key: cord-0800703-m29vdspb
authors: Kaur, Harneet; Kochhar, Anuraj Singh; Gupta, Harshita; Singh, Gurkeerat; Kubavat, Ajay
title: Appropriate orthodontic appliances during the COVID-19 pandemic: A scoping review
date: 2020-10-21
journal: J Oral Biol Craniofac Res
DOI: 10.1016/j.jobcr.2020.10.014
sha: 4e8c7a99c389d321e8da3111674daa5f9643fae9
doc_id: 800703
cord_uid: m29vdspb

INTRODUCTION: The esoteric Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection or COVID-19 has been an unusual plummet in dental/orthodontic practice. Based on current recommendations for various amendments in an orthodontic practice, this scoping review aims to identify orthodontic appliances that are most appropriate to us during this on-going pandemic. METHODS: Electronic databases (PubMed, Scopus, Web of Science, Science Direct, and Google Scholar) were searched up until August 11, 2020. Full-text articles in English with keywords “COVID-19 and Orthodontics” and related search terms were included. RESULTS: Out of 17 retracted articles, only 4 articles were found to be brief the choice for orthodontic appliances in pandemic times speculating clear aligner therapy (CAT) to be a pragmatic solution. The remaining articles were also thoroughly studied and the new norms set by the pandemic were determined. Criteria for orthodontic appliance selection included careful patient screening and collection of records, minimal physical visits, efficient use of technology, virtual consultations but the use of PPE for physical appointments; and lesser AGPs with a lesser risk of airborne transmission. CONCLUSIONS: Subject to regional demands, CAT can be considered as the relatively safer modality-predictable and effective apposite to fixed orthodontic appliances in these unprecedented times.

The World Health Organization (WHO) officially named Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2 or 2019-nCoV) disease as 'COVID-19 'on February 11, 2020, and declared this outbreak, a pandemic on March 11, 2020. 1 With the reporting cases more than 22 million and 768K deaths till now, the mortality rate is lower (3.4%) when compared to previous SARS-CoV (10%) and MERS-CoV (3.4%) outbreaks in 2009 and 2012 respectively. 2 However, its uncertain mode of transmission through droplets, fomites, and probably air-borne as well make it a highly infectious contagion. With 29 candidate vaccines in evaluation, out of which 6 have reached Phase III clinical-stage trials, 3 it can be predicted that the contagion or its effects may exist in the community for months from now. Mass commercial production and community vaccination are much awaited.

Dental professionals and associated health care providers are risks of contracting and transmitting SARS-CoV-2 infection through either direct transmission (inhalation of droplets/ aerosols or exposure to mucous membranes) or indirect transmission (via contaminated surfaces). While the risk of transmission through aerosol-generating procedures cannot be excluded, even more, worrisome is that asymptomatic patients or patients in their incubation period are also carriers of SARS-CoV-2 and can be infectious. 4 In this scenario, almost all aspects of the dental, as well as an orthodontic practice, have been impacted. Strict infection control measures with the highly transmissible SARS-CoV-2 is a major area of concern. There are many published guidelines and new protocols followed by individual nations to restore dental services across the globe. [4] [5] [6] [7] For orthodontics as well, restarting the suspended services demands not just reinforcing the already existing protocols with new guidelines, but also manipulation and utilization of newer technologies with an updated digital workflow that reduces the manual task and hence the chair-side time. [8] [9] [10] [11] Although there is avalanche information regarding the types of orthodontic appliances available, there is still a dearth of data on the suitable appliances that could be more beneficial to use in the J o u r n a l P r e -p r o o f current pandemic. Aligners may prove beneficial in these times when elective treatment procedures have been temporarily suspended by the regulatory bodies in certain countries. 10, 11 Do Clear Aligner Therapy (CAT) offer a pragmatic solution to the practice of social distancing during the current pandemic?

To this unfold enigma, a thorough strategic analysis of literature was planned to map the evidence for recommendations for orthodontic appliance selections during this pandemic. The aim of this scoping review was to check for the various amendments required in orthodontic practice and their effect on the preference for orthodontic appliances in the new norms set by the pandemic. The speculation was to contemplate whether clear aligner therapy (CAT), in these unprecedented times, prove beneficial for orthodontists as well as patients when compared to any other apposite.

