Abstract
Abstract
Objectives
The primary objective was to determine peritraumatic distress among orthodontic patients during the COVID-19 lockdown. And the secondary objective was to determine the relationship between peritraumatic distress in relation to different appliance types.
Design
Cross-sectional study.
Setting
Primary hospital between May and June 2022.
Participants
Patients in the process of orthodontic treatment, able to read Mandarin online, provided informed consent for the use of the data recorded and completed the questionnaire within a reasonable time.
Interventions
None.
Primary and secondary outcome measures
The demographic information and orthodontic urgencies were collected using online questionnaires. The peritraumatic distress symptoms were assessed by the COVID-19 Peritraumatic Distress Index (CPDI). The temporomandibular joint (TMJ) pain was evaluated using a Visual Analogue Scale.
Results
A total of 480 participants were enrolled, including 331 with fixed appliances, 131 with clear aligners and 18 with removable appliances. For all participants, the median CPDI score was 12 (4, 19). Higher CPDI scores were observed in participants with urgency (14 (6, 21) vs 8 (2, 15), p<0.001), participants aged ≥18 years (15 (6, 23) vs 8 (2, 15), p<0.001) and participants with TMJ pain (15 (8, 24) vs 11 (3, 18), p<0.001). Linear regression showed that age >18 years (β=0.271, p<0.001), TMJ pain (β=0.169, p<0.001) and urgency (β=0.144, p=0.001) were independently associated with the mean CPDI score.
Conclusions
The study suggested that during catastrophic events such as the COVID-19 lockdown, orthodontic urgencies may exacerbate patients’ peritraumatic distress, especially among adult patients and those who suffer from TMJ pain.
Keywords: Pain management; ORAL & MAXILLOFACIAL SURGERY; Education, Medical
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The study included a relatively large number of patients.
The study was performed in the COVID-19 context, which could decrease generalisability in the post-pandemic context.
Using cross-sectional data limits the ability to control unobserved heterogeneity among the respondents.
Recall bias and response bias could influence the results.
It was a city-based survey, and only a limited number of participants were involved.
Background
About 85% of orthodontic patients experience some kind of urgency during treatment.1 Although orthodontic issues can be urgent, they do not threaten the patient’s life (in opposition to emergencies).2 Still, they can be distressful to patients because of pain, difficulties moving the mouth, fear of failed treatment, fear of missing treatment opportunities and high costs.2 Timely and appropriate management of the urgency will relieve pain and distress for the patient.3 In addition, regular oral hygiene education during every visit also helps patients maintain oral hygiene.4
Still, sudden factors can impair the timely seeking and delivery of appropriate care for orthodontic urgencies, including disasters. Either natural or human-made, they can occur anywhere at any time and have been increasing in frequency and number of victims.5 Continuity of care is a central issue during a disaster.6 Still, triage will usually have to be implemented during a disaster,7 and patients with urgencies will be asked to stay home or be turned back. In addition, non-emergency healthcare professionals, including orthodontists, can be called on duty to help manage disaster-related health crises. COVID-19 has rapidly spread worldwide, leading to major health and humanitarian crises of unprecedented magnitude.8 Efforts to control the spread of COVID-19 have led to serious service disruptions, forcing regional and national emergencies and lockdowns, leaving only essential services to continue.9 Furthermore, dental professionals were morally inclined to reduce their services for fear of spreading COVID-19 among their patients and their families.10 Since orthodontic treatment is a long and continuous process, the scheduled care of many patients was abruptly halted. Timely return visits are necessary for the continuous and stable movement of teeth and to guarantee successful orthodontic treatment, especially during emergencies and disasters,11 such as the COVID-19 lockdown period in Shanghai, China.
Therefore, during disasters, patients with orthodontic urgencies can be left to themselves and have trouble finding help for their urgency. They can also fear quitting their haven to seek treatments, as was observed for several conditions during COVID-19, including for emergencies like acute myocardial ischaemia.12 Disasters are physically, mentally and psychologically challenging situations that can induce fear, distress, anxiety, depression and other psychological issues.13 Peritraumatic distress is defined as the emotional and physiological distress experienced during and/or immediately after a traumatic event.14 Yavan and Eğlenen15 16 showed that anxiety was high among orthodontic patients in Turkey. Turkistani17 reported that delayed orthodontic care during the COVID-19 pandemic could result in orthodontic urgencies, such as bracket detachment, sharp ligature tie and temporomandibular joint (TMJ)-related pain. Patients from a public clinic and with fixed appliances reported more problems than others during the quarantine.18 A study in India showed that orthodontic treatment and emergencies were not a factor contributing to stress during the COVID-19 lockdown.19 However, the relationship between peritraumatic distress and orthodontic urgencies during the lockdown period of public health emergencies has not been explored in China.
