Oral and dental health comorbidity in COVID-19 era: social aspects and impacts on community dentistry in Saudi Arabia

INTRODUCTION

Coronavirus infectious disease 2019 (COVID-19) is a viral pneumonia first recognized in Wuhan city, China on 17 November 2019.¹ The causative agent of COVID-19 is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), one of several coronaviruses discovered.²

The World Health Organization (WHO), on 30 January 2020, pronounced COVID-19 a public health emergency of global concern, and the disease soon and became a challenging problem for all countries worldwide.³ According to the WHO and centres for disease control and prevention (CDC), the virus is thought to spread primarily through person-to-person transmission between individuals in direct contact and through respiratory droplets (within about 6 feet); some recent studies have also suggested that COVID-19 may be spread by asymptomatic carriers.⁴ The most common signs and symptoms that appear in infected individuals are fever, sore throat and dry cough. The disease may either resolve spontaneously or progress to a fatal condition.³

The Kingdom of Saudi Arabia, initiating an early response, applied immediate protective measures to prevent COVID-19 transmission amongst its population even before the first case in the Kingdom, which was reported on 2 March 2020, occurred. The Saudi government suspended all air flights and personal events, closed workplaces (excluding police forces and hospitals) and encouraged residents to stay safely at home.⁵

The most vulnerable populations, as announced by the Saudi ministry of health, are the elderly, diabetics, and patients afflicted with obesity, hypertension, cardiac disease, chest and respiratory diseases, immunodeficiency, human immunodeficiency virus (HIV), cancer and kidney disease.⁶

Older adults and those who are medically compromised, in other words, are at greater risk than other persons of severe illness and mortality associated with SARS-CoV-2.⁷ Initial symptoms of immunodeficiency may be observed in the oral cavity, as it is a common site of bacterial infections.⁸ Numerous studies demonstrate the links between oral health and quality of life.^9,10 Oral diseases can affect dental functions and social interactions; for example, dental decay may cause impaired chewing, decreased appetite, sleep problems and poor performance at school or work.⁹

Gingivitis and periodontitis are the most common inflammatory diseases amongst adults and individuals with impaired immunity.¹⁰ Periodontal (gum) disease is also the most common cause of tooth loss among adults in the United States. According to the CDC, nearly half (46%) of adults aged 30 years and older have some form of periodontal disease.¹¹

Additionally, there has been a dramatic increase in the number of patients seeking treatment for dental pain in emergency rooms throughout the United States. According to the American dental association, there were more than two million visits to emergency rooms for dental problems in 2010.¹² This number will grow even larger if emergency rooms remain the only option for treatment or if patients’ levels of pain or infection are aggravated to the point of necessitating hospital admission.

Emergency room physicians treat pain and infection, but they do not perform restorative procedures or tooth extractions. As a result, the causes of patients’ visits are not treated, but another problem may arise, which is exposure to SARS-CoV-2.

Opening dental clinics to all patients is not a solution. Dental procedures involve the use of instruments that create droplets, which are the primary means through which SARS-CoV-2 is transmitted. Such droplets can land on nearby operatory surfaces or be ingested by dental-care team members, creating a high risk of cross-contamination. Accordingly, the deep concern of the American dental hygienists’ association for the health and well-being of the public, dental hygienists and the entire dental team has led it to strongly recommend that non-emergency and elective procedures be postponed while dental clinics remain open to patients with urgent needs.¹³ As has been noted, oral diseases are mostly preventable conditions.¹⁴

Providing oral-health instruction and promoting dental hygiene via different media channels is crucial because such instruction and promotion can be important contributors to limiting the needs of patients to leave their homes in order to seek treatment.¹⁵ Global healthcare accreditation (GHA) patients who remain at home instead of visiting dental clinics or emergency rooms will be less likely to contract COVID-19 or to transmit the virus to others. Moreover, pharmacies should provide home-prevention and interim-treatment solutions, such as dental mirrors, scalers and temporary fillings, that can be easily utilised by individuals in the convenience of their homes. In this study, we will discuss the knowledge of residents of Saudi Arabia -both healthy individuals and patients with systemic illnesses -concerning the availability of emergency dental procedures. We will also focus on residents’ behaviour towards their oral health during the COVID-19 outbreak in the Kingdom of Saudi Arabia.

