Keywords
parental awareness - COVID-19 - Oral health - Children
Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh human coronavirus,
first discovered in Wuhan, Hubei province of China, led to an outbreak of pneumonia
in January 2020. In the span of the next few months, the spread of this virus reached
the rest of the world.[1] As of October 2021, 261,763,799 people all around the world have been affected by
this virus, with over 5,217,311 deaths.[2] This virus has ever since caused a catastrophe across the world. The incubation
period varies between 3 and 14 days; however, a 24-hour incubation period has also
been reported.[3] Most infected people have been shown to remain asymptomatic or have a few symptoms.[3] Infected patients reported mainly having night fever, dry cough, sore throat, and
asthenia; more severe symptoms exhibited were dyspnoea. However, the occurrence of
severe symptoms has been observed only in about 15 to 25% of the infected patients,
with an impairment of respiratory function requiring immediate hospitalization and
assisted ventilation.[3] It presents with acute respiratory distress syndrome (ARDS), distinguished by potentially
lethal interstitial bilateral pneumonia.[4] The mode of spread is through airborne contamination and direct contact with contaminated
surfaces, which makes it highly contagious and transmissible. Most infected people
remain asymptomatic, potentially threatening the rate at which the infection spreads.
Having said so, saliva acts as the main nidus in the spread of infection. Saliva is
a distinctive and protective body fluid that is present in the oral cavity mainly
consisting of water and organic molecules. It plays an important role in the digestion
of food and helps in swallowing by lubricating the oral structures, speech, cleaning,
and preserving the oral cavity, to name a few. Of all the important roles mentioned,
saliva has been instrumental in preventing the entry of pathogens into body through
its antibacterial action and buffering capacity. However, SARS-CoV-2 acquisition in
saliva can happen either through the upper or lower respiratory tract or via blood,
which may enter the gingival crevicular fluid, or through the infection of major or
minor salivary glands.[5] A study done by Wang et al suggested that SARS-CoV-2 attaches itself to the angiotensin-converting
enzyme 2 (ACE-2) receptors found on the epithelium of salivary glands, agglutinates
with them, replicates, and lyses cells to trigger apparent signs and symptoms, such
as discomfort, inflammation, and pain in major salivary glands.[6]
Owing to the nature of the spread of this disease, stringent action needs to be taken
toward the oral hygiene measures. Children are one of the most vulnerable groups as
they are unable to keep up with oral hygiene measures independently and constantly
depend on their parents or caregivers for supervision. Parents or guardians must have
ample knowledge about the ongoing pandemic and its deleterious consequences on the
oral cavity. During a period of health emergency of pandemics like COVID-19, management
of specific oral health care needs becomes difficult and the only way to manage these
conditions is through disease prevention, which is possible only by spreading awareness.
Hence, the aim of this study was to assess and evaluate the attitude and level of
awareness of parents of healthy children during the global COVID-19 pandemic.
Materials and Method
Ethical clearance was obtained from the institutional ethical board. The source of
the data was 500 parents of children aged between 6 and 12 years residing in the Mangalore
taluk. A set of close-ended questions was formulated with Google Forms and circulated
to the parents between May and September 2020 via school teachers and health educators
through social media platforms such as WhatsApp and e-mail. Due to the added responsibilities
of online teaching for school teachers during the pandemic, a stipulated time of 15
days was given to the parents by the school authorities to fill out the questionnaire.
The study was conducted to evaluate and assess the level of awareness and knowledge
of parents residing in and around the Mangalore taluk about the COVID-19 pandemic
and to know the necessary precautions they would like to take for their children in
case of dental emergencies. This communication was established during the pandemic
to ascertain their needs during the crisis, which they may oversee postpandemic.
A well-structured, close-ended questionnaire was given to the parents after validation
and a brief explanation was given to the parents regarding the objective of the study.
The first part of the questionnaire consisted of demographic details and a consent
form, which explained the brief intent and authenticity of the study. The questions
were divided into awareness- and attitude-based questionnaires.
The data were analyzed using MS Excel and R version 4.1.0 software. All the tests
of significance were carried out at a 5% level of significance. The statistical methods
used were descriptive and inferential statistics.
Results
Out of the 500 parents, a total of 416 responses were obtained at the end of 2 weeks.
Since the parents were approached through the school authorities who had a better
outreach, 395 (79 %) responses were obtained within the first week of circulation
of the forms. Following this, a single reminder was given to the parents at the end
of the first week through the school authorities leading to a response of 416 (83.2%)
at the end of 2 weeks.