Therefore, this study aimed to determine the peritraumatic distress among orthodontic patients and its relationship to orthodontic urgencies with different appliance types during the COVID-19 lockdown.
Methods
Patient and public involvement in research
Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.
Study design and participants
This cross-sectional study enrolled orthodontic patients during the COVID-19 lockdown period in Shanghai, China, between May and June 2022. It was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine (approval #XHEC-C-2022–071). Informed consent was obtained from all participants. Adults who were 18 years of age or older only needed their own consent. Minors under the age of 18 required consent from both themselves and their legal guardian.
The inclusion criteria were: (1) in the process of orthodontic treatment, (2) able to read Mandarin online, (3) providing informed consent for the use of the data recorded and (4) completing all the items in the questionnaire within a reasonable time. The exclusion criteria were: (1) having severe uncontrolled mental disorders, (2) being uncooperative or (3) inability to understand the content of the questionnaire and being unable to complete the questionnaire.
12 orthodontists were commissioned to present the quick response codes of the questionnaire online via WeChat (Tencent, Shenzhen, China), which is openly accessible to their orthodontic patients during quarantine in Shanghai. The online survey platform used was Wenjuanxing (www.wjx.cn). Minors needed to complete the questionnaire under the guidance of their legal guardians.
Questionnaires and quality control
The questionnaires comprised five parts: (1) demographic and clinical information (gender, age, types of appliances and medical institution), (2) self-reported orthodontic urgencies and solution methods related to different appliances, (3) oral hygiene states, (4) the impact of lockdown on orthodontic follow-up and (5) the COVID-19 Peritraumatic Distress Index (CPDI).20 Regarding urgencies, fixed appliance (FA) urgencies included bracket detachment, displaced archwire, mucosal injury, accidental ingestion, toothache, mini-implant issues and TMJ pain. Clear aligner (CA) urgencies included attachment falling off, aligner crack, mucosa injury, toothache, mini-implant issues and TMJ pain. The questionnaire employed objective and neutral language to avoid leading questions, and each question offered neutral options to prevent subjective bias.
The 15-item CPDI was used to assess the frequency of anxiety, depression, specific phobias, cognitive changes, avoidance and compulsive behaviours, physical symptoms and loss of social functioning in the past week. The 15-item CPDI had a total score ranging from 0 to 60. A cut-off score of 10 points was used to indicate suspicion of symptoms. A cut-off score of 14 points was used to indicate certain distress. The Cronbach’s α coefficient of the 15-item CPDI is 0.932.20 A Visual Analogue Scale (VAS) was used to grade the TMJ pain.
Sample size calculation
A single population proportion formula, n=[(Zα/2)2*P(1 P)]/d2, was used to calculate the sample size.21 Since there were no prior studies on the CPDI score among orthodontic patients in the Chinese population, the sample size was calculated based on an expected proportion of 50% for patients experiencing certain distress. With a confidence level of 95% and a margin of error of 5%, the minimum required sample size was 384 individuals. To account for a potential 20% non-response rate, the final target sample size was 480 individuals.
Statistical analysis
All analyses were performed using SPSS V.18.0 (SPSS, Chicago, Illinois, USA). Cronbach’s α coefficient and Kaiser-Meyer-Olkin (KMO) test were used to verify the reliability and validity of the 15-item CPDI. The continuous variables were tested for normality using the Shapiro-Wilk test. Continuous variables with a normal distribution were presented as means±SD and analysed using independent-sample t-tests. Continuous variables with a skewed distribution were presented as median (Q1, Q3) and analysed using the Mann-Whitney U-test. The categorical data were presented as n (%) and analysed using the χ2 test. Linear regression was used to evaluate the factors associated with the outcomes and to adjust for confounders, with the CPDI score as the dependent variable. Statistical significance was evaluated using a 95% CI and a two-tailed p value of <0.05.
Results
Basic characteristics
A total of 482 questionnaires were distributed, and 480 questionnaires were returned and included, and there were 331, 131 and 18 participants with FA, CA and RA, respectively. The response rate to the questionnaire was 99.6% (online supplemental figure S1). For the reliability and validity of the 15-item CPDI, Cronbach’s α coefficient was 0.935 (>0.7) and the KMO value was 0.939 (>0.7).
