How Did the COVID-19 Pandemic Effect Dental Patients? An Italian Observational Survey Study

The primary aim of this observational survey study was to assess patients’ attitudes toward clinical dental practice during the COVID-19 pandemic; the secondary aim was to evaluate patients’ attitudes towards oral health by maintaining an appropriate lifestyle and oral hygiene at home. The questionnaire was developed using Google Forms. The questionnaire consisted of three parts: Part A—geographic, demographic, and personal data; Part B—patients’ attitude toward oral health selfcare and lifestyle; Part C—patients’ attitude toward dental practice. This survey, conducted during the months of November and December 2020, enrolled 1135 subjects throughout Italy. All data were statistically analyzed. COVID-19 has changed patients’ approach to dental procedures. Most of the people interviewed lived in families, and their greatest fear was infecting a family member. Restrictive measures forced people to stay at home, which led to an increased consumption of various types of food, including cariogenic foods. People said they felt safe when they went to the dentist, but they also paid special attention to measures to prevent contagion. Among the measures that should be introduced in similar situations in the future, people wanted telemedicine, a phone recall, and the possible use of video clips for home oral care instructions.


Introduction
In December 2019, the novel coronavirus (SARS-CoV-2) was identified in China; soon after, in February 2020, the virus spread to Europe, and finally, on 11 March 2020, the World Health Organization called it COVID-19 and declared it a pandemic [1]. By 25 March 2020, the country with the most confirmed COVID-19 cases was the United States, with 81,864 cases, and Italy was the most affected country in number of deaths, with 74,386 cases and 7503 deaths [1].
Health systems' capabilities and performance were the main issues in all the affected countries, and in the interest of "flattening the curve" [2], meaning to decrease the number of new cases and hence the number of patients requiring hospitalization-restrictive measures were put in place. The restrictions consisted in flight limitation, borders closing, shutting down cafes and restaurants, closing of schools, and self-isolation at first and restriction of movement afterwards, with a total lockdown being the last resort [2].
In this scenario, dental practice was identified as a working place with a most potential high risk of cross-infection, as face-to-face communication and consistent exposure to body fluids, such as blood and saliva, are frequent and common in dentistry [3].
COVID-19 transmission in dental settings was described, and it was assessed that it occurs through four major routes: (1) direct exposure to respiratory secretions containing droplets, blood, saliva, or other patient materials; (2) indirect contact with contaminated surfaces and/or instruments; (3) inhalation of suspended airborne viruses; and (4) mucosal (nasal, oral, and conjunctival) contact with infection-containing droplets and aerosols that are produced by dental procedures [4,5].
Control of infection transmission in dental offices was achieved through the use of well-defined protocols and operating procedures, with a strong recommendation for all the healthcare personnel to use personal protective equipment, such as masks, protective goggles, gowns, helmet, gloves, caps, face shields, and shoe covers. In the meantime, dental patients were also allowed to be treated with special considerations when treatment was urgent and could not be postponed. The combined use of mouth rinses, rubber dam, antiretraction handpieces, and disinfectants proved to lower the risk of COVID-19 transmission in the dental setting [6].
The primary aim of this observational survey study was to assess patients' attitudes toward clinical dental practice during the COVID-19 pandemic; the secondary aim was to evaluate patients' attitudes towards oral health by maintaining an appropriate lifestyle and oral hygiene at home.

Study Type
An observational survey study was carried out. The study was approved by the Institutional Review Board of territorial NHS facilities (n. 080420). The survey was carried out from 1 November to 30 December 2020.

Study Population
Patients in dental clinical settings throughout Italy were asked to answer to the questionnaire.

Data Collection Technique
A team of 10 hygienists belonging to the AtasioLab Research Club completed the questionnaire with patients in dental clinical settings throughout Italy. The questionnaire was developed using Google Forms (Google, Mountain View, CA, USA) tool.
The questionnaire consisted of three parts: Part A-geographic, demographic, and personal data (questions n = 10); Part B-respondents' attitude toward oral health selfcare and lifestyle (n = 16); Part C-respondents' attitude toward dental practice (n = 13).

