key: cord-1037911-roqkgqfh
authors: Wafaie, Khaled; Mohammed, Hisham; Mohamed, Abdelrahman MA.; Zhou, Jinshu; Daniel, Ben; Yiqiang, Qiao
title: A qualitative study of orthodontic patients' experiences in quarantine during the COVID-19 pandemic outbreak
date: 2021-12-13
journal: Am J Orthod Dentofacial Orthop
DOI: 10.1016/j.ajodo.2021.11.010
sha: b865e4090393310240ecea929a9e9df3bd93e64b
doc_id: 1037911
cord_uid: roqkgqfh

Introduction COVID-19 is one of the most formidable challenges that influenced all domains of healthcare delivery. This research explored the experiences and challenges orthodontic patients faced in quarantine during the COVID-19 outbreak. The goal was to learn from patients about their oral health and general practices during this time to provide optimal delivery of orthodontic treatment care. Methods A phenomenographic qualitative design involving semi-structured face-to-face interviews. A purposive sampling strategy was deployed to collect qualitative data from 24 orthodontic patients who quarantine during the COVID-19 pandemic. All interviews were digitally recorded, and afterwards, they were transcribed verbatim. Results Four main themes and associated sub-themes were identified. The themes were (1) oral-health-related behavioral changes, (2) impact on treatment progression, (3) psychosocial impact and attitude changes, and (4) areas for future enhancements in healthcare delivery. Overall findings revealed both positive and negative behavioral changes in orthodontic patients regarding their adjustment during the quarantine and its implications to general health and well-being. Conclusions Findings from this study suggest that COVID-19 impacted dental healthcare delivery to orthodontic patients during the quarantine. Patients reported psychosocial and behavioral changes as a consequence of treatment disruption and pandemic lockdown. Clinical significance The implications of these findings to the clinical dental environment and patient education are pivotal to further target areas in dental healthcare delivery that require strengthening. As such, clinicians could expect behavioral changes from orthodontic patients and identify better strategies to mitigate clinical challenges resulting from such changes.

On December 2019, Wuhan Municipal Health Commission (WMHC) reported 27 cases of viral pneumonia, of which 7 cases presented with a critical illness. However, it was not until early Jan 2020 that the World Health Organization (WHO) expressed great interest in the pathogenesis of such respiratory virus designated "2019-nCoV"; later referred to in the media as a coronavirus [1] . At such a tremendous pace, the progression of COVID-19 in terms of its transmission and mortality urged China to start a lockdown process in many Chinese cities. Later, many countries initiated lockdown and quarantine procedures as WHO declared COVID-19 a global pandemic [2] . These quarantine procedures act as a measure to control the spread of the virus [3] . However, such measures negatively impacted the citizens, leading to financial losses, frustration, boredom, post-traumatic stress symptoms, anger, and even violent behavior. Thus, a pandemic lockdown could be highly stressful and nerve-racking without transparent information about the quarantine time and the designated protocols [4] . Previous research has shown a direct relationship between stress/socioeconomic level and oral health; patients with more anxiety have poorer oral health [5] .

Healthcare systems faced challenges pertinent to supplying sufficient medical equipment to sustain effective management of various medical conditions while ensuring a safe environment for patients and their treating physicians. Incorporating the latest technologies and healthcare guidelines would decrease cross-infection and develop a safe patient environment [6] [7] [8] . Studies have shown that dental clinics should adopt stricter infection control protocols during the pandemic [9, 10] . Over the last few years, the focus has been on developing and launching new healthcare applications to help track patients' treatment progression. Furthermore, it serves as a reminder system for those receiving long-term treatment, such as orthodontic patients [11] . The reliance on artificial intelligence, digital applications, and online sources to obtain healthcarerelated information increased dramatically during the COVID-19 pandemic [12] [13] [14] . Additionally, studies have shown that these applications have helped save time, decreased the workload, and improved the quality of services [15] [16] [17] [18] .

