Awareness, Challenges and Impact of COVID-19 Lockdown: Orthodontic Patient’s Perspective

Context: Owing to the increase in COVID 19 cases, a lockdown was declared in India on 24th March 2020. All the dental facilities except for emergency procedures were suspended. Due to the lockdown, the periodic visit to the Orthodontist became difficult, which would eventually affect the Orthodontic treatment. Aim: The aim of this study was to assess the awareness, challenges and impact of COVID-19 Lockdown on Orthodontic patients. Materials & Methods: A self-designed online questionnaire of 24 questions was designed and distributed among 450 participants via WhatsApp messenger and email. Statistical analysis used: Comparison of frequencies was done using chi square test. Results: The study revealed that majority patients were affected due to the pandemic and feared increase in duration of the treatment due to the same. Most common problems were loose bands/brackets and poking wire. Some faced resistance from family for visiting the Orthodontist during pandemic. Conclusions: Majority found it necessary to continue treatment even after all difficulties. Continuous reassurance to the patients by the Orthodontist is required, by doing regular follow ups. At the same time, the awareness about the pandemic should be increased amongst the patients so that precautionary measures can be taken from their side to prevent the spread while continuing their orthodontic treatment.


Introduction
In December 2019, there was an outbreak of a severe pneumonia of unknown etiology in Wuhan China. The concerned virus was initially called the novel coronavirus 2019-nCoV, then as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses [1]. COVID 19 was declared a pandemic by WHO on January 30, 2020 and since then there has been a rapid spread throughout the world. There have been 214,468,601 confirmed cases of COVID-19 globally, including 4,470,969 deaths, reported to WHO. In India, from January 3, 2020 to August 27, 2021, there have been 32,603,188 confirmed cases of COVID-19 with 436,861 deaths, reported to WHO [2].
Patients reported with COVID-19 show symptoms of lower respiratory tract infection, including coughing, fever, generalized fatigue, sneezing, vomiting, and severe pneumonia [3,4]. The symptoms range from mild, moderate, severe, critical, and sometimes leading to death. Many are asymptomatic while others present with symptoms like Acute Respiratory Distress Syndrome, sepsis, septic shock, and multiple organ failures in critical patients with high reported deaths [5].
The mode of transmission includes sneezing, coughing, close contact talking, aerosol contamination and direct contact with any contaminating surfaces. The incubation period is 14 days up to 24 days [3,6,7].
Various orthodontic procedures such as bonding, debonding, replacement of debonded brackets are aerosol generating. These travel short distance and settle on dental surfaces, operator and/or patients, posing high risk of cross infection. However, meticulous infection control measures could reduce the risk of cross infection [8].
Owing to the rising cases in India, a lockdown was declared on March 24, 2020. In the initial phases of the COVID-19 "lockdown" in India, dental clinics were shut as it was feared that aerosols generated in dental practice could fuel the spread of the virus and other factors [9,10].
With the pandemic increasing, the importance and need for oral health emergency requirements was understood, strict regulations and guidelines were issued, and emergency services were opened up.
Orthodontics is an elective specialty, dealing with the treatment of malocclusion, with the treatment lasting for about two-three years and the need for regular reporting of the patient to the clinic every six-eight weeks. Thus, delaying the treatment until the end of pandemic will inadvertently prolong the treatment. COVID 19 has not only affected the orthodontic treatment due to missed appointments and fear of contracting the disease, but also due to emotional, psychological and financial crisis [11].
This study aims to assess the impact of COVID-19 lockdown and the challenges it posed on the orthodontic patients. It will also assess the knowledge and attitude of the patients towards the disease and

Material and Methods
This was a cross-sectional descriptive study carried out in 2021. Self-formulated structured multiple-choice questionnaire consisting of 24 questions, were distributed to consenting participants. The participants were patients undergoing treatment in our institute. Simple random sampling technique was used.
The questionnaires were distributed in form of an online data collection platform (Google Forms) amongst 450 participants. The respondents were reached using WhatsApp and via emails. The questionnaire consisted of demographic characteristics such as age, sex, occupation and address followed by questions regarding the participants perceived impact of the pandemic and lockdown on their orthodontic treatment.
Data was subjected to statistical analysis using Statistical package for social sciences (SPSS v 26.0, IBM). Comparison of frequencies of categories of variables with groups was done using chi square test. For all the statistical tests, p<0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study as 80%.

Results
450 participants responded to the survey. The questionnaire consisted of questions, categorized into three domains (Tables 1-3): The predominant age group was found to be >20 years (53.3%) with a female predominance (60%). A majority of the respondents were students (74.7%) [ Table 1].
A set of questions addressed the details about the ongoing orthodontic treatment and the challenges faced due to the COVID -19 Lockdown. A majority of the respondents had been undergoing orthodontic treatment since 12-24 months (29.3%). Maximum patients had not visited their orthodontist for a span of less than three months (74%) with the majority having visited their orthodontist less frequently than usual (57.3%). A majority of the patients did not experience any appliance breakage during the pandemic (62%) and did not encounter any kind of pain or discomfort (38.7%). Amongst the ones who experienced pain and discomfort, the problem in the majority was broken brackets/bands (14%) and poking wires (13.3%). Most of these respondents handled their problem over the call with their orthodontist (39.3%) and very few visited a local dentist (6%). Majority felt that their treatment was delayed due to the pandemic (60%) [ Table 2].
Questions were asked to assess the perceived risk assessment and the impact of COVID 19 Lockdown. A majority of the respondents preferred their Orthodontist to be wearing an N-9 5 mask (27.3%) and the found the standard of care provided by their Orthodontist to be better than before (60.7%). Majority was satisfied by the protocols adopted by the Orthodontist (95.3%). Amongst the participants unsatisfied with the protocols, the major reason was unclean instruments (4%) and the Orthodontist not wearing surgical gown (3.3%). Only 18.67% of participants reported of change in fees. A majority of respondents did not find any difficulty in travelling (55.3%). 20.7% participants faced definite resistance from the family to visit the Orthodontist during the pandemic. A majority of the patients feel the necessity to visit the Orthodontist even after all these challenges (80.7%) [ Table 3].
Significant associations were observed between the questions

