Introduction
This study aimed to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on the orthodontic patient. It also assessed the knowledge and attitude of patients to the COVID-19 infection and the willingness to carry out specific precautionary measures in the orthodontic clinics to mitigate the spread of the virus.
Methods
It was a cross-sectional descriptive study. Questionnaires were distributed to orthodontic patients via Google forms. The questionnaire assessed participants’ knowledge, attitude, the impact of the COVID-19 pandemic on orthodontic treatment, and willingness to carry out infection control precautionary measures in the orthodontic clinic.
Results
A total of 304 responses were obtained; 83 males (27.3%), 221 females (72.7%) with a mean age of 35.6 years. Subjects demonstrated good knowledge of COVID-19 infection (94.7%). Most respondents (95%) considered the infection as dangerous and believed the orthodontic patient was at risk of contracting the disease but were willing regardless to carry on with their orthodontic treatment during the pandemic. Fear of contracting the COVID-19 virus during orthodontic appointments and missed orthodontic appointments (74%), and increased treatment time (50%) were the immediate and long-term concerns, respectively. A high acceptance rate of compliance to precautionary measures to mitigate virus spread in the clinic was observed.
Conclusions
The COVID-19 pandemic has had a negative impact on the orthodontic treatment and the financial and emotional wellbeing of orthodontic patients. Patients were willing to continue with orthodontic management during the pandemic while complying with precautionary measures to prevent disease spread in the orthodontic practice setting.
Highlights
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Orthodontic patients are willing to continue treatment during the coronavirus disease 2019 pandemic.
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Fear of contracting the virus during an appointment was an immediate concern.
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Missed appointments and increased treatment time were long-term concerns.
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A high acceptance rate for precautionary measures was observed.
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Age, sex, and treatment duration were correlated with willingness to continue treatment.
Coronavirus disease 2019 (COVID-19) is caused by a new strain of the coronavirus, severe acute respiratory syndrome coronavirus 2, first reported in Wuhan, China, in December 2019. The COVID-19 infection has been reported to cause a wide spectrum of symptoms in humans ranging from mild to severe disease manifestations and may sometimes be fatal. It was declared a pandemic by the World Health Organization on January 30, 2020, and since then has spread very rapidly, affecting almost all the countries in the world, with over 10.98 million reported patients, multiple hospitalizations, and 524,036 mortalities as of July 3, 2020.
The first official patient with COVID-19 in the country was reported on February 27, 2020. Since then, the infection has spread rapidly to all 36 states in the country, including the Federal Capital territory, with palpable strain on the health sector. The National Centre for Disease Control has reported approximately 27,110 COVID-19 cases and 616 COVID-19 related deaths.
The mode of transmission of COVID-19 is primarily via droplet and aerosol spread by coughing, sneezing, talking, and direct contact with droplet/aerosol contaminated surfaces, with an incubation period lasting 2-14 days. ,
Dental care involves the treatment and prevention of oral diseases/conditions, often using rotary dental and surgical instruments. These instruments produce sprays that contain large particle droplets of water, saliva, blood, microorganisms, and other debris. These sprays move a short distance and settle on dental surfaces, dental office staff and or patients.
Dental treatments require proximity between the patient and dental health care workers. Orthodontic procedures such as bonding, debonding, interproximal reduction, replacement of broken brackets are capable of generating aerosols. This issue poses a consequent risk of cross-infection (patient to patient, patient to dental health care provider, and dental health care provider to dental health care provider transmission), especially if meticulous infection control measures are not employed. ,
In view of the aforementioned risks in the dental practice setting, many national dental associations all over the world have recommended that dental clinics close down during this period or significantly scale down the level of dental care provided to strictly emergency and urgent dental care, while all elective dental procedures are suspended. Many countries also recommended a total or partial lockdown of the system to curtail the virus spread.
Orthodontics is a specialty of dentistry that deals with the management of malocclusion, with comprehensive fixed orthodontic treatment lasting approximately 2-3 years and regular review appointments about 6-8 weeks. Deferring treatment until the end of the pandemic will inadvertently prolong the treatment time with possible associated consequences on the patients and their orthodontic treatment.
With this consideration in mind, many orthodontists may have to resume clinical practice in the nearest future, bearing in mind the risk of infection and putting measures in place to prevent this.
However, it is important to bear in mind that compliance with meticulous infection control measures and protocols by all dental health care workers is important to prevent COVID-19 spread in the dental clinic.
A good understanding of the pathogenesis of the disease is also required by the patients, as well as a willingness to comply with recommended measures to prevent the spread. Some of these precautions include frequent hand hygiene using soap and water or alcohol-based hand rub, proper respiratory hygiene, use of facemask, and physical distancing. These must be strictly adhered to ensure the safety of the dental health care workers and the patients alike if orthodontic practices are reopened.
