key: cord-0762663-8324eeup
authors: Ludwig, David C.; Nelson, J. Luke; Burke, Andrea B.; Lang, Melanie S.; Dillon, Jasjit K.
title: WHAT IS THE EFFECT OF COVID-19-RELATED SOCIAL DISTANCING ON ORAL & MAXILLOFACIAL TRAUMA?
date: 2020-12-14
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2020.12.006
sha: b09503ef7fb7a722d51079d11092a0e8659aaaa4
doc_id: 762663
cord_uid: 8324eeup

PURPOSE: The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of oral and maxillofacial fractures at an urban, Level I trauma center in the United States. MATERIALS AND METHODS: The investigators designed a retrospective cohort study and enrolled a sample of 883 subjects who presented for evaluation of oral and maxillofacial fractures (OMF) between March 1 and June 30 in the years 2018 through 2020. The primary predictor variable was evaluation of OMF during a period with social distancing policies (2020 – experimental group) or without social distancing policies in place (2018 or 2019 – control group). The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at p<0.05 for all tests. RESULTS: The number of subjects presenting with OMF was lower during the period of social distancing (n=235 in 2020) than during the periods without (2018: n=330; 2019: n=318). During the period of social distancing, there were more individuals who presented secondary to assault, whereas less individuals presented secondary to falls (p=0.05). On average, those who presented in 2020 had more severe oral and maxillofacial injuries (mean AIS = 3.2 ± 1.2 in 2020 vs 3.0 ± 1.1 in 2019 and 3.0 ± 1.1 in 2018. p=0.03) and more overall injuries (mean ISS = 20.7 ± 13.1 in 2020 vs 19.2 ± 12.5 in 2019; 17.8 ± 12.8 in 2018. p=0.03). CONCLUSION: The investigators found that during the period of social distancing through the COVID-19 pandemic, the number of OMF cases decreased but that the severity of oral and maxillofacial and overall injuries was higher.

Oral and maxillofacial fractures (OMF) are a significant cause of morbidity for individuals in the United States and around the world. 1 Each year over 400,000 emergency department visits involve a facial fracture in the United States contributing to a significant use of healthcare resources. 2, 3 While the cause of facial trauma varies by geographic region, falls are the most common cause globally with assault, motor vehicle collision, bicycle collision, and sports-related injuries being other common causes. 1, 2, 4 In general, individuals with facial fractures are initially evaluated by providers in an emergency or urgent care facility. However, given that facial fractures often occur in the setting of multi-system trauma, trauma centers often see a larger number of individuals with these injuries. 5, 6 Social distancing is a community mitigation measure, or non-pharmaceutical intervention, used to mitigate the burden and spread of an infectious disease. 7, 8 Social distancing has been discussed previously in the literature as it relates to the reduction of respiratory virus transmission and, most recently, as part of the worldwide response to the SARS-CoV-2 (COVID-19) pandemic. 7, 9 Community mitigation measures differ by geographic region and can be enacted at the town/city, county, state/province, or national level. During the COVID-19 pandemic, the State of Washington enacted a series of policies aimed at reducing the community transmission of the novel coronavirus.

These policies included the closure of educational facilities (3/13/2020), a stay-at-home order (3/23/2020), and the closure of non-essential services (3/25/2020). 10 Apart from mitigating the rapid and widespread transmission of this disease, it is unclear how changes in behavior related to these policies affect the incidence and etiology of facial fractures.

The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of facial fractures. The authors hypothesized that the number of facial fracture cases in general would decrease as the result of social distancing policies during the COVID-19 pandemic. The authors also hypothesized that the mean severity of injury would increase, and the etiologic distribution of injuries would change, based on the senior author's observations during this period. The specific aims were to 1) measure and compare the frequency of facial fractures sustained by individuals who presented during a period with social distancing policies in place versus those without;

2) estimate and compare the severity of facial fractures between the two groups; and 3) estimate and compare the etiology of facial fractures between the two groups.

To address the research questions, we designed and implemented a retrospective cohort study. The The time periods were selected to capture patients who presented while measures of social distancing were (experimental group) and were not in effect (control group) and to provide a historical trend and control group for comparison given there may be annual and seasonal variability in trauma patterns. 11 The University of Washington (UW) (Seattle, WA) Institutional Review Board approved the present study (UW IRB #10060).

