ASSESSMENT OF PERIODONTAL HEALTH DURING COVID-19 LOCKDOWN IN RIYADH CITY. A CROSS-SECTIONAL STUDY

Abstract

A new severe acute respiratory syndrome virus belonging to the coronaviruses group was discovered in January 2020. [...]the WHO announced an international health emergency due to the COVID19 outbreak [8,9]. During the lockdown period, Riyadh residents were not permitted to leave their households for extended periods of time. [...]the long quarantine period created depression and anxiety issues for many individuals in several populations in Saudi Arabia [11,12]. Psychological problems and anxiety are major obstacles in performing selfcare, and OH can subsequently be affected [13]. [...]the aims of the present study were to assess the prevalence of periodontal diseases in the adult population and to evaluate people's oral hygiene practices during the COVID-19 lockdown in Riyadh city, Saudi Arabia. 2.MATERIALS AND METHODS This study was approved by the Institutional Review Board of King Saud University in Riyadh, Saudi Arabia (IRB approval number: [...]variables such as daily living performance (e.g., exercise, sleep patterns) and low social activities during the COVID-19 lockdown, and medication intake had no statistically significant relationship with periodontal disease symptoms (p = 0.946, p = 0.662, p = 0.128).

Headnote

Abstract

Introduction: The present study aimed at assessing the prevalence of periodontal diseases and oral hygiene in adults during the COVID-19 lockdown in Riyadh city, Saudi Arabia. Materials and methods: A web-based survey with a link was distributed to the participants through social media. A questionnaire consisting of 24 multiple-choice questions was used to obtain data like participants' medical information, activity performance, social life, emotional status, and oral hygiene during the COVID-19 lockdown (576 completed questionnaires). Results and discussion: The emotional status of participants during the lockdown, smoking, male gender, and nationality appeared as having a positive influence on the prevalence of periodontal diseases (OR = 1.93, OR = 1.91, OR = 1.82, OR = 2.74, p < 0.05. respectively). Oral hygiene practices of Riyadh residents were not affected (p = 0.765) and the use of interdental cleansing aids increased (p = 0.006). Conclusions: COVID-19 lockdown can affect periodontal health in stressed or depressed people.

Keywords: Riyadh residents, COVID-19 lockdown, periodontal diseases prevalence, emotional status, oral hygiene practices.

1.INTRODUCTION

Dental caries and periodontal problems have become the most common diseases in the last 500 years. Studies have shown a correlation between dental cleaning behavior, occurrence of dental diseases, and tooth loss [1]. A good oral hygiene (OH) is an essential indicator for health surveillance and for a good quality of life [2,3]. The oral cavity integrates many crucial functions, including chewing, speaking, and preforming facial expressions. Healthy oral and dental structures are crucial for maintaining the nutritional status of human bodies, general systematic health, and selfesteem [3,4].

Neglecting OH practices increases the incidence and prevalence of periodontal diseases [5]. Gingivitis and periodontitis are the two primary forms of periodontal disease, being caused by microbial biofilm deposits, known as plaques, in the oral cavity [6]. Periodontitis is characterized by the destruction of toothsupporting structures, constituting an important cause of tooth loss [7].

In November 2019, pneumonia cases of an unknown origin appeared in Wuhan City, and they were reported to the World Health Organization (WHO) office in China. A new severe acute respiratory syndrome virus belonging to the coronaviruses group was discovered in January 2020. Therefore, the WHO announced an international health emergency due to the COVID19 outbreak [8,9]. COVID-19 is transmitted through the respiratory tract (sneezing or coughing) or by touching contaminated surfaces. The common symptoms of COVID-19 are fever, fatigue, dry cough, and shortness of breath [9]. However, COVID-19 can result in serious complications, such as blood clotting, renal failure, and sometimes death. In contrast, some cases are mild or asymptomatic [9].

