Journal of International Oral Health

ORIGINAL RESEARCH
Year
: 2022  |  Volume : 14  |  Issue : 4  |  Page : 409--415

Impact of COVID-19 pandemic on orthodontic patient’s inflow in daily orthodontic practice: A cross-sectional study


Talat H Al-Gunaid1, Mohammad M Hammad2, Maher O Shahada3, Hamzah S Allam3, Abdulqader Z Abuanq3, Ghaidaa S Zakour3, Hazim H Zubaidi3, Ghofran A Karbouji3,  
1 Department of Pediatric Dentistry and Orthodontics, College of Dentistry, Taibah University, Madinah, Saudi Arabia; Department of Orthodontics, Faculty of Dentistry, Ibb University, Ibb City, Yemen
2 Department of Preventive Dentistry, College of Dentistry, Jordan University of Science and Technology, Irbid, Jordan
3 College of Dentistry, Taibah University, Madinah, Saudi Arabia

Correspondence Address:
Prof. Talat H Al-Gunaid
Department of Pediatric Dentistry and Orthodontics, College of Dentistry, Taibah University, Madinah
Yemen

Abstract

Aim: To evaluate the effects of the COVID-19 pandemic and lockdown on orthodontic patients’ apprehension and inflow and to investigate the treatment-related problems encountered during the pandemic. Materials and Methods: A cross-sectional study was carried out in Saudi Arabia, and patients with active orthodontic treatment were reached via an online questionnaire. A total of 260 orthodontic patients agreed to participate in the study. The sample size calculation was performed using the Raosoft sample size calculator based on the estimation of 75% of the population need orthodontic treatment. The questionnaire included three sections: demographic data, patient fear, and troubles encountered during the lockdown. A link was sent to the participants via different social media platforms and applications. The chi-square goodness-of-fit test was used to assess differences between the variables. Pearson correlation, binomial logistic regression, and multiple logistic regression tests were used to assess the extent of the relationship between patient apprehension and safety measures of COVID-19, as well as between patient orthodontic-related problems. Results: About half of the participants (52.3%) were not afraid of COVID-19 or panicked; however, 54% of them felt depressed during the lockdown. More than 80% were not afraid of visiting the orthodontists or thinking of changing their orthodontists for safety measures and did not want to postpone their treatment. The participants felt that excellent disinfection was the most important measure of infection control followed by wearing masks, face shields, and protective clothing. Conclusion: COVID-19 and the lockdown have a noticeable impact on the patients’ apprehension and dejection. A very high percentage of patients in this study showed no hesitation to visit their orthodontists, and they did not want to stop their treatment during the pandemic. The most common treatment-related problem reported was cheek injury, followed by bracket breakage.



How to cite this article:
Al-Gunaid TH, Hammad MM, Shahada MO, Allam HS, Abuanq AZ, Zakour GS, Zubaidi HH, Karbouji GA. Impact of COVID-19 pandemic on orthodontic patient’s inflow in daily orthodontic practice: A cross-sectional study.J Int Oral Health 2022;14:409-415


How to cite this URL:
Al-Gunaid TH, Hammad MM, Shahada MO, Allam HS, Abuanq AZ, Zakour GS, Zubaidi HH, Karbouji GA. Impact of COVID-19 pandemic on orthodontic patient’s inflow in daily orthodontic practice: A cross-sectional study. J Int Oral Health [serial online] 2022 [cited 2022 Dec 4 ];14:409-415
Available from: https://www.jioh.org/text.asp?2022/14/4/409/355025


Full Text

 Introduction



COVID-19 is a human transmitted disease. It had outspread globally with high morbidity and mortality rates. The pandemic had aggressively spread and affected millions of people’s lives. The health and economic consequences of the pandemic and the lockdown have been severe, widespread, and devastating. The disease can be identified with a range of symptoms, some of which are similar to the characteristic symptoms of influenza, which include fever, headaches, dry cough, sore throat, asthenia, myalgia, and advanced-stage dyspnea, anosmia, and dysgeusia.[1],[2],[3] Some oral manifestations were reported such as aphthous-like lesions, oral dryness, and vesiculobullous lesions.[3]

The disease transmission is rapid; it can be through direct contact, aerosol, and droplets.[4] Dentists are considered to be at high risk because of the exposure to aerosols produced by rotatory instruments and the direct contact with saliva during dental procedures.[3] Because the risk of cross-infection between patients and dental practitioners is high, studies have shown that patients were anxious about attending dental appointments during the pandemic.[5]

