Keywords
oral problem - attitude - dental patients - COVID-19
Introduction
Coronavirus disease, commonly known as COVID-19, is an ongoing, highly devastating,
and contagious viral infection of the respiratory system that has caused 6,927,378
global deaths as of May 2023.[1]
[2] The World Health Organization (WHO) declared the disease a global pandemic on March
11, 2020.[1] In Thailand, the pandemic has caused 30,349 deaths[3] and economic damages from the prolonged quarantine since December 2020.[4]
[5]
According to the WHO, the disease can spread through oral and nasal cavities via direct
contact, droplets, and, in some cases, airborne transmission.[6] Furthermore, the presence of SARS-CoV-2's angiotensin-converting enzyme 2 in the
oral cavity confirms that the oral cavity is one of the main entries for the virus.[7] Dental treatments, which naturally create droplets and aerosol, are thus limited
to only emergency treatments during the pandemic.[7]
[8] The limited access to dental services could lead to a decline in oral health and
more oral-related diseases as preventive intervention through regular oral health
checkups is imperative to good oral health.[9]
Another effect of COVID-19 is the change in patients' attitudes toward dental practices
due to increased anxiety and stress levels.[10] Various studies reported that anxiety and stress may negatively affect oral health
care behavior and diet, leading to poor oral health.[7]
[10]
[11] The patients with dental phobia tend to avoid routine checkups for preventive care,
resulting in visiting the dentist less than once a year.[11] The avoidance of preventive oral health care could increase the risk of long-term
chronic medical conditions, especially those correlated to oral disease such as gingivitis.[11]
The effect of the COVID-19 pandemic on dental health has been widely studied across
the world. Ciardo et al recently reported good Oral Health-Related Quality of Life
(OHRQoL) for most adult participants in Germany during the pandemic.[12] In contrast, a study conducted in India found that COVID-19 could worsen OHRQOL
especially among females.[13] It is suggested that distinctive sociopolitical circumstances across regions and
countries result in different impacts of the pandemic on social, professional, and
personal life. Investigating the impact of COVID-19 in various countries is, therefore,
essential to understand the situation unique to that country. This study aims to comprehensively
investigate the wide-ranging impacts of the COVID-19 pandemic on both oral health
and patient attitudes in Thailand. Despite limited understanding of the full extent
of COVID-19's influence in this region, our primary focus is to gain crucial insights
that can inform the development of a comprehensive preventive protocol. By doing so,
we aim to enhance global preparedness in anticipation of future pandemics.
Materials and Methods
This is a cross-sectional study that was approved by the Ethics Committee of Human
Research, Faculty of Dentistry, Mahidol University, Bangkok, Thailand (COA. No. MU-DT/PY-IRB
2021/091.1510). The participants are the patients at the Faculty of Dentistry, Mahidol
University, who are older than 25 years, living in the Bangkok metropolitan area since
April 1, 2021, and can read/listen and answer questions within the questionnaire.
The participants were given the option to withdraw at any time. The researchers employed
the convenience sampling technique to recruit participants for the study. The sample
size was determined through the formula for cross-sectional descriptive study at a
95% confidence interval.[14] The minimum required number of participants to represent an entire population of
197,354 patients who used the dental service at the Faculty of Dentistry, Mahidol
University, between October 2019 and March 2020 was set as 384 participants.
The questionnaire was developed to suit the COVID-19 situation in Thailand. The validity
of the questionnaire was evaluated by three experts (two in dental education and one
in advanced general dentistry specialist) using content validity analysis. Language
clarity, practical pertinence, and theoretical relevance of each question were evaluated.
The question with an index of item-objective congruence (IOC) less than 0.5 was revised
according to the evaluator suggestion; otherwise, it remained unchanged. Then, the
pilot survey was performed with 10 dental patients who had a similar background to
the targeted participants to perform reliability analysis through the test–retest
procedure. The questionnaire was applied by the researchers and the pilot group of
participants answered the questions (test). A week later, the questionnaire was reapplied
to the same group (retest). The internal and external consistencies of the questionnaires
were evaluated with Cronbach's α coefficient of 0.87 and correlation coefficient of
0.65.
