Investigation

The impact of COVID-19 lockdown on

maintenance of children’s dental health
A questionnaire-based survey
Maya Gotler, DMD; Liat Oren, MSc, DMD; Shoshanna Spierer, DMD; Noam Yarom, DMD;
Malka Ashkenazi, DMD

ABSTRACT

Background. The COVID-19 pandemic has been associated with several changes in maintenance
of children’s dental health. The aim of this study was to evaluate the extent of these changes.
Methods. Parents were asked to respond anonymously to a questionnaire regarding alterations in
their children’s oral habits, such as frequency of eating and drinking, toothbrushing, signs of stress,
and receiving oral health care during the lockdown period. The participants were reached either
during their visit to the clinics or via the social media groups of the authors.
Results. There were 308 parents of children aged 1 through 18 years who responded to the
questionnaires. The authors found associations between increased frequency of eating and drinking,
decreased frequency of toothbrushing, and postponing oral health care. Among the children, 11%
experienced more frequent oral signs of stress, such as temporomandibular disorder and aphthous
stomatitis, during the lockdown. Although children from all age groups ate and drank more
frequently between meals, younger children received a diagnosis of carious lesions more often during
the lockdown (P ¼ .015).
Conclusions. During the lockdown, many children changed their eating, drinking, and tooth-
brushing habits and, thus, increased their risk of developing caries.
Practical Implications. During pandemic-associated re-care visits or recall visits, it is imperative to
conduct a detailed interview regarding changes in oral health habits. In children at high risk,
dentists recommended more diagnostic and preventive measures to prevent deterioration of their
oral health. Moreover, dentists should put more emphasis on motivational interviewing to help
children resume healthier routines after the lockdown.
Key Words. Toothbrushing; caries; dental; eating habits; treatment; periodic dental examination.
JADA 2022:153(5):440-449
https://doi.org/10.1016/j.adaj.2021.10.004

OVID-19 was first reported in China in December 2019. It quickly spread to 181

C countries (as of May 2020) and became a global pandemic, which affected millions of
people worldwide. To reduce transmission, social distancing and lockdown were rec-
ommended.1-3 During lockdown, several changes took place in the family routine: parents and
children stayed at home, and the children received lessons via online learning applications,
connected with friends by cell phones, spent their free time playing games on the computer,
and did not attend social or physical activities. These lifestyle changes, together with the higher
availability of food and drinks at home while playing on the computer or participating in online
meetings, have led to increased frequency of meals and snacks and intake of sugary drinks
during the COVID-19 pandemic.4-6
Moreover, possible changes in children’s sleep routines (for example, waking up late in the
morning and staying awake late at night) may have led to more frequent eating at night and reduced
frequency of toothbrushing.5,7 As a consequence, these children may have been at higher risk of
Copyright ª 2022
developing new carious lesions.8-13 An opposing possibility is that parental presence at home during
American Dental
Association. All rights the lockdown increased supervision of the children, leading to improved oral hygiene habits and
reserved. consumption of more healthy food.4,13

