The Management of Dental Practices in the Post-COVID 19 Era: An Economic and Operational Perspective.

BACKGROUND: In order to protect dental teams and their patients during the COVID-19 pandemic, dentists have had to adopt several measures (operating and post-operating procedures) which may increase the total treatment time and costs relating to individual protective measures. This paper will propose a thorough analysis of operating dentistry procedures, comparing the economic performance of the activity in a dental surgery before and after the adoption of these protective measures, which are required to contain the risk of SARS-COV-2 infections.
METHODS: The economic analysis is articulated in three approaches. Firstly, it assesses a reduction in markup by maintaining current charges (A); alternatively, it suggests revised charges to adopt in order to maintain unvaried levels of markup (B). And the third Approach (C) examines available dental treatments, highlighting how to profitably combine treatment volumes to reduce markup loss or a restricted increase in dental charges.
RESULTS: Maintaining dental charges could cause a loss in markup, even rising to 200% (A); attempting to maintain unvaried levels of markup will result in an increase in dental charges, even at 100% (B); and varying the volumes of the single dental treatments on offer (increasing those which current research indicates as the most profitable) could mitigate the economic impact of the measures to prevent the transmission of SARS-COV-2 (C).
CONCLUSIONS: The authors of this paper provide managerial insights which can assist the dentist-entrepreneur to become aware of the boundaries of the economic consequences of governmental measures in containing the virus infection.

1. Introduction

From the first days of the containing of the COVID-19 pandemic, dental activity throughout the world has been drastically interrupted and thereafter characterised by uncertainty and subject to revised measures. The latter were included in recommendations provided by single governing bodies [1,2,3]. In order to obviate such challenges, the dentist has been obliged to adopt a series of protective measures, all of which are having a marked financial impact on finances and a lengthening of treatment times. This is the sum of time required for operating, and pre- and post-operating procedures, currently leading to generic economic loss, and leading to much uncertainty regarding future of the profession. In brief, maintaining the maximum level of SARS-CoV-2 safety would lead to a marked increase in costs and a reduction in the maximum number of treatments, which can be offered to patients on the timescale of reference (usually one year).

As discussed in a recent McKinsey report [4], business leaders should initially determine the scale, pace, and degree of intervention required in addressing one of the most far-reaching humanitarian crises of our time. This report can be considered as a contribution to this phase in assisting dentists to comprehend the extent of the effects of the COVID crisis.

Small businesses are the most threatened by the economic crisis created by COVID-19. An American survey by the Becker Friedman Institute [5] has demonstrated how many businesses can be considered to be financially vulnerable: “The median firm with expenses over $10,000 per month has only enough cash on hand to last for two weeks. Three-quarters of respondents state that they only have enough cash on hand to cover two months of expenses or less”.

The aim of this research is to assist the dentist-owner of a dental practice in their attempt to overcome the financial crunch, which may arise as a consequence of the adoption of anti-COVID measures.

