|Year : 2020 | Volume
| Issue : 4 | Page : 187-192
Orthodontists' apprehension and viewpoint regarding COVID-19: A survey of Indian orthodontists
Sakshi Rakhyani, Prashant Sharma, Pradeep Raghav, Munish Reddy, Shalu Jain
Department of Orthodontics and Dentofacial Orthopedics, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India
|Date of Submission||02-Jun-2020|
|Date of Decision||20-Jun-2020|
|Date of Acceptance||02-Jul-2020|
|Date of Web Publication||30-Nov-2020|
Department of Orthodontics and Dentofacial Orthopedics, Subharti Dental College, Swami Vivekand Subharti University, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To assess the apprehension and viewpoint of Indian orthodontists about the outbreak of pandemic COVID-19. Subjects and Methods: A survey was conducted in April 2020, for which an online questionnaire was prepared in English language using Google Forms to collect the data. The questionnaire consisted of ten multiple-choice questions; one concerning the work setting of participants and the remaining concerning the information and effect of coronavirus pandemic. The data were summarized in percentage form for the ease of evaluating results. Results: 314 forms were completed and returned. 88.9% of orthodontists believed that COVID-19 and the following lockdown imposed by the authorities to prevent its spread has profoundly affected orthodontic practice. About 56.1% of the orthodontists said that more than three-fourths of their patients understand that there will be a delay in their treatment due to the pandemic. About 38.1% of the orthodontists believed that around 3–6 months will be required for the practice to normalize. Most importantly, 39.4% of the orthodontists were unable to make up their mind regarding transferring the cost of personal protective equipment to their patients when practicing emergency/elective procedures on them. Conclusions: Orthodontists as well the patients undergoing orthodontic treatment understand the gravity of epidemic and therefore more importance is being given to solve the emergencies over the call itself. Orthodontists believe that with a decrease in the disposable income of people, there will be a decline in orthodontic requirements in the country and that a time period between 3 and 6 months will be required to normalize the practice.
Keywords: Corona, COVID-19, orthodontic practice, survey
|How to cite this article:|
Rakhyani S, Sharma P, Raghav P, Reddy M, Jain S. Orthodontists' apprehension and viewpoint regarding COVID-19: A survey of Indian orthodontists. J Dent Res Rev 2020;7:187-92
|How to cite this URL:|
Rakhyani S, Sharma P, Raghav P, Reddy M, Jain S. Orthodontists' apprehension and viewpoint regarding COVID-19: A survey of Indian orthodontists. J Dent Res Rev [serial online] 2020 [cited 2021 Jan 16];7:187-92. Available from: https://www.jdrr.org/text.asp?2020/7/4/187/302054
| Introduction|| |
COVID-19 is the most recently discovered infectious disease, traced by the outbreak to a novel strain of coronavirus in Wuhan, China, in December 2019. The WHO declared COVID-19 a pandemic in March 2020 and many countries were impacted worldwide. The typical most common clinical symptoms of the patients who suffered from the novel coronavirus were fever, dry cough, and fatigue with abnormal chest computed tomography.,,, The infection was found to transmit from the infected people, whether symptomatic or asymptomatic, to the healthy ones through small droplets, which are expelled when a person with COVID-19 sneezes, coughs, or speaks. These droplets being relatively heavy do not travel far and quickly sink to the surface and can land on objects and surfaces around the person. Healthy people can become infected if they come in contact with these objects or surfaces and thereafter touch their eyes, nose, or mouth.
Many medical and paramedical practitioners were reported to have acquired the disease when working on infected patients. A similar possibility of transmitting and acquiring the infection between staff or individuals is present in those working in dental clinics also. Moreover, because of the close contact with the patient and the nature of the treatment, there is more risk for the virus to spread in a dental clinic or hospital setting. Furthermore, both the relatively long incubation period of the disease (the median incubation period was estimated to be 5.1 days or up to 14 days for some cases), and the novel nature of the virus make it challenging for dental staff to recognize the existence of COVID-19 infection and ascertain preventive measures to control its spread. The federal, state, and local civic and public health or professional regulatory bodies are making continuous efforts to contain the spread of the disease throughout the world by ordering regional and, in many cases, national emergencies and lockdowns, leaving only essential services to continue. Dentists, including orthodontists thereby, should contribute to control and manage its spread through maintaining a high level of awareness and integrity to deal with the disease.
