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. 2024 Jul 19;19(7):e0307429. doi: 10.1371/journal.pone.0307429

COVID-19’s psychological toll on oral health: A cross-sectional study in Iranian adults

Mahsa Karimi 1,2, Mohammad Reza Khami 1,2, Shabnam Varmazyari 2,3,*, Ahmad Reza Shamshiri 1,2, Mahmoud Hormozi 4, Nourhan M Aly 5, Morẹ́nikẹ́ Oluwátóyìn Foláyan 2,6,7
Editor: Hadi Ghasemi8
PMCID: PMC11259255  PMID: 39028738

Abstract

Background

The Coronavirus disease 2019 pandemic increased global psychological distress, emotional distress, and sleep disturbances, all known risk factors for compromised oral health. Despite this, there is limited understanding of the impacts of these psychological factors on oral health in certain populations, including Iranians. Thus, the present study investigates the associations between sociodemographic characteristics, emotional distress, sleep pattern changes, tooth brushing frequency, and oral ulcer reports in a sample of Iranian adults during the Coronavirus disease 2019 pandemic.

Materials and methods

This cross-sectional, web-based study collected data from Iranian adults between July and September 2022 using respondent-driven sampling. The Mental Health and Wellness questionnaire was used to gather information on sociodemographic characteristics, emotional distress, sleep pattern changes, toothbrushing frequency, and oral ulcer reports. Simple and multiple logistic regression served for statistical analysis.

Results

Among the 240 participants, comprising 164 females and 76 males, with a mean age of 35.3 years (±13.3), 28 individuals (11.7%) reported reduced tooth brushing frequency, and 35 individuals (14.6%) reported oral ulcers. Male gender (OR = 2.75, p = 0.016) and sleep patterns changes (OR = 2.93, p = 0.01) increased the likelihood of reduced tooth brushing frequency. Additionally, being younger than 30 (OR = 2.87, p = 0.025) and fearing coronavirus transmission (OR = 3.42, p = 0.009) increased the odds of oral ulcers.

Conclusions

Male gender and sleep pattern changes were risk factors for reduced tooth brushing frequency among the present sample of Iranian adults during the Coronavirus disease 2019 pandemic. Additionally, being under 30 and fearing coronavirus transmission were identified as risk factors for oral ulcers in this population. To preserve and promote adults’ oral health during public health crises, targeted educational initiatives, public health awareness campaigns, and integrated mental and oral healthcare approaches are encouraged.

Introduction

The Coronavirus disease 2019 (COVID-19) pandemic affected millions of people across the globe [1]. It caused widespread disruptions in daily life and massively altered all aspects of individuals’ health and well-being [1]. The loneliness and uncertainty brought about by the pandemic resulted in increased psychological distress, including rises in stress, anxiety, depression, suicidal behavior, and post-traumatic stress disorder [2, 3]. Emotional distress intensified, marked by increases in negative emotions such as anger, fear, frustration, and boredom, and declines in positive emotions [3]. Sleep quality also deteriorated, evidenced by frequent reports of insomnia, delayed bedtimes, daytime sleepiness, and nightmares [4, 5].

Psychological and emotional distress, along with sleep disturbances, are particularly detrimental to oral health. Two ways through which these conditions compromise oral health include neglect of oral hygiene habits and development of oral ulcers [6–9]. Their resulting neglect of oral hygiene is driven by a combination of factors, including diminished motivation and interest, reduced energy and enthusiasm, adoption of unhealthy behaviors and lifestyle choices, and disruption of routines and self-care activities [6, 7, 9–12]. Additionally, their subsequent oral ulcers arise from changes in immune cell numbers and functions, as well as elevated oxidative stress and inflammatory markers in both saliva and serum [8, 13–16].

Neglected oral hygiene and the presence of oral ulcers can lead to pain, infection, aesthetic concerns, hindered nutrition, and disrupted speech [17]. Beyond these immediate effects, their negative impacts on oral health can harm socialization, damage self-esteem, undermine systemic health, reduce overall quality of life, and impose significant financial challenges, especially in lower-middle-income countries [18–20].

Considerable knowledge gaps persist regarding the psychological impacts of the COVID-19 pandemic on oral health. While conflicting reports exist regarding increases, decreases, or no changes in oral hygiene habits during the pandemic, limited reporting is available on the underlying psychological reasons for such changes [21]. Additionally, while during the COVID-19 pandemic, oral ulcers commonly appeared as aphthous lesions, herpes zoster, herpetic gingivostomatitis, candidiasis, and reactivation of herpes simplex virus (HSV-1) [22, 23], their potential psychological and emotional contributors remain relatively understudied, with their occurrences primarily attributed to viral disruption of oral epithelial cells, chemotaxis of lymphocytes and neutrophils, and treatment side-effects [22]. Most studies have focused on the pandemic’s impact on emotional distress, sleep disturbances, oral hygiene habits, and oral ulcers individually, rather than exploring these factors’ interrelationships in this context [24–26]. Finally, the limited studies that explored these relationships did not include the Iranian population [24, 27–29]. This research gap is notable, given the significant psychological distress and sleep disturbances experienced by the Iranian population during the pandemic [30, 31] coupled with this population’s vulnerability to oral health threats due to Iran’s lower-middle-income status, poor baseline oral health conditions, limited dental insurance coverage, and dental care accounting for 15.5% of total household healthcare expenditure [17, 20, 32]. Thus, understanding the psychological impact of the COVID-19 pandemic on Iranians’ oral health could mitigate both immediate and long-term post-pandemic oral health challenges and inform preparations for future public health crises.

