UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3597

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

Inﬂuência nos cuidados ortodônticos, pós-COVID 19, na perspectiva do paciente

Mayara Paim PATEL

, Gabryelle Fagundes NOVATO

, Gabriela Santos DOURADO

, Ana Carla Raphaelli NAHÁS

,

Murilo MATIAS

, Liliana Ávila MALTAGLIATI



1 – Universidade Guarulhos. Guarulhos, SP, Brazil.

How to cite: Patel MP, Novato GF, Dourado GS, Nahás ACR, Matias M, Maltagliati LÁ. Post-COVID-19 inuence in orthodontic care from

the patient’s perspective. Braz Dent Sci. 2023;26(2):e3597. https://doi.org/10.4322/bds.2023.e3597

ABSTRACT

Objective: considering the behavioral and paradigm changes due to the social isolation imposed by the new

coronavirus pandemic, patients and orthodontists also have anxieties and insecurities in face of the new reality

in dental clinics and educational institutions. This study aimed to evaluate, by means of an online questionnaire,

the applicability of tele-orthodontics and tele-assistance, the behavior of patients regarding the initiation of or

return to orthodontic treatment, and the new changes in clinical care. Material and Methods: the questionnaire

was based on the Google Forms platform and consisted of three parts: the rst one involved study presentation

and informed consent form; the second one involved demographic data collection and characterization of

the respondents, and the third one was the questionnaire itself. The questionnaire was sent by email and

instant-messaging apps, with data being submitted for descriptive analyzis. Results: a total of 116 replies were

returned, and most of the respondents were aged between 18 and 30 years old, female, and residents of the

Southeast region. The results showed that tele- orthodontics is still unknown to a signicant number of patients

(66.4%) and almost half of them (41.4%) want their treatments to be monitored in person, even those whose

devices do not require activation. They also prefer the rst consultation and diagnosis to be done in person

(55.2%). However, they are receptive to the idea of having their data and images transmitted via the Internet,

including some remote consultations interspersed with in-person ones, understanding that costs can be lowered.

Conclusion: tele-orthodontics is a reality, but for orthodontic patients, its applicability remains restricted to

sending images and records.

KEYWORDS

Covid-19; Pandemic; Orthodontics; Tele-health; Clinical protocols.

RESUMO

Objetivo: considerando as mudanças comportamentais e de paradigmas decorrentes do isolamento social imposto

pela pandemia do novo coronavírus, pacientes e ortodontistas também apresentam ansiedades e inseguranças

diante da nova realidade nas clínicas odontológicas e instituições de ensino. Este estudo teve como objetivo avaliar,

por meio de questionário online, a aplicabilidade da teleortodontia e da teleassistência, o comportamento dos

pacientes quanto ao início ou retorno do tratamento ortodôntico e as novas mudanças no atendimento clínico.

Material e Métodos: o questionário baseou-se na plataforma ‘Google Forms” e foi constituído por três partes: a

primeira envolveu a apresentação do estudo e o termo de consentimento livre e esclarecido; a segunda envolveu

a coleta de dados demográcos e caracterização dos respondentes, e a terceira foi o próprio questionário. O

questionário foi enviado por e-mail e aplicativos de mensagens instantâneas, sendo os dados encaminhados

para análise descritiva. Resultados: foram devolvidas 116 respostas, sendo a maioria dos respondentes com

idade entre 18 e 30 anos, do sexo feminino e residentes na região Sudeste. Os resultados mostraram que a

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

INTRODUCTION

In December 2019, COVID disease was rst

reported in China and since then it has spread very

quickly across that country and all over the world,

leading the World Health Organization to dene

this pathological condition as a pandemic in January

2020 [1,2]. This severe acute respiratory syndrome

(Sars-COV-2) stemming from COVID-19 caused

symptoms in humans, ranging from mild to severe

disease manifestations, sometimes fatal.

The spread primarily occurs by coughing,

sneezing, talking, and direct contact with surfaces

contaminated with droplets and aerosols, with an

incubation period lasting 2-14 days [3].

Because of the easy and fast dissemination,

several precautions had to be taken such as the

closing of numerous labor sectors considered

non-essential during the red phase of isolation

imposed by the government aiming to avoid

proximity and contamination [4].