Through the sociodemographic details, it was observed that 261 (62.74%) parents who
participated in the study had a male child. Out of the 416 parents, 397 (95.43%) parents
were aware of the COVID-19 pandemic and 388 (93.27%) had educated their children regarding
the pandemic. When the parents were asked how they felt about the pandemic, 123 (29.57%)
of them felt that this phase shall pass, 122 (29.33%) felt anxious, 105 (25.24%) felt
fearful, while 38 (9.13%) were casual about the situation. When asked about the kind
of masks they preferred to wear, 172 (41.35%) parents preferred N95 masks, 97 (23.32%)
chose cloth masks, and 89 (21.39%) preferred three-layered masks ([Table 1]). When asked if their children were willing to wear masks, 346 (83.17%) parents
said that their children did accept it ([Table 2]). On asking about how they maintain the oral cavity of their children, 287 (68.99%)
parents said that their kids brush their teeth twice daily. Three hundred and fifty-three
(84.86%) parents knew that the COVID-19 virus spreads through saliva so it was imperative
for them to keep their child's mouth clean; most parents had started using mouth rinses
for their children, 158 (37.98%) used salt water, 171 (41.11%) preferred the use of
plain water, and only 3 (0.72%) agreed to use povidone-iodine (PVP-I).
Table 1
Response to questions evaluating the attitude of parents
Questions asked (416 respondents)
|
Answers
|
Results
|
If yes, how do you feel about the current situation?
|
Fearful
Anxious with each passing day
Casual
This too shall pass
|
105 (25.24%)
122 (29.33%)
38 (9.13%)
123 (29.57%)
|
What is the portal of entry of coronavirus into the body?
|
Nose, eyes, and mouth
Mouth alone
None of the above
|
392 (95.19%)
12 (2.88%)
8 (1.92%)
|
What type of mouth mask do you think is best suited to protect your child?
|
2-layered masks
3-layered masks
Cloth masks
N95 masks
|
58 (13.94%)
89 (21.39%)
97 (23.32%)
172 (41.35%)
|
How often does your child brush his/her teeth
|
Does not brush
Once daily
Twice daily
|
5 (1.20%)
124 (29.81%)
287(68.99%)
|
Are you using a homemade mouth rinse?
|
Saltwater
Povidone iodine
Plain water
None of the above
|
158 (37.98%)
3 (0.72%)
171 (41.11%)
84 (20.19%)
|
What would you consider a dental emergency for your child?
|
Pain
Broken tooth
Black spot on the tooth
Pus discharge from the oral cavity
Halitosis/bad breath
|
237 (56.97%)
33 (7.93%)
63 (15.14%)
60 (14.42%)
23 (5.53%)
|
If your child has a toothache, what would you do
|
Call a dentist and schedule an appointment
Call a dentist for an online consultation
Give the child a painkiller
|
250 (60.10%)
141 (33.89%)
25 (6.01%)
|
Would you prefer online consultation or hospital consultation?
|
Online
Hospital
Neither of the above
Any of the above
|
138 (33.17%)
190 (45.67%)
12 (2.88%)
76 (18.27%)
|
If you decide to take your child to a dental clinic or hospital, how long after the
lockdown do you prefer to take your child there?
|
Immediately after this is over
2–3 mo later
4–6 mo later
6 mo later
|
182 (43.75%)
118 (28.37%)
27 (6.49%)
89 (21.39%)
|
Table 2
Response to questions evaluating the knowledge of parents
Questions asked (416 respondents)
|
Yes
|
No
|
Maybe
|
Are you aware of the coronavirus pandemic?
|
397 (95.43269)
|
19 (4.567308)
|
NA
|
Have you educated your child about coronavirus?
|
388 (93.27)
|
28 (6.73)
|
NA
|
Did you know that this virus could transfer through saliva?
|
353 (84.86%)
|
25 (6.01%)
|
38 (9.13%)
|
Is your child willing to wear a mouth mask?
|
346 (83.17%)
|
40 (9.62%)
|
30 (7.21%)
|
Are you aware that mouth masks are available in different types?
|
404 (97.12%)
|
5 (1.20%)
|
7 (1.68%)
|
Further when parents were asked about what condition they would consider a dental
emergency for their child, 237 (56.97%) parents said that they would only consider
pain as a dental emergency and 190 (45.67%) would prefer hospital consultation, 138
(33.17%) would prefer an online consultation for the same, and 76 (18.27%) would prefer
either hospital or online consultation, whatever is available to them. When asked
about their willingness to take their child to a dental clinic or hospital and how
long after the lockdown ceased would they prefer to take their child, 182 (43.75%)
parents said that they would take their children to the dentist immediately after
the lockdown ceased, while 118 (28.37%) parents preferred to go to the hospital or
dental clinic 2 to 3 months later.
