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 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.

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).

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:

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.

[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.

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].

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.

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.