Orthodontic patient perception during the COVID era and teleorthodontics. A review of the literature

Mental wellbeing during the pandemic

Recent evidence suggests the existence of several barriers that might have impacted patients' attendance of orthodontic appointments during the pandemic.^15,16,17,18 A recent cross-sectional survey looked at the mental health status of the orthodontic patients during the pandemic, using Kessler-10 Psychological Distress Scale, as well as examining the level of anxiety, with respect to treatment duration, outcome, compliance and the ability to deal with an orthodontic emergency. Using an online questionnaire distributed to 458 patients, 38% experienced mental distress; it was more common among female orthodontic patients, and in rural areas compared with urban centres. Patients with fixed appliances were more anxious than those with removable appliances or clear aligners. Interestingly, patients with lingual fixed appliances exhibited lower anxiety levels in comparison to those with buccal fixed appliances. This could be attributed to the higher socio-economic status of the patients with lingual braces.¹⁹ In support, another online cross-sectional survey, via social media, explored the impact of the COVID-19 pandemic on orthodontic patients. Three domains were assessed: the importance of regular follow-up appointment; the impact of the COVID-19 lockdown on dental visits; and on mental health. In total, 408 respondents were included in the study. Of these, 73.5% were concerned about the increased length of the orthodontic treatment. There were also concerns that problems with orthodontic appliances could occur. The participants appeared to have appreciated the importance of follow-up appointments prior to the lock down. Meanwhile, there was some apprehension about the possibility of a heavier financial burden on the patient due to the extended treatment duration as a result of the pandemic. Although more than 50% of the respondents were not worried when visiting their orthodontist post-lockdown, 27.5 % were concerned about the impact of COVID-19 worldwide an 19.6% reported that they would not visit their orthodontist until the pandemic was over, thus posing a major dental health worry.¹⁸ Peloso and colleagues recruited 595 private dental patients, of whom the majority were orthodontic patients.¹⁷ Using an online questionnaire, they looked at patients' willingness to attend their dental appointments, as well as their psychological status. Most of the patients were willing to attend their appointments with no concerns (56.3%); 20.2% reported that they would wait as they deemed their treatment not urgent; 18.6% were worried about cross-infection and the transmission of the virus to their families; while only 5% were concerned that dental appointments may transmit the disease.¹⁷ In another study, Jiang et al assessed the psychological factors that could impact dental patients' use of dental services via a cross-sectional survey that recruited 956 participants.¹⁶ Most of the respondents (69.1%) were worried about the potential risk of getting infected with COVID-19 when attending the clinic, and the majority associated hospital attendance with increased risk of infection transmission. The authors also reported a statistically significant gender difference, with females being more anxious than males.¹⁶ This is in line with other studies that found males were generally calmer and more willing to attend their appointments.¹⁷

With respect to orthodontic emergencies, Turkistani studied the impact of delayed orthodontic provision during the COVID-19 lockdown on disability and pain of 150 orthodontic patients. She reported that those who experienced poking of their archwires had significantly higher pain score than those who did not, with only 9.3% seeking a consultation for their pain.²⁰ Using the Manchester Orofacial Pain Disability Scale (MOPDS), there was a strong correlation between the severity of pain and disability, with almost quarter of the respondents reporting orofacial pain for >24 hours. In terms of physical disability, being unable to eat hard food (51.3%), taking longer to finish a meal (46%), and no longer enjoying food (36.7%) were mostly reported, while difficulty in talking for long periods (30.7%), and being irritable, angry and frustrated (26.7%), were the most commonly noted psychosocial disabilities.²⁰

Sociodemographic factors

Socio-economic status can play an important role in orthodontic treatment outcome.²¹ It has been reported that living in rural areas may negatively influence orthodontic patients. This could be attributed to the lower income levels, transport difficulties during the lockdown restrictions, and the fear of self-isolation, being detached from family, friends and society.¹⁹ This is in line with previous studies that showed how socio-economic differences can influence the outcome of orthodontic treatment, with reduced improvement in occlusion among lower socio-economic groups.²¹ With the worldwide economic disruption and job losses during the pandemic, income diminution was also shown to be a statistically significant factor influencing the mental wellbeing of patients attending their dental appointments.¹⁶ Dunbar et al looked at patient satisfaction with face-to-face appointments compared with virtual consultations. They reported full satisfaction with face-to-face appointments, while over 40% of the participants were neutral about video consultations. The majority however were sure that teleorthodontics would save time, cost and inconvenience. The authors concluded that living in urban areas – especially in the vicinity of the hospital where the study was conducted – could have influenced the results, with fewer favouring virtual consultation.⁴

Patients treated in public sector, and with fixed appliances, presented with more problems than patients with removable appliances or clear aligners.²² In contrast, this study reported that patients registered at private dental clinics, showed lower independence in dealing with orthodontic emergencies compared with those attending dental hospitals; this may be attributable to the more comprehensive and clearer instructions given to the patients.¹⁹ This warrants future investigation to better understand the factors that influence attitude and behaviour among the NHS and private patients, when dealing with orthodontic emergencies.