Some possible effects of the COVID-19 pandemic on the orthodontic patients may not only be limited to missed orthodontic appointments and fear of contracting the virus but may span through psychological, emotional, and financial consequences.
This study aimed to assess the perceived impact of the COVID-19 pandemic on the orthodontic patient. It also assessed the knowledge and attitudes of patients to the COVID-19 infection, as well as a willingness to carry out specific precautions to help prevent the spread of the virus, especially in the orthodontic clinics.
Material and methods
The study was a cross-sectional descriptive study. Ethical approval for this study was obtained from the Institutional Review Board of the Lagos University Teaching Hospital, Idi-araba, Lagos, Nigeria. Self-administered structured multiple-choice questionnaires were distributed to consenting participants through an online data collection platform (Google forms). A purposive sampling technique was used. The study population comprised orthodontic patients receiving treatment in public and private dental facilities in the state.
The respondents were reached using the WhatsApp (Facebook, Inc, Menlo Park, Calif) platform, and via e-mails. The questionnaire ( Supplementary Text ), modified from a study carried out by Khader et al and Isiekwe et al was used as the instrument for data collection in this study. The questionnaire contained 4 sections: Section 1 : participants’ sociodemographics; Section 2 : participants’ perceived impact of the COVID-19 pandemic on orthodontic treatment; Section 3 : participants’ knowledge about the COVID-19 infection; and Section 4 : risk perception and attitude toward the COVID-19 infection.
A pilot study was done. The questionnaire was distributed to 10 orthodontic patients to assess the validity of the instrument. These were not included in the overall samples used for the study. The questionnaire distribution was carried out for over 6 weeks. The study instrument was sent out to 400 patients.
Statistical analysis was carried out using SPSS (version 23.0; IBM, Armonk, NY). Data were subjected to simple descriptive statistical analysis (means and standard deviation or median and interquartile range), and results were presented in frequency tables and charts. Comparisons between groups were carried out using the chi-square for categorical variables, and the level of significance was set at 0.05.
Results
A total of 400 questionnaires were sent out, with a response rate of 67% (304 responses). The demographic characteristics of the study subjects showed 304 respondents aged 9-56 years, with a mean age of 35.6 years. The predominant age group of respondents was 11-20 years. A higher female predominance was observed, accounting for 72.7% of the surveyed population. Approximately 62% of the subjects had attained a tertiary level of education ( Table I ). A majority of the respondents were undergoing fixed appliance orthodontic treatment (91.1%), accessing treatment in a government hospital (64.5%), and were paying out of pocket for orthodontic care (88.8%) ( Table I ).
| Variable | Frequency (%), n = 304 |
|---|---|
| Age, y | |
| <10 | 10 (3.3) |
| 11-20 | 132 (43.4) |
| 21-30 | 83 (27.3) |
| 31-40 | 49 (16.1) |
| 41-50 | 26 (8.6) |
| 51-60 | 4 (1.3) |
| Sex | |
| Female | 221 (72.7) |
| Male | 83 (27.3) |
| Religion | |
| Christianity | 274 (90.1) |
| Islam | 29 (9.5) |
| Others | 1 (0.3) |
| Marital status | |
| Married | 56 (18.4) |
| Single | 243 (79.9) |
| Others | 5 (1.6) |
| Level of education | |
| Postgraduate | 92 (30.3) |
| Primary | 11 (3.6) |
| Secondary | 105 (34.5) |
| Tertiary | 96 (31.6) |
| Number of months in orthodontic treatment | |
| 1-12 | 122 (40.1) |
| 13-24 | 85 (28.0) |
| 25-36 | 48 (15.8) |
| 37-48 | 11 (3.6) |
| >48 | 38 (12.5) |
| Facility where you are receiving treatment | |
| Government hospital | 196 (64.5) |
| Private hospital | 108 (35.5) |
| Modality of payment of orthodontic treatment | |
| Out of pocket (self) | 270 (88.8) |
| Health insurance | 3 (1.0) |
| A combination of both | 10 (3.3) |
| Others | 21 (6.9) |
| Type of orthodontic treatment | |
| Removable appliance | 25 (8.2) |
| Fixed | 277 (91.1) |
| Others | 2 (0.7) |
Almost all the participants considered their level of knowledge of COVID-19 to be moderate to high (98%). They demonstrated a good knowledge of disease etiology, symptoms, modes of transmission, and prevention of the COVID-19 infection. Hand hygiene with soap and water (99.3%), routine disinfection of contaminated surfaces (97.7%), hand sanitization using alcohol-based hand rub (96.4%) were popular preventive measures among respondents ( Table II ).