The authors of this paper have made an analysis of the production and economic performance of a dentist’s practice in order to assess the economic impact of the aforementioned recommendations in limiting the transmission of SARS-CoV-2. Furthermore, the result of such an analysis places the dentists at the centre of a systematic analysis of their activity regarding operating/commercial choices. It will no doubt be of interest to the dentist as an entrepreneur to foresee the degree of predicted losses if pre-COVID charges are adhered to or how much to increase dental charges in maintaining markup levels. These tasks will be accomplished by adopting Approaches A and B, as proposed in this paper. In brief, Approach A assesses the loss in markup leaving the charges for dental treatments unchanged, while Approach B investigates the reverse situation: that is, maintaining unvaried the markup and assessing the increase in the charges for dental treatments. Having delimited the range of economic performance in terms of markup and dental charges with the first two approaches, it is of interest to address another variable available to the dentist entrepreneur; namely, the typologies and availability of related volumes of treatments. With the third approach, C, the authors will demonstrate that economic results depend on treatment volumes. Indeed, this third approach will demonstrate how to modify the dental treatment mix available (product mix) so as to contain the loss in economic performance. The authors would like to suggest how to combine these treatments by favouring those with a lesser differential economic impact (i.e., those which impact less on pre/post-COVID in terms of turnover or profit) or the more profitable treatments under the new scenario arising from the adoption of anti-COVID recommendations. The authors of this paper hope that it may be considered as pioneering in the body of literature, which can only flourish. Indeed, a rapid reaction can be the keystone of the survival of small businesses when times are harsh. To the best of the authors’ knowledge, only Schwendicke et al [6] have hitherto researched this field to provide economic insights into the post-COVID scenario of a dental surgery. Their paper analyses the German healthcare service from the perspective of a dental provider. While Schwendicke et al. [6] have focused on the differential economic impact of Covid-19 as an effect of the reduction in the utilization of dental services (in turn caused by the policies of COVID-19 mitigation/suppression), the research presented in this paper will examine the accounting and operations of a dental practice in order to initially assess the reduction in dental service volume and the increases in the dental treatment costs, and therefore the impact on economic performance. This approach is crucial in those countries, such as Italy, in which the provision of dental services is almost totally managed in the private sector. Indeed, according to a classification of the healthcare provision system relating to European countries, provided by Widstrom and Eaton (2004), the Italian system has adopted a “Southern European Model” where the private sector plays a leading role in the provision of dental services, whereas in Germany a Bismarkian insurance system prevails. The private sector in Italy accounts for more than 89% of oral healthcare, as highlighted in a 2016 report compiled by the Italian Government: on average a mere 10% of healthcare out-of-pocket costs are covered by health insurance [7,8]. Whilst the scenario under consideration is different, the findings outlined in this paper are in agreement with those of Schwendicke et al. [6] in that they confirm a stronger impact on economic performance (also taking into account the increase in costs). Guidelines relating to mitigating this impact will also be suggested.

The authors of this paper contend that its innovation lies in its multidisciplinary approach combining knowledge from the field of operations management (McLaughlin et al. [9]), accounting (Warren et al. [10]), revenue management (Birkenshaw Garabelli [11]) and dental practice management.

In conclusion, it is hoped that the research findings will assist the dentist-entrepreneur to become aware of the consequences of their decisions on the economic and operative sides, thereby providing revealing insights for managing post-COVID professional activities. This is in addition to alerting the policy maker as to the threats to public health, which could derive from short-sighted economic measures.

2. Materials and Methods

The starting point of the study was an analysis of the most common dental treatments (Table 1).

Table 1

Analysis of the most common dental and oral medicine treatments.

Procedure	Timing and Risk-LevelPost-COVID-19
	Duration of Procedure (Minutes)+ 45 min after Each Patient	Risk-Level	Charges from the National Italian Price List (in Monetary Units) *
Orthodontic checks	30–60	Low	1 **:Orthodontic interceptive therapy: 1500/yearFixed orthodontic therapy: 2000/yearLingual orthodontics: 3000/yearInvisible aligners (complete therapy): 4500/year
Manual reduction of dislocation of the jaw	≤30	Low	150
Mobile/fixed orthodontic appliance positioning	>60	Low	1
X-rays	≤30	Low	Intraoral X-ray: 30Intraoral X-ray status: 200Orthopantomography: 80Lateral Teleradiograph: 80
Periodontal therapy	≤30	Low	100
Topical treatment of dental hypersensitivity and caries prophylaxis	≤30	Low	100
Test of night guards	≤30	Low	800
Impression	≤30	Low
Dental prosthesis tests, positioning and adaptation (temporary/definitive, removable/fixed)	30–60	Low	2:Gold-porcelain/zirconia crown750
Biopsy	≤30	Low	200
Bone graft (autogenous/biocompatible material) without rotating tools	>60	Low	400–700(with membrane)
Mucogingival surgery (quadrant)	30–60	Low	600
Subgingival curettage without rotating tools (quadrant)	30–60	Low	500
Removal of cysts or small benign neoplasms	30–60	Low	500
Surgical medication	≤30	Low
Oral minor surgery (e.g., abscess incision, frenulectomy, frenulotomy)	≤30	Low	150–300
Salivary stone removal	≤30	Low	150–500
Extraction without rotating tools	30–60	Low	130
Gingivectomy/gingivoplasty	≤30	Low	300
Endodontic treatment (1 root) with rubber dam (in subsequent appointment after access cavity)	≤30	Low	3:180 + 100 (for each additional canal)
Pulp-capping, pulpotomy, pulpectomy (in subsequent appointment after access cavity) with rubber dam	30–60	Low	130
Bleaching	>60	Medium	450
Orthodontic splinting (1 dental arch)	≤30	Medium	200
Orthodontic splinting (2 dental arches)	30–60	Medium	400
Periodontal splinting (1 dental arch)	≤30	Medium	200
Periodontal splinting (2 dental arch)	30–60	Medium	400
Intra-oral examination	≤30	Medium	100
Tartar removal	30–60	High	110
Extraction with rotating tools	30–60	High	150–300
Sinus lift	>60	High	600–1200
Cavity access (rotating instruments)	≤30	High	3
Implantology	>60	High	1200
Subgingival curettage (quadrant) (rotating tools)	≤30	High	500
Resective/regenerative bone surgery (rotating tools)	>60	High	750–900
Rhizectomy/rhizotomy (rotating tools)	30–60	High	150–300
Sealing of dental grooves	≤30	High	50 (for each tooth)
Apicectomy with retrograde filling	>60	High	300–500
Autologous bone harvest (rotating tools)	≤30	High	300–450
Abutment tooth preparation	≤30	High	2
Odontoplasty (1 tooth)	≤30	High	100–250 (for each tooth)
Simple/complex filling using rotating tools	30–60	High	150–250
Extraction of impacted tooth with rotating tools	>60	High	300–500