Orthodontic treatment duration and outcome

One of the major concerns communicated was that the overall treatment duration could have been prolonged as a result of the imposed restrictions of the COVID-19 pandemic.^17,18,19,22 The majority of orthodontic patients were concerned about the increased length of their orthodontic treatment.^17,18,19,22 There was also anxiety about the potential problems with orthodontic appliances, and the possibility of increased financial burden on the patients due to the prolonged treatment time as a result of the pandemic.^17,18

Dealing with orthodontic emergencies

Patients with fixed appliances presented with more problems than those with removable appliances or clear aligners, with the most commonly reported issues being the orthodontic archwire poking the cheeks, and breakages of the appliance.^19,20,22 Favero and colleagues recruited 10 orthodontic patients, aged 10–16 years, who were instructed via mobile videophones, and given remote orthodontic advice when dealing with orthodontic emergencies. They found that most orthodontic emergencies could be dealt with remotely, and both participants and their parents, found the consultations easy, useful and reassuring.²³ In support, a more recent study included 30 patients who received different orthodontic treatments: 10 had aligner therapy; 10 fixed straight wire appliances; and 10 had functional orthodontic appliances. Follow-ups were provided via video calls, exchange of intra- and extra-oral photos, and messaging.⁵ The patients were appreciative of such consultations during the pandemic, were reassured with the follow-ups, and had their concerns addressed. They also reported the cost effectiveness and time-saving aspect of these consultations.⁵ A recent qualitative systematic review reported a high level of acceptability of virtual consultations by children and their parents, with younger generations demonstrating a greater willingness to interact with the technology.³ It was also noted that not all patients with orthodontic emergencies sought professional advice²⁰ nor were willing to attend their appointments during the pandemic.^17,18

Lack of communication with their orthodontist

Lack of communication can impose barriers to the provision of high-quality patient care. Not all patients were able to contact their orthodontists during the lockdown.^18,19,22 A recent study that explored the impact of COVID-19 on orthodontic patients, reported that more than half of the participants did not receive any communication from their orthodontists. This could have had a negative impact on both dental health and psychological wellbeing of these patients. Furthermore, some of the respondents were concerned about the worldwide impact of COVID-19, while others reported that they would not visit their orthodontist until the pandemic was over.¹⁸ The misconception that hospitals were the infection transmission hubs and attending dental appointments could therefore pose risk of infection, was a major concern to some.¹⁷ This lack of awareness should be addressed, since it may negatively impact dental health and wellbeing.^18,19

Good communication

Good communication with the patients, encompassing the assessment of their perception and experience, is an important factor in achieving a high quality of care.²⁴ This became even more important during worldwide disruption. Thus, acknowledging the mental health of orthodontic patients, and effective communication, are essential for reassurance and addressing all of their concerns.^18,19,20,22 In addition, directing patients to the latest guidance and videos on how to manage dental and orthodontic emergencies from home, can be reassuring. The British Orthodontic Society provided extremely useful video tutorials for home repair of orthodontic appliances. They also provided a helpful guide for taking intra-oral photographs that aided orthodontic emergencies during the COVID-19 pandemic and lockdown.^7,25

Patient-centred research

Cunningham discussed patient-centred orthodontics, looked at patients' experience, satisfaction, reported outcomes, and involvement in research, not only as study subjects, but when actively involved in the design of the research studies, and afforded the opportunity to voice their questions.²⁴ This approach should be encouraged.

Other areas of interest include exploring the long-term implications of lockdown on mental and oral health, and further research into the impact of different fixed appliance therapy on patients' mental health.¹⁹

Teleorthodontics

During a national emergency, such as the COVID-19 pandemic, and in light of the benefits of teledentistry, several authors have recommended regular contact between the orthodontist and his/her patients. They recommended educating patients to rectify problems and manage emergencies related to their appliances at home^{5,19,20,22,23} with greater focus on females and those living in the rural areas,¹⁹ and giving instructions about oral hygiene.^18,19,22 Most of the orthodontic emergencies could be easily addressed remotely, and to the satisfaction of participants, thus limiting visits to instances of unequivocal need.²³ Teledentistry can also be a viable option in providing timely orthodontic referrals.⁶ With virtual consultation, several tasks can be performed remotely, such as remote consultation, screening, diagnosis, treatment planning, follow-ups and emergency appointments.^2,3,5