key: cord-0829348-0wgb0m54 authors: Vakili, Ava; Chaffee, Benjamin W.; Oberoi, Snehlata title: Impact of COVID-19 on Orthodontic Education in Predoctoral and Postdoctoral Programs in the United States date: 2021-08-31 journal: Am J Orthod Dentofacial Orthop DOI: 10.1016/j.ajodo.2021.08.010 sha: 76c382415e8f99e076375d774ffa389e157f3404 doc_id: 829348 cord_uid: 0wgb0m54 Introduction The aim of the study was to characterize the impact of the COVID-19 pandemic on predoctoral and postdoctoral orthodontic education. Methods Electronic surveys were distributed via email to predoctoral orthodontic directors at accredited dental schools (n=66), postgraduate orthodontic program directors at orthodontic programs (n=73), and craniofacial orthodontic fellowship directors (n=5) in the United States and Canada. Results The predoctoral orthodontic survey received a response rate of 38%, of the which 62% indicated significant curriculum modifications. However, orthodontic curriculum hours were largely unchanged due to the COVID-19 pandemic. Of the responding predoctoral orthodontic programs that had graduate orthodontic programs where dental students can gain clinical experience (n=14), all but two reported not allowing or limiting observation or assisting opportunities. The postdoctoral orthodontic survey received a response rate of 39% and were affected by clinic modifications including financial limitations, SARS-CoV-2 testing, decreased clinical hours, among other modifications. Conclusions COVID-19 pandemic has had a measurable impact on orthodontic clinical education for the predoctoral and postdoctoral orthodontic programs evaluated. Overall, less patient care was delivered, potentially resulting in delayed treatment for patients and fewer training opportunities for learners, particularly for predoctoral dental students, whose clinical observation and assisting hours were limited. Globally and locally, the COVID-19 pandemic has changed the way education systems function; impacting teaching and learning on a large scale 1 . The WHO officially declared COVID-19 a global pandemic on March 11, 2020 , and the pandemic has since changed the trajectory of world economies, educational systems, and government leadership 2 . As of June 27,2020, more than 180.8 million COVID-19 cases had been reported globally with 3.9 million deaths 3 . With stay at home orders, social-distancing, and online learning, for many students the educational system was put on pause and/or substantially reconfigured as part of mitigation effects to reduce SARS-CoV-2 spread 1 . Given that SARS-CoV-2 has been detected in infected patients' saliva, and can be easily spread through respiratory droplets commonly generated in dental procedures, the COVID-19 pandemic has had a direct effect on dental practice and dental education 4 . On March 16th, 2020 the American Dental Association (ADA) called for dentists to limit care provision only to emergency procedures 5 . The Occupational Safety and Health Administration (OSHA) classified dentists as "very-high-risk" for infection because of aerosol-producing procedures 6 . The COVID-19 pandemic has disrupted the way dental educational institutions treat patients and train students. The present study explores the impact of the COVID-19 pandemic on one component of dental education --predoctoral and postdoctoral training in orthodontics. With the practice of orthodontics deeply grounded in an understanding of underlying principles gained Study investigators compiled a list of all postgraduate (N= 73) and craniofacial fellowship (N= 5) orthodontic directors' emails and contact information in the United States and Canada. Postgraduate and craniofacial fellowship orthodontic directors for the 2020-2021 academic year at all accredited orthodontic postgraduate programs were considered. Contact information was primarily collected from the American Association of Orthodontists (AAO) website. Names and emails of program directors were checked against the program's website for accuracy. In total, 30 surveys were initiated (response percentage: 30/78 = 39%), and 24 fully completed responses were included in analysis. No responses were received from programs in Canada. including class size and number of orthodontic faculty 7 . Respondents took on average 6.6 minutes to complete the predoctoral survey, 9.1 minutes to complete the postdoctoral survey. Appendix Table 1 , 2, and 3 provide a complete list of measurement items. The analysis was descriptive: counts and percentages were calculated for each endorsed response option across relevant survey items, separately for predoctoral and postdoctoral programs. Given the relatively small number of responses and the descriptive and exploratory nature of this study, statistical hypothesis testing was not performed. From the completed responses (n=21), the majority of responding program directors (62%) of predoctoral programs reported annual DDS or DMD cohorts of greater than 90 students (Table 1 ). All completed responses were from the continental United States; no response was received from invited predoctoral programs in Puerto Rico. Seventy-six percent of responding program directors indicated zero to four full-time faculty members and 57% of reporting programs indicating 5 or more part-time faculty members. Seventy-one percent of the responding programs indicated having a graduate-level orthodontic program at their institution and 67% indicated that the curriculum time offered at their institution is adequate. J o u r n a l P r e -p r o o f Sixty-two percent of predoctoral orthodontic directors agreed there had been significant curriculum