Orthodontic treatment aims to improve patients' oral health-related quality of life, as it tackles different domains related to boosting patients' self-esteem after treatment and psychosocial behavior [19] . Thus, a patient-centered approach would allow the clinician to understand patients' J o u r n a l P r e -p r o o f treatment needs setting achievable goals throughout treatment. Many studies explained the relation between oral health and its impact on the patient's quality of life [20] [21] [22] . However, current challenges are more extensive than any other time, with the COVID-19 pandemic placing patients and their clinicians in an unprecedented situation. With the lack of prior published qualitative research focusing on those long-term dental patients receiving orthodontic treatment, our paper would present a first-hand insight into understanding the impact of the COVID-19 pandemic on those patients and accordingly deliver practical means for clinical practice.

Orthodontic patients often present for long-term treatment and require regular check-up visits every 4-6 weeks. Maintaining excellent oral hygiene ensures their oral health is not affected by decalcifications and periodontal disease [23] . These patients are given suitable instructions to aid in effective management during their course of treatment. This qualitative research aims to understand orthodontic patients' experiences and perceptions during the COVID-19 outbreak and quarantine. This would shed some light on the psychosocial effects on the patients, their families, and how it has affected their oral-health habits, along with their expectations from their treatment.

The ethical committee review board approved the study at XX University (2020-XX). This qualitative phenomenographic research adopted face-to-face semi-structured interviews to get in-depth data on the experiences of orthodontic patients who had undergone COVID-19 pandemic lockdown. This study followed the standard criteria of reporting qualitative studies; COREQ (Consolidated criteria for Reporting Qualitative Research) checklist [24] .

The main aim of the phenomenographic approach was to identify how participants dealt with oral health and how that relates to their general health. Purposive sampling was used to recruit participants, and this ensured that adolescent and adult participants encompass a wide age range and are in different stages of their orthodontic treatment experience. Participants identified as adolescents and adults (16-35 years) who underwent fixed upper and lower appliance treatment J o u r n a l P r e -p r o o f in XX public university hospital and attended a full quarantine lockdown due to the COVID-19 pandemic in XX were eligible for inclusion. Participants were not eligible for inclusion if they had syndromes or further needed a combined orthodontic-orthognathic approach.

Before interviews, verbal information, accompanied with written consent, was given to the participants. Participants' confidentiality was assured by using a password-secured folder and a number identifier instead of names. Data collection and recruitment were done in parallel, guiding the decision process until new themes were identified and data saturation occurred.

The study employed a non-probability purposive sampling technique, where participants were invited to undertake interviews because they met the criterion of orthodontic patients who underwent quarantine during the COVID-19 pandemic. Semi-structured interviews were done in the XX University, in a private non-clinical room for an average of 38 minutes. A list of questions and a developed topic guide were prepared and guided the first five pilot interviews.

Data saturation was met after recruiting 24 patients (mean age 25.2 ± 0.9 years; 17 females and seven males). The demographics and baseline characteristics, the severity of malocclusion as assessed with the Dental Aesthetic Index [25] , treatment stages, and utilized appliances are presented ( Table 1 ).

The interviews were done between May 2020 and August 2020 in XX language, digitally recorded and transcribed verbatim, and translated afterwards into English using a professional translator. During interviews, the interviewer had the freedom to pose new questions, and any new themes raised by patients guided the subsequent interviews. Interviews were conducted by one investigator who possesses a Master of Science in orthodontics. The interviewer has been trained in qualitative research interviews at the school of public health before the commencement of interviews.

The interviews were read more than once by two independent reviewers and reviewed by a third reviewer. Interviews were analyzed, coded, and compared using Computer-Assisted Qualitative Data Analysis Software (CAQDAS) using the NVivo software (QSR International Pty Ltd, Australia, Version 11). Central themes were identified along with the critical question of the J o u r n a l P r e -p r o o f semi-structured interviews. The three reviewers discussed the nature of the initial themes. The themes relate to Patients' oral health experiences, the effect of the COVID-19 outbreak on the quality of treatment, psychosocial changes, and general reflections on health and well-being during the lockdown.

In addition to the four main themes, sub-themes were further identified from the qualitative data ( Table 2) . These themes enabled further elaboration from a patient-centered angle and helped with questioning during the interviews. All participants spent a standardized period of 2+ months of enforced COVID-19 lockdown and quarantine. They are instructed to contact the hotline number and share their private application accounts if there is a need for an urgent video call in an emergency.