* The charges reported in the far right column refer to the maximum values of the ANDI (Italian association of Dentists) 2009 price list [12]. ** The numbers 1, 2 and 3 in bold in the far right column indicate that the procedure described is not an independent service (with a single price) but it is always associated with other services with the same code number, where an all-encompassing charge is applied.

These require an average treatment time, as documented in the literature, and as displayed in the list of the dental charges of the larger Italian associations in the field [12]. Table 1 describes the risk level, which is associated with each treatment. This depends on the exposure to droplets produced during the procedure. As proposed in a recent article [13], each level of risk is attributed to the single procedure based on: (1) contact with saliva, (2) contact with blood, (3) the use of instruments producing low levels of spray/aerosol (air-water syringes), (4) the production of high levels of spray/aerosol produced by rotating, ultrasound and piezoelectric tools, and (5) the duration of the procedure (operator-dependent). This analysis was necessary for classifying the various treatments according to criteria selected in function of the analysis to be undertaken. The revised recommendations regarding the prevention of COVID-19 for dental activities fundamentally produced two economic effects:

an increase in the time period between subsequent treatments (time Δt), reducing the time available in a given time period (generally one year) for the treatment, and

an increase in fixed costs (e.g., the adapting of air-conditioning plants) and variable costs (e.g., personal protective equipment (PPE).

The increase in the time period between subsequent treatments is a general measure, which has been introduced to sufficiently air the dentist’s room. As a further consequence, this may cause an increase in the incidence of fixed costs per unit of treatment (fixed costs have to be allocated to each production output; that is, each treatment, to compute the cost per unit) due to the reduction in the maximum business volume.

These effects can cause a reduction in total markup because per unit markup (the difference between earnings and the costs of a single treatment) and the total business volume (in terms of number of treatments) are reduced. Figure 1 summarises the effects of COVID-19 on the dentist’s markup and three possible approaches to the economic choices of the owner of a dental practice.

Figure 1

The effect of anti-COVID recommendations on the markup of a dental surgery and three possible approaches for making economic choices.

2.1. Methodology

The following are discussed in Appendix A: the variables used in the following sections and the relationship between the total treatment volume before (V) and after (V*), the anti-COVID measures adopted, between treatment costs before (c) and after (c*), the adoption of anti-COVID measures. In general, the superscript “*” denotes the considered variable after the anti-COVID measures. Moreover, it provides an insight into the pricing of treatments and the effects of the anti-COVID measures, which have been adopted. These effects will be more marked for treatment with reduced pre-COVID working times and higher associated risks.

