key: cord-307929-286i4rue authors: Bustati, Nour; Rajeh, Nada title: The Impact Of COVID-19 Pandemic on Patients Receiving Orthodontic Treatment- An Online Questionnaire Cross Sectional Study date: 2020-10-23 journal: J World Fed Orthod DOI: 10.1016/j.ejwf.2020.10.003 sha: doc_id: 307929 cord_uid: 286i4rue Background The spread of COVID-19 has led to a major public health issue; most dental clinics were closed and millions of orthodontic patients were unable to complete their treatment, this study aimed to assess the challenges faced by patients receiving orthodontic treatment and their proffered solutions to overcoming these challenges during this pandemic. Methods An online questionnaire was developed and sent to patients receiving orthodontic treatment at a public or private clinic. Results 388 responses were analyzed. Mean age 20.4 ± 4 years, 75% (291) were females and 58% (226) received their treatment at a public clinic. 27.3% (106) of all participants were still unable to attend to their appointments and 69% (244) stated that closing of the clinic was the main reason for missing their appointments. Depending on their type of appliance the patients faced different problems and chose multiple ways to deal with them. The majority of participants had Fixed Appliances 84% (327) and only 21% (64) of them stated that they had no problem compared to 39% (11) and 36% (8) for Removable Appliances and Clear aligners groups respectively. Conclusion The COVID19 pandemic has significant impact on orthodontic treatments. Almost each orthodontic patient had to stop attending to their appointment which put them in complicated situations and in fear of delayed treatment. Patients from a public clinic and patients with fixed appliances reported more problems than others. More attention should be giving to teleorthodontics, also orthodontists should prepare their patients to deal with some of the problems related to their appliances when possible. At the end of 2019 an outbreak of a novel coronavirus (COVID-19) started from Wuhan, China and later on spread widely around the globe and led to a major public health issue [1] . To the day of writing this article more than 30 million confirmed cases of COVID-19 including more than 940,000 deaths globally have been reported to the WHO (World Health Organization) and the number is on a rise [2] . Different policies and strategies were taken by each affected country to face this pandemic and minimize the number of cases, from partial to complete lockdown, giving that in the absence of vaccine WHO has recommended some precautions to control infection such as regular hand hygiene, the use of face masks, following cough etiquette and most importantly keeping social distancing [3] . The main way of transmission is through close contact with infected individual. However, numbers of asymptomatic carriers were reported which increases the possibility of transmission without cautious actions being taken [4] . Although most governments encouraged people to stay and work from home, society is in need for healthcare workers in everyday life and during this J o u r n a l P r e -p r o o f pandemic specifically and this put them in high risk. In particular of all healthcare aspects dental producers require more direct contact with aerosols which resemble even higher possibility of infection [5] . Despite numerous modifications and guidelines that were recommended to dental practice during this pandemic, several dental clinics were closed and only patients with emergency cases could visit their dentist under strict precautions and it was suggested that all other regular treatments should be postponed [6, 7] . On the other hand, patients receiving orthodontics treatment require multiple checkup visits to their orthodontist to adjust their appliances over a long-lasting process which sometimes may take up to more than 2 years, therefore millions of orthodontic patients weren't able to receive the care they needed when this pandemic and the closing of clinics that followed took place [8] . This led to higher level of anxiety and mental distress among orthodontic patients in comparison with patients receiving other types of dental treatments [9] . The aim of this study was to assess the challenges faced by orthodontic patients during the COVID- 19 pandemic to understand what they went through and their attitudes towards it. This study was a cross-sectional which was carried out with a web-based questionnaire using docs.google.com/forms. The target population was patients age (15-30 years), currently undergoing orthodontic treatment at a public or private clinic. The questionnaire was developed following CHERRIES Checklist for Reporting Results of Internet E-Surveys [10] . The questionnaire was structured into four sections, the first section consisted of personal information (age, gender, type of clinic and type of appliance), the second section had one question regarding the period of time the respondent have missed their visits during this pandemic. Those who answered with ''did not miss any visit'' were directed into the submit page while the other respondents were able to proceed to the third section( the reason for missing the appointments, communication with the orthodontist, main concern, degree of agreement towards closing of clinics) and the last section was about the problems they faced and their ways to address that. To validate the questionnaire first it was sent to an experienced orthodontist to evaluate whether the questions effectively capture the purpose of the study, second an expert of questionnaire construction checked it for confusing and leading questions. For the pilot study, the questionnaire was sent to 30 orthodontic patients. they were asked to specify if any question was unclear and an open option was added at the end of every questions