This study was carried out immediately after the end of the lockdown in Italy (May 2020). The aim was to understand through a survey how concerned dental patients were about the possibility of contracting an infection in the dental practice and if this may affect their attendance at the dentist and the orthodontist.
The sample was a good representation of different age ranges, different levels of education, different jobs, and different levels of distress. The PHQ-4 indicated that 336 participants (21.7%) had moderate/severe psychological distress (score equal to or higher than 6) during the lockdown period. This percentage was greater compared with the data presented of the general population in the pre-pandemic period, where about 5% of the population presented these scores [21]. It could be assumed that the tough situation of the pandemic might influence the psychological status of the participants.
Almost half of the patients (44.7%) thought that the dental practice is a place where there is a higher risk of COVID-19 infection; in 45.6% of participants, COVID-19 increased their fear of attending the dental practice, and 42.8% did not feel safe to go back to the dentist. Among these, the most scared were older people (> 60 years old) and women. Regarding the elderly, it is quite obvious that they were more scared because COVID-19 affects them more frequently and more severely [22]. The association with women is consistent with the data from a previous study by Cotrin et al., which found a greater level of anxiety among female patients compared to males [18]. Moreover, these results are in accordance with our findings of the PHQ-4, which indicated higher levels of distress, anxiety, and depression in women, and with a nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic, where women showed significantly higher psychological distress than men [23]. It must be considered that in dental practices, there were already strict protocols for infection control of several infective diseases, such as hepatitis B, hepatitis C, human immunodeficiency virus infection, tuberculosis, and herpes simplex, even before the COVID-19 pandemic [24]; therefore, dentists have always been prepared to face viruses. With the COVID-19 pandemic, these protocols became even more stringent [25] and in May 2020 the minister of health published national guidelines [14]. Furthermore, it was observed that more change in behaviors was associated with lower country COVID-19 fatality rates [26]. For these reasons, dentists should be able to improve communication with their patients, considering that some patients’ characteristics could induce fear of returning to the practice, and calm those who are more anxious. Indeed, patients not returning to the dental practice could be considered an indirect harmful effect of the COVID-19 pandemic, especially those who must be treated with frequent controls, such as patients with periodontal disease or those undergoing orthodontic treatment.
A part of the questionnaire was dedicated to patients in orthodontic treatment or parents of patients in orthodontic treatment. Sixteen per cent of respondents declared that they would not return to the dental practice to continue orthodontic treatment. Among those, 83.8% thought the dental practice was a place with greater risk of contracting COVID-19 and 89.2% were scared to go to the dentist due to the pandemic. These findings are consistent with previous studies, showing that patients who were willing to go to the dental office were more calm or indifferent, and reporting significantly lower scores of anxiety than patients that would not go [17, 18]. The dentist should explain to the more anxious patients that the practice is a safe place and that the damage resulting from a missed control of the orthodontic appliance could be serious. It should also be noted that orthodontic procedures have a low risk of infection because most of them do not require aerosols. Therefore, correct communication between patient and orthodontist is of fundamental importance. Meanwhile, orthodontists should re-organize their schedules for the following reasons: to reduce the number of patients per day, to prevent gatherings in the waiting room, and to perform the disinfection procedures provided in the guidelines. In addition, 41.8% of patients reported that not having been monitored by the orthodontist for more than 2 months caused them discomfort; those with fixed appliances in particular were more disturbed. This could be explained by the fact that removable appliances generally cause less discomfort to patients and result in a lower average number of emergency visits as compared with fixed appliances [27, 28]. Hence, it could be argued that for this reason the COVID-19 pandemic could accelerate the trend already occurring in orthodontics towards an increase in removable appliances, such as clear aligners or activators.
The survey also had four questions to investigate the presence of TMD before the onset of the pandemic and after the lockdown. The 21.3% of respondents referred to having TMD-related pain and 21.5% reported TMJ sounds before the start of the pandemic. These data were consistent with the prevalence of TMD reported in previous Italian epidemiological studies [29, 30]. The pain and the TMJ sounds were more frequent in women, according to current scientific evidence [31]. After the lockdown, there was a slight increase in the frequency of pain, while TMJ sounds decreased. In addition, there was an association between high levels of distress and the presence of pain or TMJ sounds after the outbreak of COVID-19. This could be due to the relation between the onset of muscular pain or TMJ sounds and the level of distress and anxiety of subjects. In particular, during the lockdown, people presented a higher level of distress and anxiety due to the complex situation that may contribute to the prevalence of TMD pain.
This study presents some limitations: it is a survey-based study; thus, information is self-reported, and the collection time was only 2 weeks. However, it also presents some strengths, such as the high number of participants, the good representation of the population, and its depiction of the situation of Italian dental patients, focusing on those with TMD or under orthodontic treatment.