The present study aimed to evaluate the most common urgencies and emergencies in orthodontics during the coronavirus disease 2019 (COVID-19) pandemic and to assess how orthodontists in Brazil were dealing with patients and challenges.
Early in 2020, as the COVID-19 pandemic spread around the world, routine dental care was suspended in many countries, and only patients needing urgent or emergency care could be seen. During this period, orthodontists in Brazil were invited to participate in an anonymous online survey. Over 48 hours (May 1-3, 2020), 395 orthodontists (specialists, MScs, and PhDs) responded. They answered questions regarding dental office and appointments during the pandemic, the type of urgency or emergency care provided, the type of appliance and urgencies, etc. The level of concern about the impact of the pandemic on patients’ orthodontic treatments and the financial impact on the dental office was also evaluated. Descriptive statistics were performed with percentages, and responses were compared between specialists, MScs, and PhDs, using chi-square tests.
Specialists were the majority of respondents. Most orthodontists were handling only emergencies or urgencies. The most frequent urgencies were bracket breakage, archwire breakage, and breakage of molar tubes and/or bands. Stainless steel fixed appliances were the most common type of appliance related to unscheduled appointments. The majority of patients got in touch with the orthodontist using the professional WhatsApp messenger (WhatsApp Inc, Menlo Park, Calif). Orthodontists were more concerned with the financial impact of the pandemic than with the orthodontic treatment itself.
Breakage of brackets, archwires, or tubes and/or bands were the most common causes of urgency and/or emergency appointments during the pandemic. The level of concern about the financial impact of the stay-at-home orders and the COVID-19 pandemic was significantly greater for specialists and MScs than for PhDs.
We surveyed orthodontists in Brazil during the coronavirus disease 2019 pandemic.
Most frequent urgencies were breakages of brackets, archwires, molar tubes, or bands.
Stainless steel fixed appliances were the type most related to unscheduled appointments.
Most patients contacted the orthodontist using the professional WhatsApp messenger.
Orthodontic specialists and MScs were more concerned than PhDs about financial impacts.
During orthodontic treatment (which usually lasts between 2 and 3 years), patients are required to wear a variety of removable and fixed appliances, and about 85% of patients experience some kind of urgency during their treatment period.
Emergencies generally involve risk of death and urgencies do not. However, in dentistry, any dental problem that requires immediate treatment to save a tooth, stop ongoing tissue bleeding, or alleviate severe pain is considered a dental emergency. Orthodontic emergencies are rare, but orthodontic urgencies—problems arising from orthodontic appliances or accessories, in which a timely additional appointment is required—are not uncommon. In Brazil, according to the Code of Consumer Protection and Defense, the dentist is considered a supplier of services and has the obligation to be well-prepared to offer a service to the patient. Orthodontists are responsible (regardless of the existence of guilt) for compensating any damage caused to the consumer related to poor service or insufficient or inadequate information on the provision and risks of these services.
With the pandemic caused by the coronavirus disease 2019 (COVID-19) outbreak in the world, specific guidelines are constantly published and updated by the World Health Organization, National Institutes of Health, National Ministries of Health, and national councils for each professional area. Routine dental care was suspended in many countries as governments sought to halt the spread of COVID-19. , In Brazil, the Federal Council of Dentistry presented guidelines for evaluating dental urgency and emergency during the coronavirus pandemic. Dentists were advised to manage urgencies and emergencies only; however, the professional can decide to maintain the opening of dental offices or to care only for patients with urgencies or emergencies.
In orthodontics, urgencies—such as breakage of appliances, brackets, or tubes—are not life-threatening, but it is advised to resolve them quickly or to avoid prolonging the treatment time, decreasing the patient motivation, and losing the patients’ confidence in the orthodontist. Appropriate handling of orthodontic urgencies will provide relief from pain and distress for the patient. ,
All dental professionals are feeling a moral duty to reduce routine care for fear of spreading the COVID-19 disease among patients, their families, and community, but are concerned about the financial consequences.
The objective of this survey was to evaluate the most common orthodontic urgencies and emergencies during the initial months of the coronavirus pandemic in Brazil and to assess how orthodontists are dealing with patients and the challenges of the current scenario.
Material and methods
This study was approved by the Ethics Research Committee of the UNINGÁ University Center (protocol no. 4.002.200) and all subjects signed informed consent to participate in the survey.
Sample size calculation was performed with a confidence interval of 95% and a margin of error of 5%. Considering that the population of orthodontists in Brazil is approximately 28,000, conducting a questionnaire would require at least 379 subjects and/or answers.
A Google Forms questionnaire was sent to about 1000 orthodontists from Brazil, most of whom graduated from 4 universities in various cities, through WhatsApp Messenger App (WhatsApp, Inc, Menlo Park, Calif). The orthodontists were not identified.
The questionnaire was constructed on the basis of what we intended to report, but this was not a validated questionnaire because we did not intend to evaluate a health condition or quality of life. We administered a survey, with several questions that allowed us to evaluate the most common urgencies and/or emergencies in orthodontic practice during the coronavirus pandemic, to assess how orthodontists are dealing with patients and how are they concerned with the orthodontic treatment of their patients and with the financial impact of the pandemic in their dental offices.
