COVID-19 pandemic impact on dentists in Latin America’s epicenter: São-Paulo, Brazil

Tatiane Fernandes Novaes; Maisa Camillo Jordão; Carlos Felipe Bonacina; André Oswaldo Veronezi; Carlos Ariel Rodrigues de Araujo; Isabel Cristina Olegário; Daniele Boina de Oliveira; Veranika Ushakova; Alexander Birbrair; Danielle da Costa Palacio; Debora Heller

doi:10.1371/journal.pone.0256092

Peer Review History

Original SubmissionJanuary 6, 2021
16 Jun 2021 Decision Letter - Endi Lanza Galvão, Editor PONE-D-20-40253 COVID-19 pandemic impact on dentists in Latin America’s epicenter: São-Paulo, Brazil PLOS ONE Dear Dr. Heller, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jul 31 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Partly Reviewer #4: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is an interesting manuscript that provides relevant information about the economic impact of the COVD epidemic for dentists in a large Brazilian city. The relevance of this manuscript highlights the need for more information about individual protection methods for the performance of dentists. Reviewer #2: This cross sectional study was done in Sao Paulo Brazil to evaluate the impact of COVID 19 among dentists. A good study to evaluate an important dimension. I have some observation mentioned below Abstract Line 37 : How many dentists were approached? Result Line 136 : Pl recheck n 2348-2113 = 235 Line 140/141 : please use uniform nomenclature in table and text Conclusion : Please try to have a reflection of objectives Reviewer #3: I declare that I have no conflict of interest with the authors and the institution by which the work was developed. The work is in ethical compliance. The article brings an interesting theme in view of the various impacts that the pandemic has brought to the population. Health professionals are part of the front line and special attention must be paid to all of them. However, there are methodological limitations and some unclear points. The following are some doubts and questions about the clarity of the data: Summary: 1- As the study recruited only dentists from the state of São Paulo, and only 2.26% of them participated in the survey, it is wrong to conclude “This study provides evidence of the negative impact of the COVID-19 pandemic on dentistry in Brazil.” Introduction: 2- The authors claim to have followed the standards proposed by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), however, they do not present the study hypothesis as guided by the guide. Methodology: 3- Was it considered only active registration or were dentists who deactivated their registration also considered? 4- In which month / period of time did the study take place? According to STROBE, this information must come in the methodology section. 5- How long was the data collected for? This should also come in the methodology and not in the results section. 6- In relation to dentists who were not working in dentistry, but registered in CROSP (active or inactive), how was this controlled? 7- The authors state in the supplementary document with the completed STROBE that the item “variables” in the methodology section does not apply to the study. Because? Since the authors work with categorical variables. Clearly define exposures and potential confounders. 8- How much does the recruited sample represent the population of dentists in the state of SP? Results: 9- Why did the data collection only last 8 days? 10- Why were the variables from the “COVID -19 Education Characteristics” domain of the questionnaire not used in the regression? ” 11- Could the sample size be a limitation? 12- Talk about the internal and external validity of the data. Discussion 13- Why did older dentists suffer less from the financial impacts compared to younger ones? Conclusions 14- The authors conclude for the Brazilian population only 2.26% of dentists in the state of São Paulo. The conclusions do not answer the objective objectively. Reviewer #4: This study aimed to assess the impact of the COVID-19 pandemic on dentists in the State of São Paulo. Through a questionnaire, via Google form, the authors sought information about changes in dentists' routine during the pandemic. Important evidence was generated confirming the negative impact of the pandemic on the income of these professionals. In addition, interesting results about the difficulty in purchase PPE and the lack of specific training to control coronavirus transmission were found. I believe this study brings clarity about the need to improve the dissemination of information about care against coronavirus. I congratulate the authors for this work and suggest minor changes before publication. 1. Introduction section - Page 3 - line 55: The infection is caused by SARS-CoV 2 which causes COVID-19 disease. Correct the sentence: “COVID-19 infected cases have since grown exponentially…” 2. Methods section: I suggest informing that research was carried out with professionals from the State of São Paulo, at first seemed to be only with professionals from the capital. 3. I consider the results on training to control coronavirus transmission and disposal of PPE of the most important in the study. Therefore, I suggest including in the summary and conclusion as one of the main results found. 