COVID-19 - CHALLENGE TO ORTHODONTIC
MANAGEMENT IN VIRTUAL ERA
Bharath kumar Asokan,
Professor & Head of the department,
Post graduate (Final Year)
kumar Asokan, Kalaiselvi
Department of orthodontics&dentofacial orthopaedics, Tagore dental college, Chennai.
Department of orthodontics, KarpagaVinayaga Institute of Dental Sciences.
COVID-19 - CHALLENGE
MANAGEMENT IN VIRTUAL
The novel coronavirus or severe acute respiratory coronavirus syndrome 2 was a
causative agent of acute respiratory disease that resulted in an unexpected outbreak in
China in December 2019. Protocols for the provision of dental treatment during the
J Contemp Orthod 2020;4(4):
COVID-19 pandemic were created after analysis of the severity of the COVID-19
pandemic and were focused on grouping patients by diagnosis and need, and
considering interventions by risk and benefit. The purpose of this article is to comment
on the emergence, epidemiology, threats and to safeguard orthodontists during this
pandemic crisis. It is hoped that the recommendations proposed in this work would
continue to manage dental treatment around the world before and after this
Source of Support:
Conflict of Interest:
Orthodontic virtual management, Dental Practice
decontamination measures can benefit to reduce the risks.
Although it has also presently been suggested that dental clinics
Since the beginning of
2020, coronavirus disease
limit their practice only to not deferrable emergencies, this is not
(COVID-19) caused by severe acute respiratory syndrome
. Some ongoing treatment such as orthodontic
coronavirus 2 (SARS-CoV-2; first named as the 2019-novel
therapies and/or critical situations, like conditions that must be
coronavirus or 2019-nCoV) has rapidly spread throughout the
identified in the early stages and treated immediately to avoid
inhabited world and led to unprecedented major health,
more serious outcomes, require timely follow-up appointments.
humanitarian, and financial crises
The routes of
Indeed, continuous monitoring by the orthodontist is a must in
transmission of betacorona viruses i.e. biological details can
orthodontic treatment so as to evaluate the efficacy and/or any
pass from one individual to another through exhaled droplets,
.COVID-19 manifestations range from a
aerosols, contamination of surfaces, and possibly through
complete lack of symptoms to symptomatic patients with severe
. This viral infection is of great
complications leading to multi-organ dysfunction, septic shock,
concern due to its high contagiousness and morbidity, as well
and systematic failure. COVID-19 can be classified into mild,
as its ability to evolve into a potentially lethal form of
moderate, severe, or critical diseases
interstitial pneumonia and its possible evolution into a
potentially lethal form of interstitial pneumonia
. We must
anticipate and be prepared for the effects of unsupervised
Based on the experience and cumulative data on COVID-19
orthodontic treatment in case a future lockdown is imposed in
outbreak certain measures should be appropriately taken for
the wake of a COVID-19 resurgence.
screening and management of dental emergencies. According to
, confirmed the presence of ACE2 receptors in oral
The National Health Committee keeps receiving an ever-
mucosa and the epithelial cells of tongue bringing into the light
increasing number of confirmed, suspected, and fatal cases
the infection susceptibility of oral cavity and potential risk it
reported from all over the world. To date, they are still
poses to dentist and dental professionals. VanDoremalen,et al
carrying out world surveillance. There was an estimated
the recent research concluded that the virus remained viable in
human-to-human healthcare-related transmission of about
aerosols throughout the duration of the experiment (3 hours)
41% at the beginning of the outbreak. Many health care
with the reduction in the infectious titre from 103.5 to 102.7.
workers got and still are getting infected
. The use of
appropriate personal protective equipment (PPE) is must in
Patient before entering the clinical area requires:
avoiding cross infection during clinical procedures between
1. Screening every asymptomatic patient squarely.
patients and healthcare workers and the embracing of suitable
2. Identifying the critical need of the patient and aiming on
Periodontal abscess around molar band - Send a photo to
managing it with minimally invasive procedures.
the dentist, symptomatic therapy with paracetamol,
eventually prescription of antibiotic
3. Categorising dental treatment according to the urgency
of the required treatment and the risk and benefit
Pre-activated, non-removable appliances
associated with each treatment.
Take a picture every 20-40 days; if the patient feels pain or
4. Identifying the required dental treatment for each patient
swelling, see as an emergency in the dental office and .
and the risks and benefits associated with that treatment.
(e.g., Pendulum, Forsus, Distal Jet appliance,transpalatal
5. Using contact, and airborne precautions including proper
bar) eventually remove the appliance
aerosol-generating procedures personal protective
IMPLICATIONS FOR ORTHODONTIC
equipment (PPE) for every procedure.
The dental treatment should also be classified according to the
All dental professionals, including orthodontists, may be at risk
severity of the case and the degree of procedure invasiveness
of acquiring COVID-19 through multiple transmission routes,
including the following
Dental Treatments Categories are:
(1) Respiratory droplets from coughing and sneezing or
b) Urgent conditions that can be managed with minimally
(2) Indirect contact with viral droplets on a surface that
invasive procedures and without aerosol generation.
orthodontist later contacts,
c) Urgent conditions that need to be managed with invasive
(3) Aerosols created during dental or orthodontic procedures,
and/ or aerosol-generating procedures.
