 Abstract | | |
Introduction: The ongoing pandemic has transformed the entire structural and functional framework of the world including the medical and dental healthcare services. The current study intends to examine the pattern of dynamically changing working conditions and orthodontic treatment delivery during the various phases of pandemic. Method: An online survey was conducted using Google form for orthodontic specialists practicing in India. Information regarding the impact of the pandemic on various aspects like patient turnover, treatment demand, clinical management, and new challenges faced were analysed through a self-designed close-ended questionnaire for two phases. Phase I (March 2020 to September 2020) corresponded to the onset of COVID 19 pandemic and lockdown, whereas the Phase II (October 2020 to March 2021) coincided with the time of Unlock and resumption of activities thereafter. Results: The parameters showing similar trend in Phases I and II included the willingness of ongoing orthodontic patients to report for appointments, choice of treatment modality, number and type of emergencies, cost of materials, guidelines for work, and duration of non-delivery of orthodontic procedures. The new patients reporting, complex orthodontic therapy, tele-consultation, and financial wellbeing showed an improvement while the usage of personal protective equipment kit, fear amongst orthodontists reduced in Phase II. Conclusions: Challenging situations warrant prudent measures to combat and continue the essential services, especially those related to the healthcare. A detailed analysis of the various phases of the ongoing pandemic will enable us to devise suitable measures to ensure uninterrupted orthodontic treatment even in such critical times.
Keywords: COVID-19, orthodontic emergencies in pandemic, orthodontic treatment trend
How to cite this article:
Grewal H, Bhutiani N, Balachandran R. The effect of COVID-19 on orthodontic treatment demand and its delivery in India. Indian J Dent Res 2022;33:367-72 |
How to cite this URL:
Grewal H, Bhutiani N, Balachandran R. The effect of COVID-19 on orthodontic treatment demand and its delivery in India. Indian J Dent Res [serial online] 2022 [cited 2023 Jun 9];33:367-72. Available from: https://www.ijdr.in/text.asp?2022/33/4/367/372902 |
| Introduction | |  |
The current COVID-19 pandemic has greatly impacted every aspect of life globally since its outbreak with the first reported cases in Wuhan, China, in December 2019.[1] COVID-19 is an acute respiratory illness caused by coronavirus belonging to the family Coronaviridae.[2] The disease spreads through human-to-human contact resulting in the community spread of the disease worldwide. Hence, the dental healthcare, especially, the procedures involving direct exposure to aerosols is prone to increased risk of contracting infection as the saliva of infected persons contains very high viral load.[3] In view of the great risk of rapid spread of this virus, many of the nations imposed lockdowns. In India, the nationwide lockdown was implemented in various phases from 25th March 2020. The initial phase of lockdown was 21 days that was gradually increased till the end of May 2020. As per a dental advisory issued by the Ministry of Health & Family Welfare, Government of India, on 19 May 2020 only emergency and urgent dental procedures were allowed despite phased unlock from 1st June 2020 onwards wherein other activities were gradually opened up.[4] During this phase, the tele-consultation was promoted for complaints that could be resolved through appropriate advice telephonically. The orthodontic therapy spans over 2–3 years in majority of cases and warrants regular recall visits every 3–4 weeks. Therefore, despite the routine nature of the orthodontic therapy, few instances in the ongoing treatment may need urgent attention like poking wires, appliance breakages, soft tissue ulceration. This necessitated recall of patients with appropriate precautions as soon as the guidelines were relaxed to minimize the chances of any damage to oral tissues. Moreover, the patient's options, choices and the availability of services has greatly changed in view of the uncertain and dynamically changing conditions brought about by the pandemic.[5] This present survey aims to evaluate such impact of the COVID-19 pandemic on orthodontic practice at the very onset of pandemic spanning from end of March 2020 to end of March 2021, that is, during and after the first wave, but prior to the second wave. This would help in understanding the trend in orthodontic practice as India battled through various phases in the first year of the ongoing pandemic.
| Materials and Methods | | |
This cross-sectional web-based questionnaire study was conceived in April, soon after which the very severe second wave of COVID-19 struck the nation. The questionnaire was prepared following CHERRIES (Checklist for Reporting Results of Internet E-Surveys) as a Google form to gain insight into the impact of Covid pandemic on the specialty of orthodontics. The self-designed close ended questionnaire aimed at understanding the dynamics of orthodontic treatment demand and its delivery during such times of crisis [Supplementary file]. Thus, the first year of the ongoing pandemic was sub-divided into two time periods March (end) 2020 to September 2020 (Phase I – 1st wave and lockdown) and October 2020 to March 2021 (Phase II – period of unlock post first wave with decline in cases).
