Keywords
Jordan - COVID-19 - Treatment - Orthodontic - Appointment - Lockdown
Introduction
The novel coronavirus disease 2019 (COVID-19) broke out in Wuhan, China, at the end
of 2019 and, then, spread globally, causing major health, humanitarian, and financial
crises.[1] Each affected country has adopted different policies and strategies to combat the
pandemic, and many clinics closed partly or completely to control the infection in
the absence of vaccines.[2] Dental offices were no exception, especially since the main route of the transmission
of the virus is through the respiratory tract, direct or close contact with infected
persons, and the asymptomatic carriage of the virus, which could increase the possibility
of transmission.[3]
Despite the recommendations released on methods of protection and proper precautions
to follow,[4] many governments preferred to lockdown their countries with a complete closure for
unnecessary health care.[5] Oral and dental care during the lockdown considered only urgent care under strict
precautions, and all other routine procedures were postponed, causing a massive delay
in receiving care and compensating for patients' appointments.[6]
Orthodontic treatment requires a regular visit over a long period that could reach
2 years and the COVID-19 pandemic affected patients' treatment schedule and disrupted
the success of a quality treatment because of prolonged and missed appointments.[1]
[7] According to Xiong et al 2020, 90.39% of orthodontic patients had their appointments
delayed for over a month.[8] Beckwith et al reported that orthodontic treatment was prolonged for 1.09 months
with each missed appointment.[9] During this pandemic and subsequent clinic closures, most of the orthodontic patients
were unable to get the care they needed, causing anxiety and psychological distress.
Hence, the purpose of this study was to evaluate the challenges faced by orthodontic
patients at prince Rashid Hospital in the north of Jordan during the COVID-19 pandemic,
ways they managed these challenges, and concerns about their orthodontic treatment.
Material and Methods
Study Design and Settings
This was a cross-sectional study conducted on orthodontic patients who attended the
orthodontic clinic at Prince Rashid Hospital in the north of Jordan after the lockdown
was lifted.
Sampling
A self-administered questionnaire was handed to a total of 130 patients who visited
the orthodontic clinic to receive treatment. Patients were approached on random days
during the first month of re-opening of clinics after the lockdown (May 2020). During
their waiting time, the main investigator of the study talked to patients in the waiting
room about the purpose of the study and method of participating, explaining the optionality
of participation, confidentiality, and privacy of information. Those who consented
and successfully completed the self-administered questionnaire were 120, forming a
response rate of 92.3%. No interruption during filling the questionnaire or assistance
in explaining questions was provided to participants to avoid any bias toward certain
answers and ensure that the investigators' opinions are not imposed on their answers.
Instrument
The questions of the questionnaire were developed after reviewing related studies
and adopted questions that meet the study objectives.[4]
[10]
[11] The questionnaire consisted of four parts. The first part included personal information
(age, gender, and type of appliance), the second part was related to patients' attitude
during the closure, the third part discussed problems encountered and their management,
and the last part was related to patients' concerns about their orthodontic treatment.
The questions were first developed in English and checked by the investigator and
another researcher for their comprehensibility and adaptability with study objectives.
A translator was asked to translate the questionnaire into Arabic and another one
to translate it back into English to check the proficiency and correctness of the
translation. The main investigator and the other researcher checked the Arabic version
before it was provided to participants.
Ethical Considerations
This study gained approval from the internal review board of the Royal Medical Services
in Jordan.
Results
Although 130 patients were outreached to participate in the study, 120 were included
in the analysis and 10 respondents were excluded due to inconsistencies of answers
they provided to repeated questions and some incomplete answers.
The mean age of the participants was 18.5 years, including 40 (33.3%) males and 80
(66.7%) females. Patients who had fixed appliances (FA) were 86, divided into 26 males
and 60 females, while those who had removable appliances (RA) were 34, divided into
14 males and 20 females.
[Table 1] illustrated the attitude of patients toward their orthodontic treatment during the
lockdown. Three out of each four patients (76.6%) did not communicate with their orthodontists
during the lockdown, while only 6.6% communicated three or four times. In addition,
over 60% of them disagreed with the closure of dental clinics and had missed their
appointments for over a 2-month period. This is reflected on 68% who responded that
they stopped visiting the orthodontic clinic because the clinic was closed and not
because they feared the COVID-19 spread (9.2%).