In order to analytically assess the economic impact of the post-COVID changes, of paramount importance is an estimate of the loss in markup, which would be incurred in leaving the dental charges for treatment unchanged (Approach A). Thereafter, the trend in the economic performance of the dental surgery was studied by varying the two operating decision variables available to the dentist: pricing (Approach B); and the treatment volumes available within the time limits and resource constraints (Approach C, developed in Appendix B). Following Approach B, the trend in variation in dental charges applicable in the post-COVID era was analysed by keeping the pre-COVID markup constant. Following Approach C, the choice of the treatment mix of the different treatments available, leading to different economic results (markup and turnover), was analysed. In brief, an assessment of the economic impact of the recommendations for containing COVID-19 was performed according to three possible approaches, as described below:

Leave the dental charges of single treatments unchanged with a resulting loss in markup;

Increase the charge of single treatments in order to maintain unvaried markup; and

Modify the dental treatment mix available (product mix) so as to contain the loss in economic performance.

2.2. Operating Phases

In order to obtain an initial production performance analysis prior to an economic performance analysis of a given dental surgery, both considered necessary for assessing the COVID impact, it can be hypothesized that the patient passes summarily through three stages: reception, treatment and checking out. In effect, there are five operating phases involving the dental team: (1) reception; (2) preparing the dental staff and patient; (3) treatment; (4) check out; and (5) preparing the room for the next patient (Figure 2).

Figure 2

Five operating phases: phase 1, receiving the patient; phase 2, preparing the dental staff and patient; phase 3, treatment, phase 4, patient check out; and phase 5, preparing the room for the next patient.

Phases 2, 3 and 5 deploy the same resources (the dentist’s room and chair; that is, the treatment room (TR)), whilst phases 1 and 4 generally regard the waiting room/secretary’s area. An intuitive conclusion can be reached; that is, that the space deploying the greatest amount of resources is the TR, and it thereby becomes the critical resource or the bottleneck of the dental procedure. It is precisely this bottleneck which determines the production pace; that is, the speed by which the treatments can be performed and, therefore, the treatment volumes. In order to determine the latter, the dentist’s surgery can be here considered as a single-dentist practice or in possession of one TR with the hypothetical maximum use of the TR resource or system saturation.

The various phases involving the TR have a total duration (t), which is given by the sum of time required to prepare the dental staff, the effective treatment time (t), and the time necessary to make the TR operational between two successive appointments (the set-up time or t). Such a time period (t) in the post-COVID era has increased by approximately 30 min (15 min for obligatory airing of the TR and an extra 15 min for sanitizing procedures) [1,14]. This incremental time will henceforth be indicated by Δt. The duration of the bottleneck phase will determine the productivity (the number of treatments in any given time period T) of the entire process; in this context, it coincides with the cycle time tc of the process; that is, the time period between two successive treatments (t = t).

3. Results

Analysing the two main Approaches (A and B) produces the following results:

3.1. Approach A (Dental Charges and Product Mix Unchanged)

It can be pondered as to how much the markup loss, the difference between the post-COVID and pre-COVID markup, () per treatment unit ( is worth if dental charges remain unchanged (pre-COVID charge, p is equal to post-COVID charge, p*): denoting c* in function of c () and V* in function of V (V* = as explained in Appendix A, and keeping dental charges unvaried (p* = p), the following will be obtained:

In order to quantify the markup loss in a dimensionless measure, the percentage value as compared to the unit markup , which was obtain pre-COVID, can be calculated:

Figure 3 illustrates the trend in percentage loss of markup per treatment unit when costs are increased (z) with a decrease in treatment volume (k), keeping the dental charges unchanged. As input data, the following can be assumed: an average dental charge, p, equal to 200 monetary units and a unit cost C equal to 100 monetary units. The choice of expressing the relationship between operating pre- and post-COVID variables, which have changed due to the new recommendations by means of dimensionless parameters, renders the trend in Figure 3 independent of the specific values of the assumed inputs.

Figure 3

Percentage markup loss per treatment unit (V*) of an increase in costs (z) and a reduction in treatment volumes (k), keeping dental charges unchanged (p = 200 monetary units; c = 100 monetary units).

