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A qualitative study of orthodontic patients’ experiences in quarantine during the COVID-19 pandemic outbreak

A qualitative study of orthodontic patients’ experiences in quarantine during the COVID-19 pandemic outbreak



American Journal of Orthodontics and Dentofacial Orthopedics, 2022-05-01, Volume 161, Issue 5, Pages e498-e506, Copyright © 2021 American Association of Orthodontists


Introduction

Coronavirus disease 2019 (COVID-19) is one of the most formidable challenges that influenced all domains of health care delivery. This research explored the experiences and challenges orthodontic patients faced in quarantine during the COVID-19 outbreak. The goal was to learn from patients about their oral health and general practices during this time to provide optimal delivery of orthodontic treatment care.

Methods

A phenomenographic qualitative design involving semistructured face-to-face interviews. A purposive sampling strategy was deployed to collect qualitative data from 24 orthodontic patients who quarantined during the COVID-19 pandemic. All interviews were digitally recorded, and afterwards, they were transcribed verbatim.

Results

Four main themes and associated subthemes were identified. The themes were (1) oral-health-related behavioral changes, (2) impact on treatment progression, (3) psychosocial impact and attitude changes, and (4) areas for future enhancements in health care delivery. Overall findings revealed both positive and negative behavioral changes in orthodontic patients regarding their adjustment during the quarantine and its implications to general health and well-being.

Conclusions

Findings from this study suggest that COVID-19 impacted dental health care delivery to orthodontic patients during the quarantine. Patients reported psychosocial and behavioral changes as a consequence of treatment disruption and pandemic lockdown. The implications of these findings to the clinical dental environment and patient education are pivotal to further target areas in dental health care delivery that require strengthening. As such, clinicians could expect behavioral changes from orthodontic patients and identify better strategies to mitigate clinical challenges resulting from such changes.

Highlights

  • Social life during quarantine directly relates to the initiative to maintain proper oral health.

  • Orthodontic patients believed a negative impact on the overall duration of treatment may occur.

  • Compliance with orthodontic instructions was suboptimal during the quarantine period.

  • COVID-19 lockdown was stressful and added an extra psychological burden to the patients.

  • Clinicians could expect behavioral changes from orthodontic patients during these periods.

On December 2019, Wuhan Municipal Health Commission reported 27 patients with viral pneumonia, of which 7 were critically ill. However, it was not until early January 2020 that the World Health Organization (WHO) expressed great interest in the pathogenesis of such respiratory virus designated “2019-nCoV” and later referred to in the media as a coronavirus disease 2019 (COVID-19). Because of its rapid spread, the progression of COVID-19 in terms of transmission and mortality urged China to start a lockdown process in many Chinese cities. Later, many countries initiated lockdown and quarantine procedures as WHO declared COVID-19 a global pandemic. These quarantine procedures act as a measure to control the spread of the virus. However, such measures negatively impacted the citizens, leading to financial losses, frustration, boredom, posttraumatic stress symptoms, anger, and even violent behavior. The pandemic lockdown, without transparent information about the quarantine and the designated protocols, was highly stressful and nerve-wracking to many people. Previous research has shown a direct relationship between stress levels and oral health; patients with more anxiety have poorer oral health.

Health care systems faced challenges pertinent to supplying sufficient medical equipment to sustain effective management of various medical conditions while ensuring a safe environment for patients and their treating physicians. Incorporating the latest technologies and health care guidelines would decrease cross-infection and develop a safe patient environment. Studies have shown that dental clinics should adopt stricter infection control protocols during the pandemic. , Over the last few years, the focus has been on developing and launching new health care applications to help track patients’ treatment progression. Furthermore, it serves as a reminder system for those receiving long-term treatment, such as orthodontic patients. The reliance on artificial intelligence, digital applications, and online sources to obtain information related to health care increased dramatically during the COVID-19 pandemic. In addition, studies have shown that these applications saved time, decreased the workload, and improved the quality of services.