The primary predictor variable was the period during which the subject presented for evaluation of their The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. The AIS and ISS have been used previously in the literature to aid in our understanding of the epidemiology of oral and maxillofacial injuries. 12,13 These variables were abstracted from the institutional trauma registry and the patients' electronic medical record. The OMF diagnosis was determined based on the ICD-10 diagnosis code associated with the patient encounter. The AIS and ISS were abstracted directly from the trauma registry. The mechanism of injury was defined as assault, bicycle, fall, gun, motor vehicle, motorcycle, pedestrian, or other, as defined in the trauma registry database.

Demographic study variables included age at injury, gender, race, and ethnicity. Race was recorded in the trauma registry and was reported as White, Black or African American, Asian, Native American, J o u r n a l P r e -p r o o f Native Hawaiian or Other Pacific Islander, or Not Documented. Ethnicity was reported as Hispanic, Non-Hispanic, or Not Documented.

Other study variables included admission status (outpatient versus admitted), length of hospitalization (defined as # of days), alcohol level (positive, negative, or not tested), toxicology screen (positive for substance, negative, or not tested), payment source (Medicaid, Medicare, charity, commercial, healthcare service corporation (HCSC), Labor and Industries (L&I), self-pay, other, or unknown), workrelated (yes or no), abuse reported (yes or no), and abuse investigated (yes or no).

Two methods of data collection were used: 1) abstraction of study variables from the institutional trauma registry, and 2) abstraction of other or missing variables from the subject's medical record. All data was de-identified and kept in a secure spreadsheet accessible only by members of the research team. Descriptive statistics were used to describe the subjects and were broken down for each cohort (2018, 2019, or 2020 cohort). Data analysis was conducted using SPSS (SPSS, Inc, Chicago, IL) and the level of statistical significance for all tests was defined as 0.05.

The study sample was composed of 883 subjects who presented to HMC for the evaluation and J o u r n a l P r e -p r o o f Table 1 describes the subjects' demographics. Most subjects were male (79% in 2020, 76% in 2019, and 70% in 2018). The majority (78.8%) of subjects were white and 11.3% were Hispanic. There was a small, but non-significant increase in the number of Hispanic (14% in 2020 vs. 10% in both 2019 and 2018. 

Oral and maxillofacial fractures contribute to significant morbidity for individuals and their management contributes to a consequential use of healthcare resources. The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of individuals presenting with OMF to an urban, Level I trauma center in the United States.

Our study found that the number of individuals presenting for the evaluation of OMF was lower during the COVID-19 pandemic while social distancing policies were in place (n=235 in 2020, n=318 in 2019, n=330 in 2018). This was not unexpected when we consider that after March 5, 2020, typical mobility in Washington state, as measured by cell phone location data, was consistently lower than average. 14 This decrease in mobility for individuals peaked between March 30 and April 5, 2020 when mobility was 51% lower than is typical. 14 This has been sustained at around a 20% decrease in mobility for the duration of the COVID-19 pandemic (as of October 2020). 14 Furthermore, Washington state has had between 20 and 50% less highway traffic than is average. 15 As the result of the pandemic and restrictions put in place (e.g. "Stay at Home Order") people are moving around less and staying at home more, making them less likely to sustain oral and maxillofacial injuries in the process.

Our study found that most individuals who sustained OMF were male (78.4% of all subjects) which is consistent with prior literature on the topic. 3, [16] [17] [18] While most individuals in our study were white (78.8% of all subjects) there were small but non-significant increases in the proportion who were Hispanic (14% in 2020 vs. 10% in both 2019 and 2018. p=0.28) and Black/African American (14% in 2020 vs. 8% in 2019 and 5% in 2018. p=0.07). According to data from the U.S. Bureau of Labor Statistics, 19.7% of Black or African American workers can work from home compared to 29.9% of white workers. 19 Furthermore, only 16.2% of Hispanic or Latino workers can work from home when compared to 31.4% of non-Hispanic or Latino workers. 19 It may be that a smaller proportion of Hispanic and Black or African American workers who remained employed were able to stay at home during the pandemic, contributing to a relatively larger proportion of the population who sustained OMF. There are likely many more variables at play, when considering the incidence of oral and maxillofacial trauma by race/ethnicity which are outside the remit of this paper and these findings may warrant further investigation.