Thereafter, the first case in Saudi Arabia was recorded on March 2, 2020, and the disease spread rapidly, resulting in a nationwide lockdown (curfew) as part of the efforts made to control the spread of COVID-19 [10]. During the lockdown period, Riyadh residents were not permitted to leave their households for extended periods of time. Therefore, the long quarantine period created depression and anxiety issues for many individuals in several populations in Saudi Arabia [11,12]. Psychological problems and anxiety are major obstacles in performing selfcare, and OH can subsequently be affected [13].

Therefore, the aims of the present study were to assess the prevalence of periodontal diseases in the adult population and to evaluate people's oral hygiene practices during the COVID-19 lockdown in Riyadh city, Saudi Arabia.

2.MATERIALS AND METHODS

This study was approved by the Institutional Review Board of King Saud University in Riyadh, Saudi Arabia (IRB approval number: E-20-5403). We followed the recommendations of the Declaration of Helsinki, revised in 2013, and all participants signed informed consent forms for participation.

PARTICIPANTS

A total of 600 people living in Riyadh, Saudi Arabia were randomly selected. The sample size was determined using a web program known as the sample size calculator (Surveysystem.com). Based on the total number of residents in Riyadh city, and setting a confidence level of 95% and a power level of 80% with a moderate effect size, the targeted sample size was determined to be 400. However, to avoid a low response rate, which may affect the sample size, a larger sample was recruited. A final sample of 600 participants was finally obtained using purposive sampling.

STUDY DESIGN

This study used a cross-sectional design. The inclusion criteria were adults aged 18 years and above, who experienced the COVID-19 lockdown situation between April and June 2020, and were living in Riyadh, Saudi Arabia. Participants who responded from outside Riyadh and those younger than 18 years of age were excluded.

QUESTIONNAIRE

The questionnaire consisted of 24 multiplechoice questions. The first five questions assessed demographic information; four questions were about periodontal disease symptoms, and four were about OH practices before and during the COVID-19 lockdown. The performance of daily living activities (exercise), sleep patterns, emotional status (anxious or depressed), and low social activities during the COVID-19 lockdown were investigated through five questions. In addition, there were four questions about participants' medical information, a question about different reasons for visiting dentists, and one regarding participants' satisfaction with health care accessibility during the COVID-19 lockdown in Riyadh, Saudi Arabia.

The questionnaire was novel and selfdeveloped. However, it was reviewed and edited by a consultant and professor in Periodontology at "King Saud" University. It was also tested by a group of postgraduate students, interns, and general dentists (20 people), and all their comments were taken into consideration. They were instructed to rate the importance of each question. For face validity, 10 dental students assessed the clarity of the questionnaire and how they understood each question.

SETTING

Online voluntary and private surveys were used. A web-based survey (in a Google Form format, with a link provided) was distributed to participants through a social media invitation to acquire sufficient samples.

STATISTICAL ANALYSIS

The responses were coded and manually entered. The Statistical Package for the Social Sciences database (IBM Corp., SPSS version 22, NY, USA) was used. All p values below 0.05, at a 95% confidence interval (Cl), were considered statistically significant. Frequency and percentages were calculated. Group comparisons were analyzed using the chi-square goodness of fit test. Independent chi-square and binary logistic regression tests were used to determine the effect of different variables on the prevalence of periodontal disease symptoms.

3.RESULTS

A total of 576 participants agreed to participate and filled in the questionnaire. All participants were aged 18 years and above and were residents of Riyadh city, Saudi Arabia. The questionnaire was designed to obtain information from participants during the COVID-19 lockdown between April and June 2020.

The number of Saudi participants was 541(93.9%), of which 391 (67.8%) were women and 185 (32.2%) were men. Approximately 505 (88%) participants were young, below 30 yearold. More than half of the participants (332, 58%) reported excellent general health, but hypertension was the most common illness reported by the participants (25, 4.4%). Most participants were non-smokers (485, 84.2%) (Table 1).