(4) Treating patients who may have experienced indirect
contact transmission from removing and replacing aligners,
appliances, and rubber bands, and
(5) Being in contact with multiple such persons, including
those who accompany the patients.
Orthodontists must be especially cognizant of the available
Functional - If it is broken or does not fit, send photos to
evidence to provide a safe environment for themselves, their
the orthodontist and suspend the use.
patients (and patient family members), and the entire orthodontic
team. In the current stage of the COVID-19 pandemic, a true
Aligners - Remain on the current/go on with treatment
dental emergency is one that deals with swelling, uncontrollable
pain, bleeding, infection, and trauma to teeth and or bones
broken or lost get back to the previous and ask the
should be provided. Orthodontic emergencies may include the
embedment of an orthodontic appliance into the gingiva or oral
- If broken or lost, ask to the dentist to
mucosa leading to severe pain and or infection, circumstances
buying hot customable preforms on e-
related to dental trauma, or conditions where a lack of
management would be harmful to the patient
. In dealing with
COVID-19, orthodontist should have a emergency plan in place
for the management of the patients.
Loose bracket - Send a photo to the dentist, eventually
The following key steps are recommended, based on an
remove it with tweezers
accumulation of the recommendations and suggestions of
Poking distal wire - Send a photo to the dentist, use wax,
multiple professional regulatory bodies
eventually cut with disinfected nail clipper/hardware
(1) Provide patients with a broadcast communication explaining
the changes in access to the orthodontic clinic/office as per
recommendations of the local public health and or dental
Poking ligature - Send a photo to the dentist, use wax,
eventually push it back with eraser of a pencil
(2) Provide active patients with suggestions for treatment
advancement on an individual basis as appropriate or in a
Journal of Contemporary Orthodontics, Oct-Dec 2020;4(4):16-20
Balaji Krishnan et al
correspondence to all patients (eg, when to stop activating
Orthodontic markers can be autoclaved or disinfected
an expander, what to do when the patient has reached their
using glutaraldehyde solution.
final aligner, etc.). Patients should also be reminded to
4. According to Benson Cleaning photographic retractors with
always wash their hands prior to and after placing and
washer disinfector were reported as the most effective
removing appliances or elastics, to clean their appliances
method of decontamination
regularly by wiping with alcohol, and to store appliances
in their cases.
5. Tungsten carbide debonding burs could be effectively
decontaminated from bacterial infection.
(3) Provide a means of communication (phone number or
email) to patients to allow them to contact the
6. It is safe to use tried-in orthodontic bands after adequate
orthodontist or an orthodontic team member with any
precleaning and sterilization.
questions or concerns, and send problem related intraoral
7. Decontamination does not jeopardize clinical stability of
mobile-phone digital images,
miniscrews nor mechanical properties of elastomeric
(4) Use phone calls or, video-calling or appropriate
teledentistry facilities to assist patients in resolving any
8. Flushing dental unit waterline for at least 2 min or using
emergent orthodontic problem that can be managed at
disinfectants improves the quality of water within the
dental unit and minimize the risk of infection.
(5) Provide emergent orthodontic treatment in a safe
manner, where necessary, and
Patient should rinse his/her mouth before any procedure using
(6) Exercise evidence-based precautions during the
0.12%- 0.2% chlorhexidinegluconate could help minimize the
provision of any in-office emergency treatment.
number of microbes within the oral cavity
and hand hygiene
measures according to WHO recommendations (washing hands
PERSONAL PROTECTION AND INFECTION
20 seconds minimal). Personal protective equipment,
including facial mask, face shield, eye protection, gowns, and
Orthodontists usually do not perform very intense tissue
gloves, are essential protective gear must be worn by the
surgery and do not treat infectious diseases.. It is not possible
operator during the outbreak.
to obtain a complete sterilization in orthodontics clinics, it is
possible to approach ideal sterilization by using new
Polishing the enamel surface with pumice and the use of a three-
During oral operations which are likely to spill blood, saliva
way syringe for rinsing during conventional bonding produces
and oral fluids, dental gloves, safety goggles, and protective
aerosol. Many non-AGP (non-Aerosol generating procedures)
face masks should be worn. If there is a chance of infection of
options for bonding are available although it must be emphasized
the blood or saliva, wear sterile gowns or lab aprons. Such
that these can compromise bond strengths
aprons should be changed when contaminated with blood.