so they can add more answers if needed. Then the questionnaire was modified in accordance and the data were cleared. Since some answers may vary over a short period of time, test-retest correlation was inapplicable. To test reliability a question (type of appliance) was repeated twice. The questionnaire was uploaded to the website and the generated link was sent to patients from 1 public clinic (University clinic) and 5 private clinics via mobile phone application (WhatsApp Messenger). Responses were received over the period of 3 weeks. This was an open voluntary questionnaire and all questions were mandatory. FpFrattive questioning was used hence some questions were on displayed in accordance to the previous answer. Also, respondents were able to click on the back option to change their answer if they wanted before submitting. Uncompleted questionnaires were not submitted. Ethical approval was obtained from Ethical Committee of Research of the authors' University. To obtain Informed Consent, In the description bar on the first page of the questionnaire detailed information was given about the aim of the study, that it would take 5-10 minutes to complete and that all the responses were confidential and anonymous. Consent was obtained if the respondent clicked on ''agree to participate''. Sample size was determined having the population of patients receiving orthodontics treatment in author's country as 3 million with 95% confidence level and 5% confidence interval. The required sample size was 384 participants. For data protection, no sign-in process was required from the respondents. All the responses were anonymous and only authors had access to the collected data. For data analysis, responses were automatically linked to a spreadsheet on Google Sheets then the data was downloaded to Microsoft Excel 2019 where the statistical analyses were performed in accompany with IBM SPSS Statistics for Windows, version 25. 400 responses were received, while 4 did not agree to participate, giving the participation rate of 99%. However, 12 respondents were excluded because they were inconsistent and answered to the repeated question differently. The final number of responses that were analyzed was 388. The average age of participants was 20.4 ± 4 years. Descriptive statistics of responses from section 1 are shown in Table 1 . Regarding to the second section 9% (35) of participants reported that they did not miss any visit to their orthodontists and were directed to the submit page. Table 2 shows descriptive statistics of section 2 and section 3 and were dichotomized according to those who attended public or private clinics. Also, responses from third section were divided according to the type of appliance the patient was using. Table 3 , shows descriptive statistics of section 3 regarding the type of appliance. J o u r n a l P r e -p r o o f What was your main concern during this period? Treatment time will be extended 87% (179) 6% (13) 7% (14) My teeth would relapse 84.4% (124) 10.2% (15) 5.4% (8) To what extent do you agree or disagree about closing the dental clinics to minimize the spread of COVID-19? Strongly disagree (1) 89% (63) 3% (2) 8% (6) disagree (2) 69.2% (18) 15.4% (4) 15.4% (4) Somewhat disagree (3) 87% (39) 11% (5) 2% (1) Neutral (4) 89% (72) 7% (6) 4% (3) Somewhat agree (5) 85% (33) 10% (4) 5% (2) Agree (6) 92% (23) 0% (0) 8% (2) Strongly agree (7) 83% (55) 11% (7) 6% (4) About the final section of the survey patients were divided into 3 groups according to their type of appliance. 21% (64) of patients with fixed appliances stated that they had no problem compared to 39% (11) and 36% (8) of removable appliances and clear aligners patients respectively. J o u r n a l P r e -p r o o f Requesting an emergency appointment 10% (24) Lost elastic/spring 14% (33) searching for a solution over the internet 6% (15) Run out of elastic band 13% (32) Orthodontic pain 35% (6) Ignoring the problem 35% (6) Loose appliance 29% (5) Searching for solution over the internet 35% (6) Broken part 24% (4) Calling my orthodontist 18% (3) Appearing of spaces 12% (2) Sending a picture to my orthodontist 12% (2) Gum swelling 6% (1) Visiting a nearby dentist 6% (1) Requesting an emergency appointment 6% (1) Clear aligner Loose aligner 86% (12) Calling my orthodontist 57% (8) Broken part 14% (2) Requesting an emergency appointment14% (2) Orthodontic pain 14% (2) Ignoring the problem 14% (2) Gum swelling 7% (1) Visiting a nearby dentist 14% (2) Appearing of spaces (0) Searching for solution over the internet 7% (1) *more than one answer can be chosen. Globally, the COVID-19 pandemic has been the main concern among society since many limitations have occurred to the everyday life. Being in high risk of infection, most dental clinics were closed which put the patients who were receiving orthodontic treatment in complicated situation since they require regular visits to their orthodontist for a long period of time. This study aimed to assess the challenges faced by patients receiving orthodontic treatment and their proffered solutions to overcoming these challenges during this pandemic in order to avoid such problems in the future. Over the period of 3 weeks, the link of the questionnaire was sent to patients via WhatsApp Messenger since it is used by most of them which made it easier to reach them during quarantine. The main focus was to access the percentage of patients that were still unable to complete their treatment. The majority of them were receiving their treatment at the public clinic of the university and reported that the clinic being closed was the main reason for that. This can be justified by the governmental decision of mandatory closing of schools and universities and patients being unable to afford the cost of their treatment somewhere else. The majority of the participants kept