Oral Health and Teledentistry Interest during the COVID-19 Pandemic
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Journal of Clinical Medicine Article Oral Health and Teledentistry Interest during the COVID-19 Pandemic Magdalena Sycinska-Dziarnowska 1 , Marzia Maglitto 2 , Krzysztof Woźniak 1 and Gianrico Spagnuolo 2,3, * 1 Department of Orthodontics, Pomeranian Medical University in Szczecin, Powstańców Wielkopolskich Street 72, 70111 Szczecin, Poland; firstname.lastname@example.org (M.S.-D.); email@example.com (K.W.) 2 Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80131 Napoli, Italy; firstname.lastname@example.org 3 Institute of Dentistry, I. M. Sechenov First Moscow State Medical University, 119435 Moscow, Russia * Correspondence: email@example.com Abstract: Background: The COVID-19 pandemic outbreak has significantly changed access to dental treatments. Methods: The data related to oral health and teledentistry topics were collected from the open database Google Trends. The analyzed material was collected from 19 June 2016 to 6 June 2021 among anonymous search engine users. The following expressions were analyzed: “dental care”, “emergency dental care”, “oral health”, ”periodontitis”, “teledentistry”, “is it safe to go to the dentist”, and “COVID-19” and ”PPE dentist”. Results: During the first lockdown in 2020, a significant increase in “emergency dental care” phrase queries was detected, with a simultaneous decrease in regular “dental care” questions, as well as a peak in the queries for “periodontitis” preceded by lower interest in “oral health.” The number of searches stated for “teledentistry” increased during the time of the pandemic 5 times and for and “PPE dentist” 30 times. The risk of visiting the dental studio was seen in almost 40 times increase in the query “is it safe to go to the dentist.” Conclusions: The COVID-19 Citation: Sycinska-Dziarnowska, M.; imprinted a stigma on oral health care. In this difficult epidemiological situation, teledentistry might Maglitto, M.; Woźniak, K.; Spagnuolo, G. Oral Health and Teledentistry become a helpful solution. Interest during the COVID-19 Pandemic. J. Clin. Med. 2021, 10, 3532. Keywords: oral health; teledentistry; Google Trends; COVID-19 pandemic https://doi.org/10.3390/ jcm10163532 Academic Editors: 1. Introduction Hans-Peter Howaldt and Sameh Attia In late June 2021, about 182 million COVID-19 cases were reported globally, with almost 4 million people deaths . It seems very likely that the COVID-19 pandemic had Received: 22 July 2021 an impact on oral health-related behaviors. The stringent measures undertaken to limit Accepted: 10 August 2021 the spread of COVID-19 disease with social distancing rules made access to dental offices Published: 11 August 2021 more troublesome. The risk of contagion can be reduced by introducing teledentistry . Teleconsultation, which begins with an online triage, was a compromise that limited patient Publisher’s Note: MDPI stays neutral access but also ensured effective treatment and relief from symptoms . with regard to jurisdictional claims in According to some studies, routine dental care and emergency dental care have been published maps and institutional affil- iations. immensely influenced by the waves of COVID-19 [4–7]. The large impact of the COVID- 19 pandemic on dentistry was shown in the study conducted by Soltani et al., in which as many as 659 articles published by dental journals were found in PubMed regarding implications of the COVID-19 pandemic in dentistry . Moreover, many people did not want to visit the dental studios due to the fear of virus transmission. Moreover, as proved Copyright: © 2021 by the authors. in many studies in pre-pandemic time, the prolonged lack of regular oral health check- Licensee MDPI, Basel, Switzerland. ups may lead to periodontitis [9,10]. Another unprecedented situation happened during This article is an open access article the COVID-19 pandemic. Greater demand for personal protective equipment (PPE) was distributed under the terms and detected globally and led to a shortage in masks, gloves, and almost all PPE . Difficult conditions of the Creative Commons Attribution (CC BY) license (https:// access to PPE was significant and obvious in the early phase of the COVID-19 pandemic. creativecommons.org/licenses/by/ In order to minimize the viral spread risk during the current COVID-19 pandemic and 4.0/). J. Clin. Med. 2021, 10, 3532. https://doi.org/10.3390/jcm10163532 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2021, 10, 3532 2 of 12 post-pandemic times, the global project to define the best organization of dental offices was conducted . Rapid changes in the epidemiological situation might be easily and strongly visible in the surveillance of the more widely used search engines, for example, the Google search engine, the most used engine with the vast majority of the market share, as much as 92.26% . The aim of this study was to analyze the impact of the COVID-19 pandemic on oral health and the interest in teledentistry. 