key: cord-0978880-h1f5owum
authors: Xiang, Jie; Xin, Yilin; Wang, Raokaijuan; Zhou, Hongling; Zou, Yiran; Shim, Sangbeom; Zhao, Lixing
title: Appointment impact and orthodontic emergency occurrence during the COVID-19 pandemic: A retrospective study
date: 2021-02-06
journal: Am J Orthod Dentofacial Orthop
DOI: 10.1016/j.ajodo.2020.12.016
sha: ddb9dcff93aa42113f39cfac9d7e31b87de75a59
doc_id: 978880
cord_uid: h1f5owum

Introduction This retrospective study aimed to quantify the impact of COVID-19 on the orthodontic appointment and make an analysis of orthodontic emergencies that occurred during the pandemic. Methods A total of 628 patients were randomly sampled from 3489 subjects who were undergoing active orthodontic treatment of fixed appliances and the medical records were reviewed. Orthodontic emergency (OE) occurrence was analyzed from 617 patients who had explicit return-visit records after the COVID-19 outbreak. Wilcoxon signed-rank tests, Chi-square tests and a binary logistic regression were performed. Results The return-visit of 98.6% patients was delayed significantly with an increase over 8.98 ± 4.76 weeks (P < 0.001). In general, 32.3% patients suffered from various OEs while waiting for their first return-visit and bracket/band debonding was the most frequently reported category. Most of OEs didn’t receive timely treatments due to the lockdown. The incidence was nearly twice higher than that of the normal appointment times. No correlation was found between OE occurrence and different demographic/clinical characteristics of patients. The therapeutic progress of patients, especially those in stage 3, was postponed due to the occurrence of OEs. Conclusions Regardless of the limitations, our study suggested it’s highly possible that the COVID-19 pandemic has delayed appointments of fixed orthodontic patients. Orthodontic emergencies did bother a minority of patients and couldn’t be settled in time during the lockdown, which had a negative impact on the near-term treatment progress and should be prevented. Further studies are required to investigate the long-dated influence of COVID-19 on orthodontic practices.

The ongoing coronavirus disease 2019 (COVID-19) has disrupted the human society catastrophically since its outbreak, bringing a suspension or stagnation to almost every field throughout the world. Since no effective treatment and safe vaccine is applicable up to now, J o u r n a l P r e -p r o o f social distancing measures are still the most feasible way to control the spreading of this devastating pandemic, which may be necessary until 2022. 1, 2 Due to the distinctive treatment procedures, large quantities of droplets and aerosols could be generated during the implementation of dental/orthodontic services. [3] [4] [5] As a consequence, the pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be transmitted potentially in the meanwhile, which exposes dentists/orthodontists and patients to a high risk of infection. [5] [6] [7] [8] Therefore, a mandatory suspension of nonemergency dental care, including orthodontic treatment, was conducted in several countries. [9] [10] [11] Different from other dental therapies, orthodontic treatment requires regular return-visits for active adjustment every 4-6 weeks in a period of nearly two years or even longer. [12] [13] [14] Thus, the shutdown of dental hospitals/clinics did arouse great challenge to both orthodontists and their patients. Although earlier publications have indicated that the scheduled appointment of patients could be affected before the lockdown was relieved, few studies currently report the influence in a quantitative way. 13, 15, 16 It's acknowledged that there is a need to close orthodontic practices during the pandemic, however, the treatment of orthodontic emergencies shouldn't be completely ignored too. An orthodontic emergency (OE) may include a problem arising from orthodontic appliances or accessories, where an unavailability of management would be intolerable or detrimental to the patient. 17, 18 Scenarios that could result in OEs can be found in previous studies. 17, [19] [20] [21] Furthermore, the occurrence of some OEs such as bracket debonding probably contributes to a prolonged orthodontic treatment duration. 17, 22, 23 Consequently, the prevention and timely management of OEs are crucial not only to minimize the burdens of patients but also to avoid a prolonged treatment time through maintaining the efficacy of appliances.

This single-center study was aimed at quantifying the impact of COVID-19 pandemic on the orthodontic appointment of patients. Moreover, the occurrence of OEs was recorded, and the correlation between OEs occurrence and different demographic/clinical characteristics was detected. Impact of OEs occurrence on the treatment progress in the near term was also analyzed. Although it seems impractical to validate the long-term influence of the pandemic at present, it is still valuable for us to carry out this study since the findings may provide helpful information for orthodontists and patients who are devoting in minimizing the impact J o u r n a l P r e -p r o o f of COVID-19 on their treatment.

This retrospective study was approved by the ethics committee of XX (Approved number: XX).