The frequency of OMF in our study, from highest to lowest was: skull base (n=380), malar/maxilla/zygoma (n=290), cranial vault (n=288), nasal bone (n=235), orbit (n=203), other (n=192), mandible (n=102) and tooth (n=70). This distribution, when it comes to facial fractures only (excluding skull base and cranial vault), with malar/maxillary/zygomatic fractures being the most common, has been seen previously in the literature. 16, 18, 20 Our study found that oral and maxillofacial injuries were more severe during the COVID-19 pandemic. In particular, the mean head/face AIS was higher during the period of social distancing (mean AIS = 3. shown that injury severity may increase secondary to alcohol or drug use but that this varies by mechanism of injury. 21, 22 Finally, it is unclear if triage behavior for trauma patients in the catchment area of our institution changed during the pandemic as the result of differential allocation of healthcare resources.

Our study found that a greater proportion of individuals were injured secondary to assault (21% in 2020 vs. 15% in 2019 and 18% in 2018, p=0.05) and gun violence (7% in 2020 vs. 3% in both 2018 and 2019, p=0.05) and less were injured secondary to falls (29% in 2020 vs. 38% in both 2018 and 2019, p =0.05).

The distribution of motor vehicle, motorcycle and bicycle related injuries was largely unchanged. Less J o u r n a l P r e -p r o o f individual mobility and more people staying at home may explain the decreased proportion of fallrelated injuries. The rise in interpersonal violence and subsequent oral and maxillofacial trauma may be explained by economic and overall stressors, social isolation, and sociopolitical conflict during the COVID-19 pandemic. 23 Interestingly, there was no change in our study to the number of individuals specifically reporting domestic abuse. Regardless, communities should continue to make available services to those who are at risk of abuse during times of social distancing and trauma centers should continue to identify individuals who were victims of interpersonal violence.

There are several limitations to our study which was performed at a single Level I trauma center in the United States. It is unclear if a different proportion of trauma patients were transported to our institution or if patients were selected for transfer/transport that had sustained more severe injury. The period of inclusion for our study was during the early phase of the COVID-19 pandemic "lockdown". It is unclear how the results would change during shorter or longer periods of social distancing or if they would change based on geography or local politics. Furthermore, the catchment area for HMC began to "open up" as Washington state's "Stay Home, Stay Healthy" order expired on June 1, 2020 and King County, Washington entered "Phase 2" of re-opening on June 19, 2020. However, as mentioned before, mobility and highway traffic remained lower than average during the month of June. 14, 15 Regardless, it is important to understand the burden of oral and maxillofacial trauma and how social distancing policies may result in fewer patients with more severe injuries that individually may require more healthcare resources.

In conclusion, the number of OMF cases decreased but the severity of oral and maxillofacial and overall injuries was higher during the COVID-19 pandemic when social distancing policies were in place. Tables: Table 1 . Patient's Characteristics Table 2 . Trauma Characteristics J o u r n a l P r e -p r o o f

Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study

Epidemiology of facial fracture injuries

The financial burden of mandibular trauma

Aetiology of maxillofacial fractures: a review of published studies during the last 30 years

Occurrence and severity of concomitant injuries in other areas than the face in children with mandibular and midfacial fractures

Contemporary Characterization of Injury Patterns, Initial Management, and Disparities in Treatment of Facial Fractures Using the National Trauma Data Bank

Effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review

Centers for Disease Control and Prevention

Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev

Seattle's Coronavirus Timeline, from Toilet Paper to Mask Laws

Identifying temporal patterns in trauma admissions: Informing resource allocation

Helmets Decrease Risk of Bicyclist-Related Maxillofacial Injuries But Not Severity

Communities With Bikeshare Programs Might Have a Lower Risk of Bicycle-Related Maxillofacial Injuries: Results From an Early Adopter of Bikeshare Programs

COVID-19 Projections -Washington State

COVID-19 Multimodal Transportation System Performance Dashboard

Epidemiology and Pattern of Oral and Maxillofacial Trauma

Changing pattern in the characteristics of maxillofacial injuries

Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries

Not everybody can work from home: Black and Hispanic workers are much less likely to be able to telework

Fracture patterns and causes in the craniofacial region: an 8-year review of 2076 patients

Alcohol level and injury severity: is the floppy patient myth true?

Substance use and type and severity of injury among hospitalized trauma cases: Ohio

Danger in danger: Interpersonal violence during COVID-19 quarantine

Johns Hopkins Coronavirus Resource Center

Johns Hopkins University and Medicine -Coronavirus Resource Center

J o u r n a l P r e -p r o o f