Effect of COVID-19 on orthodontic treatment/practice- A systematic review and meta-analysis Alam MK, Abutayyem H, Kanwal B, Alswairki HJ

REVIEW ARTICLE

Year : 2023 | Volume : 12 | Issue : 1 | Page : 26

Effect of COVID-19 on orthodontic treatment/practice- A systematic review and meta-analysis

Mohammad Khursheed Alam¹, Huda Abutayyem², Bushra Kanwal³, Haytham Jamil Alswairki⁴
¹ Preventive Dentistry Department, Orthodontic Division, College of Dentistry, Jouf University, Sakaka 72345, Saudi Arabia; Department of Dental Research Cell, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India; Department of Public Health, Faculty of Allied Health Sciences, Daffodil lnternational University, Dhaka, Bangladesh
² Department of Clinical Sciences, Center of Medical and Bio-Allied Health Sciences Research, College of Dentistry, Ajman University, Ajman, United Arab Emirates
³ Orthodontic Specialist, Practicing in Dental Clinic, AlBaha, Saudi Arabia
⁴ Department of Orthodontic, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia

Date of Submission	15-Dec-2022
Date of Decision	09-Jan-2023
Date of Acceptance	19-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Mohammad Khursheed Alam
Preventive Dentistry Department, Orthodontic Division, College of Dentistry, Jouf University, Sakaka 72345

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jos.jos_118_22

Abstract

Coronavirus disease of 2019 (COVID-19), which has affected almost all medical professions, has had a significant negative influence on dental care. Additionally, non-urgent dental procedures were stopped during the epidemic in a number of countries. The purpose of this systematic review was to examine the impact of COVID-19 on individuals who had undergone or are currently having orthodontic treatment in any capacity during/after the pandemic's occurrence. After a thorough search of the online journals, a total of 634 documents were found, and 416 of the papers were initially chosen. The removal of 362 similar or duplicate publications that followed led to the initial availability of 54 separate papers. The final selection consisted of 23 documents, mostly in vitro investigations, cross-sectional studies, and comparative evaluations, which satisfied the necessary inclusion and exclusion criteria. COVID-19 had a significant impact on nearly every sphere of the patients' lives who were undergoing orthodontic treatment. However, people who are currently availing of various orthodontic treatment modalities did not experience the same issues as the ones faced by patients earlier. Teleorthodontics emerged as a viable option to access treatment during the lockdown period caused due to the pandemic. COVID-19 also had an overall negative impact on the psyche and morale of orthodontists around the world.
PROSPERO Registration Number: CRD42022380823

Keywords: Anxiety, COVID-19, orthodontic appliances, orthodontic treatment, orthodontics, teleorthodontics

How to cite this article:
Alam MK, Abutayyem H, Kanwal B, Alswairki HJ. Effect of COVID-19 on orthodontic treatment/practice- A systematic review and meta-analysis. J Orthodont Sci 2023;12:26

How to cite this URL:
Alam MK, Abutayyem H, Kanwal B, Alswairki HJ. Effect of COVID-19 on orthodontic treatment/practice- A systematic review and meta-analysis. J Orthodont Sci [serial online] 2023 [cited 2023 Jun 10];12:26. Available from: https://www.jorthodsci.org/text.asp?2023/12/1/26/375352

Introduction

Dental care has been severely impacted by the Coronavirus disease of 2019 (COVID-19), which has affected nearly all medical specialties.^[1] It should be noted that non-urgent dental operations were suspended in several nations during this time.^[2] Global socioeconomic effects from COVID-19 have resulted in a drop in average monthly income for all persons.^[3] Dentistry is thought to have a high infection risk because of direct contact with patient fluids during appointments and potential cross-infection. Transmission mechanisms have affected a number of professions.^[4],[5]

Numerous studies have documented large rises in people's levels of anxiety and despair as a result of rising health worries, unemployment, and decreased social interaction brought on by isolation and lockdown during the early stages of COVID-19.^{[3],[6],[7],[8]} According to studies done on orthodontic patients during the first wave of the pandemic, the patients were extremely anxious about attending their appointments, worried about the length and delay of their treatment, and even worried that there might be a rise in the failure rate of their orthodontic appliances and a decline in their periodontal health.^[9],[10] More than one-third of orthodontic patients in the early stages of the pandemic reported experiencing mental distress, and Xiong et al.^[11] found that the type of appliance, length of time since the previous dental appointment, and method of communication with the orthodontist all had an impact on how severe this distress was.

