Modifications in Orthodontic Practice Post COVID Lockdown in Pakistan


Erum Behroz Khan                      BDS, FCPS, C-Orth, MTFPDP, C-HPE

Mairah Shah                                  BDS

Samar Fatima                                BDS

Zuhair Ahmed                                BDS 

Sunia Therwani                              BDS

Sunia Therwani                             BDS

OBJECTIVE: The objective of this paper was to evaluate the marginal location preference and periodontal health in extra
coronal restoration of anterior and posterior teeth.
METHODOLOGY: In this prospective case control study, a total of 652 patients who had crown and bridge for not less than
six months were included. The gingival margin location preference and reasons behind choosing a particular gingival margin
was asked from the patients. Additionally, the teeth with and without restoration were also examined for periodontal health.
Split mouth technique was used as unrestored, healthy contra lateral teeth in the same individual served as controls. Descriptive
statistics and Chi square test were used for analysis to formulate the results.
RESULTS: Ironically, 92% patients were not given a chance by their dentist to give input about margin location preference.
The majority of patients preferred equi gingival margin for their anterior crowns 495 (75.92%) and supra gingival margin 586
(89.87%) for their posterior teeth, with esthetics 547 (83.89%) and hygiene 599 (91.87%) respectively being the most common
reasons for selecting the particular margin location. The clinical examination revealed that supra gingival and equi gingival
margins demonstrated superior gingival health indices as compared to subgingival margins
CONCLUSION: This study concluded that the supra gingival and equi gingival margins demonstrated superior gingival health
indices as compared to subgingival margin and in order to achieve optimal periodontal health and patient satisfaction the health
professionals should wisely consider the margin location and involve the patient in treatment decisions wherever possible.
KEY WORDS: Crown and Bridge, Margin location, Patient preference, Periodontal Health.
HOW TO CITE: Salim M, Tirmizi R, Abbasi MS, Ahmed N, Lone MA, Rashid H, Jouhar R. Evaluation of the marginal
location and periodontal health in crowns and bridges - A patient preference based Study. J Pak Dent Assoc 2021;30(3):194-198.
Received: 18 July 2020, Accepted: 02 April 2021

   An outbreak of a novel coronavirus was experienced by Wuhan, an emerging business hub of China in December 2019, that killed more than eighteen hundred and infected over seventy thousand individuals within the first fifty days of the epidemic.1 The patient’s infected by the virus had symptoms of breathing difficulty, lung infection, fever and pneumonia, hence the pathogen was identified as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).2,3 It came into view that a single animal-to-human transmission started the COVID-19 outbreak, followed by sustained human-to-human spread. Interpersonal transmission is now believed to occur mainly via respiratory droplets and contact transmission.4 The virus had spread to 113 countries and territories by 11 March 2020, with the number of registered cases reaching 118,162 and the number of deaths reaching 4290 (mortality rate 3.63%), hence WHO declared coronavirus disease 2019 (COVID-19) a global pandemic.2,5
Pakistan reported it’s first case of COVID-19 on 26th February 2020.2 Data from the COVID-19 Health Advisory
Platform by Ministry of National Health Services Regulations and Coordination revealed that close to 317,595 cases have been reported so far, with approximately 6,552 deaths till date of this study.6 A provincial lockdown was instituted on March 23, 2020, to curb and restrain further spread of the disease, all non-essential movement were restricted, affecting the provision of health services.7 Ever since Pakistan lifted the lockdown in early May coronavirus cases have been growing exponentially.8 COVID-19 transmission routes, and their relative contributions, remain unknown, but this knowledge is imperative as these transmission routes determine the
strategies required to protect healthcare workers from occupationally acquired infection. A research was conducted
among healthcare personnel (HCP) providing care to infectious patients to explore the contributions of three transmission routes-contact, droplet, and inhalation-to the risk of COVID19 infection, the key finding was that droplet and inhalation transmission routes preponderate over the contact route, contributing 35%, 57%, and 8.2% of the probability of infection, on average, without use of personal protective equipment.9 Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, oral health professionals are vulnerable and have a higher risk of the transmission of COVID-19 between patients and dental practitioners.4,10 In daily clinical work, the standard protective measures are not effective enough to prevent the spread of COVID-19, especially in patients undergoing incubation period, who are unaware they are infected, or choose to hide their infection. Strict and effective infection control protocols are urgently needed for dental practices and hospitals in areas that are likely affected with COVID-19.4 The American Dental Association (ADA) took the current rapid spread of infection in consideration and highlighted key steps to be taken by dentists in addition to the standard universal precautions such as assessing signs and symptoms of respiratory tract infection; taking patient’s
recent travel history; recording patients’ body temperature; mouth rinsing with 1% hydrogen peroxide prior to commencement of any procedure; using a rubber dam and high volume suction during procedures; and frequently cleaning and disinfecting public contact areas including door handles, chairs and, washrooms.11
A study was conducted to assess dentists knowledge about various practice modifications to combat COVID-19, in
Pakistan, Saudi Arabia and other parts of the world. The study reveiled that a large number of dentists (90%) were aware of recent modifications in the treatment protocols. However, execution of amended treatment protocol was recorded as 61%.11
Over the last few months, the delivery of orthodontics has rapidly changed due to COVID-19 pandemic. Routine
dental services were required to close all over the world. The remaining dental care centres were suggested to restrict
treatment to urgent or emergency care only, with the overarching message being to avoid aerosol generating procedures (AGPs) wherever possible.12
The aim of this study was to assess positive changes in orthodontic practice in Pakistani governmental and private workplaces after lifting of COVID-19 lockdown to prevent cross infection. If positive changes aren’t being implemented, webinars and online workshops should be arranged to spread