The participants included 151 male participants and 329 female participants. The participants were between 7 years and 47 years of age. A total of 330 respondents completed the questionnaire independently, while 150 respondents completed it with the help of their legal guardians. The characteristics of the participants are shown in table 1.
Table 1. Characteristics of the participants.
| n=480 | N (%) | Mean±SD |
|---|---|---|
| Gender | ||
| Male | 151 (31.46) | |
| Female | 329 (68.54) | |
| Age | 21.36±8.39 | |
| <18 years | 220 (45.83) | 13.99±1.84 |
| 18–30 years | 177 (36.88) | 24.00±3.36 |
| ≥30 years | 83 (17.29) | 35.24±4.78 |
| Types of appliances | ||
| Fixed appliance | 331 (68.96) | |
| Clear aligner | 131 (27.29) | |
| Removable appliance | 18 (3.75) | |
| Medical institution | ||
| General hospital | 295 (61.46) | |
| Stomatological hospital | 103 (21.46) | |
| Dental clinic | 82 (17.08) |
For the routine visit delays, 51.88% of the participants reported a delay of over 2 months, while 30.21% had a delay of over 3 months. Additionally, 336 participants (70%) reported that the dental clinic or hospital was closed during lockdown. Moreover, 50.21% of the participants had activity restrictions and traffic constraints during lockdown, and 45.83% refused scheduled orthodontic appointments due to concerns about contracting COVID-19. Regarding the intention of orthodontic care, 323 participants (67.29%) wanted to attend a visit immediately after the lockdown, while the remaining participants wanted to prolong the follow-up time. Finally, 91.04% of the participants thought the lockdown would prolong their treatment duration. Finally, 77.92% of the participants worried that the treatment efficacy would be influenced by the pandemic.
The oral hygiene states were collected: 144 (30%) participants were more cautious than usual about oral cleaning, while 138 (28.8%) participants reported tooth brushing more than three times daily. In contrast, 57 (11.9%) participants were more relaxed about oral hygiene, and concerning tooth brushing, 35 (7.29%) participants did so once a day.
Urgencies encountered during lockdown
A total of 306 (63.8%) participants reported urgencies during the lockdown. Specifically, 60.4% of FA participants, 72.5% of CA participants and 61.1% of RA participants reported urgencies. Among the FA participants, the prevalences of bracket detachment, mucosa injury by ligatures and mucosa injury by archwires were 26.6%, 16.0% and 14.5%, respectively (figure 1A). The lack of a sufficient number of aligners (55.0%), aligner cracks (16.0%) and attachment falling off (13.7%) was common for CA participants (figure 1B). Among the RA-related urgencies, the common urgencies included appliance fracture or loss (22.2%) and mucosal injury or dental pain (27.8%) (figure 1C). Approximately 23.1% of all participants reported TMJ pain. The average VAS score was 2.36±1.5. A total of 105 (21.8%) participants reported that they could go to the emergency room for search help. A total of 213 (44.4%) participants had contact information for their orthodontist and received help via telephone. 91 participants could solve the problem by themselves using their experience. 59 (12.3%) participants sought help online, including medical websites, social media sharing and popular science articles. 23 participants (4.79%) reported that they could not find any way to solve the problem (figure 2).
Figure 1. (A) Most frequent problems encountered by patients with fixed appliances (%). (B) Most frequent problems encountered by patients with clear appliances (%). (C) Most frequent problems encountered by patients with removable appliances (%). TAD, temporary anchorage device.
Figure 2. Solutions taken when encountering urgencies.
CPDI scores
The distribution of the CPDI scores is shown in table 2. For all participants, the median CPDI score was 12 (4, 19). There were 215 participants with a CPDI score of <10 points, 68 participants with scores between 10 and 14 points and 197 participants with a score of >14 points. The median CPDI score was 13 (4, 20) for FA participants, 12 (2, 18) for CA participants and 10 (0, 19) for participants with removable appliances, without significant differences among groups (p=0.168). The median CPDI score of the urgency group was higher than that of the non-urgency group (146 21 vs 8,2 15 p<0.001). Participants ≥18 years old (vs. <18 years; 156 22 vs 8,2 15 p<0.001) and those with TMJ pain (vs without TMJ pain; 158 23 vs 11,3 18 p<0.001) had significantly higher CPDI scores (online supplemental table 1).
