Dental care delivery in the context of the COVID-19 pandemic: a bibliometric analysis and review of emerging trends

Introduction

The outbreak of the COVID-19 pandemic significantly impacted the number and range of medical procedures performed. Fear of infection and numerous restrictions caused a reduction in the number of screening tests and preventive services [1]. The main routes of SARS-CoV-2 transmission are respiratory droplets and close contact with infected patients or their belongings, making it a serious threat to medical services [2]. Due to close contact with the oral cavity and aerosol gene­rated during procedures, dentists faced the highest risk of coronavirus exposure [3]. During the acute phase, this resulted in a reduction of routine visits, restricting them to urgent dental procedures only. The number of surgical treatments increased, while the rate of conservative procedures simultaneously decreased [4].
The primary reason for this shift was the desire to limit aerosol exposure, generated mainly by devices used during conservative procedures as well as to shorten the duration of treatments to reduce the risk of contamination [5]. Innes et al. [6] demonstrated that procedures involving high-speed air rotors, ultrasonic scaling, and water-air syringes, pose a higher contamination risk than extractions. Large droplets (> 5 μm in diameter) primarily settle on the operator’s torso and arms as well as the patient’s body, while smaller droplets (≤ 5 μm in diameter) due to their low settling velocity, can remain suspended in the air for extended periods [7, 8]. This presents a potential risk of cross-infection between patients, who are treated in the same dental office. There are documented cases of patients diagnosed with COVID-19 infection undergoing dental procedures involving aerosol-generating techniques [9]. This underscores the necessity of effective ventilation to facilitate air exchange as well as extended time period between visits, to ensure thorough decontamination of dental office [10, 11]. Additional measures should be taken to limit aerosol spread through the use of rubber dam isolation, high-volume saliva ejectors, and anti-retraction dental handpieces [7, 12].
The utilization of antiseptic mouth rinses is also re­commended. Patients should gently gargle and disinfect oral cavity for 30 seconds as well as the throat for another 30 seconds, using one of the following solutions: 1.5% or 3% hydrogen peroxide (15 ml), 0.2%, 0.4%, or 0.5% povidone-iodine (9 ml), 0.12% chlorhexidine (15 ml), or 0.05% cetylpyridinium chloride (15 ml) [13]. For personal protection, dental practitioners should employ N95 or FFP2 standard masks, face shields, or protective eyewear to safeguard the eyes, and oral and nasal mucosa [14].
The impact of the COVID-19 pandemic on medi­cal and dental services seems to be widely described. Previously, we have examined the long-term impact of the COVID-10 pandemic on spectrum of dental procedures in the fields of conservative dentistry and oral surgery [15]. Since there is a lack of comparable studies, we attempted to systematize the available literature using bibliometric analysis, while synthetically discuss the main trends presented in the analyzed papers.

Material and methods

The search was conducted using the Web of Science database from Clarivate by applying the following query: TS = ((COVID-19) AND (“dental care” OR “dental service*” OR “dental procedure*” OR “dental treatment”) AND (“conservative dentistry” OR “restorative dentistry” OR “endodontics” OR “surgery”)). No filters were utilized.
As of February 10, 2025, the database contained 90 records. Two researchers carried out the selection process by reviewing titles, abstracts, and full texts in some cases. There were 88 relevant records considered for inclusion. Two indexed papers did not contain the connection between dental care and the pandemic. The number of the selected publications and their citation counts are presented in Figure 1. The chosen records were obtained from the Web of Science database and examined using VOSviewer version 1.6.20, a bibliometric tool created by the Centre for Science and Technology Studies at Leiden University. Citation and key word co-occurrence maps were generated based on bibliographic data. In these maps, bubble size represented the number of publications, while their proximity indicated relatedness. The network visualization groups similarly colored bubbles into clusters, signifying close collaboration. Further details are provided in the figure legends.