4. Conclusion section: The authors' conclusion was: “We presented evidence of the negative impact of COVID-19 pandemic on dentists in the State of São Paulo, Brazil. Brazilian dentists reported an income reduced by more than 50% and the dental private sector shouldering twice the burden of those in the public sector. While these are unprecedented challenging times, we hope this study will help dental and other health care professionals to better understand the consequences of disease in dental settings and strengthen preparedness throughout the dental health care system.” I suggest making the conclusion more clearer and objective. Suggestion: COVID-19 pandemic caused major negative impacts on the routine of dentists in the state of São Paulo, Brazil. These professionals reported reduced income by more than 50% and the private dental sector was more affected than the public sector. In addition, about 83% reported not having received any specific training to control the transmission of coronavirus in the health area. This data added to the difficulty in finding PPE is extremely worrying since the dentist is among the occupations at greatest risk for the contamination of COVID-19. We hope that this study will help dentists and other health professionals to better understand the consequences of the disease and thus search more information’s about care against COVID-19. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: No Reviewer #4: Yes:** Tamires Szeremeske Miranda [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-20-40253_reviewed 12 March.pdf https://doi.org/10.1371/journal.pone.0256092.r001
Revision 1
8 Jul 2021 Author Response São Paulo, 7/08/2021 Academic Editor, PLOS ONE Dear Dr. Endi Lanza Galvão, The authors of the manuscript entitled “COVID-19 pandemic impact on dentists in Latin America’s epicenter: São-Paulo, Brazil” have carefully evaluated the reviewers’ comments and express their thanks for their constructive critique. All suggestions and questions have been addressed in the revised manuscript. The changes suggested by the reviewers have been incorporated in the manuscript and are listed below. We would like to point out that we made additional modifications and corrections in order to improve the clarity of the manuscript. Again, we would like to thank the reviewers for theirs constructive suggestions. We hope that the changes meet with your approval and make this manuscript acceptable for publication. Sincerely, Dr. Debora Heller July 8, 2021 We appreciate the expert feedback provided by the reviewers. It has enabled us to increase the clarity and quality of the manuscript. We incorporated the requested major changes. Below we present a point-by-point response to clearly identify the changes made to the text (changes also marked in the manuscript). Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: We checked all style requirements and modified the manuscript accordantly. 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: We included captions for all Supporting Information files at the end of the manuscript, and updated all in-text citations to match accordingly. Response to the reviewers’ comments Reviewer #1 This is an interesting manuscript that provides relevant information about the economic impact of the COVD epidemic for dentists in a large Brazilian city. The relevance of this manuscript highlights the need for more information about individual protection methods for the performance of dentists. Response: We thank the reviewer for the positive feedback on our manuscript and are glad to learn that our message was clear to him/her. The feedback was valuable to us and also taken into consideration while preparing the revisions. Reviewer #2 This cross sectional study was done in Sao Paulo Brazil to evaluate the impact of COVID 19 among dentists. A good study to evaluate an important dimension. I have some observation mentioned below Response: Thank you for the positive feedback and critique. Abstract Line 37: How many dentists were approached? Response: A semi-structured questionnaire was sent via e-mail to 93.280 dentists registered in the Dental Council of São Paulo (CROSP). This information has been added to the abstract (Line 35) Result Line 136: Pl recheck n 2348-2113 = 235 Response: Thank you for your correction. This information was corrected in the text. In fact, 101 participants refused to participate after accessing the informed consent; the others refused before that, totalizing 235. Line 140/141: please use uniform nomenclature in table and text Response: Uniform nomenclatures have been added to the table and text as suggested. Conclusion: Please try to have a reflection of objectives Response: This critique is in agreement with the other reviewers and was addressed by making the conclusion more clear and objective (Lines 257-267). Reviewer #3 I declare that I have no conflict of interest with the authors and the institution by which the work was developed. The work is in ethical compliance. The article brings an interesting theme in view of the various impacts that the pandemic has brought to the population. Health professionals are part of the front line and special attention must be paid to all