2. Materials and Methods The data for the study were collected from the open database—Google Trends (GT) service among anonymous search engine users related to oral health and teledentistry subjects [14,15]. Each data record represents a weekly worldwide number of queries processed by Google engine and available according to the selected time period. In the study, the analyzed material was collected from 19 June 2016 to 6 June 2021. All data imported from GT represent queries were normalized to the time and location. The resulting numbers are scaled on a range of 0 to 100, where 100 is the maximum number of searches in a stated period of time. The following expressions were analyzed: “dental care”, “emergency dental care”, “oral health”, “periodontitis”, “COVID-19” and ”PPE dentist”, as well as the phrases “teledentistry” and “is it safe to go to the dentist”, were investigated to check the interest for online consultations. The data analysis was divided into two sections. The first section provides the detailed level description of data, its structure, and main samples characteristics needed in order to perform further calculations. In the second section, the pairwise correlation between data series was analyzed. For each time series data, the trend, cyclical, and random fluctuations analyses were performed. The purposes of this section were as follows: • To present pairwise time series visualizations; • To perform time series decompositions indicating the trend, cyclical, and random fluctuations; • To analyze the cross-correlation between chosen time series pairs with statistically significant estimation; • To evaluate a pairwise of mutual influence (where possible). To estimate the dynamics rate (hereinafter), the comparisons of two mean rates for two periods were made: first one for the period before the 22–23 January 2020, when the World Health Organization (WHO) Director gathered an Emergency Committee to discuss whether the new virus outbreak determined a public health emergency of worldwide concern  (that refers to dates from 19 June 2016 to 19 January 2020 in our weekly split data set) and the second one from 19 January 2020 to 6 June 2021. For simplicity, we further refer to those periods as before and during the pandemic. In the study, we aimed to check the time before the official pandemic onset, as the search engines may have shown some interest in the subject before official regulations were made. For the qualitative and quantitative analysis of the correlation, the time series collec- tions were divided into the following 4 pairs: • “Dental care”–“emergency dental”; • “Oral health”–“periodontitis”; • “Teledentistry”–“is it safe to go to the dentist”; • “COVID-19”–“PPE-dentist”. All statistical estimations with data visualizations were programmed by the “R” programming language  with “R studio” version 1.4.1106 open-source software for data science, scientific research, and technical communication .
J. Clin. Med. 2021, 10, 3532 3 of 12 J. Clin. Med. 2021, 10, x FOR PEER REVIEW 3 of 12 3. Results 3.1. Time Series Visualizations 3.1. Time Series Visualizations A graphical illustration of time series was presented by a paired graph of the dynam- A graphical illustration of time series was presented by a paired graph of the dynamics ics of requests in the study period. For the purposes of analyzing the trend, cyclical, and of requests in the study period. For the purposes of analyzing the trend, cyclical, and random fluctuations, the time series were decomposed for each collection separately. random fluctuations, the time series were decomposed for each collection separately. The pairwise time series visualization of “dental care”–“emergency dental care” is The pairwise time series visualization of “dental care”–“emergency dental care” is presented in Figure 1a. The plot clearly shows a high proportion of uncertainty in demand presented in Figure 1a. The plot clearly shows a high proportion of uncertainty in demand fordental for dentalservices servicesatatthe thevery verybeginning beginningofof2020. 2020.This Thisisisevidenced evidencedbybya asharp sharpdecline declineinin demand for planned dental procedures with a simultaneous sharp increase demand for planned dental procedures with a simultaneous sharp increase in demand in demand for for emergency ones. However, this phase had a short-term character, and during the1– emergency ones. However, this phase had a short-term character, and during the next 2 months, next the structure 1–2 months, of demand the structure returned of demand to its normal returned state. state. to its normal (a) (b) Figure Figure 1.1.Pairwise Pairwisecomparison comparisonofofweekly weeklyrequests requestsduring during2016–2021: 2016–2021:(a)(a)“dental “dentalcare”–“emergency care”–“emergencydental dentalcare”; care”; (b) (b) “oral “oral health”–“periodontitis”. health”–“periodontitis”. Thepairwise, The pairwise,time timeseries seriesvisualization visualizationofof“oral “oralhealth”–“periodontitis” health”–“periodontitis”isispresented presented ininFigure Figure1b.1b.TheTheplotplotshows showslargelargeinterest interestgrowth growthwhenwhenregarding regarding“periodontitis” “periodontitis”with with thepeak the peakatatthe thebeginning beginningofofthe theyear year2020 2020with withstable stableand andslight slightgrowth growthininthe thenumber numberofof