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 Table of Contents  
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 88-93

COVID-19 risks and extra-protective measures practised among Nigerian orthodontists and orthodontic residents

1 Department of Child Dental Health, Faculty of Dental Sciences, College of Medical Sciences, University of Calabar, Nigeria/ University of Calabar Teaching Hospital, Calabar, Nigeria
2 Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences, Bayero University, Kano/ Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt Teaching Hospital/ University of Port Harcourt, Port Harcourt, Rivers State, Nigeria

Date of Submission06-Jun-2021
Date of Decision21-Jul-2021
Date of Acceptance26-Jul-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Dr. Tope Emmanuel Adeyemi
Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences, Bayero University, Kano/ Aminu Kano Teaching Hospital, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_576_21

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Background and Aims: There is a high possibility of transmitting the coronavirus (severe acute respiratory syndrome coronavirus 2) in the orthodontic clinic because orthodontists and their patients are in very close contact when orthodontic care is being given. The aim of this study was to evaluate the knowledge and perception of Nigerian orthodontists and orthodontic residents about the risks of COVID-19 as well as the extra-protective infection control measures that need to be taken. Materials and Methods: This was a descriptive, cross-sectional study. The questionnaires were distributed and retrieved from consenting participants through an online platform. The questionnaires were analysed using the Statistical Package for the Social Sciences software version 23. The results were presented in tables and charts. Results: Out of a total of 90 members on the association's WhatsApp group as at the time the study was being conducted, a total of 48 respondents participated in this study. There were more females (60.4%) than males. Majority (97.9%) of the respondents agreed/strongly agreed that an infected patient could infect the orthodontic clinic staff members with COVID-19 while most were of the view that debonding (95.8%) and retainer delivery (70.8%) posed a risk for spread of the virus. More than half of the respondents (52.1%) considered it necessary to change N95 masks after each patient as an extra-protective measure against COVID-19. Conclusions: Majority of the respondents knew about the risks that COVID-19 posed to different aspects of orthodontic practice and were also knowledgeable about some of the extra-protective measures that they should take. There is a need to improve the knowledge of the participants concerning the use of appropriate mouth rinses to reduce the risks of transmission of COVID-19 in the dental/orthodontic clinic.

Keywords: COVID-19, infection control, Nigeria, orthodontists, protective measures

How to cite this article:
Adekoya MN, Adeyemi TE, Aikins EA. COVID-19 risks and extra-protective measures practised among Nigerian orthodontists and orthodontic residents. Niger Postgrad Med J 2021;28:88-93

How to cite this URL:
Adekoya MN, Adeyemi TE, Aikins EA. COVID-19 risks and extra-protective measures practised among Nigerian orthodontists and orthodontic residents. Niger Postgrad Med J [serial online] 2021 [cited 2022 Sep 28];28:88-93. Available from: https://www.npmj.org/text.asp?2021/28/2/88/325561

  Introduction Top

The Coronavirus disease 2019 (COVID-19) is a viral infection that was reported to have started in Wuhan city, Hubei province, China, in 2019.[1] The novel coronavirus was initially named 2019-nCoV, and then, later officially known as severe acute respiratory syndrome coronavirus 2 (SARSCoV-2).[2]

The World Health Organisation (WHO) announced that COVID-19 outbreak constituted a public health emergency of international concern in January 2020.[3] It was initially identified on 7th January 2020 from the throat swab of a patient.[4] The virus was first reported in Nigeria on the 27th February 2020 by the Federal Ministry of Health through the Nigeria Centre for Disease Control (CDC) and it was declared a global pandemic by the WHO.[5]

The clinical manifestations of COVID-19 infection have similarities with SARS-CoV in which patients have fever, dry cough, dyspnoea, chest pain, fatigue and myalgia commonly but less commonly have the symptoms of headache, dizziness, abdominal pain, diarrhoea, nausea and vomiting.[6],[7] Hypoxaemia, shock, arrhythmia, ARDS, acute kidney and cardiac injuries are the severe complications that have been reported among COVID-19 patients.[8] The common routes of transmission of COVID-19 are direct transmission (cough, sneeze and droplet inhalation transmission) and contact transmission (contact with oral, nasal and eye mucous membranes).[9]

