A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Marriam Mahmood, BDS Independent Researcher, San Jose, CA, USA. Abstract Objectives: Investigating the impact of COVID-19 pandemic on oral health and patient attitudes towards a dental visit is essential to improving access to oral health care during the pandemic. This calls for studying the chief patient fears, preferences and future intentions related to dental visits during the COVID-19 pandemic. Methods: A web-based survey was administered to the public within the US in December 2020. The participants (N=502) answered questions about their oral health, trust level for dental offices, and chief concerns and preferences related to dental visits during the COVID-19 outbreak. We used descriptive statistics (e.g., Chi-square, Shapiro-Wilk and Kruskall-Wallis tests) to find if demographics, oral health history or social behaviors were associated with the relevant patient attitudes. Results: When queried about COVID-19’s impact on oral health, 62.5% respondents reported a minimal impact, 7.2% a positive impact, and 30.3% a negative impact. There were statistically significant differences in responses based on respondents’ ethnicity (N=502, P=.033) and dental visit history during the pandemic (N=502, P=.008). The public trust rating for COVID-19-related precautions was more favorable towards the medical offices than the dental offices (N=502, P<.001). The majority considered contracting COVID-19 from the other patients in the dental office waiting area (60.4%), from the dentist/hygienist/dental assistants (54.2%), and from the aerosols (50.8%) as their chief concerns. 20.1% respondents preferred no other patient, 25.1% only one more patient, and 31.1% up to three more patients in the waiting area during a dental visit. Conclusion: The reported impact of COVID-19 on self-perceived oral health was modest for most respondents. Patients’ chief concerns for a dental visit include contracting COVID-19 infection from other patients, dentists, and aerosols in the operatory. It may be beneficial if dental practices avoid scheduling multiple patients in the waiting area to improve access to oral health care. Keywords: COVID-19; dentistry; patient comfort; oral health. Citation: Mahmood, M (2022). A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Dentistry 3000. 1:a001 doi:10.5195/d3000.2022.183 Received: May, 7, 2021 Accepted: September, 28, 2021 Published: June, 7, 2022 Copyright: ©2022 Mahmood, M. This is an open access article licensed under a Creative Commons Attribution Work 4.0 United States License. Email: marriammahmood12@gmail.com Introduction Coronavirus disease 2019 (COVID- 19) is caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) [1]. It spreads through respiratory droplets and aerosols produced by the infected person’s breathing, coughing, speaking and sneezing [2,3]. A person can get infected if these droplets/aerosols settle on the mucous membranes or are inhaled [2–4]. Although SARS-CoV-2 is usually transmitted via close person-person contact, it can also spread through contaminated surfaces [2–4]. In dental settings, SARS-CoV-2 can potentially be transmitted through aerosols generating dental procedures (AGDP) [5–8]. COVID-19 has had a profound impact on all aspects of dentistry [9–11]. The American Dental Association (ADA) Health Policy Institute (HPI) has been regularly polling dentists to track the economic impact of COVID-19 on dental practices [12]. In the early days of the pandemic (March 2020), most dental practices were closed except for emergency http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu services. The patient volume has since gradually risen to 81% of the pre-pandemic levels as per the recent HPI poll (February 15, 2021) [13]. The reduced patient volume during the pandemic can be attributed to the fear of contracting COVID-19 at the dental office. However, there is no existing detailed study on the specific concerns of the patients regarding dental visits during the pandemic. Moreover, the information available on how COVID-19 has impacted the oral health is rather limited [14]: An increased prevalence of stress- related conditions such as bruxism and clenching during the pandemic has been reported [13]. An association between poor oral health and the severity of COVID- 19 symptoms has also been suggested [15]. COVID-19 related restrictions are expected to