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. 2023 Jan 19;18(1):e0280533. doi: 10.1371/journal.pone.0280533

Perspectives on dental health and oral hygiene practice from US adolescents and young adults during the COVID-19 pandemic

Long Zhang 1, Marika Waselewski 2, Jack Nawrocki 3, Ian Williams 4, Margherita Fontana 1, Tammy Chang 2,5,*
Editor: Tanay Chaubal6
PMCID: PMC9851495  PMID: 36656822

Abstract

Background

Adolescence is a critical time for adopting health behaviors which continue through adulthood. There is a lack of data regarding perspectives of US adolescents and young adults on their dental health and oral hygiene practice.

Methods

Adolescents and young adults, age 14–24, from MyVoice, a nationwide text message poll of youth. were asked five open-ended questions on the importance of dental health and impact of the COVID-19 pandemic. Responses were qualitatively analyzed using thematic analysis. Chi-square test was used to examine differences in experiences by demographics.

Results

Of 1,148 participants, 932 responded to at least one question. The mean age was 19 years. Respondents were largely male (49.5%) and non-Hispanic white (62.4%). Most (92%) respondents perceived dental health as important or somewhat important and emphasized overall dental health and hygiene (38.6%) and aesthetics (18.3%). About half (49.2%) of respondents stated they have had at least one cavity since middle school. Just over half (54.8%) reported brushing and flossing to care for their dentition. 58% visited a dentist at least every 6 months, while 38% visited a dentist less frequently or not at all. Being non-cisgender, non-Hispanic black, Hispanic, and receipt of free or reduced lunch was associated with less frequent dental visits. 44% stated COVID-19 impacted their dental health, with many mentioning scheduling difficulties or worsened dental hygiene.

Conclusions

Most youth in our study consider dental health important, though their oral hygiene practice may not follow ADA guidelines and self-reported dental caries are high. Dental healthcare among youth has been affected by the COVID-19 pandemic with interruption in regular dental visits and changes in hygiene habits. Re-engagement of adolescents and young adults by dental care providers via greater access to appointments and youth-centered messaging reinforcing hygiene recommendations may help youth improve dental health now and in the future.

Introduction

Oral health is an essential part of the overall health and well-being of an individual. Dental caries (or tooth decay, which can result in painful cavities in teeth) in children remain the primary oral health challenge in the United States [1] and the world [2]. Untreated tooth decay can result in pain and infection, which may affect an individual’s eating, speaking, playing, and learning. Poor oral health in children is linked to school absence and worse academic performance [3].

Adolescents represent a unique and often overlooked group of children who experience many biological, developmental, and social transitions. Adolescence is a critical time of life for adopting health behaviors which continue through adulthood. According to the oral health surveillance report in 2011–2016 from CDC, more than half (57%) of adolescents aged 12–19 years experienced dental caries. One in six adolescents aged 12–19 years had untreated tooth decay [4]. There has been no detectable improvement in disease burden of dental caries in adolescents in the past two decades in the United States [5]. However, even though dental caries remains highly prevalent in adolescence, this period of life has been largely neglected in oral health research [5].

Previous studies attributed the high level of dental caries during adolescence to an increase in susceptible newly erupted permanent tooth surfaces, high carbohydrate dietary habits, independence to seek or avoid dental care, a low priority for oral hygiene, and additional social factors [6]. The American Academy of Pediatric Dentistry (AAPD) recommends fluoride, oral hygiene, diet management, and sealant placement as the primary prevention strategies to control dental caries in adolescents [6]. Yet the success of these preventive efforts depends on how adolescents perceive the importance of their dental health, maintain oral hygiene routine, and follow up with dental health care professionals. Also, in the context of COVID-19 pandemic, there is a lack of data regarding adolescents’ perspectives of impact of the COVID-19 pandemic on their dental health.

The aim of our study was to understand the perspectives of a nationwide sample of adolescents and young adults regarding the importance of their dental health, experiences with dental caries, how they care for their dental health, how often they visit a dentist, and the impact of COVID-19 pandemic on their dental health.