440 JADA 153(5) n http://jada.ada.org n May 2022

 Another consequence of the COVID-19 outbreak is related to the warnings regarding the risk of
receiving dental treatment during this period. During dental treatment, increased spread of aerosols
while drilling and scaling, as well as the physical proximity between the dentists and their patients
and between patients in the waiting room, may increase the risk of being infected by the virus.14 As
a result, the Centers for Disease Control and Prevention and several other health authorities around
the world instructed dental staff members to treat only emergency cases during the COVID-19
pandemic and recommended the public to postpone nonessential dental treatments and periodic
examinations.1,15 Adhering to these warnings and fearing being infected, many parents may have
postponed their children’s dental appointments.6
Only 5 previous studies in the English language have evaluated the effect of COVID-19 lock-
down on maintenance of children’s oral health. Most of them did not assess the extent of these
changes, referring instead to a dichotomic evaluation,6,7,13 or did not compare the existing habits
during the pandemic with those during the previous period.5,7 Moreover, few of the studies included
adolescents and concentrated on limited ranges of ages (3-6 years, 0-12 years, < 14 years, 6-12 years,
or 3-15 years) and thus could not assess the effect of age on these changes.4-7,13,14
An additional issue in regard to the lockdown and staying at home to prevent spreading the
disease is increase in emotional stress of the children,4,7,15,16 which concomitantly could have been
expressed orally via temporomandibular disorders (TMDs) or recurrent aphthous stomatitis (RAS).
TMD affects the function of the temporomandibular joint along with the muscles of mastication.17,18
It can be provoked by emotional depression, stress, anxiety, oral parafunction,19,20 and even reduced
sleep quality.21 Moreover, patients with TMD are affected more commonly by anxiety and depres-
sion.22 This disorder can affect 5% through 12% of the population, including children.
RAS is another oral expression of stress, affecting 5% through 25% of the population, and is
characterized by periodic eruption of painful solitary or multiple ulcerations of the oral mucosa.23,24
RAS can affect quality of life by affecting patients’ speech, nutrition, physical appearance, self-
esteem, and social interaction. Its onset is usually during childhood, with a peak onset from 10
through 19 years and with a tendency to diminish in frequency and severity with age.25
Although several previous studies have confirmed the relationship between emotional stress and
anxiety and TMD and RAS,4,7,17,26 to our knowledge, no study has evaluated the possible oral
manifestation of the lockdown-related stress via onset of TMD or RAS.
We hypothesized that the COVID-19 lockdown might affect children’s oral health and care.
Accordingly, the aims of our study were to evaluate the impact of the COVID-19 lockdown on
several parameters of children’s maintenance of oral health (frequency of eating, drinking, tooth-
brushing, and receiving oral health care during and after the lockdown) and oral manifestation of
stress, as well as the correlation between these variables and the child’s age and oral health care
providers.

METHODS
Study population and setting
We conducted this study during February and March 2021. Parents of children aged 1 through 18
years were asked to respond anonymously to a questionnaire regarding changes in maintenance of
dental health and care and manifestation of stress-related oral symptoms during the COVID-19
lockdown. Before the study, the questionnaire was reviewed by all authors and validated by 15
parents to verify clarity and reliability.
The variables in the questionnaire included
n demographic data (such as sex and age)
ABBREVIATION KEY
n health condition of the child CPD: Certified pediatric
n training of the attending dentist dentist.
GP: General practitioner
n type of dental clinic that provided the service regularly (private clinic, health maintenance or-
dentist.
ganization [HMO], hospital-associated dental clinic) HMO: Health maintenance
n presence of parents at home during the lockdown organization.
n changes in timing and frequency of eating food (healthy and snacks) and drinking sugary drinks RAS: Recurrent aphthous
stomatitis.
n increase in weight
TD: Teledentistry.
n changes in oral hygiene habits (frequency and timing of toothbrushing) TMD: Temporomandibular
n manifestation of emotional stress (via TMD and RAS) disorder.

JADA 153(5) n http://jada.ada.org n May 2022 441

 Table 1. Distribution of answers to the questionnaire regarding demographic characteristics of the study population.

VARIABLES ANSWER OPTIONS RESULTS, NO. (%)

Age, Y <6 69 (22.5)

6-10 139 (45.3)

 11 99 (32.2)

Sex Male 159 (51.8)

Female 148 (48.2)

Health Condition Healthy 267 (87.54)

Developmental disorder 8 (2.62)

Autism spectrum disorder or attention deficit/hyperactivity 21 (6.9)

disorder

Chronic diseases 8 (2.62)

Chronic disease and autism spectrum disorder 1 (0.32)

Place of Receiving Routine Dental Private dental clinics 170 (56.9)

Treatments

n treated by a general practitioner 52 (17.4)

n treated by a certified pediatric dentist 118 (39.5)