Therefore, the present study evaluates the associations between the independent variables of sociodemographic characteristics, pandemic-induced emotional distress, and sleep pattern changes, and the outcome variables of tooth-brushing frequency and oral ulcer reports in a sample of Iranian adults during the COVID-19 pandemic. The study revealed significant associations between male gender, changes in participants’ disrupted sleep patterns, and reduced tooth-brushing frequency, as well as between being aged under 30, fearing coronavirus transmission (a form of pandemic-induced emotional distress), and self-reporting oral ulcers.

Methods

This cross-sectional, web based-survey study was conducted in Iran between July 1st to September 30th, 2022 following approval from ethics committee of Tehran University of Medical Sciences on August 29th, 2021 (ethics code: IR.TUMS.DENTISTRY.REC.1400.110).

Sample size

Using the sample-to-item ratio guide of 5-to-1 [33–35] the minimum pre-survey sample size required for this study was determined to be 135 valid responses for its 27 independent study variables. This sample size would allow for conducting regression tests with up to eight predictors, maintaining a minimum probability level (p-value) of 0.05.

Participants

Adults were considered eligible for participation if they were 18 and above, were able to understand the survey language, and had access to the survey via an electronic device with internet connection. Respondent-driven sampling was employed for recruitment, leading to a sample of 240 adults. The Iranian online platform, Porsline, was used to create the survey link that got shared on social media platforms such as Telegram, WhatsApp, and Instagram. Additionally, the link was sent to a convenience sample of cellphone numbers using the Short Message Service.

Research tool and procedure

The questionnaire included an introductory section explaining study aims, assuring respondents of data confidentiality and anonymity preservation, and emphasizing the voluntary nature of participation. It also included the investigator’s contact information. Respondents only proceeded to study questions after providing written informed consent. The questionnaire platform allowed one submission per participant, and submission was only possible after survey completion.

Data were collected using the Mental Health and Wellness (MEHEWE) questionnaire, an instrument that covers various aspects of mental health and wellbeing of adults in relation to the multidimensional impacts of the COVID-19 pandemic [36]. It was validated for global use with an overall content validity index of 0.83 [24].

The questionnaire was translated from English to Persian, and then back-translated to English, to ensure translation accuracy. The overall Cronbach’s alpha for the Persian version of the questionnaire was 70%. Necessary changes were made to bring this version closer to the English one. The finalized Persian questionnaire took on average 10–15 minutes to complete.

Independent variables

Socio-demographic characteristics: Age (in years), gender (male, female, others), education level (none, primary school or lower, high school diploma, undergraduate education, postgraduate education), marital status (single, married, divorced/ separated, widowed), testing positive for COVID-19 (yes, no), and employment in healthcare (yes, no).

Pandemic-induced emotional distress: Respondents were asked about experiencing any of the following ten forms of emotional distress during the pandemic: fear of contracting COVID-19, fear of transmitting COVID-19, being worried about others, being others’ target of stigma or discrimination (getting treated differently by others due to one’s identity, demonstrating COVID-19 symptoms, or other relevant reasons), frustration or boredom, anxiety, depression, loneliness, anger, grief or a feeling of loss. Checking the box for each distress was categorized as having experienced that distress during the pandemic.

Sleep Pattern Changes: Respondents were asked about experiencing changes in their sleep patterns (sleeping less, sleeping more, or other deviations from normal sleep) during the pandemic. Checking the box for each change was categorized as having experienced that change during the pandemic.

Outcome variables

Toothbrushing frequency: Respondents were asked: Did your frequency of tooth brushing change during the pandemic? The response options were ‘Yes, it increased’; ‘Yes, it decreased’; or ‘No changes’

Oral ulcers: Respondents were asked: Did you experience oral ulcers during the pandemic? The response options were: ‘Yes’; or ‘No’.

Statistical analysis

We downloaded all the responses from Porsline onto a Microsoft Excel 2013 sheet. After encoding and organization, the data were transferred to IBM SPSS Statistics version 26 for Windows (IBM Corp., Armonk, N.Y., USA) for statistical analysis.

Descriptive statistics were calculated as frequencies and percentages for qualitative variables, and means, and standard deviations (SD) for quantitative variables. Since the outcome variables were categorical and dichotomous, simple and multiple models of logistic regression served to assess their associations with the independent variables. Independent and confounding variables with p-values less than 0.2 in simple logistic regression (Tables 2 and 3) were included in multiple logistic regression using the Forward method (Table 4). Sociodemographic variable categories of less than 20 frequencies were combined with a neighboring category with similar results in each model (S1 and S2 Files). Significance was set at the level of 5% for all tests.

Table 2. Associations between sociodemographic characteristics, emotional distress, sleep pattern changes, and reduced tooth-brushing frequency of participants (n = 240).