Results

Most of the articles were categorized under the “Dentistry Oral Surgery Medicine” category (n = 45, 51.1%), followed by “Public Environmental Occupational Health” (n = 17, 19.3%). Top ten of the most common categories in the Web of Science (WoS) are shown in Figure 2. Some papers were classified into multiple categories by the database.
In the Citation Topics Meso analysis, the majority records were classified within “1.104 Virology-General” (n = 57, 64.8%), followed by “1.49 Dentistry and Oral Medicine” (n = 10, 11.4%), as shown in Figure 3.
For the Citation Topics Micro analysis, the most frequently occurring term was “1.104.1353 Coronavirus” (n = 55, 62.5%), as depicted in Figure 4.
Table 1 lists the publishers, which released at least 5 articles, with Springer Nature leading the group by publishing 17 papers, representing 19.3% of the total analyzed output. Table 2 shows the journals that most frequently featured studies investigating the impact of COVID-19 on dental care as well as those with the highest overall citation counts. In terms of total citations, “Journal of Endodontics” (Elsevier, impact factor of 3.5) ranked first. Figure 5 illustrates the citation network among journals, where “International Journal of Environmental Research and Public Health” demonstrated the strongest total link strength, scoring a value of 8. In terms of author contributions, Prof. Anna Surdacka (Poznan University of Medical Sciences, H-index 16, 74 publications, 751 citations) was the most prolific, with 3 publications totaling 48 citations. Figure 6 demonstrates the network of collaborative links among the authors. Seven research institutions received over 50 citations, with Cardiff University in the UK achieving the highest count. Comprehensive information can be found in Table 3. As shown in Figure 7, the majority of institutions were connected to Karolinska Institutet in Sweden, which recorded the highest total link strength of 17.
The majority of the included articles originated from England (16 publications, 18.2%) and the USA (15 publications, 17.0%). Table 4 presents countries with at least 5 published papers. In terms of citation frequency, the USA led with 648 citations and a total link strength of 37, followed by England with 349 citations and a link strength of 21, as shown in Figure 8. Table 5 displays the 20 most frequently used key words in the dataset, with “COVID-19,” “dentistry,” and “coronavirus” being top-ranking key words, as anticipated.
Figure 9 presents the network analysis of co-occurrence relationships among the 20 most frequently used key words. In the figure, clear clusters can be observed regarding COVID-19 pandemic impact on dental care, especially oral surgery and induced anxiety (red), transmission or infection control associated with endodontics, i.e., rubber dam use (green), and personal protective equipment and aerosols in dental treatment (blue).
Table 6 demonstrates the most frequently cited arti­cles, including those receiving more than 15 citations. The most cited paper was a review article, “Corona­virus Disease 19 (COVID-19): Implications for Clinical Dental Care” (Ather et al., Journal of Endodontics, 2020; n = 382).

Discussion

There were 3 main thematic trends identified in the articles included in the bibliometric analysis, such as impact of the COVID-19 pandemic on dental care deli­very, COVID-19-related psychological aspects among dental staff and patients, and safety protocols and adjustments in dental procedures due to COVID-19 restrictions.

