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 Table of Contents  
ORIGINAL RESEARCH
Year : 2022  |  Volume : 14  |  Issue : 3  |  Page : 316-323

Impact of COVID-19 quarantine on oral health among pediatric patients and the parental attitude towards dental treatment at King Abdulaziz University: An observational study


1 Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Faculty of Dentistry King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission28-Sep-2021
Date of Decision06-Apr-2022
Date of Acceptance11-Apr-2022
Date of Web Publication28-Jun-2022

Correspondence Address:
Dr. Ghidaa Mouawad
Faculty of Dentistry King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_267_21

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  Abstract 

Aim: The Saudi government implemented a lockdown from March to August 2020 to reduce the risk of COVID-19 transmission. As a result of the lockdown, it was possible for children to improve or develop detrimental eating habits. In addition, parental fear and anxiety may change their attitude toward dental visits. The present study was conducted to assess the pandemic’s impact on oral health in pediatric patients due to dietary choices, oral hygiene, and parental fear and anxiety of getting the infection by COVID-19 from dental visits. Patients and Methods: An observational study, included children with mixed dentition and their parents who have been seen at King Abdulaziz University Dental Hospital in Jeddah, Saudi Arabia before the quarantine and came back after the quarantine to the dental clinics to continue dental treatments. Demographic data, diet evaluation, plaque index, dmfs, and DMFS scores were obtained from the electronic dental record systems from the time periods of before and after the lockdown. In addition, a retrospective diet evaluation during the pandemic and a parental fear and anxiety questionnaire were obtained by telephone interview. Results: A total of 52 children met the study’s criteria. During the quarantine, most children did not take their required amount of the basic foods. In particular, vegetable consumption deteriorated during the pandemic (P = 0.048). Moreover, there was a significant increase in the consumption of lollipops and candy bars as snacks (P = 0.039). Scores of dmft/DMFT and dmfs increased significantly during the quarantine compared to the time period before the pandemic (p=0.001). About 44.2% of parents thought the dental treatment could expose their child to become infected by COVID-19. However, 88.5% of them reported more confidence in visiting dental clinics if they were assured dental clinics are implementing high standard protective measurement against COVID-19. Conclusion: Children had more cariogenic snacks and parents’ confidence increased after knowing the protective measures in dental clinic.

Keywords: Caries Progression, Cariogenic Diet, Coronavirus, Mixed Dentition, Quarantine


How to cite this article:
Helal N, Mouawad G, AlSadun L, Felemban O. Impact of COVID-19 quarantine on oral health among pediatric patients and the parental attitude towards dental treatment at King Abdulaziz University: An observational study. J Int Oral Health 2022;14:316-23

How to cite this URL:
Helal N, Mouawad G, AlSadun L, Felemban O. Impact of COVID-19 quarantine on oral health among pediatric patients and the parental attitude towards dental treatment at King Abdulaziz University: An observational study. J Int Oral Health [serial online] 2022 [cited 2022 Aug 17];14:316-23. Available from: https://www.jioh.org/text.asp?2022/14/3/316/348415


  Introduction Top


Coronavirus disease 2019 (COVID-19) was first reported in December 2019 in China as a pneumonia of unknown origin. Sars-COV-2 virus belongs to a large family of single-stranded RNA viruses that cause illnesses ranging from common cold to more severe diseases. This virus family has a high animal to human transmission potential.[1] The first transmission from animals to humans occurred in the Huanan seafood market in Wuhan.[2] Consensually, the virus spread rapidly and a pandemic was declared by the World Health Organization (WHO) on March 11, 2020.[3] The COVID-19 has been detected in saliva, bodily fluids, and feces.[4] It spreads through droplets and direct contact with an infected person who may be symptomatic or asymptomatic.[5] Therefore, primary prevention measures including hand hygiene and social distancing are advised to be implemented at all times.[6]