Discussion
Coronavirus pandemic has affected the health care delivery significantly globally. Orthodontic treatment, though an elective treatment, requires regular follow up every four-six weeks. Some orthodontic procedures are time consuming and aerosol producing, which puts the patient and the orthodontist both at a greater risk of contracting COVID-19. Owing to the lockdown, which was announced in March 2020 in India, there were restrictions on travelling, strict laws pertaining to leaving the home unless necessary. Dental clinics were also not functioning except for emergency procedures.
The objectives of this study to assess the impact of COVID-19 lockdown and the challenges it posed on the orthodontic patients.
70% of the participants replied that it has been less than three months since their last follow up. Fixed Orthodontic treatment includes brackets and bands fixed into the patient's mouth, which increases the plaque accumulation and increased oral hygiene care. This requires repeated reinforcement and inspection by the Orthodontist. Along with oral hygiene assessment, the change of elastics periodically is vital since the elastic force decays over time, which would significantly affect the treatment. However, the patient due to the unawareness often overlooks this. Sixty-two percent participants replied that they experienced no breakages of appliances    during the pandemic and only 57.4% experiences mild to moderate pain. Majority reported back to the dentist due to loose bands or brackets (14%) or poking wire (13.3%). Other problems like loose mini-screws, hurting retainers/ulcers were also reported of, but they were not many.
% handled the problem over the call with their orthodontist and only 8% required an emergency appointment. Caprioglio et al and Suri et al have also mentioned in their article that the patients could handle emergencies themselves by a few simple solutions like using a nail cutter to cut the distal end of wire, use of wax to block the hurting wire or tube, etc [12,13].
This study revealed that about 60% of the participants were worried about the pandemic causing the delay in their treatment. Treatment length and patient compliance are inversely proportional to each other. This provides a possible explanation for the reduced patient compliance during the pandemic [14]. Twenty-four percent patients were not concerned about the pandemic causing the delay in treatment. This was in concordance with the results of survey performed by Shenoi et al [14]. This can be attributed to the external motivation for treatment or lack of interest.
Page -05 ISSN: 2377-987X respondents who were not satisfied with the protocols followed by their orthodontist were > 20 years of age. Resistance from the family to visit their orthodontist during the pandemic was more in 10-20 years of age, next in > 20 years of age. These all results imply the possibility of there being a greater fear of encountering COVID 19 in the age group > 20 years [15][16][17][18].
Limitation of this study included the sample chosen included patients undergoing treatment from varied period. The restrictions imposed have reduced with time with the gradual easing of the lockdown. Thus, the response would vary.

Significance
This study elaborates on the difficulties faced by the patients during the pandemic and the impact it had on their orthodontic treatment. With the emergence of different variants of coronavirus, this study will provide transitory changes for better patient management, in such uncertain situations in future.
A swift shift to effective electronic and postal means of communication is necessary. Incorporating illustrative videos, Questions pertaining to the standard of care taken by the orthodontist in the pandemic revealed that 60.7% patients felt that their Orthodontist took better care than before. 95.3% were satisfied with the protocols followed by their orthodontist. The 4.7% who were not satisfied had major concerns with the unclean instruments. Majority of the patients (27.3%) found the use of N95 mask alone adequate. About 18% respondents preferred their orthodontist to wear a PPE kit and about 12% wanted their Orthodontist to wear PPE kit+ mask+ face shield. Significant relations were found between age and sex with reference to a few responses by the participants. There was a highly significant difference with high frequency for response mild pain and discomfort with females. Higher frequencies of females were concerned about there being a delay in their treatment due to the pandemic.
Highly significant difference with higher frequency in the age group > 20 years was found for less frequently visiting their orthodontist during the pandemic. They preferred handling their problem over the call with their orthodontist. Majority of the Page -06 ISSN: 2377-987X reminder messages and video calls could manage the situation better. This would ensure constant contact with the patient and provide reassurance to the patient.
During this period, emphasis should be placed on maintaining proper oral hygiene practices. This would reduce the adverse effects of decalcifications, gingival recession and root resorption in the patient.

Conclusion
Even after all the challenges, 80.7% of the participants found it necessary to continue the treatment. Thus, it becomes necessary for the orthodontist to give their patients a sense of comfort and reassurance by regularly checking up on them, empathizing with them. This would assure the patient that their doctor cares for their treatment and this would improve the patient compliance in these difficult times. At the same time, they should be informed about the seriousness of the pandemic and the required personal protection measures they should employ to reduce the spread. Only by increasing the awareness among the patients can the spread of this disease be reduced along with not having their treatment affected.