Assessment of oral health problems, dietary, and lifestyle changes among pediatric dental patients during the COVID 19 pandemic – A cross sectional pilot study

Padma Yangdol; Namita Kalra; Rishi Tyagi; Amit Khatri; Drishti Kaushal; Puja Sabherwal

doi:10.4103/sjoralsci.sjoralsci_1_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 2 | Page : 99-114

Assessment of oral health problems, dietary, and lifestyle changes among pediatric dental patients during the COVID 19 pandemic – A cross sectional pilot study

Padma Yangdol, Namita Kalra, Rishi Tyagi, Amit Khatri, Drishti Kaushal, Puja Sabherwal
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital (University of Delhi), New Delhi, India

Date of Submission	17-Jan-2022
Date of Decision	04-Apr-2022
Date of Acceptance	29-Apr-2022
Date of Web Publication	31-Aug-2022

Correspondence Address:
Prof. Namita Kalra
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi - 110 095
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjoralsci.sjoralsci_1_22

Abstract

Introduction: The COVID-19 pandemic has affected the routine lives of people worldwide because of lockdowns/restrictions. Children have been largely confined to home due to the suspension of schools, which may lead to potential behavioral changes. Routine dental services have been nonfunctional, and oral health problems have been frequently neglected.
Aims: The present study aimed to assess oral health problems, dietary, and lifestyle changes among pediatric dental patients during the COVID-19 pandemic.
Materials and Methods: This is a cross-sectional study that employed a structured 38-item questionnaire through teledentistry to 121 children who previously visited the dental department of a tertiary hospital in Delhi. The Dental Problems and Treatment Needs (DPTN-COVID-19) Questionnaire and Dietary Habits Lifestyle Changes (DHLC-COVID19) Questionnaire, customized and validated for the study, were administered for the assessment of oral needs of children and how they were managed during the pandemic. We also evaluated their dietary/lifestyle changes.
Results and Discussion: Participants were interviewed telephonically; as a general trend, oral health was observed to be significantly affected among children. A majority of the children (83.47%) suffered from toothache, 34.71% had tooth-related swelling, and 18.1% experienced dental trauma. More than half of the parents of the participants (54.5%) preferred the management of dental problems with self-medication. Oral hygiene of the children was affected primarily due to decreased brushing frequency during the COVID-19 pandemic (43.8%). A considerable proportion of parents (44.6%) believed that the COVID-19 infection could spread by dental treatment and perceived the dental environment to be more dangerous than other places. A significant number of parents (59.5%) observed the changes in their children's dietary habits, with a drastic reduction in the consumption of high-carbohydrate snacks in children during the COVID-19 pandemic. Many parents (67.8%) observed a change in their children's hunger and satiety levels during the COVID-19 lockdown, with decreased appetite in 38.8% of the children. Moreover, a significant increase in screen time and changes in sleeping patterns was also observed during the pandemic. Multivariate logistic regression analysis was found to be significant predictors for brushing frequency, carbohydrates intake, and lifestyle changes before and during COVID-19. It was a good fit as analyzed on Pearson goodness-of-fit Chi-square test. The likelihood ratio of during COVID-19 model was statistically significant. The model was able to explain variance in the outcome measure before and during COVID-19, respectively, as analyzed on Nagelkerke pseudo R².
Conclusion: In the present pandemic situation, amid the burden of increased biological and financial needs, oral health needs of children may have been neglected. This has been accompanied by associated dietary and lifestyle changes, leading to a vicious cycle demonstrating a need for appropriate strategies to address the issue.