The first case of COVID-19 in Saudi Arabia was detected in March 2020.[7] To combat the COVID-19 pandemic, the Saudi government immediately implemented a nation-wide lockdown and mandated schools and universities to shift to online learning.[8] As a result of the lockdown, in which many people were confined to their houses, a significant number of physical, physiological, and financial changes occurred, such as a drastic decline in family activity, exercise, and effects on diet and nutrition due to limited access to groceries. It also had an impact on families’ income, resulting in changes to the quality and quantity of food consumed, including ultra-processed and high-carb foods.[9],[10]

In addition, ‘Coronaphobia’ is a sense of fear caused by the uncertain nature of the disease, and fear of getting infected leads to behavior changes in parents, such as increases in anxiety and stress levels.[11]

Inadequate diet and nutrition have a significant impact on both general and oral health. In fact, given that children have a preference for sweetened foods and soft drinks that are rich in sugars, they are highly susceptible to caries development and progression.[12] During the COVID-19 pandemic, a study conducted in Brazil showed the negative impact of the COVID-19 pandemic on children’s dietary choices and oral health.[13] The study found that most people changed their eating habits and increased their food intake. Furthermore, parental fear and anxiety during the COVID-19 pandemic may lead to changes in attitude toward children’s dental visits. A study found that about two thirds of parents thought that the dental environment was more dangerous than other places and that their children could be easily infected with the virus through blood droplets or medical equipment.[14]

This study aimed to assess the impact of the COVID-19 pandemic on oral health of children due to dietary choices, oral hygiene, and parental fear and anxiety of COVID-19 infection resulting from seeking dental treatment.


  Materials and Methods Top


Setting and design

This is an observational study involving a chart review of pediatric patients and a telephone interview of their parents at King Abdulaziz University Dental Hospital, Jeddah, Saudi Arabia.

Sampling criteria

The study aimed to include pediatric patients between six and 13 years of age and their parents who had been seen at the King Abdulaziz dental hospital during the 6 months period before the start of COVID-19 quarantine in March 2020 and who were continuing their dental treatment after the quarantine ended in August 2020. The sampling time took 1 month to collect. Patients who had completed their treatment before the COVID-19 quarantine were excluded [Figure 1].
Figure 1: Summarized methods

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The data of the subjects were extracted from the dental records system (CS R4, version 6.4.6., Carestream Dental LLC, Atlanta, GA, USA) by two trained and calibrated researchers. It took one month to collect all of the information needed. The pre-quarantine oral health data of the subjects collected from the dental chart system (for the period before March 2020) included demographic data, diet evaluation, plaque index, dmfs, and DMFS scores. The post-quarantine data (August 2020 to April 2021) were also collected from the dental charts and included updated plaque index, dmfs, and DMFS scores. To collect data about the diet of subjects during the quarantine, the researchers contacted all parents by telephone to complete a retrospective diet evaluation during the quarantine. In addition, they were asked questions to determine fear and anxiety about their children being infected by the virus from dental treatment. The questionnaire contained four questions and was based on similar Chinese and Brazilian studies.[13],[14] Two experts assessed face validity, and made the adjustments needed for the questionnaire to be suitable for our population. Each interview took two minutes on average to complete. [Table 1]
Table 1: Parental fear and anxiety toward dental treatment

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Dietary evaluation

It consisted of two parts that yielded a diet score and a cariogenic score. The diet score part was comprised of five questions that assessed consumption of basic foods. Participants were asked whether or not they had two servings (five ounces) of meat daily, two and a half cups daily of vegetables, one and a half cups daily of fruit, six servings daily of grains, and three cups daily of milk or milk products. The possible responses were either “yes” which was scored as one, or “sometimes”, or “no” which were scored as zero. The total diet score ranged from zero to five. A score of five was rated as excellent, a score of four was regarded as fair, and a score of less than four indicated a need for improvement.