Orthodontic treatment aims to improve patients’ oral health–related quality of life, as it tackles different domains related to boosting patients’ self-esteem after treatment. Thus, a patient-centered approach would allow the clinician to understand patients’ treatment needs setting achievable goals throughout treatment. Many studies explained the relation between oral health and its impact on patients’ quality of life. However, current challenges are more extensive than any other time, with the COVID-19 pandemic placing patients and their clinicians in an unprecedented situation. With the lack of prior published qualitative research focusing on those long-term dental patients receiving orthodontic treatment, our paper would present first-hand insight into understanding the impact of the COVID-19 pandemic on those patients and accordingly deliver practical means for clinical practice.

Orthodontic patients often present for long-term treatment and require regular check-ups every 4-6 weeks. Maintaining excellent oral hygiene ensures their oral health is not affected by decalcifications and periodontal disease. These patients are given suitable instructions to aid in effective management during their course of treatment. This qualitative research aims to understand orthodontic patients' experiences and perceptions during the COVID-19 outbreak and quarantine. This will shed some light on the psychosocial effects on the patients and their families, and how it has affected their oral-health habits and their expectations from treatment.

Material and methods

The ethical committee review board approved the study at the First Affiliated Hospital of Zhengzhou University (2020-KY-190). This qualitative phenomenographic research adopted face-to-face semistructured interviews to get in-depth data on the experiences of orthodontic patients who had undergone COVID-19 pandemic lockdown. This study followed the standard criteria of reporting qualitative studies: Consolidated criteria for Reporting Qualitative Research checklist.

The main aim of the phenomenographic approach was to identify how participants dealt with oral health and how that relates to their general health. Purposive sampling was used to recruit participants, and this ensured that adolescent and adult participants encompass a wide age range and different stages of orthodontic treatment. Participants identified as adolescents and adults (aged 16-35 years) who underwent fixed maxillary and mandibular appliance treatment in the First Affiliated Public Hospital of Zhengzhou university and experienced a full quarantine lockdown because of the COVID-19 pandemic in China were eligible for inclusion. Participants were not eligible for inclusion if they had syndromes or needed a combined orthodontic-orthognathic approach.

Before interviews, verbal information was given to the participants, accompanied by written consent. Participants’ confidentiality was assured using a password-secured folder and a number identifier instead of names. Data collection and recruitment were done in parallel, guiding the decision process until new themes were identified and data saturation occurred.

The study employed a nonprobability purposive sampling technique, in which participants were invited to undertake interviews because they met the criterion of orthodontic patients who underwent quarantine during the COVID-19 pandemic. Semistructured interviews were done in the First Affiliated Hospital of Zhengzhou University, in a private nonclinical room for an average of 38 minutes. A list of questions and a developed topic guide were prepared and guided the first 5 pilot interviews. Data saturation was met after recruiting 24 patients (mean age 25.2 ± 0.9 years; 17 females and 7 males). The demographics and baseline characteristics, the severity of malocclusion as assessed with the dental aesthetic index (DAI), treatment stages, and used appliances are presented ( Table I ).

Table I
Demographic and descriptive characteristics of participants
Demographics
Age, mean (standard deviation), range in years 25.2 (0.9), 16-35
Gender
Female 17
Male 7
Ethnicity
Han Chinese 24
Marital status
Married 8
Single 16
Highest education level
Junior high school 3
Bachelor 15
Masters 6
The severity of malocclusion (DAI scores)
Mild (<26) 0
Moderate (26-30) 2
Severe (31-35) 8
Handicapping (>35) 14
Treatment stage
Alignment 3
Space closure 13
Finishing 8
Extraction vs nonextraction
Extraction-based treatment 17
Nonextraction treatment 7
Appliances
Fixed appliances plus miniscrews 15
Fixed appliances plus bite planes 2
Fixed appliances alone 7

The interviews were done between May 2020 and August 2020 in Mandarin Chinese. They were digitally recorded and transcribed verbatim, and then translated into English using a professional translator. During interviews, the interviewer could pose new questions, and any new themes raised by patients guided the subsequent interviews. Interviews were conducted by 1 investigator (J.Z.) who possesses a Master of Science in orthodontics. The interviewer was trained in qualitative research interviews at the school of public health before the commencement of interviews.