A stratified random sampling (sampling rate=20%) based on the appointment time was conducted through 3489 patients in XX, who met the following inclusion criteria: (1) receiving orthodontic treatment of labial fixed appliances in the Department of Orthodontics;(2) having regular appointment records both before and after the outbreak of COVID-19. The recruitment deadline was 12th, August, 2020. Finally, 628 patients were included in the study after an exclusion of 69 patients who were not under active treatment and the medical records were reviewed for data extraction independently by two researchers before integration into the final database used for analysis. Any disagreement was discussed and solved with a third consultant. The patient inclusion procedure was presented in Figure 1 . shutdown.

To test the interrater reliability of the two reviewers, Kappa coefficients regarding the stage division and the category of the near-term treatment progress which may be controversial during the reviewing process were calculated. The basic information and OEs occurrence details of included patients were presented as Means (±SD), frequencies or ratios. A Wilcoxon signed-rank test was employed to compare the scheduled and actual appointment interval. Chi-square tests were used to compare frequencies or ratios between groups with different demographic/clinical characteristics. Moreover, to explore the correlation between OE occurrence and multiple factors (gender, age, Angle's classification, extraction protocol, treatment duration and stage division), a binary logistic regression was conducted.

All the aforementioned analyses were performed with SPSS 21.0 (IBM Corp., Armonk, NY, USA). A P value under 0.05 was set as statistical significance.

The Kappa coefficients of both stage division and treatment progress category were excellent (0.924 and 0.922), indicating a good interrater reliability.

According to the eligibility criteria, 628 fixed orthodontic patients were ultimately included in this study, with a mean age of 20.54 ± 7.49 years. Detailed information about gender, age, Angle's classification, extraction protocol, treatment duration and stage division of patients before COVID-19 outbreak was presented in Table I .

The mean interval of scheduled appointment was 7.26 ± 1.99 weeks, which is longer than the recommended return-visit interval for orthodontic patients (4-6 weeks) due to the influence of New Year holiday. While the actual appointment interval was 16.26 ± 5.19 weeks on average.

The result of Wilcoxon signed-rank test showed that the difference was statistically significant (P < 0.001). Totally 98.6% patients (n=619) could not receive the regular treatment at the appointed time, despite that 0.9% patients (n=6) visited their orthodontist on time and 0.5% (n=3) in advance. The increase in return-visit interval was 8.98 ± 4.76 weeks J o u r n a l P r e -p r o o f on average and the distribution trend was summarized in Table II . Notably, 1.8% patients (n=11) didn't return to visit until 12th, August, 2020, whose increase in appointment interval was exhibited to be over 20 weeks.

OE occurrence was analyzed among 617 patients who had explicit return-visit records after the outbreak of COVID-19. In general, 32.3% patients (n=199) suffered from different kinds of OEs while waiting for their first return-visit and 42 out of 199 paid a visit to dental emergency department to have it managed. The occurrence frequency, management strategy (dental emergency department seeking or not) of OEs and their relationship with appointment delay were summarized in Table III .

Details about the OEs occurred were acquired from 199 included patients. Totally 183 out of 199 patients mainly complained about one single OE symptom, whereas 16 patients suffered from two kinds of OEs. The specific category of recorded OEs was presented in Table IV .

Since bracket/band debonding was the most frequently reported orthodontic emergency, the number and position of loose brackets/bands were analyzed. Results showed that 90 out of 149 patients had only one bracket/band loosen, despite 2 out of 145 reported at most 6 brackets bonding failure. The position analysis revealed that the debonding of mandibular bracket/band was more recorded than maxillary bracket/band (64.8% VS 35.2%) and posterior bracket/band debonding was more reported than anterior ones (74.5% VS 25.5%), especially those on molars (48.2%).

The intergroup comparability was acceptable since no significant differences were found in the demographic and clinical characteristics. As for the occurrence of OEs, 99 patients in the normal appointment group were recognized with emergencies suffering at a percentage of 16 .0%, which was significantly lower than the OE incidence of patients in the COVID-19

shutdown group (P< 0.001).

A binary logistic regression was run to explore the correlation between OE occurrence and gender, age, Angle's classification, extraction protocol, treatment duration, as well as stage J o u r n a l P r e -p r o o f division, however, no correlation with statistical significance was detected. Moreover, the incidences of OEs, bracket/band debonding and poking distal wire among patients with different demographic/clinical characteristics were compared respectively using Chi-square tests but no significant difference was found.

The subsequent treatment during the first return-visit after COVID-19 outbreak was categorized into three kinds: progressing into the next step, retreating to the last step, maintaining the existing treatment. Results showed that patients having experienced OEs were less likely to progress into the subsequent treatment than those didn't and the difference was statistically significant (P< 0.001), detailed information was summarized in Table V. Among patients with OEs, the possibility of retreating to the last step was higher in the treatment of patients in stage 3 than those in stage 2 and stage 1 (41.2% VS 32.4% VS 0.9%, P< 0.001, seen in Table VI ).