Dental healthcare specialties require

proximity to the patients, which puts dental

professionals at high risk of acquiring

COVID-19 [5]. Orthodontics, particularly, is

considered not essential because it is a long

continuous treatment having no direct relation

to oral or urgent diseases. In this sense, the

recommendation was not to treat orthodontic

patients, except for emergencies. In general,

patient evaluation and routine orthodontic

appointments were recommended to be postponed

during the outbreak [6].

Nevertheless, orthodontics usually works with

comprehensive xed appliances for a treatment

that takes around two years to be nished and

needs regular appointments (e.g., monthly

visits). Such a long-time treatment without

any monitoring protocol can lead to possible

consequences, not only an extended treatment

time but also other complications like inadvertent

tooth movements and appliance breakage

causing mouth injuries and gum inammations.

Therefore, orthodontists bore in mind the risk of

infection and took all the hygiene and protective

measures as sooner or later they would have

to resume the clinical practice [1]. But during

the pandemic, many professionals have turned

to social networking technologies to maintain

contact with their patients, which was facilitated

by the evolution of interpersonal communication

media such as remote care software. According to

Giudice et al. [2], the Internet is to date the only

way to develop a signicant linker platform for all

medical professionals and particularly for dental

practitioners. Internet has made it easy to use

tele-dentistry through tele-consultation for patient

orientation, tele-diagnosis for image exchange,

and tele-monitoring, all being implemented to

minimize the risk of COVID-19 dissemination [2].

Moreover, such technology was found to be

particularly useful in orthodontics because minor

emergencies could be solved at home instead of at

the ofce as photographs can be used for diagnosis

and orientation. With the routine use of intraoral

scanners and digital imaging in dentistry, clinicians

can use digital models and photographs to analyze

and review cases and communicate with other

professionals, patients, and laboratory staff [7].

Many could expect that those arrangements

would last a short time, with life resuming its

normal pace and tele-dentistry or tele-orthodontics

being no more necessary as in-person visits

would eventually be reintroduced. However,

COVID-19 contamination persists as people are still

becoming infected after two big waves, meaning

that this pandemic will not end anytime soon.

teleortodontia ainda é desconhecida por um número signicativo de pacientes (66,4%) e quase metade deles

(41,4%) deseja que seus tratamentos sejam acompanhados presencialmente, mesmo aqueles cujos aparelhos

não requerem ativação. Preferem também que a primeira consulta e diagnóstico seja presencial (55,2%). No

entanto, eles estão receptivos à idéia de ter seus dados e imagens transmitidos pela Internet, incluindo algumas

consultas à distância intercaladas com as presenciais, entendendo que os custos podem ser reduzido. Conclusão:

a teleortodontia é uma realidade, mas para os pacientes ortodônticos sua aplicabilidade permanece restrita ao

envio de imagens e registros.

PALAVRAS-CHAVE

Covid-19; Pandemia; Ortodontia; Telessaúde; Protocolo clínico.

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

This virus may become just another endemic virus

in our communities and may never go away [8].

In this context, changes in the dental practice

during the pandemic tend to be perpetuated and

tele-orthodontics will be increasingly used, thus

becoming incorporated into the routine dental

practice as it offers advantages such as remote

screening of suspected COVID-19 patients, rst

consultation, diagnosis, and appliance monitoring

through video-conference. This “new normal”

should consider the best care possible by focusing

on the patient, including his or her comfort and

healthcare. Special attention is necessary not

only to the orthodontic treatment itself but also

to the patient’s anxiety about it [9]. The way

professionals adjust their services can have a

direct impact on the patient’s behavior and his

or her acceptance of returning to and continuing

the treatment. In this context, it is extremely

important to know the patients’ opinions and

perspectives regarding behavioral changes

in clinical care, including their expectations,

insecurities, and uncertainties.

Given these considerations, we proposed to

investigate the patients’ perspectives and opinions

about a new hybrid orthodontic treatment care

with remote and in-person appointments, when

necessary, and their ideas about returning to

in-person appointments.

METHODOLOGY

This is an investigative study that

was approved by the local research ethics

committee according to protocol number

33350920.6.0000.5506.