As can be noted in Figure 3, marked reductions in volumes (k = 50%) and substantial increases in costs (z = 2) will lead to a markup loss of 200%; markup losses (the difference between post and pre-COVID profit) greater than 100% (represented by the grey and yellow areas in Figure 3) imply a loss (where costs exceed earnings).

3.2. Approach B (Markup and Product Mix Unchanged)

The dentist can manage the change in variable costs and working time (and, therefore, the same amount of resources used, i.e., their productive capacity) by intervening in pricing. For example, it could be decided to vary the average dental charges in order to leave the markup unvaried. By how much should the average post-COVID (p*) dental charge increase, compared to the pre-COVID dental charges (p) if we wish to leave the markup unchanged? In the latter case (markup unchanged), the dental charges p* must be sufficient to guarantee the following parity of pre- and post-COVID markup: from which it follows that the dental charges p* must be: and, therefore, the percentage variation compared with the pre-COVID dental charges will be:

Figure 4 shows the percentage variation in dental charges when modifying an increase in costs (z) and a reduction in the number of treatments (k), by keeping the markup unvaried. As input data, an average dental charge p, equal to 200 monetary units, and a unit cost, equal to 100 monetary units, is also assumed here. As with Figure 4, the choice of expressing the relationship between operating pre- and post-COVID variables, which change due to the new recommendations, in terms of dimensionless parameters, renders the trend in Figure 4 independent of the specific values of the assumed inputs.

Figure 4

Percentage variation in dental charges of varying an increase in costs (z) and a reduction in the number of treatments (k), keeping the markup unchanged (p = 200 monetary units; c = 100 monetary units).

It can be noted in Figure 4 that marked reductions in treatment volumes and substantial increase in costs can lead to a doubling of dental charges (percentage variation in dental charges = 100%). Thus far, the dentist-entrepreneur has left the treatment mix with Approaches A and B unchanged; Approach C (Appendix B) investigates another opportunity, demonstrating how changing the mix by increasing certain treatments might impact on markup and turnover, which this research has indicated as the most profitable. After a comment regarding the managerial implications of Approaches A B, the Discussion section will elaborate on Approach C.

4. Discussion

The anti-COVID recommendations promulgated by governments have dramatically changed the competitive scenario for dental practice owners. In order to survive, they need to react quickly to a changing landscape and be aware of the economic and operational consequences of their decisions. The authors of this paper hold that the model presented in this paper is an easy tool for measuring the economic consequences of these changes. It is also hoped that the results of this research will indicate the way for the dentist-entrepreneur to measure the profitability of given treatments in the post-COVID era, thereby providing support in the decision-making of prices and treatment mix. The analysis performed on Approaches A and B enables the dentist to assess the total markup loss, and, on the basis of resources of slack financial assets (an excess in financial assets), to evaluate their resilience; that is, the capacity to resist change, as imposed in the post-COVID era. According to Reeves et al. [15], the application of the principle of resilience in developing policies is one of the 12 principles with which to guide a business through the coronavirus crisis. An increase in fixed costs is a long-term increase (whose duration is equal to the useful life of new investments) whilst an increase in variable costs could be temporary; however, this situation could change drastically with the eradication of the disease. The dentist must, therefore, assess whether the capacity of the activity can cope with long- and short-term investments, deciding whether to maintain dental charges unchanged and, therefore, assess the expected losses and their sustainability. The alternative is to pass on the costs of the post-COVID effects to the patients, deciding whether to keep their own markup unaltered by increasing dental charges.

Thus, the dentist has at their disposal a range of dental charges (from those pre-COVID to post-COVID, the latter which guarantees unvaried markup), which facilitates the assessing of the appropriacy of greatly increasing pre-COVID dental charges, according to the financial resources available. This decision necessitates a compromise between the first alternative (whereby the dental surgery absorbs the economic effect of COVID) and the second (whereby the market absorbs these effects).

The loss in markup will be even greater for smaller dental practice owners (like those of single treatment room), who are usually unable to exploit economies of scale (a reduction in average production costs of increasing the productive capacity by, for example, duplicating the number of a dentist’s rooms).