questionsasked questions askedduringduringthe theanalyzed analyzedperiod. period.TheThenumber numberofofqueries queriesfor for“oral “oralhealth” health”isis more stable. A peak in “periodontitis” queries was detected after more stable. A peak in “periodontitis” queries was detected after the hard lockdown and the hard lockdown and the thelower lowerinterest interestininthe the“oral “oralhealth” health”subject. subject. Furthermore, Furthermore,the pairwise, the pairwise, time series time visualization series visualizationof “teledentistry”–“is of “teledentistry”–“is it safe to goto it safe togothetodentist” is presented the dentist” in Figure is presented 2a. Both in Figure 2a.terms Both under terms consideration rarely occurred under consideration rarely oc- incurred the pre-pandemic in the pre-pandemic time. Only at theatbeginning time. Only of 2020 the beginning diddid of 2020 these concepts these concepts become become widespread. widespread. The plot clearly shows a peak when the request for both terms reachesitsits The plot clearly shows a peak when the request for both terms reaches maximum. maximum.The Thedemand demandfor forthe the“teledentistry” “teledentistry”term termthen thenbegins beginstotodecline declineexponentially exponentially until until the end of the period under review, reaching levels preceding thepandemic, the end of the period under review, reaching levels preceding the pandemic,and andthe the expression expression“is “isititsafe safetotogogototothe thedentist” dentist”isischaracterized characterizedbybysteady steadydemand demandthroughout throughout almost almostallallofof2020, 2020,reaching reachinglocallocalhighs highsduring duringperiods periodsofoflockdowns lockdownsand andexacerbations exacerbationsofof restrictions. restrictions. However, at the end of the period under review, requests forthis However, at the end of the period under review, requests for thisterm termalso also reached a minimum, slightly exceeding pre-pandemic reached a minimum, slightly exceeding pre-pandemic levels. levels.
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 4 of 12 J. Clin. Med. Med.10, 2021, J. Clin. 3532 2021, 10, x FOR PEER REVIEW 4 of 124 of 12 (a) (b) (a) (b) Figure 2. Pairwise comparison of weekly requests during 2016–2021: (a) “teledentistry”–“is it safe to go to the dentist”; (b) Figure 2. Pairwise 2. Pairwise comparison of weekly requests during 2016–2021: (a) “teledentistry”–“is it safe to go to the dentist”; (b) comparison Figure “COVID-19”–“PPE dentist”. of weekly requests during 2016–2021: (a) “teledentistry”–“is it safe to go to the dentist”; “COVID-19”–“PPE dentist”. (b) “COVID-19”–“PPE dentist”. The pairwise, The pairwise,timetimeseries visualizationofof“COVID-19”–“PPE series visualization “COVID-19”–“PPE dentist” dentist” is presented is presented in in The pairwise, time series visualization of “COVID-19”–“PPE dentist” is presented in Figure 2b.2b. Figure Both Bothexpressions expressions came intouse came into useimmediately immediately with with the the onset onset of theofpandemic. the pandemic. Figure 2b. Both expressions came into use immediately with the onset of the pandemic. TheThe demand demand curve curvefor for“COVID-19” “COVID-19” isischaracterized characterized byby thethe presence presence of three of three globalglobal highs highs Thethat demand curve occurred forjunction “COVID-19” is characterized by the presence of at three global highs that occurred atatthe the junction of 2019–2020, 2019–2020,ininthethefirst quarter first of 2020, quarter and of 2020, andtheatjunction the junction thatofoccurred 2020/2021,at which the junction of 2019–2020, corresponds to in the first pandemic quarter ofwaves. 2020, The and at the“PPEjunction of 2020/2021, which corresponds tothe thetime timeofofglobal global pandemic waves. topic The topic “PPE of 2020/2021, dentist” whichforcorresponds standing personal to the equipment protective time of globalwas pandemic waves. characterized by the The topic greatest de-“PPE dentist” standing for personal protective equipment was characterized by the greatest de- dentist” mandstanding for personal at the beginning of the protective equipment pandemic; over the nextwas1.5 characterized years, the level by of the greatest interest mand at the beginning of the pandemic; over the next 1.5 years, the level of interest demand at the dropped beginninguntil exponentially, of the the pandemic; over under end of the period the next 1.5 years, review, where the level it again of interest reached dropped exponentially, the pre-pandemic until the end of the period under review, where it again reached level.until the end of the period under review, where it again reached dropped exponentially, the pre-pandemic level. the pre-pandemic level. 