The final version of the questionnaire was divided into four parts. The first part
was about demography, job-related information, general health status, and COVID-19
vaccination. The second part acquired information about oral health problems before
and during the COVID-19 outbreak in Thailand. The Third part asked about the daily
and oral hygiene care behavior of the participants during the pandemic. The last part
concerned attitudes toward the effects of COVID-19 situation on oral health problems,
in which we used the 5-point Likert scale to record the score. The answer scores of
4 and 5 were categorized as favorable scores. The final questionnaires were randomly
distributed to the dental patients at different departments in the Faculty of Dentistry,
Mahidol University. The responses from the participants were then anonymized and recorded
on Google sheets.
The descriptive statistics were used to evaluate the distribution of data in each
part. Pearson's chi-squared was used to determine a correlation between each demographic
data and attitudes of whether the COVID-19 situation has an impact on the oral health
or not at a significant level of 0.05. To assess the association of oral problems
before and during the pandemic, McNemar's test was employed at a significant level
of 0.05. All analyses were performed through STATA/BE version 17.0 (Stata Corp., College
Station, TX, United States).
Result
The survey was performed during November to December 2021. The original number of
participants was 414, but we excluded 5 of those who returned the questionnaire with
less than 90% completion. The characteristics of the final 409 respondents are summarized
in [Table 1]. It is noteworthy that the number of respondents answering each question can be
different as some of them may omit or skip some questions. The respondents were divided
into the yes and no groups based on their attitude toward the effect of COVID-19 outbreak
in August 2021 on their oral health problems (question 1 in the 4th part of the questionnaire).
The respondents in the “yes” group were those who responded with favorable scores,
that is, agree or strongly agree. Other responses were classified as “no.”
Table 1
General characteristic of participants (n = 409)
|
Factors
|
Total
|
Oral health status affected by COVID
|
p-value
|
|
n (%)
|
No, n (%)
|
Yes, n (%)
|
|
|
Gender
|
|
Male
|
138 (33.7)
|
68 (49.3)
|
70 (50.7)
|
0.007
|
|
Female
|
271 (66.3)
|
96 (35.4)
|
175 (64.6)
|
|
Age (
n
= 408)
|
|
21–34
|
115 (28.2)
|
46 (40.0)
|
69 (60.0)
|
0.938
|
|
35–44
|
78 (19.1)
|
30 (38.5)
|
48 (61.5)
|
|
45–59
|
126 (30.9)
|
49 (38.9)
|
77 (61.1)
|
|
60–79
|
89 (21.8)
|
38 (42.7)
|
51 (57.3)
|
|
Education level (
n
= 408)
|
|
Less than bachelor's degree?
|
99 (24.3)
|
46 (46.5)
|
53 (53.5)
|
0.154
|
|
Bachelor's degree
|
231 (56.6)
|
83 (35.9)
|
148 (64.1)
|
|
More than Bachelor's degree?
