA Calls Upon Dentists to Postpone Elective Procedures https www ada org en press room news releases 2020 archives march ada calls upondentists to postpone elective procedures American Dental Education Association n d Need For Diversity ADEA GoDental https www adea org godental dentistry_101 need_for_diversity aspx Ather A Patel B Ruparel N B Diogenes A Hargreaves K M 2020 Coronavirus Disease 19 COVID 19 Implications for Clinical Dental Care Journal of endodontics 46 5 584 595 https doi org 10 1016 j joen 2020 03 008 Bailit H Beazoglou T Demby N McFarland J Robinson P Weaver R 2006 Dental safety net Current capacity and potential for expansion The Journal of the American Dental Association 137 6 807 815 https doi org 10 14219 jada archive 2006 0294 Baracco B Ceballos L Llorente A Fuentes V 2021 Impact of COVID 19 on the work of Spanish dentists An early response to the pandemic Journal of clinical and experimental dentistry 13 2 e148 e155 https doi org 10 4317 jced 57941 Bekes K Ritschl V Stamm T 2021 COVID 19 Pandemic and Its Impact on Pediatric Dentistry in Austria Knowledge Perception and Attitude Among Pediatric Dentists in a Cross Sectional Survey Journal of Multidisciplinary Healthcare 14 https doi org https doi org 10 2147 JMDH S285093 Brian Z Weintraub J A 2020 Oral Health and COVID 19 Increasing the Need for Prevention and Access Prev Chronic Dis 17 https doi org 10 5888 pcd17 200266 Burger D 2020 Dentists are facing difficulties in recruiting dental team members during recovery American Dental Association https www ada org en publications ada news 2020archive october dentists are recruiting again during

recovery utm_source cpsorg utm_medium covid main lp utm_content cv hpi covidlp utm_campaign covid 19 Centers for Disease Control and Prevention 2020 Guidance for Dental Settings https www cdc gov coronavirus 2019 ncov hcp dental settings html Conrad D A Lee R S Milgrom P Huebner C E 2010 Estimating determinants of dentist productivity new evidence J Public Health Dent 70 4 262 268 https doi org 10 1111 j 1752 7325 2010 00180 x Cucinotta D Vanelli M 2020 WHO Declares COVID 19 a Pandemic Acta bio medica Atenei Parmensis 91 1 157 160 Diab Z Shara N Chou J Libin A Kuhn A Farmer Dixon C Jackson A Hughes B Laurence B 2021 The contrasting short term effects of COVID 19 on dental care practices in the United States https doi org 10 1002 cre2 398 Clinical and Experimental Dental Research n a n a https doi org https doi org 10 1002 cre2 398 dos Santos M B F Pires A L C Saporiti J M Kinalski M D A Marchini L 2021 Impact of COVID 19 pandemic on oral health procedures provided by the Brazilian public health system COVID 19 and oral health in Brazil Health Policy and Technology https doi org https doi org 10 1016 j hlpt 2021 02 001 Elangovan S Mahrous A Marchini L 2020 Disruptions during a pandemic Gaps identified and lessons learned J Dent Educ 84 11 1270 1274 https doi org https doi org 10 1002 jdd 12236 Estrich C G Mikkelsen M Morrissey R Geisinger M L Ioannidou E Vujicic M Araujo M W B 2020 Estimating COVID 19 prevalence and infection control practices among US dentists Journal of the American Dental Association 1939 151 11 815 824 https doi org 10 1016 j adaj 2020 09 005 Fairlie R W 2020 The Impact of Covid 19 on Small Business Owners Evidence of Early Stage Losses from the April 2020 Current Population Survey https www nber org papers w27309 Frenier C Nikpay S S Golberstein E 2020 COVID 19 Has Increased Medicaid Enrollment But Short Term Enrollment Changes Are Unrelated To Job Losses Health Aff Millwood 39 10 1822 1831 https doi org 10 1377 hlthaff 2020 00900 Garc a D T Akinkugbe A A Mosavel M Smith C S Brickhouse T H 2021 COVID 19 and Dental and Dental Hygiene Students Career Plans JDR Clinical Translational Research 2380084420984772 https doi org 10 1177 2380084420984772 Gurenlian J R Morrissey R Estrich C G Battrell A Bessner S K Lynch A Mikkelsen M Araujo M W B Vujicic M 2021 Employment Patterns of Dental Hygienists in the United States During the COVID 19 Pandemic The Journal of Dental Hygiene 95 1 Health Resources and Services Administration n d HPSA Find https data hrsa gov tools shortagearea hpsa find Hunter T 2020 COVID 19 How has it affected dental assistants https www dentistryiq com dental assisting career enhancements article 14174596 covid19how has it affected dental assistants Iyer P Aziz K Ojcius D M 2020 Impact of COVID 19 on dental education in the United States J Dent Educ 84 6 718 722 https doi org https doi org 10 1002 jdd 12163 Kranz A M Gahlon G Dick A W Stein B D 2021 Characteristics of US Adults Delaying Dental Care Due to the COVID 19 Pandemic JDR Clin Trans Res 6 1 8 14 https doi org 10 1177 2380084420962778 Lanthier T 2021 Survey COVID 19 compounds dental staffing challenges https www dentaleconomics com macro op ed article 14198501 survey covid19compounds dental staffing challenges