3.2. Trends Analysis 3.2.Trends 3.2. Trends Analysis Analysis Regarding the “dental care” time series, during the period under consideration, there areRegarding two periods the Regarding theof“dental“dental trend growthcare”Figure care” timeseries, time series, during 3a: the during first (more the the periodunder under pronounced) period from consideration, there the beginningthere consideration, are of two2018 to the periods beginning of trend of growth2019, and Figure the second 3a: the (more first (moresmoothed) from pronounced) are two periods of trend growth Figure 3a: the first (more pronounced) from the beginning the beginning from the of beginning 2020. to of2018 2018 There was no downtrend thebeginning beginning 2019,during of2019, andthe thesecond the pandemic period. (more Regarding smoothed) fromthe “emergency thebeginning beginningofof of to the of and second (more smoothed) from the dental 2020. There care” Therewas time wasno series nodowntrend (Figure downtrendduring 3b), the duringthe direction thepandemic is multidirectional pandemicperiod. (with period.Regarding Regarding local theups and “emergency 2020. the “emergency downs) with a general upward trend. After reaching the minimum in 2018 through mid- dentalcare” dental care” timeseries series(Figure (Figure3b), 3b), thedirection direction ismultidirectional multidirectional(with (withlocal localups ups and 2020, theretime was a significant increase,the followed by aisshort-term moderate decline (proba- and downs) downs) with bly during a with athe general general upward generalupward lockdown). trend. trend. After An After upward reaching reaching trend was the minimum theobserved minimum since in inthe 2018 2018 through through second mid- half mid- 2020, 2020, there of there was a significant was a reached 2020, which significant increase, followed increase, followed its maximum values at the by by end a short-term a short-term moderate moderate of the period decline (proba- decline (probably under review. bly during during the general the general lockdown). lockdown). An upward An upward trend trend waswas observed observed sincesince the the second second halfhalf of of 2020, 2020, which which reached reached its maximum its maximum values values at the at the endend of the of the period period under under review. review. (a) (b) Figure 3. Decomposition of time series (month granularity): (a) “dental care”; (b) “emergency dental care”. (a) (b) Figure3.3.Decomposition Figure Decompositionof oftime timeseries series(month (monthgranularity): granularity):(a) (a)“dental “dentalcare”; care”;(b) (b)“emergency “emergencydental dentalcare”. care”.
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 5 of 12 J.J. Clin. Clin. Med. Med. 2021, 2021, 10, 10, 3532 x FOR PEER REVIEW 55 of of 12 12 Regarding Regardingthe the“oral “oralhealth” health”timetimeseries, series,during duringthe theperiod periodunder underconsideration, consideration,there there are Regarding the “oral health” time series, during the period under consideration, there are two periods of trend growth Figure 4a: the first (minor one) from the two periods of trend growth Figure 4a: the first (minor one) from the beginning beginning of of are two 2017 to theperiods beginningof trend of growth 2018, and Figure the 4a: the second (a first (minor one) pronounced one) from frommid-2018 the beginning to of early 2017 to the beginning of 2018, and the second (a pronounced one) from mid-2018 to early 2017 to 2020. the beginning of 2018, and the second (a pronounced one) from mid-2018 to early 2020. Periods Periods of of growth growth are are followed followed by by periods periods of of decline decline withwith similar similar severity severity and and du-du- 2020. ration. Periods of growth are followed by periods of decline with similar severity and ration. Since Since the the beginning beginning of of the the pandemic, pandemic, aa negative negative trend trend waswas recorded recorded withwith small small duration. periods Since the beginning of the pandemic, a negative trend wasnorecorded with small periods of of stabilization stabilization with with aa tendency tendency to to smooth smooth out.out. There There were were no upward upward trends. trends. In In periods ofthe mid-2021, stabilization level of with aistendency demand close to thetominimum smooth out. valuesThere for were the no upward period under trends. review. mid-2021, In mid-2021, the the level of demand level ofthedemand is close to theto is close minimum theseries valuesvalues minimum for the for period the under period review. under Furthermore, Furthermore, regarding regarding the “periodontitis” “periodontitis” time time series (Figure (Figure 4b), 4b), for for most most of of the the period period review. under Furthermore, review, the trend regarding the “periodontitis” time series (Figure 4b), for most of under the review, period under trend was thereview, was the characterized characterized trend was as as moderately moderately characterized as growing growing with moderately with small small corrections growing corrections with small and and short short declines. declines. Since Since the the beginning beginning of of 2019, 2019, there there has been has2019, protracted beenthere protracted growth, growth, which which corrections reached its and short maximum declines. during the Since the pandemic. beginning At the end ofof the period has under been protracted review, there reached growth, its whichmaximum reached during its trend, the maximum pandemic. during At the end the pandemic. of the period At the under end oflevels review, the period there under