Keywords: COVID-19, dietary habits, lifestyle, oral health, pediatric dentistry

How to cite this article:
Yangdol P, Kalra N, Tyagi R, Khatri A, Kaushal D, Sabherwal P. Assessment of oral health problems, dietary, and lifestyle changes among pediatric dental patients during the COVID 19 pandemic – A cross sectional pilot study. Saudi J Oral Sci 2022;9:99-114

How to cite this URL:
Yangdol P, Kalra N, Tyagi R, Khatri A, Kaushal D, Sabherwal P. Assessment of oral health problems, dietary, and lifestyle changes among pediatric dental patients during the COVID 19 pandemic – A cross sectional pilot study. Saudi J Oral Sci [serial online] 2022 [cited 2023 Apr 2];9:99-114. Available from: https://www.saudijos.org/text.asp?2022/9/2/99/355219

Introduction

In December 2019, a novel coronavirus, popularly known as COVID-19, first emerged in Wuhan, Hubei Province, China. The WHO officially designated COVID-19 as a global pandemic on March 11, 2020, and declared it a causal factor for a variety of potentially fatal consequences despite the health conditions of patients and attributed to its rapid spread.^[1],[2] Approximately 318,648,834 confirmed infections of COVID-19 and 5,518,343 deaths have been recorded as of January 14, 2022, according to the WHO statistics.^[3] India has by far seen a high number of cases and deaths and is the second-worst COVID-19-affected country globally.^[4]

COVID-19 may be transmitted through direct/indirect contact with infected individuals or their contacted surfaces through respiratory droplets released while coughing, sneezing, talking, or expiration.^[5],[6] Presentations of COVID-19 in children tend to be relatively asymptomatic or milder with lesser severity, an equal or greater risk of infection, and a better prognosis than in adults.^[7],[8] Children may play a crucial role in community transmission and have a greater potential for cross-infectivity when presenting to a dentist or a pediatric dentist for the dental treatment.^[9] Considering its high transmissibility potential, dental professionals are at a high risk of infectivity since they deal with the intraoral region, leading to direct contact through saliva- and aerosol-generating procedures. This poses a serious challenge to oral health-care systems.^[10],[11]

India faced a major challenge with COVID-19 during the second wave, which affected older people as well as made a noticeable impact on younger individuals.^[12] It was noted that the virus in the second wave was more transmissible, had a shorter incubation period, and had higher infectivity compared to the first wave. A range of new gastrointestinal symptoms was added to the already existing symptoms, and the severity of hypoxia episodes led to an increased requirement for oxygen and mechanical ventilators.^[12] With an unmet demand for oxygen due to the rapid surge in COVID-19 infections, there was an unprecedented loss of lives, which left many families scarred for life. The emergence of the third wave of the COVID-19 pandemic, which is largely driven by the new variant “omicron” with a higher infectivity and transmission rate, has compounded a rapid surge in COVID-19 infections worldwide.^[13]

To control the rampant spread of COVID-19 infections, many governments had to prioritize regulatory restrictions and lockdowns, leading to a huge economic crisis with an unprecedented job loss that shifted the prioritization toward necessities.^[14] Moreover, restrictions in dental services led to dental neglect and reduced access to necessary dental care.^[15] Furthermore, with the restricted availability of dental services, the degree of dental challenges faced by families and their children during the two peak phases of the COVID-19 pandemic is less known.

Therefore, the objective of the present pilot study was to assess the impact of the COVID-19 pandemic on pediatric oral health and problems (if any) and methods adopted by parents to resolve their children's dental concerns. Furthermore, changes in children's dietary and lifestyle behaviors were observed by parental response through teledentistry. Parents' perception of the oral health of their children was also evaluated.

Materials and Methods

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Committee of the University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India (IEC-HR-2020/PG/46/80-R1). Informed consent was obtained from parents/guardians, which included telephonic consent on a preapproved pro forma (recording through telephonic conversations) taken from one parent of each child. Verbal assent was obtained for children aged 7–12 years. For children aged 12–14 years, an assent form was used to take assent on the phone and a telephonic recording was made. The local language, i.e., Hindi, was used for informed consent as well as pediatric verbal assent. Teledentistry was employed to interview parents. The purpose and the nature of the study were explained, and patient confidentiality was maintained. All necessary telephonic recordings were also preserved.

Questionnaire design and data collection

A cross-sectional observational pilot study through a telephonic interview questionnaire (tele-questionnaire) during April and May 2021 in accordance with the STROBE guidelines was conducted. Phone numbers of the previously registered pediatric patients were obtained from the Department of Pedodontics and Preventive Dentistry. A total of 121 participant responses were collected.

