Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments.
This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.
The alleged first case of COVID-19 in Italy was diagnosed on 20 February 2020 in the town of Codogno, Lombardy.
Despite the attempt to limit the outbreak to the defined “red zone”, by quarantining all citizens and denying entry or departure from the area, similar cases were diagnosed in other cities without evident epidemiological correlation, starting the day after the first identification.
During the last week of February, the prevalence of Covid-19 started to rise not only in Italy but, with a delayed but similarly increasing trend, also in the rest of Europe. As we are writing, the cumulative incidence is of more than 80 000 cases of COVID19 in Italy. Nevertheless, because of a series of unclear factors, northern Italy (in particular Lombardy, Veneto, and the Emilia Romagna regions) suffered a heavier healthcare and, tragically, death burden.
Although general practitioners, emergency departments, infectious diseases units, respiratory disease units, and intensive care units (ICUs) were and still are standing in the font line of the action, every department of every hospital all over Italy was increasingly involved in facing this unique and unprecedented health emergency. Since maxillofacial surgery departments are not standing in the front line of this struggle, elective surgeries have been postponed to free up beds and offer human and material resources and day-to-day care has been revolutionised in order to respond to the rapidly evolving health emergency.
This article, involving 23 maxillofacial surgery departments from northern to southern Italy, focuses on the first four weeks of this pandemic, aiming to describe both the features of and obstacles to their involvement.
Material and methods
We compiled an inventory of 32 questions to evaluate the impact of SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments, which were chosen to represent the present situation across the country, with an emphasis on the role of teaching departments whenever possible. Each department designated a specialist from the staff to answer the questionnaire. Answers were subsequently collected anonymously, keeping track of the location of the department in order to geographically correlate answers.
The questionnaire (see Supplemental Material) was built around three major aspects:
Changes in the workload in terms of outpatient clinic, day-surgery and general anaesthesia surgery;
Screening COVID-19 procedures used for patients and/or healthcare workers;
Workforce and patient protection methods to avoid SARS-COV2 spreading during daily activities.
Moreover, personal protective equipment (PPE) supply was considered to be a relevant topic in our field, due to the high frequency of oral and nasal cavity explorations.
Quantitative and qualitative data were recorded and statistically analysed using Excel software 15.0 (Microsoft Corp). Our analysis divided Italian maxillofacial units into 3 areas: high SARS-COV2 diffusion area (“red zone” including Lombardy, Emilia-Romagna and Veneto regions), intermediate SARS-COV2 diffusion area (“yellow zone” including Piedmont and Liguria regions) and low SARS-COV2 diffusion area (“green zone” including the remaining Italian regions).
We observed a reduction in the number of team members for all the considered zones, mostly among maxillofacial specialists (16% reduction vs. 11% reduction for residents) [ Table 1 ].
|Number of specialists||Number of residents|
|Pre-epidemic||In-epidemic||Variation rate||Pre-epidemic||In-epidemic||Variation rate|
|Red zone||7.2 (1.99)||5.90 (2,33)||-18%||4.5 (2.91)||4.2 (2.93)||-6%|
|Yellow zone||8.50 (0.71)||4.50 (6,36)||-47%||7.00 (9.89)||7.00 (9.89)||0%|
|Green zone||7.27 (2.20)||6.73 (2,41)||-6%||4.18 (6.06)||3.36 (5.50)||-20%|
|23 Maxillofacial Units||7.35 ( 1,99 )||6,17 ( 2,67 )||-16%||4,56 ( 5,02 )||4,04 ( 4,77 )||-11%|
Some maxillofacial surgeons, mostly in the red and yellow areas, had positive SARS-COV2 naso-pharyngeal swabs (4% of all maxillofacial specialists and residents in 22% of all maxillofacial departments assessed) and were isolated for 14 days in the so-called “standard quarantine”, waiting for symptoms’ remission or negative test results in order to return to work [ Table 2 ].
|Yes, there are positive doctors in my department||No, there are not positive doctors in my department||I don’t know if there are positive doctors in my department|
|Standard quarantine||Prolonged quarantine||Come back work|
|23 Maxillofacial Units||4%||0%||0%||87%||9%|
Among the causes of staff reduction there was also the full-time or part-time re-allocation of maxillofacial surgeons, both specialists and residents (17% of team members). The majority went to COVID internal medicine units (50% of the reallocated resources), while 19% of physicians were included in emergency departments, 13% in the service medicine units, 6% in the infectious disease units and 6% in the respiratory disease units. The re-allocation process of maxillofacial surgeons took part mostly in red and yellow zones [ Table 3 ].
|Re-allocated doctors||Wards for re-allocation|
|COVID internal medicine||NON-COVID internal medicine||Infectious disease||Respiratory disease||ER||ICU||Service medicine||Other|
|Red zone||3.60 out of 117||44%||0%||6%||6%||6%||0%||6%||0%|
|Yellow zone||0 out of 31||0%||0%||0%||0%||0%||0%||0%||0%|
|Green zone||1.00 out of 126||6%||0%||0%||0%||13%||0%||6%||6%|
|23 Maxillofacial Units||2.04 out of 274||50%||0%||6%||6%||19%||0%||13%||6%|