is a slight is a slight decrease decrease in the in the trend, inwhich, which, however, however, exceeds exceeds the demand theexceeds demandthe levels of the pre- of thelevels pre- review, pandemic there is period. a slight decrease the trend, which, however, demand pandemic period. of the pre-pandemic period. (a) (a) (b) (b) Figure 4. Decomposition of time series (month granularity): (a) “oral health”; (b) “periodontitis”. Figure 4. Decomposition of time series Figure 4. Decomposition of(month granularity): time series (a) “oral health”; (month granularity): (b) health”; (a) “oral “periodontitis”. (b) “periodontitis”. Regarding Regarding the the “teledentistry” “teledentistry” timetime series series (Figure (Figure 5a), 5a), until until thethe second second half half ofof 2019, 2019, the trend the trend waswas an was an almost analmost flat almostflat curve, flatcurve, with curve,with a barely witha abarely barelynoticeable noticeable noticeable increase, increase, increase, which which which is replaced is replaced is replaced by by abysharp a sharp a sharp growth growth phase growth phase lasting phase about lasting lasting about a year. about The a year. a year. growth for The growth The growth the specified forspecified for the period the specified was periodperiod about was aboutwas 20 20 points. about points. Then, Then, the 20 points. the growth Then, phase the growth growth was was replaced phasephase by by aa moderate was replaced replaced decline by a moderate moderate decline phase, decline phase, which phase, which con- which con- tinued continueduntil the until end the of end the of period the under period under review. review. Similarly, Similarly, in tinued until the end of the period under review. Similarly, in the “is it safe tointhe the “is “isititsafe safe toto go go to to the the the dentist” dentist” time time series series (Figure (Figure 5b),5b), until until the the second second half half of of 2019, 2019, the the trend trend was was trend was flataa flat flat line line with with aa zero zero value, value, which which waswas replaced replaced byby aa phase phase of of sharp sharp growth growth that that lasted lasted forforabout for aboutaaayear. about year. year. The growth for The growth for the the indicated the indicated period indicated period was period was about was about 40 about 40 points. 40 points. Then, the points. Then, the growthgrowth growth phase phase gave phase gave gave way way to way to aaa moderate to moderate decline moderate decline phase, decline phase, which phase, which lasted which lasted until lasted until the until the end the end of end of the of the period the period under period under review. under review. review. (a) (a) (b) (b) Figure Figure5. Decomposition Decompositionof time timeseries series(week (weekgranularity): granularity):(a) (a)for for“teledentistry”; “teledentistry”;(b) (b)for for“is “isitititsafe safeto go gototothe thedentist”. Figure 5.5.Decomposition ofoftime series (week granularity): (a) for “teledentistry”; (b) for “is safe totogo to the dentist”. dentist”.
J.J. Clin. Clin. Med. 2021, 10, 3532 x FOR PEER REVIEW of 12 6 of 12 The The trend trend line line for for both both expressions expressions in in Figure Figure 6a,b—“COVID-19” 6a,b—“COVID-19” and and “PPE “PPE dentist”— dentist”— repeats the pattern of the previous pair. Until mid-2019, a horizontal repeats the pattern of the previous pair. Until mid-2019, a horizontal line at line at the the 00 level level is is observed, after which the annual growth phase with a maximum increase observed, after which the annual growth phase with a maximum increase of up to 30 points of up to 30 points is observed. is observed. The growth The growth phase phase is replaced is replaced by a moderate by a moderate decline decline phase,phase, whichwhich con- continues tinues until until the endthe of end of the period the period underunder consideration consideration (the volume (the volume of decline of decline for “COVID- for “COVID-19”— 19”—5 points, for “PPE dentist”—10 5 points, for “PPE dentist”—10 points). points). (a) (b) Figure 6. Decomposition of time series Figure 6. Decomposition (week of time granularity): series (a) for “COVID-19”; (week granularity): (b) for “dentist (a) for “COVID-19”; (b) forPPE”. “dentist PPE”. 3.3. Cyclical 3.3. Cyclical and and Random Random Fluctuations Fluctuations Indications Indications Analysis Analysis In the In the “dental “dental care” care” time time series series (Figure (Figure 3a),3a), there there isis aa single single negative negative peakpeak of of average average severity in the second half of 2018. There were no positive peaks severity in the second half of 2018. There were no positive peaks in the similar intensity. in the similar intensity. When When regarding regarding the the “emergency “emergency dental dental care” care” timetime series series Figure Figure 3b, 3b, there there are are two two peaks: peaks: the most pronounced at the beginning of the period (breaking through the 20 marks) and the most pronounced at the beginning of the period (breaking through the 20 marks) and slightly less slightly less pronounced pronounced in in the the second second halfhalf