The second part (cariogenic score) was divided into drinks and snacks. Five questions assessed the regularity with which participants drank soda-pop, juices, sports or energy drinks, flavored waters, and sweetened beverages, and whether or not the child used a sippy cup regularly. In addition, five questions assessed whether or not snacks were consumed more than once per day between meals. Snacks included cakes/pastries, candy, lollipops or hard candies, and packaged cereals or crackers. The questions also assessed how frequently each item was consumed per day. Moreover, parents were asked about which snacks were eaten on a regular basis. The choices included fruit, cheese, crackers or peanut butter toast, potato chips/graham crackers/cookies/cake, lollipops or candy bars, and fruit roll-ups or dried fruit. Parents could indicate more than one choice. The total cariogenic score was 15. If the child received a score 15 it was regarded as excellent, a score of 13 was considered good, and scores below 13 showed a need for improvement.

Ethical approval and informed consents

It was approved by the Research Ethics Committee of the Faculty of Dentistry at King Abdulaziz University (approval number 149-12-20). The consent was obtained after explaining the purpose of the study.

Data analysis

The pre-quarantine and post-quarantine dental caries and plaque index scores were compared using paired t-tests. The pre-quarantine dietary evaluation responses were compared with the responses pertaining to the period of the quarantine using the Wilcoxon signed-rank test. The total diet scores and cariogenic scores from before and during the quarantine were compared using paired sample t-tests. A simple linear regression was modeled to evaluate the effects of significant variables on the changes in dental caries. P-values less than 0.05 were considered statistically significant. IBM SPSS Statistics 23 was used for the data analysis (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp).


  Results Top


Demographic data and parental fear and anxiety questionnaire

The sample consisted of 52 subjects. Of the study sample, 27 subjects (51.9%) were males and 25 subjects (48.1%) were females. The mean age of the participants was 8.79 ± 1.71 years. More than half of the subjects (55.8%) were in the age group nine to twelve years old and 23 subjects (44.2%) were in the age group of six to eight years old. Twelve parents (23.1%) reported that they had taken their child to an emergency dental visit during the quarantine. In this sample, there were parents who did not take their child to an emergency dental visit during the quarantine, seven parents (13.5%) reported they feared contracting COVID-19; 30 parents (57.7%) reported that they thought that dental treatment was not urgent; and three parents (5.8%) reported that dental treatment was not accessible. No subjects reported financial constraints or that their children had COVID-19 symptoms as reasons that prevented them from seeking dental treatment. Twenty-three parents (44.2%) thought that dental treatment could expose their child to infection. Forty-six parents (88.5%) expressed confidence that dental clinics implemented adequate protective measures against the virus.

dmfs, DMFS, dmfs/DMFS, and plaque index (PI)

The mean dmfs and total dmfs/DMFS for primary teeth showed a statistically significant increase after the pandemic compared with the one before the pandemic (P < 0.001). The mean DMFS for permanent teeth showed a slight increase after the pandemic compared with the one before the pandemic. No changes were found between the mean plaque index after and before the pandemic. [Table 2]
Table 2: dmfs, DMFS, dmfs/DMFS, and PI

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Diet and cariogenic scores before and during quarantine

No statical significant difference between the mean diet and cariogenic scores of children before and during the pandemic. [Table 3]
Table 3: Diet and cariogenic scores before and during quarantine

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Diet evaluation analysis

The comparison of dietary habits between pre-quarantine and during quarantine time periods is presented in [Table 4]. Vegetable consumption deteriorated, and children increased consumption of lollipops and candy bars regularly during the pandemic. These differences were statistically significant. [Table 4]
Table 4: Diet evaluation analysis

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The effects of fear of infection, reduced vegetable intake, and increased snaking on dental caries

Children of parents who reported that they were fearful of dental visits during the quarantine showed an increase in dmfs/DMFS by an average of 3.63 compared with children of parents who were not afraid of dental visits, but the association was not statistically significant (p = 0.273). Children who were reported to have decreased their vegetable intake during the quarantine had higher dmfs/DMFS scores on average by 0.87 but the increase was not statistically significant (p = 0.786). Children who increased their consumption of cariogenic snacks had an average increase in dmfs/DMFS by 0.15, but the increase was not statistically significant (p = 0.964). [Table 5]
Table 5: Simple linear regression to evaluate the effects of fear of dental visits, the decrease in vegetable intake, and the change in snack consumption on the increase of dental caries during the quarantine

