The COVID-19 pandemic has been going on for more than two years. As a result, thousands of fatalities and millions of cases have been documented globally. As per the American Academy of Pediatric Dentistry, individuals with CSHCN may be at an increased risk for oral diseases throughout their lifetime. Habits such as teeth grinding, clenching, food pouching, mouth breathing and tongue thrusting commonly noticed contribute further to oral diseases. The new post-pandemic routine may impact the family well-being by reducing its income, raising fears, and increasing anxiety, stress, and instability which adds to the already burdened caregivers of these children who are dependent on them throughout their lifetime.,
Children with special healthcare needs require constant attention and assistance in facilitation of their routine oral healthcare practices irrespective of the pandemic, which could justify why 104 parents (68.0%) in our study reported that they noticed no change in their child’s toothbrushing habits even during the pandemic. However, in contrast, it was observed that the pandemic had a detrimental impact on the daily toothbrushing habits of 6 to 11 years old Peruvian children which was linked to economic and emotional instability of these families that deprioritized non urgent practices like toothbrushing and 25.1% of the children evaluated by Gotler et al. who revealed that lower frequency of toothbrushing was greater among older children who brush their own teeth and speculated that it was an impact of alteration in daily routine (2022) Other studies found that 22.9% and 21.9% of children decreased their frequency of toothbrushing, 16 parents (10.5%) reported an increase in their toothbrushing frequency which was also observed by Costa et al. (2022) that revealed that 12.9% of Spanish children and 14.3% of Portuguese children of caregivers with higher level of education increased the frequency of toothbrushing during the lockdown when compared to the previous period. Mothers statistically significantly (p < 0.01) responded with observing no change in assisting their child in toothbrushing during the pandemic. This could be attributed to the fact that mothers are the primary caretakers of children ever since their birth. Parents from upper SES found no change in their ability to supervise oral care as compared to those from a lower SES (p < 0.01). This could be accredited to the work-from-home scenarios allowing more time around children along with higher awareness and adequate income to provide full-time, stay-at-home maids.
25.5% of parents reported a significant incline in their child’s sweet intake during the pandemic as compared to before. The new routine, work-at-home for parents, remote classes for children and economic instability have contributed to changes in dietary habits. The findings were comparable to a study by Bairagi et al. in 2022 demonstrating that the cost of staple foods like rice and atta (wheat flour) dramatically increased during the pandemic compared and families may have shifted their demand away from basic meals; whereas pasta, sandwiches, snacks, and other items with high sugar content and poor nutritional value may be more reasonably priced options. Similarly it is reported that there was an increased consumption of sugary drinks and potato chips while consuming fewer vegetables and fruits amongst Italian children during the COVID-19 outbreak.21, In a study involving adolescents aged 10 to 19 years, Ruiz-Roso et al. found ingestion of sweet foods increased among 7.1% of teenagers who did not consume any sugary foods at all before lockdown A significantly high number of parents i.e. 39 reported an increase (25.5%) in food pouching in their children. Increased screen time during the lockdown can be linked to such an increase as it leads to less control of the tongue and cheek, which are important auxiliaries for digestion and elimination of food from the oral cavity.
More than half of the parents (n = 102) admitted that their child had an episode of pain (66.7%) and 84 observed new cavities in their teeth (54.9%) during the COVID-19 pandemic. Apart from the aforementioned reasons for deteriorating children’s oral health, an increase in screen time could be a confounder as it also exposes children to commercials of caries-inducing foods and beverages. In line with the major complaints, in another study, several children (32.3%) were identified as having dentoalveolar abscesses during the lockdown and the most frequent result (36%) was caries during the times of the lockdown. There was a statistically significant (p < 0.01) corelation between appearance of caries in children of lower-class SES. The majority of parents (70.2%) stated that financial constraints to provide basic necessities (food, clothing, shelter) led to negligence in seeking dental care with a statistically significant (p < 0.01) response from mothers. With the loss of jobs and income for certain families the pandemic likely amplified one or more of these barriers to oral health care for the majority of families. This led to a reduction in dental visits as only half of the total respondents 78 had attended dental clinics (51.0%) during the pandemic. Skipping out on these services can have an impact on a child's growth. Avoiding basic dental care may cause periodontal disease, dental infections, caries, and neglect of dental injuries, as well as worsen oral health. Guo et al. observed a 38% drop in patients visiting the dental emergency clinic in Beijing, China at the start of the COVID-19 epidemic, which is consistent with our data. In a public health system in Israel, Tobias et al. observed a decrease in dental emergency treatment from March 17 to April 30, 2020.
Structural barriers such as the dentist's attire, additional screening and other mandatory protocols created inconvenience among 67.9% of respondents attending the operatory. Apart from this, the compulsion of having only one parent to accompany the child was a difficulty for about one-third 25 (32.0%), of the patients as these children often need a companion to talk and play around, whereas 12 (15.3%) found empty waiting rooms due to which there were fewer patients, lack of social interactions and inability to form a connection with other patients as an additional hurdle for attending the operatory. 74 parents were afraid of their child contracting the virus in the dental operatory (48.4%). Since parents with higher levels of fear are also more likely to take their children to the dentist only in dental emergencies (66.6%), it leads to greater caution when seeking dental treatments. An Australian qualitative study that indicated that parents of challenged children avoided taking them to doctor's appointments out of worry about contracting the disease lends credence to our conclusions. This shows that those who care for people with impairments may experience the pandemic's effects more acutely than others. On the contrary, Sabbagh et al. in 2022 found that as the pandemic progressed, caregivers eventually gained confidence on the sanitary measures and a decline in fear of seeking dental treatment was observed Travel restrictions were a barrier to attain dental care for a significant number of respondents. Manoeuvring logistics for specially-abled individuals with wheelchairs requires more resources, manpower and structural designing. A lack of appropriate vehicle services, preponderance of tertiary healthcare in primate cities, absence of training and awareness among nurses and medical professionals on specific needs of these vulnerable people, neo developmental children, all added up to creating challenges ; not to mention empathy, especially in nursing and care that was short in supply. 20
Merely 14.4% of the parents were aware of the concept of teledentistry. Parents with low education status statistically significantly (p < 0.01) lacked awareness about Teledentistry. Remote consultations can maintain the level of care by bringing the parents together and assisting them in understanding the issues of CSHCN especially during emergency situations in the new era of social isolation.
Limitations of the study
1. This cross-sectional study appraised the response only of parents who attended the clinic after the first two outbreaks of the pandemic and disregarded on those who still did not have access to dental care.
2. Parents below poverty line who could not afford mobile phones and older parents who could not use google forms were not evaluated, which could act as a selection bias.
3. Challenges faced by the caregivers would vary for different kinds of disabilities as various oral conditions are more prevalent in a certain group as compared to the other. For this reason, it would be better to segregate each type of disability and understand their difficulties separately.
4. As the parents were interviewed about their past experiences and challenges faced during the oral health management of their children, there was a likelihood of a recall bias.