ofof 2018 2018 (approaching (approaching the the 2020 marks). marks). Negative Negative peaks peaks ofof similar similar intensity intensity were were notnot observed. observed. Regarding the “oral health” Regarding the “oral health” time series time series (Figure (Figure 4a),4a), there there are are several several cycles cycles ofof low low severity breaking severity breaking through through the the 10-point 10-point mark markin inboth bothdirections. directions.Moreover, Moreover,ininthe the“perio- “peri- odontitis” time series (Figure 4b), there are several peaks of average severity approaching dontitis” time series (Figure 4b), there are several peaks of average severity approaching the 10-point mark in both directions. The most pronounced is the positive cycle at the end the 10-point mark in both directions. The most pronounced is the positive cycle at the end of the period under consideration. of the period under consideration. In the “teledentistry” time series (Figure 5a), there is one pronounced cycle with an In the “teledentistry” time series (Figure 5a), there is one pronounced cycle with an increase in the parameter of about 60 points, and there is one pronounced cycle with an increase in the parameter of about 60 points, and there is one pronounced cycle with an increase in the parameter of more than 40 points when describing the “is it safe to go to the increase in the parameter of more than 40 points when describing the “is it safe to go to dentist” time series (Figure 5b). the dentist” time series (Figure 5b). Two pronounced cycles are clearly visible in the “COVID-19” time series in Figure 6a—at Two pronounced cycles are clearly visible in the “COVID-19” time series in Figure the junction of 2019/2020 and in the first half of 2020, with an increase of about 35 points. No 6a—at the junction of 2019/2020 and in the first half of 2020, with an increase of about 35 pronounced negative peaks are observed. A series of peaks regarding the expression “PPE points. No pronounced negative peaks are observed. A series of peaks regarding the ex- dentist” at the junction of 2019/2020 with gains of more than 50 points is clearly visible. No pression “PPE pronounced dentist” negative at the peaks werejunction recorded of (Figure 2019/2020 6b).with gains of more than 50 points is clearly visible. No pronounced negative peaks were recorded (Figure 6b). 3.4. Changes in Request Average during COVID-19 Pandemic 3.4. Changes in Request Average during COVID-19 Pandemic The mean of “dental care” time series request rate in the pre-pandemic period has a rateThe of mean of “dental 79.9; during the care” time series pandemic, the meanrequest rate rate was in increased the pre-pandemic to 80.2. period Thus, hasfroma rate of 79.9; during the pandemic onset the pandemic, to the present,the themean “dental ratecare” was requests increasedmean to 80.2. rateThus, from the has remained pandemic onset particularly to the present, unchanged the “dental (the increasing ratecare” requests is about 0.4%).mean rate has remained Moreover, the mean partic- of the ularly unchanged “emergency dental(the care”increasing time series rate is about request rate0.4%). in theMoreover, pre-pandemic the mean periodofhas thea “emer- rate of gency dental 48.73, and care”the during time series request pandemic, the meanraterate in the pre-pandemic increased to 52.6. period has athe Thus, from rate of 48.73, pandemic and onset to the present, the main rate of “emergency dental care” increased by 7.9%.onset during the pandemic, the mean rate increased to 52.6. Thus, from the pandemic The to the of mean present, the health” the “oral main rate of “emergency time series requestdental rate in care” increased by 7.9%. the pre-pandemic Thehas period mean of a rate the “oralduring of 62.0; health” thetime series request pandemic, the mean raterate in the pre-pandemic changed periodfrom to 61.8. Thus, has the a rate of 62.0; pandemic during onset tothe the pandemic, present, thethe mean “oral rate requests health” changedmean to 61.8. rateThus, from particularly remained the pandemic onset to unchanged
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 7 of 12 J. Clin. Med. 2021, 10, 3532 7 of 12 the present, the “oral health” requests mean rate remained particularly unchanged (the decreasing rate is about 0.3%). The mean of the “periodontitis” request rate in the pre- pandemic period has a rate of 35.7; during the pandemic, the mean rate changed to 41.1. (the decreasing rate is about 0.3%). The mean of the “periodontitis” request rate in the Thus, from the pandemic onset to the present, the main rate of “periodontitis” increased pre-pandemic period has a rate of 35.7; during the pandemic, the mean rate changed by 15.1%. Moreover, the mean of the “teledentistry” time series request rate in the pre- to 41.1. Thus, from the pandemic onset to the present, the main rate of “periodontitis” pandemic period has a rate of 4.3; during the pandemic, the mean rate changed to 21.4. increased by 15.1%. Moreover, the mean of the “teledentistry” time series request rate in Thus, from the pandemic onset to the present, the “teledentistry” requests mean rate char- the pre-pandemic period has