This study was performed to analyze whether

the patient would return to orthodontic treatment

during the COVID-19 pandemic or whether the

patient would accept a remote attendance. Data

from questionnaires answered by individuals

attending private clinics as well as private or

public institutions were collected according to

the following inclusion criteria: individuals aged

18 years or older at the beginning of orthodontic

treatment or already undergoing it; individuals

who are familiar with audiovisual resources;

patients who are not in treatment with another

specialty, but orthodontics. All participants were

asked to read and sign an informed consent

form before accessing the 3-item questionnaire

developed on the Google Forms online platform.

The questionnaire was prepared by four

orthodontists who, in addition to being educators,

also work clinically. Next, a statistics professor

reviewed the questions and respective answers to

verify the statistical applicability of the answers

and data collection.

By using the WhatsApp application

(WhatsApp Inc., California, USA), the

questionnaire was sent to several groups of

patients from private clinics and orthodontists

working in private and public institutions, dental

clinics, or universities for 1 month.

1 The questionnaire was organized into three

parts: The rst part consisted of the initial page,

with the title and proposal of the research,

and the consent form to participate in the

study. The two remaining parts consisted of

questions to characterize the sample, such as

participants’ age group, gender, occupation,

demographic information, and questions on

the main topic, which addressed aspects of

the orthodontic treatment after the COVID-

19 pandemic period, more precisely, patient’s

behavior regarding initiation or return to

orthodontic treatment and new changes in

the clinical care.

2 All the answers were kept anonymous

as there was no way to trace them, thus

avoiding possible embarrassment to the

respondents and consequently eliminating

possible interference with the results.

At the end of the data collection period, a

descriptive statistical analyzis was performed

with the frequency given in percentage and

absolute number.

RESULTS

The virtual questionnaire had 116 answers

from patients who wear orthodontic appliances.

Of these, 69% were female, 31% were male, and

41.3% were aged between 18 and 30 years old.

Just over half (54.8%) were adult patients aged

between 30 and 60 years old and a small minority

was older than 60 (Table I). There was a greater

concentration of individuals with a monthly

income of up to R$ 3,000.00 and currently

residing in Southeast Brazil. Most respondents

were in re-treatment, whose distribution was

equal to that of those who complained of

aesthetic or functional problems.

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

DISCUSSION

A strong ally has been developed and

improved during the pandemic period, the tele-

orthodontics, which is part of tele-dentistry. Tele-

orthodontics corresponds to providing remote care

and is used for following up patients in treatment

or who are about to start a treatment or who need

a virtual consultation. This model of care began in

the 1960s with tele-medicine for monitoring and

caring for patients living in more remote or less

favored locations and who have difcult access to

larger centers where treatment, assistance, and

diagnosis resources are readily available [10].

Tele-orthodontics increased rapidly during

the period of social isolation, which changed

the paradigm of orthodontic care [11]. Such

a resource has been used by social networks,

instant messaging applications, and audio/

video calls as a tool to facilitate communication

between specialists and patients. To test its

feasibility, a system for monitoring patients

undergoing orthodontic treatment with a rapid

maxillary expander was investigated in terms of

reliability and accuracy [7]. The use of WhatsApp

was evaluated, and the conclusion was that this

application can be very efcient for holding a

relationship between dentist and patient.

We aimed at evaluating how frequently

dentists have kept contact with their patients

during the isolation period. Less than a half of the

patients answered that they received messages

from their dentists, one-third of these were

concerned with their treatment, and one-fourth

were concerned with their well-being (Table II).

Social media are an easy way to keep in touch

with patients, but these seem to be used by a

minority of professionals [7].

Dental clinicians can also take advantage

of new technologies, such as intraoral scanners

and digital imaging devices, for diagnosing,

analyzing, and reviewing cases and for holding

communication with doctors, patients, and

laboratories [7].

A monitoring tool using a secure web

server could enable professionals to schedule

consultations, including the rst remote visit, for

diagnosis and follow-up of their patients’ treatment

with fewer ofce visits [12]. Our results showed

a good representativeness of the usage attributed

to tele-orthodontic technologies. More than two-

thirds of the respondents are either beginning

their treatment or are already in treatment for the

second or third time (68.2%).