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  Discussion Top


The present study aimed to assess the impact of the COVID-19 pandemic on oral health in pediatric patients due to dietary choices, oral hygiene, and parental fear and anxiety of COVID-19 infection resulting from seeking dental treatment. We found a significant increase in caries progression; most children did not consume the required amount of basic foods and ate more cariogenic foods. However, there were no significant changes between the diet and cariogenic scores before and during the pandemic. In addition, many of the children who participated were found to have poor oral hygiene, which worsened their oral health. Besides, oral health can be affected by many factors including age, gender, social norms, social status, or level of education.[15] Another finding was that many parents were fearful and anxious about their children receiving dental treatment. Therefore, most of them preferred to treat their children at home by doing an online consultation and given them pain killers when they have severe pain rather than going to a dental clinic. However, they expressed more confidence after learning of the protective measures taken against COVID-19 in dental settings.

In particular, vegetable consumption deteriorated during the pandemic, which had a negative impact on participants’ nutrition and oral health. However, there were no significant changes in the consumption of meat, fruit, grains, and dairy products before and during the pandemic. Moreover, most of the children have a preference for sweetened foods and soft drinks that are rich in carbohydrates, and there was a significant increase in the consumption of lollipops and candy bars on a regular basis, which can increase caries risk. Our findings are largely in agreement with a study conducted in Italy, which found that consumption of high levels of sugary drinks and red meat increased significantly during the lockdown, although there were no changes in vegetable consumption and an increase in fruit intake.[10] A previously mentioned study conducted in Brazil found that 61.5% of participants changed their eating habits, with most of them increasing their food intake.[13] Of those who reported changes in eating habits, only 33.1% said they were choosing healthier foods, while the others increased the consumption of pasta, sandwiches, snacks, and other foods with low nutritional value and high sugar content. Moreover, Similar results were found in a recent studies conducted in Brazil and Israel found an increase in the consumption of sweetened products..[16],[17] Additionally, the previous study and a conducted study in Spain found a significant reduction in fruits, vegetable, and nuts during the lockdown.[16],[18] A possible explanation for these findings could be associated to difficulties balancing family and working life, as many parents were forced to telework while caring for their children during the Covid-19 pandemic; this condition could have resulted in bad eating habits.

In fact, the oral cavity has an optimal neutral pH (6.75 to 7.25), and dental caries develops at a pH of 5.5 or less. The pH in plaque can decrease to five rapidly after sugar consumption. As a result of bacterial metabolism, more aciduric species like streptococcus mutans and lactobacillus will accumulate. These bacteria are normally absent or only minor components found in dental plaque. Such a change in the bacterial plaque composition predisposes a surface to dental caries. Therefore, they are regarded as being high risk factors for the development of caries, which explains the significant increase in dmft/DMFT and dmfs scores during the pandemic in this study. In addition, caries progression could be one of the consequences of the shutting down of dental clinics as a protective measure against COVID-19. Further, primary teeth are more prone to faster caries progression from enamel to dentine.[19] Our findings are in accordance with a study conducted in Israel which found 14% received a diagnosis of more carious lesions during the last dental examination after the lockdown.[17] Many children who participated in this study had poor oral hygiene, which is a factor associated with the development and progression of dental caries. In the present study, there were no changes found in the plaque index, which means that their oral hygiene remained poor and potentially increased the dmft/DMFT scores. Further investigation into all aspects of oral hygiene like frequency and duration of brushing, brushing time, and flossing should be done to determine why oral hygiene did not improve. Two conducted studies in Israel and Brazil found that 25.1% and 22.9% of children decreased their frequency of tooth brushing.[17],[20] It might be the consequences of family routine due to social distancing, children not attending school, and parents working from home.