in touch with their orthodontist using many different ways from voice calling to SMS but more than half chose to use a mobile phone application which is in line with a recent study assessing orthodontists' experience that found the majority of patients got in touch with their orthodontist using WhatsApp messenger [11] ,this reveal the importance of teleorthodontics in general and during this period specifically, in order to reduce unnecessary visits to the clinic while still monitoring patients from a distance [12] . also it might be an easier way to communicate using images instead of words and more appropriate to illustrate the problem they were facing, in addition there are variable options of applications nowadays and the Internet is available everywhere [13] . Regarding their main concern, more patients were concerned about the duration of treatment rather than that their treatment might relapse, this result ties well with a previous study [14] . This is expected as patients' first question is about the length of treatment from the initial visit [15] . However, participants from public and private clinics had different opinions towards the closing of dental clinics, this is linked to the difference of what each participant went through during this period and the main reason that led them to stop attending to their appointments. According to their type of appliance participants were divided into 3 groups. Fixed Appliances group (FA), Removable Appliances group (RA) and Clear Aligners group (CA). Participants with FA faced more problems than the RA and CA groups. This could be linked to FA causing discomfort due to the friction between the end of wire and the inner cheek or the tongue, also FA have multiple parts that could break or irritate the oral mucosa [16] . These two problems were the most reported issues between participants from this group and are consistent with the findings of recent similar studies [11, 17] . Also, number of these participants chose the appearance of new spaces between teeth as their main complication, that may cause patients to be concerned if this possibility wasn't explained to them clearly before. In addition, gum swelling was a common answer in this group, this is normal since FA accompany with gingival enlargement especially in absence of good oral hygiene [18] . On the other hand, the main problem for RA group was orthodontic pain, although several studies have reported less level of orthodontic pain among these patients [19] , while the majority of CA group chose the loosening of the aligner as their main problem, this goes to the suggestion that patients should change to the next aligner after 2 weeks [20] . Also, participants defer between groups regarding to the way of addressing their problems. FA participants used orthodontic wax to cover sharp ends which was not an option in the other groups. While most FA and CA patients tend to their orthodontist in facing what encountered them, most RA patients chose to look for a solution online, giving that the internet has become an alternative way for some patients to seek information and find experiences of people who went through their same situation [21] . Considerable number of participants in all groups reported that they ignored their problems, this could be justified by their fear of infection and choosing not to visit any clinics. In the light of these findings, more attention should be given towards orthodontic patients and their long journey with treatment. Many acceleration methods have been reported in the J o u r n a l P r e -p r o o f literature and should be taking into consideration in practice to help in shortening treatment time and avoiding most problems associated with this long period [22] . Also, the type of appliance may have an important role in making treatment process easier. In addition to their aesthetic appearance Clear Aligners seems to be more comfortable and less complicated than Fixed appliances [23] and practitioners around the world are widening the use of CA to treat different cases while limited cases can be treated with removable appliances. Thus, it is recommended to choose CA as a treatment when possible especially during this pandemic. However, it is advisable that new patients with no urgent cases would postpone their treatment until we have further knowledge regarding this pandemic. On the other hand, many of the problems that patients were facing could have been solved by providing them with emergency guidelines like the British Orthodontic society Covid-19 Orthodontic Emergency Protocol [24] and train patients to address these problems when possible. Also, Orthodontists can benefit from many recommendations and guidelines that have been suggested in the literature [8] to be able to provide their patients with proper care and protect themselves as well. The main limitation of this study is that most participants had FA and this may have affected the results derived from RA and CA groups. The COVID19 pandemic has significant impact on orthodontic treatments. Almost each orthodontic patient had to stop attending to their appointment at some point during J o u r n a l P r e -p r o o f What was your main concern during this period? Treatment time will be extended 87% (179) 6% (13) 7% (14) My teeth would relapse 84.4% (124) 10.2% (15) 5.4% (8) To what extent do you agree or disagree about closing the dental clinics to minimize the spread of COVID-19? Strongly disagree (1) 89% (63) 3% (2) 8% (6) disagree (2) 69.2% (18) 15.4% (4) 15.4% (4) Somewhat disagree (3) 87% (39) 11% (5) 2% (1) Neutral (4) 89% (72) 7% (6) 4% (3) Somewhat agree (5) 85% (33) 10% (4) 5% (2) Agree (6) 92% (23) 0% (0) 8% (2) Strongly agree (7) 83% (55) 11% (7) 6% (4) The outbreak of COVID-19: An overview World Health Organization. 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