The tele-questionnaire [Annexure 1] consisted of 38 items structured into two sections. In the first section, demographic details such as age and gender of the child, parent's age, gender, socioeconomic status with the level of education according to the Modified Kuppuswamy Scale 2020, and family's financial status before and during the COVID-19 pandemic were collected. Children's dental problems, dental trauma, and the management of such problems during the COVID-19 pandemic were recorded and analyzed using the DPTN-COVID-19 (Dental Problems and Treatment Needs) Questionnaire. Questions regarding their parents' oral health perceptions and their knowledge of the COVID-19 pandemic were also asked, which were either dichotomous (yes/no) or multiple-choice questions.

The second part of the questionnaire analyzed the immediate impact of the COVID-19 pandemic on dietary habits and lifestyle changes among the participating children through the DHLC-COVID19 (Dietary Habits Lifestyle Changes) Questionnaire. The questionnaire focused on (a) changes in the child's eating habits, (b) daily consumption of certain foods according to the Indian diet such as fruits, vegetables, roti, rice, pulses, milk, nuts, eggs, chicken, meat sweets, and dairy products, using dichotomous yes/no options or response options of “increased intake,” “decreased intake,” “same as before,” or “do not consume,” (c) snacking frequency and snacking between meals before and during the COVID-19 pandemic, and (d) information on lifestyle habits, such as the child's hunger and satiety during the COVID-19 pandemic, changes in the weight of the child, physical activity, screen time, playing, and hours of sleep.

Interview

The primary investigator called the participants one by one over the telephone and conducted a telephonic interview. Before administering the questionnaire, a preapproved introduction, written and approved in the vernacular language, i.e., Hindi, was narrated to each participant. This included the details of the purpose and nature of the interview process. The participants' willingness to participate was assessed, and the informed consent and assent were recorded telephonically.

Each participant was interviewed for 15–20 min, and 4–5 patients could be interviewed in a session lasting approximately 3 h. A few participants did not respond to the phone calls. These participants were given a second phone call at a later time. There were also a few respondents who wanted to reschedule the time of the interview, and they were interviewed at the time they provided. This was done to maximize the rate of responses. Twenty-nine participants did not respond, including those who did not pick up both the phone calls,^[15] those who were not willing to participate in the study,^[9] and those who were unavailable at the available contact numbers.^[5] During the tele-questionnaire interview, most of the parents understood the questions and were able to respond. Some of the parents did not understand some questions, and for them, an effort was made to make them understand easily by repeating the questions two to three times with further explanation. If, due to some reason, communication still failed, then the child was excluded from the study. After excluding the nonrespondents, poor respondents, and those who did not give consent, the interview process was repeated with the remaining participants in a proper manner.

Validity and reliability of the questionnaire

A customized tele-questionnaire was developed by the primary investigator after reviewing the available related literature, and the questionnaire was face-validated by experts in the particular field. The questionnaire's face validity was checked by distributing it to 25 parents of the children who had visited the department, who were given certain revisions, and the time they took to complete the questionnaire was measured. The updated questionnaire was then sent to the expert panel, which was made up of academic members from the department, to examine the content validity. Common mistakes, such as confusing, misleading, or double-barreled questions, were discovered and corrected. Five questions were eliminated because their Aiken's index was <0.7. Internal consistency (Cronbach's alpha, which addressed the reliability and validity of the questionnaire data) was also assessed and was found to be 0.6 for the DPTN-COVID-19 Questionnaire and 0.65 for the DHLC-COVID19 Questionnaire. The final version was then pilot-tested among 121 participants.

Statistical analysis

Data were entered on an Excel sheet and analyzed using the SPSS software, version 25.0, IBM Corp. Chicago, USA. The continuous parametric data were reported as mean and standard deviation, whereas continuous nonparametric data were reported as median and interquartile range. The categorical data were reported in percentages. The comparison of categorical data between the groups was done using the Chi-square test. A multivariate multinomial logistic regression model was constructed to analyze the significant covariates for oral health, dietary habits, and lifestyle changes during the COVID-19 pandemic.