According to our results, more than 60% of the

respondents had never heard of tele-orthodontics,

and although their age group corresponds to the

absorption of new technologies, half of them

reported that they prefer the rst appointment

for a general evaluation to be in-person (55.2%)

as they do not trust a diagnosis made remotely

(Table III).

One-third of the respondents (32.8%) do

not trust at all the diagnosis made remotely and

another one-third trust only if the diagnosis is

Table I - Sociodemographic characteristics

VARIABLE N %

Gender

Female 80 69

Male 36 31

Age

Between 18 and 30 yrs 50 43.1

Between 30 and 45 yrs 34 29.3

Between 45 and 60 yrs 28 24.1

Over 60 yrs 4 3.5

Monthly Income

Up to BR$ 3000,00 57 49.1

From BR$ 3000,00 to BR$ 5000,00 18 15.5

From BR$ 5000,00 to BR$ 10000,00 16 13.8

More than BR$ 10000,00 25 21.6

Area of Residence

North 22 19.0

Northeast 21 18.1

South 14 12.1

Southeast 50 43.1

Middle west 9 7.8

Orthodontic Treatment Time

I will begin my treatment now 11 9.5

I’m already in treatment for the ﬁrst time 26 22.4

I will begin my treatment now for a

second time (or more times)

25 21.6

I’m already in treatment for the second

time (or more times)

54 46.6

What Was the Main Reason for Seeking Treatment?

Smile improvement 58 50

Bite improvement (better intercuspation) 50 43.1

Demand or inﬂuence from the society 1 0.9

Demand or inﬂuence from parents and/

or friends

1 0.9

Others 6 5.2

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Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

made by videoconference (29.3%), corresponding

to more than 60% of the responses. These data are

interesting as the orthodontic diagnosis is based

primarily on the analyzis of patient documentation.

This is even more evident when the respondents

report that they do not mind having their data

and photographs transmitted via the Internet,

meaning that they trust the remote diagnosis,

which reects the current technologies used to

exchange data and images remotely. Similarly,

they do not mind having the contract digitally

signed and they also devalue the online service.

This reinforces the idea that the fees should be

lower as the infrastructure resources are not used,

denoting that the surveyed population has a poor

cultural understanding of intellectual and material

values. This was also pointed out by Moylan et al.

(2019) [7] and Giudice (2020) [2], who found

that many appointments for simple evaluation

could be eliminated and consequently cost and

chair time could be reduced while the delivery of

orthodontic care improved.

The participants were also asked about

how they see the fact of having both diagnosis

and planning made by a specialist and the

treatment performed and followed up by another

professional, and they answered in two ways:

30.1% of them accepted having their treatment

performed by another professional, being seen by

other ones and once in a while visiting a specialist,

whereas 69.9% prefer to go (having risk or not)

to a specialized clinic so that the treatment is

performed by the same professional. Moreover, a

good number of respondents reported that they

are willing to resume their in-person care as soon

as possible and not oppose the continuity of their

treatment, provided that all hygiene measures

are taken (76.7%) (Table IV). In a recent study

also conducted by interview, most patients were

willing to continue their treatments during the

pandemic, even though they considered the new

coronavirus infection dangerous and the risk of

contamination(12). The main concerns among

these patients were the fear of contracting the

disease and the increase in treatment time.

However, they were willing to return to face-to-

face care as soon as possible because they were

well-updated and aware of the protective methods,

besides knowing well what PPE is and trusting it.

In the orthodontic specialty, most appliances allow

being monitored remotely for a longer period.

Nevertheless, the in-person participation of the

orthodontist still seems to be the preference of

most of the respondents, even periodically, which

is in contrast with studies supporting the reduction

in the number of appointments and establishing

a hybrid treatment protocol (Table V) [2,8,12].

The answers of the survey given by the

participants may reect the natural characterize

a research bias.