Data Analysis Procedure
The R statistical program [7] was used for the calculations and graphical presentation of results. The variables in regression models were considered statistically significant at p < 0.05, and model specifications were chosen by Akaike Information Criterion (AIC) [8].

Part A-Geographic, Demographic, and Personal Data (Questions n = 10)
A total of 1135 subjects participated into the study. Female participants were 782 (68.9%) and male 353 (31.1%). Age ranges were 14-20, 3.0%; 20-40, 51.8%; 40-60, 38.2%; and 60-80, 7%. Area of geographic origin was 54.1% in the Center of Italy and 20.6% and 25.3% in the north and the south, respectively. The majority of the participants were married (63.9%). Single people were 25.9%, in separation 8.6%, and widow(er)s were 1.6%. The vast majority of 80.2% lived with family, while 19.8% lived alone; of these, 45.8% had children, and 54.2% did not. The level of education was basic, secondary, and higher for 6%, 47%, and 46.7% of the respondents, respectively. The major social characteristics of respondents are summarized in Table 1. In the second part of the questionnaire the patient's responses were collected regarding the frequency of professional oral hygiene sessions before and during the COVID-19 pandemic, changes in the direction of professional and at-home oral procedures during the COVID-19 pandemic, at-home oral hygiene habits during COVID-AP, and lifestyle changes, especially in the most important aspects of maintaining the health of oral cavities. The answers to the questions in this part are presented in Table 2.

Part C-Patients' Attitude toward Dental Practice (n = 13)
The answers to the questions contained in this part are presented in Table 3.

Regression Models
Logic regression model was used to evaluate the influence of a person's characteristics on the probability of eating too much (declaration of eating too much) and on the probability of introducing of cariogenic food during first lockdown. The person's characteristics included age, gender, region, living with family or alone, having children, education level, and having tested positive or not. Model specifications were selected based on Akaike information criterion (AIC).

Probability of Eating Too Much
Model estimation result is presented in Table 4. Living in the south macro region (comparing with north) and having tested positive in the past have statistically significant influence on the probability. Log of the odds ratio increases by 0.643 and 0.712 for persons living in the south region and for persons who have tested positive in the past, respectively. Figure 1 presents the probability response curves for persons living in north/south macro regions and those having tested positive/negative.

Probability of Introducing Cariogenic Food
Model estimation result is presented in Table 5.

Probability of Introducing Cariogenic Food
Model estimation result is presented in Table 5. Age, region, and living with family have statistically significant influence on the probability. The influence of age is negative (elder = less probable), and the influence of living in the center or south macro region (comparing with north) and of living with family is positive. Log of the odds ratio decreases by 0.19 for every 10 years of age; increases by 0.535 or 0.620 for persons living in the center or south, respectively; and increases by 0.595 for persons living in a family. Figure 2 presents the probability response curves for persons living in north/south macro regions and living with family or alone.

Discussion
This survey, conducted during the months of November and December 2020, enrolled 1135 subjects throughout Italy. The specificity of the organization of this study resulted from the possibility of engaging about 10 dental hygienists throughout the country, all belonging to the Atasio Scientific Association, which allowed for high capillarity in the distribution of enrolled subjects. The main objective of the study was to collect data on the attitudes of patients towards dental procedures in private settings, while the secondary objective was to collect data on lifestyle and the ability to maintain good oral hygiene at home. All the questions collected related to the period of restrictions during the COVID-19 pandemic, which hit Italy particularly hard.
The first wave of the COVID-19 pandemic begun in Italy in early March 2020, with restrictive measures as total lockdown in place until early May 2020. The second wave of the COVID-19 pandemic in Italy continued in November and December 2020, when this study was conducted. There was a curfew from 23:00 throughout Italy, the regions were closed, and it was not allowed to move from the province to the province except for proven health or work reasons. Moreover, school activities at all levels took place remotely; congresses, fairs, and all other events that normally involve gatherings were prohibited. Swimming pools, sports centers, spas, and cinemas were closed, and the population was instructed not to leave their homes unless for serious health or professional reasons, and all who may were called upon to work remotely. From 6 November, 2020, a