|
78 (19.1)
|
34 (43.6)
|
44 (56.4)
|
|
Occupation (
n
= 405)
|
|
Laborer
|
18 (4.4)
|
8 (44.4)
|
10 (55.6)
|
0.293
|
|
Private company employee
|
78 (19.3)
|
26 (33.3)
|
52 (66.7)
|
|
Government employee including soldier and police
|
125 (30.9)
|
45 (36.0)
|
80 (64.0)
|
|
Service worker and freelance
|
63 (15.6)
|
26 (41.3)
|
37 (58.7)
|
|
Merchant
|
40 (9.9)
|
21 (52.5)
|
19 (47.5)
|
|
Currently not working, retirement
|
81 (20.0)
|
37 (45.7)
|
44 (54.3)
|
|
Dental service coverage (
n
= 408)
|
|
No dental coverage
|
106 (26.0)
|
51 (48.1)
|
55 (51.9)
|
0.112
|
|
Civil servant medical benefit scheme
|
141 (34.6)
|
53 (37.6)
|
88 (62.4)
|
|
Social security system
|
99 (24.3)
|
40 (40.4)
|
59 (59.6)
|
|
Universal health coverage
|
25 (6.1)
|
5 (20.0)
|
20 (80.0)
|
|
Private insurance
|
37 (9.1)
|
14 (37.8)
|
23 (62.2)
|
|
Underlying medical disease
|
|
No or unknown
|
220 (53.8)
|
88 (40.0)
|
132 (60.0)
|
0.965
|
|
Yes
|
189 (46.2)
|
76 (40.2)
|
113 (59.8)
|
|
Diabetes mellitus
|
34 (8.3)
|
13 (38.2)
|
21 (61.8)
|
|
Hypertension
|
62 (15.2)
|
26 (41.9)
|
36 (58.1)
|
|
Cardiovascular disease
|
13 (3.2)
|
6 (46.2)
|
7 (53.9)
|
|
Dyslipidemia
|
78 (19.1)
|
29 (37.2)
|
49 (62.8)
|
|
Other
|
88 (21.5)
|
32 (36.4)
|
56 (63.6)
|
|
History of COVID vaccination
|
|
No
|
10 (2.4)
|
2 (20.0)
|
8 (80.0)
|
0.328[a]
|
|
Yes
|
399 (97.6)
|
162 (40.6)
|
237 (59.4)
|
|
Received at least 2 COVID vaccine shot
|
|
No
|
19 (4.7)
|
5 (26.3)
|
14 (73.7)
|
0.209
|
|
Yes
|
390 (95.4)
|
159 (40.8)
|
231 (59.2)
|
a Using Fisher exact test, while the rest used Chi-square test.
The final 409 participants consisted of 138 (33.7%) males and 271 (66.3%) females.
A majority of females (64.6%) believed that the COVID-19 situation impacted their
oral health, while roughly half of males (50.7%) had a similar opinion. Based on the
chi-squared test, the attitude toward the effect of the COVID-19 outbreak on the oral
health was statistically related to sex with a p-value less than 0.05. The largest population of the participants (30.9%) were in
the age ranges of 45 to 59 years. The second in rank was the population in the age
group of 21 to 34 years, which comprised 28.2% of the participants. Most of the participants
(75.7%) had at least a bachelor's degree. The occupation of the participants varied
from government employees (30.9%) and retirees (20.0%) to private company employees
(19.3%). Dental expense of most respondents was covered by the government civil servant
benefit (34.6%) or the social security system (24.3%), which was mainly for private
company employees. The percentages of the participants using government benefit and
social security system to support their dental expenses were larger than the number
of government employees and those currently working in private companies, simply because
the retired participants could still use their benefits. About half of the participants
(46.2%) knew their health conditions and had at least one disease including diabetes
mellitus, hypertension, and cardiovascular disease. The top three underlying diseases
were dyslipidemia (19.1%), hypertension (15.2%), and diabetes mellitus (8.3%). The
majority of the respondents had good and very good physical health (77.8%) and mental
health status (74.6%) before the COVID-19 pandemic. Finally, 97.6% of all respondents
received at least one shot of COVID-19 vaccine, while 95.4% received at least two
shots.
[Table 2] shows the number of the participants who faced oral problems before and during the
pandemic. Among all listed problems, halitosis and gum bleeding escalated, while temporomandibular
disease (TMD), dental prostheses–related problems, and tooth crack/fracture declined
significantly during the pandemic. In all, 15.4% of participants had halitosis after
the pandemic as against only 9.3% before the pandemic. Patients with complaint of
gum bleeding increased from 5.9% before the pandemic to 10.3% during the pandemic.
On the other hand, the percentage of participants with complaints of TMD substantially
decreased from 8.1% before the pandemic to 4.2% during the pandemic. Complaints pf
dental prostheses also declined significantly during the pandemic. Those with problems
related to fixed prostheses accounted for 7.6% of the participants in comparison to
14.4% before the pandemic and those with removable prostheses complaints totaled up
to 2.7% during the pandemic, which was less than 6.6% before the pandemic.
