Material and methods

The study protocol was approved by the West China Hospital of Stomatology (Approval no. WCHSIRB-D-2020-218). Because the investigator could reach the participants only by telephone or the Internet, an anonymous online questionnaire consisting of 5 sections ( Figs 1 and 2 ) was developed in Mandarin Chinese via www.wjx.cn .

Sections 1-3 of the questionnaire. Y/N , yes or no.

Sections 4 and 5 of the questionnaire.

A total of 48 orthodontists were invited to distribute the questionnaire to be completed by their patients. The inclusion criteria were as follows: (1) in the process of orthodontic treatment, (2) able to read Mandarin online, (3) had informed consent for the use of the data recorded, and (4) completed all the items in the questionnaire within a reasonable time. The questionnaire was available online from February 20 to February 22, which was during the early stage of the pandemic.

Section 1 assessed demographic and COVID-19-related epidemical information, such as sex, age, education level, residence, family income, marital status, profession and employment status, history of COVID-19–related symptoms, close contact with subjects from Hubei Province, and close contact with confirmed or suspected patients.

Section 2 focused on the perception of the pandemic, which included the knowledge and severity of the pandemic, the risk of infection for themselves and the people around them, and the main concerns about the pandemic.

Section 3 focused on the orthodontic state of the patients, including the type of their dental institutions and orthodontic appliances, the time since their last dental visit, the duration since treatment began, the way they received the suspension notice, and frequency of contacts from their orthodontist.

Section 4 assessed the orthodontic-related mental state. There are 15 items in this section with a 5-point scale ranging in score from 1 to 5 for each item. The 15 items aimed to evaluate the patients’ anxiety about treatment duration and outcome, their compliance, patience, and independence. Specifically, compliance is defined as the ability to perform the home instructions such as elastics use, sequential change of aligners, and oral hygiene maintenance. Independence refers to the ability to deal with orthodontic accidents and the initiative to communicate with the dentist. Patience is defined as the willingness to wait for the appointment until the pandemic was under control. Sections 1-4 were developed by a proficient orthodontist (J.W.) who has more than 20 years of experience with the help of 2 junior orthodontists (X.X. and X.F.). All these items were validated preliminarily.

Section 5 focused on the Kessler-10 Psychological Distress Scale, which included 10 items to evaluate the mental distress of patients over the past 4 weeks. The 5-point scale for each item ranged from a score of 1 (none of the time) to a score of 5 (all of the time), with a total score range of 10-50. The Chinese version of the scale was shown to have highly acceptable validity and reliability (Cronbach α ranged from 0.80-0.87) in previous studies. A total score of 10-19 was considered normal, whereas a score of 20-50 was indicative of mental distress.

After data collection, the internal consistency of items in Sections 4 and 5 was evaluated by calculating Cronbach α coefficients. The items in Section 4 were selected for subsequent principal component analysis (PCA). Sampling adequacy was tested using the Kaiser-Meyer-Olkin test. Then K-means cluster analysis was performed using each principal component (PC) to classify the study samples into 2 categories on the basis of the characteristics of each PC. The mental distress and the classifications of PC, which were binary variables, were considered as dependent variables in bivariate logistic regression analysis to assess the association with their independent variables. The strength of the relationship was interpreted using odds ratios (ORs) with 95% confidence intervals (CIs). The model adequacy in bivariate logistic regression was approved with Hosmer and Lemeshow goodness of fit test. All statistical tests were 2-sided and were performed by IBM SPSS Statistics (version 24; IBM Corp, Armonk, NY) with a significance level of 0.05.

Results

A total of 458 valid questionnaires were collected by February 22, 2020. The mean age of the participants was 24.78 years, with a standard deviation of 6.33 years. Descriptive statistics of the sample are reported in Tables I-IV . For categorical data, the frequency and percentage of each category are reported. There were 354 females (77.29%) and 104 males (22.71%). For residence, 22 (5.68%) patients were in Hubei Province, and 432 patients were not ( Table I ).

Table IV

Assessment of patients’ orthodontic status (n = 458)

Independent variables	Category	Frequency, n	Percentage, %
Medical institution	Orthodontic department in dental hospital	264	57.64
	Dental department in general hospital	81	17.69
	Private dental clinic	113	24.67
Type of appliances	Fixed labial appliances	309	67.47
	Fixed lingual appliances	35	7.64
	Clear aligners	94	20.52
	Functional appliances	20	4.37
Duration from the last appointment	Within 1 mo	44	9.61
	1-2 mo	350	76.42
	2-6 mo	48	10.48
	More than 6 mo	16	3.49
Duration since the beginning	Within 1 mo	10	2.18
	1-3 mo	63	13.76
	4-12 mo	152	33.19
	1-2 y	147	32.10
	More than 2 y	86	18.78
Way to get the suspension	Informed by doctor	242	52.84
	From the official account or Web site	181	39.52
	Told by other patients	16	3.49
	Not aware	19	4.15
Frequency of contact from dentist	0-1 time	283	61.79
	2 times	105	22.93
	3 times and more	70	15.28

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