Results

Internal consistency of each questionnaire was assessed by calculating the Cronbach's alpha, which was 0.6 for the DPTN-COVID-19 questionnaire and 0.65 for the DHLC-COVID-19 questionnaire. The sociodemographic characteristics of the study participants are presented in [Table 1]. A total of 121 participants took part in this cross-sectional pilot study. The majority of the participants were boys, with a mean age of 9.42 ± 2.60; the mean age of girl participants was 8.46 ± 2.73. Among parents, the majority of the respondents were mothers, with an average age of 38.45 ± 5.43. A total of 44 mothers did not receive any formal education. Socioeconomic trend assessment showed that 55.37% of the families who participated in this study belonged to the upper-lower category in the Modified Kuppuswamy Scale. A major change in income was reported by the families during the COVID-19 pandemic, with 42.97% reporting a drastic reduction in income, 38.84% reporting a total loss of income, and 14.8% reporting a slight reduction, with only 3.3% reporting no impact on income. During the study, family members of 79 participants contracted COVID-19 infection, 40 of whom got hospitalized and 12 lost their lives.

Table 1: Demographic characteristics

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The oral health status of the children during the COVID-19 pandemic is presented in [Table 2] and illustrated in [Figure 1]. Using the DPTN-COVID-19 Questionnaire, it was observed that 83.47% of the children suffered from pain/toothache, followed by swelling (34.71%). The contributing factor for toothache and swelling exacerbation in these children was found to be a cumulative effect of various factors such as carious teeth (28.10%), incomplete treatment (25.62%), dislodged restoration (22.31%), abscess (14.05%), and discoloration (6.61%). On the other hand, only 18.1% of the parents declared that their children experienced dental trauma during the COVID-19 pandemic, which is lower than other dental problems reported in children during this pandemic.

Figure 1: Graphical representation of dental problems experienced by children during the COVID-19 pandemic

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Table 2: Description of dental problems experienced by children and management adopted by parents during COVID-19 using self-prepared questionnaire dental problems and treatment needs (COVID-19) questionnaire

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During the assessment of the methods adopted by parents to manage their children's dental problems during the lockdown, it was observed that most of the parents (54.5%) managed dental problems at their home, 14% did not opt for any intervention, and 13.2% and 12.4% obtained formal consultation from dental and medical professionals, respectively. Very few went to a government hospital for treatment and consultation (4.1%) and 1.65% to nondegree dentist doctor. Home management of dental problems of the children through self-medication using previous prescriptions was preferred as the treatment option by 41.32% of parents. A few parents (33.06%) followed saltwater rinsing in their child's oral hygiene routine, while some others (23.93%) used clove as a pain-relieving home remedy. Using garlic and using other methods were also employed. The oral hygiene of the children was affected due to the decrease in brushing frequency during the COVID-19 pandemic (43.8%), which is a major decline compared with that before the pandemic (61.2%). The number of children practicing occasional/irregular brushing before the COVID-19 pandemic (4.1%) increased to 24.8% during the pandemic. Furthermore, the number of children who did not brush increased compared with the pre-COVID-19 times (from 0.8% to 5%). The multivariate logistic regression model was applied to identify significant covariates for oral health change in the frequency of brushing teeth before and during COVID-19. It was observed that, none of the covariates were the significant predictors of brushing habit before COVID-19. However, sex of the child was a significant covariate for brushing habit during COVID-19. Both models had a good fit as analyzed on Pearson goodness-of-fit Chi-square test. The likelihood ratio of during the COVID-19 model was statistically significant. The model was able to explain 41.6% and 47.4% variance in the outcome measure before and during COVID-19, respectively, as analyzed on Nagelkerke pseudo R² [Table 3].