cause a degradation in the oral health of vulnerable populations such as older adults [16,17]. As the existing work is mostly based on information gathered from dental providers, the patients’ perspectives on oral health during COVID-19 remain little-known. We aim to address these gaps by providing further insights on these aspects in this study. In this cross-sectional study, we investigate the impact of COVID-19 on oral health and dental visits from a patient’s perspective. It has three main objectives. Firstly, assess if the ongoing pandemic has affected the patients’ self- perceived oral health. Secondly, quantify how much the patients trust the COVID-19 related precautionary measures taken by the dental offices versus those by (non-dental) medical offices. Thirdly, identify the chief patient fears related to dental visits during the COVID-19 pandemic and learn about their intentions for a future visit under different scenarios. We use statistical analysis of the collected data to see if demographics, oral health history or social behaviors impact the relevant patient attitudes. Methods We administered a web-based survey hosted on Google Forms and SurveyMonkey during Dec 3- Dec 24, 2020. The survey was circulated using e-mail and messaging apps to the public within the US. The ethical review and approval of the study was provided by HML IRB (FWA# 1102). The survey was completely anonymous, and the informed consent of the participant was obtained prior to accessing the survey questions. There was no monetary benefit offered to the respondents. The designed survey included 27 closed-ended questions on the following topics: demographics; oral health and the impact of COVID-19 pandemic; future intentions and history for dental visits during COVID-19 pandemic; trust level for dental offices and key concerns for dental visits amid the COVID-19 pandemic; and lifestyle. The questionnaire contained both mandatory and optional questions. The section on demographics contained questions on gender, age group, ethnicity, race, state of residence, and living status (with or without family). Respondents were asked to rate their current oral health (excellent, good, fair/poor), caries risk category based on the number of needed dental interventions (low risk: once a year, moderate risk: 2-3 times a year, high risk: 4 or more times a year), and oral hygiene habits (twice daily, once daily, irregular) for brushing and flossing. We then asked how the COVID-19 pandemic had affected their oral health and oral hygiene routines (positive impact, little or no impact, negative impact). This was followed by a set of questions related to whether they had visited the dental office during the pandemic, and if they intend to do so in the next 6 months. We asked the respondents about their trust level for the COVID-19 http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu related preventive measures taken by dentists/dental offices and doctors/medical offices using a 5- point Likert scale (1 = lowest trust level, 5 = highest trust level). We also asked them to identify their greatest concern(s) for a dental visit amid COVID-19. Options included contracting COVID-19 infection from: the dentist/dental assistant/hygienist; front desk staff; patients in the waiting area; physical contact with dental equipment/office surfaces; and aerosols/air droplets in the operatory. We further asked if the number of patients present in the waiting area of a dental office was an important consideration when planning a dental visit. We also queried about the preferred number of patients in the waiting area (1, 2, 3-4, any number of patients). There was also a question about their attitudes towards a dental visit in the post- pandemic era (same as in pre- pandemic times, same as during the pandemic, somewhere in- between). Finally, they were asked about their general lifestyle: whether working from home, outdoor activity level (regular, sometimes, rare) and shopping style (online, curbside, in-store) during the preceding three-month period. We performed the statistical analysis on the collected survey data using IBM SPSS software. We used the Chi-square test and the exact Fisher test to check for statistical independence between categorical variables. We used the Shapiro-Wilk test to check for normality of ordinal data. We used non-parametric tests (Mann- Whitney U and Kruskall-Wallis 1- way