When coming to orthodontic care, there were millions of patients who were already undergoing the treatment when the elective treatment services were abruptly suspended globally due to widespread coronavirus. During the lockdown, continuous special efforts are being called for to assure and follow these patients, especially if they are experiencing discomfort or problems related to the orthodontic appliance; therefore, their management and care have become relatively a hard task. In addition, due to the uncommon nature of this pandemic, the unknown length of time that mandatory suspension of elective treatment may be in effect in different regions, and the lack of consolidated information and guidelines for the clinical orthodontic management of patients during and after the COVID-19 pandemic is leaving the orthodontists globally in an unfamiliar zone to deal with. Hence, it is necessary to find out what the thoughts of our fraternity are and how are they dealing with the basic intricacies of treatment delivery and patient care during this time of pandemic on a broader level. Therefore, this study aims to assess the apprehension and viewpoint of Indian orthodontists about the outbreak of pandemic COVID-19.
| Subjects and Methods|| |
The survey was conducted in April 2020, for which an online questionnaire was prepared and circulated in English language using Google Forms to collect the requisite data.
Pilot testing of the survey questionnaire was performed on ten experienced orthodontists for surface validation before conducting the final survey and their comments were incorporated in the final version of the survey, but their responses were excluded from the test sample similar to a previous survey which was taken as the template for this survey. The final questionnaire consisted of ten multiple-choice questions; the first question was concerning the work setting of participants and the remaining nine questions emphasized on collecting the information regarding the effects of coronavirus pandemic on the orthodontic practice [Table 1].
A simple random sampling method was used by drawing the name lots of registered orthodontists (both practitioners and PG students) in the Indian Orthodontic Society. The survey was mailed to 600 of these randomly selected orthodontists. The survey was concluded 2 weeks after the initial mailing, whereby any response after that period was not included in the study. Confidentially of the information provided was assured and the participation was voluntary.
The requested information may be grouped as follows:
- Work setting of the orthodontists
- Effects of pandemic on orthodontic practice
- Interaction with patients during COVID-19
- Post-pandemic orthodontic practice.
The data were summarized in percentage form for the ease of evaluating results.
| Results|| |
Six hundred questionnaires were mailed, out of which 314 were completed and returned. Since the survey was aimed at obtaining substantial expertise which could be helpful in catering to patient's needs in times of crisis like this pandemic, the waiting period for the response was only 2 weeks which might be considered as a potential reason for a low response rate.
Work setting of orthodontists
A majority of about 37.9% of the responding orthodontists were private practicing clinicians, while 23.6% were engulfed in a combination of more than one commitment (ranging from owning a clinic, consultant to other clinics or hospitals, and/or an academician) and around 19.7% of the respondents were enrolled in postgraduation program in orthodontics across different institutions [Figure 1].
Effects of pandemic on orthodontic practice
Majority of the orthodontists (88.9%) believed that COVID-19 has profoundly affected their orthodontic practice, whereas only a mere 4.5% were of the view that the ongoing pandemic had no ill effects on their practice.
Interaction with patients during COVID-19
About 56.1% of the orthodontists said that more than three-fourths of their patients understand about the eventual delay that will occur in their treatment due to the pandemic [Figure 2].
In the same progression, about half of the orthodontists (55.2%) received <2 calls/day since the day of lockdown, while 19.4% received 2–4 calls. Furthermore, 54% of the orthodontists attended no patients since the day of lockdown.
Loose brackets, bands, or molar tubes (55.2%) and impinging wire (54.3%) were the most common complaints of patients calling to seek orthodontic care during the lockdown, followed by soft tissue soreness (14.9%) and loose O-ring (12.7%) [Figure 3].
Conventional labial braces required most assistance (63.2%) followed by lingual braces (13.7%) and removable appliances (7.3%) [Figure 4].
|Figure 4: Bar graph showing the type of appliance requiring most assistance|
Click here to view
Postpandemic orthodontic practice
Orthodontists had mixed reviews when it came to the time that will be required to normalize the orthodontic practice once the severity of the current situation eases. About 38.1% of the respondents believed that around 3–6 months will be required for the practice to normalize, while 34% of them believed that the time period to normalize the practice will range somewhere between 1 and 3 months [Figure 5].
|Figure 5: Viewpoint regarding time period required to normalize orthodontic practice|
Click here to view
Most importantly, 39.4% of the orthodontists were still unclear with regard to transferring the cost of personal protective equipment (PPE) to their patients when practicing emergency or elective procedures on them, while on the other hand, 35.9% were of the view that it is all the more logical and feasible to transfer the necessary cost of PPE to their patients.
