Introduction

More than 110 million people around the world were infected with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) by March 1, 2021, following the initial outbreak of the virus in Wuhan, China in December 2019 [1, 2]. Some of those infected individuals developed the novel Coronavirus Disease (COVID-19), and more than 2.5 million of them have already lost their lives to this disease following the first, second, and now third wave of infections caused in part by variants, despite vaccinations. Virus spread among populations has been associated with aerosolized transmission, droplets generated from speech, and sneezing or coughing, as well as contact with contaminated surfaces [3–5]. There are also potential sources for airborne transmission associated with aerosol-generating dental care procedures; therefore, by March 16, 2020, dental regulatory authorities across Canada strongly recommended the suspension of all routine and elective oral health care to contain the transmission of SARS-CoV-2 during the first wave of infections [6]. As the majority of Canadian dental offices were closed for preventive and clinical care, only emergency cases were addressed at that time–mostly related to pain relief and management of infection [7, 8]. The COVID-19 pandemic itself brought sweeping changes to the way oral health care is performed, leading to uncertainties among various members of the oral health workforce who are currently delivering oral health care [9]. Uncertainties appear to be “rooted in the incompleteness of knowledge” [10], and they are inherent to everyday clinical practice [11–14]. However, the extent to which the first wave of COVID-19 infections led to uncertainties in the professional and personal lives of dentists and dental hygienists is unknown. The objective of this study was to explore the ways in which the novel coronavirus outbreak resulted in uncertainties experienced by members of the oral health care workforce in British Columbia, Canada, during the first wave of infections in the Spring of 2020. The study presented herein was part of a larger project entitled “Structural preparedness during the COVID-19 pandemic and the provision of urgent oral health care”. As such, we are only presenting the findings pertaining to this study’s objective, which focuses on perceived uncertainties.

Methods

Ethics approval was granted by the University of British Columbia’s Behavioural Research Ethics Board (# H20-01147). Written consent to participate was obtained from all participants. A qualitative inquiry engaged frontline oral health care workers, including dentists, dental hygienists, certified dental assistants, and staff, who either stopped the provision of oral health care or continued to work to treat dental emergencies after the curtailment of oral health care services in British Columbia on March 16, 2020. Participants were purposefully recruited from a province-wide professional email list or by word-of-mouth (snowball sampling) [15] and contacted the first author by email in April 2020. They were given the rationale for the study and its objectives, were informed about the interview process, and received an informed consent form via email. In addition, participants received a $150 honorarium in appreciation for their time. Interviews were scheduled at a date and time convenient for the participants between April 20 and May 4, 2020; face-to-face interactions did not occur, instead the interviews took place via phone, Zoom© video communication, or Skype Microsoft©. In-depth, semi-structured interviews were conducted in order to obtain even representation among the professions and roles, along with a fair distribution of gender (when possible), work location, and years of experience (Table 1). Upon mutual agreement, the first two interviews were conducted in the format of a conference call with numerous members of the research team (MB, TM, LD, KMM, HCvB) to calibrate and refine the main and probing questions. The interview guide included the following questions:

1) What do you know about the COVID-19 outbreak?

    What do you know about the transmission of the virus?

    How can a patient be at risk for transmission?

2) What do you understand about “preparedness” or “being prepared” to offer oral health care during the pandemic?

    Can you give an example?

    How do you think we/you should prepare during the pandemic?

3) Based on your own awareness and experiences, what actions and/or procedures would you like to see implemented (or that you are implementing) in order to resume care?

    Can you give examples?

    How are you modifying your clinic infection control protocols to keep up with the new information that is constantly emerging about COVID-19?

4) Is there anything else that still concerns you about the COVID-19 outbreak?

    Why? Please explain.