ANOVA) to check for association between ordinal and categorical variables. We used the Wilcoxon Signed Rank test to compare the results of two ordinal variables. We used a P-value of .05 to determine the statistical significance. Results Demographics We received N=502 completed responses. The completion rate of individual questions varied as not all questions were mandatory. The demographics, social behaviors and self-reported dental history are provided in Table 1. We note that the racial demographics resemble that of an urban metropolitan region [18]. Oral health during COVID-19 outbreak We asked the respondents about the impact of the COVID-19 outbreak on their oral health and oral hygiene routine. For oral health, 62.5% of the respondents reported a minimal impact, 7.2% reported a positive impact while 30.3% reported a negative impact (see Figure 1). http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Table 1 - Demographics, social behaviors, and dental history of respondents. Characteristics % (No.) Demographics Gender (N=502) Male 46.6 (234) Female 52.5 (266) Prefer not to say .004 (2) Age group (N=502) 18-24 15.7 (79) 25-34 36.3 (182) 35-44 19.3 (97) 45-54 14.1 (71) 55-64 9.0 (45) 65+ 5.6 (28) Ethnicity (N=502) Hispanic or Latino 12 (60) Not Hispanic or Latino 88 (442) Race (N=502) American Indian or Alaska Native 0.4 (2) Asian 31.7 (159) Black or African American 5.2 (26) Native Hawaiian or Pacific Islander 0.8 (4) White 44.8 (225) Other 17.1 (86) US census region (N=497) Midwest 14.1 (71) Northeast 16.1 (81) South 27.9 (140) West 40.8 (205) Living status (N=430) Single 20.23 (87) With family 79.77 (343) Social behaviors Nature of work (N=419) Working from home 75.18 (315) Going to work 24.82 (104) Outdoor exercise (N=428) Rarely 21.73 (93) Sometimes 41.59 (178) Regularly 36.68 (157) Shopping style (N=427) Online 17.09 (73) Curb-side pickup 12.18 (52) In-store 70.73 (302) Dental history Caries risk category (N=423) Low risk 39.24 (166) Moderate risk 52.72 (223) High risk 8.04 (34) Current oral health (N=432) Excellent 20.14 (87) Good 64.58 (279) Fair/Poor 15.28 (66) Brushing routine (N=431) Twice daily 64.73 (279) Once daily 31.55 (136) Irregular 3.71 (16) Flossing routine (N=418) Twice daily 11.00 (46) Once daily 32.30 (135) Irregular 56.70 (237) Dental visit history in the 5 years period before COVID-19 (N=432) Twice a year or more 49.07 (212) Once a year 26.16 (113) Once every 2 years 10.19 (44) Once or twice in 5 years 14.58 (63) http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Figure 1 Impact of COVID-19 outbreak on respondents’ oral health and oral hygiene routine. There were statistically significant differences in responses based on ethnicity (N=502, P=.033) due to a considerably higher negative impact reported by the Hispanic respondents (see Table 2). There were statistically significant differences in the responses depending on the respondent’s current oral health (N=432, P<.001), brushing habits (N=431, P<.001), flossing habits (N=419, P<.001), and whether they had visited a general dentist during the COVID-19 pandemic (N=502, P=.008). There was also an association between the caries risk category that the respondents belonged to and the impact of COVID-19 pandemic on respondent’s self-perceived oral health (N=423, P=.013). As shown in Table 2, the self-reported negative impact was most prevalent among those with poor oral hygiene habits. Conversely, those with good oral hygiene habits reported the highest positive impact on their oral health. Similarly, the negative impact was disproportionately high among those with poor oral health and/or belonging to “high risk” caries category. Finally, a lower negative impact was observed among those who sought routine dental care during the pandemic. When asked about COVID-19 outbreak’s impact on oral hygiene routine, 76.16% of the respondents reported a minimal impact, 10.88% reported a positive impact whereas 12.96% reported a negative impact (see Figure 1). There were statistically significant differences in the responses depending on the respondent’s gender (N=432, P=.019), current oral health (N=432, P<.001), and oral hygiene habits ((N=432, P<.001) for brushing; (N=419, P<.001) for flossing). The disruption in oral hygiene routines due to the pandemic was observed to be higher among females than males. Similarly, the association between oral health and hygiene follows from the