     This study was conducted as a cross sectional questionnaire-based study, carried out on 143 dental practitioners who are currently practicing orthodontics. The duration of the study was 3 months. After obtaining ethical approval from the institute (JSMU/IRB/2020/-388). A wellconstructed computerized closed ended questionnaire was designed at an online website i.e., google drive, the study was briefly described in the questionnaire and participants were asked to sign informed consent before filling out the survey form. The online questionnaire link was circulated by principal investigator through social media and by e-mail to dental practitioners currently performing orthodontics and their responses were collected on google drive. The questionnaire comprised of 16 closed ended questions, based on a previous similar study which was used to asses knowledge and practice of dentists about COVID 1911 and Centers for Disease Control and Prevention (CDC) guidelines to collect data regarding modifications in participant’s orthodontic practice post COVID lockdown. Sample size for the study was calculated by using WHO sample size calculator for single population with reported execution of amended treatment protocol recorded
as 61%, Absolute precision of 0.08, Level of confidence 95%.11 Responses were collected from 143 orthodontists who
participated from all over Pakistan, change in dental practice was assessed by comparing the results with CDC guidelines, keeping positive response cutoff 70%.
Inclusion criteria: Both genders were included i.e., male and female dental practitioners who are currently performing orthodontics, of all ages. Graduates or postgraduates working as orthodontists in private and hospital setting.
Exclusion criteria: Dental students, paramedical staff and dental practitioners who have practiced orthodontics for less than a year.
Data was analyzed by using SPSS 22. A Cronbach’s alpha analysis was conducted on a sample of 29 responses to assess the reliability of the questionnaire. Mean and standard deviation was calculated for quantitative variable, age. Frequency and percentage were calculated for qualitative variables like gender, educational qualification, work place and positive/ negative responses. Confounders, like educational qualification, gender and workplace were controlled through stratification. Post stratification Chi square Test was applied to assess the association of dentist’s response with gender, educational level, age and workplace, keeping P value < 0.05.

