Assessment of the willingness of Nigerian Orthodontists to offer face-to-face orthodontic services to patients infected with Covid-19

Introduction Efforts to contain the spread of the COVID-19 disease led to suspension of many services which caused orthodontists to resort to providing only emergency services. The aims of this study were to assess the willingness of Nigerian Orthodontists and Orthodontic resident doctors to treat patients infected with Covid-19 as well as to ascertain advice given regarding traumatic arch wires and aligners during the pandemic. Participants and study design This was a descriptive cross-sectional study. We included dentists who were Orthodontists and orthodontic resident doctors practicing in Nigeria. Data was collected via an online questionnaire (Google form) which was sent three times weekly throughout May/June, 2020 and analysed using SPSS version 23. Descriptive statistics were used to analyse the data. Results Forty-eight out of the 90 members of the WhatsApp group responded within the allotted time, giving a response rate of 53.3%. Out of a total of 48 respondents, 39 (81.3%) were unwilling to treat patients infected with COVID-19 during the pandemic. The major reason was fear of infection with the virus (12, 25.0%). Most of the respondents (41, 55.4%) suggested the use of wax for relief of trauma from arch wires. Conclusion Majority of Orthodontists and orthodontic residents practicing in Nigeria expressed unwillingness to treat patients infected with COVID-19. Aligner therapy was proffered as an alternative to bracket therapy.


Introduction
From the beginning of 2020, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread throughout the world causing a major upheaval. 1 Efforts to contain the spread of the disease led to the suspension of many services which included orthodontic treatment. 1 This scenario caused anxiety for many orthodontic patients as well as orthodontists as only emergency services were provided at this time. 2 As the pandemic progressed, orthodontists sought novel ways of communicating with their patients. Social media handles especially WhatsApp became very useful communication tools. 3 The ability to communicate remotely served both to allay the anxieties of patients and to enable the monitoring of progression of treatment. Tele-orthodontics became a popular tool during the pandemic and still remains relevant in order to ease treatment demands on the Orthodontist as well as the patient without reducing the quality of orthodontic treatment received. 4 Although the pandemic has been brought somewhat under control with effective treatments and vaccinations and orthodontic offices having reopened, there is still a lot of anxiety among Orthodontists due to the uncertain nature of the disease and the ease with which the disease can be contracted in the dental office. This anxiety has impacted the attitude of Orthodontists towards their practice as well as Orthodontist-patient relationships. 5 Many Orthodontists did not resume full practice immediately due to the fore mentioned factors and continued with remote consultations via WhatsApp platforms and other social media handles. Essential areas of adaptation to ensure in-person safe practice of orthodontics included "microbiologic control measures, social distancing, new ergonomics and bioethical considerations". 3 Covid-19 is a disease with variable manifestations whereby some patients do not develop symptoms although they are infected with the coronavirus and can transmit the infection. We therefore thought it expedient to report on the willingness of Nigerian Orthodontists and Orthodontic resident doctors to treat patients infected with COVID-19 as well as to ascertain advice given to orthodontic patients regarding traumatic archwires and aligners during this period.

Materials and Methods
Ethical approval from the Ethics Committee of the Aminu Kano Teaching Hospital, Kano, Nigeria, and informed consent from each participant were obtained before the commencement of this descriptive cross-sectional study. Participants: This study was carried out among Orthodontists and orthodontic resident doctors practicing in Nigeria. We included Dentists who were either Orthodontists or Residents doctors who were in training to become Orthodontists.

Setting
This was carried out in Nigeria.

Design
This was a cross-sectional survey. Data was collected via an online questionnaire (Google form) which was validated by testing the questionnaire on three consultants and two resident doctors with suggested corrections made before it was sent to the WhatsApp group containing dentists who met the inclusion criteria. Reminders were sent to the WhatsApp group and also to the individual WhatsApp pages of eligible participants three times weekly throughout May/June, 2020. The questionnaire was made up of two sections. Section A sought information concerning Socio-demographics, section B assessed the participant's willingness to treat patients infected with COVID-19; reasons for lack of willingness, advice given concerning orthodontic emergencies and their opinion concerning the use of aligners as it relates to COVID-19. The responses to the questionnaires were downloaded into a passworded computer for data protection purposes and then analysed using IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. Descriptive statistics were used to analyse the data.

Results
Out of the ninety orthodontists and orthodontic residents on the WhatsApp group, forty-eight of them responded within the allotted time, giving a response rate of 53.3%.