Considering a continuously updating COVID-19 data on a day to day basis, this review included publications that accorded the search terms as searched on August 11, 2020. The PRISMA search strategy was planned using the MESH terms and Boolean terminology: (Orthodontic*) AND (COVID-19*) AND (SARS-CoV-2*)/ "Orthodontic*" AND "COVID-19*" OR "SARS-CoV-2*"AND "Dental Bonding" AND "Dental Aesthetics"/ "Orthodontic Appliance" AND "COVID-19" AND "Dental Bonding". This search strategy was applied to the key databases PUBMED, SCOPUS, WEB OF SCIENCE, and Google Scholar. Due to the lack of clinical studies and trials with the interruptions caused by the pandemic, surveys/ reviews/ letters to editors/commentary/ preprints/ guidelines were also included to gather knowledge of the clinical requirements that mandate the restart of clinical practice. (Table 1) Screening of titles and abstracts of all the search results was performed and the full texts of included articles available in English were retrieved and scrutinized by 2 reviewers (H.K and H.G) followed by a third reviewer (A.K). Disagreements were resolved by discussion among all the authors. The included articles were screened thoroughly for and the level of evidence was also determined as per J o u r n a l P r e -p r o o f based on Oxford Centre for Evidence-based Medicine (OCEBM). References of included articles also were screened using the snowballing technique. (Figure 1 )

A total of 17 articles were retrieved for full text and thoroughly studied. (Table 2 ,3) Amongst these, 5 studies were focusing on the psychological impact of the pandemic on Orthodontic patients, dental students, and orthodontists themselves. 11 were review articles providing guidelines and recommendations about the risk of SARS-CoV2 transmission within orthodontic clinics, the preventive measures to be followed, and the strategies of sterilization and infection control. (Table   4 ) Apart from following the standard operative protocols, appropriate appliance selection is also a mandate. 4 articles were found to be recommending approaches for orthodontic appliances to be used during this pandemic, acclaiming aligners could be beneficial over multi-bracket appliances.

SARS-CoV-2 or COVID-19 pandemic has affected the economic, psychosocial, and social lives of orthodontists as well as orthodontic patients, with increased levels of anxiety and distress. For a patient who seeks treatment and is additionally concerned regarding these risks of infection, what could be the most comfortable and safest appliance to place? From the present evidence of COVID-Era, the potential demands for appliance selection include careful patient screening and collection of records; minimal physical visits; utilizing technology at its best; virtual consultations but the use of PPE for physical appointments; and lesser AGPs with a lesser risk of air-borne transmission. (Table 4 ) Removable appliances such as aligners alone create the least risk for the transmission of SARS-CoV-2 when compared to fixed labial/ lingual appliances, but cannot be used in every case. When compared with fixed appliances, CAT offers a clear advantage of shorter chair-time, minimal bonding requirements, lesser recall visits to the office, remote monitoring through virtual means, higher accuracy of treatment planning with digital scans, and fewer iatrogenic effects. [11] [12] [13] To achieve a good finish or handling severe malocclusion, CAT can be coupled to multi-bracket appliances, where the bonding of braces can be delayed until the pandemic J o u r n a l P r e -p r o o f subsides. However, the treatment modality offered by a clinician to the patient is also hinged upon the clinician's proficiency and the measures for time efficiency. Thus, to reach substantiated conclusions, further clinical investigational studies and surveys are required to know the potential choice of appliances used in clinical practice with the unfastening of dental practices.

The prerequisite criteria for the selection of orthodontic appliances for a clinician in the current pandemic situation is to consider all the preventive measures safeguarding patients, staff, and colleagues. Comparing CAT with other treatment options, it can be very well instituted that CAT together with digital scanners can be considered as the relatively safe modality to weather the storm.

However, given the regional demands set by the pandemic and to meet the requirements of both the patients and the clinicians, a customized approach should be undertaken. 9 Eliades et al, 16 2020 To list the sources of aerosol production during an orthodontic standard procedure, analyze the constituent components of aerosol and their dependency on modes of grinding, the presence of water and type of bur, and suggest a method to minimize the quantity and detrimental characteristics of the particles comprising the solid matter of aerosol. Minimization Review of reported data 5 10 Guo et al, 17 2020 To update the preventive strategies for control of SARS-CoV-2 transmission to protect both staff and patients during the orthodontic practice.

Narrative review 5 11 Turkistani K., 18 

To report to orthodontists on the emergence, epidemiology, risks, and precautions during the disease crisis.