Many medical staff were reported to have contracted the infection while attending to infected individuals.[10] There is a high possibility of transmission of infection between staff members and between staff and patients. This is due to the fact that the clinic is an enclosed area, and also because orthodontists are in close proximity to their patients during the duration of treatment. Although individuals who have been diagnosed with the disease are not supposed to receive routine orthodontic dental treatments, especially during the incubation period of the virus which can be up to 14 days, this becomes inevitable when there are orthodontic emergencies.[11],[12]

In the wake of this novel coronavirus and the transmission between humans through droplets and direct contact with the eyes, nose and mouth, it became expedient that clinicians and other health caregivers are abreast with the risks of COVID-19 and the measures to take to prevent cross infection while treating patients, especially those that may be infected but are asymptomatic.

Orthodontists work in the oral cavity which is known to be a reservoir of COVID-19 in infected individuals, as the virus has been detected in saliva.[13] Thus, it is very important that this risk be identified and mitigated against. Aerosol-generating procedures such as scaling and polishing, bracket bonding and debonding procedures have been identified as very high risk source of COVID-19 infection in the dental/orthodontic clinic.[14]

Thus, the aim of this study was to evaluate the knowledge of Nigerian orthodontists and orthodontic resident doctors about the risks of COVID-19 and their opinions concerning extra-protective infection control measures in the clinics.

  Materials and Methods Top

This was a descriptive, cross-sectional study carried out among orthodontists and orthodontic residents in Nigeria. Ethical approval for the conduct of the study was obtained from the research and ethics committee of the teaching hospital. All consenting participants were included in the study. Only specialist orthodontists and resident doctors training to become orthodontists were included in this study.

Sampling[15] was undertaken to distribute and retrieve the questionnaires through an online platform (Google form) due to the COVID-19 pandemic restrictions. The participants received and answered the survey online. The total number of orthodontists and orthodontic residents are presently about 100 in the country.[14] In order to increase the response rate contacts were made through the WhatsApp group page of the Nigerian Association of Orthodontists, also the Google form was sent privately to the members on three occasions at 1 week intervals in May/June, 2020. A total of 48 participants responded out of 90 in the group.

The questionnaire was made up of four sections. Section A sought information concerning sociodemographics, Section B assessed knowledge of the level of risk of exposure concerning the virus, and Section C assessed knowledge of the extra-protective measures to be adopted during orthodontic practice. The questionnaires were then analyzed using the IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. The results were presented in tables.

  Results Top

A total of 48 respondents participated in this study out of 90 members of the Nigerian Association of Orthodontists' WhatsApp group as at the time the study was being conducted, giving a response rate of 53%. [Table 1] shows that there were 8 (16.7%) junior residents, 18 (37.5%) senior residents and 22 (45.8%) orthodontists. The females were more than the males as evidenced by 60.4% of the responses, and most fell within the young- and middle-aged groups with the mean age of 42.35 ± 8.83 years. The ages of the respondents ranged from 25 to 66 years. Majority (98%) of the respondents were Christians, and most (87.5%) of them were married. Most (87.5%) of the respondents had practiced dentistry (or orthodontics) for more than 10 years. A larger number of them were located in the southern part of Nigeria, with Lagos state having about 24 (50%). Most of the orthodontists practiced in government or military hospitals as evidenced by 39 (81.3%) of the response.
Table 1: Sociodemographic characteristics

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Majority 47 (97.9%) of the respondents agreed/strongly agreed that an infected patient can infect the orthodontic clinic staff members with COVID-19, as shown in [Table 2]. Most (93.8%) of the respondents did not believe that a patient's temperature of 37.2° C or below is a guarantee that the patient is not infected with COVID-19 [Table 3].
Table 2: Perception of the level of risk orthodontists are exposed to during coronavirus disease-19 pandemic

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Table 3: Knowledge of the duration of aerosols and opinions concerning risk of coronavirus disease-19 associated with the different stages of orthodontic treatment

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[Table 2] also revealed the perceived contagious period of COVID-19 by respondents, where about 87.5% of them indicated that the contagious period was from the time of exposure through 14 days. On the knowledge of the respondents on the risk of virus infection during orthodontic treatment, about 89.6% respondents agreed they would recommend that patients continue to wear their intraoral elastics as prescribed before the COVID-19 pandemic, while 95.8% believed that debonding/removing the attachments at the end of treatment would lead to transmission.