Methods

Data from five open-ended questions were obtained from the MyVoice cohort. MyVoice is an ongoing longitudinal nationwide text message poll that seeks to understand youth opinions on salient issues related to health and policy. Participants are a diverse sample of over 1,000 youth aged 14–24 years; details on study procedures have been previously described elsewhere [7]. Briefly, participants’ age, gender, race/ethnicity, education level, census region of residence, and free lunch status were collected upon consent for the study. This study was approved by the University of Michigan Institutional Review Board with online written consent completed by all participants and a waiver of parental consent for minors as the study was deemed minimal risk.

Questions were sent to 1,148 MyVoice participants on May 21, 2021 and were iteratively developed by a research team of youth, physicians, dentists, and mixed-methods research experts. Participants were sent the following five questions, which aimed to assess participants’ beliefs surrounding the importance of dental health and the impact of the COVID-19 pandemic on their dental care experience:

  • How important is dental health to you? Why?

  • Since middle school, have you had any cavities? Tell us about it!

  • What do you do to take care of your teeth?

  • How often do you go to the dentist? What for?

  • How has the COVID-19 pandemic affected your dental health?

The survey responses were qualitatively analyzed using thematic analysis. A codebook was iteratively developed by the research team by first reviewing several hundred responses and identifying major concepts or codes. Codes were then defined with illustrative examples to complete the codebook for each question. Two independent researchers reviewed each question and applied codes to each response. Discrepancies between coders were identified and discussed to reach a consensus. Summary statistics were calculated using Microsoft Excel (2016). Chi-square test was used to analyze the difference of selected outcomes by demographics with SAS 9.4 software (Cary, NC, USA).

Results

Of 1,148 participants, 932 responded to at least one question (response rate = 81.2%). The mean age of respondents was 19 years old (standard deviation: 2 years). Respondents were largely male (49.5%), non-Hispanic white (62.4%), had an education level of some college or technical school (41.0%), resided in the Midwest (32.3%), and did not receive free or reduced lunch (61.2%), a measure of low socioeconomic status (Table 1).

Table 1. Respondent demographic characteristics (n = 932).

Demographic characteristic n (%) or mean (std)
Age 19.3 (2.4)
    14–17 232 (24.9)
    18–24 700 (75.1)
Gender
    Male 461 (49.5)
    Female 375 (40.2)
    Other 96 (10.3)
Race and Ethnicity
    Non-Hispanic White 580 (62.4)
    Non-Hispanic Black 63 (6.8)
    Hispanic 95 (10.2)
    Non-Hispanic Other 192 (20.7)
Education level
        Less than high school* 243 (26.1)
    High school graduates 136 (14.6)
    Some college or technical school 382 (41.0)
    Associate’s degree or technical graduate 29 (3.1)
    Bachelor’s degree or higher 142 (15.2)
Region
    Midwest 298 (32.3)
    Northeast 168 (18.2)
    South 253 (27.4)
    West 203 (22.0)
Received free or reduced lunch
    Yes 359 (38.8)
    No 567 (61.2)
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*includes respondents still in high school

Overall, 92.0% (852/926) considered dental health important or somewhat important to them. The most cited reasons why dental health is important included overall dental health and hygiene (38.6%) and aesthetics (18.3%). Participants who reported on the importance of overall dental health and hygiene noted “it’s important to have good dental hygiene”, they have “only one set permanent teeth”, and “we need our teeth to eat, bite, and talk.” (Table 2). The proportion of people who perceived dental health important or somewhat important did not significantly vary by gender, race, or free or reduced lunch receipt (Table 3).

Table 2. Summary of results of thematic analysis.