of them. However, there are methodological limitations and some unclear points. Response: Thank you for your feedback. All critiques and suggestions have been addressed in the revised manuscript. The following are some doubts and questions about the clarity of the data: Summary: 1- As the study recruited only dentists from the state of São Paulo, and only 2.26% of them participated in the survey, it is wrong to conclude “This study provides evidence of the negative impact of the COVID-19 pandemic on dentistry in Brazil.” Response: To address this reviewer’s critiques we have replaced this statement as follows: “This study provides evidence of the negative impact of the COVID-19 pandemic on the routine of dentists in the state of São Paulo, Brazil.” Introduction: 2- The authors claim to have followed the standards proposed by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), however, they do not present the study hypothesis as guided by the guide. Response: The null hypothesis of the study is that the COVID-19 pandemic would not impact the routine of dentists in the state of São Paulo. The study's alternative hypothesis is that the COVID-19 pandemic would impact the routine of dentists in the state of São Paulo. This information has been added to the text. Methodology: 3- Was it considered only active registration or were dentists who deactivated their registration also considered? Response: Only active registrations were considered. This information has been added to the text. 4- In which month / period of time did the study take place? According to STROBE, this information must come in the methodology section. Response: The present study took place from June 25, 2020 until July 02, 2020. This information has been added to the methodology section (Lines 111-112). 5- How long was the data collected for? This should also come in the methodology and not in the results section. Response: The data was collected for 8 days. This information has been added to the methodology section as suggested (Line 111). 6- In relation to dentists who were not working in dentistry, but registered in CROSP (active or inactive), how was this controlled? Response: Only dentists with active registrations were contacted by email and included in this study. This information has been added to the text. 7- The authors state in the supplementary document with the completed STROBE that the item “variables” in the methodology section does not apply to the study. Because? Since the authors work with categorical variables. Clearly define exposures and potential confounders. Response: All independent variables were considered in the regression model. So, the adjusted model was presented, describing the Confidence Interval and Odds Ratio values. This information was added in the Statistical analyses section. The STROBE checklist was also corrected. 8- How much does the recruited sample represent the population of dentists in the state of SP? Response: From total of 93.280 dentists with active registration in the Regional Dental Council of Sao Paulo, 2.113 participated in this study. This represents 2.3% of the population of dentists in the state of SP. This information has been added to the text and addressed accordantly. Results: 9- Why did the data collection only last 8 days? Response: This study took place in June 2020, when São Paulo was the epicenter of the COVID-19 Pandemic in Latin America. In order to gather reliable information and help the dental community, we decided to limit the questionnaire for 8 days. The response rate was higher in the first three days (80% of total responses), decreasing to 7, 6, 4, 2 and 1% on each of the following day. We believe that even a longer period of data collection would not impact in higher participants number in the present survey, since not many responses were obtained after 7-8 days. 10- Why were the variables from the “COVID -19 Education Characteristics” domain of the questionnaire not used in the regression? ” Response: The primary outcome of the present study was the COVID-19 financial impact. As the presence of training/education on COVID aspects does not have a plausible association with financial impact, the authors decided not to include this independent variable in the regression analysis. However, the descriptive report of this variable has been added into this paper to describe to the reader that many dentists at the time of the present study did not have any previous educational support in dealing with COVID pandemic. 11- Could the sample size be a limitation? Response: From total of 93.280 dentists with active registration in the Regional Dental Council of Sao Paulo, 2.113 participated in this study. The responses could be influenced by the fact that the participants were not randomly selected (convenience sample) and the results are only representative of those who answered the online survey. We agree that this could be a study limitation and added to the discussion section. 