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Table 1. Demographic information about the participants including profession, gender, years of experience, practice location, and working status.

https://doi.org/10.1371/journal.pone.0249186.t001

All interviews were audio recorded and transcribed verbatim for thematic analysis concurrent to data collection. While demographic data (e.g., gender, profession, work location, and years of practice) were recorded, a unique code was added to each de-identified transcript after information pertaining to gender was removed (Table 1). The de-identified transcripts were analyzed thematically between April 20 and May 30, 2020; an initial round of interactive analysis of the first five transcripts was performed to develop an audit trail and organize the coding scheme, then the remaining transcripts were analyzed independently by five of the authors (MB, TM, LD, KMM, HCvB). Coding refers to an inductive process of assigning a word or short phrase to a sentence or excerpt from the transcript. Each code refers to a specific idea or concept within the various segments of the transcript. Similar codes representing related ideas or concepts are grouped into categories or subthemes that are then clustered under a theme, as we have employed in previous studies [16–19]. Rigour was reached by employing reflexivity [20] during data collection and analysis, achieving data saturation [21], and conducting member checking [22] in order to reduce subjectivity and achieve the required standards for ethics and quality in qualitative research [23, 24]. Follow up interactions with the participants occurred via e-mail and/or a second round of interviews to clarify issues brought up in the first interviews; member checking was also offered to attest to the accuracy of our thematic analysis.

Results

We recognized repetition of the responses after forty interviews, and it was decided to conduct at least one more interview with a representative from each participating group (e.g., dentist, dental hygienist, certified dental assistant, staff) to ensure that saturation had been achieved. The data collection process was then terminated resulting in 45 initial interviews lasting between 39 and 74 minutes each, and included information from 18 dentists (6 females), 12 dental hygienists (11 females), 6 certified dental assistants (all females), and 9 administrators/front desk staff (7 females). These 45 interviews led to 51 hours of audio recordings and more than 650 single-spaced pages of transcripts. Following the calibration coding of the first five transcripts, the previously mentioned five authors separately coded a different set of eight transcripts each. Although the authors independently coded each reflection, they met via conference calls to discuss the identified codes, categories, and themes, as well as to reach consensus on the thematic analysis process. In the context of the first wave of SARS-CoV-2 infections, five main themes emerged pertaining to uncertainties surrounding COVID-19, patient care, personal lives and infectiousness, concern for the future, and variations among different pandemics. These uncertainties surfaced during the first wave of a novel pandemic when information about the disease was still somewhat incipient and there was no vaccine in sight. Although the five themes might overlap in some respects, they are presented separately herein. For illustration purposes we used excerpts from the transcripts while including their respective participant demographic information for context.

Discussion

This study explored the various ways in which the first wave of infections caused by the novel coronavirus outbreak led to feelings of uncertainty experienced by 45 oral health care providers and administrators in British Columbia, Canada, during the Spring of 2020. As the interviews took place during the first wave of infections, the findings have to be understood under that context–even if a second and third wave were assumed to happen, a vaccine was to be developed, and a protocol for care during a pandemic was presented [25] participants were not asked about these now pressing developments [26]. The uncertainties shared by the participants were dependent upon what was (un)known about the disease, what could be done to safely provide oral health care, to what extent the pandemic would impact participants’ lives, what the future of oral health care would look like, and how similar/dissimilar the outbreaks of HIV and SARS-CoV-2 were by the Spring of 2020.

Uncertainties, like those reflected in the participants’ responses, are not entirely surprising given that they “permeate every aspect of clinical practice–from diagnosing and managing dental caries to predicting success for [a treatment]” [10] and occur as early as during undergraduate dental education [27, 28]. The COVID-19 pandemic has produced other uncertainties, considering information has changed almost daily due to the rapid rate knowledge is obtained about this novel coronavirus. Such rapid availability of new information from multiple sources has led to many different interpretations, and even the misinterpretation of information, as was seen with the media debate around wearing facial coverings–including masks–in public. The idea of wearing facial coverings does not readily fit some existing preconceived notions in western cultures, but acceptance of the necessity of wearing masks during the pandemic seems to have become more mainstream in various contexts [29] while also becoming “a catalyst for political conflict … viewed through a partisan lens” [30]. Some participants appeared to gather information from primary sources, such as the Provincial Dental Associations, Centers for Disease Control (CDC), and World Health Organization (WHO) [6, 31], and seemed to be more confident in their knowledge and could clearly articulate their thinking. Participants who referenced other sources of information, including media and social circles, were less certain about the evidence they provided, perhaps due to confusion or cognitive dissonance over what they learned and what they believed, which ultimately reflected an incompleteness in their knowledge [10].