Question, code n (%) Example quote
How important is dental health to you? Why? (n = 926)
Level of Importance
Important 776 (83.8) “Very important” “Important enough”
Somewhat 76 (8.2) “Semi important” “Moderately important”
Not Important 50 (5.4) “Not that important” “Not at all”
Reasons Important
Overall Dental Health and Hygiene 357 (38.6) “. . .it’s important to have good dental hygiene”
“. . .only one set permanent teeth”
“. . .we need our teeth to eat, bite, and talk. . .”
“. . .I want to have healthy teeth later in life”
Aesthetics 169 (18.3) “. . .a smile communicates a lot” “Smiles are how I make a good first impression”
Prevention 107 (11.6) “. . .without dental health other health problems can occur” “. . .I care about how I look and reducing risks”
Personal experience w/poor dental health 65 (7.0) “I’ve had dental issues so I take it serious” “I have very sensitive gums/teeth”
To avoid the dentist 46 (5.0) “I also hate going to the dentist for cavity fillings so it motivates me to brush and floss well” “. . .because dental issues are expensive and painful”
Reasons Unimportant
Not top priority 68 (7.3) “. . .I value it but it’s not a top priority” “Not too high on my priority list, but still important”
No issues 15 (1.6) “I don’t have issues, so I don’t seek care” “I’ve never had issues with my teeth”
Since middle school, have you had any cavities? Tell us about it! (n = 899)
Yes 442 (49.2)
One 89 (9.9) “Yes I’ve had one and it was a painless experience” “I’ve had one cavity my whole life”
Multiple 252 (28.0) “Yes, I actually just had 3 filled, it was fine” “Yes, I had a few small ones that were filled!”
Not specified 101 (11.2) “Yes”
No 457 (50.8) “No” “I’ve never had a cavity and I’m pretty proud of that.”
Cavity Experience (n = 442)
Received treatment 108 (24.4) “i had one cavity, i got it filled by my regular dentist” “yes. i’ve had a couple of cavities filled throughout the years.”
Caused by poor hygiene 42 (9.5) “Yes, a few because I didn’t floss in middle school or high school” “Lots—my parents didn’t teach us dental hygiene so my husband has been a huge help”
Cause by poor diet 28 (6.3) “YES! A lot. I ate candy and soda as a kid and I guess it adds up” “Yes because of junk food”
Related to health condition 27 (6.1) “A tiny one on the top back molar bc I had acid reflux and needed to start medicine for it” “I have deep ridges in my teeth and tend to mouth breathe which makes me more susceptible to cavities”
Didn’t visit dentist 11 (2.5) “Yes I’ve had many cavities because I was too poor to afford dental care” “Yes but I didn’t need to go to the dentist for them”
Cavity caused pain 15 (3.4) “Yes I had a few it wasnt the best thing ever it was the worst because it gave you a toothache and headache” “Yes, I’ve had a couple. It caused me a lot of pain, and those experiences really motivated me to take care of my teeth to a high extent.”
Cavity progressed 14 (3.2) “One of my teeth rotted and I had to get a crown” “I’ve had many cavities, a root canal, and recently dental implants”
What do you do to take care of your teeth? (n = 883)
Brushing 858 (97.2) “i brush my teeth twice a day and go to the dentist regularly”
Flossing 495 (56.1) “Brush 2x/day and use mouthwash. Occasionally floss”
Mouthwash 219 (24.8) “I brush twice daily and use mouth wash and visit dentist twice a year”
Visit the dentist 95 (10.8) “Floss and brush and clean my tongue and go to dentist”
Avoiding damaging foods 49 (5.5) “Brush my teeth, floss, don’t eat or drink a lot of sugar”
Nothing 8 (0.9) “I don’t do anything to take care of my teeth” “No that much”
How often do you go to the Dentist? What for? (n = 878)
Visit Frequency
Every 6 months or more frequently 513 (58.4) “Twice a year for my checkup and cleaning”
Less frequently than every 6 months 330 (37.6) “Once every two years usually for a check up”
Reasons for Visits
Checkup 662 (75.4) “Every 6 months for a checkup”
Emergency 29 (3.3) “I try to go to the dentist once a year or whenever I have pain in my teeth”
Restoration 23 (2.6) “At least 2 times a year and for cleanings. And if I need to go back for a cavities”
Orthodontics 20 (2.3) “Once a month for my braces”
How has the COVID-19 pandemic affected your dental health? (n = 864)
No impact 488 (56.5) “It has not changed”
Impact 376 (43.5) “I did not go to the dentist for a year and I put off getting my wisdom teeth removed” “I missed an appointment, but I’ve since gotten back on track”
Type of Impact
Scheduling 267 (30.9) “I have to wait an extra couple mouths for my appointment…” “I have had to delay dental appointments”
Worsened hygiene 62(7.2) “I have brushed my teeth less” “I have brush my teeth a lot less and have gotten more cavities due to eating more”
Improved dental health 24 (2.8) “If anything, it has gotten better” “I think it’s made it better and more self aware”
Safety concerns 16 (1.9) “I didn’t go as frequently due to fear of it being unsafe”
Eating habits 9 (1.0) “Improved it, eating out less and more time to care for my hygiene”
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Table 3. Comparisons of outcomes between demographics.

