key: cord-0830830-t4s2f8dy authors: Samuel, Srinivasan R; Kuduruthullah, Syed; Khair, Al Moutassem B; Shayeb, Maher Al; Elkaseh, Abed; Varma, Sudhir R title: Dental Pain, Parental SARS‐Cov2 Fear and Distress on Quality of Life of 2‐6‐Year‐Old Children During COVID‐19 date: 2020-11-21 journal: Int J Paediatr Dent DOI: 10.1111/ipd.12757 sha: e189eabbf0e5a981072e7e643ad9ba9483b07172 doc_id: 830830 cord_uid: t4s2f8dy BACKGROUND: Corona virus disease (COVID‐19) has crippled life, families and oral health care delivery in India due to nation wide lockdown. AIM: Through cross‐sectional design we investigated the impact of child’s dental pain, caregiver’s fear of SARS‐CoV2 and parental distress on oral health related quality of life (OHRQOL) of preschoolers during the nationwide COVID‐19 pandemic lockdown. DESIGN: Preschool children self‐reported their pain using pieces of hurt scale; caregiver SARS‐CoV2 fear was assessed using fear of COVID‐19 scale and parental distress evaluated using 4‐item scale. Child’s oral health assessed using dmft index and OHRQOL evaluated using early childhood oral health impact scale. Bivariate, multivariate regression analysis was conducted to identify predictors; statistical significance was set at 5%. RESULTS: Sample mean age was 4.58 years, and about 69% were boys. Children reporting higher pain scores (OR=1.9) due to decayed teeth and having dmft >5 (OR=4.25); followed by greater parental distress (OR=4.13) and fear of SARS‐CoV2 (OR=3.84) were significantly associated with poor OHRQOL during the COVID‐19 pandemic. CONCLUSIONS: Greater parental distress and fear of COVID‐19 among caregivers, higher self perceived dental pain among children and caries experience is associated with poor OHRQOL of preschool children during the COVID‐19 pandemic. The 2019 novel corona virus (SARS-CoV-2) has infected 10.3 million people and has caused over 503000 deaths world wide as of June 30, 2020. India, enforced the strictest lockdown in the world to control the COVID-19 pandemic. Tamil Nadu, the southern most state in India reported 86224 confirmed cases, and 1141 deaths as of June 30, 2020 and state lockdown had been extended until July 31, 2020 to control the disease. COVID-19 severity among children and younger adults is reported to be mild, 1 but a greater number cases among infants and younger children are emerging. 2 COVID-19 pandemic has restricted children inside their homes which can affect them mentally, 3 and in China, 3-6-year-olds were more likely to exhibit symptoms of behavior, emotional disorders during this pandemic. 4 Furthermore, caregiver's anxiety and fear of acquiring SARS-CoV2 infection exacerbates their emotional distress and can worsen the stress of parenting during lockdown. 5 Dental services are one of the worst hit during COVID-19 pandemic as all non essential services were restricted and almost all practices were closed due to fear of SARS-CoV2. Early childhood caries (ECC) is an endemic disease in India and its prevalence in Tamil Nadu is reported to be 63.4%. 6 ECC negatively impacts the oral health related quality of life (OHRQOL) of children and their parents, 7 and children often need emergency management as it causes severe pain or life threatening infections. COVID-19 pandemic is a unique situation causing severe and lasting psycho-social impact on families which can affect their child's mental health. Moreover, a child suffering from dental pain during this pandemic can impact the whole family as oral health services are unavailable during lockdown, and over the counter painkillers are restricted. Hence, we evaluated the impact of child's dental pain, parental distress and parental fear of SARS-CoV2 on the OHRQOL of 2-6-year-old children visiting emergency care in a tertiary dental institution during the COVID-19 pandemic in Chennai, India. This article is protected by copyright. All rights reserved This cross-sectional study was conducted among parent-child dyads who visited our dental institute from March-June 2020 to manage their child's dental pain as dental services were not available any where else in the city. The protocol was approved by the institutional ethical committee (SDC/SIHEC/2020/0619-0320) and only parents who provided consent were included in the study. Positive travel history, contact with COVID-19 patients, from containment zones, symptoms of fever, and not willing to consent were excluded from the study. Convenience sampling was employed and every parent-child dyad visiting the center was invited to participate in the study. Among those who agreed to participate, demographic characteristics such as age, gender of child, annual family income and gender of caregiver accompanying child were recorded. Children were requested to report their dental pain using pieces of hurt pain scale, 8 following which caregivers reported the impact of child's oral health on their child (CIS-9 item) and family (FIS-7 item) using early childhood oral health impact scale (ECOHIS-13 a item). 9 Parental distress a was assessed using a four item questionnaire described here. 10 Each item was graded from 1 (Never) to 4 (Always) and the scores were added to have an aggregate parenting stress score and higher scores indicated greater stress. The fear of SARS-CoV2 infection was assessed using fear of COVID-19 scale (FCV-19S a ). It is a seven-item questionnaire with response rated on a five-item likert scale ranging from strongly disagree to strongly agree and the score ranges from 7-35; higher scores indicating grater fear of COVID-19. 