Changes in orthodontics during the COVID-19 pandemic that have come to stay

Abstract

The coronavirus disease 2019 pandemic will have a long-lasting impact on orthodontic practice. Some of the adaptations needed will improve the orthodontist's line of work when the pandemic will be defeated, but others will not be sufficiently cost-effective. These changes concern 4 areas of orthodontic practice: (1) microbiologic control measures, with increased use of personal protective equipment, stricter protocols inside and outside of the clinical area, and minimization of procedures that generate aerosols; (2) social distancing measures by redistributing spaces and decreasing the number of patients and companions in the clinics; (3) increasing teleorthodontics and use of appliances and techniques that require fewer scheduled and urgent appointments; and (4) bioethical considerations that promote a broader view of the psychosocial aspects of patients, their families, and the community. Some of these important adaptations, implemented while we are still suffering the effects of the pandemic, may be reversible, but others have come to stay.

Highlights

• •The coronavirus disease 2019 pandemic presents challenges to the orthodontic practice.
• •Strict microbiologic controls are required.
• •Increasing interpersonal distance in the dental office will be important.
• •Teleorthodontics and appliances that generate fewer appointments should be embraced.
• •The broader psychosocial vision of orthodontics in difficult times is needed.

The coronavirus disease 2019 (COVID-19) pandemic has posed such a threat to public health around the world that even when we have managed to defeat the infection through effective treatment and/or vaccination, dramatic and long-lasting changes are expected to affect the way we live, work, and relate to each other.¹ This will have a direct impact on all social settings and professions, and orthodontics will be no exception. Some of the important adaptations implemented in orthodontic practice while we are still suffering the effects of the pandemic may be reversible, but others will not be. Many of them will improve the orthodontist's line of work when normality is restored, but others will not be cost-effective enough and, as a result, may get in the way for those professionals who would prefer returning to their normal routine as soon as possible. However, it seems that the concept of normality in orthodontics, as in many other areas, will never be the same, and only the professionals who manage to adapt to the new scenario will be able to go ahead. The essential adaptations concern 4 areas of the orthodontist practice: microbiologic control measures, social distancing, new ergonomics, and bioethical considerations.

Measures to reinforce infection transmission control

Extended use of personal protective equipment (PPE)

In our regular practice, orthodontists and clinical staff use gloves, surgical masks, and gowns, but as a result of the pandemic, the routine use of complete personal protective equipment may be advisable, not only when required by the health authorities in each country, but also because of an increase in demand moved by a traumatized society experiencing the effects of COVID-19.² This equipment, that's usefulness is unquestionable, is very uncomfortable in the day-to-day clinical activity and also hinders psychological interaction with the patient—a fundamental tool in the treatment of children and adults.

New cleaning and sterilization procedures

In addition to the thorough cleaning and sterilization of instruments and other supplies, which are routinely carried out in dental offices, during the pandemic it has been considered paramount to implement other systematic cleaning protocols between patients regarding the waiting room furniture, toilets, floors, and other surfaces. These new protocols will probably continue to be applied, at least partially, in the future, even if they slow down the pace of practice.

Minimize the use of aerosol generating procedures

Many orthodontic procedures such as the bonding and debonding of brackets and attachments generate a substantial amount of aerosols which, in turn, pose potential risks of infection transmission.³ Depending on the size of the office, it will be advisable to designate an isolated and adequately equipped space to carry out those procedures that require the use of rotatory instruments as handpieces or ultrasonic scalers and, if possible, concentrate these appointments when organizing the agenda.

Measures to increase social distancing

Redistribution of spaces

Orthodontic clinics often have several chairs that are relatively close together in open spaces sharing common facilities. To achieve the appropriate physical distance, may be necessary to rearrange chairs and place partitions between them. In many cases, this will require costly structural refurbishments, which can make it difficult for the orthodontist and their staff to move around the clinical area.

Decreasing the number of patients in the clinic

In orthodontics practice, it is common for the orthodontist to treat several patients simultaneously, especially if they are children. The need to increase interpersonal distances may require changing this form of collaborative and dynamic work in addition to reducing the number of patients seen per day. This approach could potentially have a negative economic impact at a time when the expenses derived from adaptations hinder the survival of many practices.

Reduce the number of companions

The adult patient should go to the office alone. Children should be accompanied by a single adult who, unless instructed to do otherwise, should remain in the waiting room. This change can be a problem for some parents who pick up the patient from school with 1 or more siblings and go directly to the orthodontist's office. Moreover, many orthodontists prefer parents (or legal guardians) to be present during procedures to request and offer information and also to involve them in the decision-making process while increasing psychosocial interaction.

A new form of ergonomics

Throughout its history, orthodontics has undergone many changes, some of them temporary, but a small number have been true milestones in its evolution, among them the advent of brackets, 3-dimensional radiology, skeletal anchorage, digitalization of records, or invisible orthodontics. The effects of the COVID-19 pandemic will accelerate another fundamental change: a new ergonomic approach to our line of work, 1 of those main objectives will be to reduce the number of face-to-face appointments and meetings. To do so, it will be necessary to do the following:

• (1)Enhance internet communication, telemonitoring, and virtual assistance for managing continued and urgent patient care.^{4 , 5} This new way of working requires learning and a change of attitude from the orthodontist and his team. Creating and updating the messaging systems and Web sites according to the changing needs is time-consuming, and if the professional lacks experience in this area, specialized help will be needed.
• (2)Promote the use of appliances and supplies that require fewer changes and activations and avoid devices that can give rise to unscheduled appointments due to damage, debonding, injuries to the oral mucosa, etc. This strategy may compel the orthodontist to change their habits and preferences with respect to some appliances they have always trusted.

New bioethical considerations

In orthodontics, as in all health professions, the biopsychosocial approach to the patient's pathology has always been important. At present, and presumably more so in the future, this broad vision will be essential. Many families may be victims of unemployment and the financial repercussions of this pandemic that may extend over time. Orthodontists must consider these circumstances when deciding on issues regarding suitable times to begin treatments or the advisability of postponing them, or when assessing the cost-effectiveness of some treatments.⁶

Orthodontics is important for the patient and their family, but in the current circumstances, its importance is only relative in many cases, and orthodontists can never lose the ethical perspective behind their specialty. In these difficult times and those to come, orthodontists must more than ever prioritize the psychosocial interests of patients and the community, while continuing to convey, without pressure, the role of oral health in society.

Conclusions

We do not know the true extent of the financial and bioethical problems we will have to face as a result of the COVID-19 pandemic, nor whether the measures that have proved necessary in the last few months will be relaxed over time, but we are certainly beginning to take a glimpse at what will be a new era in the evolution of orthodontics.