key: cord-0799061-aiixwqcs authors: Turkistani, Khadijah A. title: Impact of Delayed Orthodontic Care During COVID-19 Pandemic: Emergency, Disability and Pain date: 2020-08-01 journal: J World Fed Orthod DOI: 10.1016/j.ejwf.2020.07.004 sha: 54e9d400dc85c3f20b85d0ad165e345cbbb3e3a3 doc_id: 799061 cord_uid: aiixwqcs • Highest reported orthodontic emergencies are pocking wires & debonded brackets; • Pain predictors: pocking wire, sharp ligature tie, and problematic palatal device; • With orthodontic emergencies, patients experience pain & disability, yet low scores; • In pandemic: decision to resume clinical service need evaluation of risk & benefit. The novel coronavirus disease 2019 (COVID-19) was announced as a public health emergency of international concern by the World Health Organization WHO on March 13th, 2020.(1) Since the emergence of the disease late December 2019, it became a pandemic and spread out widely affecting more than 200 countries and territories. (2, 3) Number of global confirmed cases reached (13, 378, 853) with total deaths exceeding half a million by July 17th, 2020. The highest reported cases were in the United States (3, 405, 494) Incubation period was reported as high as 14 days that could reach up to 24 days. (8, 9) Furthermore, this virus could remain viable in aerosol for up to three hours with half-life of more than five hours on stainless steel and plastic surfaces. (10) This presents a potential risk of treating patients during their latency yet contagious period or asymptotic carriers. This is especially alarming for orthodontists who tend to see high volumes of patients in a short period of time. To control transmission of this highly infectious disease, strict infection control measures were recommended. Personal Protective Equipment PPE including eye and face protection, aspirator mask and reduction of aerosol producing procedures were advised. (9, 11) Several orthodontic procedures produce significant amount of aerosol production including preparation for bonding, debonding, scaling, and adjustment of appliance.(12) Even more, any procedure that elicit gaging reflex such as impression taking could provoke coughing or vomiting which could spread infection. (13) Efforts to contain COVID-19 and minimize the risk of cross-transmission has been implemented by multiple countries. (14) This included quarantine measures, dusk-to-dawn curfew and 24-hour lockdown with particular emphasis on social distancing.(15) Among these measures are countrylevel closure of dental services except for emergency treatment only. (11) Pulpitis, abscess and dental trauma were reported to be the main dental emergencies presented to clinics during the pandemic. (16) Orthodontic emergencies occasionally occur and they represent urgencies rather than emergencies. Pain and discomfort are the main reported emergencies experienced during orthodontic treatment. (17, 18) In orthodontic practice, patients present to clinic regularly for activation of appliance and continuity of care. In between visits, patient could experience adverse events including pocking wire, irritation, pain, or appliance breakage. (19) These adverse events are not considered true emergencies yet require prompt action to assure the patient and alleviate discomfort. (19) As a result of the clinical closure implemented during COVID-19 crisis, access to orthodontic facilities and care delivery to active patients was restricted. For this, the aim of this study was to evaluate the impact of clinical closure and delayed orthodontic care delivery in terms of types of emergencies, pain intensity and disability experienced by orthodontic patients during COVID-19 pandemic. This study was reviewed and approved by the Research Ethical Committee at the Faculty of Dentistry, King Abdulaziz University (KAUFD). This is a descriptive cross-sectional study that was performed in 2020, after two months of clinical closure because of COVID-19 outbreak. Convenient sampling method was implemented to include patients who visited orthodontic screening clinic at KAUFD and University Dental Hospital (UDH). An anonymous electronic survey in Arabic language was created and sent out to patients' and patients' guardians' registered contacts. The first part of the survey included an outline describing aim of the research with a consent form. Participation was voluntary and anonymous with no patients' identifiers required. Confirmation for willingness to participate in the research was mandatory to proceed to survey content. Any patient who selected "No, I am not welling to participate" were automatically directed out of the survey. Next, a confirmation statement of current active treatment or retention was necessary to proceed. Patients who were not undergoing active orthodontic treatment nor orthodontic retention were excluded. The second part of the survey was dedicated for demographic questions including age, gender, and educational background. This was followed by questions related to participants' orthodontic treatment including type of orthodontic appliance (Fixed, removable, clear aligner, retainer), when was their last orthodontic visit, and any current orthodontic problem. A list of most common orthodontic emergencies were provided as a checklist and participants were required to select all answers that applied to him/her including: debonded bracket, long pocking wire, sharp end of ligature tie, broken fixed retainer, broken or loose expander, lost or broken removable retainer, oral ulcer, inflammation, swelling, exudate, bleeding, bad odor, or others. Each item in the list was accompanied by an illustrative image for simplification purposes. represent the worst pain imaginable. The higher the score, the greater the pain. Statistical Analysis: NRS-11 