According to data from previous pandemics, psychological discomfort may continue long after the pandemic is gone in addition to having acute consequences on mental health.^[12] The psychological effects of COVID-19 quarantine may also be extensive, powerful, and long-lasting; this has been hypothesized. According to a longitudinal study by Veldhuis et al.,^[13] although the prevalence of depressive symptoms and suicidal thoughts and behaviors increased between April 28 and September, the prevalence of acute stress symptoms decreased. This study evaluated the effects of the COVID-19 pandemic on mental health in 2020. In a different longitudinal study, Pieh et al.^[14] assessed participants' mental health before the COVID-19 lockdown and six months later. They found that while stress levels significantly dropped and well-being levels significantly rose, the percentage of participants with mental health issues did not change.

Since the field of dentistry is considered to have a high infection risk due to appointment-related direct contact with patient fluids and possible cross-infection, this systematic review and meta-analysis aimed to analyze the impact of COVID-19 on patients who had undergone or are currently having orthodontic treatment in any capacity following the occurrence of the pandemic. This study's secondary goal was to evaluate how the pandemic affected orthodontists as well.

Materials and Methods

Protocol employed

This systematic review was performed as per the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) strategy and rules from the Cochrane group and the book Orderly reviews in Health Care: Meta Examination.^[15]

Review hypotheses

This systematic review and meta-analysis was aimed at analyzing the effects of COVID-19 on the patients who underwent/are currently undergoing orthodontic treatment in any form after the incidence of the pandemic. Also, a secondary objective of this study was to assess the effect of the pandemic on orthodontists as well.

Study selection

There were a total of 634 documents discovered after an extensive search of the online journals, and 416 of the papers were selected initially. Following that, 362 similar/duplicate articles were eliminated, which resultantly made 54 separate papers available at first. The abstracts and titles of submissions were then reviewed, and a further 31 papers were eliminated. Finally, 23 documents [Figure 1] that met the requisite inclusion and exclusion criteria were chosen, which primarily included in vitro studies, literature reviews, and comparative assessments.

Figure 1: Representation of a selection of articles through PRISMA framework

Click here to view

Inclusion criterion

Articles that contained relevant data for our review objectives were selected for full-text screening. Studies that reported clinical trials, in vitro studies, randomized/non-randomized studies, systematic/literature reviews containing substantial sample volume, and detailed case reports were considered for inclusion in our review. We also monitored studies that possessed a higher methodological quality.

Exclusion criteria

The following were excluded from the scope of our systematic review: incomplete data, seminar presentations, scholarly articles, grey literature, placebo-controlled studies, and opinion articles.

Since the literature available on this topic was quite scant in volume, we did not limit our search in terms of the time period when the studies were published, that is we took into account all the papers that were published with context to our topic (where the number of papers itself was found to be quite sparse in number). Also excluded were literature reviews and cases published in languages other than English.

Search strategy

Using relevant keywords, reference searches, and citation searches, the databases PubMed-MEDLINE, Web of Science, Cochrane, and Scopus were all searched. “Anxiety,” “COVID-19,” “Orthodontics,” “Orthodontic appliances,” and “Orthodontic treatment” were the search terms used to access the database.

Data selection and coding

Two independent reviewers located the relevant papers by using the right keywords in various databases and online search tools. The chosen articles were compared, and a third reviewer was brought in if there was a dispute.

After choosing the articles, the same two reviewers independently extracted the following data: author, year of publication, country, kind of publication, study topic, population demographics (n, age), outcome measure(s), relevant result(s), and conclusion(s). The data were compared and any differences were discussed with the third reviewer.

Statistical analysis

After selecting data on the sample size, variables analyzed, and various elements of the investigations, the data were then entered into the Revman 5 programme for meta-analysis. Forest plots illustrating the odds ratio for different study methodologies were obtained as part of the meta-analysis for our study, as shown in [Figure 2], [Figure 3], [Figure 4].

Figure 2: Odds ratio of studies selected in this systematic review that assessed the impact of COVID-19 on orthodontic treatment modalities represented on a forest plot after meta-analysis

Click here to view

Figure 3: Risk ratio of studies selected in this systematic review that assessed the impact of COVID-19 on orthodontic treatment modalities represented on a forest plot after meta-analysis

Click here to view

Figure 4: Risk difference of studies selected in this systematic review that assessed the impact of COVID-19 on orthodontic treatment modalities represented on a forest plot after meta-analysis

Click here to view

Risk of bias assessment

The AMSTAR-2 technique^[16] was used to evaluate the risk of bias in the studies we chose. AMSTAR 2 joins a number of other instruments that have been released for this purpose as a critical evaluation tool for systematic reviews. As seen in [Table 1] below, it is a 16-point checklist. Two instruments that have drawn a lot of attention served as the foundation for the creation of the original AMSTAR tool. The original AMSTAR was duplicated into two newly produced instruments. The AMSTAR 2 risk of bias items identify the domains specified in the Cochrane risk of bias instruments for systematic reviews. In each case, these indicate an agreement that was achieved after input from more than 30 methodology experts [Table 2].

