Dentistry Section DOI : 10.7860/JCDR/2021/48361.14750
Year : 2021 | Month : Mar | Volume : 15 | Issue : 03 Page : ZC36 - ZC44

Orthodontic Practice in the Times of COVID-19 Pandemic: An Online Survey

Suman1, Maninder Singh Sidhu2, Seema Grover3, Ashish Dabas4, Namrata Dogra5, Archana Jaglan6

1 Postgraduate Student, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.
2 Head, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.
3 Professor, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.
4 Professor, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.
5 Reader, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.
6 Postgraduate Student, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Suman, Postgraduate Student, Department of Orthodontics, Faculty of Dental Sciences, SGT University, Gurgaon-122505, Haryana, India.
E-mail: dr.suman.summi@gmail.com
Abstract

Introduction

Coronavirus Disease 2019 (COVID-19) pandemic is not the first one which the globe has faced but never came across a health crisis that moved so quickly across continents. COVID-19 outbreak presently posed a very serious threat to the existence of mankind on earth. The massive impact of COVID-19 pandemic was evident in all aspects of life-personal, social as well as professional. The field of dentistry including orthodontics was no exception to this.

Aim

To describe the impact of COVID-19 pandemic on orthodontic practice, exploring the basic sterilisation protocols being followed during COVID-19 pandemic and to predict the future of orthodontics in post-COVID era.

Materials and Methods

The Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India, conducted this questionnaire based cross-divtional survey in May 2020 over a time span of 20 days. A web-based questionnaire of 15 multiple choice questions in English was created as a Google Form in Google Documents. The link to this form was shared online with the orthodontists and postgraduate students (Orthodontics) of dental colleges situated in the National Capital Region (NCR) through WhatsApp groups and e-mails. A total of 254 responses were received.

Results

A 97.6% of respondents agreed that COVID-19 affected their orthodontic practice. The odds ratio between those not likely to resume practice and those likely to resume practice taking educational qualification as the significant predictor was calculated to be 8.976 at 95% confidence intervals. There was wide variation in the selection of the safety protocols by the orthodontists in the present study (p<0.01). Increased digitalisation in orthodontics (45.7%) followed by less demand of orthodontic treatment (18.5%) were opted as the future in post-COVID era (p<0.01).

Conclusion

The present survey found that orthodontic community as a whole was affected greatly by COVID-19 pandemic and is quite apprehensive. The future of orthodontics in the post-COVID era is unpredictable presently. Digitalisation in orthodontics is the key option to have minimum physical contact with the patients. The study suggested the need and importance of basic sterilisation protocols and a training program for dental settings during COVID-19 for patient’s as well as clinician’s safety.

Introduction

Coronavirus Disease (COVID-19) outbreak is one of the most deadliest pandemics that the world has faced till now. COVID-19 disease caused by SARS-COV-2 virus emerged as a challenge for the governments as well as medical fraternity throughout the globe [1,2]. World Health Organisation (WHO) declared COVID-19, a public health emergency on January 30, 2020 [3].

A mild to severe respiratory illness caused by the Coronavirus gets transmitted by respiratory droplets characterised by fever, cough and shortness of breath may progress to pneumonia or Acute Respiratory Distress Syndrome (ARDS) [4]. The chances of developing serious illness in older patients with health related issues like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are very high. Notably, 80% of the patients have only mild flu-like symptoms and seasonal allergies, which might lead to an increased number of undiagnosed cases [5]. It is known to be highly transmissible when patients are most symptomatic. Incubation period can range from 2 to 14 days; hence transmission can occur before any symptoms become apparent. These asymptomatic patients can act as “carriers” and also serve as reservoir for re-emergence of infection [6].

The COVID-19 spread exponentially is leading to a global public health crisis. Various studies were conducted to check the efficacy of existing drugs like hydrochloroquine and other treatment strategies in the treatment of COVID-19 positive patients. Scientists and researchers throughout the world struggled hard to find a vaccine against this deadly Coronavirus to finally achieve success recently [7-9]. Specific guidelines for health workers on basic sterilisation protocols, use of Personal Protective Equipments (PPEs), N95 masks, face shields etc., have been suggested and constantly being updated by WHO, Centers for Disease Control and Prevention (CDC) and Indian Council of Medical Research (ICMR) in India [10-12].