a rate of 4.3; during the pandemic, the mean rate changed acterized by a 5 times increase. The mean of the request rate for the “is it safe to go to the to 21.4. Thus, from the pandemic onset to the present, the “teledentistry” requests mean dentist” time series in the pre-pandemic period has a rate of 0.8; during the pandemic, the rate characterized by a 5 times increase. The mean of the request rate for the “is it safe tomean go torate the changed to 31.9. dentist” time Thus, series from in the the pandemic pre-pandemic onsethas period to the present, a rate of 0.8; the requests during the mean rate is characterized by an increase of almost 40 times. The mean pandemic, the mean rate changed to 31.9. Thus, from the pandemic onset to the present, of the “PPE den- tist” the requestmean requests rate inrate theispre-pandemic characterizedperiod has a rateofofalmost by an increase 0.8; during the pandemic, 40 times. The mean theof mean rate changed to 24.0. Thus, from the pandemic onset to the present, the “PPE dentist” request rate in the pre-pandemic period has a rate of 0.8; during the “PPE den- the tist” request pandemic, themean meanraterateischanged characterized to 24.0.by an increase Thus, from theofpandemic 30 times. onset Whentoregarding the the present, “COVID-19” the timerequest “PPE dentist” series, this meanexpression did not exist by rate is characterized before the pandemic. an increase of 30 times. When regarding the “COVID-19” time series, this expression did not exist before the pandemic. 3.5. Cross-Correlation 3.5. Cross-Correlation The time series pair “dental care”–“emergency dental” cross-correlation function plotTheis shown in Figure time series pair 7a. Therecare”–“emergency “dental are a number of significant correlations onfunction dental” cross-correlation both sides plotof is0.shown All significant in Figure correlations 7a. There areare positive, a number of from whichcorrelations significant it follows, onan both increase sidesinofone pa- 0. All rameter leads significant to an increase correlations in another. are positive, from There whichisit no significant follows, correlation an increase in oneatparameter h = 0. Fur- thermore, leads the time in to an increase series pair “oral another. Therehealth”–“periodontitis” is no significant correlation cross-correlation function the at h = 0. Furthermore, plot time seriesin is shown pair “oral7b. Figure health”–“periodontitis” The correlation magnitude cross-correlation and the number function plot is shown of significant in correla- Figure tions are7b. greater The correlation magnitude on the left side of 0. andThethemost number of significant dominant correlationsoccurs cross-correlation are greater at h = on−2.the The leftcorrelation side of 0. The most dominant is positive, indicating cross-correlation that an above-average h = −2. occurs at value ofThe “oralcorrelation health” is islikely positive, indicating to lead that an above-average to an above-average value of value of “oral health” “periodontitis” about is likely tolater. 2 months lead to an Addi- above-average value of “periodontitis” about 2 months later. Additionally, tionally, a below-average value of “oral health” is associated with a likely below-average a below-average value of “oral health” “periodontitis” valueisabout associated 2 months withlater. a likely below-average Moreover, the time“periodontitis” value about series pair “teledentistry”– 2“is months it safelater. to goMoreover, the time to the dentist” series pair “teledentistry”–“is cross-correlation function plot is itshownsafe toingoFigure to the7c.dentist” There cross-correlation function plot are a number of significant is shown only correlations in Figure on the7c. There right sideare of a0.number of significant All significant correla- correlations only onFinally, tions are positive. the right theside timeofseries 0. Allpair significant correlationsdentist” “COVID-19”–“PPE are positive. Finally, cross-correla- the time series pair “COVID-19”–“PPE dentist” cross-correlation tion function plot is shown in Figure 7d. There are a number of significant correlations function plot is shown on inboth Figure 7d. There are a number of significant correlations on both sides sides of 0. There is also a significant correlation at h = 0. All significant correlations of 0. There is also are apositive, significant from correlation which it at h = 0. All follows, an significant increase incorrelations one parameter are positive, leads to from which itin an increase follows, an increase in one parameter leads to an increase in another. another. An above-average value of “COVID-19” is highly likely to lead to an above-av- An above-average value erageofvalue“COVID-19” is highlyabout of “PPE dentist” likely 4toweeks lead tolater. an above-average value of “PPE Since both expressions existeddentist” in GT about 4 weeks later. Since both expressions existed in GT searches searches for less than 2 years, the use of month granularity was impossible, which is why,for less than 2 years, the use of month granularity was in this case, a week granularity was used.impossible, which is why, in this case, a week granularity was used. (a) (b) Figure 7. Cont.
