Received: 16-Sep-2021 Accepted Date: Sep 23, 2021 ; Published: 31-Dec-2021

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Abstract

Purpose: Coronavirus Disease 2019 (COVID-19) is a complex infectious pathology characterized by systemic inflammation. Monoclonal antibodies are being currently being tested to reduce inflammation, but their long-term effects are unknown. The purpose of this report is to give an insight on late manifestations of the disease, including unusual ocular involvement. Patients: We describe a case of an immunocompetent 57 years old man, presenting with a decreased visual acuity after COVID-19-related pneumonia and ARDS. He underwent mechanical ventilation and received Tocilizumab. After recovery from respiratory failure and seroconversion, SARS-CoV-2 was persistently not detected on nasopharyngeal swab, but inflammatory markers and interleukin-6 were persistently elevated. Several haemocultures confirmed Candida albicans. The ophthalmologic examination detected a unilateral (left eye) chorioretinitis. Intravenous voriconazole was administered with complete resolution of both clinical and ophthalmoscopic findings. Conclusion: This is a case report on COVID-19 respiratory distress and haematogenous candida spp. spread leading to unilateral chorioretinitis. Candidiasis is likely more common than what is reported during and after critical illness. Furthermore, anti-inflammatory targeted-therapy such as Tocilizumab, may interfere on long-term immune response. For this reason, coinfections should be carefully investigated, and ophthalmologic examination should be performed in presence of candidemia.

Keywords

Oral health; Early childhood caries; Parents; Oral health education; Children

Introduction

Early Childhood Caries (ECC) is defined as the presence of 1 or more decayed, missing, or filled tooth surfaces in any primary tooth in a child 71 months or younger. ^[1] ECC is one of the prevalent chronic diseases among young children, which may become evident from the eruption of first teeth. ^[2] This disease is one of the more widespread public health issues globally. ^[2-4]A recent systematic review postulated that dental caries had become Saudi Arabia’s public health problem, ^[5] and the authors reported that government officials and the dental

professions would mandate immediate attention. Furthermore, in Saudi Arabia, a high ECC prevalence was reported due to dietary habits, improper oral hygiene practices, and lack of awareness among parents. ^[6-11] In an Arabian study, the DMFT (decayed, missing, and filled teeth) of six-year-old children was 3.43 for girls and 4.14 for boys, respectively. ^[9] Consequently, another study from Jeddah reported DMFT scores of 2.9 to 6.3 per child, and the authors also observed 70% to 76% of dental caries in children of six years old. ^[7] Therefore, the parental role is of utmost importance to avoid dental caries in infants and toddlers. A recent systematic review with meta- analysis^[6] reported that caries in primary teeth was high compared with caries in permanent teeth in the Arab region Wyne et al. ^[9] further acclaimed studies to measure ECC prevalence. The prior reports from Saudi Arabia reported high caries prevalence among preschool children. A study from Tabuk^[11] reported 92% of primary teeth in children of 6 years of age affected by ECC. Therefore, it is imperative to create awareness among the parents, regarding their children’s oral health and early childhood caries, especially in Saudi Arabia ^[12].There is a need to assess parents’ knowledge, attitude, and practices about their children’s oral health in Saudi Arabia. Therefore, the study was aimed to evaluate the knowledge, attitude, and practice towards children’s oral health and early childhood caries among the Arabian parents resided in Riyadh province.

Materials and Methods

The respondents were 866 (n=866), and all respondents were from the Riyadh region. Among 866 participants 55.9% (n=484) were males and 44.1% (n=382) were females. Results revealed that 34% (295) of those surveyed were above 40 years of age, while 32.7% (283) were between 31-40 years, and 33% (288) were between >20-30 years of age. Among the participants, 23.4% (203) were businessmen, while 28.4%