Further investigations would be directed towards an assessment of the opportunities of, on the one hand, modifying treatment pricing (for example, differentiating the percentage mark up on costs), and, on the other hand, increasing the volumes of product mix of those treatments, which have been affected less by the anti-COVID recommendations. As previously expounded, these treatments have the lowest risk and Δt/t. The latter hypothesis (varying the mix of treatments) has been investigated in Approach C (Appendix B); it suggests that the dentist might reconsider their operating choices in the pre-COVID era.

Let us assume that, in the pre-COVID era, the trade-off between satisfying the market demand for a set of treatment types and the constraints of available resources (human and technological) led to the adoption of a business model with an assigned time frame for each typology of treatment considered (MIX2 in Appendix B). The risk is that myopic profit maximization could lead the dentist-entrepreneur to eliminate certain treatments in order to mitigate the economic impact of the anti-COVID measures, which have been adopted. If, for example, the compromise between satisfying the market demand for the treatment types considered in the Approach C (Table 2) and the constraints of available human and technological resources (analysed from an economic point of view) had led to the adoption of a business model with an assigned time frame for each typology of treatment considered (MIX2 in Appendix B) in the pre-COVID era, an assessment or elimination of certain treatments could be made in the post-COVID era. For example, this business model would refer to dental practices which make use of external specialists (corresponding to specified treatments types) in a specified time period (once or twice per week). The eliminated treatments would no longer be profitable or the dentist could consider changing the business model, approaching that with the same treatment volumes for each typology of treatment (MIX1 in Appendix B), which is based on a greater flexibility of resources.

Table 2

Grouping of the dental treatments on the basis of the time and risk variables, and the risk of contagion.

Dental Treatments		Risk-Level
		Low	Medium	High
	tw ≤ 45’(low)	Manual reduction of dislocation of the jaw X-rays Topical treatment of dental hypersensitivity and caries prophylaxis Biopsy Oral minor surgery (e.g., abscess incision, frenulectomy, frenulotomy) Salivary stone removal Gingivectomy/gingivoplasty	Orthodontic splinting (1 dental arch) Periodontal splinting (1 dental arch) Intraoral examination	Subgingival curettage (quadrant) (rotating tools) Sealing of dental grooves Abutment tooth preparation Odontoplasty (1 tooth)
TIMING (tw)	45’ < tw ≤ 75’(medium)	Mucogingival surgery (quadrant) Subgingival curettage without rotating tools (quadrant) Removal of cysts or small benign neoplasms Tooth extraction without rotating tools	Orthodontic splinting (2 dental arches) Periodontal splinting (2 dental arches)	Tartar removal Extraction with rotating tools Simple/complex filling using rotating tools
	tw > 75’(high)	Bone graft (autogenous/biocompatible material) without rotating tools	Bleaching	Sinus lift Implantology Resective/regenerative bone surgery (rotating tools) Apicectomy with retrograde filling Extraction of impacted tooth with rotating tools

In addition to the proposed approaches discussed in this paper, it would be possible to adopt a comprehensive empirical solution in concentrating a greater number of treatments regarding the same patient in one sitting with a net reduction in the expenditure and the total time between one patient and the other. Lastly, the benefit of duplicating the so-called bottleneck resources could be assessed, that is, to have at least two TRs functioning independently of each other. However, this latter solution necessitates an audit of a break-even volume; that is, that minimum treatment volume which equalises costs with earnings and, therefore, the level under which markup is negative. Indeed, if the treatment request is less than the break-even volume, the solution would not be economically advantageous. Unfortunately, this could be a probable result from the moment when recent investigations have revealed a drop in the request for dental care [16].