METHODS

This study was a cross-sectional descriptive survey of 1,000 residents of the kingdom of Saudi Arabia. The study was conducted during the first two weeks of July, from 2 July 2020 to 14 July 2020. To be part of the sample, respondents were required to fulfil each of the following inclusion criteria: Anyone unwilling to participate, younger than 15 years old or not living in Saudi Arabia was excluded. A questionnaire was designed to assess the behaviour, attitude and knowledge of both healthy individuals and patients with systemic illness towards dental and oral health during the COVID-19 pandemic. The questionnaire was piloted with 50 patients to determine its validity. The study was approved by the ethics committee of the University of Hail. Informed consent was given by each eligible participant before the questionnaire was administered. The investigators informed willing participants in detail about the research project and its consequences. The data was collected through online self-administration of the questionnaire on the Google forms platform, by snowball sampling technique. The questionnaire was given in both Arabic and English and consisted of multiple-choice questions.

The questionnaire contained twenty-one questions, divided into three sections. The first section collected participants’ demographic information, such as gender, age, nationality, level of education, monthly income and region of residence. The second section assessed past and present medical history, including questions about the COVID-19 pandemic and respondents’ eating habits during that time. The final section asked questions to measure participants’ knowledge and behaviour of their own oral and dental-health care before and during the COVID-19 pandemic. This section also asked participants about the availability of emergency dental management.

The obtained data was recorded and cleaned in Microsoft excel and was then transferred to IBM statistical package for the social sciences (SPSS) statistics 23 for statistical analysis. Continuous variables were tested for normality; a Shapiro-Wilk test (p<0.05) showed that the data was normally distributed. Frequencies and percentages were used to present categorical data, and any relationships between the categorical item variables were analysed using Pearson’s chi-squared test. A p value less than 0.05 was considered statistically significant.

RESULTS

The study was conducted by way of an online questionnaire sent to residents of various provinces of the Kingdom of Saudi Arabia. We received and analysed a total of 1,000 completed responses. Respondents to the questionnaire were 36.5% male and 63.5% female (Figure 1). Participants’ ages were distributed as follows: 22.4% were ≤25 years old; 42.1% were 26-45; 31.8% were 46-65; 3.7% were ≥65 (Figure 2). More than half of participants (55.1%) reported changing their eating habits during the COVID-19 pandemic. This change had a statistically significant association with graduate-level-or-higher educational attainment (p=0.002) (Table 1), as well as a statistically significant association with monthly incomes greater than 9,000 SAR (p=0.001) (Table 2). In our study, 75.7% of participants reported that they brushed their teeth daily at least once; daily brushing was statistically significantly associated with being female rather than male (p<0.001) (Table 3). A comparison of brushing habits between different age groups revealed that participants younger than 45 were more likely than other age groups to have brushed at least once per day (p=0.005) (Table 3). It was also found that participants with education attainment at the graduate level or higher were more likely than those with less education to have brushed at least once per day (p<0.001) (Table 1). Participants who had incomes greater than 12,000 SAR per month were more likely to have brushed at least once per day than those who with monthly incomes less than 12,000 (p=0.003) (Table 2).

When we recorded the frequency of routine dental check-ups, we found that only 28% of participants had maintained the typical frequency of their check-ups; maintaining this frequency was significantly associated with graduate-level-or-higher education (p=0.031) (Table 1). Participants’ responses showed that 44.8% visited the dentist at least once per any period shorter than 1 year (i.e. visited more than once per year), 22.2% visited once per year, 13.8% did so once every two years, 5.7% visited once every 3 years and 13.5% visited just once in more than 3 years. Visiting the dentist more than once per year displayed a statistically significant association with being female (p<0.001) (Table 3); males were less likely to visit the dentist more than once per year. Making dental visits more than once per year was also significantly associated with being 25 years old or younger (p=0.014) (Table 4), being of Saudi nationality (p=0.024) (Table 5) and having a graduate-level education or higher (p<0.001) (Table 1). The data showed that 55.3% of respondents had experienced tooth loss. A history of tooth loss displayed a statistically significant association with being older than 46 (p<0.001) (Table 4) and also with having a sub-graduate education level (p=0.016) (Table 1).