(246) were professionals, and 48.2% (417) were skilled workers. Of the total respondents, 52.0% (450) had a graduate degree, while 16.3% (141) have a diploma, and 19.2% (166) have high school degree. All the demographic characteristic of the study population was summarized in Figure1. Regarding the number of children to parents, 43.3% (375) have more than three, while 29.7% (257) have two and 27.0% (234) have one. The overall responses to the questionnaire were summarized in [Table.1]. A majority of participants (87.5%) agree that sweets can cause tooth decay, while 8.4% disagree and 4.0% have no idea. Nearly 46.3%% of parents were aware that caries could affect infants below two years, but 30.1% of parents answered incorrectly, and 23.6% have no idea. 28.8% of parents were aware that nighttime bottle/breastfeeding causes tooth decay, but 44.3% of parents disagree, and 26.9% have no idea. The majority of participants (78.2%) quoted that decayed primary teeth require restoration. More than ninety percent of participants agreed that their child’s teeth are cleaned regularly, and failure to do so can cause early childhood caries. Astonishingly 56.2% of participants quoted that children can brush their teeth effectively on their own. Only a minority responded that children require regular dental visits (37.6%). Among the participants, 54.5% brushed their teeth once, and 45.5% brushed twice, whereas 63.7% responded that their children should brush twice daily. Among parents, 85.5% use fluoride toothpaste and 14.5% use non-fluoride toothpaste. The percentage of parents using fluoridated toothpaste for children declined to 50.6% compared to their personal use (85.5%). Among the study population, 43.6% of fathers and 49.7% of mothers agreed that dental caries could affect children below two years of age and no statistical significance was evident among the genders (p>0.05). A majority of fathers (88.6%) and mothers (86.1%) agreed that eating sweets can cause dental decay (p>0.05). A statistically significant difference (p<0.05) was noticed between fathers (75.40%) and mothers (81.70%) regarding the knowledge and awareness to opt for dental fillings to decayed teeth for children at an early age. There were mixed opinions evident among the genders [Table 2], age groups [Table 3], and education [Table 4]. There was no statistically significant difference (p>0.05) in the opinion of night feeding by breast or bottle as an etiology of early childhood caries. Only a minority of respondent fathers (27.1%) and mothers (30.9%) viewed night feeding as the culprit. No difference was observed between fathers and mothers on daily brushing, with more than ninety percent opined to brush daily. Important notice on brushing frequency is that more percent of mothers (54.5%) had a good knowledge to brush twice daily than fathers (38.4%) (p<0.05).

Figure 1: Demographic characteristics of study population

Discussion

The present study explicated Arabian Saudi parents’ knowledge and awareness of their children’s oral health residing in the Riyadh region. However, the Arabian parents’ knowledge and awareness varied according to the type of questions asked, and in the present study, the authors used a self-administered questionnaire. In the present study, 866 parents participated in the study, and this is a more significant number of participants to previous studies reported from Saudi Arabia where Hamasha et al. ^[12] study reported with 324 Alshunaiber et al. ^[13] reported with 202 parents. Al-Zahrani et al. ^[14] conducted a study with 101 mothers from Saudi Arabia; the findings are not comparable with the present study. The present study compared knowledge and attitudes of Saudi Arabian parents based on gender, age, and education. Hamasha et al. ^[12] found that less than 30% of parents could identify the number of primary teeth, the ideal duration of tooth brushing. Similar findings were evident in the present study. Sixty-three percent of Arabian parents were not aware of the best time for their child to visit dentists for the first time^[15]. A recent longitudinal prospective study ^[15] reported that tooth brushing could partially diminish the association between sugar consumption and dental decay outcomes in children less than five years. Similarly, in the present, the parents were aware (87.5%) that tooth decay could cause by sweets consumption. The majority of the parents believed in this concept, and there was statistical significance evident only for age comparison (p<0.05), while comparison among parent gender and occupation was found statistically significant (p>0.05).

Bottle feeding habit at night has been considered significant risk factors of early childhood caries. ^[16-19] Most of the children in our study were fed with a bottle according to their parents, but only a few had ECC. Only 28% of the parents felt that the bottle feedings at night cause tooth decay, and surprisingly 44.3% were disagreeing this concept. The use of night bottle lack of awareness was evident in the present study. Similar findings were apparent in a study from Ghana reported that the knowledge of ECC prevented by feeding by the majority (89.3%) of the respondents was statistically significant. ^[18] There is a need to improve the understanding of the specific benefits of feeding in preventing dental diseases.