The interviews were read more than once by 2 independent reviewers (K.W. and H.M.) and then again by a third reviewer (B.D.). Interviews were analyzed, coded, and compared using the NVivo software (version 11; QSR International Pty Ltd, Victoria, Australia). Central themes were identified along with the critical question of the semistructured interviews. The 3 reviewers discussed the nature of the initial themes. The themes relate to patients’ oral health experiences, the effect of the COVID-19 outbreak on the quality of treatment, psychosocial changes, and general reflections on health and well-being during the lockdown.

Results

In addition to the 4 main themes, subthemes were further identified from the qualitative data ( Table II ). These themes enabled further elaboration from a patient-centered angle and helped with questioning during the interviews. All participants spent a standardized period of >2 months of enforced COVID-19 lockdown and quarantine. They were instructed to contact the hotline number and share their private application accounts if there was a need for an emergency video call.

Table II
Main themes and subthemes
Main themes Subthemes
Oral-health related behavioral changes Changes in frequency and duration of brushing during the quarantine Factors affecting oral hygiene habits Diet changes in quarantine
Impact on treatment progression Quality and duration of treatment Following orthodontic instructions Anxiety from having an emergency and its solution
Psychosocial impact and attitude changes Significant negative emotions from treatment pause Feeling helpless Social interaction Fear of infection Positive emotions and memorial moments
Areas for future enhancements in health care delivery Short-term recommendations Long-term recommendations

Oral health-related behavioral changes

Oral health is a fundamental component of general health; it is directly related to cardiovascular diseases, pneumonia, pregnancy, and birth complications. Patients’ perceptions, measures, and motivations for maintaining optimum oral health differ from one person to another. This theme was subdivided into 3 subcategories.

Changes in the frequency and duration of brushing during the quarantine

Some participants expressed that staying at home alone for long periods negatively impacted their oral health and brushing habits. As staying at home for longer hours, and not having any social interaction with others, had an undesirable impact on their behavior.

“To be honest, I didn't; take care of my oral hygiene that much during the lockdown because I was always at home. I didn't have any social obligations since I hardly ever went out, and for that reason, I didn't brush my teeth much, which I admit is something I should have worked on.” (Participant 15)

In contrast, participants who stayed at home for extended times with their families felt more impelled by their families to maintain good oral health. They brushed their teeth 2-3 times a day for 2-3 minutes. Others even stated that they brushed their teeth for a more extended period (5-10 minutes).

“During this time, I helped my son develop good oral hygiene habits; I believe now he brushes his teeth better. My husband also has good brushing habits.” (Participant 7)

“I have more free time at home, so I brush my teeth after lunch, and I do it more carefully, and I brush for longer periods.” (Participant 10)

Factors affecting oral hygiene habits

All participants agreed that the type of food they ate affected their oral hygiene. Some types of food require longer brushing time because it sticks to the braces. At the same time, others explained that the frequency of eating is the main factor that makes them brush more. Participants also stated that staying at home for long hours made them careless about their hygiene because they were spending longer hours playing games or hanging around family.

“At home, I often eat fruits and snacks, which leads to an increase in the number of times I brush my teeth. In addition, some types of food affect the duration of brushing, especially food that's difficult to clean.” (Participant 1)

Diet changes in quarantine

All participants have had diet changes regarding the kind of food they ate and the number of times they ate throughout the day. The majority of participants ate more snacks and fruits during the lockdown. They stated that having their routine of going to work or university made them more inclined to eat a balanced diet. They stated that they usually ate healthy meals in their workplace or university cafeterias. However, they frequently indulged in their favorite food during the lockdown because they had extra time at home to cook their preferred recipes. They also expressed worries about bad breath, mainly if they ate more than 1 meal or snacks without brushing.