Most participants did not visit a dental clinic during the COVID-19 lockdown (67.8%). Changing a prosthesis or restorations and the routine dental checkup were the two main reasons (7% and 14%, respectively) for visiting dental clinics during the COVID-19 lockdown (Fig. 1).

More than half of the participants (59%) were satisfied with health care service accessibility during the COVID-19 lockdown in Riyadh city. The rest were slightly satisfied or unsatisfied (31.3%-27.8%) (Fig. 2).

The investigated symptoms of periodontal diseases, including bad oral odor, gingival bleeding, and tooth mobility, are shown in Figure 3.

Regarding the prevalence of symptoms of periodontal disease during the COVID-19 lockdown in Riyadh city, the results indicated the existence of a statistically significant relationship between anxious/ depressed individuals, male gender, smokers, and nonSaudi participants, and the symptoms of periodontal disease (p < 0.05) during the COVID-19 lockdown (Table 2).

Results of the binary logistic regression test (Table 2) showed that the emotionally affected ones (anxiety/ depression) during the COVID-19 lockdown had almost twice the risk of developing symptoms of periodontal disease (OR = 1.933, p = 0.005, < 0.05). This indicated that non-Saudis had almost a three-fold higher probability of developing periodontal disease symptoms (OR = 2.744, p = 0.012, < 0.05), and men had a twofold increased risk of developing symptoms of periodontal disease compared to females (OR = 1.912, p = 0.002, < 0.05). Smokers also had a two-fold increased risk of developing symptoms of periodontal disease (OR = 1.82, p = 0.007, < 0.05) (Table 2).

In contrast, variables such as daily living performance (e.g., exercise, sleep patterns) and low social activities during the COVID-19 lockdown, and medication intake had no statistically significant relationship with periodontal disease symptoms (p = 0.946, p = 0.662, p = 0.128).

Table 3 shows the assessment of OH practices during the COVID-19 lockdown. Tooth brushing practice (times per day) during the COVID-19 lockdown did not change comparatively with the period before it (p = 0.765). Interestingly, interdental aid use (times per week) increased during the COVID-19 lockdown and was statistically significant (p = 0.006, < 0.05) (Table 3). Interdental aid use included regular floss, water floss, and toothpicks.

4.DISCUSSION

The results of the present study indicated that the emotional status (anxiety/ depression) of participants during the COVID-19 lockdown, smoking, male sex, and nationality have a positive, statistically significant influence on periodontal disease prevalence. Many studies have investigated dental issues related to the COVID-19 pandemic; however, the prevalence of periodontal disease during the COVID-19 lockdown in Riyadh city, Saudi Arabia, has not yet been discussed.

The COVID-19 pandemic lockdown could increase life stresses or lead to depression. This lockdown has tremendously changed normal community patterns and people's daily activities [14]. Psychological disorders like anxiety and panic, depressive symptoms, obsessivecompulsive symptoms, insomnia, or digestive problems are common after stressing periods [15]. This study found that anxious/ depressed participants during the COVID-19 lockdown had a two-fold increased risk of developing periodontal disease symptoms, such as bad odor, gingival bleeding, or teeth mobility. The relationship between stress and periodontal diseases has been widely discussed in literature, and a positive influence has been found in many studies [16-19].

Smoking is a risk factor and a grade modifier in periodontal diseases, increasing the prevalence and severity of periodontal diseases [20,21]. In the present study, smoking was found to increase two times the prevalence of periodontal disease symptoms in smokers. Male participants also showed a two-fold higher risk of developing symptoms of periodontal disease than female participants. Similar to some diseases and conditions that manifest differently by gender, periodontal diseases have a higher prevalence in men than in women [22,23]. The reason could be a different immune responses or different steroid hormones in women, which modify body's response to periodontal diseases compared to men [24]. In addition, women tend to care more about their aesthetic and oral health than men. This attitude is appreciable for periodontal disease prevention and treatment [24]. However, sex is not a risk factor for periodontal disease.

