Impact of the COVID-19 pandemic on oral health-related quality of lifeABSTRACT
Objective: To analyze the impact of the COVID-19 pandemic on oral health-related quality of life among patients receiving care at a dental teaching clinic.
Methods: This cross-sectional study included 40 patients aged 12 years or older who were undergoing treatment at a dental teaching clinic, including pregnant and lactating women. Oral health-related quality of life was assessed using the Oral Health Impact Profile-14. The total Oral Health Impact Profile-14 score was calculated using the additive method, and participants were grouped according to age range. The internal consistency of the instrument was evaluated using Cronbach’s alpha coefficient.
Results: The Oral Health Impact Profile-14 demonstrated excellent internal consistency, with a Cronbach’s alpha of 0.92. The mean Oral Health Impact Profile -14 score was 11.32. Physical pain was the most affected domain, particularly regarding discomfort while eating and severe oral pain, both of which had a prevalence greater than 28%. A statistically significant difference was observed between the mean Oral Health Impact Profile-14 score and age group (p<0.05). Lactating women experienced the greatest negative impact on oral health-related quality of life.
Conclusion: The COVID-19 pandemic had a moderate to high negative impact on the oral health-related quality of life of patients treated at the dental teaching clinic. Lactating women were the group most negatively affected.
Indexing terms
COVID-19; Oral Health; Quality of Life
RESUMO
Objetivo: Analisar o impacto da pandemia da COVID-19 na qualidade de vida relacionada à saúde bucal de pacientes atendidos em uma clínica de ensino odontológico.
Métodos: Estudo transversal realizado com 40 pacientes em atendimento odontológico, de ambos os gêneros, com idade a partir de 12 anos, incluindo gestantes e lactantes. A qualidade de vida relacionada à saúde bucal foi avaliada por meio do questionário Oral Health Impact Profile-14. O índice foi calculado pelo método aditivo, e os participantes foram distribuídos segundo a faixa etária. A consistência interna do instrumento foi avaliada pelo coeficiente alfa de Cronbach.
Resultados: O Oral Health Impact Profile-14 apresentou excelente consistência interna, com alfa de Cronbach de 0,92. A média do índice foi de 11,32. Observou-se predomínio do domínio dor física, especialmente nos itens “sentir-se incomodado ao comer algum alimento” e “sentir fortes dores na boca”, ambos com prevalência superior a 28%. Houve diferença estatisticamente significativa entre a média do Oral Health Impact Profile-14 e a faixa etária dos participantes (p< 0,05). O grupo de mulheres lactantes apresentou o maior impacto negativo na qualidade de vida relacionada à saúde bucal.
Conclusão: A pandemia da COVID-19 apresentou impacto moderado a elevado na qualidade de vida relacionada à saúde bucal dos pacientes atendidos na clínica de ensino odontológico. As mulheres lactantes constituíram o grupo mais afetado negativamente.
Termos de indexação
COVID-19; Saúde Bucal; Qualidade de Vida
INTRODUCTION
The World Health Organization (WHO) [1] officially declared on March 11, 2020, Coronavirus Disease 2019 (COVID-19) as an infectious disease caused by the novel coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This global pandemic is characterized by its ability to severely affect the respiratory system of infected individuals. Transmission occurs mainly through saliva droplets and nasal secretions expelled by infected people, either through coughing, sneezing, or even speaking, making it highly contagious and easily spread. Consequently, strict prevention and control measures were required to contain its dissemination.
The Pan American Health Organization (PAHO) [2], starting on March 11, 2020, adopted fundamental measures for disease prevention, including social distancing, hand hygiene, mask use, and consequently, dental care practices were also modified.
The Oral Health Impact Profile (OHIP) questionnaire is a valuable and widely used tool for assessing oral health and measuring the impact of oral conditions on individuals’ quality of life. Developed by Slade and Spencer in 1994 [3], OHIP stands out as a multidimensional instrument addressing several dimensions of oral health impact, going beyond traditional measures that focus only on the presence or absence of diseases [4].