The ethical guidelines for online surveys were followed for framing the questions and the identity of the participants was kept strictly confidential along with the revised Helsinki Declaration, 2000.[6] The introductory segment of the form duly explained the purpose of the survey and a brief overview of its content to the participants and form could be filled only after voluntary consent. The questionnaire contained following sections – personal details, vaccination status, effect on OPD, orthodontic emergencies, and managing challenges during current pandemic with same questions and responses to be answered twice according to the two distinct time periods, that is, Phase I and Phase II as described earlier [Supplementary file] for both phases. The confidentiality of the submitted responses was ensured and only the authors could access the submitted data. The ethical clearance was waivered owing to the nature of the study.
The questionnaire was pre-tested prior to distribution by sending it to five orthodontists and two orthodontic residents. After minor changes to enhance the ease of comprehension as per their suggestions, the questionnaire was mailed to 1,000 members of the coveted Indian Orthodontic Society through an online data collection platform (Google forms) using the purposive sampling technique and randomization. Reminder emails were sent twice at a gap of 15–20 days to maximize the response.
The data was entered in Microsoft spreadsheet. The data analyses were performed using SPSS Statistic Software Package (version 19, SPSS, Chicago, Illinois, United States). To assess the agreement between the phases, the Kappa statistics was used.
| Results | | |
A total of 105 responses were received out of which one respondent refused to participate in the survey. Hence, the data was derived from 104 respondents out of which 56 were females and 48 were males. Maximum number of respondents (66) were into private practice, whereas 44 were involved in academics. As regards the institutional setup, 22 respondents were working in Governmental institution while 17 were associated with private institutes. Many respondents reported no associated morbidity conditions, while one had SLE and others reported diabetes mellitus, hypertension, hypertriglyceridemia, and wheezing in 1 to 2%.
Vaccination status
Out of the 104 respondents, 92.2% (95) received at least one dose of the vaccine while 7.7% did not receive any vaccination. Covishield was taken by 78.1% (75), whereas 16.7% (16) received Covaxin. A majority of respondents (82.3%) had received both the doses of the vaccine.
Phase I versus phase II
i. Effect on OPD
New patients – Nearly half of the respondents (47.1%) reported a sharp decline in new patients willing for orthodontic treatment in Phase I which was only 0–25% of the normal OPD. This increased in Phase II with 33.7% respondents reporting new cases ranging from 50 to 75% of normal OPD while only 36.5% experienced getting the new orthodontic cases in the range of 25 to 50% of the normal OPD [Figure 1]a. | Figure 1: (a) Number of new patients requesting orthodontic treatment. (b) Willingness to continue orthodontic treatment. (c) Inability to deliver orthodontic care. (d) Preferred treatment modality. (e) Complex orthodontic treatment
Click here to view |
Willingness to continue orthodontic treatment – In the ongoing cases, a majority of patients preferred to visit for their regular appointments during both Phase I (66.4%) and Phase II (67.3%) [Figure 1]b.
Inability to deliver orthodontic care – During the initial period of lockdown (Phase I), 47.1% respondents reported inability to offer treatment services for around 2 to 3 months which is very similar to that in Phase II with 44.2% respondents reporting the same [Figure 1]c.
Preference for orthodontic treatment modality – In both the phases, nearly equal number of respondents noted no particular preference for any type of orthodontic treatment modality (58.7% in Phase I and 55.8% in Phase II for metal braces) [Figure 1]d.
Complex orthodontic treatment involving orthognathic surgeries – These were reported to show a decline by 77.9% of respondents in phase, being done in only 0–25% of cases as compared to pre-covid times and improved slightly in Phase II (64.4%) [Figure 1]e.