Narrative review 5 12 Xiong Xi et al, 19 2020

To evaluate the mental distress of orthodontic patients and to investigate the level of their anxiety on treatment duration and outcome during the early stage of the pandemic. 14 Shenoi et al, 21 2020

To assess the impact of the COVID-19-related lockdown on the treatment and psychology of patients undergoing orthodontic treatment. To discuss essential adaptations that concern four areas of the 

New office environment

• Installation of physical barriers at reception and waiting area • Patient screening via telecommunication for obtaining a patient's health history or contact history related to COVID19. • An electronic screening questionnaire to be filled and temperature should be checked on the arrival of a patient at the office. • Utilization of proper ventilation with negative suction in operatory rooms and air purifiers • Tele dentistry for non-emergency appointments Infection Control

• Proper use of PPE is critical, including fit-tested N95 masks, double gloving, over the gown, and face/eye protection in case of any emergency treatment to be done. • Hand hygiene should be maintained by all present in the office either by washing hands by soap for 20seconds or by using alcoholbased hand rubs. • The patient may be advised to do preoperational mouth rinse containing 1% hydrogen peroxide or 0.2% povidone-iodine for 15seconds • Thorough disinfection and waste disposal should be followed after the dental procedure is done. • Rigorous sterilization should be done along with appropriate autoclaving of materials used.

• Tele-dentistry/ Virtual consultations for initial screening • Categorize and schedule based on urgency and procedure required.

• Pre-examination and triage • Emphasize basic COVID-safety protocols (Facemasks, hand sanitization, social distancing) • Patient/ accompanying persons to wait in the car until instructed Orthodontic emergencies

• Some can be managed by the patient at home like soft tissue irritation by bracket/wire, broken/loose elastic chains/ligatures/ elastic ties, broken bracket, part of appliance or retainer, etc. • Emergencies to be managed at the clinic-active and functional appliances, part of any appliance embedded in gingiva leading to pain and discomfort, etc.

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

• Extraoral radiography is preferred over intraoral radiography • Photographs should be taken in separate rooms and for one patient single-use retractors or reflectors should be used. • Intra-oral digital scanners or CBCT generated STL files may be used for 3D software models instead of alginate or silicone impressions

Bonding and other AGPs

• High-volume suction is critical for AGPs • For bonding self-etch primers or liquid gel and/or low viscosity etchants with minimal or no rinsing; use of GIC or BPA free adhesives • Use of rubber dam • Indirect bonding techniques or CAT can be preferred • Use of rubber dam / peri-oral dam is also recommended for all AGPs

• Can be avoided until any signs of abscess or cyst may be seen • Over-spitting of saliva avoided and high-volume suction may be used • Prefer local anesthetics gels over sprays

• Use of individualized packed archwires • Disinfect archwire with 75% alcohol when removed from the mouth • Use a double layer of gloves in the potential risk of laceration from the archwire De-bonding • Use of anti-retraction handpieces and high-volume suctions • Most bonding material remnants be removed via hand instruments • For removing large composite attachment, use carbide of tungsten burs under water cooling conditions and powerful suction system or hand instruments whenever possible to reduce aerosol.

• Thermoplastic retainers may be preferred as can be fabricated through 3D software models of the patients • Postpone fixed retention J o u r n a l P r e -p r o o f 

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Draft landscape of COVID-19 candidate vaccines

Considerations for the provision of essential oral health services in the context of COVID-19

CDC Guidance for Providing Dental Care During COVID-19

COVID-19 Pandemic and Dental Practice

COVID-19 precautions and recommendations

Clinical orthodontic management during the COVID-19 pandemic

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Orthodontics in the COVID-19 Era: The Way Forward Part 1 Office Environmental and Infection Control

Orthodontics in the COVID-19 Era: The Way Forward Part 2 Orthodontic Treatment Considerations

Utilizing Aligners to Solve the COVID-19-Affected Orthodontic Practice Conundrum!

RETURNING TO THE ORTHODONTIC PRACTICE AMID COVID-19 CRISIS

Perceived impact of the COVID-19 pandemic on orthodontic practice by orthodontists and orthodontic residents in Nigeria

Impact of coronavirus pandemic in appointments and anxiety/concerns of patients regarding orthodontic treatment

Minimizing the aerosol-generating procedures in orthodontics in the era of a pandemic: Current evidence on the reduction of hazardous effects for the treatment team and patients

Control of SARS-CoV-2 transmission in orthodontic practice

Precautions and recommendations for orthodontic settings during the COVID-19 outbreak: A review

Mental distress in orthodontic patients during the COVID-19 epidemic

Impact of Delayed Orthodontic Care During COVID-19 Pandemic: Emergency, Disability and Pain

Impact of COVID-19 Lockdown on Patients Undergoing Orthodontic Treatment : A Questionnaire Study

Changes in orthodontics during the Covid-19 pandemic that have come to stay

The authors declare that they have no conflict of interests.