How important is dental health to you?
Important or somewhat important, n (%) not important, n (%) P-value
Female 344 (92.2) 29 (7.8) 0.188
Male 426 (92.8) 33 (7.2)
Other 82 (87.2) 12 (12.8)
Non-Hispanic White 521 (90.6) 54 (9.4) 0.140
Non-Hispanic Black 57 (90.5) 6 (9.5)
Hispanic 89 (94.7) 5 (5.3)
Non-Hispanic Other 183 (95.3) 9 (4.7)
Received free or reduced lunch 321 (90.4) 34 (9.6) 0.175
Not received free or reduced lunch 525 (92.9) 40 (92.9)
Since middle school, have you had any cavities?
Had cavities, n (%) No cavities, n (%)
Female 202 (55.6) 161 (44.4) <0.001
Male 181 (40.6) 265 (59.4)
Other 59 (65.6) 31 (34.4)
Non-Hispanic White 269 (48.4) 287 (51.6) 0.667
Non-Hispanic Black 35 (56.4) 27 (43.6)
Hispanic 46 (50.6) 45 (49.4)
Non-Hispanic Other 91 (48.4) 97 (51.6)
Received free or reduced lunch 174 (51.0) 167 (49.0) 0.440
Not received free or reduced lunch 267 (48.4) 285 (51.6)
How often do you go to the Dentist?
Visit a dentist every 6 months or more frequently, n (%) Visit a dentist less frequently than every 6 months, n (%)
Female 209 (60.1) 139 (39.9) 0.002
Male 267 (60.7) 173 (39.3)
Other 37 (41.1) 53 (58.9)
Non-Hispanic White 342 (62.9) 202 (37.1) 0.001
Non-Hispanic Black 27 (44.3) 34 (55.7)
Hispanic 41 (46.1) 48 (53.9)
Non-Hispanic Other 102 (56.0) 80 (44.0)
Received free or reduced lunch 175 (51.6) 164 (48.4) 0.001
Not received free or reduced lunch 336 (63.0) 197 (37.0)
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In our sample, 49.2% (442/899) respondents reported having had at least one cavity since middle school. Among all respondents, 9.9% (89/899) specified having one cavity, 28.3% (254/899) reported multiple cavities, and 11.2% (101/899) reported an unspecified number of cavities. The percent of respondents who reported having had at least one cavity significantly varied by gender but did not vary by race or free or reduced lunch receipt. Among those who had tooth decay, 24.4% (108/442) said they received dental treatment for tooth decay. Some respondents attributed their cavity to poor oral hygiene (9.5%, 42/442), poor diet (6.3%, 28/442), a health condition or a genetic predisposition (6.1%, 27/442), not visiting a dentist (2.5%, 11/442) or not being able to afford visiting a dentist (1.8%, 8/442). Some respondents revealed that having a cavity caused pain (3.4%, 15/442) or led to an advanced dental treatment such as a crown, root canal treatment, or extraction (3.2%, 14/442).

Among the 883 who answered the question on how they take care of their teeth, 97.2% (858/883) reported brushing and 56.1% (495/883) reported flossing. Over half (54.8%; 484/883) noted that they both brush and floss to care for their teeth, though only 19.1% (169/883) described habits that specifically met the ADA guidelines of brushing twice daily and flossing daily. Other ways respondents reported caring for their teeth included using mouthwash (24.8%), visiting a dentist (10.8%), and avoiding damaging foods like high sugar items such as candies (5.5%).

Most youth (58.4%, 513/878) reported visiting a dentist every 6 months or more frequently, while some youth (37.6%, 330/878) went to a dentist less frequently than every 6 months. Of note, 10.4% (91/878) never visited a dentist for dental care. Common reasons for visiting a dentist included checkups (75.4%, 662/878), dental emergency (3.3%, 29/878), restoration (2.6%, 23/878), and orthodontics (2.3%, 20/878). There was a significant difference in the rate of respondents visiting a dentist every 6 months or more frequently based on gender, race, and status of receiving free or reduced lunch.