The outbreak of COVID-19 pandemic has brought huge limitations to dental care, especially treatments like orthodontic practice which requires a regular return-visit for active adjustment. 3 As a consequence, patients are at a great risk of appointment delay or missing.

In this study, the actual interval since last appointment was proved to be over 16.26 ± 5.19 weeks on average, extremely longer than that of the scheduled appointment. Treatment was delayed in 98.6% patients and the average delay was more than 8.98 ± 4.76 weeks. This might be primarily explained by the suspension of non-emergency dental services which involved orthodontic treatment and the subjective procrastination of patients. It was universally acknowledged that dental treatments were at an extremely high risk of SARS-CoV-2 infection since virus-contaminated aerosols could be generated potentially during the operation. 4, 5, 7 Therefore, dental hospitals and clinics were recommended to shut down temporarily by professionals and authorities, resulting an unavailability of non-emergency treatment. 25, 26 On the other side, the anxiety and concerns about the pandemic could also act as a hindrance to patients' willingness in attending orthodontic appointment, as reported by Cotrin et al.. 16 

The principal influence of missed/delayed appointment was thought to be the prolongation of orthodontic treatment duration. Beckwith et al. claimed that another 1.09 months were increased for each missed return-visit. 12 Except for treatment time, we believe that the therapeutic outcomes should also be taken into consideration if a long-term appointment delay occurred. It was found in our clinical examination that the extraction space of some patients got smaller after a long-term unattendance resulted from COVID-19, which put a negative impact on the retraction of anterior teeth. Furthermore, as Humam Saltaji et al. said, certain cases couldn't be left unattended for over 10-12 weeks such as patients with a reverse-curve NiTi wire. 19 However, the influence on therapeutic outcomes still needs further investigation in the long run.

To date, a unanimous perfect way to balance the regular monitoring and the security of patients during the pandemic lockdown haven't been found yet although teleorthodontics was reported to be a feasible solution. 27, 28 Perhaps orthodontists could only make plans based on their own situation to reduce the treatment delay as far as possible.

Orthodontic emergency occurrence was analyzed in our study. Totally 32.3% patients experienced various OEs during the prolonged appointment interval resulted from the COVID-19 shutdown. By comparison, only 16.0% patients were found to be bothered with OEs during an appointment interval of normal times. The relative risk reached 2.01, suggesting that missed/delayed appointments may increase the risk of orthodontic emergency occurrence. No correlation between OE occurrence and gender, age, Angle's classification, extraction protocol, treatment duration, stage division was detected by logistic regression, indicating that OE was a common trouble for all patients. 42 out of 199 paid a visit to the dental emergency department to have their OEs solved, revealing that a minority of orthodontic patients also needed emergency dental care despite orthodontic treatment was regarded as non-essential during the pandemic. 10, 29 Therefore, any "one size fits all" recommendation to suspend all orthodontic treatments probably should be avoided.

To deal with OEs, previous publications have promoted series of advices. 18, 20 The first step may locate in evaluating the severity and urgency of OE and virtual assistance such as photo, video or video call was suggested to be used. 20, 27, 28, 30 After the evaluation, orthodontists may decide whether the emergency could be managed by private practice of the patients J o u r n a l P r e -p r o o f themselves under specific direction or a visit to dental emergency department was needed.

For the former circumstance, detailed solutions could be found in the publications of Alberto Caprioglio et al. and Paul Dowsing, which consequently wouldn't be re-discussed in this study. 20, 21 While for the latter circumstance, it's believed that a contingency plan must be formulated in advance and personal protective equipment is needed for both patients and orthodontists. 3, 18 Generally speaking, the best way to manage OEs when appointments are inconvenient is to prevent. 20 Therefore, it's quite essential for orthodontists or dental institutions to keep in contact with patients and provide practical tips for avoiding the occurrence of OEs.

Among the specific categories of OEs recorded, bracket/band debonding was the most frequently occurred and poking distal wire was the second. Position analysis exhibited that mandibular brackets/bands were more likely to get loose than maxillary ones and posterior ones were more reported than anterior ones, especially those on molars, which was in consistency with previous studies. [31] [32] [33] [34] These information might be helpful when making decisions on what to be emphasized to patients in terms of OE prevention.

Considering the impact of OEs, previous studies have proved that patients may suffer from discomfort due to certain urgencies like poking distal wire and the treatment duration may be prolonged under circumstances such as brackets debonding. 17, 22, 23, 35, 36 It could be inferred that these adverse effects were highly possible to be exacerbated during the COVID-19 pandemic since most of OEs didn't receive timely management as Table 3 indicated.