On a brighter note, the Boston Consulting Group recently surveyed approximately 7000 patients nationwide. The results of this survey indicated that providers of health care services can influence the conditions affecting a patient’s willingness to reschedule delayed care. Addressing concerns such as “The procedures are clear to me,” and “The location is certified free of COVID-19” are within the control of healthcare providers [17]. A contraction of demand could only exacerbate the analyses of the economic performance regarding Approaches A and B, and, on reflection, Approach C: the three Approaches are based on a full deployment of resources. If such a deployment of resources should diminish, on account of a drop-in demand, the impact of increased fixed costs would probably increase, in addition to a reduction in volumes. This, in turn, would lead to a further loss in markup and turnover or a further increase in dental charges in keeping markup constant. However, this latter solution (an increase in dental charges) must contemplate a net contraction in the economic situation and a reduced willingness of the patient to pay. These demand side issues have not been tackled in this paper, the latter being strictly related to the specific market associated with the public health system in a given context. The change in the willingness to pay will modify the patient’s behaviour regarding the purchasing of dental services; the patient may then be obliged to seek financing (a solution generally offered by franchises) or request delayed payment terms for treatment which cannot be postponed. Such a request would lead to further repercussions on the finances of the dentist practice, which may, therefore, increase the financial requirements of working capital or liquidity, which are necessary to keep the dentist practice operational. Manson, in a Harvard Business Review Insight, has outlined a survival strategy for small businesses in the COVID era: the securing of liquidity, the ensuring of access to capital and the engagement with policy-makers are considered to be the three elements which small businesses need to survive in the coronavirus crisis [18].

Another consideration in this analysis regards the assumption of standalone treatments: indeed, complex treatments require multiple appointments which cannot be eliminated from the mix, which is on offer without eliminating the completion of the treatment. In this case it could be helpful to consider a further mix made of complex treatments, including all the single treatments required.

Finally, consideration should be made regarding the financial support of the policymaker in adjusting to the revised, protective recommendations. Such an injection of liquidity, also by means of guaranteed loans or non-repayable grants, would permit the moderation of a natural increase in dental charges which, in turn, would boost the choice of seeking medical care where those dental charges are lower (for example, health tourism). A potential risk here would not only be a reduction in demand and, therefore, business volume, but it could also have a feedback effect on the public health system in the country in question.

5. Conclusions

The authors of this paper aspire to provide useful managerial insights which can assist the dentist-entrepreneur to become aware of the boundaries of the economic consequences of governmental measures in containing viral infection.

Table A1

Variables used in the analysis. The symbol indicates the sum of generic variables , attributing all possible values to r (r varies from 1 to R in this study).

Variables Used in the Analysis	Description
CF	pre-COVID fixed cost in period T
ΔCF	increase in fixed costs
CF* = CF + ΔCF	post-COVID fixed cost in period T
R	number of treatments
cfr	pre-COVID unit fixed cost of r-th treatment
cvr	pre-COVID variable unit cost of r-th treatment
cr = cfr+ cvr	pre-COVID unit cost of r-th treatment
Δcfr	increase in fixed unit costs of r-th treatment
cfr * = cfr+ Δcfr	post-COVID fixed unit cost of r-th treatment
Δcvr	increase in variable unit costs of r-th treatment
cvr * = cvr + Δcvr	post-COVID variable unit costs of r-th treatment
cr* = cfr*+ cVr*	post-COVID unit cost of r-th treatment
pr	pre-COVID dental charge of r-th treatment
pr*	post-COVID dental charge of r-th treatment
Vr	number of pre-COVID r-th treatment
Vr*	number of post-COVID r-th treatment
V=∑V_r	total volume of pre-COVID treatments
V^*=∑V_r^*	total volume of post-COVID treatments
P=∑V_r·p_r	total pre-COVID markup from the sum of markup for each treatment
P^*=∑V_r^*·p_r^*	total post-COVID markup from the sum of markup for each treatment
T	Timeframe for analysis: 1 year
mix_r=V_r∑V_r	percentage volume of r-th treatment on total volume
mixr*=Vr*V^*	percentage volume of r-th treatment on total post-COVID volume
z	increase in post-COVID unit costs
K	reduction in post-COVID volumes
tb	preparation time for staff and treatment slot
ts	time necessary to render the OR operational between successive treatments
tw	total treatment duration
tc	cycle time or time interval between completing two successive treatments
Δt	increase in time ts, resulting from anti-COVID recommendations

Table A2

The mix under consideration yields 9 treatment types by classifying the treatments on the basis of the working time (i) and the risk level (j) (as in Table 2).

	j = l	j = m	j = h
i = tw1	mixtw1l	mixtw1m	mixtw1h
i = tw2	mixtw2l	mixtw2m	mixtw2h
i = tw3	mixtw3l	mixtw3m	mixtw3h