Variable categories Odds ratio 95% CI p-value
Age
    29 or younger Ref.a - -
    30–39 years-old 1.48 0.59 to 3.68 0.40
    40 or older 0.87 0.27 to 2.81 0.82
Gender
    Female Ref. - -
    Male 2.42 1.09 to 5.37 0.03
Marital status
    Married 1.26 0.57 to 2.79 0.57
    Alone Ref. - -
Education level
    Diploma and lower Ref. - -
    Undergraduate education 1.46 0.43 to 4.98 0.54
    Postgraduate education 1.22 0.38 to 3.94 0.74
Positive COVID-19 test
    Yes 1.62 0.73 to 3.57 0.23
    No Ref. - -
Health-care worker
    Yes 1.72 0.78 to 3.81 0.18
    No Ref. - -
Fear of contracting COVID-19
    Yes 1.47 0.67 to 3.23 0.34
    No Ref. - -
Fear of transmitting COVID-19
    Yes 0.92 0.41 to 2.06 0.84
    No Ref. - -
Worrying about others
    Yes 1.77 0.69 to 4.56 0.24
    No Ref. - -
Stigma or discrimination
    Yes 3.33 1.09 to 10.18 0.04
    No Ref. - -
Frustration and boredom
    Yes 1.65 0.62 to 4.42 0.31
    No Ref. - -
Anxiety
    Yes 0.95 0.42 to 2.21 0.9
    No Ref. - -
Depression
    Yes 1.76 0.74 to 4.15 0.2
    No Ref. - -
Loneliness
    Yes 1.89 0.77 to 4.62 0.16
    No Ref. - -
Anger
    Yes 1.75 0.76 to 4.04 0.19
    No Ref. - -
Sadness and grief
    Yes 1.71 0.74 to 3.94 0.21
    No Ref. - -
Sleep pattern changes
    Yes 2.59 1.17 to 5.77 0.02
    No Ref. - -
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aRef.: reference categories with which other categories of each variable were compared in the regression model.

Table 3. Associations between sociodemographic characteristics, emotional distress, sleep pattern changes, and oral ulcer reports of participants (n = 240).

Variable categories Odds ratio 95% CI p-value
Age
    29 or younger Ref.a - -
    30–39 years-old 2.73 1.10 to 6.75 0.03
    40 or older 1.23 0.39 to 3.98 0.72
Gender
    Female Ref. - -
    Male 1.33 0.63 to 2.81 0.45
Marital status
    Married 0.56 0.27 to 1.17 0.12
    Alone Ref. - -
Education level
    Under diploma Ref. - -
    University degree 0.68 0.23 to 1.99 0.48
    Higher education 0.91 0.35 to 2.36 0.85
Positive COVID-19 test
    Yes 2.02 0.98 to 4.15 0.06
    No Ref. - -
Health care worker
    Yes 1.06 0.51 to 2.19 0.88
    No Ref. - -
Fear of getting COVID-19
    Yes 1.39 0.68 to 2.85 0.37
    No Ref. - -
Fear of transmitting COVID-19
    Yes 3.36 1.33 to 8.44 0.01
    No Ref. - -
Worrying about others
    Yes 1.99 0.83 to 4.78 0.13
    No Ref. - -
Stigma or discrimination
    Yes 1.76 0.54 to 5.70 0.35
    No Ref. - -
Frustration and boredom
    Yes 0.94 0.34 to 2.60 0.9
    No Ref. - -
Anxiety
    Yes 1.29 0.63 to 2.65 0.49
    No Ref. - -
Depression
    Yes 2.36 1.10 to 5.09 0.03
    No Ref. - -
Loneliness
    Yes 1.35 0.57 to 3.20 0.5
    No Ref. - -
Anger
    Yes 1.75 0.76 to 4.04 0.19
    No Ref. - -
Sadness and grief
    Yes 1.71 0.74 to 3.94 0.21
    No Ref. - -
Sleep pattern changes
    Yes 2.59 1.17 to 5.7 0.02
    No Ref. - -
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aRef.: reference categories that the other categories of each variable were compared to in the regression model.

Table 4. Risk indicators for reduced tooth-brushing frequency and oral ulcer reports among participants (n = 240).

Outcome Risk Indicators Odds ratio 95% Confidence Interval p-valuea
Reduced toothbrushing frequency Gender
Female Ref.b - -
Male 2.75 1.21 to 6.25 0.016
Changes in sleep patterns
Yes 2.93 1.29 to 6.66 0.010
No Ref. - -
Self-reported oral ulcers Age
29 or younger 2.87 1.14 to 7.19 0.025
30 to 39 1.38 0.43 to 4.43 0.584
40 or older Ref. - -
Fear of transmitting COVID-19
Yes 3.42 1.35 to 8.68 0.009
No Ref. - -
Open in a new tab

aOnly the significantly associated variables (p-value<0.05) produced by multiple logistic regression were reported in this table.

bRef: reference category which other categories of a particular variable were compared within the regression model.

Results

Table 1 demonstrates that 240 individuals completed the questionnaire. The participants’ mean age was 35.3 with a standard deviation (SD) of 13.3 and a range of 19 to 97. The study population consisted of 164 (68.3%) females, 125 (52.1%) married respondents, and 198 (82.5%) university-educated individuals. Out of the participants, 28 (11.7%) reported reductions in their tooth brushing frequency and 35 (14.6%) reported experiencing oral ulcers during the COVID-19 pandemic.