This questionnaire comprises a series of items that explore physical, psychological, and social aspects related to oral health [5]. Items address functional issues, such as chewing and speech ability, as well as emotional aspects, such as self-esteem and anxiety related to oral health.
The application of OHIP in scientific studies allows for the collection of reliable and comprehensive data, contributing to a deeper understanding of the implications of oral health on quality of life [3-5]. Moreover, its use has proven valuable in both clinical and epidemiological contexts, providing relevant information for the development of strategies for oral health promotion and disease prevention [4,5].
The reliability and validity of OHIP have been confirmed in various populations and cultures, making it a versatile and applicable tool in diverse contexts. Its self-administered and easy-to-understand nature makes it accessible to different population groups, ensuring consistent and comparable data collection [6].
In a study conducted by Oliveira & Nadanosvsky et al. [7], the psychometric properties of the Brazilian version of OHIP-14 were analyzed with 504 postpartum women, with a mean age of 24 years. The model’s validity was confirmed, as well as the correlation between questionnaire scores and self-perceived oral and general health.
According to Zucoloto et al. [8], it is important to highlight that OHIP-14 includes a psychometric scale developed to estimate the impacts caused by oral health problems on individuals’ lives, which may affect their quality of life. The study concluded that the reduced OHIP-14 version was parsimonious, reliable, and valid to capture the construct “impact of oral health on quality of life”.
Ferreira et al. [9] and Silveira et al. [10] performed validity and reliability assessments in two different adolescent age groups, 12 years and 15-19 years, respectively. The results demonstrated that the Oral Health Impact Questionnaire (OHIP-14) presented acceptable fit indices, supporting its validity based on normative oral health conditions.
Rosell et al. [11] found, in their study conducted on pregnant women, a significant association (p<0.05) between OHIP-14 and educational level, last dental visit, and decayed, missing, and/or filled teeth (DMFT).
The COVID-19 pandemic triggered significant changes in healthcare-seeking behaviors, and dentistry was no exception [12]. Concerns about virus spread led many patients to postpone or avoid regular dental visits for preventive care, resulting in potential negative impacts on oral health [13,14]. Fear of exposure, combined with safety restrictions and protocols implemented in dental clinics, caused a notable decline in demand for routine checkups, cleanings, and preventive consultations. This reluctance to seek preventive dental care may result in long-term consequences, such as worsening of pre-existing dental conditions and the emergence of new problems [15].
According to Silva et al. [16], the physical and psychological changes associated with puberty make adolescents more susceptible to developing certain oral and general diseases. Therefore, it is crucial to direct attention to this population since, despite positive indicators regarding daily brushing frequency in Brazil, oral hygiene quality is still unsatisfactory.
Aleixo et al. [17] highlight the close relationship between pregnancy and the emergence of oral pathologies, attributing it to hormonal changes during this period. In light of the evidence in the literature, the importance of dentists’ intervention in prevention programs aimed at pregnant women is emphasized.
According to Peloso et al. [18], the social distancing recommended during the pandemic impacted both dentistry and patients’ anxiety, showing an association between patients’ feelings and their willingness to attend appointments. Continuity of dental treatment increased patients’ willingness to attend.
Furthermore, Wu et al. [19] observed a tendency among patients to opt for dental extractions and refuse endodontic treatments in private clinics due to the clinical and economic scenario caused by COVID-19.
Thus, questions arise regarding the oral health conditions and their impact on the quality of life of patients who required dental care during the pandemic.
The objective of this study was to analyze the impact of the COVID-19 pandemic on oral health-related quality of life in patients treated at a dental teaching clinic.
METHODS
This is a cross-sectional analytical observational study conducted through the application of the OHIP-14 questionnaire.
Participants
The sampling process was carried out by convenience, since both the study participants and the site for administering the questionnaires were selected. A total of 40 patients who sought or were scheduled for the Basic Care Clinic of the School of Dentistry of Araraquara – Universidade Estadual Paulista (Unesp) in 2020 were included. Due to the peak of the COVID-19 pandemic, these patients were not attended to at that time and returned for treatment later, in 2021 and 2022.