The massive impact of COVID-19 pandemic was evident in all aspects of life; personal, social as well as professional disrupting the entire health, economic and social framework of the whole world [13]. The field of dentistry including orthodontics was no exception to this. In fact, the dentists are at the greatest risk of exposure to pathogenic microorganisms, including viruses and bacteria that infect the oral cavity [14]. Indian Dental Association (IDA) and Indian Orthodontic Society (IOS) issued guidelines to the dentists and orthodontists to restrict dental operations to emergency and urgent treatment procedures only after teleconsultation, and through prefixed appointment with all the necessary standard precautions [15,16].

In the present scenario, the fear of orthodontists might be decreased demand of braces neither being any emergency nor an urgency among the general public in developing country like India. Also, an additional financial burden of upgrading the clinical set-up and following all the necessary standard protocols to ensure safety of patients as well as dental professionals was a big worry. Dentists should understand the moral responsibility to prevent the spread among the patients in spite of the financial consequences [17].

Many studies have been published highlighting preappointment tele-triage, available sterilisation protocols and how to deal with different orthodontic emergencies at home or in office during COVID-19 pandemic [18,19]. A few studies are available on the impact perceived by the orthodontists on ground [20]. The present study is novel as it tried to identify how severely COVID-19 affected orthodontic practice, whether sterilisation protocols being advertised are being followed or not and what are the fears in the minds of orthodontic community.

This paper was an attempt to describe the impact of COVID-19 on orthodontic practice, exploring the basic sterilisation protocols being followed during the COVID-19 pandemic and to predict the future of orthodontics in the post-COVID era.

Materials and Methods

The Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India, conducted this questionnaire based cross-sectional survey in May 2020 over a time span of 20 days.

Inclusion and Exclusion criteria: Inclusion criteria were orthodontists and postgraduate students (Orthodontics) of dental colleges situated in the NCR and the exclusion criteria were non orthodontic professionals. A list of total of 360 faculty members and postgraduates of orthodontic departments of the colleges of the NCR region was generated as a whole sample.

Questionnaire: A web-based questionnaire consisting of 15 multiple choice questions was created as a Google Form in Google documents (https://docs.google.com/forms/d/e/1FAIpQLSfvp5KdcV_I21Dn6iGvmEfpQp8cEAIYYwmrfsVuqaIpnCO0yA/viewform?usp=sf_link) [Annexure-1].

The questionnaire was designed on the basis of objectives of our survey. Multiple choice questions included three parts:

The first part was related to demographic data (Type of practice, years of practice) and effect of COVID-19 on orthodontic practice.

Second part consisted of questions to assess the knowledge of basic sterilisation protocols being followed among orthodontists during the COVID-19 pandemic.

Third part consisted of questions regarding future of orthodontics in post-COVID era in India.

The pilot study with the same questionnaire was conducted on 20 faculty members and postgraduates of our Department of Orthodontics, Faculty of Dental Sciences, SGT University and the Cronbach’s alpha value recorded was 0.87 indicating an acceptable level of reliability of the survey questionnaire.

The link to this form was shared online with the list of 360 Orthodontists and postgraduate students (Orthodontics) of dental colleges situated in the NCR through WhatsApp groups and e-mails. Personal e-mails were obtained from Departments of Orthodontics of Dental Colleges situated in the NCR.

An introduction at the beginning of the questionnaire stating the purpose of the study and acceptance to participate was considered as consent and no incentives were given to the respondents. Confidentiality and anonymity were confined so that responses cannot be linked to individual participants.

A total of 254 responses were received for this online survey form link active for 20 days only with a response rate of 70.5%. [Table/Fig-1] shows the distribution of responses received into groups on the basis of educational qualification/designation and years of experience.

Distribution of study subjects.

According to educational qualifications/designation
Educational qualificationNumberPercentage (%)
Pursuing MDS in Orthodontics (Postgraduates)12850.4
Completed MDS in Orthodontics12649.6
1. Private Practitioner/Consultant7429.1
2. Academician (Private)4015
3. Academician (Government)124.7
Total254100
According to years of experience
Years of experienceNumberPercentage (%)
<5 years14657.5
5-10 years5320.9
11-15 years197.5
>15 years3614.1
Total254100

Statistical Analysis

Data collected was tabulated using Microsoft excel and analysed using Statistical Package for Social Sciences (SPSS) version 20. (IBM SPASS statistics, IBM corp. Armonk, NY, USA released 2011). Descriptive statistics of the explanatory and outcome variables was calculated by mean and standard deviation for quantitative variables. Frequency and proportion was calculated for qualitative variables. Chi-Square/Fisher Freeman Halton test by cross tabulation was used to compare frequencies. Binominal and Multinominal logistic regression analysis was carried out at 95% Confidence Intervals to identify variables affecting the responses to questions. Any p-value less than 0.05 were considered to be significant for all analyses (two-tailed).