Oral health is a fundamental component of general health; it is directly related to cardiovascular diseases, pneumonia, pregnancy, and birth complications [26] . Patients' perceptions, measures, and motivations for maintaining optimum oral health differ from one person to another. This theme was sub-divided into three sub-categories.

Changes in the frequency and duration of brushing during the quarantine Some participants expressed that staying at home alone for long periods negatively impacted their oral health and brushing habits. As staying at home for longer hours, and not having any social interaction with others, had an undesirable impact on their behavior.

On the contrary, participants who stayed at home for extended times with their families felt more impelled by their families and made them prone to maintaining good oral health. They brushed their teeth 2-3 times a day for 2-3 minutes. Even others stated that they brushed their teeth for a more extended period (5-10 minutes). Factors affecting oral hygiene habits All participants agreed that the type of food they ate affected their oral hygiene. Some types of food require a longer time to brush than others because it sticks to their braces, which require excess time in brushing. At the same time, others explained that the frequency of eating is the main factor that makes them brush more. Participants also illustrate that staying at home for long hours made them carefree about their hygiene because of spending long hours playing games or family activities.

teeth. Also, some types of food affect the duration of brushing, especially food that's difficult to clean".

Diet changes in quarantine.

All participants have had diet changes in the kind of food they ate and the number of times they ate throughout the day. The majority of participants ate more snacks and fruits during the lockdown. They stated that having their routine of going to work or university made them more inclined to eat a balanced diet. They stated that they usually ate healthy meals in their workplace/university cafeterias. However, they frequently indulged in their favourite food during the lockdown since they had extra time at home to cook their preferred recipes. They also expressed worries about bad breath, mainly if they ate more than one meal with snacks without brushing. Orthodontic treatment may cause several risks like decalcification, root resorption, gingival recession, and alveolar bone loss. However, these risks can be controlled with proper compliance from the patients. This theme was sub-divided into three sub-categories.

Quality and duration of treatment Some participants felt that their teeth were not moving in the right position; others felt that the treatment progression became very slow. However, all participants agreed that the quarantine would not affect treatment results, and however, it could impact the overall duration of treatment by two to three months. 

Half of the participants stopped using the elastic bands as instructed. Most of them forgot to wear it during the quarantine period because they were busy with social activities with family, while others ran out of elastics, so they needed to wait until the Covid-19 lockdown was lifted.

Most participants tried to take extra care of their braces by eating small portions over time because they knew it would not be possible to re-bond their brackets or have an emergency appointment.

Anxiety from having an emergency and its solution All participants felt worried about emergencies, so they took good care of their braces and followed all instructions. Some emergencies occurred instead of being cautious, such as having an excess wire, debonded brackets, and gingival bleeding. Participants expressed their gratitude for having a video call with their orthodontist, which solved their problems temporarily. 

Several studies suggest that staying at home for long periods and decreasing activity can lead to bone and muscle weakness. Moreover, the decreased exposure to sunlight affects mental health due to the decline in vitamin D levels, resulting in a compromised immune system and making people prone to infectious diseases [27, 28] . On the other hand, it can be a direct cause of rumination and lethargy. The extent of these physical and mental effects differs from one patient to another according to their environment, social circle, and individual circumstances. This theme was sub-divided into five sub-categories.

Participants stated that the quarantine period was a very stressful period for different reasons.

Some participants came from places far away from the hospital, and being in quarantine will make them go through a longer duration of treatment which will affect their plans. Besides, they were worried about their treatment progress; they felt their teeth were moving in the wrong direction or worse than before.

"To be honest, I want to remove the appliance early. My home is 450km away from XX, and it takes me 1.5 hours to get to XX by high-speed train. If I could finish treatment earlier, I would not have to run around; to be honest, I was a little impatient. I'm also worried that the bracket will fall off". should start to prepare for the exams, and when will their exams be held. Also, during this period, some unauthorized websites sought to have more followers, so they spread rumours on the Internet about the COVID-19 situation, causing more stress on people who don't have access to official sources.