11 The validity of questionnaire used were checked using back translation from Tamil to English and was found satisfactory. Reliability of the questionnaires was assessed among 20 caregivers randomly using test-retest and intra-class correlation was found to be greater than 0.80 for all three scales. Oral examinations were performed by two trained pediatric dentists who diagnosed dental caries experience based on dmft index for deciduous dentition and the inter-examiner reliability was 0.96. Based on the initial diagnosis and distance to travel for treatment; extraction, single/multi-visit pulpectomy was performed to alleviate the pain symptoms. Data was analyzed using SPSS V 23 (IBM, IL, CH). Crude associations of independent variables with OHRQOL were assessed using chisquare and independent T test. Adjusted associations were estimated using multivariable logistic regression; ECOHIS and dmft were dichotomized into high/low based on median scores for regression analysis. A total of 3799 parent-child dyad visited our institution from March-June 2020, and only 222 fulfilled the inclusion and exclusion criteria. Sample baseline characteristics are presented in Table 1 . Mean age of children was 4.58 years, 69.2% were males and mean dmft was 6.45 (3.6) . Almost 45% of the caregivers reported annual family income of less than four lakh rupees (5555.5 USD), 64% had high This article is protected by copyright. All rights reserved fear of SARS-CoV2 infection and 36% reported greater parental distress. Tooth extraction (92), single visit pulpectomy (110) and pre-fabricated stainless steel crowns (SSC) were placed in 89 children. Multiple visit pulpectomy with SSC was performed in 20 cases. All the variables except child's age and gender were significantly associated with OHRQOL at the bivariate level (Table 2) , and only significant variables were included in the regression model. Higher pain scores reported by the child increased the risk of poorer OHRQOL by almost two times (OR, 1.9; 95% CI 2.6-16.8); dmft score >5 increased the (OR, 4.2; 95% CI, 1.1-13.6) odds by four times.Greater parental distress (OR, 4.1; 95%CI, 1.3-12.7) and fear towards COVID-19 among parents (OR, 3.8; 95%CI, 1.1-13.0) were significantly increased the risk of poor OHRQOL of the child by almost four times as compared to parents with lower distress and fear of COVID-19 (Table 3 ). ECC is an endemic problem in India and millions of children suffer from this debilitating disease world wide. This cross sectional study was conducted to assess the impact of dental pain caused by untreated decayed teeth in preschool children, and parental distress, COVID-19 fear on the OHRQOL of the child during national lockdown. Higher scores of self reported pain and dental caries experience, greater parental fear of SARS-CoV2 and distress during the pandemic lockdown were negatively associated OHRQOL of the child. COVID-19 has caused unprecedented challenges towards seeking and provision of routine dental care due to fear of SARS-CoV2. The primary route of transmission of SARS-CoV2 is through respiratory droplets and saliva, 12 and dentists are among the most exposed to the COVID-19 infection as almost every procedure generates salivary bioaerosols at close proximity 13 and SARS-CoV2 can transmit through aerosols. 14 SARS-CoV2 survival on surfaces like plastics, cupboards, stainless steel and masks can range from 8h to 7 days depending on environmental conditions, risks the entire dental team. 14 Routine Dentistry and oral surgery procedures generating aerosol have been suspended in several countries and Indian government posed restriction on all elective dental procedures during COVID-19 national lockdown. Pediatric cases pose unique threat as majority children are secondary cases due to confinement, and show no symptoms of COVID-19, but can transmit the disease. 1 World health organization and united nations children education fund have provided recommendations to caregivers regarding reduction of parental stress while dealing with their healthy children. COVID-19 has disrupted the child's routine by closing preschools, playgrounds and they are not able to meet their friends which can lead to distress and confusion. 15 Further, a child suffering from pain during this pandemic can become more demanding, impatient and hostile, and distressed parents can further exacerbate the fragile situation and cause florid mental distress in the child. 3 Parental distress is further exacerbated by lack of access to care and their inability to alleviate child's pain during this COVID-19 pandemic. To the best of our This article is protected by copyright. All rights reserved knowledge only one protocol has reported studying the parental stress during COVID-19 and their association with depression and anxiety (https://clinicaltrials.gov/ct2/show/NCT04377074). ECC is an chronic infectious disease affecting children below six-years and cause acute phases of pain. Parents of children suffering from asthma, diabetes, cancer, juvenile rheumatoid arthritis report greater distress, 16 and ECC is no exception. Caregivers who reported higher distress score negatively impacted their child's OHRQOL and we believe we may be the first to report an association between parental distress and child OHRQOL. Fear of COVID-19, termed as 'coronaphobia' caused by the unpredictable nature of the disease, uncertainty and fear of getting infected leads to mental distress and behavior change in common people. 