Results

Participants of this survey were between the age ranges of 23 to 58 years with varying clinical experience from less than 5 years to more than 15 years. A 50.4% of the respondents were pursuing postgraduation and 49.6% were academicians and clinicians/consultants. [Table/Fig-2] shows the responses of study subjects to different questions under different subheadings:

Responses of study subjects.

QuestionsResponsesNumberPercentage (%)
a) Effect of COVID-19 on orthodontic practice
Has COVID-19 affected your orthodontic practice?Yes24897.6
No62.4
Do you feel it is safe to resume your orthodontic practice in the current situation?Yes3614.2
No15962.6
Can’t say5923.2
In your practice, most of the patients require orthodontic treatment primarily forAesthetics17970.5
Functional problems72.7
Growth modification20.8
Combination6626.0
Is your staff willing to work in such conditions?Yes8935.0
No7027.6
May be9537.4
b) Sterilisation protocols being followed during COVID-19
What all safety protocols will you follow/are following in your orthodontic set up?PPEs (Disposable), N95 masks, eye glass protectors2710.6
PPEs (Disposable), N95 masks, Face shield3313.0
PPEs (Disposable) with hood and shoe covers, N95 masks, eye glass protectors5622.0
Autoclavable surgical coveralls, head caps, shoe covers, surgical masks, Face shields4517.8
PPEs (Disposable) with hood and shoe covers, N95 masks, Face shields9336.6
Which basic qualities one should check while buying PPEs/autoclavable coveralls?High GSM, SITRA approval228.6
High GSM, non-woven, laminated, taped, waterproof239.1
Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent3112.2
High GSM, SITRA approval, Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent17870.1
Can N95 mask be reused?Yes14958.7
No6626.0
Can’t say3915.3
What basic precautions/measures will you take/are taking to prevent aerosol generation in your orthodontic practice?Just Avoid using air rotor, ultrasonic scaler and 3-way syringe10240.1
Use of micromotor and hand scaler with irrigation with syringe239.1
Use of handpiece with anti-retraction valves with Extraoral high volume suction124.7
HEPA filter along with Use of handpiece with anti-retraction valves with Extraoral high volume suction6224.4
Aerosol generating procedures done in Isolation negative pressure operatory/Airborne Infection Isolation Rooms (AIIRs)5521.7
Managing Biomedical Waste Management (BMW) of PPEs will be?Easy2811.0
Difficult17568.9
No idea5120.1
c) Future of orthodontic practice in post-COVID era
Do you think that the cost of dental materials/equipments and orthodontic treatment is going to increase post-COVID?Yes22387.8
No135.1
No idea187.1
According to you, who will bear the additional cost of extra safety protocols?Patient6124.0
Orthodontist3714.5
50% Patient + 50% Orthodontist15059.1
Others062.4
Which treatment modality is preferable in post-COVID era?Fixed orthodontic treatment5722.4
Functional/Orthopaedic appliances041.6
Removable orthodontic appliances062.4
Clear aligners11043.3
Combination7730.3
In your opinion, what could be the future of orthodontics in developing countries like India in the post-COVID era?Less demand of orthodontic treatment4718.5
Same as before the COVID-19 pandemic outbreak4517.7
Increased digitalisation in orthodontics11645.7
Can’t say3112.2
Both Option 1 and 3155.9

a) The effect of COVID-19 on orthodontic practice.

b) The sterilisation protocols being followed during COVID-19 outbreak.

c) The future of orthodontic practice in post-COVID era.

Taking consideration of orthodontic treatment objectives, 70.5% orthodontist reported aesthetics and 26% ticked multiple options of aesthetics, functional problems, growth modification and other difficulties like Temporomandibular Disorders (TMDs). Willingness of the staff to work in the present Corona times was questionable due to fear of life on one hand and earning livelihood on the other. A 35% of responses reported that the staff was ready to work; but 27.6% denied and 37.4% had no idea. About 36.6% of the respondents selected the option of PPEs (disposable) with hood and shoe covers, N95 masks, face shields followed by 22% who preferred eye glass protectors in place of face shields and 17.7% adopted autoclavable surgical coveralls, head caps, shoe covers, surgical masks, face shields [Table/Fig-2]. Increased digitalisation in orthodontics (45.7%) followed by less demand of orthodontic treatment (18.5%) were opted as the future in post-COVID era (p<0.01).