modifications due to the COVID-19 pandemic. However, survey results showed orthodontic curriculum hours per year were largely unchanged due to the COVID-19 pandemic. The results indicate a modest change for the second year (Class of 2023) and third year (Class of 2022) DDS/DMD cohorts (Table 2) . Of the responding programs that had graduate orthodontic programs where dental students can observe, assist, and gain clinical experience (n=14), 86% reported not allowing or limiting observation and assisting hours for dental students during the COVID-19 pandemic. Of these programs, 64% indicated requiring 0-10 hours of clinical observation and assisting hours pre COVID-19 pandemic. Compared to during the COVID-19 pandemic, 86% of programs with postgraduate orthodontic programs, required 0-10 hours of clinical observation and assisting hours. Prior to the COVID-19 pandemic, 76% of all responding programs allowed dental students to treat orthodontic patients in their own capacity with the help and supervision of orthodontists and trained faculty. However, due to implemented COVID-19 restrictions and curriculum modifications, 52% of responding programs reported limiting dental students' treatment in orthodontic cases (Table 1) . Of the responding predoctoral programs that are currently allowing dental students to treat orthodontic patients (n=10), 90% reported students treated/co-treated one to two patients during their clinical years. All completed responses were from the continental United States; no response was received from invited postdoctoral programs in Canada. From the completed responses (n=24), the majority of responding program directors (58%) reported the mean cohort size for incoming postdoctoral orthodontic students as greater than 7 students (Table 3) . Seventy-five percent of responding programs indicated one to four full-time faculty members and 50% of responding programs indicated having seven or more part-time faculty at their institution (Table 3) . Due to the COVID-19 pandemic, modifications to clinic procedures and operations were reported. Fifty-four percent of responding programs did not SARS-CoV-2 test orthodontic patients for any procedures or appointments. While, 38% of responding programs performed SARS-CoV-2 testing for aerosol generating procedures. However, when asked if dental professions are a part of the of the screening, prevention, and diagnosis of SARS-CoV-2, 63% indicated "yes." Fifty-five percent of responding programs surveyed placed patients undergoing aerosol producing procedures in separate confined spaces (i.e., negative pressure room) and used medical grade air purifiers in their clinics. Additionally, many J o u r n a l P r e -p r o o f programs (70%) instilled a mouth rinse protocol (i.e. hydrogen peroxide) universally for all patients. More than half of responding programs (65%) indicated donning N95 (or respirator with similar characteristics) 5 or more times. Additionally, tele-orthodontics was utilized among 46% of the orthodontic programs surveyed; 96% of responding programs that use tele-orthodontics used this technology for 0-10 percent of their appointments. When asked if there is a need for training in delivery of tele-orthodontics, 63% indicated a need for staff training. Twenty-two percent of responding programs SARS-CoV-2 tested orthodontic residents and 18% of responding programs SARS-CoV-2 tested orthodontic faculty members. Zero of the respondents indicated layoffs in the orthodontic department at their programs. However, 91% of respondents indicated an increased cost of delivery of care in the orthodontic practice due to the COVID-19 pandemic. The results for predoctoral and postdoctoral orthodontic programs, point to clinical changes for students, residents and craniofacial fellows, as well as financial implicants for the orthodontic clinics and decreased care delivery for patients. For predoctoral students, clinical observation hours were reduced due to COVID-19 pandemic shutdowns and new physical and social distancing protocols. While changes in clinical observation hour requirements were modified, orthodontic curriculum hours modified only slightly, suggesting greater reliance on didactic teaching. For postdoctoral resident and fellows, clinical hours were reduced, and many new protocols were put in place to reduce the spread of SARS-CoV-2. In postdoctoral orthodontics, 90% of responding programs indicated increased cost of delivery of care in the orthodontic practice due to the COVID-19 pandemic. It warrants monitoring in future studies whether increased costs to programs will result in increased treatment costs for patients. Any increase in treatment fees at university-based clinics could result in reduced patients service utilization 8 . If patients are required to pay more for treatment they may elect not to receive care, which can greatly impact residents' and fellows' ability to start and finish orthodontic cases and, more importantly, limit access to orthodontic care 9 . Tele-medicine allows opportunities to provide supportive care to patients and triage more urgent issues to face-to-face clinic visits 10 . A silver lining that came about with the current pandemic is many state boards and legislative bodies have voted favorably towards tele-dentistry, allowing healthcare workers to stay connected to patients and get reimbursed for doing so 11 . During the COVID-19 pandemic and national public health emergency, the federal government has waived penalties for HIPAA violations against providers that provide care using telehealth in good faith 12 . With approximately half of the programs surveyed using