Along with this, 53% of the orthodontists said that with a decrease in the disposable income of the general masses, there will be a decline in the orthodontic requirements, whereas 26.7% of them were not able to make up their mind about the same [Figure 6].
|Figure 6: Feasibility of transferring PPE cost to patients and decline in orthodontic practice|
Click here to view
| Discussion|| |
This survey provides an insight into the daily problems of Indian orthodontists and their viewpoints on practice management with COVID-19 at the time of the outbreak in 2020. For this purpose, a questionnaire focusing on closed-ended questions was used to gather information about orthodontists' fear and any practice modifications employed to combat the COVID-19 outbreak. Questionnaire-based studies are proven for gathering information regarding preferences, attitudes, opinions, and experiences of participants; however, careful data collection and interpretation is required.
In a dental clinic, close contact with the patient and the nature of the treatment involved makes it a greater risk environment for the spread of virus. The main cause of worry is the potential infection from an asymptomatic carrier. Previous studies have reported that asymptomatic persons are playing a major role in the transmission of severe acute respiratory syndrome (SARS)-coronavirus-2. As much as it is risky for a health-care worker to work on a patient at this time, similar risk is involved for a patient who is visiting a hospital or rather any health-care setup which might be the reason for 88.9% of the responding orthodontists stating that COVID-19 has affected the routine orthodontic practice.
To contain the spread of this virus, national emergencies and lockdowns have been imposed, leaving only essential services to continue. When the elective services were abruptly suspended in India, there were thousands of patients who were undergoing the treatment and were in different phases of their treatment progress such as initial phase, mid-phase with bulky appliances fitted in their oral cavity, or the end phase who were expecting the treatment to end soon. Out of these patients, while many would have understood the severity of the situation and the necessary action of suspension of elective treatment, some would have appeared to be worrisome. When the study respondents were asked about the number of patients who understood the reason for delaying of their treatment, 56.1% of the orthodontists said that more than three-fourths of their patients have understood the situation, whereas the rest of the respondents observed lesser percentage of patients who could understand the gravity of situation causing a delay in their treatment. This clearly stated a need of significant efforts to be taken by the orthodontists in making the patients understand the reasons for delay in their treatment.
The reasons for apprehension among patients could be the basic problems such as mastication and speech which can occur either because of the orthodontic or orthopedic appliances fitted in their oral cavity as part of treatment or because of the uncertain nature of the pandemic situation. As reported in this study, about half of the orthodontists (55.2%) received <2 emergency calls/day from their patients daily since the day of lockdown, whereas 19.4% received 2–4 emergency calls from their patients and only 2.2% of them received >10 emergency calls per day. A positive aspect reported by the present study was that majority of the participants were aware of the possible cross-transmission implications that could have resulted if they had attended all of the emergency patients in their hospitals or clinics. Most of telephonic advice was related to assisting the patients in dealing with issues of loose brackets, bands, or molar tubes (55.2%) and impinging wire (54.3%), followed by soft tissue soreness (14.9%) and loose O-ring (12.7%). Necessary instructions that could be given in such cases are usually keeping the brackets secure and safe in case of loose brackets or applying wax wherever the orthodontic appliance parts were impinging in the oral cavity. Probably because the orthodontists were within the reach of a telephonic call for their patients in case of any discomfort, only 3.2% of the orthodontists attended >20 patients since the day of lockdown to the date of the study conducted, whereas the rest of them attended even a lesser number of emergency patients. This lays down the foundation for the development of a better network of digital consultations soon to keep us prepared for any such crisis. The appliance system that required maximum assistance during the lockdown as reported by the participants was conventional labial appliance (63.2%), which is justified as it is the most used appliance system by the Indian orthodontists.
Studies on previous outbreaks of similar infectious diseases such as SARS demonstrated various factors, leading to psychological trauma in health-care workers including the fear of being isolated and depressed to fatality infected when treating an infected patient and in turn infecting a family member., With the prolonged incubation period of the coronavirus (as long as 14 days), it is impossible to identify all the cases present in the community. Furthermore, there is no vaccine or approved treatment, available as of now. All these combined put health-care workers at a higher risk level of acquiring coronavirus infection, which has affected orthodontic practice or in general complete dental practice. About 38.1% of the study participants believed that it will take around 3–6 months for the practice to normalize, whereas 34% of them believe the period can range between 1 and 3 months, which is similar to the perception of a large number of general dentists who fear getting infected by their patients or coworkers.