Orthodontic emergencies
Emergency cases – Around 67.3% respondents reported seeing emergency cases in the range of 0–20 patients in Phase I while in Phase II, the number of emergency cases being attended to increased slightly [Figure 2]a. | Figure 2: (a) Average (no. of) orthodontic emergencies attended. (b) Emergency calls resolved through teleconsultation. (c) Common orthodontic emergencies
Click here to view |
Teleconsultation – In the Phase I, 43.3% respondents recorded solving patient problems through tele-consultation in 0–25% patients while 31.7% reported resolving search queries through teleconsultation in 25–50% patients. Nearly the same trend was reported in the second phase as well [Figure 2]b.
Common orthodontic emergencies – Poking wire and broken brackets were the most common of the emergencies reported in both the phases accounting for nearly 90% of all orthodontic emergencies reported [Figure 2]c.
Managing challenges
Use of personal protective equipment (PPE) kit – PPE was used for all patients as reported by 61.5% respondents in Phase I but its use was reduced in the second phase. Only 43.3% respondents reported using PPE for all patients in Phase II [Figure 3]a. The orthodontist's fear of contracting the infection through clinical procedures reduced in Phase II as noticed from the shift of higher percentage of respondents from being scared (46.2% in Phase I and 29.4% in Phase II) to little scared (25% in Phase I vs. 44.1% in Phase II) [Figure 3]b. Greater percentage of respondents (45.2%) reported that their financial well-being was badly affected in Phase I that improved in Phase II with only 34.3% selecting option of badly affected category [Figure 3]c. | Figure 3: (a) Use of PPE kit. (b) Fear of becoming COVID positive amongst orthodontists. (c) Financial well-being
Click here to view |
The most common problem in arranging logistics for managing orthodontic patients was reportedly greater expense of products in both the phases, as per 62.5% and 59.8% of the respondents in Phases I and II, respectively [Table 1]. Nearly half of the respondents reported that the guidelines issued by government on carrying out clinical procedures in the times of pandemic were very helpful in both the phases (48.1% in Phase I and 49% in Phase II). On the other hand, 37% felt that these were confusing while a very small fraction reported being unaware of the existence of such guidelines in both the phases. | Table 1: Have you faced any issues related to material supply and availability
Click here to view |
The Kappa statistics revealed that amongst the studied parameters, good agreement between Phase I and Phase II was seen for the parameters like the most demanded... foremost demanded treatment modality, teleconsultation, the most common orthodontic emergencies, usage of PPE kit, and the impact of COVID (lockdown) on financial well-being [Table 2]. The rest of the parameters had poor agreement between the two phases showing dissimilar trend. | Table 2: Kappa statistics for assessment of agreement of responses between two phases
Click here to view |
| Discussion | | |
The COVID-19 pandemic has undoubtedly changed the way the world functions with phases of restrictions and relaxations resulting in dynamically changing work strategy. The dental profession is especially at high risk of viral transmission owing to high salivary concentration, generation of aerosols during various procedures, and the close proximity of the operator to the patient during treatment.[7] Hence, the dental services in all the specialties came to a near halt except for emergency management, especially in the early part of 2020.[8]
However, the year from end of March 2020 to March 2021 witnessed phases of variable functioning in all walks of life as we became better equipped to combat the pandemic. The current study was an attempt to study this pattern of changing orthodontic practice trend in the first year of pandemic. Though the response rate was weak, in view of the difficult times that each one of us was going through both at professional and personal level during the period of study only two reminder emails were sent. The period of study coincided with the devastating second wave of COVID-19 which may have affected the response.
In a study by Martina et al.,[9] 84% patients considered going to dental practice to continue orthodontic treatment after lockdown as safe. This demonstrates that COVID protocols could ensure trust in patients regarding safety of getting dental procedures done in the ongoing pandemic.
