Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes?

ABSTRACT Introduction: The global outbreak of coronavirus disease 2019 (COVID-19) has led all dental governing bodies across the world to minimize or cancel routine/elective dental procedures and limit dental services to only acute emergency situations. Orthodontic treatment is a long-term treatment that necessitates several appointments. However, if patients are left unsupervised during this pandemic, serious harms might arise apart from acute orthodontic emergencies. Objective: In this article we highlight these harms and their negative impact on patients and the overall success of their treatment. Conclusion: We briefly presented actions needed to be undertaken by orthodontists to gradually allow for recalling patients according to the stage of their treatment to avoid any potential harms to the treatment outcome and avoid any subsequent medicolegal consequences.


INTRODUCTION
The global outbreak of coronavirus disease 2019  has dramatically changed the world in all aspects. This has led the World Health Organization (WHO) to declare this disease outbreak as a global pandemic. 1 The common mode of COVID-19 transmission is either by respiratory droplets or contact routes. As a result, guidelines for healthcare workers started to emerge in an attempt to prevent COVID-19 transmission. 2,3 In the dental profession, it is well known that dental procedures produce aerosols and droplets that pose real risk of disease transmission.
Furthermore, coronavirus can remain suspended in the air for longer periods and can contaminate surfaces and instruments that can lead to indirect transmission. 4 The fact that dental practices are focal points for cross-infection has led all dental governing bodies across the world to minimize or cancel routine/elective dental care, and limit services to only acute emergency situations, relying on telecommunication, pharmaceutical options, the use of high-volume saliva ejectors and avoid the use of aerosol-generating procedures or any procedure that can stimulate coughing. In addition, guidelines have been published during this pandemic to maximize personal protection equipment (PPE) in an effort to reduce the risk of COVID-19 transmission. Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 5 Although several vaccines have been recently introduced, it is not known how long COVID-19 will last, given the fact that little is known with respect to its characteristics. Furthermore, there is no effective treatment or medication for this disease, until now, that can aid in reducing severe complications or mortality rate. This in turn, will have negative long-term implications on patients whose care involves several appointments, such as orthodontic patients, who are at the moment experiencing delays in their routine follow-ups.
A recent review summarized advice that can be provided to patients for the short-term management of orthodontic emergencies. Among recommendations presented, were: treatment advice should be delivered first remotely and, only when necessary, in-person treatment can be given, provided strict infection control protocols are implemented. 5 However, there are other problems that might arise, in addition to acute orthodontic emergencies, which may lead to different types of harm, with respect to treatment outcomes.
Such problems are related to the stage of treatment, whether in active or passive phases of orthodontic treatment, and require an urgent need to be highlighted in this unprecedented situation. Therefore, the aim of the present paper is twofold.
Firstly, to highlight harms that might arise, other than acute Dental Press J Orthod. 2021;26(2):e21ins2 Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 6 orthodontic emergencies, in unsupervised orthodontic cases, due to global suspension or delay of routine orthodontic follow-ups during the COVID-19 outbreak. Secondly, to briefly present actions needed to be undertaken by orthodontists to gradually allow for recalling patients, according to the stage of their treatment, to avoid any future potential harms to the final treatment outcome.

HARMS RELATED TO UNSUPERVISED ORTHODONTIC PATIENTS
Orthodontic treatment is a long-term treatment that necessitates several appointments on a monthly basis or sometimes less, depending on the type of appliance used. To achieve successful treatment outcomes, orthodontists should conduct comprehensive examination, give accurate diagnosis and plan treatment steps efficiently. In addition, every effort should be made to protect the health of both hard and soft oral tissues and the psychological well-being of the patient from any harm. 6,7 The WHO defines patient harm as "an incident that results in harm to a patient, such as impairment of structure or function of the body and/or any deleterious effect arising there from or associated with plans or actions taken during the provision of healthcare, rather than an underlying disease or injury, and Dental Press J Orthod. 2021;26(2):e21ins2 Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 7 may be physical, social or psychological (e.g., disease, injury, suffering, disability and death)". 8 Although harms and complications related to orthodontic treatment are not life-threatening and less severe than other medical interventions, it is well reported that they might cause functional, social and psychological impairments to patients. 9  Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 9

HARMS RELATED TO FINISHED TREATMENT
Retention is one of the most important stages of orthodontic treatment. The aim of this stage is to maintain the stability of the corrected occlusion, as teeth have inherent tendency to return to their original positions. 11 Retention can be achieved by either fixed or removable retainers. Therefore, careful monitoring, adjustment and assessment of retainers should continue post-treatment, to prevent relapse. It is not uncommon to experience problems related to retainers with respect to patients' compliance, breakages or losing them. 12 Usually, the patient is instructed to report any problems related to retainers as soon as they occur. However, during this pandemic, and due to the current regulations, problems related to retainers are not considered an urgent situation that necessitates immediate care. As a result, relapse will take place, with variations in severity depending on the type of malocclusion before treatment. This will lead to serious psychological harm to the patient after complying with long-term treatment and incurring all financial expenses. On the other hand, this will frustrate the orthodontist and will lead to extra treatment time, depending on the extent of the problem. Therefore, problems related to retainers during the COVID-19 outbreak should be regarded as an urgent need for care and be given priority, in order to prevent any sort of relapse.