and MOPDS scores were recorded. Descriptive statistics were reported in mean, median and range. Wilcoxon's rank-sum test and linear regression were used to measure association between emergency type with pain intensity. Linear regression was used to determine the association between levels of pain intensity and disability score. The level of statistical significance was set at P<0.05. All analyses were performed using STATA Version 16.0 (StataCorp, College Station, TX, USA, 2019) statistical software package. A total of 259 responses to the electronic survey were received. Of those, 150 patients were undergoing orthodontic treatment at KAUFD and agreed to participate comprising 57.9% of total respondents. The remaining 109 respondents did not agree to participate or were not currently undergoing any orthodontic treatment. Characteristics of the study population are presented in followed by removable appliance 6%, retainers 6%, and aligners 1.33%. Around 64% of patients haven't seen an orthodontist for more than 2 months, and almost 59% of them reported having current orthodontic problem. Figure 1 presents the most common emergencies reported by respondents. The most common orthodontic emergency was pocking wire which was reported by 30% of the respondents. This was followed by debonded bracket 27.3%, bad odor 24%, and sharp ligature tie 20% respectively. Inflammation and bleeding were reported by 9.3%, ulcer was reported by 8.7%, and problematic palatal device by 8% of respondents. Nine respondents reported swelling, and two respondents reported exudate and lost retainers. Four out of the 150 respondents reported broken fixed retainers. Other reported complications included: loose elastomeric chain, loose molar bands, pain related to molar bands, teeth are moving in a wrong direction, spaces between teeth, ran out of elastics, cheek biting, and remaining sutures related to impacted canine exposure. Based on the type of orthodontic appliance used, the main emergencies reported with aligners were inflammation and swelling, while ulcer, bad odor, problematic palatal device, and lost retainer were reported by patients undergoing retention. Ulcer, inflammation, bleeding, bad odor, and problematic palatal device were reported with removable appliances while the remaining emergencies were reported with fixed appliances as displayed in Figure 1 . No significant difference was found in intensity of pain between males and females, and among different age groups. Patients who reported poking wires had significantly higher pain scores compared to those who didn't (p<0.001). Similar findings were observed in pain scores between who reported sharp ligature tie, ulcer and problematic palatal device than those who didn't (Table 2) . Confounding factors in these correlations were studied using linear regression models. After adjustment of confounders, pocking wire, sharp ligature tie, and problematic palatal device were found to be significant predictors of pain intensity. On the other hand, the presence of ulcer was not found to be a significant predictor for pain intensity. From the study sample, 21.3% reported pain for more than 24 hours in their face, jaws, or mouth. Of those, 53% were males with mean age 22 years (range: 13-45). From all 150 respondents, around 9.3% reported seeking professional consultations for their pain. The median reported pain intensity of the whole group on the NRS-11 was 3 (range: 0-9). (Figure 2 ). With each unit increase in pain intensity, the disability score increases by 1.18 (95% CI: 0.67-1.69). Most patients included in this study have not been seen by their treating orthodontist for more than 2 months. During this prolonged period, patients could experience discomfort due to a problem arising from the orthodontic appliance requiring an emergency appointment or at least a consultation and reassurance. Furthermore, patients could lose motivation and trust, and stop wearing their elastics or appliances that are critical and time sensitive.(17) They could experience anxiety, fear, and abandonment which could exacerbate their discomfort. (24, 25) For this, assuring patients using virtual assistance through teleorthodontics and maintaining appropriate communication channels is advised. (17) Majority of respondents in the current study were females however there was no difference in the median pain intensity experienced by males compared to females which is in line with the findings of Zheng et al. (26) This might indicate that females could have higher tendency to seek treatment when experiencing pain. Additionally, the most common reported orthodontic emergency was pocking wire 30% followed by debonded bracket 27.3%, and ulcer was reported as 8.7% which contradicts the findings of Dyke et al. (27) who reported majority of unscheduled orthodontic appointment to be resulting from detached bracket 28.2% followed by an extended arch wire 8.2%. Moreover, Popat et al. (28) reported debonded bracket 37% to be the most common orthodontic emergency followed by protruding wire 25%, while ulcer was 4%. In their study, they distributed electronic surveys to general dental practitioners to assess the number of orthodontic emergencies they encounter and were confident to treat. However, in the current study we measured the outcomes reported from the patients themselves. Even more, patients would usually present to general dentists for emergency treatment appointment that could occur in between their regular orthodontic visits. While in this study, patients had not been seen for an extended period of time which could explain the difference in the findings favoring higher percentage of adverse events including pocking wires, which was found to be significantly associated with pain. They reported that emergency treatment was significantly associated with pain, which goes along with our findings that pocking wire, sharp ligature tie, and problematic palatal device were significant pain predictors. Although ulcer in the current study was found to be significantly associated with pain initially, yet further analysis using regression model revealed that this was influenced by the confounding effect of other predictors. This could be explained by the low number of incidence of ulcer (13 only) among the study sample which could dilute the effect of the variable, given the fact that true emergencies in orthodontics are not very common. In this study we used MOPDS which is an orofacial pain specific disability measure. Previous studies reported significant association between orofacial pain symptoms and psychological distress.