Table 1: AMSTAR-2 16-point checklist of risk of bias assessment in studies selected for the systematic review

Click here to view

Table 2: Description and outcomes as observed in the studies selected for the systematic review

Click here to view

Results

[Table 2] lists the study's design, methods, description, and results. [Figure 2], [Figure 3], [Figure 4] show the findings of the meta-analysis.

Discussion

Most dental offices were shut down during the various lockdowns due to the increased danger of infection, which created a challenging scenario for patients undergoing orthodontic treatment because they normally need frequent visits to their orthodontist over a lengthy period of time.^[19]

Because orthodontic treatment is elective and lasts a long time, thousands of patients in lockdown areas missed their monthly appointments. Both patients and orthodontists expressed tremendous anxiety and perplexity regarding the unexpected cessation of treatment as well as any potential issues that orthodontic appliance components may have produced during this extended interval. Despite the fact that orthodontic treatment involves aesthetic and elective components, emergency situations might nonetheless arise.^[19]

Clinicians and patients both welcomed the use of teleorthodontics in the pandemic's emergency management, and the publications analyzed in this study highlighted a number of advantages. The ability to triage remotely to determine whether a patient needs an office visit or if there is a chance to resolve the issue through the media,^[17],[18] the ability to cut down on the amount of time the patient spends in the chair,^[26] and the ability to send and evaluate images and radiographs quickly^[10],[19] are a few of these benefits. The ability to reassure patients who experience anxiety, fear, or a sense of abandonment during therapy,^{[19],[26],[27]} as well as the potential for periodically checking on patients' oral health status and encouraging them to practice good oral hygiene,^[26],[27] are additional positive aspects that should be highlighted.

On the other side, the drawbacks of teleorthodontics were also looked into. Even though it doesn't appear to be appropriate in every circumstance or for extended periods of time, Saccomanno et al.^[27] in their study from 2020 believe that using teledentistry is a good answer. Clinicians demonstrated that the use of teleorthodontics could merely manage functional appliances and aligners, requiring just follow-up to continue therapy. However, due to the rigorous hands-on nature of teledentistry, the advancement of multibracket therapy is constrained. With the occasional exception of oral hygiene checks or visits to address a problem, almost all mandated follow-ups involve in-person visits.

In order to avoid cross-contamination and stop new outbreaks, dental and orthodontic care during the pandemic and in the future will require precautionary and selective case review based on the practitioner's judgment.^[33] The practitioner should adhere to the instructions given by the relevant health regulatory agencies. To maintain effective ventilation, air circulation, and standard PPE, the dental clinic may need to be modified and redesigned. Until the COVID-19 pandemic is no longer a concern, efficient telescreens and triaging should be a regular part of clinical screening protocols. Deferred orthodontic treatment and a referral to the COVID-19 screening unit should be given as a top priority to any suspected COVID-19 patient who exhibits symptoms. The dental procedure should involve little contact, be minimally intrusive, and prevent the creation of aerosols. The COVID-19 epidemic has had a significant impact on orthodontists and dental health workers in general. Costs associated with running a practice have increased due to growing demand and a desire for clinical inventory. However, orthodontists and dental professionals should strike a balance between the quality of care and the associated cost. The updated standards for infection control measures and the associated costs should be fully disclosed to patients.^[38] Pre-treatment, during treatment, and after treatment, the clinic's disinfection procedures must be rigorously followed. The health of the personnel and patients should be given first attention. The article's suggested workflow and guidelines, which were compiled from a number of health regulatory authorities, will allow for the appropriate and efficient management of dental and orthodontic care both during the COVID-19 pandemic and in the years after it. Virtual examination is a practical replacement for traditional examination methods, but when implementing initiatives, it's crucial to find and create a platform that is patient-friendly. If the patient's earlier x-rays and photographs are stored on a database system and are easy for an orthodontist to access when necessary, they can also be evaluated for reference during a virtual examination of the patient.^[39] Certain situations cannot be avoided because they will impair the mastication process and may cause food lodgments, which will then cause chewing issues. The orthodontist is unable to handle such situations, especially if traveling great distances for orthodontic consultations is involved. Therefore, those issues necessitate prompt attention from a dental doctor who practices close by.^[40],[41] If the government or governing health authorities have made a provision permitting the clinician to visit a patient, the dentist may choose to attend such crises.

