Discussion
Our study shows that the lockdown in Italy because of the COVID-19
pandemic had a significant impact on both general and dental hygiene of
medical students. We selected this population because we assumed that
knowledge of the disease and good hygiene practices (i.e., washing hands
frequently or wearing a surgical mask) should have mitigated the
negative psychological effects of the Covid-19 pandemic. However, it
appears that this was not the case. Despite having a good knowledge of
general infectious diseases, stress related to COVID-19 strongly
affected the examined population. Self-assessment of stress and anxiety
showed that almost all students perceived increased fear, anxiety, and
stigma.
To our knowledge, this is the only study that specifically explores the
effects of stress induced by the COVID-19 pandemic on dental hygiene.
Several studies have evaluated the impact of COVID-19 and
quarantine-related restrictions on student populations. [2,3,4,7]
A recent survey of medical students during the Covid-19 pandemic,
reported an increase in anxiety (61%) and depression (70%). [2]
Fear, anxiety, and depression are strongly associated with the
development of unhealthy habits, characterized by unhealthy diet,
reduced physical activity, and increased sitting time. [11]
A study by Esteves et al. supported these observations, reporting that
many students changed their lifestyle habits to maintain social
distancing, that is, not practicing physical activities and maintaining
contact with friends only via telephone. [3] Distance learning may
have contributed to an increase in lifestyle changes. [12,13]
Wilson et al. reported a significant decline in the mental health of
college students during the COVID 19 outbreak. In addition, physical
activity did not appear to protect against deterioration in mental
health. [14]
A previous study showed that the lockdown and restrictions imposed by
the Italian government produced psychological distress and anxiety
symptoms among students, which negatively impacted their sleep quality
and sleep hygiene. [5]
These results are in agreement with ours; we observed increased anxiety
among students leading to unhealthy eating and weight gain, reduced
physical activity, and increased sitting time.
Personal hygiene and dental hygiene were maintained during quarantine,
with only a small group of students reporting a reduction in personal
and dental hygiene. However, when we compared the students from
dentistry and dental hygiene courses against those from other courses,
we observed that the former had better dental hygiene practices.
Likewise, they showed better knowledge of the tools used in maintaining
oral hygiene.
The lack of knowledge of the tools for oral care by students of other
medical courses is surprising. All students belonged to the medical
field and were expected to have good knowledge about tools for oral care
and hygiene. This is an important issue that needs to be addressed by
delving into the aspects of oral disease prevention among medical
students. It has been shown previously that oral hygiene plays an
important role in the prevention of chronic diseases, such as diabetes
and cardiovascular diseases. [15]
The persistence of the pandemic appears to have exacerbated the
stress-and stress-related lifestyles of students. [16,17,18,19]
Despite efforts to share reliable information on healthy lifestyles, the
psychological orientation of young people, particularly their health and
food consumption, appears to have not changed during the second wave
period. [19]
Interestingly, a large number of students from dentistry and dental
hygiene courses reported a change in the quality of mouthwash with an
increase in the use of chlorhexidine mouthwash during quarantine. This
was because of the effect of some studies that supported the efficacy of
mouthwash in fighting the COVID-19 infection. In the study by
Cavalcante-Leao et al., in which the asymptomatic patient has been
mentioned multiple times, special attention has been given to dental
risk since the epithelial cells of the salivary glands have high
expression of the angiotensin converting enzyme 2 (ACE2) receptor, which
is a functional receptor for COVID-19. They systematically reviewed
evidence in the literature regarding the effectiveness of three types of
mouthwashes in decreasing the viral load of the oral cavity; the three
types of commonly used mouthwashes in dentistry are chlorhexidine,
hydrogen peroxide, and povidone-iodine (PVP-I). They concluded that
PVP-I, at concentrations of 1% and 7%, appeared to be the most
effective mouthwash for reducing COVID-19 viral load in human saliva.
However, the level of scientific evidence related to the use of PVP-I
mouthwash in reducing SARS-CoV-2 viral load is very low because it was
demonstrated only in two in vitro studies. The guidelines for
dental care refer to the use of hydrogen peroxide; however, there is
insufficient scientific evidence to support this recommendation.
[20,21,22]
Our study had some limitations. First, the questionnaires were
self-administered, and subjective evaluations were described. No
validated tools were used to assess stress and depression among
students. Second, we used a web-based survey, which may have resulted in
possible selection bias. We selected a restricted cohort of medical
students; therefore, it is not possible to extend our findings to the
general population. However, this very select population of medical
students provides important information on how young individuals
perceived the lockdown and the effects it has had on their hygiene
habits.