Public dental clinics 129 (43.1)

n health maintenance organization 119 (39.8)

n hospital 10 (3.3)

n changes in the maintenance of oral health (receiving periodic dental examination and treatment)
n reason for cancelation of dental treatment or periodic dental examination (fear of COVID-19,
infection)
n need for urgent oral health care during pandemic and its availability (Tables 1-5).
The study population included parents of children who were treated regularly before the lock-
down either in hospital-affiliated clinics, in HMO dental clinics, or in private clinics by general
practitioner dentists (GPs) or certified pediatric dentists (CPDs). To include all these groups of
parents, we reached them either during their visit to private dental clinics of CPDs, during their
visit to a hospital-affiliated clinic, or via the authors’ social media groups to reach parents whose
children are treated regularly by GPs in HMOs or in private clinics. We considered the filling out of
the questionnaire as informed consent.
In the clinics, the questionnaires were given to the parents by the secretary after the dental visit.
If the parents arrived with several children, they were asked to fill out only a single questionnaire
regarding 1 of their children, and they returned the questionnaires anonymously into a pool of
returned questionnaires without any intervention of the dental staff members. For the electronic
form, the participants completed the questionnaire anonymously and submitted it online. The
institutional review board of the Sheba Medical Center (research 779-20-SMC) approved the
study.

Statistical methods
We tabulated all study variables overall and by age groups and dental health care providers. We
compared the categorical variables using the c2 test or Fisher exact test (when the numbers were
small), and we compared the 1 continuous variable (age) among groups using analysis of variance.
We examined correlations between variables using Kendall correlations owing to the large
number of ties and tested for significance. We tested associations between variables using the c2
test (or Fisher exact test). In all tests performed, we considered P values below .05 statistically
significant. We performed statistical analyses using R (Version 3.4.1; R Foundation for Statistical
Computing).

442 JADA 153(5) n http://jada.ada.org n May 2022

Table 2. Distribution of answers to the questionnaire regarding presence of parents at home during COVID-19 lockdown.

ANALYSIS OF VARIANCE
P VALUE AMONG
VARIABLE ANSWER OPTIONS AGE GROUPS, NO. (%) AGE GROUPS TOTAL NO. (%)

<6Y 6-10 Y ‡ 11 Y
(n [ 69) (n [ 139) (n [ 99)
Presence of Parents at Home Parents stayed at home only 55 (79.7) 97 (70.3) 56 (56.5) .025 208 (68)
During COVID-19 Lockdown during the lockdown

Parents stayed at home regularly 7 (10.15) 15 (10.9) 17 (17.2) 39 (12.8)

Parents worked away from home 7 (10.15) 26 (18.8) 26 (26.3) 59 (19.2)

RESULTS
Study population
Of all questionnaires, 145 were delivered to parents in 4 different private dental offices of CPDs after
their child received a dental examination or treatment, and 240 were delivered electronically via
the authors’ social media groups.
In total, 308 parents responded to the questionnaire, with a total response rate of 80%. The
response rate from the electronic delivery was 70.8% (170/240) and that of questionnaires delivered
at the dental clinics was 95% (138/145). Of 170 parents of patients who were reached via social
media group, only 3 claimed that their children were treated regularly by a CPD.

Demographic characteristics of the children

The mean (standard deviation) age of the children was 8.8 (3.6) years (range, 1-18 years). Of the
total number of children, 159 (51.6%) were boys (the male to female ratio was 1.14:1). For analysis,
we divided the children into 3 age groups: younger than 6 years (69 children); 6 through 10 years
(139 children); and older than 11 years (99 adolescents). Tables 1 through 5 show the distribution
of answers to the questionnaire regarding demographic characteristics of the study population and
their dental health maintenance during the lockdown.

Presence of parents at home during COVID-19 lockdown

Significantly more parents of children younger than 11 years stayed at home during the lockdown
than parents of older children (P ¼ .025) (Table 2). Presence of parents at home was correlated
positively with an increase in consuming healthy food more frequently between meals (0.1; P ¼ .05)
(Table 6).