The lack of randomized control trials can be attributed to being a major flaw in this systematic review of ours; however, the impact of COVID-19 on the field of orthodontics as a whole has been studied and observed during the time of the pandemic and immediately after the pandemic ended, which explains the lack of these types of trials. Also, we do not believe that a long-term study concerning the impact of the pandemic on orthodontic patients/practitioners has been reported yet. Therefore, more studies are needed to ascertain the pros/cons of these emerging trends so as to establish their credibility as trends that are beneficial to not just orthodontists but patients as well.

Conclusions

Nearly every aspect of the patients' lives who were receiving orthodontic therapy was significantly impacted by COVID-19, and a majority of them faced issues such as anxiety, paranoia, and fear of going for treatment due to the COVID-19 scare. However, people receiving various orthodontic treatment approaches today did not have the same problems as patients in the past. During the pandemic-related lockdown, teleorthodontics became a feasible option for receiving therapy. The psychological well-being and morale of orthodontists all throughout the world were also adversely affected by COVID. More case control trials and original research are required to determine whether the impacts on patients are still detectable in the post-pandemic era.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 Outbreak: An overview on dentistry. Int J Environ Res Public Health 2020;17:2094.
2.	Iacobucci G. Covid-19: All non-urgent elective surgery is suspended for at least three months in England. BMJ 2020;368:m1106.
3.	Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, et al. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg 2020;78:185-93.
4.	Coulthard P. Dentistry and coronavirus (COVID-19)-moral decision-making. Br Dent J 2020;228:503-5.
5.	Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig 2020;24:1619-21.
6.	Liu X, Luo W, Li Y, Li C, Hong Z, Chen H, et al. Psychological status and behavior changes of the public during the COVID-19 epidemic in China. Infect Dis Poverty 2020;9:58.
7.	Usher K, Jackson D, Durkin J, Gyamfi N, Bhullar N. Pandemic-related behaviours and psychological outcomes; A rapid literature review to explain COVID-19 behaviours. Int J Ment Health Nurs 2020;29:1018-34.
8.	Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. Global Health 2020;16:57.
9.	Conville RM, Flett A, Stern M. A two-centre study assessing the impact of the COVID-19 pandemic on orthodontic patients in secondary care. J Orthod 2022;49:24-31.
10.	Cotrin P, Peloso RM, Pini NI, Oliveira RC, De Oliveira RC, Valarelli FP, et al. Urgencies and emergencies in orthodontics during the coronavirus disease 2019 pandemic: Brazilian orthodontists' experience. Am J Orthod Dentofacial Orthop 2020;158:661-7.
11.	Xiong X, Wu Y, Fang X, Sun W, Ding Q, Yi Y, et al. Mental distress in orthodontic patients during the coronavirus disease 2019 pandemic. Am J Orthod Dentofacial Orthop 2020;158:824-33.e1.
12.	Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N. et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
13.	Veldhuis CB, Nesoff ED, McKowen AL, Rice DR, Ghoneima H, Wootton AR, et al. Addressing the critical need for long-term mental health data during the COVID-19 pandemic: Changes in mental health from April to September 2020. Prevent Med 2021;146:106465.
14.	Pieh C, Budimir S, Humer E, Probst T. Comparing mental health during the COVID-19 lockdown and 6 months after the lockdown in Austria: A longitudinal study. Front Psychiatry 2021;12:625973.
15.	Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Med 2009;6:e1000100.
16.	Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008. doi: 10.1136/bmj.j4008.
17.	Kumar A, Sharma A. The impact of covid-19 pandemic on orthodontic practice in India: A questionnaire based study. Int J Appl Dent Sci 2021;7:245-7.
18.	Arqub SA, Voldman R, Ahmida A, Kuo C, Godoy LDC, Nasrawi Y, et al. Patients' perceptions of orthodontic treatment experiences during COVID-19: A cross-sectional study. Prog Orthod 2021;22:17.