Regarding oral-health care practices during the COVID-19 pandemic, 25% reported that their care practices had ‘improved’; 70.7% reported that it became worse, and 4.3% reported no change. Oral-health care presented a statistically significant association with income: participants with incomes lower than 3,000 Saudi Riyal (SAR) were more likely than participants with higher incomes to report that their oral-care practices became worse (p=0.016) (Table 2). During the COVID-19 pandemic, 15.8% of respondents made a visit to the dentist. Such visits were statistically significantly associated with nationality, with non-Saudi people visiting more often than their Saudi counterparts (p=0.005) (Table 5). Participants’ self-reported medical histories revealed that 17.8% had multiple chronic illnesses. Of all participants, 4.5% had diabetes mellitus alone, 3.8% had hypertension alone, 0.6% had cardiovascular diseases alone, 4.1% had blood disorders, 2.2% had thyroid conditions, 4% had orthopaedic problems, 3.7% had asthma, 0.2% had malignancy, 0.2% had immunodeficiencies and 0.2% had epilepsy. A comparison of the relationship of different chronic diseases with oral hygiene and oral-care practices revealed that tooth loss was more prevalent amongst participants who had multiple chronic diseases (p<0.001) (Table 6). When we examined participants’ tobacco-smoking practices, we found that 13.5% increased their smoking during the COVID-19 pandemic, whereas 15.4% reported continuing to smoke at the same rates. These findings displayed a statistically significant association being male (p<0.001), being either 26–45 or 46–65 years old (p<0.001), having graduate-level-or-higher educational attainment (p<0.001) and having an income greater than 6,000 SAR per month (p=0.042) (Table 7). Of all respondents, 48.2% believed that COVID-19 is a serious health problem. An assessment of the relationships between these statements, the various socio-demographic characteristics revealed that the statement was not correlated with any demographic factor except for level of education. Participants with educational attainment at the high school level or above were comparatively more likely than those with lower levels of education to feel that COVID-19 is a serious health problem (p=0.010) (Table 8). When we assessed the reasons for participants’ visits to the dentist during this pandemic, we found that 8.6% had visited for a routine dental check-up, while 7.2% had visited for emergency dental care. Concerning respondents’ reported reasons not to visit, 50.2% stated that a visit was not necessary; 19.9% stated that a visit was not urgent. Only 33.4% of respondents were aware that only emergency treatment is being offered at dental clinics during the COVID-19 pandemic (Table 9). Possession of this knowledge was statistically significantly associated with participants’ ages and incomes. Participants aged 25 years or younger were more likely than other age groups to agree that only emergency treatments are being offered at dental clinics during the COVID-19 pandemic (p=0.013). Participants who had monthly incomes of 6,000 SAR and less were also more likely to agree (p=0.007) (Table 10).

DISCUSSION

At the time that this survey was conducted (from the 2 July 2020 to the 14 July 2020), there were about 237,000 cases in Saudi Arabia. At the time of writing these results, the 1^st of August, that number has jumped to 275,905 cases.

The World Health Organization (WHO) has recognized oral health as an essential factor of overall health and well-being.¹⁶ Evidence has linked poor oral health to several chronic diseases, microbial infections and immune disorders, as well as to oral cancer and Alzheimer’s.^14,17-19 In this study, we explored the knowledge and behaviour of patients with systemic illness towards dental and oral health during the COVID-19 pandemic across multiple regions of Saudi Arabia.

It seems that the COVID-19 pandemic has had a damaging effect when it comes individuals’ eating habits. More than half of our participants reported that their eating habits were negatively affected. Many factors could underlie such an outcome, including economic conditions and variation in how knowledgeable and aware people are about the pandemic. In our study, effects of both income and education level could be observed (Table 1 and 2).

Although more than 75% of participants stated that brushed their teeth at least once daily, this cohort mostly consisted of younger participants and those with advanced educational degrees. This can explain why most of the participants who reported having experienced tooth loss in the past were in the 46-and-older age group and had lower educational attainment (Table 1 and 4).

Among our participants, income also seems to play a vital role, having a major effect on both brushing habits and eating habits. Moreover, most of the respondents who reported degradation in the quality of their oral-care practices were amongst the lower-income groups (Table 2).

Our findings suggest that non-Saudi participants have shown a greater willingness to visit the dentist during the pandemic, if necessary, than Saudi participants (Table 5). Smoking is considered a risk factor for many systemic and oral diseases.^20,21 Half of the smokers in the study reported that their smoking increased during the pandemic. This increase was more severe amongst male participants. We suggest that this tendency towards increased smoking could be related to the stressful conditions and economic pressures that participants are experiencing during this pandemic. Much literature associates smoking with stress and anxiety.²⁰

In this study, participants who were more educated were more likely to consider the pandemic a serious threat to their health (Table 8). Severe cases of COVID-19 often occur in patients who are elderly and have secondary comorbidities.²² Chronic respiratory system diseases, diabetes, hypertension and cardiovascular diseases are considered risk factors for severe cases of COVID-19.²² As can be concluded from Table 6, more than 30% of patients suffering from bone and joint diseases, patients suffering from hypertension and patients with than one chronic disease are neglecting their oral hygiene. This negligence has its own consequences -in hypertensive patients, for example, poor oral hygiene may interfere with and worsen the regulation of blood pressure.²³ In individuals with osteoporosis, meanwhile, oral hygiene can play a major role in preventing the progression of the disease.²⁴