Table 3: Multivariate logistic regression model in identifying covariates of brushing habit of the child (oral health) before and during COVID-19 (n=121)

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Regarding the knowledge and attitude of parents toward the COVID-19 pandemic, 44.6% of the parents believed that dental treatment could lead to COVID-19 infection in their children. When they were asked about the potential source of infection during dental treatment, 83.5% believed that they can contract the virus through other patients in the clinic area, 70.2% reported that droplets during the dental procedure could be contributory, and 51.2% reported transmission through dental instruments. Furthermore, 23.1% of the parents agreed that their children can contract COVID-19 infection through health-care professionals. They had a negative perception that the risk of spread of COVID-19 infection in dental hospital environments was higher than in other public places (76.9%). Approximately 60.3% of the parents were willing to take their children to the dental department during the COVID-19 pandemic, and 78.5% also expressed confidence in getting treatment after using protective measures for disinfection.

Changes in dietary and lifestyle behaviors during the COVID-19 lockdown were inquired through the DHLC-COVID-19 questionnaire. Most of the parents (59.5%) observed a change in their child's eating habits. The pilot study also investigated the variation in food intake during the COVID-19 pandemic, which showed an increased intake of a healthy diet (fruits, vegetables, and milk) and decreased intake of chicken, eggs, meat, and sweets [Figure 2]. The percentage of children not consuming high-carbohydrate snacks (biscuits, chips, chocolates, etc.) increased to 65.3% during the COVID-19 pandemic when compared with 4.1% before the pandemic. The multivariate logistic regression model to identify significant covariates for dietary habit – change in carbohydrate intake before and during COVID-19 and it was depicted that occupation, income, and loss of job of a parent were the significant predictors of carbohydrate intake before COVID-19. However, occupation, education, and loss of job of a parent were not significant covariates during the COVID-19. Both models had a good fit as analyzed on Pearson goodness-of-fit Chi-square test. The likelihood ratio of both models was statistically significant. The model was able to explain 38.1% and 39.5% variance in the outcome measure before and during COVID, respectively, as analyzed on Nagelkerke pseudo R² [Table 4]. Many parents (67.7%) observed a change in their child's hunger and satiety levels during the COVID-19 lockdown, with a decreased appetite in 38.8% of the children. Weight assessment through parents' perceptions depicted that 38% of the parents did not know their child's weight, 24.8% observed an increase in their child's weight, 19% reported weight loss, and 18.2% reported no change in weight. Altogether an increase in screen time (72.7%) was observed as part of the children's daily activities, and a shift in sleeping patterns was seen during the ongoing COVID-19 pandemic phase (from 7 to 9 h during the pre-COVID-19 times to 9 h during the pandemic. The significant covariates for lifestyle habit – number of sleeping hours, how the child spends the whole day (studying, electronic media, sleeping, or playing) before and during COVID-19, were assessed using the multivariate logistic regression analysis. It was observed that, none of the covariates were the significant predictors before and during COVID-19. Both models had a good fit as analyzed on Pearson goodness-of-fit Chi-square test. The likelihood ratio of before COVID-19 model was statistically significant. The model was able to explain the variance in the outcome measure before and during COVID-19, respectively, as analyzed on Nagelkerke pseudo R². These details are presented in [Table 5].

Figure 2: Graphical representation of variation in food intake in children during COVID-19 pandemic

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Table 4: Multivariate logistic regression model in identifying covariates of carbohydrate intake (dietary habit) before and during COVID-19 (n=121)

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Table 5: Multivariate logistic regression model in identifying covariates of how the child passes time in COVID-19 (lifestyle habit) pre and post COVID-19 (n=121)

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Discussion

This cross-sectional pilot study provides an overview of oral health status, dietary changes, and lifestyle patterns among children based on parental oral health perceptions during the COVID-19 pandemic through teledentistry. Across the globe, the COVID-19 pandemic has had a huge impact on the general family well-being and financial conditions.^{[5],[16],[17]} India has been severely affected by the second wave of the COVID-19 pandemic, which completely shook the nation's foundations with the high rates of infectivity and mortality among both younger and older segments of the population.^[12]

