Mental distress in orthodontic patients during the coronavirus disease 2019 pandemic


The ongoing coronavirus disease 2019 (COVID-19) outbreak impacts the mental health of patients, health workers, and the public. The level of impact on the mental health of orthodontic patients in treatment is unknown. The objective of the study was to evaluate the mental health of orthodontic patients in China during the early stage of the pandemic.


An online survey was conducted on a convenience sample of anonymous participants. The questionnaire, in Chinese (Mandarin), comprised 5 sections. Sections 1-3 included demographic, epidemical, and orthodontic status of the patients. Section 4 assessed mental health-related to orthodontics. Section 5 was the Kessler-10 Mental Distress Scale. A total of 48 orthodontists were invited to distribute the questionnaires to their patients. Descriptive statistics, principal component analysis, K-means cluster analysis, and bivariate logistics regression analysis were performed with significance set at P <0.05.


Questionnaires were collected from 558 patients (104 males, 354 females; mean age 24.78 ± 6.33 years). The prevalence of mental distress was 38% (174/458). Higher odds ratios were associated with female participants, missed appointments, and Hubei residence. The type of orthodontic appliance was associated with the anxiety of prolonged treatment duration. The manner of communication with patients regarding the postponement of appointments was associated with patients’ concerns of prolonged treatment duration. The frequency of contact from dentists was associated with patients’ independence.


Over one-third of orthodontic patients experienced mental distress during the pandemic. Multiple factors affected the level of anxiety of orthodontic patients, such as the type of orthodontic appliance, time since last dental visit, manner of communication with the orthodontist, and the localities of the pandemic progression.


  • Thirty-eight percent of patients had orthodontic-related mental distress during the pandemic.

  • Orthodontic patients in the epicenter revealed higher odds of mental distress.

  • Orthodontists who contact patients personally might relieve their anxiety.

  • Patients with invisible appliances felt less anxiety about the duration of treatment.

  • The results could guide orthodontists from other countries with similar situations.

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan, Hubei Province, China, in December 2019. With stunning speed, now it is sweeping across the whole world, causing a global health emergency of international concern. On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. By May 28, 2020, the disease has been reported in over 210 countries and territories with increasing confirmed patients in Italy, United States, Brazil, Russia, and Spain. With the ongoing outbreak, the mental health of COVID-19 patients, health workers, and the public has become of great concern.

During the pandemic, all the provinces in China, as well as many cities in other countries such as Italy, have raised highest-level health emergency. Cities were locked down with residents staying at home to avoid disease transmission. Because of the prolonged lockdown, subjects are suffering from a feeling of isolation from society, which could further develop into depression and anxiety. Among these subjects, a particular focus should be on dental patients.

In a dental clinic setting, the patients, dentists, and dental assistants are exposed to the aerosol mist of saliva or blood droplets generated from high-speed handpiece or ultrasonic instruments to the surroundings. The delivery of orthodontic treatment involves close contact with patients. It was found that droplet and close contact transmission were the main transmission route for COVID-19. It has been previously reported that 9 dental practitioners were infected by the coronavirus in the School and Hospital of Stomatology, Wuhan University. Therefore, many dental hospitals and clinics were advised to provide treatment for dental emergencies only with the shutdown of all other dental departments, especially in the Hubei Province, since January 23, 2020. Thus, routine follow-up visits of orthodontic treatment had been interrupted by the pandemic. Furthermore, some patients suffered from orthodontic emergencies, such as loose brackets and protruding wire, but were unable to get timely and effective help from the specialists. After February 25, 2020, some hospitals and clinics were allowed to open with extra-protective measures such as epidemiologic record evaluation, temperature check, and upgraded personal protective measures during the dental treatment. All these factors might lead to an increase in the mental stress of the patients.

The objectives of the present study were to evaluate the mental distress of orthodontic patients and to investigate the level of their anxiety on treatment duration and outcome during the early stage of the pandemic.

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 .

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

Fig 2
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.


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 I
Basic information of orthodontic patients (n = 458)
Independent variables Category Frequency, n Percentage, %
Age ≤24 y 244 53.28
>24 y 214 46.72
Sex Male 104 22.71
Female 354 77.29
Educational level High school and lower 68 14.85
Vocational school 28 6.11
Junior college 72 15.72
Undergraduate 229 50.00
Graduate or higher 61 13.32
Monthly income <3000 yuan 56 12.23
3000 ≤ income < 6000 yuan 201 43.89
6000 yuan or more 201 43.89
Marital status Unmarried 351 76.64
Married 98 21.40
Widowed 1 0.22
Separated or divorced 8 1.75
Residence Rural area 89 19.43
City 369 80.57
Currently in Hubei Province Yes 26 5.68
No 432 94.32
Occupation and/or major Medical-related 93 20.31
Nonmedical-related 365 79.69
Live alone Yes 79 17.25
No 379 82.75
COVID symptoms Yes 4 0.87
No 454 99.13
Close contact with subjects from Hubei Province Yes 24 5.24
No 434 94.76
Close contact with confirmed or suspected patients Yes 2 0.44
No 456 99.56

Table II
Patients’ perception of the pandemic (n = 458)
Independent variables Category Frequency, n Percentage, %
Knowledge 1 2 0.44
2 2 0.44
3 55 12.01
4 292 63.76
5 107 23.36
Severity 1 0 0.00
2 2 0.44
3 9 1.97
4 143 31.22
5 304 66.38
Infection possibility 1 127 27.73
2 137 29.91
3 145 31.66
4 29 6.33
5 20 4.37
Infection possibility of people around 1 105 22.93
2 153 33.41
3 153 33.41
4 39 8.52
5 8 1.75

Note. The “Category” column ranges from 1 being “very little” to 5 being “very much.”

Table III
Patients’ main concerns about COVID-19 (n = 458)
Independent variables Category Frequency, n Percentage, %
Danger of the disease Yes 332 72.49
No 126 27.51
Risk of infection Yes 372 81.22
No 86 18.78
Isolation Yes 210 45.85
No 248 54.15
Impact on work and/or study Yes 289 63.10
No 169 36.90
Impact on daily life Yes 245 53.49
No 213 46.51
Psychological barriers and distrust Yes 149 32.53
No 309 67.47
Public psychological problems Yes 268 58.52
No 190 41.48

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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Jan 9, 2021 | Posted by in Orthodontics | Comments Off on Mental distress in orthodontic patients during the coronavirus disease 2019 pandemic
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