Table 1
Patients attitude during the closure of clinics
|
Item
|
%
|
|
How many times did you communicate with your orthodontist during the pandemic?
|
One to twice
Three times
Four times
Did not communicate
|
20 (16.7%)
4 (3.3%)
4 (3.3%)
92 (76.7%)
|
|
To what extent do you agree or disagree with closing dental clinics to minimize the
spread of COVID-19?
|
Agree
Partially agree
Neutral
Do not agree
Strongly disagree
|
16 (13.3%)
9 (7.5%)
22 (18.3%)
30 (25%)
43 (35.8%)
|
|
What was the reason you stopped visiting your orthodontic?
|
Clinic was closed
I was afraid of the COVID-19 spread
Both reasons
Other reasons
|
82 (68.3%)
11 (9.2%)
22 (18.3%)
5 (4.2%)
|
|
How long was the period during which you missed the appointments during the pandemic?
|
Did not miss any
1–2 mo
2–3 mo
More than 4 mo
|
20 (16.7%)
24 (20.0%)
30 (25.0%)
46 (38.3%)
|
Abbreviation: COVID-19, coronavirus disease 2019.
When patients were asked about their main concern regarding the closure of clinics
during the pandemic, 52.5% of them were worried about a prolonged orthodontic treatment
period, 41.7% were concerned about unexpected occurrence of problems including a problem
with their appliances, and only 5.8% were afraid that the orthodontist will get busy
and will have no time no treat them after clinics re-open.
Of 86 FA patients, 82.6% faced problems with their devices. The main problem encountered
was an exposed wire end (34.9%), followed by bracket and band loosening (16.6%), and
other problems ([Table 2]). Patients managed these problems differently: 49.3% ignored the problem, 14.1%
requested an emergency appointment, 14.1% used orthodontic wax, 21.1% searched for
a solution on the internet, and 1.4% sent a picture to their orthodontist, as demonstrated
in [Table 3]. In comparison, of 34 RA patients, over half of them (55.9%) had problems during
the pandemic, and most of these problems were a broken appliance (44.1%) or a loose
appliance (32%). Similarly, most RA patients managed their orthodontic problems by
ignoring them (52%) or by looking for a solution on the internet (34.3%).
Table 2
Problems encountered during the closure of clinics
|
Fixed appliance
|
Removable appliance
|
|
No problem (17.4%)
Exposed wire end (34.9%)
Bracket and band off (16.6%)
Gum swelling (11.6%)
Broken metal piece (9.0%)
Loss of spring (4.7%)
Pain (2.3%)
Appearance of space (2.3%)
Run out of elastic band (1.2%)
|
No problem (14.7%)
Broken part of the appliance (44.1%)
Loose appliance (32.3%)
Gum swelling (5.9%)
Appearance of spaces (3.0%)
|
Table 3
Ways patients managed their orthodontic problems during the closure of clinics
|
Fixed appliance
|
Removable appliance
|
|
Ignored the problem (49.3%)
Requested an emergency appointment (14.1%)
Used orthodontic wax (14.1%)
Searched on the internet for solution (21.1%)
Sent a picture to their orthodontist (1.4%)
|
Ignored the problem (52.0%)
Searched on the internet for solution (34.3%)
Requested emergency appointment (6.9%)
Sent a picture to their orthodontist (3.4%)
Called the orthodontist (3.4%)
|
[Table 4] shows patients' concerns regarding their orthodontic treatment. Most patients were
worried about the suspension of their regular visits to the orthodontist (79.2%) and
60% thought that it should be considered as an emergency. Only 13.3% did not think
it is a real emergency, while the rest thought that certain problems should only be
considered emergencies.
Table 4
Patients concerns about their orthodontic treatment
|
Are you worried about stopping regular orthodontic visits during the pandemic?
|
Worried (n = 95, 79.2%)
Not worried (n = 25, 20.8%)
|
|
Do you think that orthodontic treatment should be considered an emergency?
|
Yes, because I do not want anything to go wrong with my treatment (n = 72, 60.0%).
Only certain problems can be considered emergencies, such as cuts, lacerations, swellings,
etc. (n = 32, 26.7%)
No, because it is not life threatening (n = 16, 13.3%)
|
Discussion
The lockdown of dental clinics during the COVID-19 pandemic has represented a major
problem for orthodontic patients who usually need to be seen regularly by their orthodontists.