The respondents prefer to go to a dental

clinic for help from the dentist and have their

appliances tted since they do not feel comfortable

receiving them via mail. In this sense, 36.2%

of the patients think that wearing removable

appliances sold in stores is not a good option

in most cases and 41.4% would only feel safe

undergoing the treatment on an in-person basis

Table II - Answers to questions on the patient’s perspective about the professional’s concern and care during the pandemic

QUESTIONS ASKED AND RESPONSES GIVEN n %

Has your orthodontist, during the period of social isolation, been in contact with you through messages to follow up on your

orthodontic treatment or provide urgent care?

Yes, frequently 47 40.5

Yes, seldom 12 10.3

No 27 23.3

Not applicable 30 25.9

If your previous answer was yes, so how often did your orthodontist sends you messages showing concern about your

treatment?

Periodically 42 36.2

Sporadically 18 15.5

Never 15 12.9

Not Applicable 41 35.3

How often has your orthodontist sent you messages showing concern about your well-being at a time of social isolation?

Periodically 28 24.1

Sporadically 24 20.7

Never 21 18.1

Not Applicable 43 37.1

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Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

(Table V). The respondents showed no condence

in appliances sold directly from the companies

by mail, instead preferring closer contact with

a specialist without any objection regarding

self-portraits to help in the remote evaluation

of the progress of the orthodontic treatment.

Any preference for the so-called “do-it-yourself”

orthodontics is based on cost purposes rather

than on understanding what could be similar to

a specialist-driven treatment [13].

For seeking urgent dental care or returning

to treatment while new COVID-19 strains

circulate the world, professionals must reinforce

the importance of good work practices, hygiene,

and infection control in their clinics. In this sense,

dentists are avoiding the use of aerosols and

human contact by prioritizing only emergency

treatments during the pandemic due to the

high transmissibility of the coronavirus. Some

recommendations on hygiene measures for

in-person appointments have been published [14],

but clinicians may not be fully aware of them.

Despite that, patients seem to trust their dentists

as 63.8% expect them to use PPE and 53.4%

would like to resume their treatment as soon as

possible (Table VI).

Table III - Answers to questions on the patient’s knowledge and thinking about tele-orthodontics and remote ﬁrst care

QUESTIONS ASKED AND RESPONSES GIVEN n %

Have you ever heard about teledentistry or tele-orthodontics?

Yes, and I know what it means 17 14.7

Yes, but I do not know what it means 7 6

Yes, but I am not sure what it is all about 15 12.9

No, I’ve never heard 77 66.4

Do you believe that the ﬁrst appointment for anamnesis and evaluation of treatment needs could be made remotely (not face-to-face)?

Yes, I think it is perfectly feasible and I would feel comfortable doing so, synchronously or not 24 20.7

Yes, but I would only feel comfortable if done synchronously (live) 25 21.6

Yes, but I would feel more comfortable if I could watch a video and then respond asynchronously 3 2.6

No, I would only feel comfortable with a face-to-face evaluation 64 55.2

Would you trust an orthodontic diagnosis made remotely, with evaluation information and photographic images of the face and

occlusion sent by e-mail or made available in software?

I would not trust it at all as I believe that the diagnosis always needs to be face-to-face 38 32.8

I would trust it if it was made by a specialist 23 19.8

I would only trust it if it was made by a referred specialist or someone I trust 21 18.1

I would trust it only if it was made by a referred specialist or someone I trust, but along with a video conference

so that I could interact with him or her

34 29.3

If the remote orthodontic diagnosis is proven to be as eﬃcient as an in-person one, would you accept having your photos and

documentation transmitted over the Internet?

Yes, I would accept it with no problem 37 31.9

Yes, but I would make sure that the virtual environment is secure and that only the professional and radiology

center would have access to my clinical records

45 38.8

Yes, but I would make sure to receive them from the radiology center and then send them to the professional 13 11.2

No, I do not trust the security of the virtual environment as I prefer to receive them and take them to the

professional

21 18.1

In this case, would you accept that your diagnosis and treatment planning be performed by a specialist and the face-to-face care

be performed by another non-specialist professional closer to you?