The question on frequency of tooth brushing most of the parents (54%) reported that their children brush only once daily. Among participants, mothers brush 61% once daily while 45% father brushes daily and findings were statistically significant. It explains both the parents required oral health education to improve their practices. Surprisingly 63.7% of the parents want their children to brush twice daily. Among these mothers (60%) and fathers (68%) responded with twice brushing. Alshehri et al. ^[20] reported that only 30% of the parents replied twice brushing a day, and these findings were not in agreement with the present study. A recent Swedish study ^[21] reported that children’s brushes two times are more determined to dental caries. This study was conducted on 336 children less than five years. Nonetheless, it is imperative to create knowledge among the parents about tooth brushing.

The benefits of fluoride toothpaste to decrease the dental caries incidence rate. ^[21-25] It has been reported that fluoridated teeth regularly will reduce the 25% incidence rate of dental caries compared to non-fluoridated toothpaste use. ^[24,25] The majority (85%) of the parents are using fluoridated toothpaste in the present study. There is no surprise that most of the parents in the study are aware of fluoridated toothpaste use. Gender, age, and occupation do not influence fluoridated toothpaste (p<0.05).

Another^[25] from Saudi Arabia found thatonly 45.8% of the parents were aware of fluoridated toothpaste. These findings were not in agreement with the present study. The national survey of children from Scotland ^[24] recommended three concepts for primary prevention of caries in children are of (1) Oral health advice, (2) Twice tooth brushing with fluoridated (1000 ppm) toothpaste, and (3) Application pits or fissures. In the present cross-sectional survey, 89% of the parent-reported parents prefer their children to brush themselves. ^[26]

There is no relationship established among the gender, age groups, and education on allowing their children to brush themselves. Proper oral hygiene and the usage of fluoride toothpaste are the essential factors in caries prevention. ^[27-29] Parents are responsible for their children’s tooth brushing and proper oral health. ^[30] It is essential to identify carious lesions early to avoid potential sequelae of dental caries. ^[31,32] A recent study ^[33] from Sheffield performed qualitative research on parents’ experiences of tooth brushing with children and suggested developing a behavior change intervention to encourage parental supervised brushing. A systematic review ^[34] concluded that the oral health habits of parents might impact the oral health of their children. The authors also reported that special attention concerning their lifestyle and oral health habits should significantly impact children’s oral health. A study from the West Indies ^[35] reported that oral health promotion should be accessible to oral health care for family members with children, including disseminating oral health information and primary health education. Children at an early age are at a higher risk of developing dental caries in primary dentition ^[36] and its progression to permanent dentition due to their morphology. ^[37,38] Hence, parents need to know their children’s oral health ^{[4,6,11,23-26]}, which eventually affects the quality of life of school-going children.

The Google form was sent to the parents in the study via social media to determine parental knowledge and concerns about oral health. Only 866 responses were received from the parents, which may not be represent the entire Saudi Arabia. However, the sample size was comparatively more with prior published studies. The response rate was not sought since the questionnaire was sent through social media. The questionnaire was self-administered, and the tool was not validated. These are considered potential limitations.

Conclusion

The parents had sufficient knowledge of tooth decay, dietary influence on tooth decay. However, the majority of the parents were unable to reveal details of their children’s tooth brushing and toothpaste. The parent needs to improve knowledge on tooth brushing and the use of fluoridated toothpaste. It is essential to create awareness among mothers and fathers on oral health promotion to maintain optimal oral health in their children regardless of age and education.

Significance

The present study shows that despite good knowledge among parents, their attitude and practices towards brushing and using fluoridated toothpaste oral health should be improved. Parents should be informed to brush their children’s teeth at least once by parents.

Conflict of Interest

The authors have no conflicts of interest to declare

Acknowledgements

The authors would like to thank all the participants involved in the study. The authors would like to thank the Deanship of Scientific Research at Majmaah University for supporting this work.

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