The most common modality selected overall as well as by all groups in all categories was clear aligners (43.3%) followed by combination of different modalities depending upon malocclusion (30.3%), fixed orthodontic treatment (22.4%), removable orthodontic appliances (2.4%), functional/orthopaedic appliances (1.6%).

[Table/Fig-3] shows the comparison of responses of study subjects based on educational qualification. There was wide variation in the selection of the safety protocols by the orthodontists in the present study (p <0.01). [Table/Fig-4] depicts the comparison of responses of study subjects based on years of experience.

Comparison of responses of study subjects based on educational qualification.

QuestionsResponsesPursuing MDS n (%)Completed MDS n (%)Chi-Squarep-value
Has COVID-19 affected your orthodontic practice?Yes124 (96.9)124 (98.4)0.689
No04 (3.1)02 (1.6)
Do you feel it is safe to resume your orthodontic practice in the current situation?Yes09 (7.0)27 (21.4)0.02*
No91 (71.1)68 (54.0)
Can’t say28 (21.9)31 (24.6)
In your practice, most of the patients require orthodontic treatment primarily forAesthetics94 (73.4)85 (67.5)0.116
Functional problems05 (3.9)02 (1.5)
Growth modification02 (1.6)00 (0.0)
Combination27 (21.1)39 (31.0)
What all safety protocols will you follow/are following in your orthodontic set up?PPEs (Disposable), N95 masks, eye glass protectors12 (9.4)15 (11.9)0.019*
PPEs (Disposable), N95 masks, Face shield12 (9.4)21 (16.7)
PPEs (Disposable) with hood and shoe covers, N95 masks, eye glass protectors35 (27.3)21 (16.7)
Autoclavable surgical coveralls, head caps, shoe covers, surgical masks, Face shields16 (12.5)29 (23)
PPEs (Disposable) with hood and shoe covers, N95 masks, Face shields53 (41.4)40 (31.7)
Which basic qualities one should check while buying PPEs/autoclavable coveralls?High GSM, SITRA approval07 (5.5)15 (11.9)0.001**
High GSM, non-woven, laminated, taped, waterproof04 (3.1)19 (15.1)
Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent15 (11.7)16 (12.7)
High GSM, SITRA approval, Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent102 (79.7)76 (70.3)
Can N95 mask be reusedYes66 (51.6)83 (65.9)0.019*
No35 (27.3)31 (24.6)
Can’t say27 (21.1)12 (9.5)
What basic precautions/measures will you take/are taking to prevent aerosol generation in your orthodontic practice?Just Avoid using air rotor, ultrasonic scaler and 3-way syringe34 (26.6)68 (54.0)0.001**
Use of micromotor and hand scaler with irrigation with syringe14 (10.9)09 (7.1)
Use of handpiece with anti-retraction valves with Extraoral high volume suction06 (4.7)06 (4.8)
HEPA filter along with Use of handpiece with anti-retraction valves with Extraoral high volume suction36 (28.1)26 (20.6)
Aerosol generating procedures done in Isolation negative pressure operatory/Airborne Infection Isolation Rooms (AIIRs)38 (29.7)17 (13.5)
Managing Biomedical Waste Management (BMW) of PPEs will be?Easy11 (8.6)17 (13.5)0.327
Difficult88 (68.7)87 (69.0)
No idea29 (22.7)22 (17.5)
Do you think that the cost of dental materials/equipm-entsand orthodontic treatment is going to increase post-COVID?Yes115 (89.8)108 (85.7)0.572
No05 (3.9)08 (6.3)
No idea08 (6.2)10 (7.9)
According to you, who will bear the additional cost of extra safety protocols?Patient19 (14.8)42 (33.3)0.007*
Orthodontist21 (16.4)16 (12.7)
50% Patient + 50% Orthodontist85 (66.4)65 (51.6)
Others03 (2.3)03 (2.4)
Is your staff willing to work in such conditions?Yes25 (19.5)64 (50.8)0.001**
No47 (36.7)23 (18.3)
May be56 (43.8)39 (31.0)
Which treatment modality is preferable in post-COVID era?Fixed orthodontic treatment28 (21.9)29 (23.0)0.695
Functional/Orthopaedic appliances03 (2.3)01 (0.8)
Removable orthodontic appliances03 (2.3)03 (2.4)
Clear aligners59 (46.1)51 (40.5)
Combination35 (27.3)42 (33.3)
In your opinion, what could be the future of orthodontics in developing countries like India in the post-COVID era?Less demand of orthodontic treatment19 (14.8)28 (22.2)0.119
Same as before the COVID-19 pandemic outbreak19 (14.8)26 (20.6)
Increased digitalisation in orthodontics64 (50.0)52 (41.3)
Can’t say15 (11.7)16 (12.7)
Both Option 1 and 311 (8.6)4 (3.2)

(p<0.05* statistically significant; p<0.001** statistically highly significant)


Comparison of responses of study subjects based on years of experience.