The orthodontic emergency like pain and appliance breakage are common during the course of orthodontic treatment but need special attention during the pandemic due to closure of majority of dental offices resulting in prolonged interval between follow-up visits.[10] In a study by Meisha et al.,[11] it was reported that some patients were careful about visiting dental healthcare facilities even for life-threatening situations like cellulitis due to the fear of pandemic. Furthermore, only 18% of the patients showed their willingness to report for routine dental care while 35.2% opted for teleconsultation as the initial step.[11] This fear of exposure on stepping out of the house paved way for popularization of remote methods for seeking medical help. Teleconsultation, thus, emerged as a major means of resolution of patient queries in both the phases. An article by Caprioglio et al.[12] in early April 2020 reflects this fact as they concluded that WhatsApp can be successfully used to remotely manage orthodontic emergencies.
The anxiety related to COVID-19 along with missed appointments added to the stress experienced by patients undergoing orthodontic treatment. This amount of stress in orthodontic patients was found to be higher than any other category of dental patients during the ongoing pandemic.[13] Saccomanno et al.[14] concluded that teleconsultation is not only a vital means of continuing orthodontic treatment in phases of emergencies, but also offers psychological reassurance to the patients. The type of orthodontic emergency most commonly reported was poking wire and broken brackets in both phases similar to the routine complaint even in pre-covid times.[15] In a report by Sycinska-Dziarnowska et al.[16] numerous studies have been cited where aligners gained popularity over conventional bases with metallic components for ease of wear, less breakages and possibility of virtual monitoring. However, in the current survey no such trend or preference was evident.
The use of PPE has been an integral part of the dental practice safety protocol which further escalated during COVID times. This is well reflected in the in the higher percentage of Orthodontists reporting use of PPE for all procedures. However, as the guidelines evolved, the measures appropriate to the procedures were advocated as shown by reduction in the responses favouring the use of PPE in all procedures.[16]
The pandemic had a deep impact on the psychological well-being of not only the patients but the healthcare professionals as well. The dentists comprise of one of the most vulnerable groups of healthcare professionals owing to evidence of transmission of virus through fomites, aerosols, and droplets.[17] In a review by Abedi, the COVID-19 disease was found to have psychological consequences including fear, anxiety, worry about transmitting the disease to their families, stress etc., for physicians.[18] In the same study, the next most important affect was observed to be occupational consequences in terms of financial worries and career prospects. The same observation was made in the current survey where 45% orthodontists reported suffering major setback to their financial well-being consequent to mass closure of dental practices during the first wave of the pandemic. Such restrictions were necessary owing to shortage of PPE, for flattening the curve, and protection of both the patients as well as the clinicians.[19] Schwendicke et al.[20] assessed the economic impact of policy alternatives adopted by healthcare decision makers to combat SARS-CoV2 (COVID-19 dental practices in Germany using a modelling approach and concluded that the longer COVID-19 mitigation/suppression measures are upheld, the greater will be the financial distress imposed onto the dental clinics. The guidelines issued by the various government and local authorities were found to be useful by nearly half the respondents in both the phases, thus indicating the great essentiality and utility of the road maps laid down by the authorities during times of such crisis.
The statistical analysis showed good agreement of orthodontist's opinion in two phases. There was statistically significant difference in all trends in two phases except response to the choice of treatment modality, type of emergencies, teleconsultation, usage of PPE kit and the impact of COVID (lockdown) on financial well-being. The limitation of the current study lies in the weak response rate which nevertheless could still highlight the trends as became evident when the data was compiled.
| Conclusion | | |
The unprecedented times present unforeseen challenges which need to be managed efficiently and promptly by devising appropriate protocol. This ensures uninterrupted patient care in a specialty like orthodontics having longer treatment span. Hence, it is essential to understand the trend and dynamics of orthodontic patient care in a critical situation like the ongoing pandemic. This would help in laying down well-defined protocols, strengthen preparedness and exploration of more practical treatment options in such challenging times.