Some of the participants' families felt worried about their financial situation, as they kept buying family needs without having a stable income. Also, they had some worries about being not able to visit the hospital or go out in case of emergency. 

Participants stated that the psychosocial effects were caused either by the extended times spent with their families or the lack of social life for those who stay alone. Some patients explained that the lack of social life affected their hygiene habits as it made them more prone to depression and feeling less active with an increased need to eat more. The patients who stayed with their families felt that more extended stays with family, in turn, increased their house chores, making them less inclined to pay attention to their braces. 

Although most participants have had negative feelings, positive emotions will still be memorable moments. They enjoyed family gatherings and social media application games. They also showed gratitude to medical staff and governmental efforts, ensuring that the quarantine would end soon.

Reflecting on patients' points of view is mandatory for future enhancement and better management. The patient-centred treatment approach implied respect for the patients' preferences, integrated them into their treatment, and supported them physically and emotionally, resulting in better understanding and ease of access to care [29] . This theme was subdivided into two subdivisions.

These are recommendations that patients can develop by themselves or with the help of their orthodontist. Patients stated that if they could go back in time, they would increase the duration of their brushing, take extra measures about their hygiene, and improve their eating habits by eating fewer snacks and following a healthier diet. Also, they would bring more elastic bands in the future. Some patients recommend trying meditation an hour a day, as it helped them so much.

Participants recommended contacting the orthodontist directly in case of any doubt.

Long-term recommendations:

These are recommendations that need the involvement of other parties or need a long time to be developed. Participants requested an online website to be launched to help them book the next appointment and provide easy access for any emergencies. They also recommended having a scheduled online meeting with their orthodontist to keep them updated on their current situation and answer any questions besides an online instructional video for any emergency.

"I would like to make an appointment not only over the phone but also over the Internet, which I think would be more convenient". (Participant 4)

In recent years, there has been more demand for orthodontic treatment. Throughout the long journey of orthodontic treatment, many changes could be seen through treatment, which would require certain levels of compliance from the patients and adaptation from both sides, the patients and their orthodontists. COVID-19 is one of the most formidable challenges that many countries currently face. Many governments have taken active steps to control the disease's spread by imposing lockdown and quarantine restrictions as effective measures against COVID-19.

However, this may have adverse mental and physical effects on the population [4, 30] . This is the first qualitative to assess the potential impact of COVID-19 quarantine on orthodontic patients from a patient's point of view. Orthodontic treatment, mainly with fixed appliances, needs regular check-ups for adjustment. High treatment costs and discomfort would often accompany full compliance from patients after each visit, thus, placing an extra burden on patients and their families [31, 32] .

In this study, four themes were developed. The effects of quarantine on oral health and patients' behaviour were one of the most exciting themes. Patients expressed at different time points how social life changes affected their diet and oral hygiene habits. This study concluded that social life directly relates to the initiative to adhere to oral health and diet instructions. On the other side, it could be argued that quarantine also gave some patients the freedom to brush their teeth more frequently since staying home made it easier for them.

Interestingly, patients noted that their diet changed during quarantine in terms of food and the number of times they ate throughout the day. They also agreed that the type of food determines how long they brush their teeth. Patients felt anxious and stressed due to all the changes they had undergone throughout the quarantine period. Furthermore, they directly linked the changes in their behaviour to the added stress put on them, which comes as no surprise [4, 30] . However, it would be interesting if further research could outline the long-term effects of quarantine.

Moreover, patients were concerned about dealing with an emergency, as most of them expressed their fear of any issues arising with their braces, which may prolong the treatment or compromise the result. Having the ability to schedule an orthodontic appointment to address some emergencies related to attaching a debonded bracket or cutting excess wires was almost impossible during quarantine. Patients tried to deal with these emergencies by themselves, and others changed their oral health practices to be more vigilant to avoid being placed in such situations [33] .

Patients generally felt that their family and friends' presence during the quarantine played the primary role as internal motivation and external support, consistent with previous research [34] .