earlier explanation provided for COVID-19’s impact on oral health. Dental visits during COVID-19 outbreak Trust level: Dentists vs. Doctors http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Our intention was to know how much the public trusts the COVID- 19 safety precautions followed by dental practices. We also wanted to learn if the public trust ratings for doctors was any different than that towards dentists. We found that the doctors/medical offices received a more favorable rating than dentists/dental offices (see Figure 2): the average score was 3.74 (std. 1.076) for dentists/dental offices and 3.91 (std. 1.03) for doctors/medical offices (N=502, P<.001). Table 2 Impact of COVID-19 outbreak on oral health and oral hygiene routine cross-tabulated with other variables. Variables Categories COVID-19 impact on oral health COVID-19 impact on oral hygiene Positive No Negative P-value, N Positive No Negative P-value, N % (No.) % (No.) Gender Male 8.5 (20) 64.1 (150) 27.4 (64) .277, 500 14.0 (29) 76.8 (159) 9.2 (19) .019, 430 Female 6.0 (16) 61.2 162) 32.8 (88) 8.0 (18) 75.6 (168) 16.4 (37) Ethnicity Hispanic 6.7 (4) 48.3 (29) 45.0 (27) .033, 502 13.7 (7) 68.6 (35) 17.6 (9) .399, 432 Not Hispanic 7.2 (32) 64.5 (285) 28.3 (125) 10.5 (40) 77.2 (294) 12.3 (47) Brushing habits Irregular 0 (0) 25.0 (4) 75.0 (12) <.001, 431 0 (0) 31.3 (5) 68.8 (11) <.001, 431 Once daily 2.9 (4) 68.4 (93) 28.7 (39) 7.4 (10) 77.2 (105) 15.4 (21) Twice daily 7.9 (22) 63.1 (176) 29.0 (81) 12.9 (36) 78.5 (219) 8.6 (24) Flossing habits Irregular 3.4 (8) 64.6 (153) 32.1 (76) <.001, 418 7.2 (17) 74.7 (177) 18.1 (43) <.001, 418 Once a day 3.7 (5) 63.7 (86) 32.6 (44) 7.4 (10) 84.4 (114) 8.1 (11) Twice a day 23.9 (11) 56.5 (26) 19.6 (9) 32.6 (15) 65.2 (30) 2.2 (1) Current oral health Fair/Poor 4.5 (3) 31.8 (21) 63.6 (42) <.001, 432 7.6 (5) 60.6 (40) 31.8 (21) .005, 432 Good 4.7 (13) 67.0 (187) 28.3 (79) 10.4 (29) 78.5 (219) 11.1 (31) Excellent 11.5 (10) 75.9 (66) 12.6 (11) 14.9 (13) 80.5 (70) 4.6 (4) Caries risk category Low risk 4.8 (8) 70.5 (117) 24.7 (41) .013, 423 7.2 (12) 80.7 (134) 12.0 (20) .206, 423 Medium risk 6.3 (14) 60.5 (135) 33.2 (74) 12.6 (28) 74.0 (165) 13.5 (30) High risk 11.8 (4) 41.2 (14) 47.1 (16) 17.6 (6) 64.7 (22) 17.6 (6) Dental visit during COVID-19 No 5 (15) 60.5 (181) 34.4 (103) .008, 502 9.3 (24) 73.7 (191) 17.0 (44) .005, 432 Yes 10.3 (21) 65.5 (133) 24.1 (49) 13.3 (23) 79.8 (138) 6.9 (12) http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Figure 2 Trust ratings based on a 5-point Likert scale for dental offices/dentists and medical offices/doctors. 1 is the lowest and 5 is the highest trust rating. Figure 3 Patients’ chief sources of concern about contracting COVID-19 during a dental visit. We found a statistically significant difference in the trust level for dentists based on the respondent’s age (N=502, P=.004). Moreover, there were also statistically significant differences depending on whether the patient had visited a dental office (N=502, P<.001) during the COVID-19 pandemic, as well as the dental visit history prior to the COVID-19 pandemic (N=432, P=.009). As shown in Table 3, dentists enjoyed a higher trust level among the respondents who had visited their dentists during the pandemic. Similarly, the respondents who regularly visited their dentists prior to the pandemic also gave a higher trust rating compared to infrequent dental patients. Patient concerns When asked about their greatest concerns regarding visiting the dental offices during the current pandemic, the majority was concerned about contracting COVID-19 from the patients in the waiting area (60.4%), the dentists/hygienists/dental assistants (54.2%), and the AGDP (50.8%). A relatively smaller proportion regarded dental equipment/office surfaces (43%) and front desk staff (28.5%) as their major concerns (see Figure 3). There were statistically significant differences depending on the patient’s trust level for dentists and dental offices (N=432, P=.002). Furthermore, as shown in Table 4, we also found a significant association with certain demographics. For instance, a significantly higher proportion of female respondents was concerned about contracting COVID-19 from AGDP than the male respondents. Number of patients in the waiting area We wanted to learn if the public was concerned about the patient traffic at a dental office while planning their dental visits. A majority (84.9%) of the respondents agreed that the number of patients present in the waiting area of the dental office was an important consideration even if COVID-19 precautions were followed. Moreover, there was a statistically significant association between the response to this question and the patient trust level http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Table 3 Average scores for trust level for dentists/dental offices for different categories. Table 4 Patients’ concerns about contracting COVID-19 during a dental visit for different US census regions, age, and gender. (No.) P-value Age group (N=502) 18-24 (79) 25-34 (182) 35-44 (97) 45-54 (71) 55-64 (45) 65+ (28) .004 Mean 3.49 3.83 3.47 3.97 3.73 4.25 Routine dental visit during COVID-19 outbreak (N=502) Yes (203) No (299) <.001 Mean 4.01 3.46 General dentist visits in last 5 years before COVID-19 outbreak (N=432) Twice a year or more (212) Once a year (113) Less than once a year (107) .009 Mean 3.89 3.64 3.63 Greatest concern % (No.) P-value US census region (N=497) Midwest (71) Northeast (81) South (140) West (205) Patients 63.38 (45) 60.49 (49) 55.71 (78) 62.93 (129) NS (.553) Dentists 49.29 (35) 41.98 (34) 55 (77) 60.0 (123) .039 Aerosols 47.89 (34) 35.80 (29) 48.57 (68) 60.0 (123) .002 Equipment 45.07 (32) 35.80 (29) 40.0 (56) 47.8 (98) NS (.235) Front desk 30.99 (22) 19.75 (16) 21.43 (30) 35.61 (73) .008 Age group (N=502) 18-24 (79) 25-34 (182) 35-44 (97) 45-54 (71) 55-64 (45) 65+ (28) Patients 74.7 (59) 61 (111) 58.8 (57) 49.3 (35) 48.9 (22) 67.9 (19) .018 Dentists 49.4 (39) 55.5 (101) 60.8 (59) 49.3 (35) 62.2 (28) 35.7 (10) NS (.141) Aerosols 48.1 (38) 56 (102) 53.6 (52) 52.1 (37) 31.1 (14) 42.9 (12) NS (.068) Equipment 51.9 (41) 46.7 (85) 45.4 (44) 28.2 (20) 40 (18) 28.6 (8) .026 Front desk 34.2 (27) 33.5 (61) 29.9 (29) 19.7 (14) 13.3 (6) 21.4 (6) .034 Gender (N=502) Male (234) Female (268) http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu for the dental offices (N=502, P=.026). We then asked a more specific question about the number of patients in the waiting area that the respondents feel comfortable with during their dental visits. We found that about 20.1% respondents were comfortable with having no other patient, 25.1% with only 1 other patient, 31.1% with 2-3 other patients, and 23.7% with any of these options as long as COVID-19 safety precautions (social distancing and face coverings) were followed. There were no statistically significant differences between the responses based on the demographics. However, there were statistically significant differences depending on how much the respondents trust the measures taken by dental offices to prevent the spread of COVID-19 (N=502, p<.001). As illustrated in Figure 4, we observe that the higher the trust rating, the more indifferent the respondents were to the number of patients in the waiting area provided COVID-19 precautions were followed. We also asked the respondents about their attitudes towards a dental visit in a post-pandemic scenario (N=429). 45.2% (No.=194) responded that it will be the same as before the pandemic, 13.5% (No.=58) believed that it will be same as during the pandemic, whereas 41.3% (No.=177) said that it will be somewhere in between the two extremes. This is plausible given the disruptive nature of the social and psychological changes brought about by the pandemic. Future visits We also asked the respondents if they intended to visit a dental office in the 6-month period following the survey (i.e., until June 2021). The majority (55.6%, No.=279) answered yes, 29.5% (No.=147) were undecided while 15.1% (No.=76) said no. There were statistically significant differences in the received responses depending on the patients’ trust rating for dentists/dental offices (N=502, P<.001). Patients with a higher trust level were more willing to visit a dentist than those with a lower trust level. Social behaviors We also asked the respondents about their activities outside the household in the three-month period preceding the survey. There was a statistically significant association between the preferred number of patients in the waiting area and the respondents’ shopping style (N=427, P=0.012). We observed that online/curb-side shoppers preferred a smaller number of patients than in-store shoppers. This is plausible as in- store shoppers are likely to be more comfortable in crowded areas (in the context