Table 2. Presence of symptoms of CPDI.
| Item | Never | Occasionally | Sometimes | Often | Most of the time | |
|---|---|---|---|---|---|---|
| Emotion | 1. Compared with usual, I feel more nervous and anxious. | 147 (30.63%) | 143 (29.79%) | 150 (31.25%) | 28 (5.83%) | 12 (2.50%) |
| 2. I feel insecure and bought a lot of masks, medications, sanitiser, gloves and/or other home supplies. | 208 (43.33%) | 157 (32.71%) | 88 (18.33%) | 20 (4.17%) | 7 (1.46%) | |
| 3. I cannot help imagining the scenario in which my family or myself is infected, thus making me feel restless and scared. | 219 (45.63%) | 169 (35.21%) | 74 (15.42%) | 12 (2.50%) | 6 (1.25%) | |
| Anxiety | 4. I will believe the COVID-19 information from all sources without any evaluation. | 234 (48.75%) | 165 (34.38%) | 62 (12.92%) | 15 (3.13%) | 4 (0.83%) |
| 5. I would rather believe in some negative information about the epidemic than positive news. | 189 (39.38%) | 128 (26.67%) | 108 (22.50%) | 37 (7.71%) | 18 (3.75%) | |
| 6. I am constantly sharing news about COVID-19 (mostly negative news). | 233 (48.54%) | 157 (32.71%) | 73 (15.21%) | 10 (2.08%) | 7 (1.46%) | |
| Depression | 7. I am more irritable and have frequent conflicts with my family. | 202 (42.08%) | 183 (38.13%) | 81 (16.88%) | 11 (2.29%) | 3 (0.63%) |
| 8. I feel tired and sometimes even exhausted. | 160 (33.33%) | 144 (30.00%) | 113 (23.54%) | 46 (9.58%) | 17 (3.54%) | |
| 9. Due to feelings of anxiety, my reactions are becoming sluggish. | 195 (40.63%) | 138 (28.75%) | 106 (22.08%) | 31 (6.46%) | 10 (2.08%) | |
| 10. I find it hard to concentrate. | 164 (34.17%) | 154 (32.08%) | 124 (25.83%) | 32 (6.67%) | 6 (1.25%) | |
| 11. I find it hard to make any decisions. | 197 (41.04%) | 154 (32.08%) | 96 (20.00%) | 26 (5.42%) | 7 (1.46%) | |
| Somatisation | 12. During this COVID-19 period, I often feel stomach pain, bloating and other stomach discomfort. | 269 (56.04%) | 129 (26.88%) | 66 (13.75%) | 13 (2.71%) | 3 (0.63%) |
| 13. I cannot sleep well; I always dream about myself or my family being infected by COVID-19. | 322 (67.08%) | 119 (24.79%) | 35 (7.29%) | 3 (0.63%) | 1 (0.21%) | |
| 14. I lost my appetite. | 279 (58.13%) | 108 (22.50%) | 72 (15.00%) | 18 (3.75%) | 3 (0.63%) | |
| 15. I have constipation or frequent urination. | 287 (59.79%) | 113 (23.54%) | 71 (14.79%) | 8 (1.67%) | 1 (0.21%) |
CPDI, COVID-19 Peritraumatic Distress Index.
Linear regression showed that an increasing CPDI score was associated with three variables: age >18 years old (β=0.271, p<0.01), urgencies (β=0.144, p=0.001) and TMJ pain (β=0.169, p<0.001) (table 3).
Table 3. Factors associated with CPDI scores using linear regression.
| Unstandardised regression coefficient | Standard regression coefficient | P | ||
|---|---|---|---|---|
| B (95% CI) | SE | β | ||
| Age >18 years | 5.518 (3.801 to 7.236) | 0.874 | 0.271 | <0.001 |
| Urgencies | 3.049 (1.247 to 4.851) | 0.917 | 0.144 | 0.001 |
| TMJ pain | 4.082 (2.038 to 6.125) | 1.040 | 0.169 | <0.001 |
TMJ, temporomandibular joint.
Discussion
This study showed that orthodontic patients encountered urgencies, which may exacerbate peritraumatic distress related to COVID-19, especially in adults and those suffering from TMJ pain. Targeted interventions and self-management guidelines should be designed to relieve anxiety and strengthen the coping capacity of orthodontic patients during public health emergencies and disasters.