Table 2
Oral problems of participants before and during the COVID-19 pandemic (n = 409)
|
Oral problem
|
Before COVID-19,n (%)
|
During pandemic, n (%)
|
p-value
|
|
None (oral health checkups)
|
70 (17.1)
|
112 (27.4)
|
<0.001[a]
|
|
Gum bleeding
|
24 (5.9)
|
42 (10.3)
|
<0.001[a]
|
|
Toothache
|
64 (15.7)
|
67 (16.4)
|
0.775
|
|
Tooth sensitivity
|
83 (20.3)
|
95 (23.2)
|
0.200
|
|
Impacted tooth
|
25 (6.1)
|
14 (3.4)
|
0.052
|
|
Halitosis
|
38 (9.3)
|
63 (15.4)
|
<0.001[a]
|
|
TMD (joint pain/sound, limited mouth opening)
|
33 (8.1)
|
17 (4.2)
|
<0.001[a]
|
|
Problem related to fixed prosthesis
|
59 (14.4)
|
31 (7.6)
|
<0.001[a]
|
|
Problem related to removable prosthesis
|
27 (6.6)
|
11 (2.7)
|
<0.001[a]
|
|
Tooth crack/fracture
|
78 (19.1)
|
60 (14.7)
|
0.013[a]
|
|
Dislodgement of filling
|
74 (18.1)
|
64 (15.7)
|
0.229
|
|
Dental caries, abrasion
|
14 (3.4)
|
8 (2.0)
|
0.146
|
|
Orthodontic problem
|
12 (2.9)
|
2 (0.5)
|
0.002
|
a Significantly difference at p < 0.05.
[Table 3] demonstrates the daily behavior of the participants during the spreading of COVID-19
in Thailand in August 2021. The participants went to bed mostly at 9 to 11 p.m. (46%)
and 11.01 to 1 a.m. (32.1%). Most participants slept approximately 6 to 8 hours (73.5%).
Almost half of the participants did not exercise (47.1%), whereas 26% of the participants
exercised only 1 to 2 days a week. In all, 44.6% of the participants reported unchanged
consumption of sugary snacks and/or beverages. Most participants did not smoke (94.6%).
However, among those who did, 2.5% reported more frequent smoking during the pandemic,
while 2.2% reported unchanged frequency. Finally, 81% of the participants did not
consume alcohol. Among those who did (19%), 12.8% reported less consumption during
the pandemic. [Table 3] also summarizes an evaluation of oral hygiene care after being affected by the COVID-19
situation. Most of the respondents brushed their teeth more than twice a day (94.9%),
while some of them brushed their teeth once a day (3.4%). There were also those who
did not brush at all or were uncertain (1.7%). Finally, the COVID-19 lockdown in August
2021 did not affect the tooth brushing habit of most participants (86.3%).
Table 3
Daily behavior and oral hygiene caring behavior of the participant during the COVID-19
pandemic in August 2021 in Thailand
|
Activity
|
Total
|
n (%)
|
n (%)
|
n (%)
|
n (%)
|
|
|
Before 9 a.m.
|
9–11 a.m.
|
11.01 a.m.–1.00 p.m.
|
After 1 p.m.
|
|
1. What time did you usually go to bed?
|
408
|
48 (11.8)
|
191 (46.8)
|
131 (32.1)
|
38 (9.3)
|
|
Activity
|
|
Less than 6 h
|
6–8 h
|
9–10 h
|
More than 10 h
|
|
2. How many hours did you sleep in average?
|
408
|
83 (20.3)
|
300 (73.5)
|
25 (6.1)
|
0 (0)