of COVID-19) than others. Furthermore, in-store shoppers assigned a higher trust rating to dentists/dental offices than others. This led to a statistically significant association between the trust rating for dentists and shopping style (N=427, P=.008). We did not find any other significant association with the social behaviors. Discussion In this exploratory study, we have found the self-perceived impact of COVID-19 pandemic on oral health Patients 56.83 (133) 63.43 (170) NS (.132) Dentists 55.12 (129) 53.36 (143) NS (.691) Aerosols 44.01 (103) 56.72 (152) .005 Equipment 41.45 (97) 44.40 (119) NS (.505) Front desk 26.92 (63) 29.85 (80) NS (.468) http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu Figure 4 Respondents’ preferences for the number of patients in the dental office waiting area. A stratification based on the respondents’ trust rating for dental offices is also shown. to be modest. Our preliminary findings indicate a more adverse impact on the oral health for the Hispanic population. However, more specialized studies are needed for vulnerable populations as the COVID-19 pandemic may disproportionately affect the oral health care for marginalized populations. Furthermore, we found the adverse impact to be higher among those with a poor oral health or a poor oral hygiene routine. We also found that dental offices have a lower trust rating among the public when it comes to COVID- 19 precautionary measures, as compared to medical offices. We further observed that most patients were mainly concerned about contracting COVID-19 infection from the dental staff in the operatory, from the other patients in the waiting area and from AGDP. Recent studies have shown the prevalence of COVID-19 among dentists [19] and dental hygienists [20] to be extremely low. The ongoing mass vaccination drives are further expected to boost the patient confidence for dental visits [21]. We found that a significant proportion of the patients prefers to have no other patients in the waiting area of the dental office. It may be beneficial to have the patients wait in their cars instead, a protocol which many dental practices are already implementing. Teledentistry, though still in its infancy, may also prove useful in this regard [22,23]. As for AGDP, significant research efforts are needed to establish the risk factors and proper guidelines. The onset of the pandemic has already catalyzed the research on AGDP [24,25], which will prove useful in the future. To conclude, we have identified the key patient concerns and offered insights into patient attitudes regarding a dental visit during COVID-19 pandemic. Dental practices may benefit by incorporating patient preferences in their protocols and proactively communicating relevant information to patients, thus easing access to oral health care during the ongoing pandemic. Acknowledgements The authors acknowledge HML IRB for conducting the ethical review of this study. They also appreciate the valuable feedback provided by Talha Khan, Ph.D. on the statistical analysis in this study. Conflicts of interest The authors declare no competing interest. References 1. Naming the coronavirus disease (COVID-19) and the virus that causes it. World Health Organ. Braz J Implantol Health Sci. 2020 Feb;2(3). http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu 2. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Rothan HA, Byrareddy SN. J Autoimmun. 2020 May;109:102433. doi: 10.1016/j.jaut.2020.102433. Epub 2020 Feb 26. PMID: 32113704; PMCID: PMC7127067. 3. Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. JAMA. 2020 Aug 25;324(8):782-793. doi: 10.1001/jama.2020.12839. PMID: 32648899. 4. The transmission modes and sources of COVID-19: A systematic review. Rahman HS, Aziz MS, Hussein RH, Othman HH, Salih Omer SH, Khalid ES, Abdulrahman NA, Amin K, Abdullah R. Int. J. Surg. Open 2020 Sep;26:125-136. doi: 10.1016/j.ijso.2020.08.017. 5. Dental procedure aerosols and COVID-19. Epstein JB, Chow K, Mathias R. Lancet Infect Dis. 2021 Apr;21(4):e73. doi: 10.1016/S1473-3099(20)30636- 8. Epub 2020 Aug 10. PMID: 32791041; PMCID: PMC7417139. 6. The Debate: What Are Aerosol-Generating Procedures in Dentistry? A Rapid Review. Virdi MK, Durman K, Deacon S. JDR Clin Trans Res. 2021 Apr;6(2):115-127. doi: 10.1177/2380084421989946. Epub 2021 Jan 29. PMID: 33509030; PMCID: PMC7961632. 