Changes in eating and drinking habits during the COVID-19 lockdown

The distribution of children according to their changes in eating snacks and drinking sugary and
carbonated drinks between meals is shown in Figure 1. Children from all age groups increased their
frequency of consuming snacks and sugary drinks between meals. However, the magnitude of the
increase was lower in the younger than the older children ( 11 years) for both snacks (Table 3,
P ¼ .015; Table 6, P ¼ .001) and sugary drinks (Table 3, P ¼ .034).
Eating healthy meals more frequently daily was positively associated with the presence of parents
at home and negatively associated with changing the timing of toothbrushing (0.1, P ¼ .047, and
e12, P ¼ .031, respectively) (Table 6).

Oral hygiene habits during the COVID-19 lockdown

Figure 2 shows who was responsible for brushing children’s teeth during the COVID-19 lockdown
according to the child’s age. Significantly fewer children who received treatment in hospital settings
brushed their teeth by themselves: 20% versus 51.9%, 63.6%, and 64.7% of the children treated by
GPs at private clinics, by CPDs, or in HMO clinics, respectively (P ¼ .035). The percentage of
children who brushed their teeth by themselves increased with age (Table 4, P < .001). The
changes in frequency of children’s toothbrushing during the COVID-19 lockdown is shown in
Figure 3. Children aged 6 through 10 years skipped their toothbrushing in the morning more
frequently than younger or older children (Table 4, P ¼ .041).

JADA 153(5) n http://jada.ada.org n May 2022 443

Table 3. Distribution of answers to the questionnaire regarding changes in eating and drinking habits during the COVID-19 lockdown.

ANALYSIS OF
VARIANCE P TOTAL
VARIABLES ANSWER OPTIONS AGE GROUPS, NO. (%) VALUE NO. (%)

<6Y 6-10 Y ‡ 11 Y
Did Your Child Eat More Times a Day Yes, ate 1-2 more times per day 37 (53.6) 49 (35.5) 44 (44.4) .194 130 (42.5)
Healthy Food During the COVID-19
Lockdown as Compared to the Previous
Period?

Yes, ate 3-4 more times per day 6 (8.7) 17 (12.3) 13 (13.1) 36 (11.8)

No, ate similar number of meals 24 (34.8) 67 (48.6) 36 (36.4) 127 (41.5)

No, ate more orderly and less often per 2 (2.9) 5 (3.6) 6 (6.1) 13 (4.2)
day

Did Your Child Eat More Times a Day Yes, ate 1-2 more times per day 40 (58.0) 57 (41.0) 35 (35.4) .015 132 (43)
Sweets, Snacks (Such as Cakes, Cookies,
Waffles, Biscuits, Pretzels, Potato Chips,
Cornflakes, et cetera) During the
COVID-19 Lockdown as Compared to
the Previous Period?

Yes, ate 3-4 more times per day 12 (17.4) 17 (12.2) 10 (10.1) 39 (12.7)

Yes, ate even much more frequently 1 (1.4) 10 (7.2) 10 (10.1) 21 (6.8)

No, ate similar number of meals 15 (21.7) 52 (37.4) 38 (38.4) 105 (34.2)

No, ate more orderly and less often per 1 (1.4) 3(2.2) 6 (6.1) 10 (3.3)
day

Did Your Child Eat His or Her Meals at a 1 Yes, ate more breakfasts during the 21 (31.3) 43 (30.9) 23 (23.2) .097 87 (28.5)
Different Timing During the COVID-19 COVID-19 lockdown
Lockdown as Compared to the
Previous Period?

2 Yes, ate more meals/snacks in the late 14 (20.9) 30 (21.6) 38 (38.4) 82 (26.9)
evening and at night

3 No, there was no change in the 32 (47.8) 65 (46.8) 37 (37.4) 134 (44)
timing of his or her meals during the
COVID-19 lockdown

1þ2 0 (0.0) 1 (0.7) 1 (1.0) 2 (0.6)

Did Your Child Drink More Frequently Yes, consumed 1-2 more times per day 18 (26.1) 15 (10.9) 11 (11.1) .034 44 (14.4)
Sugary/Carbonated/ Juices/Soda
Between Meals During the COVID-19
Lockdown as Compared to the
Previous Period?