Logan H L Guo Y Dodd V J Seleski C E Catalanotto F 2014 Demographic and practice characteristics of Medicaid participating dentists J Public Health Dent 74 2 139 146 https doi org 10 1111 jphd 12037 Maxey H L Norwood C W Vaughn S X Wang Y Marsh S Williams J 2018 Dental safety net capacity An innovative use of existing data to measure dentists clinical engagement in state Medicaid programs J Public Health Dent 78 3 266 274 https doi org 10 1111 jphd 12272 Mertz E Calvo J Wides C Gates P 2016 The Black dentist workforce in the United States J Public Health Dent https doi org 10 1111 jphd 12187 Mertz E Calvo J Wides C Gates P 2017 The Black dentist workforce in the United States https doi org 10 1111 jphd 12187 J Public Health Dent 77 2 136 147 https doi org https doi org 10 1111 jphd 12187 Mertz E A Wides C D Kottek A M Calvo J M Gates P E 2016 Underrepresented Minority Dentists Quantifying Their Numbers And Characterizing The Communities They Serve Health Aff Millwood 35 12 2190 2199 https doi org 10 1377 hlthaff 2016 1122 Randall T 2020 Flexible staffing Your best strategy for COVID concerns https www dentistryiq com dental jobs article 14180885 flexible staffing your best strategyfor covid concerns Ren Y F Rasubala L Malmstrom H Eliav E 2020 Dental Care and Oral Health under the Clouds of COVID 19 JDR Clinical Translational Research 5 3 202 210 https doi org 10 1177 2380084420924385 Saldana J 2015 The Coding Manual for Qualitative Researchers Third ed SAGE Publicaions Ltd https us sagepub com en us nam the coding manual for qualitativeresearchers book243616 description Skinner E 2020 COVID 19 Forces New Approaches to Delivering Oral Health Care https www ncsl org research health covid 19 forces new approaches to delivering oralhealth care magazine2020 aspx Tepichin T 2020 How COVID 19 Has Changed Dental Staffing Forever and What You Can Do to Stay Ahead Oral Health Group https www oralhealthgroup com blogs how covid 19 haschanged dental staffing forever and what you can do to stay ahead U S Chamber of Commerce 2020 Coronavirus Pandemic Hits Minority Owned Small Businesses Disproportionately Hard New Poll Shows https www uschamber com pressrelease coronavirus pandemic hits minority owned small businesses disproportionately hardnew Vaughn S Floyd T Maxey H 2020 Data Report Indiana Oral Health Workforce https scholarworks iupui edu bitstream handle 1805 25123 2020 20ORAL 20HEALTH 20D ata 20Report 20 2012162020 pdf sequence 1 isAllowed y

About the Authors Hannah Maxey PhD serves as Director of the Bowen Center for Indiana University s Health Workforce Research and Policy which is dedicated to advancing policies which improve human health and well being through commitment to service and research contributions Hannah received her PhD from the Department of Health Policy and Management at the Indiana University Richard M Fairbanks School of Public Health and is currently appointed as an Associate Professor of Family Medicine at the Indiana University School of Medicine Courtney R Medlock is a Health Policy Analyst at the Bowen Center and is passionate about and actively involved in health workforce policy research at the state and national level Mrs Medlock holds a Master of Public Health degree from the Department of Health Policy and Management at the Indiana University Richard M Fairbanks School of Public Health Her expertise is in the analysis of various intersecting health and regulatory policies the engagement and management of governmental and non governmental key stakeholders and the conceptualization of strategic policy or programmatic solutions Sierra X Vaughn has served as the Bowen Center s Health Services Research Analyst since 2015 Her activities have included overseeing data management and reporting as well as managing research projects Ms Vaughn holds an MPH in Epidemiology from Boston University School of Public Health and has previous experience in clinical and academic research Personal research interests include women s health maternal and child health and reproductive health Analise Dickinson is is a research coordinator at the Bowen Center She graduated from Indiana University Fairbanks School of Public Health with a master s in public health and a concentration in epidemiology Analise is passionate about improving health outcomes by helping build innovative healthcare systems and expanding Indiana s health workforce through research data analysis and health policy Yumin Wang is a Biostatistician at Indiana University Department of Biostatistics and Health Data Science He graduated from Indiana University School of Science with a Master s in Statistics Yumin is passionate about improving health outcomes and expanding Indiana s health workforce by supporting Bowen Center for Health Workforce Research and Policy through data analytics Acknowledgements The development of this manuscript was supported by the Indiana Dental Association and commissioned by the association s Workforce Task Force The authors would like to thank Dr Angeles Martinez Mier and Dr John Williams for providing substantive feedback during the development of this manuscript Funding The study presented in this manuscript was commissioned by the Indiana Dental Association s IDA Workforce Task Force IDA funding supported the development of this article Conflict of Interest The authors of this article have no conflicts of interest to disclose