Yes, I certainly would 12 10.3

Yes, but I would like to be seen by the specialist from time to time 23 19.8

No, I would like to go to a specialist if this does not increase the cost 40 34.5

No, I would like to go to a specialist even if it means an increase in cost 41 35.3

As for the service contract, you:

Prefer to receive, sign, and send the printed version back to the professional 18 15.5

Agree to receive it digitally and then print, sign and send a hard copy 17 14.7

Agree to receive it digitally and then print, sign and send a scanned copy 35 30.2

Agree to receive it digitally and then sign and send it without printing 46 39.7

Regarding the fees paid to the professional for orthodontic treatments in which the patient has a ﬁrst online consultation and is

partially followed up remotely, do you think that:

They should be lower as the professional will have savings from working on a remote basis. 45 38.8

They should be the same because the oﬃce still must be maintained and what counts is the knowledge and

experience of the professional

34 29.3

They should be higher as the professional will have to invest in equipment and software to provide virtual care

services

3 2.6

I don’t know about that 34 29.3

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

Through the implementation of new

policies and procedures, it is possible to achieve

a high standard of cross-infection control, such

as decontamination of environments, surfaces,

and instruments, use of personal protection, and

disposal of clinical waste, all proving to be valid and

Table V - Answers to questions on the patient’s perspective about remote treatment

QUESTIONS ASKED AND RESPONSES GIVEN n %

In the case of removable appliances that do not require chair time and clinical procedures to be placed, would you accept

receiving the appliance by mail and start wearing it?

Yes, if my orthodontist follows up with me through periodic virtual meetings to answer questions or schedule a

face-to-face appointment afterward

39 33.6

Yes, if I have a dentist or orthodontist with whom I can ask questions 24 20.7

Yes, if I receive an instruction manual on how to use and take care of the appliance without follow-up care by

an orthodontist

1 0.9

No, I prefer to go to the clinic to have braces placed and receive orientation from the orthodontist 52 44.8

Some orthodontic aligner companies have opened stores in shopping malls to sell their appliances. There, an image of the

patient’s bite and face is taken, and then an orthodontist hired by the company diagnoses and plans the sequence of aligners

to be used. After they are made, the patient receives the aligners at home without any form of contact with the orthodontist,

although he or she can clarify any doubts with the company. What do you think about this? Would you buy them this way?

I ﬁnd it very interesting and support the idea, so I’d deﬁnitely buy them 11 9.5

I ﬁnd it interesting, but I think I should be seen by an orthodontist before the aligners are made, otherwise, I

would not buy them.

34 29.3

I don’t think it works and I wouldn’t buy them without an orthodontist’s opinion 42 36.2

I don’t think it works at all and I wouldn’t buy them this way 29 25

Some appliances after being placed do not need to be activated, but they need to be monitored. How would you feel about the

smooth progress of your treatment in these cases?

I would feel more secure with only periodic in-person visits 48 41.4

I would feel safe with some virtual follow-up consultations, but along with periodic in-person visits 39 33.6

I would feel safe with virtual follow-up consultations, whereas face-to-face visits would be needed only for the

activation of the appliance

22 19

I would feel safe and would not mind having only virtual consultations 7 6

In the case of remote monitoring, how do you see the need to use your smartphone to take pictures of your mouth and bite and

send them to the orthodontist according to directions on how to do so, including devices to help you move your lips apart for

better shots?

I would not bother taking my pictures and I see no problem to send them to the orthodontist 44 37.9

It would not bother me because by doing so I wouldn’t need to go to the clinic so often. 15 12.9

I would like to go to the clinic less often, but I don’t feel able to or comfortable 23 19.8

with taking pictures of my mouth

I don’t think it is my task and I would not take the pictures as I prefer to go to the clinic for evaluation 34 29.3

Table IV - Answers to questions on the patient’s perspective about the treatment

QUESTIONS ASKED AND RESPONSES GIVEN n %

By analyzing the pandemic moment through which we have just passed, when would you intend to begin or resume your

orthodontic treatment?

I would wait until next year 17 14.7

I would wait six months 3 2.6

I would begin next month 9 7.8

I would begin now 30 25.9

Others 57 49.1

For you who are in orthodontic treatment, what do you think about the continuity of your treatment?

I prefer to remove the appliance as soon as possible to avoid visits to the orthodontist. 0 0

I would like to remove the appliance, but I understand that I must resume the treatment as soon as

possible to ﬁnish it correctly.