Hence, this study aimed to evaluate the problems faced by orthodontic patients, their
concerns, and ways they dealt with their problems, which shall help to avoid such
problems in the future. In addition, exploring factors related to delayed or incomplete
dental services pour in the advantage of the overall health of patients. Low levels
of oral health care do not only lead to poor oral health behaviors but rather poor
general health behaviors,[12] which is considered a serious consequence to delayed oral health services.
Problems reported by patients with an FA were different than those reported by patients
with RA. FA patients reported more problems, and the most common problem encountered
was irritation from the wire ending due to the friction between the end of the wire
and the inner cheek or the tongue. The second most commonly reported problem among
FA patients was a loose band or bracket (band/bracket off). These results were close
to those found by Shenoi et al 2020,[10] showing that the main two problems faced by the patients were loosening of brackets,
followed by pain from exposed wire end. This is similar to orthodontic problems reported
by Gyawali et al 2019[13] and Jones et al 2016[14] indicating the most common reason for orthodontic emergency to be loosening of brackets.
On the contrary, the most commonly reported problem by RA patients was a broken part
of the device and the least common problem was appearing of space.
Most patients of both types of appliances responded to their problems by ignoring
them, as reported by 49.3% of FA and 52% of RA patients. This high percentage indicates
either poor compliance and motivation or a low level of awareness about the importance
of maintaining their appliances. Searching for a solution on the internet was adopted
by one-fifth of FA patients (21%) and one-third of RA patients (34.4%), possibly because
the internet has become an alternative way to find information and learn from the
experience of other people, who have experienced the same situation. Only few patients
of both types of appliances tried to outreach to the orthodontist by calling, sending
a picture, or requesting an urgent appointment.
A major problem was postponing of appointments. More than 63% had their appointments
postponed for more than 2 months, which is much higher than what was published by
Shenoi et al 2020,[10] showing that 48% of the patients had missed their appointments for the same period.
This could explain why most patients in the current study were worried about the duration
of which the clinics would stay closed (79.2%). A close percentage was reported by
Shenoi et al 2020,[10] demonstrating that three-fourths (73.5%) of patients were worried about the same
matter. However, this was higher than what Xiong et al. 2020 had reported.[8] Patients in the current study were not worried about getting infected during the
visits and considered their orthodontic treatment as an emergency, which, therefore,
made them to request a close rescheduling for an appointment. Although these concerns
about the closure of clinics seemed significant, most of them (76.7%) did not communicate
with their orthodontist during the pandemic and ignored their problem. A possible
explanation is that patients felt inconvenient to an alternative solution and believed
in physical presence in the orthodontic clinic. These findings were contrary to other
studies which reported that most patients found a way to contact their doctors, indicating
a different perception and probably a higher level of awareness than patients in the
current study.[15]
[16] However, it is reported that lengthy treatment courses could result in less compliance
by patients,[17] which was clear in the current study, showing only 14.1% of patients asked for help
from their doctors due to the extended treatment course. As a comparison, Shenoi et
al 2020 reported a higher percentage (49.0%).[10] These delayed periods of dental appointments were not a concern of patients alone
but was a serious concern for dentists as well who were afraid to lose their patients
after the quarantine phase and significant economic damage could result to their business
if similar quarantine periods happen again.[18]
Considering these results, more attention should be paid to orthodontic treatment
plans because of the long treatment course. Orthodontists should better use the simplest
treatment plan with the shortest course and least complicated appliances as possible,
which should help in any lockdown or pandemic in the future. In addition, patients
should be educated on how to manage their dental problems if they are not able to
seek a dental office for help.
Conclusion
The COVID-19 pandemic had a significant impact on orthodontic care and the maintenance
of appointments during the lockdown periods. Patients using fixed and RA reported
a variety of problems, with more frequent problems occurring among patients with FA.
Educating orthodontic patients on managing their appliance problems during any lockdown
periods by feasible ways is imperative. Besides, alternative ways of communication
between orthodontic patients and their dentists should be applied especially during
disasters or health pandemics. One way is using telehealth consultations, which seems
promising and supportive to the health care system[19] and could help orthodontists to outreach their patients,[20] since many patients do not have an interest in distant communication and become
less compliant with lengthy procedures.