The majority of the parents who participated in this study lost their job during the pandemic, 42.97% reported a drastic decline in their income, and 38.84% reported a total loss of income. Using the DPTN-COVID-19 questionnaire, a self-prepared and customized questionnaire, it was found that a considerable number of children were found to be experiencing pain or toothache (83.47%), followed by swelling (34.71%). These patterns were similar to those of a study conducted by Burgette et al. (2021) which found that dental care was the most unmet health-care area, and this situation got aggravated during the pandemic due to the financial crisis.^[14] In corroboration with these findings, Li et al. reported that in Wuhan, China, 44.2% of school-age children suffered pain/discomfort related to teeth during the pandemic.^[10] In our study, only 18.1% of children reported traumatic dental injuries (TDIs) during this pandemic. Similarly, Woolley and Djemal also found a 50% reduction in TDIs presenting in 2020 during the COVID-19 pandemic compared to 2019.^[18] This may be attributed to the huge burden on oral health-care needs.

Most parents preferred to manage their child's dental problems at their home itself (55.4%). A substantial percentage of parents preferred self-medication (41.3%). A recent study by Sen Tunc et al. has also reported a high preference (70.2%) for self-medication in children with dental problems in Northern turkey during the COVID-19 pandemic.^[19] In our study, some parents also preferred the management of dental problems using saltwater rinses and cloves as a home remedy for relieving pain. Very few parents obtained doctors' consultation for their child's dental treatment needs due to the fear of contracting COVID-19, which is substantiated by other studies as well.^[5],[20]

The oral hygiene practices of children were affected during the COVID-19 pandemic, with a decrease in the frequency of brushing among children. The brushing frequency decreased from 61.2% to 43.8% on a “once-daily” basis during the COVID-19 pandemic. The “occasionally brushing” category increased from 4.1% (before the COVID-19 pandemic) to 24.8% (during the pandemic). A growing tendency to avoid brushing has been observed in their brushing regimen. These results could be used as a reference to indicate the deteriorating oral hygiene behavior during the COVID-19 pandemic. This may be related to the fact that parents might be paying less attention to oral health care as they are forced to prioritize the basic necessities, which may lead to dental neglect, or because of the inability to seek timely dental treatment. Educational background, socioeconomic status, and job loss during the COVID-19 pandemic may also influence oral health behaviors. This alteration in children's toothbrushing regime was explained by Baptista et al. as the lack of social interaction due to the suspension of schools, thus leading to poor oral hygiene during this pandemic.^[2] Contrary to this, Campagnaro et al. reported an 83.5% increase in children's toothbrushing during the pandemic.^[21]

Analysis of parental knowledge and attitudes toward oral health and dental services during the pandemic indicated that 44.6% believed that dental treatments could cause COVID-19 to their children. Our study has a trend similar to that of a Chinese study which reported that a very high percentage of parents believed that dental treatment could be responsible for exposing their children to COVID-19.^[22] In contrast, Surme et al. (2021) from Turkey observed that only 25.2% of parents believed that their children could be infected with COVID-19 during dental treatment.^[23] Moreover, it was also observed that 83.5% of parents believed that their children can contract COVID-19 through other patients in the clinical area, 70.2% reported fear of contracting COVID-19 through droplets during the dental procedure, while 51.2% reported a risk of contracting through dental instruments. Furthermore, 23.1% of parents reported that their children can contract COVID-19 through health-care professionals, which indicates a lack of trust due to fear and anxiety among parents toward safety and protection measures adopted in the dental unit of the hospital setup. Based on these findings, we conclude that there is a lack of awareness and education about oral health in the Indian population. This highlights the need for reassurance to parents about infection control and strengthening COVID-19 safety protocols in dental hospitals.