However, not all patients were living with their families. That is why patients expressed their gratitude for having video calls with the treating orthodontist and for receiving illustrative videos in response to emergencies. Video calls play a central role in reassuring patients about their treatment progress, and it also aids as a reminder for them to continue following instructions. In that way, they feel actively involved with their treatment, allowing them to be optimistic about the overall conditions. Application platforms play a vital role during the epidemic by virtually guiding and instructing patients [35] . Another interesting theme was the patients' perceptions of their treatment outcomes and how they think it may affect them. Adding an extra two or three J o u r n a l P r e -p r o o f months over the whole treatment duration is acceptable to some patients, knowing that their final results will be achieved.

On the other hand, prolonging treatment could be stressful for some patients; they stated that proper supervision from their orthodontist would help them feel more involved in their treatment. Most participants expressed that following the quarantine instructions was not easy, especially wearing the elastic bands, which could be interesting for future research. Participants in this research favoured the presence of websites for obtaining information and reserving appointments. However, they felt that it must be related to authorized governmental organizations, giving more credibility to the sources of knowledge.

This qualitative research report elaborates on the impact of COVID-19 quarantine and its effects from the perspective of orthodontic patients. A thorough reflection on the essential themes discussed so far signifies the need for transitory changes and targets some areas for future improvement in the management of patients in such situations. First, such circumstances demand the orthodontists to swiftly shift to effective electronic and postal means of communication [36] . This is salient as patients discussed their sub-optimal oral health and difficulties dealing with emergencies. Incorporating illustrative videos, reminders, video calls, and electronic monitoring could successfully manage such situations. Experts' education of auxiliary staff on communication mechanisms during such tense circumstances will provide the necessary psychological support to the patients and their families [37] .

Proper communication plays a role in the proper management of treatment progress and helps deal with behavioral changes expected from patients [4, 5] . Hence, better-tailored strategies to mitigate these changes could be identified. Also, some orthodontic patients expressed feeling stressed, helpless, anxious, and depressed. Orthodontists should be aware that having braces during lockdown and quarantine placed extra burdens on the patients and their families [38] .

Thus, orthodontists' role in reassuring their patients could also extend to the awareness of other agencies providing support in such circumstances to manage proper referrals. Some governmental agencies support patients with psychological burdens by providing psychological crisis intervention plans to deal with public health emergencies during the epidemics [39] . However, J o u r n a l P r e -p r o o f recent evidence points out the lack of proper diagnosis and follow up for these patients [40] .

Governments could aim to support patients by increasing the number of licensed psychiatrists and the financial support for affected families. Orthodontists may contribute to such schemes by providing financial orthodontic treatment reduction for those affected families during the epidemic.

Orthodontic patients anticipated issues relating to their treatment progression as well as to some delays in their treatment. However, they retained their confidence in achieving adequate results. With these anticipations, orthodontists could look forwards to considering maneuvers aiming to accelerate their orthodontic treatment provision and strategies with less compliancedependent mechanics. Consequently, modifications to adapt to these unbridled changes aiming for shorter treatment may be considered and discussed with the patients as part of their informed consents-treatment plans for these patients to make it shorter and try to finish it as soon as possible. Lastly, a considerable emphasis should be placed on maintaining proper oral hygiene during these periods and the potential detrimental effects of decalcifications, root resorption, and gingival recessions to the orthodontic patient [23] .

This qualitative study highlighted the experiences and perceptions of orthodontic patients during quarantine. However, there are essential considerations to be noted. This study is based on data from the perspective of patients who experienced certain restrictions related to COVID-19 in XX, and it could be argued that it does not mimic COVID-19 circumstances globally, as every country had its response COVID-19. Also, in-depth interviews were conducted with adolescent and adult patients receiving orthodontic treatment. Therefore, it is essential to highlight that translating such results to clinical practice could not be generalized to individuals outside the selected age range. Perspectives of selected participants might differ from the younger cohort of patients who tend to demand more care and instruction from their parents/caregivers.