| Responses to questions asked on COVID-19 | Correct | Incorrect |
|---|---|---|
| What kind of infection is COVID-19 | ||
| Virus | 288 (94.7) | 16 (5.3) |
| Average incubation period of COVID-19 | ||
| 2-14 d | 276 (90.8) | 28 (9.2) |
| Symptoms of COVID-19 | ||
| May be asymptomatic | 167 (54.9) | 137 (45.1) |
| Fever | 279 (91.7) | 25 (8.3) |
| Cough | 288 (94.7) | 16 (5.3) |
| Sore throat | 249 (81.9) | 55 (18.1) |
| Shortness of breath | 286 (94.1) | 18 (5.9) |
| Diarrhea | 78 (25.7) | 226 (74.3) |
| Vomiting | 44 (14.5) | 260 (85.5) |
| Running nose | 103 (33.9) | 201 (66.1) |
| Red eyes | 26 (8.6) | 278 (91.4) |
| Skin rash | 24 (7.9) | 280 (92.1) |
| Joint/muscle pain | 79 (26) | 225 (74) |
| Loss of taste | 145 (47.7) | 159 (52.3) |
| Loss of smell | 138 (45.4) | 166 (54.6) |
| How COVID-19 can be prevented | ||
| Coughing and sneezing | 284 (93.4) | 20 (6.6) |
| Handshaking | 272 (89.5) | 32 (10.5) |
| Touching contaminated surfaces | 286 (94.1) | 18 (5.9) |
| Talking | 128 (42.1) | 176 (57.9) |
| How COVID-19 transmission can be transmitted | ||
| Regular handwashing with soap and water | 302 (99.3) | 2 (0.7) |
| Use of alcohol-based hand rub | 293 (96.4) | 11 (3.6) |
| Routine disinfection of contaminated surfaces | 297 (97.7) | 7 (2.3) |
| Use of personal protective clothing by all dental staffs | 277 (91.1) | 27 (8.9) |
| Use of facemasks by all patients | 270 (88.8) | 34 (11.2) |
| Keeping patients in well-ventilated rooms | 191 (62.8) | 113 (37.2) |
A set of questions addressed the perceived risk assessment and attitude of orthodontic patients to the COVID-19 infection. More than 95% of them considered infection as dangerous. They believed the orthodontic patient was severely (40.8%) or moderately vulnerable (30.6%) to contracting the disease, but were willing regardless to carry on with their orthodontic treatment during the pandemic (72.4%) ( Table III ).
| Questions asked and responses | Frequency (%) |
|---|---|
| Perception concerning COVID-19 infection | |
| Moderately dangerous | 124 (40.8) |
| Not dangerous at all | 11 (3.6) |
| Very dangerous | 169 (55.6) |
| Perception concerning the vulnerability of orthodontic patients | |
| Moderately vulnerable | 93 (30.6) |
| Not vulnerable | 15 (4.9) |
| Severely vulnerable | 116 (38.2) |
| Slightly vulnerable | 42 (13.8) |
| I don’t know | 38 (12.5) |
| Willing to continue orthodontic treatment during the pandemic | |
| No | 84 (27.6) |
| Yes | 220 (72.4) |
| Willing to continue orthodontic treatment after the pandemic | |
| No | 18 (5.9) |
| Yes | 286 (94.1) |
| How do you consider patients role in spreading information as regard COVID-19 | |
| Insignificant | 5 (1.6) |
| Moderately significant | 57 (18.8) |
| Very significant | 242 (79.6) |
Responses showed that most of them (70.1%) had not been to the orthodontic clinics for appointments since the COVID-19 outbreak. The minority who had visited the clinics had routine fixed appliance review appointments, whereas the others were managed for orthodontic emergencies such as protruding archwire and loose bands or brackets ( Fig ). Although the fear of contracting the COVID-19 virus during orthodontic appointments was the immediate concern of most of the respondents (39.8), they expressed worry over missed orthodontic appointments (74%) and increased treatment time (50%) in the near future ( Table IV ). The assessment of the effect of the COVID-19 pandemic on the economic, emotional, and social wellbeing of the respondents revealed a negative impact on the financial and emotional domains. Responses from the social domain showed the highest percentage of respondents (48%) saying the pandemic had a positive effect, giving them adequate time to spend with their families ( Table V ).
| Questions and responses | Frequency (%) |
|---|---|
| Effect the pandemic had on your orthodontic treatment | |
| Fear of contracting the virus during a routine appointment | 121 (39.8) |
| Missed routine appointment | 83 (27.3) |
| Increase in treatment time | 108 (35.5) |
| Increase in cost of treatment | 26 (8.6) |
| No effect | 19 (6.3) |
| Other | 6 (2.0) |
| The perceived effect the pandemic will have on your orthodontic treatment | |
| Increased cost of treatment | 67 (22.0) |
| Missed routine appointments | 226 (74.3) |
| Increase in treatment time | 153 (50.3) |
| No effect | 11 (3.6) |
| Other | 3 (1.0) |
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