Yes, consumed 3-4 more times per day 4 (5.8) 7 (5.1) 4 (4.0) 15 (4.9)

Yes, consumed even much more 2 (2.9) 4 (2.9) 9 (9.1) 15 (4.9)

frequently

No, consumed at similar frequency 42 (60.9) 107 (77.5) 69 (69.7) 218 (71.2)

No, consumed less frequently 3 (4.3) 5 (3.6) 6 (6.1) 14 (4.6)

Yes 6 (8.8) 32 (23.2) 21 (21.65) .036 59 (19.5)

Did Your Child Gain Weight During
the COVID-19 Lockdown?

No 42 (61.8) 76 (55.1) 55 (56.7) 173 (57.1)

Maybe, but the child was not weighed 11 (16.2) 25 (18.1) 17 (17.53) 53 (17.5)

I don’t know 9 (13.2) 5 (3.6) 4 (4.12) 18 (5.9)

The effect of dental caregiver on maintenance of oral health of children during the
COVID-19 lockdown
Only 30% of the patients treated in hospital-related clinics were healthy, whereas 82.4%, 89.8%,
and 91.5% of the children treated by GPs at private clinics, in HMOs, and by CPDs were healthy,
respectively (P ¼ .001). Similarly, 90% of the patients treated in hospital-related clinics claimed

444 JADA 153(5) n http://jada.ada.org n May 2022

Table 4. Distribution of answers to the questionnaire regarding deterioration of oral hygiene habits during the COVID-19 lockdown.

ANALYSIS OF
VARIABLES ANSWER OPTIONS AGE GROUPS, NO. (%) VARIANCE P VALUE TOTAL NO. (%)

<6Y 6-10 Y ‡ 11 Y
Who Routinely Brushes Your Child himself 6 (8.7) 85 (61.2) 91 (91.9) < .001 182 (59.3)
Child’s Teeth?

The parents 27 (39.1) 21 (15.1) 2 (2.0) 50 (16.3)

The child and parents alternately 36 (52.2) 33 (23.7) 6 (6.1) 75 (24.4)

Did Your Child Brush His or Her Yes, less often in the mornings 8 (11.8) 22 (15.83) 8 (8.1) .041 38 (12.42)
Teeth Fewer Times a Day During
the COVID-19 Lockdown?

Yes, less often in the evenings 3 (4.4) 6 (4.31) 7 (7.1) 16 (5.23)

Yes, less times in the mornings and 2 (2.9) 7 (5.04) 14 (14.1) 23 (7.52)
evenings

No, my child brushed his or her teeth the 55 (80.9) 104 (74.82) 70 (70.7) 229 (74.83)
same frequency as before.

Was Toothbrushing Timing Yes 12 (17.4) 38 (27.3) 33 (33.3) .072 83 (27.0)

Changed During the Lockdown
Days?

No 57 (82.6) 101 (72.7) 66 (66.7) 224 (73)

that they consumed daily medications, whereas 17.3%, 18.6%, and 7.6% of the children treated by
GPs at private clinics, in HMOs, or by CPDs claimed that they consumed daily medication,
respectively (P ¼ .038).
Regarding toothbrushing frequency, significantly fewer children treated in hospital-related clinics
brushed their teeth by themselves (20%) compared with other groups (51.9%, 64.7%, and 63.6% of
children who were treated by GPs at private clinics, in HMOs, or by CPDs, respectively; P ¼ .035).
More carious lesions were diagnosed in children treated in hospital-related clinics (20%) than in
children treated by GPs at private clinics (5.8%), in HMOs (11.0%), or by CPDs (11.2%) (P ¼
.002). Children treated by GPs in private clinics received a diagnosis of carious lesions significantly
less often than children treated by GPs in HMOs or children treated by CPDs (5.8% versus 11.0%
and 11.2%, respectively; P ¼ .002).
Significantly more children treated in hospital-affiliated clinics reported symptoms of TMD for
the first time than children treated by GPs at private clinics, in HMOs, or by CPDs (10% versus
3.8%, 5%, and 2.5%, respectively; P < .001).