The interviews were done in XX language to encourage participants to be as expressive as possible. However, this has added extra difficulty to the transcription of the interviews and J o u r n a l P r e -p r o o f increased the possibility of errors resulting from translation. Since the interviewers were orthodontists, some patients might feel uncomfortable and possibly provide responses that were expected. This factor was minimized by introducing the interviewers as researchers, and the interviews were conducted once in a private non-clinical room. Finally, it would be beneficial if objective quantitative data about compliance with treatment instructions and expected outcomes from orthodontic treatment were further explored in future research.

This study explored in-depth orthodontic patients' psychosocial changes and reflections on their treatment experiences during the COVID-19 outbreak and quarantine. Patients showed both positive and negative experiences in the quarantine period.

 Social relationships during quarantine directly relate to the initiative to maintain proper oral health.

 The patients noted changes in diet, frequency of brushing, and duration during COVID-19 lockdown.

 Orthodontic patients did not believe that COVID-19 quarantine would affect their treatment outcomes. However, they stated that a negative impact on the overall duration of treatment might occur.

 Compliance with elastic wear and orthodontic instructions were sub-optimal during the quarantine period.

 COVID-19 lockdown was stressful and added an extra psychological burden to the patients and their families, given the additional anxiety related to their treatment completion.

 Participants recommend a transition to electronic follow-up during these times to maintain adequate interaction with their treating clinician and for better healthcare delivery and outcomes.

 Clinicians could expect behavioral changes from orthodontic patients and identify better strategies to mitigate clinical challenges. J o u r n a l P r e -p r o o f 

WHO declares COVID-19 a pandemic

Centres for Disease Control and Prevention, Quarantine and Isolation

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Current stress and poor oral health. BMC Oral Health

COVID-19: ensuring our medical equipment can meet the challenge

Preventing infectious diseases in Intensive Care Unit by medical devices remote control: Lessons from COVID-19

Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine

Clinical orthodontic management during the COVID-19 pandemic. The Angle Orthodontist

Dentistry during and after COVID-19 pandemic: pediatric considerations

Reminders improve oral hygiene and adherence to appointments in orthodontic patients: a systematic review and meta-analysis. European journal of orthodontics

Artificial Intelligence (AI) applications for COVID-19 pandemic

The use of digital applications and COVID-19. Community mental health journal

Opportunities to improve COVID-19 provider communication resources: A systematic review. Patient Education and Counseling

Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals

Nurses' perception of a tailored web-based intervention for the self-management of pain after cardiac surgery

Perceptions of Practitioners on Telehealth and App Use for Smoking Cessation and COPD Care-An Exploratory Study

The Lancet Diabetes & Endocrinology

The impact of orthodontic treatment on quality of life and self-esteem in adult patients

Oral healthrelated quality of life and orthodontic treatment seeking

Does psychological well-being influence oral-health-related quality of life reports in children receiving orthodontic treatment

Oral health-related quality of life in orthodontics: a crosssectional multicentre study on patients in orthodontic treatment

Incidence of white spot formation after bonding and banding. American journal of orthodontics

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care

DAI--the dental aesthetic index

Periodontal disease and cardiovascular disease

Vitamin D deficiency and depression in adults: systematic review and meta-analysis. The British journal of psychiatry

Physical activity during the coronavirus (COVID-19) pandemic: prevention of a decline in metabolic and immunological functions. Frontiers in Sports and Active Living

Patient-centredness: a conceptual framework and review of the empirical literature. Social science & medicine

SARS control and psychological effects of quarantine

Assessment of motivation and psychological characteristics of adult orthodontic patients

Experience of pain during an orthodontic procedure. European journal of oral sciences

A qualitative study of the early effects of fixed orthodontic treatment on dietary intake and behaviour in adolescent patients. The European Journal of Orthodontics

Adolescents' experiences of using removable functional appliances

Effect of WeChat consultation group on residents staying at home in Sichuan and Chongqing regions during the Coronavirus Disease 2019 (COVID-19) outbreak in China: a cross-sectional study

Digital health during COVID-19: lessons from operationalising new models of care in ophthalmology. The Lancet Digital Health

Communicating during an outbreak or public health investigation

Effective health communication-a key factor in fighting the COVID-19 pandemic. Patient education and counseling

Crisis intervention handbook: Assessment, treatment, and research