Discussion
This survey, conducted during the months of November and December 2020, enrolled 1135 subjects throughout Italy. The specificity of the organization of this study resulted from the possibility of engaging about 10 dental hygienists throughout the country, all belonging to the Atasio Scientific Association, which allowed for high capillarity in the distribution of enrolled subjects. The main objective of the study was to collect data on the attitudes of patients towards dental procedures in private settings, while the secondary objective was to collect data on lifestyle and the ability to maintain good oral hygiene at home. All the questions collected related to the period of restrictions during the COVID-19 pandemic, which hit Italy particularly hard.
The first wave of the COVID-19 pandemic begun in Italy in early March 2020, with restrictive measures as total lockdown in place until early May 2020. The second wave of the COVID-19 pandemic in Italy continued in November and December 2020, when this study was conducted. There was a curfew from 23:00 throughout Italy, the regions were closed, and it was not allowed to move from the province to the province except for proven health or work reasons. Moreover, school activities at all levels took place remotely; congresses, fairs, and all other events that normally involve gatherings were prohibited. Swimming pools, sports centers, spas, and cinemas were closed, and the population was instructed not to leave their homes unless for serious health or professional reasons, and all who may were called upon to work remotely. From 6 November, 2020, a curfew was applied throughout the country from 10:00 p.m. to 5:00 a.m. the next morning, and movement during this time period was to be only allowed due to the need to work or proven health reasons. The territory of the country was divided into white, orange, and red zones according to the values of the Rt number. In red zones with Rt values above 1.5, where there was a fear of overloading health services, very strict restrictions were in place, with travel bans, restaurants, shops, and malls closing; distance education from the second middle class; and only grocery stores and pharmacies open along with some personal services. These restriction measures were extended for an additional period of 50 days, lasting form 6 January 2021 until 7 July 2021 [10].
At the time of submitting the questionnaire, 64.8% of the respondents said they were negative for COVID-19 (Q9), while in the past, the percentage had risen to 79.5% (Q10). When it was asked if the participants knew someone who has contracted COVID-19, the vast majority say that 69.9% were friends, only 13.3% family members, and 4.2% has been ill themselves. A minority of only 12.6% said they had never known someone who caught the virus (Q39). This answer reflected the epidemic nature of the COVID-19 infection. Moreover, for the answer to question Q33, "What worries you the most?", where a maximum of two answers could be selected, the majority of responses (61.8%) focused on the probability that a family member contracted the virus; while 22.6% said they were concerned about being personally infected with the virus. These responses clearly showed how widespread the spread of the virus was and how fear for a family member was the basis for accepting the restriction measures. A recent work by Ornell F. et al. tried to understand the psychological and psychiatric repercussions of a pandemic and the emotions involved in it, such as fear and anger. The authors underlined that, according to the recent WHO and the U.S. Center for Disease Control and Prevention recommendations, a series of psychosocial and mental health measures during pandemics and large-scale disasters should be implemented over a large scale in populations [11].
In this scenario, the dental office was identified as a place where the risk of infection could rise to its maximum, as in dentistry, face-to-face communication and consistent exposure to body fluids, such as blood and saliva, are frequent and common [3,12,13].
The following questions (Q11 to Q18) were designed to examine the patients' relationship to dental procedures at the time of the questionnaire administration (November and December 2020) and before the COVID-19 outbreak to try to analyze the difference in choices between the before and after periods.
The analyzed sample consisted of people who, before the emergence of COVID-19, in the vast majority (83.2%) underwent professional oral hygiene once (46.5%) or twice (36.7%) times a year. Only 7.4% of the respondents declared that they had not submitted to a professional oral hygiene session even once a year (Q11). Following the onset of COVID-19, the 7.4% who previously had declared to had not had a single professional oral hygiene session per year increased by 47% (Q12). An increase of 40%+ of people who opted not to have professional oral care after the emergence of COVID-19 was explained by the fear of contracting or infecting their family members. Fifty-three percent of people who decided to undergo oral hygiene treatment anyway during the first and second wave of COVID-19 declared that 38.2% had undergone tartar ablation using ultrasound, 39.6% had manual tartar ablation, and only 3.8% reported whitening and 3.3% treatment of dentin hypersensitivity (Q13). These results are in accordance with the findings of a recent international survey by Campus G et al., where it was shown that access to routine dental care was reduced due to country-specific temporary lockdown periods [14]. The abovementioned increase in fear of infection among patients may be the most leading factor. With such a reduced frequency of visits, attention should be paid to the lack of profitability of medical activity due to the stable cost of maintaining the dental office. This could have had the obvious effect of diminishing the availability of care in less affluent settings [15].
Participants were asked on a scale of 0 to 10 to rate the extent to which the fear of undergoing dental procedures increased due to the possibility of contracting the COVID-19 virus (Q15) and to what extent this fear caused a change in lifestyle (Q16) and to what extent, as a consequence, the emphasis on home oral hygiene was changed (Q17). Interestingly, 39.1% declared 0 to question 15, but only 9.3% answered 0 to question 16, and more than a third of respondents declared that they had not changed their home oral hygiene habits at all. In addition, questions 19-21 were related to home oral hygiene routines. The vast majority 91.7% of respondents stated that they used a toothbrush (38.4% electric, 53.3% manual), and it is worth emphasizing that 8.3% of respondents declared that they did not use any type of toothbrush (Q19). The use of dental floss accounted for less than half of the sample (46.9%), and it is worrying that more than half, i.e., 53.1%, do not used it. It is worth noting that the data on the use of dental floss are much better than those reported in the literature. In fact, a Delta Dental survey conducted in 2014 showed that only four out of ten Americans floss daily, and 20% of American never floss [16].