Light-cured resin-modified glass ionomer cement can be used
Sterilization of orthodontic pliers:
without any prior enamel preparation. Self-etching primers can
also be used without prior enamel preparation and etching, but
Soaking in 1% sodium nitrate can be recommended. Metal or
they require the smear layer to be removed prior to use, usually
ceramic brackets can be disinfected with Chlorhexidine
by pumicing or polishing teeth, which would be unnecessary
with an AGP. The use of three-way syringe before or after
1. Orthodontic pliers can be sterilized with autoclave
polishing and etching can be avoided by using a dry cotton roll
sterilization, ultrasound bath and thermal disinfection, or
to clean the enamel surface. Suction can still be used because it
disinfected with chemical substances 2% glutaraldehyde
or 0.25% peracetic acid. Instrument cassettes should be
Indirect bonding may be another alternative to conventional
used effectively, with pliers ideally sterilized in open
direct-bonding techniques because it reduces patient exposure. It
should be kept in mind that flash removal for indirect bonding is
2. An autoclave is preferred over cold sterilization, without
an AGP and must be performed with utmost caution
negatively affecting surface characterization of
Leveling and Alignment:
Use of round, light-gauge nickel titanium wires, produces light
forces which have a extensive amount of play that can cause
as an abscess or permanent pulpitis, according to the Single
slippage of the wire from brackets, especially on the terminal
Nations recommendations during COVID-
19 pandemic in
molars. Square or rectangular nickel titanium wires can be
private practice. Orthodontic issues, such as general dental
used to avoid emergencies caused by slippage. Additionally,
conditions, constitute injuries, not actual injuries, a video call or
the archwires can be cinched back to prevent the sharp ends
visual message may be the better ways to determine the
from impinging on the gums. Use of flowable composite is
situation. This leads to reduced patient flow to the dental office.
also recommended to prevent impingement of the archwire on
On the other hand Orthodontic patients are aware of the need for
the soft tissue
compliance and attendance to the appointments and care with the
appliance in order to obtain a good treatment result within the
Extractions and Expansion:
period stipulated by the orthodontist. Some patients (34.7%) had
Orthodontic extractions may be carried out with standard
no concern with the impact of the quarantine in their orthodontic
precautions, in a single visit to reduce patient exposure.
treatment. This indicates confidence in the orthodontist.
Communication between the orthodontist and the patient, and
Expansion treatment is still possible, but only with close
reassurance by the orthodontist is the mainly reason in predicting
monitoring after the practice reopens. Patients must be clearly
patient satisfaction, good dentist-patient relationship and patient
instructed regarding the intervals of expansion. Once rapid
cooperation in following the prescribed instructions
palatal expansion is complete, it is crucial to retain the
achieved results by recalling the patient as soon as possible in
case of a future lockdown. Over activation must be avoided to
Digital technology in imaging and impression taking, that is now
prevent undesirable buccal tipping of posterior teeth,
commonplace in most dental practices, is a powerful tool for the
potentially necessitating “roundtripping” and prolonging the
orthodontist to access, analyse and, if need be, communicate
with patients, colleagues, and/or dental technicians. Recently a
Ligation and Bite Blocks:
Smartphone technology has been developed that enables remote
control of orthodontic patients using an artificial MonitoringTM
Use of stainless steel ligatures instead of elastomeric rings to
intelligence algorithm. This application is called Dental Monitor-
tie the archwires, since the metal ligatures are more hygienic
ing. DM was designed to carry out orthodontic follow-up at a
and offer more robust ligation. Passive self-ligating brackets
distance. It tracks tooth movement through a 3D reconstruction
offer advantages in delayed appointment situations, including
of an intraoral movie taken with the smartphone camera and
fewer emergencies associated with torn or loose elastomeric
specific cheek retractors. The patients themselves make a video
rings Space Closure
that is processed into a scan by DM
WhatsApp Messenger is an instant messaging program created
Patients with removable functional appliances can be
2009 and expanded exponentially to users of all ages, for
monitored remotely through video conferencing, and
personal relationships, as entertainment, as research aid, and as a
appliance use can be stopped once the objectives are met.
virtual contact point with their community. The use of this
Retentive phase extended by placing an upper anterior
interface in the health sector reported only a small number of
inclined plane to retain the corrected incisor relationship
publications, identified by the major database, online.
impact has been investigated inadequately in the clinical setting,
WhatsApp is one of the most widely used communication tools,
Clear plastic aligners may offer some advantages in the
which may also be valuable in fostering patient-physician
COVID-19 era. A series of aligners is commonly provided to
communication and relationships.
the patient for a set period (usually six to 12 weeks) before the
patient returns for evaluation and additional aligners. In the
The best way to deal with orthodontic emergencies is to decide
infrequent instance of loss or breakage of an aligner, the
progressively. The first step should always be virtual assistance.
The virtual assistance might be performed by using photos,
patient is usually advised to wear the previous aligner71 or, if
unavailable, the next one in the series. If no aligner is
videos (better if with additional light source), or video call. For
available, a replacement “stage retainer can be fabricated with
all emergencies, the patient should send photos or videos to
the previous digital record itself
confirm the accident
IMPACT ON ORTHODONTIC
In summary, SARS-CoV-2 is the first highly contagious
pandemic infection of this millennium. Although cross-
Dentists should acknowledge only non-deferrable cases, such
Journal of Contemporary Orthodontics, Oct-Dec 2020;4(4):16-20
Balaji Krishnan et al
contamination within any dental setting has not been reported,
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