|
|
Activity
|
|
None
|
1–2 d
|
3–4 d
|
More than 4 d
|
|
3. How many days did you exercise at least 30 min in a week?
|
408
|
192 (47.1)
|
106 (26.0)
|
61 (15.0)
|
49 (12.0)
|
|
Activity
|
|
More frequent
|
Less frequent
|
Unchanged
|
I did not have sugary snack/beverage
|
|
4. How often do you have sugary snack and/or beverage?
|
408
|
115 (28.2)
|
91 (22.3)
|
182 (44.6)
|
20 (4.9)
|
|
Activity
|
|
More frequent
|
Less frequent
|
Unchanged
|
I did not smoke
|
|
5. How often do you smoke?
|
408
|
10 (2.5)
|
3 (0.7)
|
9 (2.2)
|
386 (94.6)
|
|
Activity
|
|
More frequent
|
Less frequent
|
Unchanged
|
I did not drink alcohol
|
|
6. How often do you consume alcohol?
|
408
|
7 (1.7)
|
52 (12.8)
|
18 (4.4)
|
331 (81.1)
|
|
Activity
|
|
Not brushing/uncertain
|
1 time/d
|
2 times/d
|
More than 2 times
|
|
7. How many time(s) a day did you brush your teeth?
|
409
|
7 (1.7)
|
14 (3.4)
|
301 (73.8)
|
86 (21.1)
|
|
Activity
|
|
Uncertain
|
Less frequent
|
Unchanged
|
More frequent
|
|
8. How did the spreading of COVID-19 in Thailand in August 2021 affect your frequency
in tooth brushing?
|
409
|
15 (3.7)
|
10 (2.4)
|
353 (86.3)
|
31 (7.6)
|
[Table 4] shows the patients' attitudes toward the effects of the COVID-19 situation on oral
health problems. Most of the participants (59.9%) agreed that the COVID-19 situation
affected their oral health problem(s). Among all participants, 89.5% stated that it
was getting difficult to receive dental treatment, 58.5% believed that their current
oral health problems were getting worse, and 59.0% believed that COVID-19 affected
the finance that they had prepared for their dental treatment. Nevertheless, only
13.8 and 34.9% of the participants agreed that the COVID-19 situation affected oral
health caring behavior and negatively affected their eating behavior, respectively.
Half of the participants (49.1%) paid more attention to their oral hygiene care and
oral disease prevention after the exacerbation of the COVID-19 situation. Similarly,
47.3% of the participants were not concerned about their mental health being affected
during the COVID-19 situation and 49.3% were not concerned about COVID-19 infection
while receiving dental treatment after the pandemic. Moreover, 96.1% were willing
to receive dental treatment after the pandemic. The participants decided whether or
not to receive dental treatment after the exacerbation of COVID-19 depending on the
dental health problem (93.1%), cost of dental treatment (76.5%), guidelines for preventing
the transmission of COVID-19 at the dental clinic (94.7%), getting vaccinations (dental
personnel 94.6% and the patient themselves 95.8%), and Antigen Test Kit (ATK) screening
test prior to dental treatment (78.8%). During the COVID-19 pandemic, 82.9% stated
that the situation affected their decisions to receive dental treatment. However,
some preventive measures also affected their decision; for example, opening and closing
times of dental clinics (63.3%), limiting the number of patients receiving dental
treatment per day (66.4%), screening process prior to the dental treatment (49.4%),
and additional service charges for screening and prevention of COVID-19 (49.4%).
Table 4
Patients' attitudes toward the effects of COVID-19 situation and health
|
Questions
|
Total
|
Strongly disagree (1)
|
Disagree (2)
|
Unsure (3)
|
Agree (4)
|
Strongly agree (5)
|
Favorable score (4, 5)
|
|
1. Do you agree that the spreading of coronavirus (COVID-19) situation affects your
oral health problem(s)?