PSYCHOLOGICAL HARMS ON PATIENTS
The global outbreak of COVID-19 has imposed changes to our behaviors and the way we interact with the outside world.
Restricted access to healthcare facilities is among the important changes that people have to cope with. Unless an emergency situation is present, patients cannot continue with their routine medical or dental follow ups. This issue might lead to distress, panic and immense pressure on patients, in particular, orthodontics patients. The fact that orthodontic follow-ups are discontinued during this outbreak has led many patients to question the progress of their treatment and whether any harm would happen for this long delay. In addition, several studies reported that patients who are undergoing orthodontic treatment will experience positive impact on their quality of life (QoL) during the course of treatment. 13 Such delay could lead to negative impact on their QoL that might affect their compliance to treatment and their overall expectations about the final outcome. Therefore, it is highly recommended during this pandemic to keep communicating with all patients, even in the absence of an emergency situation, to reduce their anxiety levels and build their confidence level for the coming future.
Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 11

HARMS TO TEETH AND PERIODONTIUM
In addition to improving esthetics by correcting jaws relationship and abnormal teeth positions, orthodontists aid in creating a healthy environment to teeth and the supporting tissues.
However, in some instances, orthodontic treatment can hold potential harm on the periodontal tissues. This complication could be aggravated if the patient is left unsupervised for long time. Unwanted tooth movements, as mentioned earlier, or not following strict and rigorous oral hygiene measures due to the long wait can lead to periodontal problems and demineralization of teeth -especially in teenagers, who constitute the majority of orthodontic patients. 14 Therefore, every effort should be made for oral hygiene reinforcement, by contacting patients regularly either by calling them or sending letters or emails. Such practice will eliminate harm to teeth and the periodontium, and will reduce referrals to other dental disciplines, which will lead to fewer burdens on dental practices during this pandemic.

ACTIONS NEEDED TO BE UNDERTAKEN BY ORTHODON-TISTS TO GRADUALLY ALLOW FOR RECALLING PATIENTS, TO PREVENT FAILURE OF TREATMENT AND AVOID ANY MEDICO-LEGAL CONSEQUENCES
What if the patient experienced any type of harm, previously In summary, and due to the fact that it is not known when this pandemic will end, the following actions should be considered and introduced, in addition to the current recommendations we apply in our orthodontic practices, to prevent any potential harms to both patients and treatment outcomes: 1. Comprehensive revision of all patients' records should be carried out, to develop a system that will classify them according to their stage of treatment. This will allow identifying patients who need to be seen urgently to prevent future harms, such as unwanted tooth movement or any damage to the retention protocol. Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? 14 Calling patients or using digital communication tools, such as videos, can aid in triaging patients and get a better insight about their current status. In addition, patients who are in a stage where any type of harm is unexpected should be assured and instructed to keep complying with treatment protocols, including oral hygiene maintenance. This in turn will reduce their anxiety levels during the pandemic and will boost their confidence towards the treatment and the whole healthcare system.
3. State/local health regulatory authorities should take their responsibilities to ensure effective healthcare provision during this pandemic. Among these responsibilities, protecting and defending healthcare professionals from any medico-legal issues that might arise due to suspension of routine and elective dental care, including orthodontic care. Furthermore, every effort should be made to support healthcare professionals in many respects. These include; providing them with the most up-to-date information related to COVID-19 outbreak, ensure the availability of personal protective equipment (PPE), provide regular testing for COVID-19 and give them freedom to judge every case based on the status of the patient, potential risks expected and the totality of circumstances.
Abed Al Jawad F, Alhashimi N -Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes?

CONCLUSIONS
Orthodontists should be aware of potential harms to treatment outcomes that might occur as a result of unsupervised orthodontic treatment, apart from acute emergency situations. It is not known how long COVID-19 outbreak will last, and therefore orthodontists should consider recalling patients who are in high need for care, depending on their stage of treatment.
State/local health regulatory authorities should support and protect clinicians during this unprecedented situation, and patients should be informed and educated about all possible consequences. This in turn will avoid any medico-legal issues and will prevent any jeopardy to the final treatment outcomes.