Table 1. Distribution of sociodemographic characteristics, reduced tooth brushing frequency, and oral ulcer reports among participants (n = 240).

Variable categories N (%) Reduced tooth-brushing frequency n (%) Self-reported oral ulcer n (%)
Gender
    Male 76 (31.7) 14 (18.4) 13 (17.1)
    Female 164 (68.3) 14 (8.5) 22 (13.4)
Marital Status
    Single 107 (44.6) 12 (11.2) 19 (17.8)
    Married 125 (52.1) 16 (12.8) 14 (11.2)
    Separated/Widowed 8 (3.3) 0 3 (40.0)
Education Level
    Primary school or lower 3 (1.2) 0 0
    High school diploma 39 (16.3) 4 (10.3) 7 (17.9)
    Undergraduate education 123 (51.2) 14 (11.4) 19 (15.4)
    Postgraduate education 75 (31.3) 10 (13.3) 9 (12.0)
COVID-19 status
    Positive 95 (39.6) 14 (14.7) 19 (20.0)
    Negative 145 (60.4) 14 (9.7) 16 (11.0)
Employed in Healthcare
    Yes 100 (41.7) 15 (15.0) 15 (15.0)
    No 140 (58.3) 13 (9.3) 20 (14.3)
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Table 2 demonstrates that being male (OR = 2.47; 95% CI: 1.09 to 5.37), being the target of others’ stigma or discrimination (OR = 3.33; 95% CI: 1.09 to 10.18), and changes in sleep patterns (OR = 2.59; 95% CI: 1.17 to 5.77) were related to reduced tooth brushing frequency during the COVID-19 pandemic.

Table 3 demonstrates that age (OR = 2.73; 95% CI: 1.10 to 6.75), fear of transmitting COVID-19 (OR = 3.36; 95% CI: 1.33 to 8.44), depression (OR = 2.36; 95% CI: 1.10 to 5.09), and sleep pattern changes (OR = 2.59; 95% CI: 1.17 to 5.7) were associated with higher odds of self-reported oral ulcers.

Table 4 demonstrates that being male (OR: 2.75, 95% CI: 1.21 to 6.25) and experiencing changes in sleep patterns (OR: 2.93, 95% CI: 1.29 to 6.66) led to higher odds of reduced tooth brushing frequency. Moreover, individuals younger than 30 had higher odds of self-reporting oral ulcers compared to those aged 40 and above (OR: 2.87; CI 95%: 1.14 to 7.19), and those with fears of transmitting the coronavirus had higher odds of self-reporting oral ulcers compared to others (OR: 3.42; 95% Cl:1.35 to 8.68).

Discussion

To explore the impacts of the COVID-19 pandemic’s psychological aftermath on Iranian adults’ oral health, the present study investigated the relationships between sociodemographic characteristics, emotional distress, sleep pattern changes, reduced tooth brushing frequency, and self-reported oral ulcers in a sample of this population. It found that male gender and changed sleeping patterns increased the risk of reduced tooth brushing frequency. It also discovered that being under the age of 30 and fearing COVID-19 transmission heightened the risk of oral ulcer reports. Firstly, each of these findings is compared to the literature and explained. Then, all findings are jointly discussed for their practical implications.

Due to the lack of studies on gender-related oral hygiene differences in adults during the COVID-19 pandemic, comparisons were made with non-pandemic studies. Notably, recent studies in Saudi Arabian adults and an older study in the general Iranian population found that men had poorer tooth brushing habits than women [37–39]. These gender differences in tooth brushing have been attributed to men’s lower oral health knowledge, more negative perceptions of dental care, higher self-evaluations of oral health, and lower compliance with care instructions [40, 41]. Men also visit the dentist less frequently than women, missing out on oral health education opportunities. This trend likely worsened during the pandemic, as dental care availability decreased both globally and in Iran [7, 42, 43]. Additionally, men tend to place less emphasis on esthetics and appearance, a factor noted in the general Iranian population and likely relevant to the male participants in the present study [39].

The relationship between changes in sleep patterns and increased odds of reduced tooth brushing frequency during the pandemic was similarly reported by a global study using the MEHEWE questionnaire which attributed this finding to sleep disturbances’ association with decreased motivation and unhealthy behaviors [27]. Likewise, a pre-pandemic study of Indian dental students found that individuals with high-quality sleep flossed more regularly, attributing this regularity to lower levels of sleep-related psychological distress and fatigue [7]. These explanations align well with the previously noted associations between sleep disturbances and neglected oral hygiene through unhealthy lifestyle habits, disrupted routines, heightened psychological distress, and diminished motivation and energy [6, 7, 9, 11, 12]. In the present study, sleep disturbances’ links with psychological distress may have been particularly influential, as the sample largely consisted of females, highly-educated individuals, and healthcare workers, all groups with comparatively greater psychological distress during the pandemic [44, 45].