QuestionsResponses<5 yearsn (%)5-10 yearsn (%)11-15 yearsn (%)>15 yearsn (%)Chi-squarep-value
Has COVID-19 affected your orthodontic practice?Yes143 (97.9)50 (94.3)19 (100)36 (100)0.274
No03 (2.1)03 (5.7)00
Do you feel it is safe to resume your orthodontic practice in the current situation?Yes18 (12.3)05 (9.4)03 (15.8)10 (27.8)0.174
No98 (67.1)33 (62.3)11 (57.9)17 (47.2)
Can’t say30 (20.5)15 (28.3)05 (26.3)09 (25.0)
In your practice, most of the patients require orthodontic treatment primarily forAesthetics110 (75.3)32 (60.4)11 (57.9)26 (72.2)0.104
Functional problems05 (3.4)01 (1.9)01 (5.3)0
Growth modification002 (3.8)00
Combination31 (21.2)18 (27.3)07 (36.8)10 (27.8)
What all safety protocols will you follow/are following in your orthodontic set up?PPEs (Disposable), N95 masks, eye glass protectors12 (8.2)12 (22.6)003 (8.3)0.133
PPEs (Disposable), N95 masks, Face shield19 (13.0)07 (13.2)03 (15.8)04 (11.1)
PPEs (Disposable) with hood and shoe covers, N95 masks, eye glass protectors39 (26.7)07 (13.2)05 (26.3)05 (13.9)
Autoclavable surgical coveralls, head caps, shoe covers, surgical masks, Face shields23 (15.8)11 (20.8)04 (21.1)07 (19.4)
PPEs (Disposable) with hood and shoe covers, N95 masks, Face shields53 (36.3)16 (30.2)07 (36.8)17 (47.2)
Which basic qualities one should check while buying PPEs/autoclavable coveralls?High GSM, SITRA approval09 (6.2)07 (13.2)02 (10.5)04 (11.1)0.408
High GSM, non-woven, laminated, taped, waterproof14 (9.6)03 (5.7)03 (15.8)03 (8.3)
Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent23 (15.8)04 (7.5)004 (11.1)
High GSM, SITRA approval, Impermeable to blood and body fluids, Meets or exceeds ISO 16603 class 3 exposure press or equivalent100 (68.5)39 (73.6)14 (73.3)25 (69.4)
Can N95 mask be reusedYes85 (58.2)30 (56.6)13 (68.4)21 (58.3)0.429
No34 (23.3)15 (28.3)04 (21.1)13 (36.1)
Can’t say27 (18.5)05 (15.1)02 (10.5)02 (5.6)
What basic precautions/measures will you take/are taking to prevent aerosol generation in your orthodontic practice?Just Avoid using air rotor, ultrasonic scaler and 3-way syringe48 (32.9)25 (47.2)09 (47.4)20 (55.6)0.136
Use of micromotor and hand scaler with irrigation with syringe13 (8.9)06 (11.3)02 (10.5)02 (5.6)
Use of handpiece with anti-retraction valves with Extraoral high volume suction05 (3.4)04 (7.5)01 (5.3)02 (5.6)
HEPA filter along with Use of handpiece with anti-retraction valves with Extraoral high volume suction37 (25.3)13 (24.5)04 (21.1)08 (22.2)
Aerosol generating procedures done in Isolation negative pressure operatory/Airborne Infection Isolation Rooms (AIIRs)43 (29.5)05 (9.4)03 (15.8)04 (11.1)
Managing Biomedical Waste Management (BMW) of PPEs will be?Easy12 (8.2)06 (11.3)05 (26.3)05 (13.9)0.059
Difficult103 (70.5)33 (62.3)10 (52.6)23 (80.6)
No idea31 (21.2)14 (26.4)04 (21.1)02 (5.6)
Do you think that the cost of dental materials/equipments and orthodontic treatment is going to increase post-COVID?Yes130 (89)43 (81.1)17 (89.5)33 (91.7)0.018*
No02 (1.4)06 (11.4)02 (10.5)03 (8.3)
No idea14 (9.6)04 (7.5)00
According to you, who will bear the additional cost of extra safety protocols?Patient23 (15.8)21 (39.6)10 (52.6)07 (19.4)0.001**
Orthodontist27 (18.5)05 (9.4)005 (13.9)
50% Patient + 50% Orthodontist94 (64.4)27 (50.3)08 (42.1)21 (58.3)
Others02 (1.4)001 (5.3)03 (8.3)
Is your staff willing to work in such conditions?Yes37 (25.1)25 (47.2)08 (42.1)19 (52.8)0.004*
No43 (29.5)17 (32.1)03 (15.8)07 (19.4)
May be66 (45.2)11 (20.8)08 (42.1)10 (27.8)
Which treatment modality is preferable in post-COVID era?Fixed orthodontic treatment35 (24.0)10 (18.9)04 (21.1)08 (22.2)0.178
Functional/Orthopaedic appliances02 (1.4)01 (1.9)001 (2.8)
Removable orthodontic appliances04 (2.7)002 (10.5)0
Clear aligners70 (47.9)22 (41.5)07 (36.8)11 (30.6)
Combination35 (24.0)20 (37.7)06 (31.6)16 (44.4)
In your opinion, what could be the future of orthodontics in developing countries like India in the post-COVID era?Less demand of orthodontic treatment24 (16.4)12 (22.6)03 (15.8)08 (22.2)0.002*
Same as before the COVID-19 pandemic outbreak21 (14.4)10 (18.9)03 (15.8)11 (30.6)
Increased digitalisation in orthodontics71 (48.6)20 (37.7)11 (57.9)14 (38.9)
Can’t say26 (17.8)02 (3.8)02 (10.5)01 (2.8)
Option 1 and 304 (2.7)09 (17.0)002 (5.6)