Impact of the COVID-19 pandemic on dental care delivery

Generally, previous findings emphasized a shift to urgent and necessary dental services due to pandemic restrictions. Walter et al. [16] revealed that during COVID-19 lockdown in Munich (Germany) from February to July 2020, a significant decrease in the number of patient visits was observed, especially non-emergency cases, but pain-related treatments continued even in patients with suspected or confirmed COVID-19 infection. Tong et al. [17] analyzed dental visits in university- and hospital-based dental clinics in Vancouver (Canada) during the first phase of COVID-19. Most emergency visits included oncology consultations, pedia­tric trauma, oral surgeries, and severe odontogenic pain and infections. Furthermore, Choi et al. [18] examined the impact of COVID-19 on dental care utilization and oral health conditions in U.S. federally qualified health centers. Findings showed that dental visits declined more sharply than medical visits during lockdowns, and recovered more slowly. The demand for oral surgery and tele-dentistry increased, while preventive services decreased in 2020.
Hammond et al. [19] reported the management of an urgent dental care center in Blackpool (United Kingdom) at the beginning of the COVID-19 pandemic; the center handled 1,433 telephone consultations and performed 713 extractions in their first month of operating. Similarly, Pajpani et al. [20] showed the activity at an urgent dental care center at Queen Mary’s Hospital, Sidcup (UK), focusing on the lockdown’s first months. The authors observed a significant increase in emergency dental cases, particularly pain relief, with decreasing number of routine dental treatments due to restrictions. The majority of services delivered in this emergency setting was surgical dento-alveolar procedures (84%).
In contrast, based on 176,690 dental appointment records in a Kuwait’s hospital, AlHayyan et al. [21] found a significant decline in orthodontic, endodontic, and periodontal procedures, while oral surgery, restorative procedures, and pediatric dentistry remained unaffected. Moreover, in Piracicaba (Brazil), Bado et al. [22] observed a 51% reduction in dental visits, a decrease in tooth extractions (from 14.7% to 8.9%), and an increase in temporary cavity fillings (from 22.9% to 33.2%) during the pandemic. Furthermore, Ronrang [23] noticed a significant decrease in the total number of patients involved in dental services during first phase of lockdown due to the COVID-19 pandemic in Meghalaya (India).
Previously, we explored the impact of the COVID-19 first wave on dental procedures at the University Center of Dentistry and Specialized Medicine in Poznan (Poland) [4]. There was a significant decline in conservative approaches, such as restorations and canal filling, while surgical procedures increased. Similarly, Dos Santos et al. [24] analyzed dental procedures performed in Brazil’s public health system during the first wave of COVID-19. The study found a 66% reduction in procedures from 2019 to 2020, with preventive approaches dropping by 84.5%, primary care by 60.7%, and specia­lized treatments (i.e., endodontic, periodontal, and oral surgery) by over 50%. A decline was observed across all states, regardless of case numbers or deaths.
Based on data from 5 private dental offices in Cracow (Poland), Migas et al. [25] revealed that the number of first-time visits decreased to 37%, but existing patients increased their appointments by up to 84%, as compared with 2019; the number of visit cancellations also increased (15-50%). Nosrat et al. [26] showed that endodontist private practices in 2021 had an increase in the number of non-surgical root canal treatments and apicoectomies compared with 2019. Furthermore, patients more often reported symptoms of irreversible pulpitis comparing these 2 periods. Langaliya et al. [27] found a significant increase in endodontic emergencies during the lockdown period in Ahmedabad (India), shifting more towards non-aerosol-generating procedures.
According to Amini et al. [28], in U.S. children hospitals during the COVID-19 pandemic, the reduced access to hospital operating rooms caused increased waiting times for dental procedures (82%), worsened oral health of special needs patients (64%), with more emergency visits for caries (50%) and delays in medical surgeries requiring dental clearance (45%). Based on the observations from Brescia Children’s Hospital (Italy), Tewfik et al. [29] observed also that the COVID-19 pandemic caused delays in dental treatments of children with special needs requiring general anesthesia, due to reduced clinical activity and concerns over infection.
Hopcraft and Farmer [30] analyzed the impact of the pandemic on pediatric dental services in Australia using the child dental benefits schedule. From March to September 2020, there were 881,454 fewer dental services compared with 2019, with the strongest drop occurring in April. Preventive and diagnostic services declined the most, while endodontic and oral surgery procedures were less affected. Olszewska et al. [31] compared data on children’s oral health in Greater Poland from March and April 2019 and 2020, and showed a dramatic drop in dental procedures during the lockdown. Notwithstanding, the frequency of extractions remained similar across both years, and temporary fillings in primary and permanent teeth demonstrated a significant increase.
Delayed treatments during the COVID-19 pandemic likely led to more multi-surface restorations in permanent first molars in Turkish children aged 6-15 years [32]. Furthermore, Yang et al. [33] investigated changes in pediatric dental care after the COVID-19 lockdown and clinics re-opening in Wuhan (China). The authors found a significant increase in emergency cases and a decrease in routine visits. Also, a shift towards more complex cases was observed due to delays in treatment during the pandemic. These findings emphasized the need for pro-active care strategies post-pandemic.
The COVID-19 pandemic re-shaped surgical practices and patient management in the field of oral and maxillofacial surgery. In their study, Pabst et al. [34] surveyed 54 hospitals and 240 private practices in Germany, revealing a significant reduction in elective surgeries and a shift towards emergency care during the pandemic. Yeung et al. [35] examined the effects of the lockdown on the presentation of oral and maxillofacial trauma at a central London hospital. They showed a significant reduction in the overall referrals during the lockdown, including trauma cases, with a notable decrease in injuries related to alcohol-related domestic violence.
Surprisingly, a study by Politi et al. [36] reported a decrease in maxillofacial cases due to cervicofacial infections of dental origin during the initial lockdown period in 2020 compared with previous years. This was attributed to better patient triaging in primary care units, adherence to lockdown guidelines, and the functioning of urgent dental care centers offering emergency procedures. However, hospitalized patients required more intensive procedures, such as extra-oral drainage, with shorter hospital stays. Similarly, Puglia et al. [37] observed a decrease in the number of odontogenic cervicofacial infections during the first wave of the COVID-19 pandemic compared with pre-pandemic numbers.
The COVID-19 pandemic significantly disrupted dental care delivery, with a global shift towards urgent and emergency services as well as a marked decline in routine and preventive procedures. Studies from various countries reported decreased patient volumes, especially for non-essential treatments, while surgical and pain-related interventions persisted or increased. Pediatric and special needs populations were particularly affected by treatment delays and reduced access. Tele-dentistry emerged as a compensatory strategy, and clinical prio­rities focused on minimizing aerosol-generating procedures. Overall, the pandemic underscored systemic vulnerabilities in dental care, and highlighted the need for resilient and adaptive service models during future public health crises.