Then 45.8% said they did not use any mouthwash, 29.1% used an ozone-based one, and 17.6% used a povidone-iodine one (Q20). Interestingly, ozone-based rinses have welldocumented effectiveness in neutralizing most kinds of viruses possibly present in oral cavity [17,18]. This information is in line with the initial data that indicated that subjects paid attention to dental health and that 83.2% received regular checkups and hygiene sessions. In fact, the use of ozone-and iodine-based mouthwashes reflects patients' access to information that can only be communicated in the professional sphere, emphasizing that they continued to care deeply about oral health and prevention. Probiotics were not used by 86.1% of the respondents, let alone the plaque detector (4.1%) and the tongue cleaner (1.1%) (Q21). Plenty of data exist on oral hygiene during COVID-19 pandemics. For example, a study by Bains KV and Bains R underlined that the oral cavity is portal for the virus's entry into the human body and that oral hygiene is essential in reducing infection from the oral cavity and thus its transfer to the upper and lower respiratory tract [19]. Moreover, scientific evidence suggests maintaining optimal oral health status minimizes the incidence of hospital-acquired pneumonia [20].
Questions 22 to 25 concerned lifestyle, in particular diet and smoking habits during periods of blockade, in which most people were forced to a more sedentary lifestyle and were exposed to stressful media images.; 64.2% said they abused sweets, 54.2% pizza and bread, and 10.1% meat (Q22 and Q23). The claim of abusing meat means that there is an emerging public awareness of the environmental and health impacts of meat. A total of 32.6% of the sample declared themselves to be non-smokers, and 14.5% smokers; only 11.8% said they smoke more than before COVID-19 (Q24). However, since smokers are a high-risk group for COVID-19 complications, dental hygienists need to find a way to providing effective help in smoking cessation [21]. Almost half of the respondents (47%) stated that they introduced more cariogenic foods into their diet during the lockdown (Q25). These results are in accordance with evidence found in literature. A study by Docimo R et al. on cariogenic risk and COVID-19 lockdown in a pediatric population showed that only 18.6% of the participants had high adherence to a Mediterranean diet, recording an overall increase in sweets consumption and the number of meals. Moreover, Docimo R. et al. showed that also the lifestyle habits before and during lockdown changed significantly, with an overall reduction of the sport activities during and after compared to before [22]. A national Italian survey evaluated eating habits and lifestyle changes in an adult population during COVID-19 lockdown. The study showed that with regards to eating habits and to the hunger/satiety perception, 1214 (34.4%) of the participants declared more appetite. Data on food intake showed an increase of homemade recipes (e.g., sweets, pizza, and bread), cereals, legumes, white meat, and hot beverages consumption. Moreover, 48.6% of the population declared a weight gain perception [23]. Unfortunately, the increase in dietary carcinogenicity along with the increase in weight in a significant part of the society should alarm dental hygienists. All of the above factors significantly contribute to the increased risk of periodontal disease exacerbation as well as to its longer and more difficult treatment in the future [24].
The last part of the questions, Part C, was about patients' attitudes to dental practices during lockdown, in particular about fears, concerns, experienced feelings, and preventive measures taken by dental offices, which were paid more attention by patients. The vast majority of respondents (86.2%) replied that they had never canceled the dental visit for fear of contracting the COVID-19 virus (Q30). Another 37.2% said they were not worried about having to visit the dentist for dental procedure as surgery, while 55.9% said they were worried to some extent (Q29). A total of 26% declared that they know that the employees of the dental practice/dental clinic they go to were regularly tested for COVID-19, and even 69.5% declared that they do not know whether tests are carried out on employees (Q 35). However, 41.5% said they felt very safe when visiting the dentist (Q34). Infection prevention measures in the dental office that patients paid more attention were (i) the use of personal protective equipment (33%); (ii) sanitations of rooms (19.8%); and (iii) limited access to waiting rooms (19.3%). Of these measures, the one that made patients feel safe more was the sanitation of the environments (32.1%) and the use of personal protective equipment (28.6%) (Q27 and 28).
The present survey evaluated also the psychological and psychiatric repercussions of the pandemic among the dental patients: 75% of respondents declared that they feel tired, more than half declared that they did not feel joy in everyday activities, half declared that they had difficulties concentrating and making difficult decisions and felt unhappy and scared (Q32). The need for empathy, interpersonal contact, and communication was reflected in the answer to question 37, where 73.2% declared that despite the social distance and the need for health care workers and dentists to wear very bulky personal protective equipment that cover the face, they still considered communication with the doctor/hygienist to be easy and effective. A total of 23.3% of respondents stated that they would like to stay in touch with their dentist through telemedicine services, 16.4% through telephone consultations, and 24.4% would like to receive videos of home hygiene instructions of oral cavity (Q39). Interestingly, as research shows, the vast majority of dental practitioners are not aware of how to utilize proper software for telemedicine and do not know how a conversation with a patient should proceed during teleconsultation in order to effectively check the condition of the oral cavity and provide comprehensively appropriate advice [25].