Questions involved personal information as age, sex, degree of orthodontic graduation, and time of experience with orthodontics. Questions regarding the dental office and appointments during the pandemic, type of emergency care provided, type of appliance related to the emergencies, and others were included in the survey. The levels of concern about the impact of the pandemic on patients’ orthodontic treatments and regarding the financial impact on the dental office were evaluated with a 0-10 point numerical rating scale. ,
The respondents answered the questions regarding only their solo practices.
The questions and potential responses are listed below:
How old are you? ( ) 20-40 years ( ) ≥41 years
Sex: ( ) Male ( ) Female
What is your degree of orthodontic graduation? ( ) Specialist ( ) Master (MSc) ( ) Doctor (PhD)
How long have you been working with orthodontics? ( ) ≤5 years ( ) From 5 to 10 years ( ) From 11 to 20 years ( ) ≥21 years
How were the appointments in your dental office during quarantine? ( ) Routine care appointments were maintained. ( ) Only emergency or urgency care was scheduled. ( ) Dental office closed; no orthodontic care provided.
What types of appliance have caused the most emergency and/or urgency appointments? Select all the alternatives that apply: [ ] Stainless steel fixed appliances [ ] Esthetic fixed appliances (sapphire or porcelain and/or ceramic) [ ] Self-ligating fixed appliances [ ] Removable retention appliances [ ] Fixed retentions [ ] Removable orthopedic appliances [ ] Fixed functional appliances [ ] Fixed expansion appliances [ ] Orthodontic accessories [ ] Aligners
What were the most frequent urgencies and/or emergencies you handled in your office during this period? Select all the alternatives that apply: [ ] Brackets’ breakage [ ] Breakage of molar tubes and/or bands [ ] Metallic ligatures causing injuries [ ] Breakage of archwires or causing injuries [ ] Loss of elastic ligatures [ ] Breakage of removable appliances or aligners [ ] Breakage of fixed expansion or fixed functional appliances [ ] Breakage of fixed retention [ ] Emergencies related to poor oral hygiene [ ] Emergencies related to tooth movement
Have you had emergencies related to orthodontic accessories? ( ) Yes ( ) No
If so, what type of accessories? [ ] Intermaxillary elastics [ ] Mini-implants [ ] Miniplates [ ] Kobayashis [ ] Extraoral appliances [ ] Others
How did your patient get in touch to schedule the emergency care? Select all the alternatives that apply: [ ] Through the professional office page on social networks. [ ] Through the office’s commercial telephone. [ ] Through messages to the office WhatsApp. [ ] Through my personal pages on social networks. [ ] Through my personal phone and/or WhatsApp.
During the stay-at-home order period, did you dismiss your staff? ( ) Yes, they took a vacation. ( ) Yes, but they were at home-office. ( ) No, they continued to work routinely in the dental office. ( ) Staff suspended from activities with government assistance.
Did you provide emergency care accompanied by your staff? ( ) Yes ( ) No
How concerned are you about the impact of the pandemic on your patients’ orthodontic treatments? (0 indicates not concerned and 10 indicates extremely concerned) ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) 9 ( ) 10
How concerned are you about the financial impact of the pandemic on your dental practice? (0 indicates not concerned and 10 indicates extremely concerned) ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) 9 ( ) 10
The questionnaire was available for responses for 48 hours (May 1-3, 2020). Responses were obtained and tabulated in Excel, for statistical analysis.
Descriptive statistics were performed with percentages. Comparisons of specialists × MScs × PhDs and females × males were performed with chi-square tests, 1-way analysis of variance, and Tukey tests and independent t tests.
Statistical analysis was performed with Statistica software (version 10.0; Statsoft, Tulsa, Okla), and results were considered significant at P <0.05.
Over 48 hours (May 1-3, 2020), 395 orthodontists answered the questionnaire (262 female [66.3%] and 133 male [33.7%]); 54.4% were aged 20-40 years and 45.6% were aged ≥41 years.
In addition, 66.3% were specialists, 18.0% were MSc, and 15.7% were PhDs. Regarding their experience with orthodontics, 28.4% had <5 years, 18.2% had 5-10 years, 35.7% had 10-20 years, and 17.7% had >20 years.
Most orthodontists (66.8%) are handling only emergencies and/or urgencies, 19% maintained the routine orthodontic appointments, and 14.2% closed the dental offices and are not working since the quarantine was recommended.
Regarding the type of appliances that caused most urgencies in orthodontics, 74.7% of the orthodontists mentioned urgencies related to preadjusted stainless steel fixed appliances, followed by esthetic fixed appliances (29.6%), orthodontic accessories (16.7%), fixed retentions (15.9%), fixed expansion appliances (15.4%), and self-ligating appliances (13.7%). Removable retainers and orthopedic removable appliances, fixed functional appliances, and aligners were mentioned by <10% of the orthodontists ( Fig 1 ).