A number of interviewees mentioned the zoonotic source of SARS-CoV-2 likely originated from bats, more specifically the Chinese horseshoe bat (Rhinolophus sinicus), as reported by Chan and coworkers [32] and Lu and colleagues [19]. Other interviewees were uncertain about its origin, which has recently come into question since traces of COVID-19 were found in sewage samples from Spain, Italy, and Brazil that pre-date its discovery in China [33], and after the WHO exploratory investigation in Wuhan at the beginning of 2021 [34]. Participants also seemed to disagree about whom is at risk for COVID-19. While many believed that anyone can be at risk by referring to the equalizing effect of the pandemic, others questioned that assumption by mentioning that COVID-19 disproportionately impacts certain racialized groups, including African Americans in the United States [20] and Canada [21], and those of lower socio-economic status [35], which further contributes to health inequalities rather than equalization. Many participants mentioned older adults as another group at higher risk for COVID-19, when in fact it is the multiple comorbidities present in this group that leads to the higher risk of more severe complications from the disease when compared to their healthier or younger counterparts [27, 31, 36, 37].

The reorganization of clinical work and oral health services is not straightforward and led participants to experience a great deal of uncertainty. Their concerns around PPE are legitimized by the fact that oral health care professionals are at a higher risk for contracting SARS-CoV-2 than other professionals [38]. However, participants also realized that there are still many uncertainties and unknowns related to COVID-19, from the efficacy of the current infection control protocols [25, 39] to striking a balance between self-care and patient care in their daily practice [7]. Although it is unthinkable that in this day and age an oral health professional would provide care without wearing disposable gloves, eye protection, and masks at the bare minimum, participants did mention the bare-handed dental care provided before the human immunodeficiency virus (HIV) pandemic. These disposable items are part of PPE, and fall under the principles of universal–or standard–precautions or procedures (UPs) [40, 41]. UPs refer to an approach for infection prevention and control that treats every patient and their bodily fluids, including blood and saliva, as infectious for any blood-borne pathogens in order to minimize the risk of cross-infection among both patients and health care workers [42]. As voiced by the participants, PPE and UPs were introduced to mainstream use following the Acquired Immune Deficiency Syndrome (AIDS) outbreak in the 1980’s [43, 44]. Under normal circumstances the transmission of HIV within the walls of a dental practice is very improbable [45], while the risk of SARS-CoV-2 transmission via saliva droplets is considered extremely high since droplets are part of any dental procedure; this prompted various participants to be uncertain about providing safe care while minimizing the risk of transmission to themselves and their families. In fact, when questioned about the transmissibility of SARS-CoV-2 via aerosols, no uncertainty seemed to exist as all participants mentioned the respiratory droplets route [4, 5, 46, 47]. Interestingly, none of the participants commented directly on the contact transmission route (or community transmission), which also occurs via aerosolized saliva droplets. This route has been the main reason for physical distancing measures adopted by many countries in response to the pandemic due to the likely airborne transmission of the virus [48]; hence, the suggestion of face coverage when physical distancing is not possible [30]. Moreover, Meng and colleagues [39] highlighted that “the standard protective measures in daily clinical care are not effective enough to prevent the spread of COVID-19”, which further justified the many uncertainties participants had in terms of protection during the provision of oral health care, and their concerns around bringing the virus home. Furthermore, competing personal demands, including issues surrounding the care of children and grandparents voiced by many participants, might have likely exacerbated these uncertainties on top of eclipsing pressures related to maintaining a viable practice; such pressures were found to have personal, financial, and professional implications [7].

Participants also shared their uncertainties regarding the future of the profession, their lives, and the viability of a dental practice. Financial uncertainties surfaced as dental offices were either closed or only attending to urgent care [7, 9]. Lay-offs were experienced by some of those with employee status who were on a form of government financial benefit aid, either CERB or EI; while some dentists, as business owners, were using pandemic insurance. This uncertain economic and health care environment may further affect dental care delivery [49].