    All the data was analyzed using SPSS 22. Cronbach’s analysis scale alpha level was found to be .72, which indicates
that the scale has an adequate level of inter-item reliability. 68.5% implementation of positive modifications in dental practice were recorded.
There were total 143 participants, 80 female and 63 male, majority of positive responses (35.6%) were by
female orthodontists. The ages of orthodontists ranged from
23 to 56 years, with a mean age of 31.24 ± 6.82 years. Majority of the participants (75.52%) belonged to the age
range of 23-33 years and had highest positive responses (65.7%). Most of the orthodontists were post graduate trainees (66.4%) (Figure 1). Out of all these participants, 67 were working at orthodontic OPD, 22 at private practice and 51 worked at both (Figure 2). The chi square test results were significant with P <.05 for education (P= .05) and workplace (P= .002) of orthodontist, whereas no significant relationship was found between orthodontist’s responses with gender (P= .20) and age (P= .82).
In Table 1, there is a description of changes in orthodontic practice post COVID lockdown in Pakistan; About 97% of orthodontists were aware of the mode of transmission of COVID-19 and 95.8% were routinely following universal
precautions of infection control such as disinfection and use of sterile instruments for every patient. About 83.9% of
participants were updated with the CDC or WHO guidelines for cross-infection control regarding COVID-19 and 76.2% asked every patient, their travel history before performing dental treatment. Moreover, 61.5% of participants were taking every patient’s body temperature before performing
dental treatment, 97.2% were deferring dental treatment of patients showing suspicious symptoms and 79% knew which authority to contact if they came across a patient with suspected COVID-19 infection. 38.5% orthodontists asked every patient to rinse his/her mouth with anti-bacterial mouthwash before the treatment and 98.6% washed their hands with soap and water or used sanitizer before and after treatment of every patient. 79% thought surgical mask wasn’t enough to prevent cross-infection of Covid-19 and 83.9% thought N-95 mask or a respirator should be routinely worn in dental practice due to the COVID outbreak, hence 72.7% wore an N-95 mask or a respirator while treating a patient in their dental practice.
About 54.5% were maintaining physical distance of 6 feet between people, in their practice and 79% wore eye
protection while treating a patient. 41.3% were using high-volume suction for every patient and 60.1% properly
maintained ventilation system in their practice.

    The findings from this study reported, 68.5% orthodontists have adapted positive changes in their practice and have been following CDC and WHO guidelines for Covid-19 post COVID lockdown in Pakistan to prevent its cross
It is essential for all orthodontists to strictly adhere to the most up-to-date recommendations from all public health authorities. If a patient needs to be treated in practice, negative history for COVID-19 symptoms should be confirmed that should include no recent travel and no contact with an infected individual. If possible, every patient should complete a screening questionnaire, before entering the practice. Infection prevention and control (IPAC) protocol and a very high quality of sterilization should be maintained in orthodontic practice, that should include following correct order for removal and replacement of PPE and hand hygiene before and after coming in contact with a patient, by washing them for at least 20 seconds with soap, as this breaks down virus’s lipid layer, or alcohol-based (60% ethanol) hand rub (ABHR) should be used. To reduce the risk of transmission, emergency orthodontic treatments for known cases of COVID-19 can be more appropriately managed in hospital setting where facilities such as air purifiers with high-efficiency particulate air filters and airborne infection isolation rooms (AIIR) with negative suction are available. After completion of any emergency orthodontic treatment meticulous disinfection should be carried out to curtail spread through fomites and surrounding surfaces.13
The demographic information of the participants demonstrates that majority of responses 95(66.4%) were
from post graduate trainees and the remaining 32(22.4%) were from postgraduates and 16(11.2%) were from graduates. Out of 143 participants, 80 were female (55.9%) and 63 were male (44.1%). The age ranged from 23-56 and was further divided into three categories, with 108(75.5%) participants falling between age range 23-33, 25(17.5%) between 34-44 and 10(7%) between 45-56. Most of the participants 67(46.9%) worked at hospital setting i.e., orthodontic OPD, 22(15.4%) worked at private practice and 54(37.8%) worked at both private setting and orthodontic OPD.
A previous multinational study was conducted to assess Knowledge, Attitudes and Practices of dental practitioners
regarding the COVID-19 pandemic with majority of responses from Asian continent that demonstrated, most dentists with degree of MDS, BDS and DDS had good knowledge and practice scores.14 A similar study conducted in Pakistan, showed mean knowledge score significantly differed between general dentists (16.55 ± 2.36) and dental specialists (17.15 ± 2.04).15 Our study further supports this data with majority of positive responses from postgraduate trainees.
Table 2 illustrates, positive modifications in treatment protocols were mostly found to be adapted by female

