12 Readers' forum

COVID-19 and orthodontics—A call for practice, treatment procedures using hand drills increase
the risk of virus transmission.1,2 These procedures
action include cleaning residual adhesive and cements during
deband appointments, insertion or removal of clear
W e applaud Dr Jerrold for his timely and critically
important report on the challenges encountered
by orthodontic practitioners in the era of the coronavirus
aligner attachments, removing bite turbos, and
modifying a fixed orthodontic appliance inside the
mouth (eg, hyrax expanders). Currently, many
disease 2019 (COVID-19) (Jerrold L. Exceptional orthodontists do not have the PPE needed to handle
circumstances. Am J Orthod Dentofacial Orthop orthodontic emergencies, and they also do not have
2020;157:852-5.). Although we agree with the concerns priority to get tested for COVID-19. Therefore,
and recommendations raised in the report, we would like regulatory authorities are required to help orthodontists
to supplement it with several areas of imminent concern order the appropriate PPE and give COVID-19 testing for
that require our immediate attention. orthodontists equal importance as that of other medical
First, in Canada, provincial dental regulatory author- practitioners so that we can keep our staff and patients
ities have ordered, in response to the current COVID-19 safe.
pandemic, a mandatory suspension of all nonemergency Finally, virtual orthodontic care and consultations
dental therapies, including orthodontic treatment. require regulating. As the COVID-19 pandemic worsens,
Although we acknowledge the need to close orthodontic many orthodontists across Canada and the United States
practices during this time, what constitutes an ortho- are heading toward implementing virtualized
dontic emergency has not been specified in the shut- orthodontic consultations and treatment approaches
down notice e-mails. Because many orthodontists are that remove the need for in-person meetings with
struggling to balance their own safety with their patients.3 Orthodontists are contacting patients
commitment to their patients, more concise guidance remotely using different platforms such as Zoom,
is needed for handling orthodontic emergencies using Invisalign Team, etc., some of which are not Health
circumstance-specific protocols.1 Insurance Portability and Accountability Act compliant.
In general, orthodontic emergencies can arise from Because this is a relatively new method of dental care
the following scenarios: loose intraoral fixed appliances delivery, clear rules and guidelines should be established
that are fully retrievable by the patient or parent or regarding its use, to protect both patients and
partially loose appliances that require orthodontic inter- orthodontists equally. Given that dental professionals
vention; fixed intraoral appliances impinging on the pal- are currently performing these virtual consultations
ate or gingival tissue; broken, ill-fitting, or missing without guidelines, it is concerning that the rapid
removable appliances, aligners, or retainers; a missing move toward virtual-based interactions may lower
or broken bracket; pokey wire; and broken or loose- standards of orthodontic care. Here are a few important
ended fixed retainer. In addition, there are many sce- concerns that need to be considered immediately when
narios for which an orthodontist may not be able to leave contacting patients remotely:
a patient unattended for .10-12 weeks. Examples
include patients with a reverse-curve nickel titanium  Obtaining informed consent and proper documenta-
wire or patients having treatment to retrieve an impacted tion.
tooth. Public memos about these orthodontic emergen-  Offering patients the option to connect by e-mail if
cies, prepared by provincial (or state) dental regulatory they do not feel comfortable carrying out virtual con-
authorities and geared toward patients, would be bene- sults or to connect by audio only, should they decline
ficial in communicating a uniform message to our pa- using visual aids.
tients. Orthodontists would then have the ability to  Choosing the appropriate time to contact patients
share this public memo on social media platforms and (eg, during business hours) using an unknown num-
Web sites, which can serve to educate the public and ber or private number to protect the privacy of the or-
allow orthodontists to defend their position during this thodontists.
challenging time. Moreover, the uniformity of the mes-  Disclosing financial information by e-mail as proof.
sage would also serve to build the specialty's trust Discussing orthodontic contracts verbally without
among the general public. written proof may lead to miscommunication and
Second, apart from the orthodontic emergency sche- misunderstanding once the COVID-19 pandemic is
mas, a clear guideline for COVID-19 testing and types of over.
personal protective equipment (PPE) is needed in ortho-  Maintaining professional attire and professional
dontic practice. Although limited within orthodontic setting if a virtual consult is scheduled.