Receiving oral health care during the COVID-19 pandemic

Table 5 summarizes the distribution of answers regarding receiving or canceling dental examination
or treatment during the COVID-19 pandemic. Among the study children, 76 (24.9%) claimed that
they have not yet visited their dentists since the start of the COVID-19 lockdown, and only 56.7%
received regular dental examinations. Among those, 14% received a diagnosis of more carious le-
sions during the last dental examination than before. New carious lesions were diagnosed more
frequently in younger children. For the age groups younger than 6 years, 6 through 10 years, and 11
years and older, the percentages of children who received diagnoses of new carious lesions were
16.25%, 10.1%, and 7.2%, respectively (P ¼ .007).
Regarding receiving dental treatment during the pandemic, 46 (15%) reported that they canceled
an appointment for treatment, and 19 (6.2%) would have canceled their appointment if they had
one.

Oral manifestation of emotional stress during the pandemic lockdown

According to the questionnaire responses, 3.9% of the children had, for the first time, symptoms of
TMD during the pandemic lockdown, and 1 patient (0.3%) had symptoms of TMD more frequently
than the period before the lockdown. Furthermore, 6.8% of the children experienced RAS for the
first time. Symptoms of TMD or RAS were not correlated with age.

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 Table 5. Distribution of answers to the questionnaire regarding receiving or canceling dental appointments and
treatment during the COVID-19 pandemic.

VARIABLES ANSWER OPTIONS TOTAL NO. (%)

Canceled or Postponed Dental Examination Yes 70 (22.8)
During the COVID-19 Lockdown

No 174 (56.7)

We did not have an appointment, but if we had, 44 (14.3)

we would not have canceled it

We did not have an appointment, but if we had, 19 (6.2)

we would have canceled it

Canceled or Postponed Dental Treatment Yes 46 (15.03)

During the Lockdown

No 192 (62.75)

We did not have an appointment, but if we had, 49 (16.01)

we would not have canceled it

We did not have an appointment for treatment, 19 (6.21)

but if we had, we would have canceled it

Need of Urgent Oral Health Care During Yes 44 (14.3)

the COVID-19 Lockdown

No 264 (85.7)

Availability of Urgent Oral Health Care It was easy to schedule an appointment 119 (78.8)

We had difficulties in scheduling an appointment 22 (14.6)

and were referred to a large medical center

We were unable to schedule an appointment 10 (6.6)

Diagnosis of New Carious Lesions After the Have not visited the child’s dentist since the 76 (24.9)
Lockdown lockdown

Visited their dentist:

n The dentist diagnosed more carious lesions 32 (10.5)

than usual

n The dentist did not diagnose more carious 197 (64.6)

lesions than usual

DISCUSSION
The aim of our study was to assess the effect of the COVID-19 lockdown on children’s oral health.
One aspect of maintaining good oral health is limiting the frequency of eating food (healthy and
snacks) and drinking sugary drinks to 6 times a day. In our survey, we found that 62.7% of the
children reported increasing the number of meals or snacks per day by 1 through 2 times, 3 through
4 times, or even more. In contrast, 54.4% of the children increased their frequency of consuming
healthy meals. Despite the presence of parents at home, only 3.2% through 4.2% of the children
decreased their frequency of consuming snacks or healthy meals per day. Our findings are in
accordance with those of others researchers who have found that approximately 61% of children in
kindergarten and school consumed more snacks during the lockdown,4,6 and only 4.6% of the
children younger than 14 years decreased their frequency of a cariogenic diet.5
Our finding regarding increased consumption of sugary and carbonated drinks during the
pandemic is novel and important because this behavior may increase the risk of developing caries
significantly.14 Children in all age groups increased their frequency of consuming snacks and sugary
drinks between meals, although the magnitude of the increase was more profound in the older age
group. In contrast, carious lesions were diagnosed more frequently in children younger than 6 years.
These findings may be related to the lower effectiveness of toothbrushing among the younger
children or to the fact that these children usually use toothpaste containing low fluoride concen-
tration (< 1,000 parts per million) owing to the taste. These findings may have implications for
dentists during the examination appointments of children in general and younger children in
particular.