Interestingly enough, more than 90% of the respondents that are suffering from thyroid and blood disorders, despite seeming to have decent brushing habits before the onset of the pandemic, reported that their oral-health habits worsened during the pandemic. Bacteremia is associated with gingival bleeding and poor oral hygiene. By enhancing oral hygiene, the risk of developing infective endocarditis can be decreased.²⁵ That some participants’ oral hygiene is deteriorating might be related to stress and anxiety. Both can be caused by the current conditions and are considered risk factors for pre-mature death; anxiety is a predictor of all-cause death, especially in elderly people.²⁶ Social distancing and isolation -despite being beneficial and widely recognized as the first line of defense against the transmission of COVID-19 -could actually increase individuals’ burdens of existing emotional stresses. For elderly people with comorbidities, social distancing means isolation and loneliness. Loneliness itself can lead to disability, depression and cardiovascular diseases.²⁷

Early detection and treatment for oral disease are extremely important to minimize post-operative side effects and treatment failure, as well as to mitigate the risk of developing other diseases.²⁸ To provide safe dental treatment during the pandemic, an initial assessment of COVID-19 symptoms, conducted via tele-screening, is recommended, as is the collection of a complete history of the prospective patient’s recent travel and contact others.²⁹ During the pandemic, only emergency procedures should be allowed, and elective dental treatments should be postponed for at least 2 weeks for patients with signs or symptoms of COVID-19. Some urgent cases can be treated remotely be prescribing medications to relieve acute pain.²⁹

In an effort to protect healthcare staff and patients from the transmission of SARS-CoV-2, healthcare providers across Saudi Arabia have postponed check-ups, elective surgeries and other non-urgent medical appointments that must be conducted in person.³⁰ Emergency cases that involve swellings that interfere with airways should be addressed in airborne-isolation settings or negative-pressure rooms. Neglecting tooth abscesses, which can be painless, can put the patient into a ventilator, a piece of key equipment needed to care for patients critically ill with COVID-19. Ludwig’s angina is one of the conditions that can arise as a result of a tooth abscess; it is life-threatening, rapidly expanding and causes airway obstruction that requires immediate hospitalization and intervention.

Consequently, the Saudi ministry of health and CDC both recommend that dental services be limited only to emergency care in order to prevent cross-contamination and expand available hospital capacity.⁴ Moreover, the Saudi ministry of health has encouraged dentists to sign up to join the virtual medical academy as an effort to prepare the healthcare delivery system to respond to a potential surge in COVID-19. Dental hygienists and dental assistants can also register to as part of this effort. Currently, many dentists acknowledge their part in supporting public health during this crisis.⁴ Future studies are required -especially after the pandemic ends -to understand the true extent to which the current pandemic is impacting oral and general health.

Elderly patients and individuals with chronic diseases such as hypertension, cardiovascular diseases, diabetes, blood disorders, asthma and respiratory diseases, malignancies and immunodeficiencies are considered to be in at high-risk of severe manifestations of COVID-19. Moreover, individuals with more than one chronic disease were more prone to exhibiting a stronger tendency towards negative behaviours.

Limitations

Cross-sectional studies do not give us the opportunity to see the cause-effect relationship. Furthermore, in such study designs, subjects tend to give socially acceptable answers. In addition, by conducting the study through an online questionnaire, we are sacrificing a group in the population that are not using internet. Thus, although it is a necessary sacrifice to reduce the risk of COVID-19 transmission, the findings in this study could not be generalized for the whole Saudi population.

CONCLUSION

Despite the enormous efforts that have been made around the world to provide guidelines for decreasing the risk of COVID-19 spread during dental procedures, focussing on measuring and enhancing patients’ knowledge of and behaviour towards oral health can sometimes provide information that is useful in dental practice and contexts. Our results clearly show that a very alarming percentage of participants do not see COVID-19 as threatening to their health. At the same time, a number of people needed urgent treatment but preferred to stay home because of fear and anxiety connected to the pandemic. The lack of information can lead to the exacerbation of such fear, which in turn causes individuals to neglect their oral health. This study present a baseline of information that helps to understand the level of knowledge and how the residents in Saudi Arabia will perceive, react and manage their health during this pandemic. However, there is a need to do more research in this area to build and enhance the baseline information that was established.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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