Statement of participant consent
The participants consented to the publication of the findings of this online study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Supplementary File | | |
Questionnaire
Trend for Orthodontic treatment demand and its delivery: One year of/in COVID-19
The current COVID-19 pandemic has greatly impacted every aspect of life since its outbreak. In India, the nationwide lockdown was implemented in various phases from 25th March,2020. As a result, limited services could be provided during this emergency situation. This present survey aims to evaluate the impact of the COVID- 19 pandemic on orthodontic practice from March 2020 to March 2021, i.e., during and after 1st wave but prior to 2nd wave. Thus each question is subdivided into two time periods March 2020 to September 2020 (Phase 1- 1st wave and lockdown) and October 2020 to March 2021 (Phase 2 post 1st wave with decline in cases and unlock).
Table 1: Demographic data
- Age
- Gender
- City
- Type of practice: Academic/Private practice
- If Academic: Govt/private
- Designation
- Vaccination taken – Yes/No
- If yes, which one and how many doses
Table 2: Practice trend I year in COVID
A. Effect on OPD
1. How would you classify the number of new patients requesting for orthodontic treatment in comparison to normal OPD?
Phase 1
a) 0-25% b) 25-50%
c) 50-75% d) 75-100%
Phase 2
b) 0-25% b) 25-50%
d) 50-75% d) 75-100%
2. The period for which Orthodontic treatment could not be delivered in each phase
Phase 1
a) 0-1 month b) 2-3 months
c) 4-5 months d) 5-6 months
Phase 2
a) 0-1 month b) 2-3 months
c) 4-5 months d) 5-6 months
3. In what percentage of the ongoing orthodontic cases, was there a willingness to continue orthodontic treatment?
Phase 1
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
Phase 2
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
4. The most demanded treatment modality for orthodontic correction during the 2 phases-
Phase 1
a) Metal braces b) ceramic braces
c) Aligners d) no particular preference
Phase 2
a) Metal braces b) ceramic braces
c) Aligners d) no particular preference
5. How many complex Orthodontic treatment involving orthognathic surgeries could be performed as compared to pre COVID times
Phase 1
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
Phase 2
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
B. Orthodontic emergencies
1. How many cases (no.) of orthodontic emergencies were attended on an average?
Phase 1
a) 0-20 b) 20-40
c) 40-60 d) >60
Phase 2
a) 0-20 b) 20-40
c) 40-60 d) >60
2. What percentage of emergency calls could be resolved through teleconsultation only?
Phase 1
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
Phase 2
a) 0-25 % b) 25-50%
c) 50-75 % d) 75-100 %
3. The most common orthodontic emergencies encountered
Phase 1
a) Broken brackets b) Poking wire
c) Pain d) Ulceration
Phase 2
a) Broken brackets b) Poking wire
c) Pain d) Ulceration
4. How would you describe the usage of PPE kit in managing orthodontic patients?
Phase 1
a) for all patients b) only longer duration procedures
c) for all treatment procedures but not diagnosis d) not used
Phase 2
a) for all patients b) only longer duration procedures
c) for all treatment procedures but not diagnosis d) not used
C. Managing challenges
1. How would you rate the fear of becoming COVID positive due to your clinical practice?
Phase 1
a) Very scared b) Scared
c) Cautious d) Not much
Phase 2
a) Very scared b) Scared
c) Cautious d) Not much
2. How will rate the impact of COVID (lockdown) on your financial wellbeing.
Phase 1
a) very badly affected b) manageable
c) Not much d) fairly well
Phase 2
a) very badly affected b) manageable
c) Not much d) fairly well
3. Have you faced any issues related to material supply and availability? ( we can allow more than one option in this question)