6 5.2

I see no problem in continuing the treatment if proper hygienic care is taken 89 76.7

Not applicable 5 18.1

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

necessary measures to decrease the spread of Covid-

19 in this current scenario. Thus, face-to-face care

should be provided as it seems to be the preference

of most of the patients, which further increases the

practitioner’s awareness about maintaining a safe

clinical environment. However, it is suggested to

avoid crowding of patients in the waiting room,

meaning that it is essential to schedule appointments

with longer intervals between patients and maintain

proper hygiene of the environment, furniture, and

dental materials [15].

A study on technologies, applications,

and benets available from tele- orthodontics

showed that this tool should be considered

welcome, as it is capable of successfully managing

dental emergencies by allowing reassurance

and monitoring of patients remotely without

subjecting them to unnecessary risks. In addition,

professionals can use tele-orthodontics for

sending and receiving videos and photos [16].

To overcome the challenges of these new

technologies, dentists should be adequately

trained to increase the acceptance of tele-

orthodontics by patients [17].

According to our results, tele-orthodontics

seems to play a complementary role in

orthodontic treatment, being more focused on the

communication between professional and patient

and not being directly related to the orthodontic

treatment itself. Tele-orthodontics can be very

important and advantageous, not necessarily as

a way to allow the continuity of the treatment,

but also to reassure patients about caring for their

smile and oral health.

CONCLUSION

Even in the face of a pandemic, patients

who wear orthodontic appliances are eager to

complete their treatment. Tele-orthodontics is still

little known by patients and most prefer that the

treatment itself, even with removable appliances,

should be performed in person. Patients are

more receptive to remote communication only

for exchanging information, documentation and

records, as well as for communicating their well-

being, doubts, and insecurities.

Table VI - Answers to questions on the patient’s awareness of personal protective equipment (PPE) and asepsis in the dental oﬃce

QUESTIONS ASKED AND RESPONSES GIVEN n %

Do you know the WHO recommendations for the use of PPE (personal protective equipment) in dental practice due to the

pandemic?

Yes, I do 69 59.5

Yes, but I don’t know what part of the PPE is 16 13.8

No, but I’ve heard of it, and I think it’s important 30 25.9

No, and I don’t think it is important 1 0.9

Do you feel safe resuming your orthodontic treatment?

No, I do not. I prefer to wait 3 2.6

Yes, I do. But I prefer to wait a little longer 11 9.5

Yes, I do. I would like to resume my treatment as soon as possible 62 53.4

Not Applicable 40 34.5

Is there any procedure frequently performed by your orthodontist before the pandemic that you don’t feel conﬁdent, he/she will

perform after the pandemic?

Yes 7 6

No 83 71.6

Maybe 7 6

I do not know 19 16.4

Regarding the aseptic (hygiene) conditions of the dental oﬃce, what do you expect from your orthodontist when you resume

orthodontic treatment?

Use of PPE 74 63.8

Maintenance of PPE already in use 32 27.6

I don’t care about PPE 0 0

I am indiﬀerent 10 8.6

Braz Dent Sci 2023 Apr/Jun;26 (2): e3597

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s perspective

Patel MP et al.

Post-COVID-19 inﬂuence in orthodontic care from the patient’s

perspective

Author’s Contributions

MPP, LÁM: Conceptualization. MPP, LÁM:

Methodology. GFN, GSD, ACRNS: Investigation.

MPP, GFN, GSD, LÁM: Writing – Original Draft

Preparation. ACRNS, MM: Writing – Review &

Editing. MM: Supervision. MPP; LÁM: Project

Administration.

Conict of Interest

No conicts of interest declared concerning

the publication of this article.

Funding

The authors declare that nancial support

was received by CNPq.

Regulatory Statement

Modelo: This study was conducted in

accordance with all the provisions of the local

human subjects oversight committee guidelines

and policies of: Guarulhos University. The

approval code for this study is: Opinion number

4.223.313; CAAE 33350920.6.0000.5506 .

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Mayara Paim Patel

(Corresponding address)

Universidade Guarulhos, Guarulhos, SP, Brazil.

Email: mayarapatel@gmail.com

ate submitted: 2022 July 26

Accept submission: 2023 Feb 08