{'fraction_non_alphanumeric': 0.03162836669137633, 'fraction_numerical': 0.016802569804793676, 'mean_word_length': 5.281427832384894, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 1, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Appropriate orthodontic appliances during the COVID-19 pandemic: A scoping review

Introduction The esoteric Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection or COVID-19 has been an unusual plummet in dental/orthodontic practice. Based on current recommendations for various amendments in an orthodontic practice, this scoping review aims to identify orthodontic appliances that are most appropriate to us during this on-going pandemic. Methods Electronic databases (PubMed, Scopus, Web of Science, Science Direct, and Google Scholar) were searched up until August 11, 2020. Full-text articles in English with keywords “COVID-19 and Orthodontics” and related search terms were included. Results Out of 17 retracted articles, only 4 articles were found to be brief the choice for orthodontic appliances in pandemic times speculating clear aligner therapy (CAT) to be a pragmatic solution. The remaining articles were also thoroughly studied and the new norms set by the pandemic were determined. Criteria for orthodontic appliance selection included careful patient screening and collection of records, minimal physical visits, efficient use of technology, virtual consultations but the use of PPE for physical appointments; and lesser AGPs with a lesser risk of airborne transmission. Conclusions Subject to regional demands, CAT can be considered as the relatively safer modality-predictable and effective apposite to fixed orthodontic appliances in these unprecedented times.


Introduction
The World Health Organization (WHO) officially named Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2 or 2019-nCoV) disease as 'COVID-19' on February 11, 2020, and declared this outbreak, a pandemic on March 11, 2020. 1 With the reporting cases more than over 40 million cases and 1.1 million deaths till now (as last accessed on October 21, 2020), the mortality rate is lower (3.4%) when compared to previous SARS-CoV (10%) and MERS-CoV (3.4%) outbreaks in 2009-2012 respectively. 2 However, its uncertain mode of transmission through droplets, fomites, and probably air-borne as well make it a highly infectious contagion. With 44 candidate vaccines in evaluation, out of which 11 have reached Phase III clinical-stage trials (as last on accessed October 21, 2020), 3 it can be predicted that the contagion or its effects may exist in the community for months from now untill mass commercial production and community vaccination.
Dental professionals and associated health care providers are exposed to the risk of contracting and transmitting SARS-CoV-2 infection through either direct transmission (inhalation of droplets/aerosols or exposure to saliva and mucous membranes) or indirect transmission (via contaminated surfaces). While the risk of transmission through aerosol-generating procedures cannot be excluded, even more worrisome is that asymptomatic patients or patients in their incubation period are also carriers of SARS-CoV-2 and can be potentially infectious. 4 Strict infection control measures for the highly transmissible SARS-CoV-2 is a major area of concern. There are many published guidelines and new protocols being followed by individual nations to restore dental services across the globe. [4][5][6][7] For orthodontics as well, restarting the suspended services demands not just reinforcing the already existing protocols with new guidelines, but also manipulation and utilization of newer technologies with an updated digital workflow that reduces the manual task and hence the chair-side time. [8][9][10][11] Although an avalanche information for orthodontic appliances is available, there is still a https://doi.org/10.1016/j.jobcr.2020.10.014 Received 27 August 2020; Accepted 19 October 2020 dearth of data on the suitable appliances that could be more beneficial tothe clinicians and the patients in the current pandemic.
To this unfold enigma, a thorough strategic analysis of literature was planned to map the evidence for recommendations for orthodontic appliance selections during this pandemic. The aim of this scoping review was to check for the various amendments required in orthodontic practice and their effect on the preference for orthodontic appliances in the new norms set by the pandemic. The speculation was to contemplate whether clear aligner therapy (CAT), in these unprecedented times, prove beneficial for orthodontists as well as patients when compared to any other apposite.

Materials and methodology
Considering a continuously updating COVID-19 data on a day to day basis, this review included publications that accorded the search terms as searched uptill August 11, 2020. The PRISMA search strategy was planned using the MESH terms and Boolean terminology: (Orthodontic*) AND (COVID-19*) AND (SARS-CoV-2*)/"Orthodontic*" AND "COVID-19*" OR "SARS-CoV-2*"AND "Dental Bonding" AND "Dental Aesthetics"/"Orthodontic Appliance" AND "COVID-19" AND "Dental Bonding". This search strategy was applied to the key databases PUBMED, SCOPUS, WEB OF SCIENCE, and Google Scholar. Due to the lack of clinical studies and trials with the interruptions caused by the pandemic, surveys/reviews/letters to editors/commentary/preprints/ guidelines were also included to gather knowledge of the clinical requirements that mandate the restart of clinical practice ( Table 1).
Screening of titles and abstracts of all the search results was performed and the full texts of included articles available in English were   To assess the impacts of the pandemic on orthodontists and orthodontic residents, economic, psychosocial, and social well-being, in Nigeria.
Cross-sectional study 2 8 Cotrin et al., 15 2020 To evaluate the impact of the coronavirus pandemic and the quarantine in orthodontic appointments, and patients' anxiety and concerns about their ongoing orthodontic treatment.
Local sample survey 3 9 Eliades et al., 16 2020 To list the sources of aerosol production during an orthodontic standard procedure, analyze the constituent components of aerosol and their dependency on modes of grinding, the presence of water and type of bur, and suggest a method to minimize the quantity and detrimental characteristics of the particles comprising the solid matter of aerosol. Minimization Review of reported data 5 10 Guo et al., 17 2020 To update the preventive strategies for control of SARS-CoV-2 transmission to protect both staff and patients during the orthodontic practice.
Narrative review 5 11 Turkistani K., 18 AJODO, 2020 To report to orthodontists on the emergence, epidemiology, risks, and precautions during the disease crisis. To discuss essential adaptations that concern four areas of the orthodontist practice: microbiological control, social distancing, new ergonomics, and bioethical considerations   • Emergencies to be managed at the clinic-active and functional appliances, part of any appliance embedded in gingiva leading to pain and discomfort, etc.