tele-orthodontics during shutdown and re-opening, the pandemic likely accelerated uptake of this technology; although, there is much further room to implement tele-medicine and tele-orthodontics to the fullest advantage. Total predoctoral curriculum hours were not reported to change under the pandemic, perhaps reflecting longer administrative processes required to change curricular hours formally. However, at many schools, learning modalities J o u r n a l P r e -p r o o f changed substantially, with more reliance on remote online learning and fewer opportunities for clinical experiences. Of dentists in the United States, 79% practice general dentistry, and of those general dentists, 19% provide comprehensive orthodontic treatment 13 . Thus, clinical and didactic time dedicated to orthodontics during predoctoral training is an important training opportunity that the COVID-19 pandemic may have interrupted. Several study limitations must be considered. Generalizability is limited due to the number of responses received. Future qualitative research should examine the underlying challenges, motivators, and decision-making to capture a more complete picture of how program directors, faculty, and learners adapted to the changing conditions under the pandemic. Self-report may not reflect actual practice. However, this investigation serves as an initial indication of how the COVID-19 pandemic has affected orthodontic education in North America and may inform further research. Our research represents a limited snapshot of how COVID-19 has affected orthodontic education in the fall of 2020; however, as the COVID-19 pandemic changes and evolves we anticipate the effects on orthodontic education may change. Further research is needed to establish how the COVID-19 pandemic impacted student, residents' and fellows' competency levels in orthodontics. The COVID-19 pandemic has had a range of impacts on orthodontic didactic and clinical education in the United States. In many programs, the impact in predoctoral orthodontic curriculum resulted in decreased clinical observation hour requirements and opportunities, although predoctoral orthodontic didactic curriculum hours were largely unchanged. Postdoctoral programs were affected by various clinic modifications including SARS-CoV-2 testing for patients, PPE changes, decreased clinical hours and other program specific issues. The implications of the COVID-19 pandemic on predoctoral and postdoctoral orthodontic education has been significant and are likely just part of many ways the pandemic has affected dental academia. Geographically where is your orthodontic program located? Are dental students allowed to shadow during clinical hours? Yes; Yes, however limited number of students due to new COVID-19 protocol; No, due to physical distancing and COVID-19 protocol pre-doctoral students are not allowed to shadow Are dental students required to observe and assist residents in the graduate orthodontic clinic as part of their predoctoral program? How many total clinical observation and assisting hours did the program require pre-COVID-19 for dental students? Neither you nor your school will be identified with the comment. Do you consider the allotted curriculum time and clinical experience given the impact COVID-19 has had, as adequate? Neither you nor your school will be identified with the comment. Do you have any comments or suggestions about how to improve the predoctoral orthodontic curriculum during this COVID-19 time? Neither you nor your school will be identified with the comment. Geographically where is your orthodontic program located? West Coast; East Coast; Midwest ; South; Puerto Rico, Canada What is the average cohort size of your orthodontic program at your institution? 0-2 0-2 Students; 3-4 students; 5-6 students; 7-9 students; 10 or more students Neither you nor your school will be identified in the comment Do you consider the allotted curriculum time and clinical experience given the impact COVID-19 has had, as adequate? Neither you nor your school will be identified in the comment Do you have any comments or suggestions about how to improve the graduate orthodontic curriculum during this COVID-19 time? Neither you nor your school will be identified in the comment Geographically where is your orthodontic program Neither you nor your school will be identified in the comment Do you consider the allotted curriculum time and clinical experience given the impact COVID-19 has had, as adequate? Neither you nor your school will be identified in the comment Do you have any comments or suggestions about how to improve the graduate orthodontic curriculum during this COVID-19 time? Neither you nor your school will be identified in the comment Impact of COVID-19 on dental education in the United States The novel zoonotic COVID-19 pandemic: An expected global health concern Johns Hopkins Coronavirus Resource Center Being a front-line dentist during the Covid-19 pandemic: a literature review As Some States Consider Reopening, ADA Offers PPE Guidance to Dentists COVID-19 -Hazard Recognition | Occupational Safety and Health Administration The current state of predoctoral orthodontic education in the United States The Management of Dental Practices in the Post-COVID 19 Era: An Economic and Operational Perspective Impact of SARS-CoV-2 on orthodontic education and global practice guidance: A scoping review Tele(oral)medicine: A new approach during the COVID-19 crisis COVID-19: Finding silver linings for dental education 12. Notification of Enforcement Discretion for Telehealth | HHS.gov. 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