The results of the current study highlight that a significant number (56.97%) of parents
reach out to the clinician when the dental needs of their child become symptomatic
(pain). The need of the hour is to promote preventive oral health care and raise the
awareness level among parents and primary caregivers on the same. Imparting evidence-based
information on the significance of oral health on the systemic well-being of children
is also vital.
In the present study, 50% of the participating parents had the right attitude in challenging
times like the pandemic and appropriate knowledge about the same.
The p-value for the chi-squared test was statistically nonsignificant (p > 0.05), which was indicative of a lack of association between gender and attitude
([Table 3]) as well as gender and knowledge ([Table 4]).
Table 3
Association between the gender and attitude type
Attitude group
|
Gender of the child
|
Total
|
Chi-squared test
|
df
|
p-value
|
Male
|
Female
|
Positive attitude
|
Count
|
250
|
151
|
401
|
0.747
|
1
|
0.387
|
% of total
|
60.1
|
36.3
|
96.4
|
Negative attitude
|
Count
|
11
|
4
|
15
|
% of total
|
2.6
|
1.0
|
3.6
|
Total
|
Count
|
261
|
155
|
416
|
% of total
|
62.7
|
37.3
|
100.0
|
Abbreviation: df, degree of freedom.
Table 4
Association between gender and knowledge type
Knowledge group
|
Gender of the child
|
Total
|
Chi-squared test
|
df
|
p-value
|
Male
|
Female
|
Below 50%
|
Count
|
15
|
12
|
27
|
0.638
|
1
|
0.425
|
% of total
|
3.6
|
2.9
|
6.5
|
Above 50%
|
Count
|
246
|
143
|
389
|
% of total
|
59.1
|
34.4
|
93.5
|
Total
|
Count
|
261
|
155
|
416
|
% of total
|
62.7
|
37.3
|
100.0
|
|
% of total
|
62.7
|
37.3
|
100.0
|
Abbreviation: df, degree of freedom.
Discussion
COVID-19 is an infectious transmissible disease and the fact that it is transmitted
through aerosols from one person to another makes it more infectious. Dentists, in
general, work in a closed setting where aerosol generation is rather inevitable; hence,
the risk to both patients and dentists in the dental operatory is of concern during
this pandemic. The only way to control the spread of this infection is by taking necessary
precautions. This questionnaire was designed during the COVID-19 pandemic lockdown
to assess the knowledge and attitude of parents residing in the Mangalore taluk toward
COVID-19, owing to limited studies being done in this area.
Individuals must be aware of the general protocols and the guidelines issued in the
interest of public health by the respective governments during pandemics. Owing to
the nature of the spread of the virus, health care professionals must guide and educate
the people of the community. The first step is to assess the level of knowledge and
attitude of the parents toward oral health of their children and then take the required
actions to educate them. This questionnaire study comprised demographic data indicating
that a majority of the participants had male (62.74%) children; 37.26% parents had
female children.
Parents play an important role in the lives of children; hence, parental health, beliefs,
and attitudes have a direct bearing over the child's health[7]. Parents enrolled in our study had children between the age of 6 and 12 years. This
is the age when children are most dependent on their parents for their oral health
care needs. An impressive 93.23% of the parents had educated their children about
the COVID-19 pandemic. This helped us understand that most of the parents practiced
self-directed learning and so most parents had educated themselves regarding the COVID-19
pandemic. When asked how they felt about the pandemic, the majority of the parents
were anxious and believed that this phase would pass. This questionnaire study was
conducted during the pandemic's first wave when most people were still learning about
this pandemic, while some others were busy settling down with the new setting of children
being at home. This time reflected a stressful new reality where familial lives were
severely impacted due to fear of the virus and adjusting to life amidst school closures,
quarantine, and stay-at-home orders. These realities gravely impacted parents' lives
as these changes moved childcare, schoolwork, and recreational pursuits into the home,
whereas earlier these activities were typically outsourced and parents were able to
effectively balance their lives.[8] Evaluating the parental awareness and attitude on the use of masks during the pandemic,
our survey drew the following conclusion. Regarding the kind of masks they would prefer
to wear, most parents (41.35%) chose N95 masks, whereas 23.32% of parents preferred
cloth masks. This is in accordance with the World Health Organization guidelines;
children who are in general good health can wear a nonmedical or fabric mask. Adults
providing the mask should ensure that the fabric mask is the correct size and sufficiently
covers the nose, mouth, and chin of the child; hence, an N95 mask is not mandatory.