(p<0.05*statistically significant; p<0.001**statistically highly significant)


[Table/Fig-5] shows Binominal and Multinominal logistic regression analysis carried out at 95% Confidence intervals to identify variables affecting the responses to questions. The odds ratio between those not likely to resume practice and those likely to resume practice taking educational qualification as the significant predictor was calculated to be 8.976 at 95% confidence intervals indicating that for every unit increase in educational qualification the odds of person resuming practice changed by a factor of 8.976.

Binominal and Multinominal logistic regression analysis at 95% Confidence Intervals. The first set of coefficients represents comparison between those not likely to resume practice (Responded No, coded 2) and those likely to resume practice (Responded yes, coded 1).

q4aBStd. ErrorWalddfSig.Exp (B)95% Confidence interval for Exp (B)
Lower BoundUpper Bound
Intercept-3.9990.75528.07010.000
Educational Qualification2.1950.7468.66010.0038.9762.08138.710
Designation-0.7610.4902.41410.1200.4670.1791.220
Years of experience0.2080.1921.17210.2791.2310.8451.795
Intercept-1.6880.51810.61210.001
Educational Qualification0.5650.6700.71010.4001.7590.4736.547
Designation-0.2430.4430.30010.5840.7840.3291.870
Years of experience0.1540.1730.79110.3741.1660.8311.637

B: Unstandardised beta regression coefficient; Std. Error: Standard error; df: Degrees of freedom; Sig.: Significance


Discussion

Dentistry in Corona times is shut down in most parts of the country and will not come back soon as “usual.” The current survey was done to evaluate the dilemma of orthodontic practice in the times of Corona. The COVID-19 pandemic has shattered the economy of almost the entire world [13]. A 97.6% of the respondents to this survey agreed that COVID-19 has affected their orthodontic practice. All groups (based on designation, educational classification or clinical experience) have been largely affected by this deadly pandemic. Isiekwe IG et al., reported in their study that pandemic had a negative social, economic and psychosocial impact on orthodontist’s life [20].

Guo H et al., found that at the beginning of the COVID-19 outbreak, 38% fewer patients visited the dental offices [21]. The findings highly recommend that COVID-19 had greatly impacted dental patients’ behaviour. Cotrin P et al., concluded that the COVID-19 pandemic and the quarantine duration had a great impact on orthodontic appointments and patient’s anxiety [22]. Shenoi SB et al., revealed that orthodontic patients were also affected due to inaccessibility of orthodontists and recommended that orthodontic patients should be given mental support by the orthodontic professionals [23].