12- Talk about the internal and external validity of the data. Response: We have added a brief discussion in relation to the internal and external validity of the data to our discussion section. The internal validity of this present study needs to be interpreted with caution. The results could have been influenced by the period in which the survey was taken (July 2020), when only 30% of the dental practices were open as usual. Also, dentists who were working full time at the time of the online survey could not had participated and influenced the final results. In relation to the external validity of the present data, especially when extrapolating to other regions in Brazil or other countries in a similar situation, some factors as social and political circumstances, COVID-19 incidence at the time, and local regulations could play an important role in the financial impact. Discussion 13- Why did older dentists suffer less from the financial impacts compared to younger ones? Response: There could be many reasons for this, such as more stability of older dentist (more years practicing dentistry) and or the fact that the younger dentists may also have other expenditures, such as postgraduate studies costs. This has now been addressed in the discussion. Conclusions 14- The authors conclude for the Brazilian population only 2.26% of dentists in the state of São Paulo. The conclusions do not answer the objective objectively. Response: We believe that the conclusions of the paper were not appropriately presented. We took this critique into strong consideration and modified conclusions as suggested making it clearer and objective. Reviewer #4 This study aimed to assess the impact of the COVID-19 pandemic on dentists in the State of São Paulo. Through a questionnaire, via Google form, the authors sought information about changes in dentists' routine during the pandemic. Important evidence was generated confirming the negative impact of the pandemic on the income of these professionals. In addition, interesting results about the difficulty in purchase PPE and the lack of specific training to control coronavirus transmission were found. I believe this study brings clarity about the need to improve the dissemination of information about care against coronavirus. I congratulate the authors for this work and suggest minor changes before publication. Response: Thank you for the positive feedback. 1. Introduction section - Page 3 - line 55: The infection is caused by SARS-CoV 2 which causes COVID-19 disease. Correct the sentence: “COVID-19 infected cases have since grown exponentially…” Response: Corrected as suggested. 2. Methods section: I suggest informing that research was carried out with professionals from the State of São Paulo, at first seemed to be only with professionals from the capital. Response: Replaced as suggested. 3. I consider the results on training to control coronavirus transmission and disposal of PPE of the most important in the study. Therefore, I suggest including in the summary and conclusion as one of the main results found. Response: Thank you for the suggestion. We have now added this to the summary and conclusions. 4. Conclusion section: The authors' conclusion was: “We presented evidence of the negative impact of COVID-19 pandemic on dentists in the State of São Paulo, Brazil. Brazilian dentists reported an income reduced by more than 50% and the dental private sector shouldering twice the burden of those in the public sector. While these are unprecedented challenging times, we hope this study will help dental and other health care professionals to better understand the consequences of disease in dental settings and strengthen preparedness throughout the dental health care system.” I suggest making the conclusion more clearer and objective. Suggestion: COVID-19 pandemic caused major negative impacts on the routine of dentists in the state of São Paulo, Brazil. These professionals reported reduced income by more than 50% and the private dental sector was more affected than the public sector. In addition, about 83% reported not having received any specific training to control the transmission of coronavirus in the health area. This data added to the difficulty in finding PPE is extremely worrying since the dentist is among the occupations at greatest risk for the contamination of COVID-19. We hope that this study will help dentists and other health professionals to better understand the consequences of the disease and thus search more information’s about care against COVID-19. Response: We agree that the conclusions of the paper were not appropriately presented. We took this critique into strong consideration and modified conclusions as suggested making it clearer and objective. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0256092.r002
30 Jul 2021 Decision Letter - Endi Lanza Galvão, Editor COVID-19 pandemic impact on dentists in Latin America’s epicenter: São-Paulo, Brazil PONE-D-20-40253R1 Dear Dr. Heller, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Endi Lanza Galvão Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0256092.r003
Formally Accepted
18 Aug 2021 Acceptance Letter - Endi Lanza Galvão, Editor PONE-D-20-40253R1 COVID-19 pandemic impact on dentists in Latin America’s epicenter: São-Paulo, Brazil Dear Dr. Heller: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Endi Lanza Galvão Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0256092.r004

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