In contrast to most of the research conducted both within and outside the context of the COVID-19 pandemic, the present study found that most oral ulcers reports came from adults aged under 30 [46–48]. Few studies have reported similar results, such as two pre-pandemic studies, one in South Africa identifying the highest prevalence among adults aged 25–34, and one in Iran indicating the highest prevalence among adults aged 30–40 [49, 50]. Younger adults frequently experienced greater psychological distress during the pandemic, as evidence by reports in the US, UK, and Australia, where adults under 30 faced higher psychological and emotional distress [51–53], where adults under 30 experienced higher psychological and emotional distress [51], negative emotionality [52], and post-lockdown mental distress [53]. Similar heightened psychological distress may have affected younger adults in the present study and contributed to their higher oral ulcers reports through altered immune cell function, increased cytokines, elevated cortisol and oxidative stress, and parafunctional habits like cheek and lip biting [15, 16].

The finding that fears of COVID-19 transmission increased the likelihood of reporting oral ulcers contradicted an Egyptian study that found no relationship between fears of COVID-19 contamination and experiencing oral ulcers [29]. However, it can find support in the global MEHEWE study [27], as well as studies in Nigeria [24], China [28], and Indonesia [54], all demonstrating links between pandemic-induced anxiety and stress and increased reports of oral ulcers. As the pandemic persisted, fears of coronavirus transmission likely evolved into anxiety and stress, contributing to oral ulcers by altering immune system function and increasing inflammatory markers [6, 10, 15, 16]. Such anxiety might have been particularly pronounced among the present study’s participants, many of whom were healthcare workers facing heightened risks of direct exposure to the virus.

To safeguard adults’ oral health amidst the ongoing psychological effects of the COVID-19 pandemic and prepare for future public health crises, targeted educational initiatives could offer practical tips for maintaining regular oral hygiene despite disruptions to daily routines. Gender-specific oral health education could also be integrated to address unique oral health needs. Additionally, public health awareness campaigns should focus on addressing emotional distress caused by public health crises, promoting effective coping strategies, highlighting the impact of psychological stress on oral health, and raising awareness about gender-specific vulnerabilities during these times. Integrating mental health support with oral healthcare and vice versa could also be beneficial. It would allow professionals to screen at-risk individuals, proactively discuss concerns, provide tailored advice, encourage regular checkups, offer timely interventions, and make necessary referrals. Finally, strengthening collaboration between oral health professionals, mental health specialists, and public health authorities is essential. Such collaborations can lead to the creation of community outreach programs and the development of comprehensive care protocols that address both the oral health needs and psychological well-being of adults during public health crises.

Strengths, limitations, and future directions

This study contributes to the literature by offering insight into the psychological impacts of the COVID-19 pandemic on a sample of Iranian adults’ oral health, a field with limited research. It includes no missing data, contributes to the databank from the global MEHEWE study, and enables cross-border comparisons of pandemic’s oral health impacts. However, the study also has a few limitations. The most important one is its small and skewed sample, predominantly comprising of females, university-educated individuals, and healthcare workers, which cannot be considered representative of the Iranian adult population. Several factors contributed to this outcome. Firstly, the respondent-driven sampling, chosen for efficiency and methodological alignment with the literature [24, 27], was a method that inherently limited representativeness and generalizability. Secondly, the web-based questionnaire, while improving efficiency, respondent anonymity [55], and safety per Iran’s COVID-19 regulations, excluded individuals without internet access. Lastly, despite the extended data collection duration, the process was still hampered by Iran’s frequent internet outages and social media bans in September 2022. The other study limitations include the potential for recall and social desirability biases, due to the use of self-report measures and the cross-sectional study design, though suitable for the study’s aims, preventing the establishment of causality.

In conclusion and to address these limitations, we recommend the following measures: conducting qualitative studies to deeply explore the psychological impacts of the pandemic on oral health; employing longitudinal study designs to investigate the effects of integrated oral and mental healthcare provision on these impacts; using random sampling with larger sample sizes to enhance generalizability; incorporating offline and in-person clinical data collection methods to increase validity; and replicating findings across diverse populations and time frames.

Conclusions

Despite extensive research on the relationship between oral and mental health, a substantial knowledge gap persists regarding their interplay during the COVID-19 pandemic, particularly in the Iranian population. The present study identified male gender and changes in sleep patterns as risk factors for reduced tooth brushing frequency during the pandemic. It also identified being under the age of 30 and fearing coronavirus transmission as risk factors for reporting oral ulcers during this period. Addressing these findings, the oral health of adults can be better supported in future public health crises through targeted educational initiatives, public health awareness campaigns, integrated mental and oral healthcare services, and collaborative mental and oral healthcare protocols.

Supporting information

S1 Dataset. Multiple regression for self-reported oral ulcers.

(SAV)

pone.0307429.s001.sav (24KB, sav)
S1 File. Multiple regression for reduced tooth brushing frequency.

(XLSX)

pone.0307429.s002.xlsx (19.1KB, xlsx)
S2 File. Minimum anonymized dataset.

(XLSX)

pone.0307429.s003.xlsx (20.6KB, xlsx)

Acknowledgments

We extend our gratitude to all those who took part in this study.

Data Availability

Data cannot be shared publicly because of TUMS data sharing policies. Data are available from the TUMS Ethics Committee (contact via Ethics@sina.tums.ac.ir and +9881633626) for researchers who meet the criteria for access to confidential data.