The repercussions of the rapid spread of COVID-19 will also have significant financial implications on the patients as well as the orthodontists. While it is a matter of high risk to attend any patient without using adequate personal protective gear, it is also a matter of apprehension for the orthodontists to transfer the cost of these protective gears to the patient. If during the time of a financial crisis, cost of extra protective gears required for treatment are transferred onto the patient then patients might find it a financial burden when some of them find the charges of orthodontic treatment to be heavy even in the times other that of a crisis. This could be the possible reason for 39.4% of the orthodontists being unsure when it comes to transferring the cost of PPE to their patients. The pandemic has resulted in a decrease in the disposable income of people and has also created a greater risk environment for health-care workers, which could be a major factor in making 53% of the orthodontists believe that with decrease in the disposable income of the people, there will be a decline in orthodontic requirement in the country.
The data about increase in people seeking orthodontic care in the US give a ray of hope for the orthodontists. In a study based in US, done to record the number of adult patients seeking orthodontic care, it was noted that in the 1990s, about 25% of all orthodontic patients were adults, but in 2000, the proportion of adults in orthodontic patient population dropped to 20%. By 2010, it again increased to 25%. This was because of financial constraints on treatment demand among people; the demand became normal once there were optimal economic conditions. Similarly, soon after the pandemic subsides, people would start going back to work and eventually gain financial stability and thus we can anticipate a possible boom in the number of patients seeking orthodontic care.
| Conclusions|| |
- Orthodontists as well the patients undergoing orthodontic treatment are understanding the gravity of epidemic and therefore more importance is being given to solve the emergencies over the phone itself
- Main reasons for patients seeking emergency orthodontic care are lose brackets or molar tubes and impinging wire
- Orthodontists believe that with a decrease in the disposable income of people, there will be a decline in orthodontic requirements in the country and that a period between 3 and 6 months will be required to normalize the practice
- Transferring the cost of safety equipment to the patients cannot be judiciously decided and hence it is more of an individual preference.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO Statement Regarding Cluster of Pneumonia Cases in Wuhan, China; 2020. Available from: http://www.who.int. 2020-01-09
. [Last retrieved on 2020 Jan 10].
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al
. Clinical characteristics of coronavirus disease 2019 in China. N
Engl J Med 2020;382:1708-20.
Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al
. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA 2020;323:1406-7.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:1-6.
Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS One 2017;12:e0178007.
Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al
. The incubation period of coronavirus disease 2019 (COVID-19) From publicly reported confirmed cases: estimation and application. Ann Intern Med 2020;172:577-82.
Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Surveill 2020;25:2000062.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al
. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N
Engl J Med 2020;382:1199-207.
Sharma P, Raghav P, Jain S, Mohan S, Reddy M. A survey of current trends in self-ligating brackets: An orthodontist's perspective. Int J Sci Res 2020;9:1-5.
Lydeard S. The questionnaire as a research tool. Fam Pract 1991;8:84-91.
Gandhi M, Yokoe DS, Havlir DV. Asymptomatic transmission, the achilles' heel of current strategies to control Covid-19. N
Engl J Med 2020;382:2158-60.
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-95.
Marques LS, Paiva SM, Vieira-Andrade RG, Pereira LJ, Ramos-Jorge ML. Discomfort associated with fixed orthodontic appliances: Determinant factors and influence on quality of life. Dental Press J Orthod 2014;19:102-7.
Peixoto VR, Nunes C, Abrantes A. Epidemic surveillance of COVID-19: Considering uncertainty and under-ascertainment. Port J Public Health 2020;37:1-7.
Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers. Psychol Med 2004;34:1197-204.
McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al
. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry 2007;52:241-7.
Amanat F, Krammer F. SARS-CoV-2 vaccines: Status report. Immunity 2020;52:583-9.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al
. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health 2020;17:2821.
Farooq I, Ali S. COVID 19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers. Postgrad Med J 2020.
Shrestha RM, Bhattarai P, Dhakal J, Shrestha S. Knowledge, attitude and practice of patients towards orthodontic treatment: A multi-centric study. Orthod J Nepal 2014;4:6-11.
Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, et al
. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg 2020;78:185-93.
Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary Orthodontics–e–Book. NX Amsterdam, The Netherlands, Elsevier Health Sciences; 2018. p. 15-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]