Table A3

A numeric example of Table A2.

mixij	j = l	j = m	j = h
i = tw1	8%	15%	12%
i = tw2	10%	11%	11%
i = tw3	9%	12%	12%

Table A4

The match between a coding mix with a subscript (r) and with two subscripts (ij).

subscript r	1	2	3	4	5	6	7	8	9
subscript ij	tw 1l	tw 1m	tw 1h	tw 2l	tw 2m	tw 2h	tw 3l	tw 3m	tw 3h

Table A5

Pre-COVID volumes for the 9 treatment groups in MIX2.

V*ij	j = l	j = m	j = h
i = tw1	335	213	156
i = tw2	335	213	156
i = tw3	335	213	156

Table A6

Post-COVID volumes for the 9 treatment groups in MIX2.

V*ij	j = l	j = m	j = h
i = tw1	181	138	112
i = tw2	181	138	112
i = tw3	181	138	112

Table A7

Total variable and unit costs relating to per-COVID treatments.

	i = t w 1	i = t w 2	i = t w 1
cvij (monetary units)	54	85	116
cij = cfij + cvij (monetary units)	83	131	179

Table A8

Pre-COVID treatment dental charges.

	i = t w 1	i = t w 2	i = t w 3
pij (monetary units)	125	196	268

Table A9

Post-COVID unit costs of the 9 mixes under consideration.

cij*	j = l	j = m	j = h
i = t w 1	121	172	223
i = t w 2	131	182	233
i = t w 3	141	192	243

Table A10

Post-COVID dental charges for the nine mix typologies under consideration, the average dental charge for the three treatment typologies (l, m, h), based in working times (p* average) and their percentage variation, compared to the pre-COVID dental charges (Δp* average %).

pij*	j = l	j = m	j = h
i = t w 1	181	258	335
i = t w 2	196	273	350
i = t w 2	211	288	365
pi* average	196	273	350
Δpi* average %	57%	39%	31%

Table A11

Percentage of markup loss/treatment unit with dental charges constant for the 9 mixes under consideration in the two mix scenarios (MIX1 and MIX2).

		MIX1				MIX2
mixil	144%	117%	105%	mixil	175%	117%	90%
mixim	168%	133%	116%	mixim	199%	133%	101%
mixih	192%	148%	127%	mixih	223%	148%	113%
average for i	168%	133%	116%	average for i	199%	133%	101%

Table A12

Loss in turnover in monetary units with dental charges constant for the 9 mixes under consideration in the two mix scenarios (MIX1 and MIX2). The total value appears in red in Table A12.

		MIX1					MIX2
mixil	9412	14,790	20,168	44,370	mixil	19,341	14,790	11,973	46,103
mixim	9412	14,790	20,168	44,370	mixim	19,341	14,790	11,973	46,103
mixih	9412	14,790	20,168	44,370	mixih	19,341	14,790	11,973	46,103
total by column	28,235	44,370	60,504	133,109	total by column	58,022	44,370	35,918	138,310
average for i	7%	12%	16%	35%	average for i	15%	12%	10%	37%

Table A13

Revised dental charges in monetary units to maintain markup (of the mixes and therefore totalled) constant for the 9 mixes under consideration in the two mix scenarios (MIX1 and MIX2).

		MIX1				MIX2
mixil	185	273	361	mixil	198	273	348
mixim	195	283	371	mixim	208	283	358
mixih	205	293	381	mixih	218	293	368
average for i	195	283	371	average for i	208	283	358

Table A14

Percentage increase in the dental charges necessary to maintain markup (of the mixes and therefore totaled) constant for the 9 mixes under consideration in the two mix scenarios (MIX1 and MIX2).

		MIX1				MIX2
	mix1j	mix2j	mix3j		mix1j	mix2j	mix3j
mixil	48%	39%	35%	mixil	58%	39%	30%
mixim	56%	44%	39%	mixim	66%	44%	34%
mixih	64%	49%	42%	mixih	74%	49%	38%
average for i	56%	44%	39%	average for i	66%	44%	34%