COVID-19-related psychological aspects (i.e. anxiety and safety sense) among dental staff and patients

Some studies highlighted psychological burden among dental staff working in high-risk environments during the COVID-19 pandemic, and the need for mental health support during such stressful times. According to a study by Kirli and Kirli [38], re-starting high-risk dental procedures caused a significant increase in dental employees’ anxiety levels, especially among female staff, endodontists, restorative dentists, and nurses. Dreher et al. [39] surveyed dental assistants in Germany to investigate attitudes, stressors, and work outcomes during the COVID-19 pandemic. The results showed significant stressors, including uncertainty about the pande­mic’s duration, financial concerns, and the fear of infection. Nearly half of the respondents reported symptoms of depression and anxiety.
A survey by Mylonas et al. [40] evaluated the impact of COVID-19 on clinical training and mental health of restorative and mono-specialty dental trainees in the UK and Ireland. The findings revealed significant disruptions in clinical training, with some trainees re-deployed to urgent care duties. Both waves of the pandemic negatively affected their mental well-being, with expressed concerns about long-term career impacts. One of our previous studies [41] focused on the effectiveness of blended learning in conservative dentistry and endodontics during the COVID-19 pandemic. We found that dental students were satisfied with the proposed hybrid learning model and preferred asynchronous e-learning over synchronous virtual meetings. Despite the challenges, the respondents also highlighted the importance of safety measures during clinical activities, as personal protective equipment was deemed adequate or excessive.
Most patients sought urgent dental care due to COVID-19-related anxiety, while other routine treatments were postponed. González-Olmo et al. [42] investigated the psychological impact of COVID-19 on general population of Madrid (Spain), focusing on perceived vulnerability to the virus and its effects on dental practice. People aged over 60 years and those with systemic diseases expressed higher levels of perceived vulnerability to contracting COVID-19, and were more reluctant to seek dental care. Additionally, women showed more aversion to germs and higher concern of risk when visiting dental clinics. Similarly, Pylińska-Dąbrowska et al. [43] found that 21.9% of patients undergoing oral surgery experienced an increased level of anxiety regarding dental visits during the COVID-19 pande­mic compared with pre-pandemic levels. The study also showed a rise in the moderate dental anxiety.
Additionally, Durmazpinar and Sezgin [44] explored the coronavirus-related anxiety levels in endodontic Turkish patients. The study found that 43.4% of the patients were diagnosed with symptomatic irreversible pulpitis. Regarding anxiety, 86.8% of the patients had normal anxiety levels, while 13.2% experienced disordered anxiety. In contrast, Shetty et al. [45] showed that their respondents from outpatient department of JSS Dental College Hospital in Karnataka (India) were willing to undergo conservative treatment during the pandemic, suggesting they were not aware of the spread of COVID-19 infection.
However, the pandemic and the associated restrictions on dental care significantly impacted patients’ psychological well-being, emphasizing the need for additional support in dental practices during such times. Luo et al. [46] concluded that delayed dental care was associated with depression among middle-aged and elder adults.
Tele-dentistry gained benefits by reducing physical visits, while maintaining patient care. Habib et al. [47]highlighted tele-dentistry as a valuable tool for maintaining dental care during the COVID-19 pandemic, exploring its applications in preventive dentistry, pediatric care, oral medicine, and emergency triage. Moreover, Islam et al. [48] emphasized its growing relevance for increasing access to dental services, improving patient communication, and ensuring safety during the pandemic. The importance of establishing proper protocols to ensure patient safety and confidentiality using these technologies should be emphasized.
The COVID-19 pandemic had notable psychological impacts on both dental professionals and patients. Studies reported elevated anxiety and stress among dental staff, particularly among females, specialists, and trainees, due to infection risk, financial insecurity, and disrupted training. Moreover, patients exhibited heightened anxiety, with many postponing routine care due to the fear of infection, particularly older adults and individuals with comorbidities. While some populations remained willing to undergo treatment, others reported increased dental anxiety and psychological distress linked to delayed care. Tele-dentistry emerged as a critical tool for maintaining care and reducing in-person visits, highlighting its potential for broader adoption and the need for standardized safety protocols.