17 Caregivers who expressed greater fear towards COVID-19 could have delayed the care required for their child thus negatively impacting their OHRQOL. Further, lack access to care close to home can be a significant predictor as majority caregivers had travelled atleast 10 miles for oral care. Poor oral health, decayed teeth and dental pain are established risk factors for poor OHRQOL in preschool children, and the same was found in our cohort too 18, 7 Major strength of our study includes the assessment of COVID-19 fear, parental distress and child's self report of pain. The usual predictors such as economic status (annual family income), gender, and age of the child were not significant in the multivariate analysis; this finding helps us comprehend the impact of COVID-19 upon families and child's oral health, highlighting the need for prospective studies to establish the causality. Limitations include the lack of elaborate data on demographics, psychological assessment such as depression/anxiety among the caregivers and comprehensive behaviour assessment of the child. Lastly, cross-sectional nature of the study prevent us from establishing causal associations. COVID-19 has universal impact and we believe our results can be generalized globally as schools are still closed, and majority of countries are enforcing new lockdowns and travel restrictions In conclusion, greater parental distress and fear of COVID-19 among caregivers, higher self perceived dental pain among children and caries experience was associated with poor OHRQOL of preschool children during the COVID-19 pandemic lockdown in South India. Why is this paper important to pediatric dentists  Pain from odontogenic origin in preschool children during a pandemic can negatively impact the child's OHRQOL  Greater fear of SARS-CoV2 among parents negatively affects the OHRQOL their child, and it might affect how parents seek dental care during the pandemic increasing the unmet dental needs in the child This article is protected by copyright. All rights reserved  Child suffering from pain during a pandemic and can impact a whole family as their are confined in their homes, which can adversely affect the OHRQOL of the child. The study was approved by IEC (SDC/SIHEC/2020/0619-0320) and informed consent was obtained form the parent before enrolling in the study. Conflict of Interest Statement: The authors have no conflicts of interest to declare. "Problems with the teeth, mouth or jaws and their treatment can affect the well-being and everyday lives of children and their families. For each of the following questions please circle the number next to the response that best describes your child's experiences or your own. Consider the child's entire life from birth until now when answering each question. If a question does not apply, check 'Never"' Response options: 1. Never, 2. Hardly ever, 3. Occasionally, 4. Often, 5. Very often and 6. Don't know. Coronavirus Disease 2019 (COVID-19) in Children -What We Know So Far and What We Do Not Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Psychosocial impact of COVID-19 Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic The pandemic of social media panic travels faster than the COVID-19 outbreak School Interventions-based Prevention of Early-Childhood Caries among 3-5-year-old children from very low socioeconomic status: Two-year randomized trial Impact of early childhood caries on the oral health-related quality of life of preschool children and their parents The preoperational child's reaction to immunization Parental perceptions of children's oral health: the Early Childhood Oral Health Impact Scale (ECOHIS) Associations of parent coping, stress, and well-being in mothers of children with diabetes: examination of data from a national sample Scale: Development and Initial Validation Saliva-Friend and Foe in the COVID-19 Outbreak Urgent dental care for patients during the COVID-19 pandemic Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Mitigate the effects of home confinement on children during the COVID-19 outbreak Parenting stress among caregivers of children with chronic illness: a systematic review Fear and the 2019-nCoV outbreak Toothache, associated factors, and its impact on Oral Health-Related Quality of Life (OHRQoL) in preschool children How often has your child had pain in the teeth, mouth or jaws? because of dental problems or dental treatments? (Child function domain) preschool, daycare or school How often has your child because of dental problems or dental treatments? (Child self-image/social interaction domain) because of your child's dental problems or dental treatments? (Parent distress domain) 10. been upset 11. felt guilty How often because of your child's dental problems or dental treatments 13. has your child had dental problems or dental treatments that had a financial impact on your family? Fear of Coronavirus-19 Scale Citation The participants indicate their level of agreement with the statements using a five-item Likert-type scale. Answers included "strongly disagree I am most afraid of coronavirus-19. 2. It makes me uncomfortable to think about coronavirus-19 My hands become clammy when I think about coronavirus-19 I am afraid of losing my life because of coronavirus-19 When watching news and stories about coronavirus-19 on social media, I become nervous or anxious I cannot sleep because I'm worrying about getting coronavirus-19 Associations of parent coping, stress, and well-being in mothers of children with diabetes: examination of data from a national sample Each item was rated by the respondent on a scale from 1 (Never) to 4 (Always). Item ratings were then summed together to create a total parenting stress score CHILD] is much harder to care for than most children [his/her] age? 2. During the past month, how often have you felt [he/she] does things that really bother you a lot? 3. During the past month, how often have you felt you are giving up more of your life to meet