The parents' knowledge in terms of the type of mask is as per the guidelines.[9] Parents have been making sure that their children brush twice daily. It is imperative
to do so as ACE2 is the cellular receptor for SARS-CoV2. Keeping the oral cavity clean
helps in warding off the virus. In the review article where evidence was gathered
to highlight the rationale, safety, recommendations, and dosage of PVP-I gargle/mouth
rinse as an effective method to decrease the viral loads during the pandemic, it was
seen that prophylactic use of 0.5% PVP-I as mouth rinse was safe and in vivo studies
have proven its virucidal efficacy against SARS-CoV2. The authors concluded by saying
that the use of PVP-I gargle/mouthwash is a simple, inexpensive, and safe adjunct
that can be used to reduce the risk of cross-transmission of SARS-CoV-2 viral particles
to the community and health care professionals.[10] In our study, most of the parents suggested the use of salt water as a mouth rinse;
however, since the study was done during the pandemic, most parents were unaware of
the use of PVP-I.
The COVID-19 pandemic has affected people's lives and lifestyles drastically. With
changes in working patterns due to the imposition of lockdown, serious changes have
been observed in the family dynamics including their dietary patterns. An increase
in the amount of immobility and confinement to homes further led to an increase in
food intake, especially ultra-processed and calorie-dense foods.[11] Another cause of the increased amount of food intake could be due to stress. A lot
of families face financial difficulties, and parental stress could lead to stress
on the children and an increased amount of inattention toward the child during these
periods.
A study conducted to investigate the impact of pandemic-associated stress on food
parenting practices, including interactions surrounding snacks, and child diet showed
that stress associated with the COVID-19 pandemic may be linked to child snack intake
with potential impacts on child obesity risk and suggested several modifiable points
of intervention within the family context. Improper food consumption practices can
enhance the occurrence of dental decay.[12]
It was also observed that the majority of families (>75%) made sure that children
had regular breakfast, lunch, and/or dinner times, while less regularity was noted
for snacks, potentially implying that parents provided snacks at random times or following
certain cues, for instance, to manage emotions or as a reward for good behavior.[12] It is a known fact that frequent amount of consumption of fermentable carbohydrates
leads to increased periods of pH drop in the oral cavity due to bacterial fermentation
of carbohydrates leading to a disharmony between the demineralization and remineralization
equilibrium leading to the formation of caries.[13] Once this process is allowed to progress, it leads to the formation of cavitation,
eventually causing pain and distress, impairing the quality of life and the nutritional
status in young children.
In our study, most parents considered pain as a dental emergency, which shows that
most parents know conditions like dental pain may occur and need to be addressed.
However, one limitation of the study was the lack of details about the child's existing
dental health issue. This would have given us a better idea regarding the parental
attitude and awareness about their child's existing dental health status. Studies
done to investigate the impact of a child's dental pain, caregiver's fear of SARS-CoV-2,
and parental distress on oral health-related quality of life (OHRQOL) of preschoolers
during the nationwide COVID-19 pandemic lockdown have shown greater parental distress
and fear of COVID-19 among caregivers, higher self-perceived dental pain among children,
and caries experience are associated with poor OHRQOL of preschool children.[14] However, most parents felt positive about taking their children to a dentist as
soon as the pandemic ceased, which was a very positive response showing that the parents
do realize the importance of maintaining good oral hygiene during the COVID 19 pandemic.
Also, statistically, it was observed overall knowledge of the parents was above 50%
and they had a positive attitude toward their child's oral health and well-being during
the COVID-19 pandemic. One of the main limitations of the study was that the parents
in the study group belonged to the lower and higher middle-class population in which
the majority are well educated and are aware of all the precautionary measures they
should take to ensure their families' safety.
In our study, the attitudes of the parents were positive and the level of awareness
was above average regarding the oral health of healthy children during the COVID-19
pandemic.