The present survey findings showed that 62.6% did not feel that it was safe to resume their orthodontic practice in the COVID-19 outbreak and 23.2% were confused about it. Odds Ratio of 8.976 shows that the odds of resuming practice were higher among those who completed MDS when compared to those who were pursuing MDS. Private practitioners/consultants were more likely to resume their orthodontic practice than other groups, the reason might be the financial implications (p<0.01).

The reason for this could be attributed to the high vulnerability risk for the dental team as well as patients as ACE-2 receptors expressed on oral cavity mucosa binds to SARS-CoV-2 viral spike causing COVID-19 infection, so the prevention protocol should be religiously followed in dental practice and daily life [24]. Dental professionals should play a major role in preventing the transmission of coronavirus. When the routine dental care was suspended during the period of COVID-19 pandemic, there was a need for organised urgent care delivery system fully equipped with adequate PPEs [25].

In the present survey, all groups (based on designation, educational classification or clinical experience) agreed that aesthetics was the most important concern among patients for seeking orthodontic treatment. This is in agreement to survey findings of Wȩdrychowska-Szulc B and Syrynska M, published in 2010 concluding that “Improvement in dental aesthetics was the principle motivational factor for the children, their parents/guardians, and adult patients seeking orthodontic treatment” [26].

When comparing the response on willingness of staff to work between different groups, a significant difference was found (p<0.01) in the present survey. Private practitioners, consultants and academicians were almost 2.5 times more affirmative than the postgraduates (p<0.01). Also, the orthodontists with more than 15 years of experience were more than twice affirmative than having less than 5-years experience (p<0.01). This clearly indicates that experience instills more confidence in the staff towards the clinical practice. Kerr J, concluded that experienced physicians can become better with the balance of confidence and humility which can benefit co-workers as well as patients [27].

Caprioglio A et al., classified orthodontic emergencies and proposed various guidelines for the management of those emergencies using visual assistance aids [28]. ADA has also issued interim guidance for management of emergency and urgent dental care [29]. The Guidelines for Dental Professionals in COVID-19 pandemic situation issued on 19 May 2020 specify the standard protocols to be followed in different risk care settings–low, medium and high risk [30]. CDC has reorganised guidelines for dental settings for routine dental healthcare delivery during the pandemic and providing dental healthcare to a suspected or confirmed SARS-CoV-2 infected patient [31].

There was wide variation in the selection of the safety protocols by the orthodontists in the present study (p<0.01). The reason may be different financial conditions, set-ups in different localities or unawareness. Some respondents, although a very little percentage, were satisfied with very basic surgical masks and gloves. Selcen F and Kilinc J stated reasons why Health Care Workers (HCWs) chose not to wear PPE including lack of proper training, limited material availability, increased working time, decrease in performing ability and many others [32]. Srirengalakshmi M et al., in their article highlighted the dichotomy of attitudes and responses among orthodontic professionals in accepting the “new normal” and provided guidance on precautions to be taken, preappointment screening and triage, disinfection and sterilisation protocols and aerosol mitigation during treatment of orthodontic patients in the COVID-19 era [33].

A 70.1% of the participants were of the opinion that basic qualities like high GSM, SITRA approval, impermeable to blood and body fluids, meeting or exceeding ISO 16603 class 3 exposure press or equivalent should be checked while buying PPEs/autoclavable coveralls. In this question also, the results were significantly different among different groups based on designation or educational qualification (p<0.01) but not on clinical experience.

N95 face masks are regulated by the National Institute for Occupational Safety and Health (NIOSH) and the CDC. An N-95 respirator mask is mandatory for dental professionals, is a well-known fact and CDC has recommended five mask reuse protocol for 20 working days [34]. But still there was a lot of confusion about its reusability. Only 58.7% of the reported orthodontists had given an affirmative answer to this question with some of them giving explanations like ‘use it once, keep away for three days then use again for a day, it may be sterilised etc.

Academicians and private practitioners are significantly more sure that N95 masks can be reused than postgraduates pursuing MDS in orthodontics (p<0.01). N95 masks provide protection from small airborne particles, including aerosols after fit-testing to ensure a tight seal around the user’s face. There are strict regulations dictating the filtration efficiency and breathing resistance of N95 respirators [35].