Although it is difficult to appraise the long-dated therapeutic impact currently, in this study, we analyzed the influence of OE occurrence on the near-term treatment progress and found that patients who experienced OEs were less likely to progress into the subsequent step than those didn't (patients in stage 3 in especial), which may probably contribute to the prolongation of orthodontic treatment time. Accordingly, to minimize the negative influence of COVID-19 on orthodontic treatment duration, the prophylaxis of OEs should be brought to the forefront by both orthodontists and patients, especially patients in stage 3.

In this study, we quantitatively evaluated the return-visit delay of fixed orthodontic patients caused by the COVID-19 pandemic, which confirmed the prediction of earlier studies.

Moreover, the incidence, category and short-term impact on subsequent treatment of OEs were analyzed. The results may provide valuable information for both practitioners and patients who are bothered with a suspension of orthodontic care.

However, some limitations still need to be noticed. First, our study was conducted in a single center which gradually relieved the lockdown of dental care in early April, thus the results of our investigation may get even worse in other areas where the lockdown was relieved later or remains ongoing. Second, information collected from medical records mainly revealed the objective clinical examinations but couldn't exhibited the subjective feelings of patients especially those suffered from OEs, although the chief complaint was also recorded.

Therefore, the results of our study should be interpreted in combination with other investigations focused on the perspective of patients and further studies are required. Last but not the least, it is impractical for us to evaluate the impact of COVID-19 on both treatment duration and the final therapeutic outcome of the included patients at the present stage, which motivates us to follow the treatment progress of them in the coming future.

Based on the evidences available currently, findings of this retrospective study are summarized as follows:

1. The COVID-19 pandemic has postponed the appointment of fixed orthodontic patients which makes it highly possible to experience a return-visit delay.

2. Compared with normal appointment times, the incidence of OE increased almost twofold. Orthodontic emergency / Dental emergency department" means "The situation of orthodontic emergency occurrence and the situation of seeking help from the dental emergency department". **N indicates No, Y indicates Yes (e.g., N/N indicates that the patient did not suffer from an orthodontic emergency and also did not seek help from the dental emergency department). Resistance Devices breakage ***Including 1 patient with flat bite-plate breakage and 1 patient with occlusal splint breakage ****Including 1 patient with periodontal abscess and 3 patients with severe gingivitis #Including 1 patient with miniscrew covered by mucosa and 1 patient with mucosal lesion pressed by power chain †Including 1 patient with periapical periodontitis and fistula J o u r n a l P r e -p r o o f 

Comparing SARS-CoV-2 with SARS-CoV and influenza pandemics

Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period

Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine

COVID-19 Transmission in Dental Practice: Brief Review of Preventive Measures in Italy

Minimizing the aerosol-generating procedures in orthodontics in the era of a pandemic: Current evidence on the reduction of hazardous effects for the treatment team and patients

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals

Transmission routes of 2019-nCoV and controls in dental practice

Urgent dental care for patients during the COVID-19 pandemic

Dental Care during COVID-19 Pandemic

Emergency management of prevention and control of the novel coronavirus infection in departments of stomatology

An evaluation of factors affecting duration of orthodontic treatment

Control of SARS-CoV-2 transmission in orthodontic practice

Contemporary orthodontics

How does the quarantine resulting from COVID-19 impact dental appointments and patient anxiety levels?

Impact of coronavirus pandemic in appointments and anxiety/concerns of patients regarding orthodontic treatment

Management of orthodontic emergencies in primary careself-reported confidence of general dental practitioners

Management of orthodontic emergencies during 2019-NCOV

Emergencies in orthodontics part 1: management of general orthodontic problems as well as common problems with fixed appliances

Factors Affecting Treatment Duration -A Dilemma In Orthodontics

Orthodontic treatment time: can it be shortened?

Begg orthodontic theory and technique. Philadelphia: WB Saunders

Health services provision of 48 public tertiary dental hospitals during the COVID-19 epidemic in China

Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health

Perspectives of tele-orthodontics in the COVID-19 emergency and as a future tool in daily practice

Available Technologies, Applications and Benefits of Teleorthodontics. A Literature Review and Possible Applications during the COVID-19 Pandemic

Exceptional circumstances

Virtual health care in the era of COVID-19

Faltin Junior K. Comparative study on J o u r n a l P r e -p r o o f direct and indirect bracket bonding techniques regarding time length and bracket detachment

Six-month bracket failure rate evaluation of a self-etching primer

Bond failure patterns in vivo

Shear strength of brackets bonded to anterior and posterior teeth

Factors affecting the duration of orthodontic treatment: a systematic review

Factors influencing treatment time in orthodontic patients