Interestingly, non-Saudi participants were found to have a three-fold higher risk of developing periodontal disease symptoms, compared to Saudi participants. There is limited data regarding the prevalence or rate of periodontal disease in the Saudi population [25]. A national study of high school students performed by Al Ghamdi et al.m 2020 investigated the prevalence of periodontitis. They found that periodontitis was higher in non-Saudis than in Saudi students. They have suggested cultural and socioeconomic status differences to explain this difference [26]. This difference could also be related to genetic predisposition factors. It has been found out that race and ethnicity play an influential role in clinical attachment loss [27]. For example, people with African or Latin backgrounds have a higher risk of developing periodontal disease than others [27].

In the present study, 43.4% were dissatisfied with their sleeping patterns, 46.1% were emotionally affected due to low socialization, and 54.4% were also dissatisfied with their daily activities (e.g., exercise) during this lockdown. This dissatisfaction did not influence the prevalence of periodontal disease symptoms. Poor sleep quality and duration are related to decreased immunity and increased inflammatory status. These conditions influence the occurrence and progression of several diseases, such as diabetes mellitus, the metabolic syndrome, and coronary artery disease [28]. It is also associated with an increased prevalence of periodontitis [29]. The association between sleep duration and periodontal disease was evaluated in a cross-sectional study on adults in the US. Their findings revealed a statistically significant association between sleep duration and severe periodontitis. Individuals who slept >7 h/night were less likely to suffer from periodontal disease [30]. In an animal study, alveolar bone loss and gingival inflammation were associated with sleep deprivation [31]. However, a nationally representative study of American participants aged > 30 years reported no significant association between periodontal disease and poor sleep [32].

Participants in the present study who were emotionally affected by poor socialization during the COVID-19 lockdown did not show a significant risk of developing periodontal disease. Low social meetings and prolonged isolation hours at home can modify health behaviors and habits, for example, hygiene neglect, increasing smoking, changing eating habits, changing sleeping hours, and self-harm inflecting actions [33]. Social isolation is associated with reduced immunity, cognitive impairment, and increased risk of cardiovascular diseases [34]. The relationship between physical impairment and social isolation has been linked to high inflammatory activity, due to increased levels of C-reactive protein and fibrinogen [35]. The Lancet medical journal recently published an article during the COVID-19 pandemic and stated that periods of isolation, even for less than 10 days, can have long-term effects, with the presence (up to three years later) of psychiatric symptoms [36].

Nevertheless, the OH practices for our participants from Riyadh city did not change during the COVID-19 lockdown. In fact, the use of interdental cleansing aids (e.g., regular floss, water floss, toothpicks) increased during the lockdown period, compared to the period before it (Table 2). Experts [37,38] highly encouraged OH through toothbrushing with toothpaste as a preventive approach to COVID-19. Most toothpastes contain detergents that possess significant antimicrobial properties. These detergents are found in many hand-washing formulations recommended against coronavirus. Therefore, the coronavirus located in the oral cavity would be easily disinfected before being transferred to the oropharynx and subsequently to the lungs [38].

This research was conducted through a webbased questionnaire during the COVID-19 lockdown. Therefore, clinical examinations are difficult to obtain. Nevertheless, it included residents of Riyadh. However, information obtained through our self-developed questionnaire was comprehensive and edited by an expert in periodontology. In addition, most of the participants (88%) were of a younger age (< 30 year-old), because it was an online questionnaire. We suggest that future research should investigate periodontal disease prevalence after COVID-19 immunization in the Saudi population.

5.CONCLUSIONS

OH practices of Riyadh residents were not affected during the COVID-19 lockdown. In fact, the use of interdental cleaning aids has increased. In addition, stressful people, smokers, nonSaudis, and men were more prone to develop symptoms of periodontal disease (p < 0.05). Riyadh residents dissatisfied with their sleep pattern or daily life performance, or affected by the low social life activities during COVID-19 lockdown, showed no significant relationship with periodontal disease prevalence.

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