The inclusion criteria were: patients of both genders, aged 12 years or older, including pregnant and breastfeeding women. Exclusion criteria were: patients under 12 years of age, those who had only undergone screening; those who refused to participate for any reason; and those with any type of condition impairing speech and/or comprehension.
Data collection instruments
Data collection was conducted between September 2021 and May 2022 through the administration of a sociodemographic questionnaire, with questions regarding age, gender, profession, and dental care; and a structured, previously validated instrument, the Oral Health Impact Profile (OHIP-14) [20], which assesses oral health-related quality of life.
At the beginning of the process, participants were informed about the objectives of the study, procedures, data anonymity, their right to discontinue participation at any point during the questionnaire, possible benefits of the research, and the option to withdraw from the study.
Those who agreed to participate signed the Informed Consent Form (ICF) or the Assent Form (for minors), after which the questionnaires were completed by the participants.
The OHIP-14 is a comprehensive self-administered questionnaire that assesses dysfunction, discomfort, and disability due to oral health status and is widely used to evaluate oral health-related quality of life [20].
The OHIP-14 consists of 14 items divided into seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Responses are classified on a Likert scale ranging from “never” to “always.” The higher the score, the greater the impact on oral health and the lower the oral health-related quality of life. In this study, the simplified Brazilian version of the OHIP-14 was used [20].
Ethical Aspects
The study was approved by the Research Ethics Committee of the School of Dentistry of Araraquara – Unesp (CAAE No. 52613521.0.0000.5416), in accordance with Resolutions 466/2012 and 510/2016 of the Brazilian National Health Council.
Data Analysis
Data were collected and stored in Excel and later analyzed using descriptive and inferential statistics with the BioStat 5.0 software. Normality of data distribution was evaluated using skewness and kurtosis values (-3 ≤ X ≥ 3). To assess differences between means, the homoscedastic Student’s t-test was performed. OHIP-14 scores were calculated using the additive method, due to its high discriminatory power, by summing the 14 item responses per individual. Values range from 0 to 56, with higher scores indicating worse oral health-related quality of life [20].
To assess the internal consistency of the questionnaire, Cronbach’s alpha coefficient was applied [21].
RESULTS
A total of 40 individuals were interviewed, distributed into two distinct age groups: Group A, composed of children/adolescents between 12 and 18 years old; and Group B, composed of adults between 22 and 43 years old. Group A represented 87.5% of participants (n=35) with a mean age of 13.8 years, while Group B represented 12.5% (n=5), all breastfeeding women, with a mean age of 34.2 years.
When asked if they sought another place for dental treatment during the peak of the COVID-19 pandemic (2020), 82.5% responded no (n=3), while 17.5% responded yes (n=7). Among those who answered “yes” (17.5%), 3 sought orthodontists (42.9%) for appliance maintenance, 3 sought emergency units (42.9%) due to pain, and 1 (14.2%) for routine follow-up.
Of the 40 participants, 22 (55%) were undergoing dental treatment when the pandemic began, while 18 (45%) reported not being in treatment at the beginning of 2020. Among these 18 participants, 83.3% were waiting for appointments to begin treatment (n=15), 11.1% reported fear of the pandemic as the reason for not scheduling visits (n=2), and 5.6% stated they did not need treatment at that time (n=1).
The mean OHIP-14 score was 11.54, indicating the impact of oral health on quality of life, as shown in table 1.
Frequency and mean occurrence of the items that make up the OHIP-14 index. Araraquara (SP), 2022.
There was a predominance of physical pain: discomfort while eating and pain. Considering the frequencies of occurrence “sometimes”, “fairly often”, or “very often”, the prevalences were 28%, 13%, and 10%, respectively, for “feeling uncomfortable when eating any food” and “having strong pain in the mouth”. Additionally, “difficulty performing daily tasks” was observed in only 19 patients, with 18 reporting it “sometimes” and 1 “fairly often”. No patient reported being in a state of “total inability to perform daily tasks”. Based on the data in table 1, the mean OHIP-14 index value was 11.54.