Funding Statement

This research was supported by Tehran University of Medical Sciences (TUMS), grant number: 1400-2-133-54316.

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Decision Letter 0

Hadi Ghasemi

29 May 2024

PONE-D-24-17375Psychological toll of the COVID-19 pandemic on oral health: insights from a sample of Iranian adultsPLOS ONE

Dear Dr. Shabnam Varmazyari,

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

Thanks for sharing your work with us, the following points should be kept in consideration:

1. The manuscript within the scope of the journal.

2. Both the quality and data presentation of this manuscript are acceptable and of great importance to clinicians and even patients.

3. The manuscript expands our knowledge about COVID-19 and oral health .

4. The title should be revised and reduced its characters ( precise & and informative)

5. The abstract should reflect the content of the article and must be with range of 250-300 words.

6. Four to six keywords representing the main content of the article BUT not mentioned in the title.

7. More paragraphs should be incorporated to introduction about the details of COVID including complications. i.e. suggested references:

• Aldelaimi TN, Khalil AA, Alhamdani F. Herpes Zoster Post-COVID-19 Vaccine. Arab Board Medical Journal

2022;23:52-1.

• Aldelaimi A A, Aldelaimi T.N.. Mucormycosis in a Diabetic

Patient Post COVID-19. Journal of Clinical and Diagnostic Research. 2022 Mar, Vol-16(3): ZJ03, Journal of Clinical and Diagnostic Research. 2022 Mar, Vol-16(3): ZJ03 33. DOI: 10.7860/JCDR/2022/53108.16090

8. The statements in discussion are acceptable but few paragraphs about the justification of your findings and comparison with other recent relevant studies.

9. Up to date references should be kept in your reference list and the old should be omitted. i.e. Suggested reference:

Reviewer #2: Comments to the Author/s: -

I would like to begin by expressing my appreciation for the effort and dedication that the authors have put into this manuscript. My comments and suggestions to improve clarity and overall quality of the work are as follows.

Abstract

1. I prefer to remove the terms (independent variables) and (outcome variables).

2. I prefer not to use abbreviations in the abstract section, such as (MEHEWE).

3. Please type the mean and standard deviation as mean ± SD.

4. Keywords should not exceed five words.

Introduction

1. The reference in line 57 needs to be corrected.

2. Please clarify the following statement in line 66: "They might also initiate hormonal responses that weaken the immune system and thus, lead to the development of oral ulcers.

Materials

1. The date of approval needs to be written.

2. The required sample size is preferred to be written.

3. Authors sometimes use the term (sex) and at other times use the term (gender). Please use one of them consistently.

Discussion

1. The references in line 203 need to be corrected.

Reviewer #3: I respect the limitations of your research, but the importance of this topic, the size of your country, the population, and the different methods used to share it on social media platforms cannot be reflected in your small sample size. Therefore, this cannot be considered a representative Iranian sample.

Secondly, you use the term "mouth ulcer" in your outcome variables, which is considered jargon. It would be more appropriate to use "mouth lesion" instead.

Thirdly, you did not compare the negative and positive coronavirus subjects for outcome variables.

Finally, in the discussion on line 176, you stated that “being male and having changed sleeping patterns increased the chance of reduced tooth brushing frequency.” This is not accurate because the number of males in this study is much smaller than the number of females, so it does not accurately reflect the data.

Reviewer #4: 1-The survey has insufficient number of participants.

2-The discussion of this manuscript is insufficient.

3-The number of questions in the survey could have been more. Thus, it would have been a more comprehensive research.

4-There are no concerns about research ethics or publication ethics.

**********

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Reviewer #1: Yes: Tahrir Aldelaimi

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

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PLoS One. 2024 Jul 19;19(7):e0307429. doi: 10.1371/journal.pone.0307429.r002

Author response to Decision Letter 0

25 Jun 2024

Journal: PLOS ONE

Manuscript no: PONE-D-24-17375

Revised manuscript title: COVID-19's psychological toll on oral health: a cross-sectional study in Iranian adults

Date of revision: June 2024

The team of authors would like to thank the reviewers for their painstaking efforts, we found your comments extremely useful. Provided below is a point-by-point response to the reviewers’ comments. In addition, we conducted an extensive grammar check. All revisions were carried out with “track changes on”.

In response to the journal’s comments:

1. The manuscript was evaluated to ensure compliance with PLOS ONE style requirements, especially with regards to file names.

2. Amended funding statement was included in the cover letter.

3. The minimum anonymized dataset was attached as a supporting information file.

4. References were thoroughly checked, and no retracted articles are included to the best of our knowledge.

Reviewer #1:

Thanks for sharing your work with us, the following points should be kept in consideration: The manuscript within the scope of the journal. Both the quality and data presentation of this manuscript are acceptable and of great importance to clinicians and even patients. The manuscript expands our knowledge about COVID-19 and oral health.

RESPONSE: We thank the reviewer for this positive constructive feedback.