Regarding whether the COVID-19 pandemic affected respondent’s dental health, 56.5% (488/864) said the pandemic had no impact, and 43.5% (376/864) indicated an impact. The types of impact reported by youth included difficulty scheduling appointments (30.9%), worsened hygiene (7.2%), improved dental health (2.8%), safety (1.9%), and eating habits (1.0%).

Discussion

A majority (92%) of adolescents and young adults surveyed, perceived dental health as important or somewhat important to them regardless of demographics, and many of them emphasized the importance of overall dental health and hygiene and aesthetics. This is consistent with a previous report that found adolescents considered dental appearance and oral self-care as important in terms of social interaction with peers, personal and career satisfaction, and future success in social and work life [8]. These positive beliefs in oral health among adolescents may be associated with better oral health outcomes. Broadbent et al found that individuals who held stable favorable dental beliefs from adolescence through adulthood had fewer tooth loss due to caries, less periodontal disease, better oral hygiene, and better self-rated oral health [9].

Despite having positive perspectives in oral health, our study participants (aged 14–24 years) revealed a high prevalence (49%) of self-reported dental caries since middle school, which is consistent with the CDC data that reported 57% prevalence of caries among adolescents aged 12–19 years [4]. This high prevalence of dental caries may be due to a host of factors that were not measured in our study including, the rate of caries experienced during early childhood, increased exposure to cariogenic bacteria, high frequency of sugar consumption, inadequate salivary composition or flow, delayed or insufficient fluoride exposure, and poor oral hygiene [10, 11]. Adolescent’s positive beliefs in oral health are also subject to change and the stability of dental health beliefs, rather than a snapshot, may be more predictive of self-reported oral health outcomes [9].

Females and those who identify as “other” gender also reported a statistically significant higher rate of having cavities than male respondents. But there was no significant difference of the rate of having cavities by race and receipt of free or reduced lunch (a proxy for socioeconomic status). It is known that socioeconomic factors such as race and household income level contribute to the disparity of dental caries in U.S. adolescents [4]. The reason why our study did not show the same pattern could result from a different definition of outcome, sampling method, and study period. The lack of associations between self-reported dental caries and socioeconomic status in our study warrants further investigation.

The way in which adolescents and young adults cared for their teeth included brushing, flossing, mouthwash, visiting a dentist, and avoiding damaging food. Interestingly, nearly all (97%) of participants reported brushing their teeth as a routine oral hygiene practice; however, only 56% reported flossing to care for their teeth, and 19% specifically reported following ADA guidelines of brushing twice a day and flossing once a day [12]. The difference between brushing and flossing could reflect a difference in perception of importance of each practice. A study examined the stability of oral health related beliefs including using dental floss at ages 15, 18, and 26 years, and found that 49% of adolescents thought flossing was not important at least once at the three ages [9]. This might explain why our study population favored brushing over flossing. A systematic review and meta-analysis has shown the benefits of flossing in addition to toothbrushing in reducing gingivitis compared to toothbrushing alone, though it lacks evidence of its effect in preventing dental caries [13]. The clinical benefits of flossing in preventing gum disease may help to formulate dental health messages to adolescents from a perspective of both cosmetic and health reasons [14].

Slightly more than half of adolescents and young adults in our study reported visiting a dentist every six months or more frequently, while 38% visited a dentist less frequently or not at all. This supports previous national statistics of dental visits by adolescents in the United States, which found that 64.9% of adults 18 and older visited a dentist in the past year [15]. The frequency of dental visits varies based on individual needs [16], though fewer dental visits could indicate limited resources or limited access to dental care. Our data showed that respondents that self-identified as non-Hispanic black or Hispanic and people who received free or reduced lunch were less likely to visit a dentist in a recommended schedule compared to their counterparts. Also, our study showed that about 10% of youth reported no dental visit at all, which could be due to barriers preventing adolescents from seeking dental care such as access to dental insurance, financial limitation, lack of adequate transportation, and social support. Infrequent or inadequate number of dental visits may contribute to a possible knowledge gap in maintaining oral health. For example, though the respondents commonly mentioned brushing to care for their teeth, it was rare for them to discuss the benefits of fluoride toothpaste, which plays an important role in preventing dental caries [17]. Also, some participants mentioned using mouthwash, whitening strips, and retainer to care for their teeth, which are more aesthetics driven than health driven. Access to dental health professionals and proper oral hygiene education may be an area for improvement in adolescents.