The present study also collected information on dietary and lifestyle behavioral changes in Indian children during the COVID-19 pandemic using the DHLC-COVID-19 questionnaire. Considering that the COVID-19 infection has no definitive pharmacological management, healthy and balanced nutrition is considered essential to boost the immune system and for prevention from various viral infections.^{[24],[25],[26]} The present study revealed the changes in eating habits in children, with a reduced intake of the number of daily meals on the daily basis. When analyzing the different types of foods, a higher intake of fruits, vegetables, and milk was observed. A decline in the consumption of chicken, meat, and eggs was also observed. An Italian study carried out by Di Renzo et al. on adults also revealed an immediate impact of the pandemic on food patterns and food consumption.^[24] They found a decrease in the consumption of sweets and snacks among children, namely biscuits, ice cream chips, and chocolates. These findings were likely due to limited food availability because of the closure of shops during the pandemic and the fear of contracting COVID-19 from the external food sources. On the contrary, studies on adults conducted in Italy, Kuwait, and Poland found an increase in the incidence of snacking frequency during the COVID-19 pandemic.^{[24],[25],[26],[27]} The present study also observed the changes in hunger and satiety levels, with a decrease in appetite among children. This is not consistent with studies conducted on adults, who experienced an increased appetite during the pandemic.^[24] There was a recorded reduction in physical activities among children, probably due to restrictions in movements and the closure of schools and playgrounds. Moreover, there was a change in sleeping patterns, and an increase in the number of dedicated sleep hours was also observed, probably due to the lack of physical activities. In addition, screen time increased among children, and the time dedicated to their studies decreased. These findings are consistent with the study conducted among Polish adults during the pandemic.^[28] Studies conducted in the USA and the UK among adults reported that a significant proportion of the population may not have had any detrimental impact on diet and lifestyle behaviors that have been speculated in our study.^[29]

The option of teledentistry has grown significantly as an alternative method during the COVID-19 pandemic as it seems to be a convenient, cost-effective, and long-distance communication approach. Other strengths of our study include detailed custom-made questionnaires and systematized statistical analysis of behavioral trends alongside suitable advice and referral to needy patients. The limitations to our study may include the lack of physical examinations or face-to-face interviews, which were not feasible during the pandemic. Telephonically contacting a sample of previously treated dental patients may lead to a biased hospital-representative sample and may decrease the generalizability of these findings. Future studies may include research in larger populations with a more systematic approach to ascertain a more comprehensive impact of the COVID-19 pandemic on oral health and dietary and lifestyle behaviors.

Conclusion

The present study reveals the compromised oral health and unattended dental treatment needs in children. The majority of the children suffered from pain or toothache (83.5%) followed by swelling (34.7%), while 18% of children suffered from TDIs. Nearly half of the parents preferred the management of dental problems at home using self-medication as they were unable to reach dentists during the lockdown period. In addition, 44.6% of the parents are concerned that dental treatment may lead to COVID-19 infection in their children. The vast majority of parents perceived that the dental clinic was far more dangerous than other public places. Moreover, dietary changes in the form of reduced need with variations in lifestyle behavior were also observed. Therefore, for pediatric dentists, there is a dire need to develop new strategies to help parents solve their child's oral health problems, with a particular focus on the promotion of oral health and dietary education services.

Acknowledgment

The authors would like to express their gratitude to the patient and parents who were consented to take the part in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Questionnaire

ANNEXURE I

TELE-QUESTIONNAIRE ON DENTAL IMPLICATIONS FACED BY CHILDREN DURING COVID-19 WITH KNOWLDEGE AND ATTITUDE ASSESSMENT ON PARENTS.

DEMOGRAPHIC DETAILS

Name of child- Name of parents-

Age of child- Gender of parents-

Gender of child- Age:

Address:

Contact no:

Any medical History:

SOCIOECONOMIC STATUS

INCOME - Not Impacted

................................Increased

................................Slightly reduced

................................Drastically reduced

................................Total Loss-

PARENT EDUCATION

MOTHER

illiterate

primary school
higher school
Graduate
Post graduate

Did anyone in your family member lose their job during COVID-19?

Did anyone in your family member get infected from COVID-19?

Did anyone in your family member get hospitalized due to COVID-19?

Did anyone in your family member lose their life from COVID-19?

Dental complaints (if any) experienced by your child in this pandemic period?

YES NO

Pain ☐ ☐

Swelling ☐ ☐

Broken tooth ☐ ☐

Any other specify ☐ ☐

Carious

Discoloration

Dislodged Restoration

Abscess

Incomplete Treatment

How did you manage the problem?

No management
At home
Qualified private doctor
Qualified private dentist
Government hospital
Non degree doctor/dentist/quackery

If yes to home management, what all home remedies you explore?