In response to the COVID-19 crisis, the responsible health authorities in many countries have ordered a mandatory suspension of all nonemergency medical and dental services. Orthodontic treatment requires regular multiple visits for the adjustment of the appliances and for monitoring the progress of occlusal changes; therefore, missing an appointment in an orthodontic clinic can delay the treatment to a large extent.[6] Each missed appointment tends to increase the orthodontic treatment time by 1.09 months on average.[5] Considering the long orthodontic treatment period that ranges from 12 to 18 months or even longer,[7] missing multiple appointments due to patients having additional concerns regarding this pandemic and lockdown would delay the treatment considerably.[5]

Very few studies have investigated the impact of COVID-19 lockdown on orthodontic patients’ treatment,[8],[9] and little is known regarding the patient’s apprehension, thoughts, and troubles they face during the pandemic. This study aimed to assess the impacts of the COVID-19 pandemic on the orthodontic patients’ apprehension, regular follow-up appointments attendance, and encountered treatment-related problems.

 Materials and Methods



A cross-sectional prospective survey was carried out in Saudi Arabia between January and March 2021. The ethical clearance was obtained from the ethical committee, College of Dentistry, Taibah University, approval number: TUCDREC/03122020, dated December 20, 2020.

A questionnaire was formulated using the Google forms template. The questionnaire included three sections: demographic data, troubles encountered during the lockdown, and patients’ apprehension and concerns. The questionnaire was written in English and translated into Arabic and then back-translated into English. The final step was sending the Arabic version to an Arabic language proofreader to check the validity of translation and grammatical mistakes. To further check the validity of the questionnaire, five assessors working in the dental field (two professors, three associate professors) were invited to participate in evaluating the questionnaire and give their comments on the clarity and accuracy of the questionnaire. Another 10 assessors (orthodontic patients) were asked to answer the questionnaire in two rounds, and a comparison between the first and second rounds was conducted. The internal consistency of the questionnaire was tested using Cronbach’s alpha. The intraclass correlation coefficient was used to assess reliability.

The authors made every effort to reach as many patients as possible. The survey was then distributed via social media platforms such as WhatsApp groups, Facebook groups, and email lists. Information about the aim of the study, the voluntary participation decision, and withdrawal, in addition to the confidentiality and privacy agreement, was included in the questionnaire.

Statistical analysis

The chi-square goodness-of-fit test was applied to the data to determine whether the distribution of cases in a single categorical variable consisting of two categories follows a known or hypothesized distribution. The study assumed that the data follow a binomial distribution, except for three of the variables that were composed of more than two classes, so the chi-square goodness-of-fit test was the most appropriate. This test was used to study the presence of statistically significant differences between the distributions seen and the assumed distribution in the variables related to the first axis “patients’ fear and safety measures of COVID-19,” as well as for the second axis “patient visits, communication, and problems related to orthodontic treatment.” Pearson correlation, binomial logistic regression, and multiple logistic regression tests were used to assess the extent of the relationship between patient fear and safety measures of COVID-19, as well as between patient visits, communication, and orthodontic treatment-related problems. All statistical analyses were performed using SPSS 25.0 software (version 25.0, SPSS, Chicago, Illinois, USA). The level of significance was set at P < 0.05.

 Results



A total of 260 orthodontic patients agreed to participate in the study. [Table 1] shows the patients’ apprehension of COVID-19 and their safety measures. About half of the participants (52.3%) reported that they were not afraid of COVID-19 or panicked, and 47.7% were in real apprehension of the COVID-19. More than 54% of the participants felt dejected as a result of the lockdown and the pandemic crisis. More than 83% of the participants reported that they were not afraid of visiting the orthodontists (P < 0.001), 80% were not thinking of changing their orthodontists for safety measures (P < 0.001), 81.5% did not want to postpone their treatment (P < 0.001), and more than 88% did not want to stop their treatment during the pandemic crisis (P < 0.001). More than 60% of the participants were not worried about having to extend treatment time because of the COVID-19 (P < 0.001). When asked about their standards for safety measures in the orthodontist’s clinic, more than 52% of the participants reported that excellent infection control in the clinic was the most important measure followed by wearing masks, face shields, and protective clothing, and replacing them between patients (25.8%, P < 0.001).{Table 1}

[Table 2] displays questions about the relationship between patient visits and communications during the COVID-19 pandemic. More than half of the participants answered “orthodontists closed their clinics during the pandemic, 41% of the participants did not see their orthodontists for a minimal duration of 1–2 months, and 67% of them did not get any type of contact from their orthodontics’ office during the lockdown.” More than 40% of the participants have called the orthodontists’ office directly after the lockdown. More than 85% of the participants reported that they did not think of changing or visiting another orthodontist during their orthodontists’ clinic closure. More than 40% reported that they did not have any problem during the lockdown. The most common treatment-related reported problem was cheek injury due to wires coming out of their place (25.4%), followed by brackets’ breakage (13.5%). The COVID-19 pandemic affecting either the financial condition of the patients or attending the orthodontic office was not reported.{Table 2}