As regards their knowledge of duration of floating of aerosols in the air, 52.1% believed the aerosol could remain for 45 min and above, 22.9% were convinced it stays between 30 and 44 min while 16.7% agreed the aerosols do not stay more than 14 min in the air before they settle on surfaces, as revealed in [Table 3]. [Table 3] also shows how the respondents felt about pre-orthodontic activities and risk of COVID-19 transmission. Most 47 (97.9%) of the respondents believed that there was high risk of COVID-19 infection associated with impression taking while 30 (62.5%) indicated that infection could occur during the examination. Most of the respondents associated in-orthodontic treatment activities such as scaling and polishing 40 (83.3%), fixed appliance set up 39 (81.3%) and change of arch wires/elastics 26 (54.2%) with increased risk of infection with COVID-19. Most of the respondents agreed that debonding (95.8%) and delivery of retainer (70.8%) were postorthodontic activities that posed a risk of COVID-19 infection, as shown in [Table 3].

The knowledge of the respondents on extraprotective measures appeared to be high. They all agreed that measures to be practiced by patients included maintaining social distancing by all; ensuring the use of alcohol-based sanitisers; regular hand washing with soap and water; provision of adequate personal protective mechanisms and strict adherence to the use of face mask by patients. Other measures include patients coming for their appointments alone and screening of all patients for pyrexia [Table 4].
Table 4: Opinions of extra-protective measures to be adopted in the orthodontic clinic

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[Table 5] shows the extra-protective measures adopted by respondents. More than half of the respondents 25 (52.1%) considered that it would be necessary to change the N95 masks after each patient. Most 33 (68.8%) of the respondents opined that rinsing of the mouth using hydrogen peroxide by a patient before being treated could help reduce the viral load of COVID-19; only 2 (4.2%) felt differently. Thirteen (27.1%) had no knowledge on this. Similarly, 30 (62.5%) of the respondents agreed that rinsing of the mouth using chlorhexidine by a patient before being treated could help reduce the viral load of COVID-19 while 6 (12.5%) did not think so 12 (25%) had no knowledge about this.
Table 5: Opinion of participants about extra-protective practices against coronavirus disease-19 in treating orthodontic patients

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  Discussion Top

The novel coronavirus changed the modus operandi of infection control worldwide in dental practice. Being a hitherto unknown virus as the name 'novel coronavirus' implies, the sudden appearance. The spread of COVID-19 led to a lot of reactions among dental practitioners. Majority of orthodontic practices worldwide were closed down completely whilst those that remained open-operated skeletal services, attending only to emergencies as advised by the CDC.

Our study has shown some light on orthodontic practice in Nigeria during the current COVID-19 pandemic. Our participants mostly opined that there was a need for the employment of extraprotective measures during consultations and treatment because of the attendant increased risk of cross infection with the coronavirus. These include reducing the number of people in the consulting room at any point of time, personal protective equipment (PPE) usage and recognising the procedures which generate aerosols and can contribute to rising infection levels in the clinic.

The respondents recognised that asymptomatic but infected individuals without elevated temperatures of ≥37.2°C could transmit the disease and that there was a possibility of reinfection with the virus after recovery. All these made treating patients when the pandemic was first declared very risky.