A total 44% of our surveyed population stated that COVID-19 had an impact on their dental health. Those who were affected by COVID-19 often reported scheduling conflicts and worsened dental hygiene. The responses to the COVID-19 impact in our adolescent and young adult samples shed a light on the psychosocial aspects of oral health in adolescence. For instance, one respondent said “We haven’t gone to the dentist in a while. Also I got really depressed and it was hard to brush regularly”. Another responded “Being at home all the time makes me forget to brush my teeth sometimes since I don’t have as structured of a routine and don’t have to for social reasons as often”. Social interactions among adolescents were largely affected by COVID-19 pandemic and it may be linked with less ideal oral hygiene practice in this group, given the self-reported importance of dental aesthetics in this population.

This study has several strengths including a high response rate as well as detailed qualitative data that allowed a nuanced assessment of the rationale behind participants behaviors. The information obtained can help shape public health messaging campaigns and further inform and shape dental practitioners’ approach in educating the youth about proper dental hygiene.

This study also has limitations. Participants represent a large nationwide sample of youth that opted in to a text messaging poll. However the sample is not nationally representative, which limits the generalizeability of our findings. The responses were also taken in May 2021, a very dynamic time where thoughts and opinions of COVID-19 in responses may change from the start of the pandemic to today. MyVoice is an open-ended poll designed to be only 5 questions to minimize burden on our youth participants, though this limits our ability to probe more deeply into the experiences of youth.

In summary, our study demonstrated that majority of adolescents and young adults perceived dental health to be important or somewhat important, though their oral hygiene practice may not follow ADA guidelines and the burden of self-reported dental caries is high. The COVID-19 pandemic affected adolescent’s ability to schedule a dental visit and might affect their oral hygiene practice in a socially isolated environment. Gender, race, and status of receiving free or reduced lunch were associated with less frequent dental visits. Re-engagement of adolescents and young adults in dental care by dental care providers via greater access to appointments and youth-centered messaging that reinforces hygiene recommendations may help youth achieve improved dental health now and in the future.

Data Availability

Our work uses data from MyVoice (www.hearmyvoicenow.org) a national text message survey of youth (ages 14-24). As part of our IRB approval and protections for this vulnerable population, we require Data Sharing Agreements to be executed with any individual or organization interested in accessing our data. Researchers interested in this data can contact the authors or the University of Michigan Medical School IRB (irbmed@umich.edu) for more information.