Most of the parents did not take their children for emergency dental treatment for several reasons. The most commonly reported reason was that dental treatment was not regarded as urgent (57.7%). Another reason (13.5%) was fear of contracting COVID-19 during dental treatment. In addition, (5.8%) of participants reported that dental treatment was not accessible in their area. These findings agree with a study conducted in India that reported an association between parents’ willingness to take their children to dental clinics and moderate to high fear levels. Approximately 68.3% of parents reported contacting dentists by visiting a nearby dental emergency hospital, followed by 23.3% through a phone call, 4.2% via text message, and 4.2% by social networking sites.[21] In another study, 82.49% of the parents reported that they would take their children to the hospital for treatment during the pandemic if their children had a severe toothache, while the rest said they would not.[14]

Since dental treatment can involve considerable saliva or blood splatter from the patient, it can carry a high risk of COVID-19 transmission. Therefore, the dental department has a higher risk of infection than other departments or other places. Accordingly, 44.2% of parents thought the dental treatment would cause their child to become infected by the virus. However, 88.5% of them expressed greater confidence after learning of the protective measures taken against the transmission of the virus, which include patient screening, the strengthening of hospital environment disinfection, and the provision of special protective equipment for both dentists and patients (using gargles, rubber dams, strong suctions and other equipment). This indicates that the parents had a high level of confidence in the prevention and control policies undertaken by the hospital’s health committee. Our finding is in line with the study conducted in Brazil that reported that 81.08% of the parents expressed confidence after being informed about preventive measures undertaken by the health committee.[14] One more study reported that 53.19% of the parents have the fear of Covid-19 transmission during the dental visits and preferred to do treatment in private clinics for their child.[22]

In our study, there was no significant association between fear of dental visits, decreased vegetable intake, and the change in snack consumption and the increase of dental caries during the pandemic. This finding may be because of the small sample size or other confounding variables that were not measured.

Strength of the present study is its longitudinal design, which compares data from two different periods. However, potential limitations include the small sample size as a result of the study’s inclusion criteria and that the participants were all recruited from a single institution King Abdulaziz University Faculty of Dentistry (KAUFD) in which many patients have low socioeconomic status, high caries risk, and poor oral hygiene. In addition, there was the risk of recall bias on the part of the parents during the retrospective diet evaluation.

Our recommendation is to increase the number of participants and to recruit different subject groups from different places with different social-economic statuses to reduce bias in the data collection. In addition, using diet analysis instead of diet evaluation could give a more accurate perception of children’s diets.


  Conclusion Top


Although the participating children’s diet did not change significantly, we found a significant increase in the consumption of cariogenic snacks on a regular basis and a decrease in vegetable consumption. Moreover, it was alarming that most children had poor oral hygiene. In addition, dentists should reassure parents by informing them about the protective measures in dental clinics to increase their confidence.

Acknowledgements

The authors would like to thank KAUFD Internship Training Program for their strategic support and for creating the research environment.

Financial support and sponsorship

This research received no external funding to be declared.

Conflicts of interests

The authors declare that there is no conflict of interest regarding the publication of this article.

Author contributions

N.H.: Idea initiation, study design, supervision, review and editing. G.M.: Literature review, idea initiation, data collection and manuscript writing. L.A.: Literature review, idea initiation, data collection and manuscript writing. O.F.: Study design, data interpretation, statistical analysis, supervision, review and editing. Finally, all authors approved the final version of the manuscript for publication.

Ethical policy and institutional review board statement

The study was approved by the Research Ethics Committee of the Faculty of Dentistry at King Abdulaziz University, Jeddah, Saudi Arabia on 15 December 2020.

Patient declaration of consent

Verbal consents were obtained from parents by telephone.

Data availability statement

Data is available upon reasonable request.

List of Abbreviations

dmft: decayed, missing, filled primary teeth.

dmfs: decayed, missing, filled primary teeth surfaces.

DMFT: decayed, missing, filled permanent teeth.

DMFS: decayed, missing, filled permanent teeth surface.

PI: plaque index.

KAUFD: King Abdulaziz University Faculty of Dentistry.

WHO: World Health Organization.

 
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    Tables

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



 

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