Phase 1
a) difficult to get b) could procure but expensive
c) available but short expiry d) no problem in supply and pricing
Phase 2
a) difficult to get b) could procure but expensive
c) available but short expiry d) no problem in supply and pricing
4. How helpful were the Guidelines released by Ministry and various national scientific bodies?
Phase 1
a) very helpful b) confusing
c) not helpful at all d) was unaware
5. How many Webinars did you attend ?
Phase 1
a) 1-3 b) 3-6
c) 6-9 d) 10 or more
Phase 2
a) 1-3 b) 3-6
c) 6-9 d) 10 or more
| References | | |
| 1. | |
| 2. | Parasher A. COVID-19: Current understanding of its pathophysiology, clinical presentation and treatment. Postgrad Med J 2021;97:312-20.  |
| 3. | 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. doi: 10.3390/ijerph 17082821. |
| 4. | |
| 5. | García-Camba P, Marcianes M, Varela Morales M. Changes in orthodontics during the COVID-19 pandemic that have come to stay. Am J Orthod Dentofac Orthop 2020;158:e1-3. |
| 6. | Barchard KA, Williams J. Practical advice for conducting ethical online experiments and questionnaires for United States psychologists. Behav Res Methods 2008;40:1111-28. |
| 7. | Coulthard P, Thomson P, Dave M, Coulthard FP, Seoudi N, Hill M. The COVID-19 pandemic and dentistry: The clinical, legal and economic consequences - part 1: Clinical. Br Dent J 2020;229:743-7. |
| 8. | Soltani P, Baghaei K, Tavakoli Tafti K, Spagnuolo G. Science mapping analysis of COVID-19 articles published in dental journals. Int J Environ Res Public Health 2021;18:2110. doi: 10.3390/ijerph 18042110. |
| 9. | Martina S, Amato A, Rongo R, Caggiano M, Amato M. The perception of COVID-19 among Italian dentists: An orthodontic point of view. Int J Environ Res Public Health 2020;17:4384. doi: 10.3390/ijerph17124384. |
| 10. | Cotrin P, Peloso RM, Pini NIP, Oliveira RC, de Oliveira RCG, Valarelli FP, et al. Urgencies and emergencies in orthodontics during the coronavirus disease 2019 pandemic: Brazilian orthodontists' experience. Am J Orthod Dentofac Orthop 2020;158:661-7. |
| 11. | Meisha DE, Alsolami AM, Alharbi GM. Social determinants of seeking emergency and routine dental care in Saudi Arabia during the COVID-19 pandemic. BMC Oral Health 2021;21:212. doi: 10.1186/s12903-021-01577-1. |
| 12. | Caprioglio A, Pizzetti GB, Zecca PA, Fastuca R, Maino G, Nanda R. Management of orthodontic emergencies during 2019-NCOV. Prog Orthod 2020;21:10. |
| 13. | Peloso RM, Pini NIP, Sundfeld Neto D, Mori AA, de Oliveira RCG, Valarelli FP, Freitas KMS. How does the quarantine resulting from COVID-19 impact dental appointments and patient anxiety levels? Braz Oral Res 2020;34:e84. |
| 14. | Saccomanno S, Quinzi V, Sarhan S, Laganà D, Marzo G. Perspectives of tele-orthodontics in the COVID-19 emergency and as a future tool in daily practice. Eur J Paediatr Dent 2020;21:157-62. |
| 15. | Gyawali R, Pokharel PR, Giri J. Emergency appointments in orthodontics. APOS Trends Orthod 2019;9:40-3. |
| 16. | Sycinska-Dziarnowska M, Bielawska-Victorini H, Budzyńska A, Woźniak K. The implications of the COVID-19 pandemic on the interest in orthodontic treatment and perspectives for the future. Real-time surveillance using Google trends. Int J Environ Res Public Health 2021;18:5647. doi: 10.3390/ijerph 18115647. |
| 17. | 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;12:9. doi: 10.1038/s41368-020- 0075-9. |
| 18. | Abedi N. Psychological effects of the COVID-19 pandemic on dentistry: A systematic review study. J Edu Health Promot 2021;10:311. [Full text] |
| 19. | Abdelrahman H, Atteya S, Ihab M, Nyan M, Maharani DA, Rahardjo A, et al. Dental practice closure during the first wave of COVID-19 and associated professional, practice and structural determinants: A multi-country survey. BMC Oral Health 2021;21:243. doi: 10.1186/s12903-021-01601-4. |
| 20. | Schwendicke F, Krois J, Gomez J. Impact of SARS-CoV2 (Covid-19) on dental practices: Economic analysis. J Dent 2020;99:103387. doi: 10.1016/j.jdent.2020.103387. |
Correspondence Address:
Dr. Neha Bhutiani
Orthodontics and Dentofacial Orthopedics, University College of Medical Sciences, Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijdr.ijdr_136_22
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2] |
Users online:
