According to the results of the current investigation, there was a high utilization of dental examinations (81.5%) and dental hygiene appointments (54.2%) by older seniors despite the COVID-19 pandemic, which was independent on an assigned care level. However, they found it difficult to find, understand, and use information regarding COVID-19, especially when they had an assigned care level. Thus, the working hypotheses of this investigation were partially rejected.
The high response rate to the questionnaire indicated a high activity level of the older seniors in Leipzig. Of the respondents, 21.3% stated that they had an assigned care level, which corresponds to nationwide data from Germany. According to the German “care statistics”, approximately 20.0% of Germans aged between 75 and 85 years require care . Regarding the vaccination status, the rate of the respondents with at least one vaccination shot (32.1%) was higher than the average vaccination rate in Germany (26.2%)  or Saxony (19.9%)  at the same time. This might be due to the fact that older seniors are categorized as highest priority for vaccination in Germany , whereas national and federal data include all age and priority groups.
The analysis of the older patients’ utilization of dental services represents a higher utilization rate than reported by the population-representative studies “Health in Germany up-to-date” (GEDA; 75.3%)  and the Fifth German Oral Health Study. According to the latter, approximately 73.9% of older seniors had utilized a dental examination within the previous year, whereas older seniors with assigned care levels presented a lower utilization of 52.7% . Another investigation stated an annual use of dental services by approximately 81.0% of older adults in Germany . However, in these studies, participants aged 65–75 were also involved and their answers included the frequency of both dental examinations and dental hygiene appointments. Considering that several studies revealed a decrease in utilization of dental services due to the COVID-19 pandemic [30–32], a frequency of 81.5% observed in the present study is high. This might be due to the fact, that dental clinics are considered institutions with a high standard of hygiene, implicating a self-perceived low risk for a virus transmission . Another reason for a high utilization rate might be the fact that participants of the investigation were patients of the Dental Clinic of Leipzig University, that promotes a consistent recall system. There are personal reminders regarding annual examinations or dental hygiene appointments, which might have helped reducing fears or worries toward a possible COVID-19 infection during dental treatment. Moreover, the Medical Clinic of the University of Leipzig has a good reputation among the population, especially as COVID-19 patients from other countries were successfully treated in both the medical and dental clinic. It is possible, that this helped with achieving high utilization rates of dental services, whereas patients of smaller private practices might have had less trust in hygiene concepts and therefore, possibly, used dental services less often. On the other hand, some people might prefer treatment in smaller practices as they are lower frequented and therefore might present a lower risk of virus transmission by other patients. Moreover, as part of the German statutory health care system, patients attending at least one dental check-up per year qualify for monetary boni, which might have been a strong external motivation to attend a dental check-up. However, no information on the date of the dental visit was assessed in the current study; thus, older seniors could have utilized the dental services in the summer of 2020, when low incidence rates of the coronavirus were recorded in Germany.
Nonetheless, the utilization of dental hygiene appointments was lower than the utilization of dental examinations. This phenomenon might be explained by the fact that, in Germany, costs for dental examinations are fully covered by statutory health insurances, while professional cleaning of teeth and dentures usually requires additional payment by the patients themselves.
One third of the respondents primarily feared daily activities such as grocery shopping or going to the gym/hairdresser regarding a potential transmission of the coronavirus. This is not surprising as particularly indoor activities are supposed to facilitate COVID-19 infections [34, 35] and physical activities or speaking loudly seem to increase the risk of spreading the coronavirus . Although these risk factors also apply to spending time with family and friends or going to a dental practice, only a fifth of the participants considered these issues as high-risk activities. Older seniors might tend to trust family and friends more than foreigners, even though they usually allow more intense physical contact or increased time together. Regarding dental practices, the high hygiene standards that already existed pre-pandemic accompanied by the rapid advancement of COVID-19-specific hygiene concepts might have supported faith in the dental/medical institutions. This assumption is supported by data of the German Dental Association, revealing that 88% of Germans consider dental practices as institutions with a high standard of hygiene .
When analyzing the answers regarding the health literacy, it became obvious that more than half of the participants found it difficult to judge the reliability of information on COVID-19 purported in the media, emphasizing the assumption of an “infodemic” during the Corona crisis. As for the rapid gathering of knowledge, digital media are important and a high level of digital literacy is needed to find, evaluate, and use information. A limited access to digital media by older seniors might reduce possibilities to retrieve information, while lower digital skills can complicate a differentiation between information of trustworthy sources and dishonest ones, e. g., disinformation campaigns . In addition, latest information on COVID-19 transmission rates, behavior in case of an infection or information on professional help (e. g., corona tests or vaccination appointments) were usually published online first. These issues might have caused about 40% of the participants to state that they found it difficult to judge how to behave in case of an infection and where to get professional help. Besides, the survey was conducted during the “third wave” of the COVID-19 pandemic, which was characterized by an overload of information addressing, e. g., vaccination, risk areas, or masks. Moreover, there was a high level of frustration since restrictions in everyday life had been going on for several months. According to results of the modified HLS-EU-Q16, difficulties were increased when participants had an assigned level of care. Considering that over 70% of all participants requiring care were assigned to at least CL2 – representing a major impairment or even more – it seems a logical consequence that these people rate it increasingly difficult to find, understand, and use latest information.
The limitations of the current study include that it was not possible to assess, whether the utilization rates of dental services increased or decreased in the same cohort in comparison to the situation before the pandemic. As questions of the HLS-EU-Q16 had been modified it was not possible to determine a sum score comparable to reference values; however, frequencies determined for each question can be used for future comparisons. Moreover, the evaluated data only apply to the group of patients who are treated at the Dental Clinic of the University of Leipzig. As a clinic is usually operating differently than a common German dental practice with one or few dentists, the results of the present investigation do not represent the entire older German population. In order to gain a more comprehensive overview, a survey among same-aged patients of dental practices should be performed.