The survey reported that 40.2% avoided using air rotor, ultrasonic scaler and 3-way syringe, 9.1% preferred the use of micromotor and hand scaler with irrigation with syringe and another 4.7% advocated the use of handpiece with anti-retraction valves with extraoral high volume suction. Just 24.4% responded for HEPA filter along with use of handpiece with anti-retraction valves with extraoral high volume suction and remaining 21.7% responded to perform aerosol generating procedures in isolation negative pressure operatory/Airborne Infection Isolation Rooms (AIIRs) (p<0.01). Fear factor may be a cause for highly significant difference in responses. Strategies including patient evaluation, hand hygiene, personal protective measures for the dental professionals, mouthrinse before dental procedures, rubber dam isolation, anti-retraction handpiece, disinfection of the clinic settings, and management of medical waste are a must to prevent the transmission of 2019-nCov during dental diagnosis and treatment [36,37].

Biomedical Waste Management (BMW) was considered difficult by 68.9%; 20.1% had no idea about it and some stating it ‘meticulous; similar; manageable etc’. Academicians were found to be significantly more confident about BMW (p<0.05). In addition to BMW management rules 2016, specified guidelines for the management of waste generated during diagnostics and treatment of COVID-19 suspected/confirmed patients should be followed in isolation wards, quarantine centres, sample collection centres, laboratories and common biomedical waste treatment and disposal facilities [38].

With regard to future of orthodontic practice in post-COVID 19, 87% thought that the cost of dental materials/equipments and orthodontic treatment would increase post-COVID with results significantly different among groups based on clinical experience (p<0.01). The present and the upcoming challenge in the post-COVID-19 era would be an increase in the cost of oral health services limiting the patient access to health care especially in developing countries like India [39,40]. Only 14.6% said that the orthodontists should bear the additional cost; 24% objected that it should be paid by the patient. A 59.1% agreed that cost be divided equally among the patient and the orthodontist while the remaining 2.4% gave additional options like ‘the institution which I am working with; depends on work place; govt/third party like insurance company etc.,’ (p<0.01).

The most common modality selected overall as well as by all groups in all categories was clear aligners (43.3%). The use of aligners as treatment modality in orthodontic offices can bring about efficient tooth movement with more spaced out appointments, reduced chair-side time, minimum intraoral treatments and almost negligible aerosol generation during the treatment [41]. Naseem KT et al., and Sharan J et al., in their review focused on the publications on changes in orthodontic practice due to COVID-19 pandemic, handling of orthodontic emergencies during lockdown and valuable preventive measures for orthodontic professionals [42,43].

Although, it was difficult to predict the future of orthodontics in those circumstances, but together it might become a reality. The present survey reported that increased digitalisation in orthodontics (45.7%) had the highest probability followed by less demand of orthodontic treatment (18.5%). Experienced orthodontists were optimistic that future of orthodontics in the post-COVID era will be same as before the outbreak of this pandemic with increased digitalisation (p<0.01).

Digitalisation (individualised) orthodontics is the key option to have minimum physical contact with the patient, clear aligners/appliances printed digitally with devices like accledent or biopharmacologic agents (Precision orthodontics) to enhance the orthodontic tooth movement to complete the orthodontic treatment as early as possible [44-46].

Limitation(s)

The participants were anonymous and had different levels of knowledge, different clinical experiences, set-ups in different localities and from different places/backgrounds, so the difference in opinions. Further such studies should be conducted with larger sample sizes.

Conclusion(s)

The present survey found that the orthodontic community as a whole had been affected greatly by the COVID-19 pandemic and was quite apprehensive. The study suggested the need and importance of a training program for dental settings during COVID-19 imparting adequate knowledge about basic sterilisation protocols, basic requirements of PPEs, the donning and doffing methods, reusability of N95 masks and BMW for the patient’s and the clinician’s safety. So, the entire orthodontic fraternity got together in these difficult times to ensure a better future and pulled out the anxieties by discussion and tried to find out the possible solutions. Webinars and online panel discussions conducted during current lockdowns were great endeavours.

That the future of orthodontics in the post-COVID era is unpredictable presently, it won’t be the same as it was before the lockdown. Dental procedure cost which is already considered high by many will rise even higher due to use of new PPEs for every patient and every appointment. The overall opinions in the survey might also aid in policy-making for the orthodontists in the future.

(p<0.05* statistically significant; p<0.001** statistically highly significant)(p<0.05*statistically significant; p<0.001**statistically highly significant)B: Unstandardised beta regression coefficient; Std. Error: Standard error; df: Degrees of freedom; Sig.: Significance

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