There is an increase in risk of infection when the virus is aerolised during an orthodontic procedure, which was also recognised by the study participants. Bonding as well as debonding brackets on a patient were considered as high risk procedures, and such aerosol-producing procedures were preferably not to be performed.[16] The virus when aerolised can remain in the air up to 3 h according to the CDC.[17] Although the risk of aerolisation of the virus was recognised, about half of the participants opined that the virus can only remain in the air for <45 min. This false and alarming perception will put the orthodontist and members of staff at greater risk of contracting COVID-19 in the clinic.

Certain pre-orthodontic procedures were considered to be high risk by study participants. These procedures include the making of alginate impressions, examination of a patient and taking of clinical photographs. Although these procedures do not produce aerosols, the close proximity to the oral cavity must be considered very risky, especially since the virus has been found to be secreted in saliva.[18],[19] Scaling and polishing, fixed appliance set up, changing of arch wires/elastic modules and delivery of removable appliances were in-orthodontic treatment activities mostly considered high risk for the spread of the virus by the participants. In this study, postorthodontic treatment activities such as debonding of brackets which is an aerosol-generating procedure and delivery of retainers was recognised to have a high risk of transmission of COVID-19 which is in agreement with other studies.[20]

Extraprotective measures that the orthodontists would adopt upon reopening included the use of N95 facemasks. Even though these facemasks are expensive and were in short supply at the time of this study, majority of respondents indicated that they would change the facemask after attending to each patient. This may not be necessary according to the guidelines for the usage of these masks, which includes the safe use for multiple patients for 2–3 h, together with a face shield, before removal.[17] This preserves the supply and prevents cross-contamination since the act of constant donning and doffing of these masks in itself may lead to cross-infection with the virus.[17] Furthermore, it has been reported by Liao et al. that 'heat (≤85°C) under various humidity (≤100% relative humidity)' can inactivate the virus as well as preserve the filtration properties of an N95 facemask thus ensuring it is both effective and reusable.[21] This is important and valuable due to the worldwide shortage of N95 facemasks at the beginning of the pandemic.[21] Face shields can be reused but should be removed and cleaned if there is a visible splatter on it.[17]

Another effective method to reduce risk of infection is to ask the patient to use a mouth rinse prior to treatment. Oxidising pre-operative mouthwash such as with 1%–1.5% hydrogen peroxide or 0.2% povidione iodine has been reported to kill the virus.[9],[22] Chlorhexidine (0.2%) and Listerine® mouthwashes which contain alcohol may also do same.[23],[24] However, it must be noted that plain Chlorhexidine (0.1% and 0.2%) without alcohol is not effective against the virus.[22],[25] Some of the participants in this study were aware that rinsing with Chlorhexidine (62.5%) or hydrogen peroxide (68.8%) mouth washes would reduce their risk of infection with the COVID-19 virus. This shows that the knowledge of the participants concerning the use of appropriate mouth rinses needs to be improved upon to further reduce the risks of transmission of COVID-19 in the dental/orthodontic clinic.

COVID-19 has necessitated that both orthodontists and orthodontic patients adopt some extra protective measures to prevent cross infection. These include quite a number that our participants were aware of such as strict hand hygiene with the use of soap and water or an alcohol-based hand sanitiser, use of PPE and social distancing. Several recommendations have also been made which include control of aerosols, surface disinfection and appropriate ventilation.[26] It has been suggested that aligner therapy will be very beneficial at this time when most orthodontists would prefer to reduce the number of appointments per patient to reduce the risk of exposure to the novel coronavirus.[26] It is noteworthy that with this type of appliance both treatment planning and treatment can be monitored virtually thus reducing contact with the patient.[27] This is also the opinion of orthodontists in the other parts of the world.[28]

This study had some limitations relating to data collection because majority of studies during this period were carried out through online surveys and most people were fatigued with the filling of numerous online questionnaires. We had to send several reminders to participants to surmount this limitation.

  Conclusions Top

Majority of the respondents knew about the risks of COVID-19 infection associated with different aspects of orthodontic practice and they were also knowledgeable about most of the extra-protective measures to take. However, there is a need to educate them about the duration of flotation of aerosols and the use of appropriate mouthwashes to reduce the risk of COVID-19 infection.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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