Socio-demographics
As seen from the data presented in Table 1, most of the Orthodontists were relatively young and middle-aged. Twenty respondents were aged 31-40 years accounting for 20 (41.7%) of the responses. This was closely followed by those aged 41-50 years making up 19 (39.6%) of the study population. Twenty-four (50.0%) orthodontists were practicing in Lagos, 19 (39.6%) in Southern Nigeria and 5 (10.4%) in Northern Nigeria. The gender demographics indicate that there were more female orthodontists than males as evidenced by 29 (60.4%) of the responses being female. A greater number of responses 26 (54.2%) were received from those who had practiced 10-19 years. Regarding the respondents' practice status, 22 (45.8%) were specialists/consultants; 18 (37.5%) were senior residents; and 8 (16.7%) were junior residents. Most (39, 81.3%) of the orthodontists practiced in government or military hospitals.   1.4%). These data are presented in Table 3. aligner posed a risk of re-infecting patients. Regarding the risk to clinicians, 28 (58.3%) opined that the risk was lower among orthodontist than general dentists while 20, (41.7%) opined that the risk was higher for orthodontists. Discussion This study showed that majority of the Orthodontists/ Orthodontic residents practicing in Nigeria were unwilling to offer face-to-face orthodontic services to patients infected with COVID-19 during the pandemic. This is similar to the findings from a study carried out previously. 6 Although some of the respondents did not give any reason for their unwillingness to treat such patients, others cited fear of infection with the virus, lack of Personal Protective Equipment (PPE), the highly pathogenic nature of the virus, orthodontic treatment not being considered an absolute emergency by them and that patients infected with COVID-19 should be in isolation centers receiving treatment for the ailment. Anxiety and fear concerning infection with the virus among dental practitioners was also found to be high in Italy where almost 85% of participants were worried about contracting the virus whilst attending to patients. 7 In contrast to our findings concerning the willingness to offer face-toface treatment to patients infected with Covid-19, reports from a study by Ottolenghi et 9 This could be due to availability of personal protective equipment, support to maintain recommended quarantine and isolation policy and adequate and effective training of staff. 9 A previous study 10 has documented the fact that females seem to be more willing to participate in research than males but in our study, the demographics revealed female preponderance among the participants which is reflective of the fact that there were more females in the WhatsApp group.
The unwillingness to treat such patients infected with COVID-19 exhibited by our participants may also be due to the fact that about half of them reside and practice in Lagos State which was the epicentre of the COVID-19 outbreak in the country at the period of conducting this study. They may have had firsthand experience in terms of the presentation and complications of COVID-19, thus leading to fear and anxiety in them as reported by another Nigerian study. 11 In a Chinese study carried out among orthodontists, orthodontic residents and nurses, about two-thirds of the population were found to be unwilling to treat patients infected with COVID-19 which is lower than the proportion in our study, however their reasons for this behaviour were largely the same. 12 The fear of infection which may lead to infection of their family members was their major reason which was the same reason cited by most of the Chinese participants as well as dentists from 30 countries worldwide. 12,13 The risk of transmission of COVID-19 is high among those who are in close proximity to infected individuals. 14 Orthodontists and orthodontic resident doctors work in close contact with patients and vice versa. Orthodontic procedures require that the orthodontist be in close proximity to the patient over a considerable length of time (working field and the dentist is averagely 35-40 cm) 15 which therefore puts both the orthodontists and their patients at great risk of cross infection when either of them happens to be infected with the virus. 1 The participants perceived lower risk of infection among orthodontists as compared to general dentists, may be because the latter engage in more aerosol generating procedures than orthodontists.
During the period of lockdown, orthodontists were attending exclusively to orthodontic emergencies. Orthodontic emergencies during the pandemic referred to problems with aligners, traumatic wires as well as loose brackets and bands. 16 Majority of problems encountered by our patients during this period were related to traumatic wires which is similar to that seen in another Nigerian study 17 and in a Saudi Arabian study 18 but was different in other studies where bracket, archwire, molar band and tubes breakage were the most encountered emergencies. 19,20,21 These problems were communicated via online platforms as advised by other authors. 16 A study 22 (YANA) in the United Kingdom revealed that video and telephone consultations were the means used to communicate with their patients during the pandemic. Our patients were encouraged to use wax for temporary relief, small nail clippers or wire cutters to trim the wire, or use a pencil eraser to tuck it back. This advice is similar to what obtained in other parts of the world. 2,19,23 .
Only a few of the participants indicated that they would advise the patients to call the clinic. This is in agreement with recommendations from previous studies on the management of orthodontic emergencies during 2019-NCOV which in addition to the suggestions above, also recommended that patients could carefully try to remove the arch wire with eyebrow tweezers. It is important to promptly resolve these orthodontic urgencies as quickly as possible in order to prevent decreasing the motivation of the patient, losing the patients' confidence in the orthodontist and to provide relief from pain and discomfort for the patient. 16,19,24 .
Aligner therapy has been suggested to be one method of enabling orthodontic treatment to continue without constant contact with the orthodontist, especially during this pandemic. 25,26 It was noted in a Chinese study that during the pandemic, patients on aligner therapy had less complaints/emergencies than those using fixed appliances. 27 Also the patients using fixed appliances were more anxious during the pandemic. 27 Aligners may be used in conjunction with fixed Orthodontic appliances at the beginning or end of treatment. Our study shows that most of the participants agreed to the usage of the current aligner by patients infected with COVID-19. This is in agreement with recommendations from a study by Alberto Caprioglio et al 10 as well as the Chinese study 27 in which it was suggested that patients remained on their current aligner until the end of the emergency. It was also suggested that in the case of a broken aligner, patients should use the previous aligner or they should change to the next one depending on the duration of usage of the broken/lost aligner. 16 One limitation of this study is the low response rate of 53.3%. This is attributable to burn out in filling various online questionnaires by different researchers which took place during the lock down period.
The implication of this study for clinical practice is the fact that patients could and should be taught on how to handle traumatic wires at home during normal consultation so that when the need to use it arises and the Orthodontist is not available due to unforeseen circumstance such as lockdown as occasioned by COVID-19 pandemic, such patients will then be able to render help for themselves easily.
One of the implications of this study for research is the African Health Sciences, Vol 23 Issue 1, March, 2023 need to assess the impact of the COVID-19 pandemic on the time taken to complete an orthodontic case.

Conclusion
Majority of the orthodontists and orthodontic residents practicing in Nigeria expressed unwillingness to offer face-to-face orthodontic treatment to patients infected with COVID-19. The main reason for this was their fear of being infected by the virus and infecting family members with same. They preferred to communicate with their patients via online platforms and proffer temporary solutions to traumatic wires. These solutions included the use of orthodontic wax and a small nail cutter to cut these traumatic wires. Most participants advised their patients to continue to use their current aligners.