The items were prioritized according to the level of impact they caused on patients’ quality of life, as shown in figure 1.
Ordered distribution of the items that make up the Oral Health Impact Profile-14 index. Araraquara (SP), 2022.
Among the 55% of individuals who were undergoing treatment at the beginning of the pandemic (n=22), 22.7% reported being in treatment due to carious lesions (n=5), 59.1% were undergoing routine follow-up (n=13), 9.1% reported toothache (n=2), 4.6% did not know the reason for their dental visit (n=1), and 4.5% were undergoing endodontic treatment (n=1).
Table 2 presents the classification of scores for oral health and quality of life assessment using the OHIP-14 questionnaire, as well as the value of Cronbach’s alpha coefficient, which evaluates the internal consistency of the questionnaire.
The internal consistency of the OHIP-14 index is presented in table 2. Considering all the questions that make up the OHIP-14 index, good internal consistency was observed (Cronbach’s alpha = 0.92).
When analyzing oral health and quality of life, classified into the categories “high impact”, “moderate impact”, and “low impact”, it was observed that most variables showed higher results for negative perception, with 21.4% (n=3) classified as “high impact” and 78.5% (n=11) classified as “moderate impact”.
According to the established classifications, the questions that had a high impact on oral health-related quality of life during the COVID-19 pandemic were: “Have you had painful aching in your mouth?”, “Have you felt uncomfortable when eating any food?”, and “Have you been a bit embarrassed?” All other questions of the OHIP-14 questionnaire showed a moderate impact on oral health-related quality of life during the pandemic period.
In figure 2, the statistical significance between the mean scores of Group A (patients up to 18 years old) and Group B (lactating patients) can be observed regarding global perception of oral health. It is evident that patients in Group B experienced a greater negative impact on oral health-related quality of life as a result of the COVID-19 pandemic.
Overall mean values of oral health-related quality of life from the OHIP-14 questionnaire. A) patients up to 18 years old. B) lactating patients aged 22 years and older.
DISCUSSION
Social isolation and quarantine are considered to have caused a negative impact on many aspects of people’s lives [22]. Thus, due to distancing measures, it was hypothesized that there would be negative impacts on the oral health-related well-being of patients treated at a dental teaching clinic, which provides care to children, adolescents, pregnant women, and lactating mothers. However, this study generally found that during the analyzed period, individuals’ oral health and quality of life suffered negative impacts in several aspects.
There was a predominance of physical pain, particularly in the items “having painful aching in the mouth” and “feeling uncomfortable when eating any food”, corresponding to questions 3 and 4 of the OHIP-14 questionnaire, respectively. As reported in the literature, issues related to dental emergencies were a problem during the period of distancing. During the outbreak, a decline in dental visits among both children and the elderly was observed [23]. In addition to the imposed social isolation, it is important to highlight that older adults, in particular, were considered high-risk groups for coronavirus infection [24].
Liu et al. [22] and Li et al. [24] reported that individuals experienced oral discomfort or toothache during the lockdown period, as well as difficulties in accessing and receiving dental care. In our study, a high impact was also found in the domain “feeling embarrassed” (question 10), findings that were similar to their results. Likewise, Avasthi et al. [25] also found high scores for the domains of physical pain and psychological discomfort during the pandemic period.
Nevertheless, due to differences in participants’ ages, it was necessary to divide them into two groups: adolescents (Group A) and lactating mothers (Group B). A comparative analysis between the mean scores of the groups revealed a statistically significant difference (p=0.0009). Therefore, although Group A had the largest number of participants, the greatest impact was observed in Group B. The negative outcomes regarding the group of lactating women reinforce that mothers of young children, in addition to concerns about their offspring, also experience stress linked to financial instability, employment, and unequal distribution of household tasks [26].
Furthermore, in their study, Reis et al. [27] observed that although lactating mothers present preventive dental needs, they tend to prioritize their children’s well-being over their own. This finding corroborates the results presented in our study.