|
409
|
14 (3.4)
|
55 (13.5)
|
95 (23.2)
|
191 (46.7)
|
54 (13.2)
|
245 (59.9)
|
|
2. Do you agree that the spreading of coronavirus (COVID-19) affects various factors
such as
|
|
2.1. Getting dental treatment is more difficult
|
408
|
9 (2.2)
|
17 (4.2)
|
17 (4.2)
|
223 (54.7)
|
142 (34.8)
|
365 (89.5)
|
|
2.2. As a result, existing oral health problems are getting worse
|
405
|
8 (2.0)
|
66 (16.3)
|
94 (23.2)
|
181 (44.7)
|
56 (13.8)
|
237 (58.5)
|
|
2.3. Affects the money prepared for dental treatment
|
407
|
9 (2.2)
|
81 (19.9)
|
77 (18.9)
|
185 (45.5)
|
55 (13.5)
|
240 (59.0)
|
|
2.4 Affects oral health care behavior such as reduced frequency of tooth brushing
|
407
|
68 (16.7)
|
224 (55.0)
|
59 (14.5)
|
43 (10.6)
|
13 (3.2)
|
56 (13.8)
|
|
2.5 Negatively affects eating behavior such as increased frequency of eating or eating
sweet foods more often
|
401
|
33 (8.2)
|
143 (35.7)
|
85 (21.2)
|
118 (29.4)
|
22 (5.5)
|
140 (34.9)
|
|
Questions
|
Total
|
Not pay attention (1)
|
Pay less attention (2)
|
Unchanged (3)
|
Pay more attention (4)
|
Pay very much attention (5)
|
Favorable score (4, 5)
|
|
3. After the spreading of coronavirus (COVID-19) situation, how much will you pay
attention to oral hygiene care and oral disease prevention?
|
409
|
2 (0.5)
|
8 (2.0)
|
198 (48.4)
|
151 (36.9)
|
50 (12.2)
|
201 (49.1)
|
|
Questions
|
Total
|
Strongly concerned (1)
|
Concerned (2)
|
Unsure (3)
|
Less likely concerned (4)
|
Not concerned (5)
|
Favorable score (4, 5)
|
|
4. During the spreading of coronavirus (COVID-19) in Thailand in August 2021, how
much did you concern about your mental/emotional health condition being affected by
the situation of COVID-19?
|
408
|
43 (10.5)
|
138 (33.8)
|
34 (8.3)
|
137 (33.6)
|
56 (13.7)
|
193 (47.3)
|
|
5. Will you be concerned about your safety while receiving dental treatment after
the spreading of coronavirus (COVID-19) situation?
|
407
|
23 (5.7)
|
138 (33.9)
|
45 (11.1)
|
176 (43.2)
|
25 (6.1)
|
201 (49.3)
|
|
Questions
|
Total
|
Will not receive any treatment (1)
|
Will not receive most of the treatment (2)
|
Unsure (3)
|
Will receive most of the treatment (4)
|
Will receive all treatment (5)
|
Favorable score (4, 5)
|
|
6. After the spreading ofthe coronavirus (COVID-19) situation, will you still be receiving
dental treatment normally?
|
409
|
1 (0.2)
|
3 (0.7)
|
12 (2.9)
|
197 (48.2)
|
196 (47.9)
|
393 (96.1)
|
|
Questions
|
Total
|
Not very important (1)
|
Not important (2)
|
Unsure
(3)
|
Important
(4)
|
Very important (5)
|
Favorable score (4, 5)
|
|
7. How do the following factors play an important role in your decision-making for
receiving dental treatment after the spreading of the coronavirus (COVID-19) situation?
|
|
7.1 Your oral health problem(s) such as toothache
|
408
|
4 (1.0)
|
2 (0.5)
|
22 (5.4)
|
227 (55.6)
|
153 (37.5)
|
380 (93.1)
|
|
7.2 Cost of dental treatment
|
408
|
7 (1.7)
|
50 (12.3)
|
39 (9.6)
|
219 (53.7)
|
93 (22.8)
|
312 (76.5)
|
|
7.3 Guidelines for preventing the transmission of coronavirus (COVID-19)
|
397
|
2 (0.5)
|
3 (0.8)
|
16 (4.0)
|
171 (43.1)
|
205 (51.6)
|
376 (94.7)
|
|
7.4 Dental personnel getting vaccinations
|
405
|
3 (0.7)
|
5 (1.2)
|
14 (3.5)
|
143 (35.3)
|
240 (59.3)
|
383 (94.6)
|
|
7.5 Yourself getting vaccinations
|
407
|
1 (0.3)
|
4 (1.0)
|
12 (3.0)
|
128 (31.5)
|
262 (64.4)
|
390 (95.8)
|
|
7.6 Screening test to confirm non-COVID-19 infection by ATK in dental patients before
treatment
|
406
|
6 (1.5)
|
17 (4.2)
|
63 (15.5)
|
193 (47.5)
|
127 (31.3)
|
320 (78.8)
|
|
8. How do the following preventive measures in dental clinic affect your decision-making
for receiving dental treatment during the spreading ofthe COVID-19 situation?