19.	Bustati N, Rajeh N. The impact of COVID-19 pandemic on patients receiving orthodontic treatment: An online questionnaire cross-sectional study. J World Fed Orthod 2020;9:159-63.
20.	Caprioglio A, Pizzetti GB, Zecca PA, Fastuca R, Maino G, Nanda R. Management of orthodontic emergencies during 2019-NCOV. Prog Orthod 2020;21:10.
21.	Moghadam MG, Omidkhoda M, Kazemi H. Oral health literacy and COVID-19 pandemic anxiety and concerns among Iranian orthodontic patients. Turk J Orthod 2021;34:93-101.
22.	Martina S, Amato A, Faccioni P, Iandolo A, Amato M, Rongo R. The perception of COVID-19 among Italian dental patients: An orthodontic point of view. Prog Orthod 2021;22:11.
23.	Nallamothu R, Aljohani DD, Al-Ramadhan MA, Eshag AM, Bakulka GA, Hasanian RZ, et al. Perceived impact of the COVID-19 pandemic on orthodontic practice in the Middle East. J Pharm Bioallied Sci 2021;13(Suppl 2):S975-9.
24.	Naveda R, Seminario MP, Janson G, Garib D. Concerns of orthodontic patients during the COVID-19 quarantine period. Dental Press J Orthod 2022;27:e2220229.
25.	Phaphe S, Valekar S, Manikandan J. COVID -19 lockdown and its impact on orthodontic patients. Int Dent J Stud Res 2021;8:152-7.
26.	Putrino A, Caputo M, Giovannoni D, Barbato E, Galluccio G. Impact of the SARS-Cov2 pandemic on orthodontic therapies: An Italian experience of teleorthodontics. Pesqui Bras Odontopediatria Clín Integr 2020;20:e0100.
27.	Saccomanno S, Quinzi V, Albani A, D'Andrea N, Marzo G, Macchiarelli G. Utility of teleorthodontics in orthodontic emergencies during the COVID-19 pandemic: A systematic review. Healthcare (Basel) 2022;10:1108.
28.	Sella Tunis T, Ratson T, Matalon S, Abba M, Abramson A, Davidovitch M, et al. The impact of the COVID-19 pandemic on Israeli orthodontic practice: A clinic's activity and patients' attitudes. Int J Environ Res Public Health 2022;19:1965.
29.	Shenoi SB, Deshpande S, Jatti R. Impact of COVID-19 lockdown on patients undergoing orthodontic treatment: A questionnaire study. J Indian Orthod Soc 2020;54:195-202.
30.	Shhabat Z, Ghozlan M, Kana'an N, Tashtoush A, Alelaimat A, Saadeh R. The impact of COVID-19 pandemic on patients receiving orthodontic treatment. Eur J Dent 2023;17:115-9.
31.	Suri S, Vandersluis YR, Kochhar AS, Bhasin R, Abdallah MN. Clinical orthodontic management during the COVID-19 pandemic. Angle Orthod 2020;90:473-84.
32.	Sycinska-Dziarnowska M, Bielawska-Victorini H, Budzyńska A, Woźniak K. The implications of the COVID-19 pandemic on the interest in orthodontic treatment and perspectives for the future. real-time surveillance using Google trends. Int J Environ Res Public Health 2021;18:5647.
33.	Wafaie K, Mohammed H, Mohamed AMA, Zhou J, Daniel B, Yiqiang Q. A qualitative study of orthodontic patients' experiences in quarantine during the COVID-19 pandemic outbreak. Am J Orthod Dentofacial Orthop 2022;161:e498-506.
34.	Wu Y, Xiong X, Fang X, Sun W, Yi Y, Liu J, et al. Psychological status of TMD patients, orthodontic patients and the general population during the COVID-19 pandemic. Psychol Health Med 2021;26:62-74.
35.	Yavan MA, Cingoz M, Ceylan TM, Calisir M. Incidence of orthodontic appliance failures during the COVID-19 lockdown period. Am J Orthod Dentofacial Orthop 2022;161:e87-92.
36.	Yavan MA. Effects of the COVID-19 pandemic on new patient visits for orthodontic treatment: A comparison of 2020 and the previous 3 years. J World Fed Orthod 2021;10:127-31.
37.	Yavan MA, Eğlenen MN. Evaluation of orthodontic patients' anxiety levels during the COVID-19 pandemic: A 1-year follow-up. Turk J Orthod 2022;35:180-5.
38.	Mithun K, Ashith MV, Harshitha V, Pereira VA, Kumari D. Infection control in orthodontics: A review. Indian J Forensic Med Toxicol 2018;12:10-5.
39.	McGrath J, Kman N, Danforth D, Bahner DP, Khandelwal S, Martin DR, et al. Virtual alternative to the oral examination for emergency medicine residents. West J Emerg Med 2015;16:336-43.
40.	Dowsing P, Murray A, Sandler J. Emergencies in orthodontics. Part 1: Management of general orthodontic problems as well as common problems with fixed appliances. Dent Update 2015;42:131-4, 137-40.
41.	Mohamed M, Ferguson DJ, Venugopal A, Khursheed Alam MK, Makki L, Vaid NR. An artificial intelligence based referral application to optimize orthodontic referrals in a public oral healthcare system. Semin Orthod 2021;27:157-63.