Correlations between the patients’ apprehension and safety measures of COVID-19 are presented in [Table 3]. A significant correlation was found between patients’ apprehension of COVID-19 and depression experienced during the lockdown (R = 0.21, P < 0.01) and their desire not to postpone their treatment until the crisis is over or wait for the development of a vaccine (R = 0.24, P < 0.001). In addition, a significant correlation was found between patients’ apprehension and their concerns about extending the treatment time (R = 0.27, P < 0.001). Regarding the correlation between the patients’ visits to the orthodontist office, communication, and treatment-related problems during the lockdown, only two significant relationships were found among all of the tested variables. A negative and significant correlation was found between the time passed between the patients’ last visit to the orthodontist and the patient communication with the orthodontic office (R = −0.07, P < 0.01), and positive and significant correlation with the orthodontic treatment-related problems during the lockdown (R = 0.23, P < 0.001) [Table 4].{Table 3} {Table 4}

 Discussion



The COVID-19 as a global health crisis resulted in economic and psychological problems that affected millions of people across the world. Several countries have been taking action by shutting down all health sectors, while only providing emergency medical and dental care in an attempt to reduce the risk of exposure. It has been reported that dental professionals are more prone to get infected and spread the virus to their patients, friends, and families.[10] Orthodontic care was one of the dental disciplines that suffered resulting in an economic ramification and psychological impact that affected both the orthodontists and their patients. Accordingly, the current situation may result in two main disquiets: the first difficulty is that many if not all orthodontists are struggling to reconcile their safety and their obligation to their patients through modifying their practice to emergency follow-up visits and also improving infection control practices, whereas the second matter belongs to the patient fear and safety during the pandemic. It is well known that orthodontic patients should adhere strictly to their regular follow-up and take maximum care of their teeth and their orthodontic appliances throughout the whole treatment period.

Problems that arise from not visiting the orthodontist on the scheduled appointments may result in unexpected deleterious effects such as unwanted tooth movement, e.g., continuous use of cross-elastics or power chains for a long time without close supervision from the orthodontist, or the wire may come out of the molar tubes injuring the patients’ cheeks causing pain and inconvenience.

Previous reports have mainly either studied the perception of COVID-19 among dental health personnel in different countries[11],[12],[13] or investigated the impact of COVID-19 on the patients.[8] Therefore, this study aimed to understand the effects of the COVID-19 pandemic and lockdown on orthodontic patients’ apprehension and inflow and to investigate the treatment-related problems encountered during the pandemic.

The results of this study showed that more than half of the participants (52.3%) were not terrified from COVID-19. A recent study conducted in Brazil has reported that 44.7% of the participants were calm and 46.3% were afraid or anxious from the pandemic.[9] This means that most patients have developed a good knowledge and are aware of the nature of the virus and started to adapt to the new circumstances.

More than 54% of the patients in the current study answered that they felt dejected as a result of the lockdown. The impact of the stress of staying at home during the lockdown, social distancing, no regular meeting with other people, and fear of the virus itself, all of these qualify patients to develop depression.[9],[14] Psychological consequences of the lockdown that could affect a considerable number of patients in the community should be taken into consideration.

Among the interesting findings of this study is that more than 80% of the orthodontic patients were not afraid of visiting the orthodontists and did not think of changing them for safety reasons. This may be due to patients’ confidence in their orthodontists in taking high standards of safety measures and might be due to the amount of money they paid in advance. This finding is also supported by the fact that more than 85% of the participants reported that they did not think of changing or visiting another orthodontist during their orthodontist clinic closure. Such results should make the orthodontists aware of the importance of keeping good relations with their patients and maintaining high standards of infection control not only during pandemics.

It was found that 81.5% of the patients did not want to postpone their treatment, and 88% of them did not want to stop their treatment during the pandemic crisis. This can be explained by the fact that the patients’ enthusiasm at the beginning of the orthodontic treatment is relatively high, but with time, especially in difficult cases, the patients start to feel tired and bored and want to finish as soon as possible. Therefore, it is natural for the patients to refuse to extend the treatment period. The current study findings are in line with those reported by Cotrin et al., for Brazilian patients.[9]