|
|
8.1 Opening and closing times of dental clinic
|
409
|
36 (8.8)
|
79 (19.3)
|
35 (8.6)
|
185 (45.2)
|
74 (18.1)
|
150 (36.7)
|
|
8.2 Limit the number of patients receiving dental treatment per day
|
408
|
20 (4.9)
|
64 (15.7)
|
53 (13.0)
|
195 (47.8)
|
76 (18.6)
|
271 (66.4)
|
|
8.3 COVID-19 screening process in patients before receiving dental treatment
|
409
|
49 (12.0)
|
113 (27.6)
|
45 (11.0)
|
142 (34.7)
|
60 (14.7)
|
202 (49.4)
|
|
8.4 Additional service charges for screening and prevention of COVID-19
|
409
|
35 (8.6)
|
97 (23.7)
|
75 (18.3)
|
145 (35.5)
|
57 (13.9)
|
202 (49.4)
|
|
Questions
|
Total
|
Not affect (1)
|
Less likely affect (2)
|
Unsure (3)
|
More likely affect (4)
|
Affect very much (5)
|
Favorable score (4, 5)
|
|
9. Do you think that the spreading ofthe COVID-19 situation affects your choice in
making decision to receive dental treatment?
|
409
|
5 (1.2)
|
43 (10.5)
|
22 (5.4)
|
233 (57.0)
|
106 (25.9)
|
339 (82.9)
|
Discussion
We found in this study that female participants believed that the COVID-19 situation
impacted their oral health more than the males, regardless of other demographic aspects.
Most of the participants believed that the COVID-19 situation affected their oral
health and dental treatment. However, only a few stated that the situation affected
their oral health care behavior and their eating behavior. Tooth brushing and sugary
snack and/or beverage consumption behaviors of most participants remained unchanged
across the pandemic situation. The participants were mostly not concerned about safety
while receiving dental treatment during the pandemic, but thought that the pandemic
affected their decision to receive a dental treatment. Comparing with the time before
the pandemic, patients visiting a dentist because of halitosis and gum bleeding significantly
increased during the pandemic.
Among all demographic data collected from respondents, only gender demonstrated a
statistically significant difference among participants who believed and did not believe
that the COVID-19 situation impacted their oral health. The number of female participants
who agreed that COVID-19 situation impacted their oral health was higher than that
of male participants regardless of other demographic characteristics. It might be
due to a considerable perception toward risk and emotional care exhibited by female
partcipants.[15] Moreover, based on the gender trait in coping stress, female participants demonstrated
more emotional dependency and suffered more stress than males.[16] Besides gender, our results revealed no significant correlation between the participants'
attitudes and other demographic characteristics including age, education, and socioeconomic
factors during the COVID-19 pandemic.
The impact of the COVID-19 situation on oral health could be seen from the complaints
in [Table 2]. Gum bleeding and halitosis increased significantly during the pandemic. They are
closely associated with the state of oral cleanliness as poor hygiene could cause
both complications.[17]
[18]
[19] Thus, the increased prevalence of these conditions could be explained by inadequate
oral hygiene due to lack of professional health promotion and prevention.[9] Mask wearing as a new common manner during the COVID situation could also explain
the rise in halitosis.[20] Compliance to maintain oral hygiene of patients will decline without persistent
motivation and education, which is obviously hindered by the pandemic.[21]
Stress is a subjective state depending on displeasure and high arousal.[22] Since stress levels can be observed via sleep quality and sugar consumption,[22]
[23]
[24] unchanged sleep and sugary diet behaviors in our results suggest stable stress level.