In the present study, the prevalence of participants who reported orthodontic urgencies exceeded 50%. The most common problems reported by those with FA were bracket detachment and mucosa injury. The prevalence of these problems was approximately 33% in this study, while previous studies conducted during the 2020 lockdowns reported prevalences near 50%.24 Still, the incidence of bracket detachment was 0.6–9.6% in routine scheduled care studies.22 A higher incidence of bracket detachment could occur, along with an increasing delay between visits. It has been reported that the rate of device failure increased during the pandemic, suggesting that many patients may have waited too long before consulting.23 It might also be related to patients’ lack of resistance to food temptation and carelessness without orthodontists’ routine reminders. For those with CA, the most common problem was the lack of enough aligners, some of which were solved by delivery. Aligner cracks and attachment falling off took second place, resulting in mucosa injury and unexpected tooth movement. The most common RA-related urgencies were broken or lost appliances and pain or discomfort. Both urgencies are related to the removable feature of RA, allowing them to be lost, to fall, etc. In addition, since they are removable, they can have adjustment issues or the patient can misuse them by not aligning them properly, leading to comfort issues. In addition, 63.7% of the patients who suffered urgencies reported that they could solve the situation by self-management with the help of popular science articles online or guidance from their orthodontists over the phone. As reported, appropriate communication is the most important issue in managing orthodontic patients’ urgencies, particularly virtual counselling.25 Given the suspension of routine dental practices, many orthodontic patients would seek online help. An analysis of posts on Weibo showed that the most frequently mentioned themes were missing appointments, negative feelings and problems/difficulties experienced by orthodontic patients during the 2020 lockdown.26 Regarding the solutions in the present study, patients wanted to talk to their specialists directly and read more popular science articles and official guidance online. Therefore, more attention should be given to teleorthodontics to help patients solve urgencies and reduce anxiety, especially during disasters and public health emergencies.18
Psychological disorders during the COVID-19 quarantine have been reported to include emotional and sleep disturbances, depression, anxiety, anger and emotional exhaustion, leading to an urgent need for mental healthcare for the general population.27 Anxiety has also been reported among orthodontic patients in Turkey. However, anxiety levels cannot be compared directly due to differences in measurement tools.15 16 In the present study, orthodontic patients who had TMJ pain had a significantly higher mean CPDI score than those without TMJ pain, and the mean CPDI score was over 14 points, confirming the presence of peritraumatic distress symptoms. Furthermore, the linear regression analysis confirmed that patients suffering from TMJ pain had higher CPDI scores independent of depression, anxiety and somatisation symptoms. Participants aged >18 years were associated with an increasing mean CPDI score. The median CPDI score was 15, over 14 points, indicating the presence of peritraumatic distress. It can be explained by young adults suffering higher levels of anxiety and a greater psychological impact from the pandemic than children and adolescents. Moreover, they are confronting more potentially anxiety-provoking world events than prior generations, and such event exposure is now pervasive with access to 24/7 media.28 A total of 61.4% of patients reported orthodontic urgencies, which was significantly associated with increasing mean CPDI scores. This finding indicated that patients who experienced orthodontic urgencies had a higher level of peritraumatic distress symptoms than non-urgency patients. Approximately 70% of orthodontic patients reported that they felt more nervous and anxious than usual, 55% reported feeling restless and scared about contracting COVID-19 and 60% experienced anxiety induced by negative news. People tend to obtain much information from social media without evaluation, which can easily trigger stress.29 Indeed, 65% of participants reported feeling irritable, tired and exhausted. Taken together with anxiety and depression, the explosion of social media, which is associated with increased anxiety and depression among young people, could be a contributing factor to the increase in anxiety over time.30 Concerning the somatisation factors, 40–50% of patients had stomach discomfort, digestive disorders and sleep disturbances, which were also reported in the general population during the pandemic.31 Thus, non-pharmacological therapy and TMJ home nursing guidance are necessary for patients who suffer from TMJ pain and are quarantined at home.32