Orthodontic Records
• Extraoral radiography is preferred over intraoral radiography • Photographs should be taken in separate rooms and for one patient single-use retractors or reflectors should be used. • Intra-oral digital scanners or CBCT generated STL files may be used for 3D software models instead of alginate or silicone impressions Bonding and other AGPs • High-volume suction is critical for AGPs • For bonding self-etch primers or liquid gel and/or low viscosity etchants with minimal or no rinsing; use of GIC or BPA free adhesives • Indirect bonding techniques or minimal bonding techniques like CAT can be preferred • Use of rubber dam/peri-oral dam is also recommended for all AGPs.
• Inter-proximal reduction can be coupled in same appointment as bonding. Alternatively, use of abrasive strips preferred over burs for interproximal reduction.

Extractions
• Can be avoided until any signs of abscess or cyst may be seen • Over-spitting of saliva avoided and high-volume suction may be used • Prefer local anesthetics gels over sprays

Retention
• Thermoplastic retainers may be preferred as can be fabricated through 3D software models of the patients • Postpone fixed retention retrieved and scrutinized by 2 reviewers (H·K and H.G) followed by a cross-check by the third reviewer (A.S.K). Disagreements were resolved by discussion among all the authors. The included articles were screened thoroughly for and the level of evidence was also determined as per based on Oxford Centre for Evidence-based Medicine (OCEBM).
References of included articles also were screened using the snowballing technique (Fig. 1).

Results
A total of 17 articles were retrieved for full text and thoroughly studied (Tables 2 and 3). Amongst these, 5 studies were focusing on the psychological impact of the pandemic on Orthodontic patients, dental students, and orthodontists themselves. 11 were review articles providing guidelines and recommendations about the risk of SARS-CoV2 transmission within orthodontic clinics, the preventive measures to be followed, and the strategies of sterilization and infection control.
Apart from following the standard operative protocols, appropriate appliance selection is also a mandate. There were only 4 articles that were found to be recommending approaches for orthodontic appliances to be used during this pandemic, acclaiming aligners could be beneficial over multi-bracket appliances. (Table 4)

Discussion
SARS-CoV-2 or COVID-19 pandemic has affected the economic, psychosocial, and social lives of orthodontists as well as orthodontic patients, with increased levels of anxiety and distress. For a patient who seeks treatment and is additionally concerned regarding these risks of COVID-19 infection, what could be the most comfortable and safest appliance to place? From the present evidence of COVID-Era, the potential demands for appliance selection include careful patient screening and collection of records; minimal physical visits; utilizing technology at its best; virtual consultations but the use of PPE for physical appointments; and lesser AGPs with a lesser risk of air-borne transmission (Table 4).
Removable appliances such as aligners alone create the least risk for the transmission of SARS-CoV-2 when compared to fixed labial/lingual appliances, but cannot be used in most cases. When compared with fixed appliances, CAT does offers clear advantage of shorter chair-time, minimal bonding requirements, lesser recall visits to the office, remote monitoring through virtual means, higher accuracy of treatment planning with digital scans, better plaque control, and fewer iatrogenic effects such as white spot lesions and root resorption. [11][12][13][25][26][27][28][29] However, not just that CAT may have limitations here handling complex malocclusion, finishing with CAT alone can be challenging sometimes. 30 In such cases, CAT may be coupled to multi-bracket appliances or auxiliaries such as attachments, inter-arch elastics, mini-screw implants etc. may be used, where the bonding of braces/ attachments can be delayed until the pandemic subsides.
Over all, the treatment modality offered by a clinician to the patient is hinged upon the clinician's proficiency and the measures for time efficiency. Thus, to reach substantiated conclusions, further clinical investigational studies and surveys are required to know the potential choice of appliances being used in clinical practice with the unfastening of dental practices amidst the on-going pandemic.

Conclusions
The prerequisite criteria for the selection of orthodontic appliances for a clinician in the current pandemic situation is to consider all the preventive measures safeguarding patients, staff, and colleagues. Comparing CAT with other treatment options, it can be very well instituted that CAT together with digital scanners can be considered as the relatively safer modality to weather the storm. However, given the regional demands set by the pandemic and to meet the requirements of both the patients and the clinicians, a customized approach should be undertaken.

Declaration of competing interest
The authors declare that they have no conflict of interests.