446 JADA 153(5) n http://jada.ada.org n May 2022

Table 6. Kendall correlations between alteration in consuming food and sugary drinks between meals and maintenance of oral hygiene and dental
treatment during the COVID-19 lockdown.

VARIABLES RELATED TO MAINTENANCE OF ORAL VARIABLES RELATED TO ALTERATION IN CONSUMING

HYGIENE AND HEALTH FOOD AND SUGARY DRINKS DURING THE COVID-19 PANDEMIC

Consuming More Consuming More Drinking More Sugary

Frequently Healthy Meals Frequently Snacks and Sweets Drinks Between Meals
Per Day s Value (P Value)* Per Day s Value (P Value)* s Value (P Value)*
Child’s Age 0.019 (.68) 0.17 (< .001) 0.07 (.11)

Parents Stayed at Home During COVID-19 Lockdown 0.1 (.047) 0.041 (.43) 0.0725 (.17)

Parents Brush the Child’s Teeth 0.0142 (.78) e0.11 (.03) e0.05 (.33)

Child Decreased Frequency of Toothbrushing 0.019 (.71) 0.068 (.19) 0.168 (.001)

Child Changed the Timing of Toothbrushing e0.12 (.031) e0.1 (.07) e0.11 (.04)

Parents Postpone Periodic Examination 0.0456 (.009) e0.0162 (.80) 0.0162 (.34)

Parents Postpone Treatment 0.058 (.044) e0.053 (.63) e0.0080 (.49)

* P values via c or Fisher exact tests.

2

80
71.3
70
62.7
60 54.4

50
41.4 43.2 42.7
%

40
34.1

30

20
14.3 12.7 11.7
10 6.8
3.2 4.2 4.6 4.9 4.9 4.9

0
No change Less frequently Any increased 1-2 times more 3-4 times more > 4 times more
freqency freqently freqently freqently
Alteration in frequency
Snacks Healthy food Sugary and carbonated drinks

Figure 1. Alteration in the frequency of consuming snacks and healthy food and drinking sugary and carbonated drinks
between meals by children during the COVID-19 lockdown relative to the previous period.

An additional negative effect of consuming more snacks and meals per day and staying at home
without performing physical activities is gaining weight. Indeed, 37.2% of the parents reported that
they knew for sure or suspected that their child gained weight during the lockdown period. These
changes cause deterioration not only in dental health but also in systemic health, and, therefore,
they reinforce the need to address the issue with parents and children.
Another aspect of maintenance of oral health is the frequency of toothbrushing. We found that
25.1% of the children decreased their frequency of toothbrushing in the morning, evening, or both.
These findings are in accordance with 2 other studies that found that 22.9% and 21.9% of children
decreased their frequency of toothbrushings4,7 However, these results are slightly better than those
reported by Baptista and colleagues,7 who found that 42.7% of the children aged 3 through 15 years
changed their oral hygiene habits. The decreased frequency of toothbrushing reported in our study
was greater among older children who brush their teeth by themselves (Fisher test, P ¼ .0036).
These children also changed their timing of toothbrushing more frequently than children younger
than 6 years (P ¼ .072; Table 4). Accordingly, it could be speculated that alteration in the daily
routine also may have an impact on the deterioration in maintaining oral hygiene.
In our study, which was conducted 1 year after the beginning of the pandemic, we found that
24.9% of the children still had not received a dental examination and 15% had not yet received any

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 100
91.9
90

80

70
61.2
60
52.2

%
50
39.1
40

30
23.7
20 15.1
8.7
10 6.1
2
0
<6 6-10 ≥ 11
Age of children, y
Alone Parents Child and parents

Figure 2. Distribution of children according to their age and according to who brushed their teeth.