4. The title should be revised and reduced its characters (precise & and informative)

RESPONSE: Title was revised to be more concise, precise, and informative in line with the requirement of the STROBE guidelines. It now reads as: “COVID-19's psychological toll on oral health: a cross-sectional study in Iranian adults”

5. The abstract should reflect the content of the article and must be with range of 250-300 words.

RESPONSE: All sections of the abstract especially the conclusion, were revised to ensure accurate reflection of the article. It is within the <300 word-limit range.

6. Four to six keywords representing the main content of the article BUT not mentioned in the title.

RESPONSE: The keywords were limited to five representative ones that did not overlap with the title terms.

7. More paragraphs should be incorporated to introduction about the details of COVID including complications. i.e. suggested references:

• Aldelaimi TN, Khalil AA, Alhamdani F. Herpes Zoster Post-COVID-19 Vaccine. Arab Board Medical Journal 2022;23:52-1.

• Aldelaimi A A, Aldelaimi T.N.. Mucormycosis in a Diabetic Patient Post COVID-19. Journal of Clinical and Diagnostic Research. 2022 Mar, Vol-16(3): ZJ03, Journal of Clinical and Diagnostic Research. 2022 Mar, Vol-16(3): ZJ03 33. DOI: 10.7860/JCDR/2022/53108.16090

RES RESPONSE: Additional paragraphs were incorporated into the introduction to elaborate on the effects of COVID-19 on oral health, particularly in terms of impacting oral hygiene behaviors and oral mucosa. The underlying mechanisms behind these impacts were also discussed in greater detail. While one of the suggested references was included, we regret that the other reference could not be included as it did not directly address COVID-19-related oral ulcers. Specific changes related to this comment can be found in lines 62-69 and 78-83.

To maintain coherence and flow, the entire Introduction section underwent revisions for grammar and clarity. Furthermore, the paragraph outlining the research gap (lines 75-91) was expanded to align with the aforementioned expansions in the Introduction and provide a more thorough explanation of the identified gap.

8. The statements in discussion are acceptable but few paragraphs about the justification of your findings and comparison with other recent relevant studies.

RESPONSE: We tried to improve the robustness of the discussion by elaborating the explanations, comparisons, and justifications for each of the 4 main findings and also utilized more recent relevant studies. Since these changes resulted in notable expansion of Discussion, the practical implications of findings were summarized slightly and combined. You’ll find these changes in each paragraph of Discussion. As a result of changes to Discussion, slight changes also had to be made to Conclusion section and Abstract conclusion subsection.

9. Up to date references should be kept in your reference list and the old should be omitted. i.e. Suggested reference:

RESPONSE: Newer references, particularly those published during and in the context of the pandemic, have been strongly prioritized. An effort was made to limit references to studies from after 2016 as much as possible and studies prior to this date were only included when absolutely necessary, for instance in the sample size determination subsection.

Reviewer #2:

I would like to begin by expressing my appreciation for the effort and dedication that the authors have put into this manuscript. My comments and suggestions to improve clarity and overall quality of the work are as follows.

RESPONSE: We thank the reviewer for their constructive feedback.

Abstract: I prefer to remove the terms (independent variables) and (outcome variables). I prefer not to use abbreviations in the abstract section, such as (MEHEWE). Please type the mean and standard deviation as mean ± SD. Keywords should not exceed five words.

RESPONSE: Outcome and independent variable terms were omitted from the abstract. The abbreviations MEHEWE and COVID were also omitted and replaced. The mean and standard deviation were referred to as mean ± SD. Five keywords were retained.

Introduction:

The reference in line 57 needs to be corrected.

RESPONSE: Thanks for identifying this error. That reference is now corrected.

Please clarify the following statement in line 66: "They might also initiate hormonal responses that weaken the immune system and thus, lead to the development of oral ulcers.

RESPONSE: The sentence has been re-written in the process of the revisions outlined in response to reviewer 1. It now reads as: Additionally, their subsequent oral ulcers arise from changes in immune cell numbers and functions, as well as elevated oxidative stress and inflammatory markers in both saliva and serum.

Methods:

1. The date of approval needs to be written.

RESPONSE: Ethics approval date was included: on August 29th, 2021 ,…

2. The required sample size is preferred to be written.

RESPONSE: Thanks for raising this point. We included in the methods section: Using the sample-to-item ratio guide of 5-to-1 [33-35] the minimum pre-survey sample size required for this study was determined to be 135 valid responses for its 27 independent study variables. This sample size would allow for conducting regression tests with up to eight predictors, maintaining a minimum probability level (p-value) of 0.05.

3. Authors sometimes use the term (sex) and at other times use the term (gender). Please use one of them consistently.

RESPONSE: Thanks for raising this point. The term “gender” has now been used consistently throughout the paper.

Discussion:

The references in line 203 need to be corrected.

RESPONSE: These references are now replaced due to the substantial revisions made to the discussion section per the requests of reviewers 1 and 4.

Reviewer #3:

I respect the limitations of your research, but the importance of this topic, the size of your country, the population, and the different methods used to share it on social media platforms cannot be reflected in your small sample size. Therefore, this cannot be considered a representative Iranian sample

RESPONSE: We are grateful for your understanding. To address this comment, we included details about sample size determination in the Methods section and revised the Limitations’ subsection in Discussion comprehensively to outline the reasons for this shortcoming, explain the efforts made to mitigate it, and highlight the fact that present findings, although valuable, are not generalizable to the Iranian population.