In addition, orthodontic patients suffer from different kinds of orofacial pain, including toothache, peri-implantitis and TMJ pain. Among all participants, 23.1% had TMJ pain. Temporomandibular disorders (TMDs) are comorbid with anxiety.33 Depression is associated with pain sensitivity and is predictive of twofold to threefold increases in the risk of TMD.34 A previous study reported that the aggravation of the psychoemotional status caused by the COVID-19 pandemic could result in bruxism and TMD symptom intensification and thus lead to increased orofacial pain.35 It could be speculated that orofacial pain would be the main factor influencing the peritraumatic distress of patients with urgencies. Indeed, about 33% of orofacial pain practitioners indicated that the onset of their patients’ pain was extremely often related to COVID-19, and the most common symptoms were masticatory muscle myalgia, anxiety, tension-type headaches and bruxism.36 A previous survey of dental patients in Italy indicated that 40.7% had symptoms of pain in the face, jaw or temples in the past month, and 94.7% indicated that the aggravation of their pain was due to a major life event specifically related to the COVID-19 lockdown.37 Therefore, orofacial pain and peritraumatic distress aggravated each other during the pandemic.38 For these patients, psychological counselling was suggested to improve mental well-being during times of crisis. Furthermore, it is worthwhile to contemplate the introduction of online or smartphone-based psychoeducation during the outbreak to promote mental wellness and psychological interventions such as cognitive behavioural therapy.39
In addition, the type of orthodontic appliance and gender were not associated with the CPDI score. At the same time, a previous study showed that patients with invisible appliances felt less anxiety40 and that female patients suffered a higher level of anxiety during the pandemic.24 It can be speculated that these findings can be explained by the fact that almost half of the respondents were under 18 years old, and the basic mental status of teenagers is different from that of adults, as resilience and positive coping during the pandemic have led to better psychological and mental health status among teenagers.41
Besides, most participants reported concerns about the pandemic and delayed follow-ups. In addition, 32.71% of patients, especially women, wanted to postpone their visits after the lockdown, consistent with a previous study indicating that males were more willing to attend follow-ups on time while females were less worried about the impact of delays on orthodontic treatments.42 As reported, patients willing to attend an orthodontic appointment presented significantly lower levels of anxiety than those who would not go.43 Therefore, a clinical implication of the present study could be that teleorthodontist guidance could be recommended for patient follow-up, identify and solve orthodontic problems early, mitigate concerns and relieve patients’ anxiety. This study was performed during the COVID-19 lockdown, which can occur again in the future. Still, the results could also apply to patients living far from the clinic.
Of note, the present study was performed in the COVID-19 context, which could decrease generalisability in the post-pandemic context, but the results could be extended to any long-lasting public health emergency or natural disaster. Additional studies are necessary to validate that point. This study had a few limitations. First, using a cross-sectional design limits the ability to control unobserved heterogeneity among the respondents and prevent causality analysis. Recall bias and response bias were possibilities due to the nature of the questionnaire. Second, it was a city-based survey, and only a limited number of participants were involved. Therefore, the generalisability of the findings is limited. Finally, the CDPI is used for evaluating general distress. Nevertheless, previous studies evaluated the mental state of orthodontic patients during the pandemic using classic scales such as the Kessler-10 Psychological Distress Scale and the Self-Rating Anxiety Scale.24 40 In the present study, we assessed peritraumatic distress symptoms using the 15-item CPDI, a modification of the 24-item CPDI developed by psychiatrists at the Shanghai Mental Health Center.13 The CPDI was found to be a promising screening tool by researchers all over the world for the rapid detection of potential peritraumatic stress caused by the COVID-19 pandemic.44 The 15 items assessed four psychological distress factors. Future studies should use tools designed specifically for orthodontic patients.
Conclusions
Orthodontic patients who experience urgencies are at higher risk of peritraumatic distress related to the COVID-19 pandemic. Targeted intervention and self-management guidelines should be developed to strengthen the coping capacity of orthodontic patients. Orthodontists need to pay more attention to patients who experience ongoing TMJ pain and refer them to a psychologist if necessary.
Supplementary material
Acknowledgements
We thank Dr Jian Fan for the critical reading of the manuscript and Dr Zhang Xi for the assistance in sample size calculation.
Footnotes
Funding: This study was supported by the Shanghai Municipal Health Commission (Grant NO. 20214Y0123) and the Construction Project of the "Discipline Peak-Climbing Plan" of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (grant no.XKPF2024B5002). The study’s funder had no role in study design, data collection, data analysis, data interpretation or manuscript writing.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-095959).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and the protocol was approved by the Ethics Committee of Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine (approval #XHEC-C-2022-071). The informed consent was sent to individuals or their parents (if minor) through WeChat. The informed consent form was presented at the beginning of the online survey, and the individuals could choose to agree or not to go on with the survey or quit the survey anytime during the process. This procedure was selected because the online survey was collected during lockdown, and written informed consent for wet-ink was not obtained. All methods were performed in accordance with the relevant guidelines and regulations Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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