Funding Statement

TC received funding for this research from the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.Centers for Disease Control and Prevention. Children’s Oral Health [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; Available from: https://www.cdc.gov/oralhealth/basics/childrens-oral-health/index.html. Accessed May 1, 2022 [Google Scholar]
  • 2.Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of untreated caries: a systematic review and metaregression. J Dent Res. 2015;94(5):650–8. doi: 10.1177/0022034515573272 [DOI] [PubMed] [Google Scholar]
  • 3.Griffin SO, Wei L, Gooch BF, Weno K, Espinoza L. Vital signs: dental sealant use and untreated tooth decay among US school-aged children. MMWR Morb Mortal Wkly Rep. 2016;65(41):1141–5. [DOI] [PubMed] [Google Scholar]
  • 4.Centers for Disease Control and Prevention. Dental Caries in Permanent Teeth of Children and Adolescents [Internet]. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; Available from: https://www.cdc.gov/oralhealth/publications/OHSR-2019-dental-caries-permanent-teeth.html. Accessed March 22, 2022. [Google Scholar]
  • 5.National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021. [Google Scholar]
  • 6.American Academy of Pediatric Dentistry. Adolescent oral health care. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:267–76. [Google Scholar]
  • 7.DeJonckheere M, Nichols LP, Moniz MH, Sonneville KR, Vydiswaran VV, Zhao X, et al. MyVoice national text message survey of youth aged 14 to 24 years: study protocol. JMIR Res Protoc. 2017;6(12):e8502. doi: 10.2196/resprot.8502 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Maida CA, Marcus M, Hays RD, Coulter ID, Ramos-Gomez F, Lee SY, et al. Child and adolescent perceptions of oral health over the life course. Quality of Life Research. 2015;24(11):2739–51. doi: 10.1007/s11136-015-1015-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Broadbent JM, Thomson WM, Poulton R. Oral health beliefs in adolescence and oral health in young adulthood. J Dent Res. 2006;85(4):339–43. doi: 10.1177/154405910608500411 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent. 2015;37(3):217–25. [PubMed] [Google Scholar]
  • 11.Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci. 2009;21:91–101. doi: 10.1159/000224214 [DOI] [PubMed] [Google Scholar]
  • 12.American Dental Association (ADA) Division of Science. Keeping your gums healthy[Internet]. Chicago, IL: American Dental Association; Available from: https://jada.ada.org/article/S0002-8177(15)00245-7/fulltext#relatedArticles. Accessed May 5, 2022. [Google Scholar]
  • 13.Worthington HV, MacDonald L, Pericic TP, Sambunjak D, Johnson TM, Imai P, et al. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database Syst. 2019:4(4):CD012018. doi: 10.1002/14651858.CD012018.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Macgregor ID, Balding JW, Regis D. Motivation for dental hygiene in adolescents. Int J Paediatr Dent. 1997;7(4):43–8. doi: 10.1046/j.1365-263x.1997.00048.x [DOI] [PubMed] [Google Scholar]
  • 15.Centers for Disease Control and Prevention. Oral and Dental Health [Internet]. Atlanta, GA: Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/nchs/fastats/dental.htm. Accessed March 22, 2022 [Google Scholar]
  • 16.American Dental Association (ADA). Your Top 9 Questions About Going to the Dentist—Answered![Internet]. Chicago, IL: American Dental Association (ADA). Available from: https://www.mouthhealthy.org/en/dental-care-concerns/questions-about-going-to-the-dentist/. Accessed March 9, 2022. [Google Scholar]
  • 17.Slayton RL, Urquhart O, Araujo MW, Fontana M, Guzmán-Armstrong S, Nascimento MM, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149(10):837–49. doi: 10.1016/j.adaj.2018.07.002 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Tanay Chaubal

24 Oct 2022

PONE-D-22-25483Perspectives on dental health and oral hygiene practice from US adolescents and young adults during the COVID-19 pandemicPLOS ONE

Dear Dr. Chang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

It is indeed an interesting study. However, I would suggest to respond to the reviewers comments.

Please submit your revised manuscript by Dec 08 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Tanay Chaubal

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

"This research was funded by the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. Funders had no part in the study design, data collection, analyses, interpretation of findings, or the decision to submit the manuscript for publication."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. 

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

"TC received funding for this research from the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. 

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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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: The manuscript discusses the oral health awareness of a very important age group. The questions asked

could have included the diet of the individuals and if they had access to a dentist easily. Also, the socioeconomic status is not mentioned in the demographics. The sample size is also inadequate to make a general observation of all adolescents and young adults. The questions on COVID-19 impact lack depth and could have added information if the oral health status like bleeding gums were exacerbated at that time. Overall, not a very insightful study. Adding a larger sample size with relevant questions like the above will help us get a true picture of this population.

Reviewer #2: line 168 - in the sentence the surveyed and percieved should be seperated by a comma(,)

line 170- there is extra comma after the hygiene word, please remove.

check and go through similarly such commas are being added, please remove those also

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 Jan 19;18(1):e0280533. doi: 10.1371/journal.pone.0280533.r002

Author response to Decision Letter 0

29 Nov 2022

Dear Dr. Chaubal,

Thank you for your email dated October 24, 2022, regarding our manuscript. We greatly appreciate the suggestions and have edited our manuscript accordingly. Our point-by-point responses to the comments are detailed below. Thank you for considering our revised manuscript for PLOS ONE.