Safety protocols and adjustments in dental procedures due to COVID-19 restrictions

In the literature, emergency care protocols and treatment adjustments were underlined to address urgent dental cases during restrictions related to the COVID-19 pandemic. Due to the nature of their work, dentists were considered at an increased risk of infection with the SARS-CoV-2 virus. Many dental procedures produce aerosols, which can carry the virus and be transmitted through saliva and respiratory droplets. Consequently, various procedures were developed to reduce the risk of clinician infection, including appropriate patient triage, operating room decontamination, and the use of proper personal protective equipment (PPE) by doctors and auxiliary staff.
Two surveys conducted shortly after the first wave of the pandemic assessed the knowledge of practicing dentists regarding the modes of SARS-CoV-2 transmission and protective measures used in daily clinical practice. In April 2020, Candeiro et al. [49] conducted a questionnaire study among Brazilian endodontists, and found that the knowledge of COVID-19 signs and symptoms was satisfactory. At that time, most clinicians suspended elective dental procedures and preferred complete social distancing. Similarly, in June 2020, Martinho and Griffin [50] surveyed members of the Ame­rican Association of Endodontists. All the respondents reported using special protective measures for root canal therapy, such as N95 respirators, face shields, head covers, air-purifying units, and protective suits. Also, most of them believed that using a rubber dam during endodontic treatment can help reducing virus transmission. Bizzoca et al. [51] analyzed 42 common dental procedures based on various factors, such as contact with saliva and blood, aerosol production, and procedure duration, categorizing them into low-, medium-, and high-risk transmission groups. From this analysis, they proposed corresponding PPE modifications for each risk group. Li et al. [52] investigated the effects of environmental conditions, including ventilation location, ventilation rate, and relative humidity (RH) as well as variations in patients’ breathing rates on droplets’ transmission during ultrasonic scaling. The authors recommended expanding decontamination protocols, and maintaining 50% RH and higher air changes per hour (ACH) to minimize cross-infection in dental settings.
Several methods to reduce virus transmission were examined. Qamar et al. [53] assessed endodontists regarding the use of photodynamic therapy (PDT) in daily practice. The vast majority believed that PDT could lower COVID-19 transmission rates, with over 95% expressing interest in expanding their knowledge and skills in this area. Barrett et al. [54] evaluated the clini­cal effectiveness of an extra-oral dental evacuation device in aerosol elimination. Aerosol levels at 1 minute after access preparation for endodontic treatment were similar with and without the device. However, after 15 minutes, there was a significant reduction in aerosol levels when using the device compared to high-volume suction alone. Despite this benefit, increased noise levels negatively affected patient experience, with concerns regarding additional costs and potential heat gene­ration observed.
Moreover, Capparè et al. [55] examined the use of an air purifier with a HEPA 14 filter. Their study demonstrated an 83% improvement in pollution abatement and a 69-80% reduction in contamination in the study group compared to the control group, supporting the application of portable air cleaners (PACs) in daily practice for virus transmission reduction. Fuentes et al. [56] compared 6 implant dentistry systems based on drilling speed and saline irrigation requirements, and factors influencing aerosol production. They recommended a careful selection of system used.
Li et al. [57] investigated fallow time (FT) defined as the duration needed for airborne particles to drop to safe levels before admitting the next patient after aerosol-generating procedures (AGPs). They estimated an FT range of 27-35 minutes in rooms with 6 ACH, following ultrasonic scaling. High-volume evacuation reduced FT by 3-11 minutes. The researchers emphasized the importance of PPE, particularly respiratory protection, given the prolonged suspension of particles in the air.