Secondly, you use the term "mouth ulcer" in your outcome variables, which is considered jargon. It would be more appropriate to use "mouth lesion" instead

RESPONSE: We thank the reviewer for suggesting. We opted for the term “oral ulcer” because it was used more conventionally in global studies such as the one conducted by Folayan MO, et al. (Hygiene. 2023; 3(2):85-92. https://doi.org/10.3390/hygiene3020009) and Folayan MO, et al. (Int J Environ Res Public Health. 2022 Sep 14;19(18):11550. doi: 10.3390/ijerph191811550). Thus, we hope the reviewer will agree with us that this is suitable terminology.

Thirdly, you did not compare the negative and positive coronavirus subjects for outcome variables.

RESPONSE: The independent variable “positive COVID-19 test results” was included in descriptive analyses and simple logistic regression models, with their results demonstrated in Table 1,2, and 3. The variable was then included in the multiple logistic regression for oral ulcers since its simple logistics regression test produced a p-value of less than 0.2 (p-value=0.06) and excluded from multiple logistic regression for reduced tooth-brushing frequency since its simple logistic regression result did not meet the threshold for inclusion (p-value=0.23). After multiple logistic regression analysis, no significant association was spotted between the reports of oral ulcers and coronavirus test results and thus, this variable was not reported in Table 4 which includes only the variables that ended up being significantly associated with either reduced tooth brushing or oral ulcer reports following multiple logistic regression. The methods (statistical analysis) and Results (Table footnotes) sections were revised to accurately reflect these undertaken steps.

Finally, in the discussion on line 176, you stated that “being male and having changed sleeping patterns increased the chance of reduced tooth brushing frequency.” This is not accurate because the number of males in this study is much smaller than the number of females, so it does not accurately reflect the data.

RESPONSE: Thank you for raising this point. Unequal sample sizes do not negate finding when simple and multiple logistic regression are used, as these tests automatically adjust for these imbalances through estimating the relationship between variables instead of counting and comparing raw sample counts. These tests then display these adjustments in their calculated p-values and confidence intervals.

Reviewer #4:

1-The survey has insufficient number of participants.

RESPONSE: Thanks for this observation. We incorporated sample size estimation details into the Methods section and thoroughly addressed this shortcoming in the Discussion section's Limitations subsection by outlining its reasons, explaining the utilized mitigation strategies, and emphasizing the resulting negative implications for study representativeness and generalizability.

2-The discussion of this manuscript is insufficient.

RESPONSE: We tried to improve the robustness of the discussion by elaborating the explanations, comparisons, and justifications for each of the 4 main findings and also utilized more recent relevant studies. Since these changes resulted in notable expansion of Discussion, the practical implications of findings were summarized slightly and combined. You’ll find these changes in each paragraph of Discussion. As a result of changes to Discussion, slight changes also had to be made to Conclusions section and Abstract conclusion subsection.

3-The number of questions in the survey could have been more. Thus, it would have been more comprehensive research.

RESPONSE: Your comment is valuable. We used a validated instrument for this survey that included the variables needed to address the study objectives originally inspired by the global MEHEWE study. However, the current findings can serve as hypotheses to conceptualize new studies by adding to the items of the questionnaire.

4-There are no concerns about research ethics or publication ethics

RESPONSE: Thanks for your valuable feedback.

Attachment

Submitted filename: Response to Reviewers-2.docx

pone.0307429.s004.docx (37.7KB, docx)

Decision Letter 1

Hadi Ghasemi

5 Jul 2024

COVID-19's psychological toll on oral health: a cross-sectional study in Iranian adults

PONE-D-24-17375R1

Dear Dr. Shabnam Varmazyari,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Hadi Ghasemi

Academic Editor

PLOS ONE

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Reviewers' comments:

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #2: Yes

Reviewer #3: Partly

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Thinks for sharing your work with us and thanks taking in consideration the suggested changes and comments

Reviewer #2: (No Response)

Reviewer #3: I want to thank the authors for their scholarly response and meticulous editing, which are sufficient to accept the manuscript for publication.

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Reviewer #1: Yes: Tahrir N. Aldelaimi

Reviewer #2: Yes: Muhanad L. Alshami

Reviewer #3: No

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Acceptance letter

Hadi Ghasemi

10 Jul 2024

PONE-D-24-17375R1

PLOS ONE

Dear Dr. Varmazyari,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Dataset. Multiple regression for self-reported oral ulcers.

    (SAV)

    pone.0307429.s001.sav (24KB, sav)
    S1 File. Multiple regression for reduced tooth brushing frequency.

    (XLSX)

    pone.0307429.s002.xlsx (19.1KB, xlsx)
    S2 File. Minimum anonymized dataset.

    (XLSX)

    pone.0307429.s003.xlsx (20.6KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers-2.docx

    pone.0307429.s004.docx (37.7KB, docx)

    Data Availability Statement

    Data cannot be shared publicly because of TUMS data sharing policies. Data are available from the TUMS Ethics Committee (contact via Ethics@sina.tums.ac.ir and +9881633626) for researchers who meet the criteria for access to confidential data.

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