While TMD causes are inconclusive and involve many physical and psychological factors,
it is generally accepted that the initiation, prolongation, and even exacerbation
of TMD are associated with stress and depend on the psychological state of a person.[25]
[26]
[27]
[28]
[29] The decreasing number of participants who have TMD problems during the pandemic
in our study is in accordance with the implied unchanged stress level. Di Giacomo
et al reported a similar finding in their study in Italy. They found that the participants
diagnosed with TMD showed low to moderate stress level during the COVID-19 pandemic.[30]
Facial aesthetics is important to many individuals and the mouth alone accounts for
31% of all facial aesthetics.[31] In case of Thai citizens, teeth alignment is an extremely prominent factor in facial
aesthetics.[32]
[33] Before the pandemic, aesthetics was one of the most common complaints in both fixed
and removable prostheses.[34]
[35] However, participants with prostheses reported fewer removable and fixed prosthetic
complaints during the pandemic. This is probably due to a decrease in importance of
dental aesthetics during the pandemic where lockdown and mask-wearing regulations
were implemented.
The participants in our study believed that the COVID-19 situation did affect their
oral health (59.9%) and made access to dental services (89.5%) more difficulty. This
might be explained by the impact COVID-19 had on the living conditions and access
to health care services, which was interrupted by several government policies and
actions since the beginning of the pandemic.[36] As access to health care services was prohibited and people's capability to afford
health care services depleted, it is possible that the participants could not maintain
their oral health during the pandemic.
We also found that participants were willing to receive dental treatment after the
pandemic (96.1%), which is similar to the findings of Cotrin et al.[37] The decision of the patients might be influenced by several factors. More than 90%
of the participants stated that vaccination and COVID prevention guidelines at the
clinic were the most relevant factors that influenced their decision to receive dental
treatment after the COVID-19 situation. At that time, almost every participant received
at least two vaccinations during the interview and dental professionals were already
given at least three doses of vaccination. The result is consistent with that of Nardi
et al,[38] who pointed out that patients were comfortable to visit the dental clinic that had
the COVID-19 prevention protocols in place.
The limitation of this study is that the participants were only limited to those who
visited the dental clinic at the Faculty of Dentistry, Mahidol University. Most of
them had a high level of education, stable occupations, and medical expense coverage.
Thus, this population is not a good representation of the entire population in Thailand.
Nevertheless, the results are still useful for dentists and related personnel in preparing
for a similar pandemic situation in the future.
This study can be used as a future pandemic reference. As a result of poor hygiene
during pandemics, common issues such as halitosis and gum bleeding highlight the need
for intensified preventive dental education prior to and during pandemics. Our findings
stress the role of preventive measures. This insight can guide clinic resumption plans
based on staff vaccination and guideline adherence. During the pandemic, guidelines
or protocols of visiting a dental clinic and vaccination should be clear and updated
frequently so that the patients feel comfortable and safe to visit the clinic. Online
platforms can be used to advocate this through podcasts, streaming, teledentistry,
etc. Dental care during the pandemic should be prioritized potentially based on an
online survey for severity of the case. Urgent cases involving infection can then
be addressed by well-prepared practitioners in an isolated setting, while nonurgent
cases might be postponed. In summary, this study extends to future pandemic readiness,
emphasizing dental education, preventive measures, and effective management of urgent
cases.
Conclusion
We found in this study that complaints of gum bleeding and halitosis significantly
increased during the COVID-19 pandemic in August 2021 in Thailand. On the other hand,
patients with TMD and prosthetic problems statistically declined. Finally, most of
the participants thought that the COVID-19 situation affected their dental health.
They complained that the pandemic made access to dental care services more difficult
and they were willing to visit the dental clinic after the COVID-19 situation.