Five articles described detailed patient management protocols during the COVID-19 pandemic, which could be valuable for future epidemic threats. Abramovitz et al. [58] comprehensively addressed 4 key areas: 1) triage protocol and patient flow; 2) general dental considerations; 3) endodontic considerations during the COVID-19 outbreak; and 4) oral and maxillofacial surgery procedures during the COVID-19 outbreak. Diegritz et al. [59] assigned the procedures of the Department of Conservative Dentistry and Periodonto­logy at a German university hospital, while Alterman et al. [60] outlined protocols used in the Department of Oral and Maxillofacial Surgery, later highlighting their effectiveness in preventing staff cross-infections.
Similarly, Manuballa et al. [61] shared their experiences ensuring continuity of care for cancer patients during the COVID-19 pandemic. They implemented a three-tiered patient classification system based on oral health needs, which assisted in visit planning during the crisis. Brunello et al. [62] surveyed European oral and maxillofacial surgery experts between November 2020 and February 2021 regarding infection control during the second wave of the COVID-19 pandemic. The responses were compared to a similar survey from April-May 2020. Even though the perceived transmission risk in dental settings decreased, the risk associated with AGPs remained high. Maximum PPE use was less frequently recommended for non-AGPs, but for AGPs, experts advised FFP2/ FFP3 masks, face shields/ goggles, gowns, and caps. Also, most of the respondents endorsed the use of mouth rinses. Furthermore, Widyarman et al. [63], after conducting a four-part webinar series in 2021, surveyed clinicians on updated pre-procedure dental treatment protocols. Vast majority confirmed the use of pre-surgery patient screening procedures. Vasan et al. [64] retrospectively analyzed COVID-19 infection risks among 26 dental healthcare workers (DHCWs) treating patients with standard infection control measures from March 2020 to March 2021. Nine workers (34.7%) contracted the virus during this period, but only 4 cases were traceable to department-related transmission. The study concluded that infection risks among DHCWs were significantly reduced due to the protocols implemented.
In response to the heightened transmission risk of SARS-CoV-2 in dental settings, numerous studies emphasized protocol modifications and enhanced infection control measures. Dentists adopted stringent protective practices, including advanced PPE utilization, patient triage, and environmental decontamination. Surveys revealed high awareness among clinicians regarding transmission routes and preventive strategies. The research on aerosol-generating procedures reflected in recommendations for air purification, adjusted fallow times, and the use of high-volume evacuation. Additional measures, such as photodynamic therapy and extra-oral suction devices, were explored for their efficacy in reducing aerosol spread. Institutions worldwide implemented structured patient management protocols, which proved effective in minimizing infection among dental healthcare workers. Collectively, these adaptations highlighted the profession’s rapid response, and recommended a framework for managing future infectious disease outbreaks.

Conclusions

The COVID-19 pandemic brought about profound and multifaceted changes in dental care delivery, professional practice, and patient behavior. Globally, dental services shifted towards emergency and urgent care, while preventive and routine procedures significantly reduced. These disruptions were accompanied by heightened psychological strain on both dental professionals and patients, with increased anxiety, training limitations, and deferred care contributing to broader health impacts. The dental profession demonstrated resilience through rapid implementation of safety protocols and procedural adjustments to mitigate infection risks. Enhanced personal protective equipment, environmental controls, patient triage, and the adoption of tele-dentistry were all pivotal in ensuring continuity of care while safeguarding staff and patients. The effectiveness of these measures was reflected in low transmission rates within dental settings.
Concluding, these findings underscore the importance of adaptable, evidence-based frameworks for infection control, psychological support, and service continuity. Lessons learned during the COVID-19 pandemic should strongly influence awareness strategies for future public health emergencies, ensuring that dental care system remains both safe and responsive.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References