(29) Wan et al. (30) reported strong association between severity of pain and disability score using MOPDS which is in line with the findings of the current study findings. Although median pain intensity and disability score were not significantly high, yet future implications of such delay in receiving care in addition to other physical and mental effects of COVID-19 pandemic are still questions to be answered. In general, any delay in orthodontic treatment would result in the emergencies reported in this study. However, the current study highlighted the association between these emergencies and pain and disability experienced by patients especially in the event of a pandemic, which were not very high as reported by the patients. This should help decision makers evaluate risks versus benefits when it comes to resumption of clinical operation in case of a future disease outbreak. Limitations of the study were the sample size and convenient sampling method that was used on patients from one city which could affect the generalizability of the findings. Furthermore, the validated scales measures outcomes experienced by the patients within last month, which rely on patients' recall memories that could influence their answers. Lastly, findings present the situation within three months of no treatment during this unprecedented situation of pandemic lockdown, yet it might be different in other situations or if the patients were not seen by their orthodontist for longer duration than what was addressed here. Given these limitations, to our knowledge, this is the first study to report orthodontic emergency, pain and disability experienced by patients during clinical lockdown in time of COVID-19 pandemic. Findings of this study could enhance further studies in this area in the future. In summary, delay in receiving orthodontic care could give rise to orthodontic emergencies experienced by patients, yet pain and disability resulting from these events are minimal. Pocking wires, sharp ligature ties and problematic palatal device were the significant predictors of pain. The higher the intensity of pain, the more disability was noted. Finally, decision to resume clinical service should be evaluated considering risks and benefits during an infectious outbreak. Further research to complement or contradict this study findings are required. World Health Organization. Coronavirus disease 2019 (COVID-19): situation report-11 Transmission routes of 2019-nCoV and controls in dental practice COVID-19): A Review of Clinical Features Transmission of 2019-nCoV infection from an asymptomatic contact in Germany SARS-CoV-2 Infection in Children Precautions and recommendations for orthodontic settings during the COVID-19 outbreak: A review Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 COVID-19): Emerging and Future Challenges for Dental and Oral Medicine Bacterial aerosols generated during dental procedures Possible aerosol transmission of COVID-19 and special precautions in dentistry COVID-19 lockdowns throughout the world. Occupational Medicine Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak The impact of the COVID-19 epidemic on the utilization of emergency dental services Management of orthodontic emergencies during 2019-NCOV Emergencies in orthodontics part 1: management of general orthodontic problems as well as common problems with fixed appliances. Dental update Orthodontic first aid for general dental practitioners Development and validation of the Manchester orofacial pain disability scale. Community Dentistry and Oral Epidemiology World Health Organization. Process of translation and adaptation of Instruments Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short form mcgill pain questionnaire (sf mpq), chronic pain grade scale (cpgs), short form 36 bodily pain scale (sf 36 bps), and measure of intermittent and constant osteoarthritis pain (icoap) Comparison of ideal and actual behavior of patients and dentists during dental treatment. Community dentistry and oral epidemiology Patients' anticipation of pain and pain-related side effects, and their perception of pain as a result of orthodontic treatment with fixed appliances Anxiety, pain and discomfort associated with dental treatment. Behaviour research and therapy Prediction of pain in orthodontic patients based on preoperative pain assessment. Patient preference and adherence Audit of unscheduled orthodontic appointments at Chesterfield Royal Hospital Management of orthodontic emergencies in primary care -self-reported confidence of general dental practitioners Relationship of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) with three dynamic physical tests in a group of patients with chronic low-back and leg pain. The Clinical journal of pain Orofacial pain symptoms and associated disability and psychosocial impact in community-dwelling and institutionalized elderly in Hong Kong This study was not supported by any research grant.