90
80.9
80
74.8
70.7
70

60

50
%

40

30

20 15.8 14.1
11.8
10 8.1 7.1
4.4 4.3 5
2.9
0
No change Decreased in morning Decreased in evening Decreased in morning and
evening
Alteration in frequency
Age < 6 y Age 6-10 y Age ≥ 11 y

Figure 3. Alteration in the frequency of children’s toothbrushing during the COVID-19 lockdown.

dental treatment. A dental examination, in addition to diagnosing new development of carious

lesions, usually is accompanied by preventive treatments such as application and repair of fissure
sealants and topical fluoridation. Skipping these treatments may further increase the risk of
developing caries. Indeed, 14% of the children who visited their dentist after the lockdown periods
received a diagnosis of more carious lesions than in previous years. Accordingly, we recommend that
dentists make a focused effort during dental examinations to conduct a detailed interview regarding
changes in food consumption and toothbrushing habits, as well as take steps to increase the ability
to diagnose (such as obtaining more frequent bite-wing radiographs) and prevent caries.
Because the pandemic is ongoing, dentists should consider using teledentistry (TD). TD involves
the exchange of clinical information and images over remote distances for dental consultations and
treatment planning. TD offers several advantages in the dental examination and suggestion of
emergency treatment in patients without involving the risk of being infected by COVID-19.27
Accordingly, TD can be used for patients who need emergency examinations or treatment for

448 JADA 153(5) n http://jada.ada.org n May 2022

alleviating pain or infection. TD can also be useful also for providing instructions for home care of
injured teeth and tissues for optimal healing.
Another adverse effect of the COVID-19 pandemic has been increased emotional stress of the
children, which has been expressed via reports of first-time symptoms of TMD or RAS during the
lockdown in all age groups. Accordingly, symptoms of TMD and RAS may serve as an indicator for
children’s emotional status and the need for emotional support during times of crisis, such as the
COVID-19 pandemic.
The main limitation of our study is inherent to the study design: the use of a parent-reported
questionnaire, which may lead to misreporting of data. However, the information our study pro-
vides will help design strategies in the prevention and care of children for oral damage caused during
confinement due to the pandemic.

CONCLUSIONS
Pediatric dentists should be aware of the changes in children’s oral hygiene maintenance during the
COVID-19 pandemic and their consequences on children’s dental health. Therefore, we recom-
mend comprehensive habit evaluation, dental examination, instructions, and prevention. We also
suggest that further similar long-term studies in other locations be conducted to extend the findings
from our study in other populations. n

Dr. Gotler is a faculty member, Pediatric Dentistry Clinic, Oral Medicine Dr. Ashkenazi is the director, postgraduate program in pediatric
Unit, Sheba Medical Center, Tel-Hashomer, Israel. dentistry, Pediatric Dentistry Clinic, Oral Medicine Unit, Sheba Medical
Dr. Oren is a faculty member, Pediatric Dentistry Clinic, Oral Medicine Center, Tel-Hashomer, Israel 5262000, email malka.ashkenazi@sheba.
Unit, Sheba Medical Center, Tel-Hashomer, Israel. health.gov.il. Address correspondence to Dr. Ashkenazi.
Dr. Spierer is the deputy head, Pediatric Dentistry Clinic, Oral Medicine Disclosures. None of the authors reported any disclosures.
Unit, Sheba Medical Center, Tel-Hashomer, Israel.
Dr. Yarom is the head, Oral Medicine Unit, Sheba Medical Center, Tel- This study was founded by the Oral Medicine Unit, Sheba Medical Center,
Hashomer, Israel, and a clinical associate professor, School of Dental Tel-Hashomer, Israel.
Medicine, Tel-Aviv University, Tel-Aviv, Israel.

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