July 2020  Vol 158  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Readers' forum 13

 Having a Health Insurance Portability and Account- both personally and professionally, as our collective
ability Act–compliant application to protect the in- situations unfold. This will probably be the last pandemic
formation being shared across these virtual mediums. of my lifetime, but it may not be the last for our younger
colleagues. This is an opportunity for us, as a specialty, to
In conclusion, considering the uncertainty surround-
develop the skill sets necessary to deal with situations like
ing the COVID-19 situation, it is evident that there is a
this.
need for clinical measures and guidelines for use in or-
As the authors rightly pointed out, not only will we
thodontic practices during pandemic situations. These
have to reconsider many issues around personal protec-
guidelines should provide (1) clear legislation that ex-
tive equipment, but also scheduling, office design, me-
plains which emergencies are ones that orthodontists
chanical simplifications and modifications, as well as
can attend to in their clinics and which are ones that
the integration of virtual orthodontic visits into our daily
they should defer, (2) priority for COVID-19 testing
routines. This, of course, carries with it its own consider-
and guidelines for PPE needed in orthodontic practices
ations, ranging from practice and patient management
for specific procedures, and (3) comprehensive protocols
to governmental administrative mandates, to civil law
for proper virtual consultations and appointments that
considerations through appropriate risk management
assure adequate patient care. With the passing days, it
considerations.
seems inevitable that COVID-19 has and will forever
I was recently asked by the Journal of Clinical
change the way we practice orthodontics, but with unity
Orthodontics to design an informed consent form for
and collegiality in the orthodontic community, we can
virtual orthodontic visits. You can download a copy
surmount this together.
from the American Journal of Orthodontics and
Humam Saltaji
Dentofacial Orthopedics Web site. Feel free to use it
Khaled A. Sharaf
and tweak it, as necessary. As a caveat, some
Edmonton, Alberta, Canada
jurisdictions might not allow virtual health care visits
Am J Orthod Dentofacial Orthop 2020;158:12–13 or might mandate certain restrictions or guidelines
0889-5406/$36.00 regarding their implementation. You are advised to
Ó 2020 by the American Association of Orthodontists. All rights reserved.
seek local legal counsel if you intend to offer virtual care.
https://doi.org/10.1016/j.ajodo.2020.04.006
Again, I thank the authors for their additional com-
REFERENCES ments and pray that everyone remains safe during this
trying period.
1. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19):
emerging and future challenges for dental and oral medicine. J
Dent Res 2020;99:481-7. SUPPLEMENTARY DATA
2. Dave M, Seoudi N, Coulthard P. Urgent dental care for patients dur- S upplementary data associated with this article can be
ing the COVID-19 pandemic. Lancet 2020;395:1257.
found, in the online version, at https://doi.org/10.
3. Webster P. Virtual health care in the era of COVID-19. Lancet 2020;
395:1180-1. 1016/j.ajodo.2020.04.007.
Laurance Jerrold
Brooklyn, NY
Author's response
Am J Orthod Dentofacial Orthop 2020;158:13
0889-5406/$36.00

I want to thank the authors for their response and

are a welcome addition to the timely discussions going Editor's Note: Please note that the American Associa-
on within our ranks. tion of Orthodontists (AAO) believes there are certain
Moving forward, we will literally have to re-think diagnoses and evaluations that can only be performed
everything we do. This pandemic is neither over nor will in-person or are best performed in-person (x-rays,
it totally resolve in the near future. It is almost a certainty etc.), and as a result, the AAO believes orthodontic
that there will be a second wave, and we will be treatment should not begin before a physical, in-
dealing with limiting the spread while protecting person examination/evaluation of the patient has
ourselves and our patients and modifying our behavior, occurred by a state-licensed dentist. -RGB

American Journal of Orthodontics and Dentofacial Orthopedics July 2020  Vol 158  Issue 1