Asking the participants about the standards of safety measures in the orthodontists’ clinics, more than 52% reported that excellent infection control in the clinic is the most important, followed by wearing a face mask, face shield, and protective clothing and changing them between patients (25.8%, P < 0.001). The patients’ standards found in this study agree with the most up-to-date recommendations by several health authorities[15],[16] and are similar to those recommended by other reports.[9],[17],[18] More than half of the orthodontists closed their clinics during the pandemic, and 67% of the patients did not get any type of contact from their orthodontists’ offices during the lockdown. This high percentage gives attention to the importance of the communication process between orthodontists and their patients. This requires profound attention, and the reasons behind this problem should be studied thoroughly. A possible approach to overcome the lack of communication can be by using virtual communication. According to Saltaji and Sharaf, many Canadian and American orthodontists have used virtual communication approaches during the pandemic such as Zoom for remote consultations to substitute direct meetings with patients.[19]

More than 40% of the participants reported that they did not have any treatment-related problem during the lockdown. This can be looked at as a good indicator of the orthodontists’ careful care and reflects the positive care of the patients themselves. The most common reported treatment-related problem found in this study was the wire coming out of the posterior molar’s tubes causing cheek injury (25.4%), followed by brackets breakage (13.5%). These findings are in agreement with those reported by Shenoi et al.[8] and Gyawali et al.[20] Suri et al. suggested some practical advice on how to manage each of the orthodontic emergencies. They advised the orthodontists to try to manage the emergencies over the phone or remotely and accordingly obtain an online consent of the remote devices and to record it.[21]

A significant weak correlation was found between the participants’ apprehension of COVID-19 and dejection experienced during the lockdown (R = 0.21, P < 0.01) and the participant’s concerns about extending the treatment time (R = 0.27, P < 0.001). Ahorsu et al.[22] stated that transmission, morbidity, and mortality of infectious diseases have a direct association with fear. Also, it has been reported that social distancing and isolation may lead to stress and depression, which in turn has a connection with increased vulnerability of mental health.[14] Recent research by Cotrin et al.[9] found that patients who stayed at home during the pandemic had significantly higher levels of apprehension about the COVID-19 pandemic and the impact on orthodontic treatment. This is in line with the finding of the current study.

A significant weak correlation was found between patients’ apprehension of COVID-19 and the patient’s concerns about extending the treatment time (R = 0.27, P < 0.001). It has been suggested that in cases of delayed treatment, the orthodontist should think of alternative strategies to shorten the treatment time such as using special orthodontic wires, self-ligating brackets, or utilizing clear aligners that make the treatment faster and shorter.[9],[23] A significant negative correlation was found between the time passed between the patients’ last visit to the orthodontist and the patient contact with the orthodontic office (R = −0.07, P < 0.01). In this context, the orthodontists and dental staff need to establish good and effective communication with the patients, which would bring better confidence in the orthodontic office, establish fruitful mutual trust between the two parties, and create greater patients’ satisfaction.

For the above reasons, it is recommended that the orthodontic office incorporates modern communication modalities such as social media platforms, video calls, messaging applications, emails, telehealth technologies, and others to contact or educate the patients. Establishing these types of communications will help in times of disasters and pandemics.[9],[24] Furthermore, this will bring greater confidence in the orthodontist and dental staff.[9]

It is important to note that results obtained in this study may have been influenced by varying factors such as age, education, social media, and being conducted online and solely in Saudi Arabia, and this may lead to potential bias if we apply the results of this study to other populations. Despite these limitations, the results found in this study could be useful to understand the effect of COVID-19 on the patients’ apprehension and patients’ inflow. Finally, it is recommended that future collaborative studies between different institutes in different countries should be conducted to elucidate the relationship between COVID-19 and other associated factors such as education culture and socioeconomic status.

 Conclusion



COVID-19 and the lockdown have a noticeable impact on the patients’ apprehension and depression. A very high percentage of patients in this study showed no hesitation to visit their orthodontists, and they did not want to stop their treatment during the pandemic crisis. The most common treatment-related problem reported was cheek injury resulting from the wire coming out from the molar tube followed by bracket breakage.

Acknowledgement

The authors would like to thank Miss. Sameera M. Hammad for her great input and proofreading of the article.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

Authors’ contributions

THA: concepts, design, data analysis, article preparation, and the responsible author of the integrity of the work; MMH: study design, article editing, and article review; MOS, HSA, AZA, GSZ, HHZ, GAK: literature search, data acquisition, and article preparation.

Ethical policy and institutional review board statement

This study was approved by the Ethical Committee, Faculty of Dentistry, Taibah University, approval number: TUCDREC/03122020, dated December 20, 2020.

Patient declaration of consent

Participants were explained clearly about the study purpose.

Data availability statement

Data can be obtained on written correspondence to the corresponding author on valid request (Dr. Talat Al-Gunaid, e-mail: [email protected]).

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