orthodontist (51), orthodontist between age range 23-33 (71), Postgraduate trainees (59) and orthodontists who are
worked at both workplace settings (41). A similar study was conducted in turkey, to assess the impact of the novel
Coronavirus, positive associations between increased knowledge level and factors such as being a woman, working
in a university hospital were determined.16 Our study supports this data with more positive responses from female
Limitations of this study were time constraint due to increasing changes in the severity of the Covid situation and
small sample size.

    Most orthodontists working in governmental and private setting have positively modified their dental practice post
COVID-19 lockdown in Pakistan, by following WHO and CDC guidelines for COVID-19 to curtail spread of infection.
With the rapidly evolving COVID-19 situation, orthodontic practitioners should adhere to the most up to date
recommendations from all public health authorities.

Authors have declared that no competing interests exist.


1. Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Advanced Res. 2020;24:91-8.

2. Saqlain M, Munir MM, ur Rehman S, Gulzar A, Naz S, Ahmed Z, et al. Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: A Cross-sectional survey from Pakistan. J Hospital Infection. 2020;105:419-23.

3. Trivedi M. Covid-19: Impact and Dealings in Orthodontic Practice Design Post Viral Outbreak and Lockdown. Biomed Pharmacol J. 2020;13:1387-91

4. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99:481-87.

5. Saqlain M, Munir MM, Ahmed A, Tahir AH, Kamran S. Is Pakistan prepared to tackle the coronavirus epidemic? Drugs & Therapy Perspectives. 2020;20:1-2.

6. COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and Coordination. Available at: [last accessed October 2020]

7. Chandir S, Siddiqi DA, Setayesh H, Khan AJ. Impact of COVID-19 lockdown on routine immunisation in Karachi, Pakistan. The Lancet Global Health. 2020;8:e1118-e20.

8. Hassan S, Qureshi HA, Gul M. COVID-19 Second Phase Lockdown Option and Public Opinion: A case study in Pakistan. Int J Med Sci Clin Res Review. 2020;3:316-24.

9. Jones RM. Relative contributions of transmission routes for COVID-19 among healthcare personnel providing patient care. J of Occupational and Environmental Hygiene. 2020;17:408-15.

10. Bhumireddy J, Mallineni SK, Nuvvula S. Challenges and possible solutions in dental practice during and post COVID-19. Environmental Science and Pollution Research. 2020;7:1-3.

11. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat Novel Coronavirus Disease (COVID-19) outbreak. Int J Environmental Res Public Health. 2020;17:2821 (1-11).

12. Llandro H, Allison J, Currie C, Edwards D, Bowes C, Durham J, et al. Evaluating aerosol and splatter during orthodontic debonding: implications for the COVID-19 pandemic. medRxiv. 2020.

13. Suri S, Vandersluis YR, Kochhar AS, Bhasin R, Abdallah MN. Clinical orthodontic management during the COVID-19 pandemic. The Angle Orthodontist. 2020;90:473-84.

14. Kamate SK, Sharma S, Thakar S, Srivastava D, Sengupta K, Hadi AJ, Chaudhary A, Joshi R, Dhanker K. Assessing Knowledge, Attitudes and Practices of dental practitioners regarding the COVID-19 pandemic:
A multinational study. Dental and Medical Problems. 2020;57:11-7.

15. Almas K, Khan AS, Tabassum A, Nazir MA, Afaq A, Majeed A. Knowledge, Attitudes, and Clinical Practices of Dental Professionals during Coronavirus Disease 2019 (COVID-19) Pandemic in Pakistan. Eur J Dent. 2020;14(SOI):S63-S69.

16. Sezgin GP, Sirinoglu Çapan B. Assessment of dentists’ awareness and knowledge levels on the Novel Coronavirus (COVID-19). Brazil Oral Res. 2020;34.e112