Limitations
Given the large number of patients enrolled in this observational survey study, it is possible to highlight the national setting of the study as a possible limitation. Certainly, if it was possible to organize a research group in Europe, the analyzed data could provide a broader representation of the studied phenomenon.

Recommendations
The results of this study emphasize that the character of the dentist is fundamental to the promotion of oral health and a healthy lifestyle. The role of dentistry in the daily implementation of primary and secondary prevention should be strengthened, and general practitioners (GPs) should be aware of their potential in this sense.
Continuing education programs for GPs on healthy lifestyles should be implemented, especially in the COVID-19 scenario.
Finally, it is to be hoped that technologies such as telemedicine will be further developed and disseminated in order to ensure contact between the doctor and the patient, emphasizing the importance of this possibility especially for patients with special needs but also for the sustainable development of dentistry [26].

Conclusions
COVID-19 has changed patients' approach to dental procedures. Most of the people interviewed lived in families, and their greatest fear was infecting a family member. Restrictive measures forced people to stay at home longer, which led to an increase in consumption of various types of food, including cariogenic foods. People said they felt safe when they went to the dentist, but they also paid special attention to measures to prevent contagion. Despite the social distancing and PPE worn by healthcare professionals in dentists' offices, doctor-patient communication was important. Finally, among the measures that should be introduced in similar situations in the future, people wanted telemedicine, a phone recall, and the possibility of using video clips for home oral care instructions. Institutional Review Board Statement: The study was approved by the Institutional Review Board of territorial NHS facilities (n. 080420).

Informed Consent Statement: Not applicable.
Data Availability Statement: All the raw data are available from corresponding author on a reasonable request.

Conflicts of Interest:
The authors declare no conflict of interest.