YES NO

Self-prescribed pain-relieving medicine ☐ ☐
Clove ☐ ☐
Garlic ☐ ☐
Salt water ☐ ☐
Any other specify ☐ ☐

Did your child have any dental trauma during COVID-19?

If yes, what type of injury occurred?

Knocked out tooth
Loosened or displaced tooth
Any other – specify

If yes, cause of dental trauma?

Fall while playing at home
Fall while playing outside
Road accident
Any other -specify

How did you manage

No management
At home
Qualified private doctor
Qualified private dentist
Government hospital
Non degree doctor/dentist/quackery

How many times does your child brush his/her teeth?

Do your use any other aid for your child for cleaning the teeth?

Do you take necessary precautions toward COVID-19?

Yes
No
Sometimes

How did you educate your child about COVID-19?

YES NO

Electronic media ☐ ☐
Verbally ☐ ☐
School online teaching ☐ ☐

Do you think the environment/surroundings of dental hospital is more dangerous to get COVID-19 than outer public places?

Yes
Similar
No

Do you think the dental treatment could cause your children to get infected by COVID-19?

Yes
Similar
No

How do you think your children can get infected by COVID-19 during dental treatment?

YES 1 NO 0

Droplets ☐ ☐
Blood ☐ ☐
Dental instruments ☐ ☐
Pediatric dentist ☐ ☐
Other patients ☐ ☐

If your children had toothache would you take him/her to the dental department during COVID -19?

Dental sector has taken various protective measures including patient screening, environment disinfection with provision of personal protective equipment for both dentist and patients. Will these measures give you confidence for your children to get their dental treatment?

REGARDING IMMEDIATE IMPACT OF COVID-19 ON DIETARY HABITS AND LIFESTYLE CHANGES AMONG CHILDREN (DHLC-COVID-19 QUESTIONNAIRE) QUESTIONNAIRE

DIETARY HABITS

During the COVID-19 lockdown, do you think there is a change in your child's eating habit?

Which of these foods does your child usually consume? (Please check all that apply) YES NO

Which of these foods did your child consume?

INCREASED INTAKE DECREASED INTAKE SAME AS BEFORE DO NOT CONSUME

Fruits

Vegetables
Bread/Roti
Rice
Pulses
Milk

INCREASED INTAKE DECREASED INTAKE SAME AS BEFORE DONOT CONSUME
nuts: badam, kaju
eggs
Chicken
meat
Sweets
Dairy products

What type of food do your children consume during COVID-19?

Homemade food
Street food
Both

What is the snacking frequency of your children during this period?

Lower
Higher
Same as before

How many servings of biscuits, chips, ice cream, and chocolates do your child eat?

What all immunity booster foods have you administered your child during this time?

YES NO

Fruits ☐ ☐

Vegetables☐ ☐

Eggs☐ ☐

Vitamins☐ ☐

Amla juice☐ ☐

Kadha☐ ☐

Any other specify☐ ☐

Haldi milk

Green tea

Tea

Warm water

Chawanprash

Did you observe any change in the number of daily meals in your children during this period?

Do you think, there is a change in your child's hunger and satiety during this period at home for COVID-19 lockdown?

Increase in appetite
Decrease in appetite

Did your child gain weight during COVID-19?

No, weight is stable
No, I think my child lose weight
Yes. I think my child gain weight
I don't know

Does your child perform/engage into any physical activity during this period?

As schools are closed what does your child do whole day during COVID-19?

MORE LESS SAME AS BEFORE NONE

Studying
electronic media
playing (Indoor/outdoor)
Sleeping

If more, for what purposes your child uses electronic media?

YES NO

Online classes
Social media
Gaming
Educational purposes
Television

How many hours did you child sleep before COVID-19?

< 7/hours at night
7-9/hours at night
> 9hours at night

How many hours do you child sleep during COVID-19?

< 7/hours at night
7-9/hours at night
> 9hours at night

Abbreviations:

Age (P) & sex (P) – Parents age & sex

SS (0), E, I- Socioeconomic Status (0 – occupation, E – education, I – Income

Q3M- M – Mother

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