Sincerely,

Tammy Chang, MD, MPH, MS

Associate Professor

University of Michigan

RESPONSE TO REVIEWERS

Reviewer #1: The manuscript discusses the oral health awareness of a very important age group. The questions asked could have included the diet of the individuals and if they had access to a dentist easily. Also, the socioeconomic status is not mentioned in the demographics. The sample size is also inadequate to make a general observation of all adolescents and young adults. The questions on COVID-19 impact lack depth and could have added information if the oral health status like bleeding gums were exacerbated at that time. Overall, not a very insightful study. Adding a larger sample size with relevant questions like the above will help us get a true picture of this population.

RESPONSE: The following statements have been added to the limitations section to address this reviewer's concerns:

Participants represent a large nationwide sample of youth that opted in to a text messaging poll. However, the sample is not nationally representative, which limits the generalizeability of our findings. The responses were also taken in May 2021, a very dynamic time where thoughts and opinions of COVID-19 in responses may change from the start of the pandemic to today. MyVoice is an open-ended poll designed to be only 5 questions to minimize burden on our youth participants, though this limits our ability to probe more deeply into the experiences of youth.

Reviewer #2: line 168 - in the sentence the surveyed and perceived should be separated by a comma(,)

line 170- there is extra comma after the hygiene word, please remove.

check and go through similarly such commas are being added, please remove those also

RESPONSE: The placement of the commas noted appears appropriate, though we will follow the guidance of the copy editor if changes are needed.

EDITORS COMMENTS

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

RESPONSE: We have added the formatting requirements that were overlooked. .

2. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"This research was funded by the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. Funders had no part in the study design, data collection, analyses, interpretation of findings, or the decision to submit the manuscript for publication."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"TC received funding for this research from the Michigan Institute for Clinical & Health Research and the University of Michigan Department of Family Medicine. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

RESPONSE: The above funding statement is correct and no amendment is needed. Thank you for placing it in the Funding Statement section.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

RESPONSE: As part of our NIH Certificate of Confidentiality, even de-identified open-ended responses cannot be shared publicly without agreement to the terms of data protection for the use of such data. This is because responses may be de-identified of traditional identifiers (demographics, location, etc), however, the youth's responses themselves may include identifying information. If data is requested, the requestor can sign a data use agreement that ensures protection of our participants to receive the data.

Attachment

Submitted filename: PlosOne_Response_Ltr_11222.docx

Click here for additional data file. (43.7KB, docx)

Decision Letter 1

Tanay Chaubal

2 Jan 2023

Perspectives on dental health and oral hygiene practice from US adolescents and young adults during the COVID-19 pandemic

PONE-D-22-25483R1

Dear Dr. Tammy Chang,

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Tanay Chaubal

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. 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: As stated in the response to my comments, it is acceptable that the mentioned limitations such as the number of questions and the intention not to burden the youth participants of the study are valid, especially at the peak of the COVID-19 pandemic. These responses can help understand the dental/oral health perceptions of the youth better and formulate an appropriate oral health policy for them.

Reviewer #2: line 183-comma before the word and should be deleted

line 192 - same way comma after sampling method not required

line 213 and 214 if is a single sentence should be seperated by a comma and not fullstop which is placed befor the word our.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

Acceptance letter

Tanay Chaubal

6 Jan 2023

PONE-D-22-25483R1

Perspectives on dental health and oral hygiene practice from US adolescents and young adults during the COVID-19 pandemic

Dear Dr. Chang:

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

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Tanay Chaubal

Academic Editor

PLOS ONE

Associated Data

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

    Supplementary Materials

    Attachment

    Submitted filename: PlosOne_Response_Ltr_11222.docx

    Click here for additional data file. (43.7KB, docx)

    Data Availability Statement

    Our work uses data from MyVoice (www.hearmyvoicenow.org) a national text message survey of youth (ages 14-24). As part of our IRB approval and protections for this vulnerable population, we require Data Sharing Agreements to be executed with any individual or organization interested in accessing our data. Researchers interested in this data can contact the authors or the University of Michigan Medical School IRB (irbmed@umich.edu) for more information.

    Articles from PLOS ONE are provided here courtesy of PLOS

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