7. Possible aerosol transmission of COVID-19 and special precautions in dentistry. Ge ZY, Yang LM, Xia JJ, Fu XH, Zhang YZ. J Zhejiang Univ Sci B. 2020 May;21(5):361-368. doi: 10.1631/jzus.B2010010. Epub 2020 Mar 16. PMID: 32425001; PMCID: PMC7089481. 8. CDC Updates Guidance on COVID-19 Transmission in Dental Settings: Concerns about aerosols, splashing. Evans G. Hosp. Infect. Control Prev. 2020;47. 9. Editorial: How Will COVID- 19 Change Dentistry? Eckert S. Int. J. Oral Maxillofac. Implants. 2020 May;35(3). doi:10.11607/jomi.2020.3.e. 10. Impact on Dental Economics and Dental Healthcare Utilization in COVID-19: An Exploratory Study. Patel N. J. Adv. Oral Res. 2020 Nov;11(2):128- 136. doi:10.1177/2320206820941365. 11. Impact of COVID-19 on dental education in the United States. Iyer P, Aziz K, Ojcius DM. J Dent Educ. 2020 Jun;84(6):718- 722. doi: 10.1002/jdd.12163. Epub 2020 Apr 27. PMID: 32342516. 12. COVID-19 Economic Impact on Dental Practices. Health Policy Institute, A.D.A. Available online: https://www.ada.org/en/science -research/health-policy- institute/covid-19-dentists- economic-impact (accessed on Mar 27, 2021). 13. ADANews HPI poll: Dentists see increased prevalence of stress-related oral health conditions. Available online: https://www.ada.org/en/publica tions/ada-news/2021- archive/march/hpi-poll-dentists- see-increased-prevalence-of- stress-related-oral-health- conditions (accessed on Mar 27, 2021). 14. The impact of coronavirus infectious disease 19 (COVID-19) on oral health. Dziedzic A, Wojtyczka R. Oral Dis. 2021 Apr;27 Suppl 3:703-706. doi: 10.1111/odi.13359. Epub 2020 May 6. PMID: 32304276; PMCID: PMC7264805. 15. Is there an association between oral health and severity of COVID-19 complications? Botros N, Iyer P, Ojcius DM. Biomed J. 2020 Aug;43(4):325- 327. doi: 10.1016/j.bj.2020.05.016. Epub 2020 May 29. PMID: 32713780; PMCID: PMC7258848. 16. COVID-19 pandemics and oral health care for older adults. Marchini L, Ettinger RL. Spec Care Dentist. 2020 May;40(3):329-331. doi: 10.1111/scd.12465. Epub 2020 May 11. PMID: 32391586; PMCID: PMC7272993. http://dentistry3000.pitt.edu/ A Study on Patient Behaviors Towards Dental Visits and Oral Health during COVID-19 Outbreak Vol 9 No 1 (2022) DOI 10.5195/d3000.2022.183 http://dentistry3000.pitt.edu 17. The challenges of dental care provision in patients with learning disabilities and special requirements during COVID-19 pandemic. Picciani BLS, Bausen AG, Michalski Dos Santos B, Marinho MA, Faria MB, Bastos LF, Dziedzic A. Spec Care Dentist. 2020 Sep; 40(5):525-527. doi: 10.1111/scd.12494. Epub 2020 Jul 2. PMID: 32614970; PMCID: PMC7361526. 18. What unites and divides urban, suburban and rural communities. Parker K, Horowitz J, Brown A, Fry R, Cohn D, Igielnik R. Pew Res. Cent. 2018. 19. Estimating COVID-19 prevalence and infection control practices among US dentists. Estrich CG, Mikkelsen M, Morrissey R, Geisinger ML, Ioannidou E, Vujicic M, Araujo MWB. J Am Dent Assoc. 2020 Nov;151(11):815-824. doi: 10.1016/j.adaj.2020.09.005. PMID: 33071007; PMCID: PMC7560385. 20. COVID-19 Prevalence and Related Practices among Dental Hygienists in the United States. Estrich CG, Gurenlian JR, Battrell A, Bessner SK, Lynch A, Mikkelsen M, Morrissey R, Araujo MWB, Vujicic M. J Dent Hyg. 2021 Feb;95(1):6-16. PMID: 33627448. 21. COVID-19 Vaccines and Dentistry. Samaranayake L, Fakhruddin KS. Dent. Update 2021 Jan;48(1):76:81. doi:10.12968/denu.2021.48.1.76 . 22. Teledentistry from a patient perspective during the coronavirus pandemic. Rahman N, Nathwani S, Kandiah T. Br Dent J. 2020 Aug 14:1–4. doi: 10.1038/s41415-020-1919-6. Epub ahead of print. PMID: 32801323; PMCID: PMC7427495. 23. Can Teledentistry Improve the Monitoring of Patients during the Covid-19 Dissemination? Giudice A, Barone S, Muraca D, Averta F, Diodati F, Antonelli A, Fortunato L. A Descriptive Pilot Study. Int J Environ Res Public Health. 2020 May 13;17(10):3399. doi: 10.3390/ijerph17103399. PMID: 32414126; PMCID: PMC7277372. 24. Is there an upside to COVID- 19 for dentistry? Klemmedson D. J Am Dent Assoc. 2020 Oct;151(10):713-715. doi: 10.1016/j.adaj.2020.08.005. Epub 2020 Aug 14. PMID: 32979943; PMCID: PMC7427589. 25. Can extraoral suction units minimize droplet spatter during a simulated dental procedure? Chavis SE, Hines SE, Dyalram D, Wilken NC, Dalby RN. J Am Dent Assoc. 2021 Feb;152(2):157-165. doi: 10.1016/j.adaj.2020.10.010. PMID: 33494869; PMCID: PMC7826119. http://dentistry3000.pitt.edu/