“The main change is in the increased frequency of eating, I often eat more snacks at home, but it doesn't affect my three main meals every day.” (Participant 23)

Impact on treatment progression

Orthodontic treatment may cause several risks like decalcification, root resorption, gingival recession, and alveolar bone loss. However, these risks can be controlled with proper compliance from the patients. This theme was subdivided into 3 subcategories.

Quality and duration of treatment

Some participants felt that their teeth were not moving in the right position; others felt that the treatment progression became very slow. However, all participants agreed that the quarantine would not affect treatment results, and it could impact the overall duration of treatment by 2-3 months.

“I think it may prolong my treatment time, but the outcome should not be affected. I think it depends on how skilled the doctor is. I trust my doctor in this regard; after all, he is a professional in the field.” (Participant 11)

Following orthodontic instructions

Half of the participants stopped using the elastic bands as instructed. Most of them forgot to wear it during the quarantine period because they were busy with social activities with family, whereas others ran out of elastics, so they needed to wait until the COVID-19 lockdown was lifted. Most participants tried to take extra care of their braces by eating small portions over time because they knew it would not be possible to rebond their brackets or have an emergency appointment.

“I have been eating these days very carefully because I don’t know when I'll be able to see my doctor, and my mother will be distraught if the bracket falls off.” (Participant 18)

Anxiety from having an emergency and its solution

All participants felt worried about emergencies, so they took good care of their braces and followed all instructions. Some emergencies occurred despite being cautious, such as excess wire, debonded brackets, and gingival bleeding. Participants expressed their gratitude for having a video call with their orthodontist, which solved their problems temporarily.

“During the quarantine, the wire pricked my mouth, and I called the doctor through video call; the doctor told me the solution, so the matter was resolved smoothly.” (Participant 13)

Psychosocial impact and attitude changes

Several studies suggest that staying at home for long periods and decreasing activity can lead to bone and muscle weakness. Moreover, the decreased exposure to sunlight affects mental health because of the decline in vitamin D levels, resulting in a compromised immune system making people prone to infectious diseases. , In contrast, it can be a direct cause of rumination and lethargy. The extent of these physical and mental effects differs from one patient to another according to their environment, social circle, and individual circumstances. This theme was subdivided into 5 subcategories.

Significant negative emotions from treatment pause

Participants stated that the quarantine period was stressful for different reasons. Some participants came from places far away from the hospital, and being in quarantine will force them to go through a longer duration of treatment which will affect their plans. In addition, they were worried about their treatment progress; they felt their teeth were moving in the wrong direction.

“To be honest, I want to remove the appliance early. My home is 450km away from Zhengzhou, and it takes me 1.5 hours to get to Zhengzhou by high-speed train. If I could finish treatment earlier, I would not have to run around; to be honest, I was a little impatient. I was also worried that the bracket would fall off.” (Participant 14)

“I was worried that the tooth will not move or change according to the plan designed by the doctor. If I return to the doctor regularly, the doctor can find some problems in time.” (Participant 1)

Feeling helpless

Some participants felt out of control because of the surrounding circumstances. Some participants have had to go through life-changing examinations, which made them unsure when they should start to prepare for the examinations and when their examinations will be held. In addition, during this period, some unauthorized Websites sought to have more followers, so they spread rumors on the Internet about the COVID-19 situation, causing more stress on people who didn't have access to official sources.

Some of the participants’ families felt worried about their financial situation, as they kept buying family needs without having stable income. In addition, they had some worries about not being able to visit the hospital or go out in case of an emergency.

“They had some anxiety. Because they thought I might be too nervous about the exams, I never knew when my postgraduate entrance exams would be held. So, I wanted the quarantine period to end quickly.” (Participant 3)

“My family become a little frustrated because we needed to continue paying our rent, in addition to the daily expenses, and we were not sure about my dad's salary.” (Participant 20)

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