Santos et al. [28] observed that among the population aged 18 years and older, there was a decrease in oral hygiene practices, with this negative impact being associated with stress and anxiety during the period of social isolation. This conclusion is consistent with our research, in which the adult population showed a greater negative impact on oral health-related quality of life.
Silva et al. [26] reported similar findings, indicating that psychological impacts were relevant in assessing oral health-related quality of life during the COVID-19 pandemic, being more evident in women, who represented 71% of their study sample.
This study revealed that most participants did not seek dental care during the pandemic, except for orthodontic follow-ups. Given that the COVID-19 pandemic negatively impacted the provision of dental treatments in Brazil’s public health system, such a result was expected due to quarantine and distancing recommendations [29].
The group composed of adolescents experienced a lower impact compared to the group of lactating mothers, but still showed significant effects. It was observed that this group mainly sought orthodontic consultations for follow-ups. As noted by Naveda et al. [30], many patients still felt fearful and stressed about COVID-19 and its transmission.
During the pandemic, many patients, fearing the disease, deliberately avoided dental treatment. However, postponing dental care needs may increase the likelihood of more complex problems in the future [18].
In the present study, issues related to stress had a moderate impact on Oral Health-Related Quality of Life (OHRQoL). In their study, Ciardo et al. [31] observed an aggravation of depression, anxiety, and psychological stress, all negatively associated with OHRQoL. However, the severity was mild for stress and ranged from mild to moderate for depression and anxiety. Nevertheless, the consequences of the most severe phases of the pandemic on mental health led to significant worsening of Temporomandibular Disorders (TMD), tooth loss, and sleep disorders [32].
Additionally, according to Brondani et al. [33], 63% of individuals had used dental services before the pandemic, but only 15% sought some type of dental care during the pandemic – an outcome also observed in the present study.
This scientific work has important limitations that should be considered. The first is the limited number of patients included, which may restrict the generalization of the results. Moreover, it is crucial to note that the study was conducted exclusively in a single center, which may introduce regional biases and may not fully reflect the diversity of conditions and contexts of the wider population. To achieve a more comprehensive and reliable understanding of the real impact of the COVID-19 pandemic on patients’ oral health, it would be imperative to conduct multicenter studies with a substantially larger and more representative sample. Such an approach would allow for a more robust and reliable analysis, providing stronger insights to guide clinical practices and public health policies.
In general, the COVID-19 pandemic impacted oral health not only due to restrictions on dental care but also because of economic, nutritional, and psychosocial factors. In this sense, oral health is a crucial component of overall well-being and should not be neglected in comparison with other aspects of healthcare.
CONCLUSION
It is concluded that the COVID-19 pandemic had both moderate and high impacts on the oral health-related quality of life of patients treated in a dental teaching clinic. Considering the 14 items of the questionnaire, none were classified as having a low impact regarding the relationship between the pandemic period and the resulting problems in oral health-related quality of life.
It was also possible to conclude that the group composed of lactating women experienced a greater negative impact on oral health-related quality of life due to the pandemic. However, the group consisting of adolescents also showed a significant impact in the present study.
The COVID-19 pandemic highlighted important consequences, particularly regarding access to dental care, mainly associated with the perceived risk of infection and tooth pain, underscoring the importance of maintaining continuity of dental services.
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How to cite this article
Balieiro Crescitelli G, Barros de Oliveira A, Pinotti FE, Genaro LE, Valsecki Júnior A, Lopez Rosell F. Impact of the COVID-19 pandemic on oral health-related quality of life. RGO, Rev Gaúch Odontol. 2026;74:e20260030. http://dx.doi.org/10.1590/1981-86372026003020240062
Data Availability
The research data are available from the corresponding author upon reasonable request.
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Edited by
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Assistant editor
Luciana Butini Oliveira
Note: Caption. P1: speech; P2: taste; P3: pain; P4: discomfort when eating; P5: self-conscious; P6: tense; P7: impaired diet; P8: interruption of meals; P9: difficulty relaxing; P10: embarrassed; P11: irritable; P12: difficulty performing daily tasks; P13: life less satisfying; P14: unable to function.