Moreover, changes brought about by the pandemic are inevitable. Nearly 30 years ago, Hardie concluded that “it goes without saying that the members of any professional group are more likely to modify their behavior if they are provided with logical, rational reasons to enact the suggested change” [50]. Such changes are likely being introduced now under new oral health care protocols, but it remains unclear which preparations during an outbreak are deemed necessary [51] or will remain after vaccination. Whether or not these changes will actually constitute a new normal, there is still an opportunity for the profession to innovate given the uncertainties encountered during this pandemic. In fact, Brondani and Donnelly (along with others [52]) have shared the ideas presented by undergraduate dental students who suggested a shift in the provision of oral health care to focus on less invasive and non-aerosol generating procedures, such as the use of silver diamine fluoride and tele-dentistry when applicable [27]. In addition, when considering the new normal, Profitt goes beyond the changes in treatment to also highlight changes in products and technology for the practice of oral health care, and in the healthcare system as a whole [53]. Although “unanticipated benefits” such as enhanced self-care at home were mentioned as a silver lining of the pandemic, there were potential financial and health implications when patients had to place their ongoing care on hold [49, 54].

While there might exist a culture of certainty in dentistry, particularly in undergraduate education [11], uncertainties do indeed abound in everyday clinical dental practice, from diagnosis to treatment planning and prognosis [10, 12–14, 27]. These uncertainties have also permeated our participants’ personal and professional experiences at a time when a novel coronavirus has caused a global pandemic and resulted in millions of infections and deaths, along with an unprecedented financial crisis. While some participants have alluded to a new normal during these uncertain times, the pandemic might also optimize self-reflection so we can collectively reshape the culture of the dental profession and foster stronger resilience.

This study aimed to achieve rigour through reflexivity, data saturation, and member checking [22, 23]. Reflexivity referred to how the research team described the contextual intersecting relationships between the participants and themselves, as addressed ahead when discussing the limitations of the study [55]. Saturation referred to the point during data collection where no new information was provided on the issue under investigation, and the data did indeed become repetitive within the 45 interviews [56]. Member checking occurred at different stages of the study, where participants were given the opportunity to read their transcripts, and/or the thematic analysis, and/or the final report [57]; however, no participants offered comments when prompted.

Despite the interesting findings, this study is not without limitations. Given the current preference of social/physical distancing to curb the spread of SARS-CoV-2, all interviews took place at-a-distance and likely caused the loss of a more personal connection [58]. Although we offered participants the opportunity to be involved in member checking, only four participants chose to receive the transcripts and none of them provided any actual feedback; this is comparable with our experiences in previous studies [15, 59]. The sole focus on British Columbia and the relatively small sample size prevents full generalization to all oral health care providers, even though the data was indeed saturated. The purposeful recruitment method, although targeted province-wide, was unlikely to have reached all professionals and staff in British Columbia. The participant honorarium may have been high for this type of study and might have attracted those who would express their ideas in a more socially desirable manner, that is, they responded based on what they thought the interviewer would like to hear, likely influencing the results. The mixing of different professional groups (dentists, hygienists, assistants, and so on) may have hindered the peculiarities of each group. Despite the potential personal and professional stressors to be discussed at the time, the interviewers allowed the participants to be at ease, openly share their thoughts, and probed for information only as needed. Given the inter-provincial differences in professional regulations, it is necessary to include the opinions of a larger, Canada-wide group of oral health care providers (not just those in British Columbia) in future studies. In addition, the perspectives of the patients themselves, as the recipients of oral health care during this pandemic, should also be heard. Lastly, the third wave of SARS-CoV-2 infections caused in part by the many variants in Canada and in many other countries as of Spring 2021, along with the introduction of mass vaccination [26, 60], would likely influence the results of this study if repeated.

Conclusions

This study employed semi-structured interviews with a sample of 45 oral health care providers and administrators across British Columbia to explore the ways in which the current novel coronavirus outbreak led to uncertainties in the delivery of oral health care in the Spring of 2020. Participants indicated that these uncertainties were dependent upon what was known, and also unknown, about the pandemic, given the constantly evolving information related to COVID-19. Many participants felt they did not have clear direction on how to provide safe oral health care in the present circumstances, and described their lives as being on pause for the moment; they also sensed that a new normal for oral health care is in the making. Future studies are required to include a larger sample of oral health care providers across Canada who might have experienced the pandemic differently, as well as the perspectives from patients receiving oral health care during this time.

Acknowledgments

The authors are grateful to all participants who donated their time to share their concerns, struggles, and ideas, making this study possible. Special thanks to Dr. Angela Tether for her editorial contributions. The authors attest to the originality of this research, and that it is not under publication consideration elsewhere.