J. Clin. Med. 2021, 10, 3532 x FOR PEER REVIEW 8 of 12 (c) (d) Figure 7. Figure 7.Cross-correlation plots: Cross-correlation (a) “dental plots: care”–“emergency (a) “dental dental”dental” care”–“emergency (granularity: month); (b) (granularity: “oral health”–“periodon- month); (b) “oral health”– “periodontitis” (granularity: month); (c) “teledentistry”–“is it safe to go to the dentist” (granularity:(d) titis” (granularity: month); (c) “teledentistry”–“is it safe to go to the dentist” (granularity: month); “COVID-19”–“PPE month); (d) “COVID- dentist” (granularity: 19”–“PPE week). dentist” (granularity: week). 4. Discussion Discussion The aim of the study was to investigate the impact of the the COVID-19 COVID-19 pandemic on oral health and teledentistry subjects. To the best of our knowledge, this is one of the few studies [19,20] tracing tracing thetheGTGTexpressions expressionsconnected connectedwith withoral oralhealth healthduring during thethe COVID-19 COVID- pandemic. 19 pandemic. TheThefirstfirst noticeable outcome noticeable outcome of the of research the researchwas wasa large increase a large in emergency increase in emer- dentaldental gency care questions care questionsaskedasked during the spring during lockdown the spring lockdown in 2020 withwith in 2020 a simultaneous a simultane- decrease ous in regular decrease in regular dental care dental queries. care queries. Our Ourresults resultsstrongly stronglyshow showthat thatthe the COVID-19 COVID-19 pandemic had significantly influenced dental-care-seekingdental-care-seeking behavior. According According to the recommendations and recommendations and because because of of the the fear fear surrounding surrounding the the epidemic, epidemic, peoplepeople were were averse averse to be outside and less willing to visit dental studios. Moreover, to be outside and less willing to visit dental studios. Moreover, dental care was not dental care was not widely widely available during available duringthe theearly earlyphase phaseof of thethepandemic, pandemic, with witha large number a large of patients number expected of patients ex- to seek emergency dental service only when urgent care pected to seek emergency dental service only when urgent care was needed . was needed . In line with our In line study,our with thestudy, outcomes of the study the outcomes conducted of the by FaccinibyetFaccini study conducted al. indicate et al.that during indicate thatthe hard during lockdown, 64.6% of dentists carried out only emergency treatments, the hard lockdown, 64.6% of dentists carried out only emergency treatments, with 26.1% with 26.1% of dentists stilldentists of maintaining the routine planned still maintaining the routine appointments, and with 9.3% planned appointments, of dental and with 9.3% offices of closed dental for the duration of the lockdown. An increase in urgent dental offices closed for the duration of the lockdown. An increase in urgent dental procedures procedures was noted by 44.1% was of the noted by dentists. 44.1% of the It occurred dentists. most often most It occurred due to the due often lower availability to the for a longer lower availability for period of time for regular dental care. The main causes of emergency a longer period of time for regular dental care. The main causes of emergency appoint- appointments were toothache, ments weredental trauma, toothache, dentalor trauma, broken restorations . Similarly, or broken restorations a study conducted . Similarly, a study con- in Beijing, in ducted China, withChina, Beijing, 2537 patients with 2537 involved patientsin involved the study,inindicated the study, that at the beginning indicated that at theof the COVID-19 pandemic, 38% fewer patients sought dental emergency care than before. beginning of the COVID-19 pandemic, 38% fewer patients sought dental emergency care Dental problems and oral infection increased from 51.0% in the pre-pandemic period to than before. Dental problems and oral infection increased from 51.0% in the pre-pandemic 71.9% during the COVID-19 pandemic period . A finding in line with our study is that period to 71.9% during the COVID-19 pandemic period . A finding in line with our the COVID-19 pandemic outbreak had strongly influenced the emergency dental services. study is that the COVID-19 pandemic outbreak had strongly influenced the emergency The large influence of COVID-19 disease on oral cavity was shown in the study conducted dental services. The large influence of COVID-19 disease on oral cavity was shown in the by Gherlone et al., as 83.6% of patients reported anomalies of the oral cavity, such as dry study conducted by Gherlone et al., as 83.6% of patients reported anomalies of the oral mouth or salivary gland ectasia, that lasted even up to 3 months after hospitalization due cavity, such as dry mouth or salivary gland ectasia, that lasted even up to 3 months after to COVID-19 . hospitalization due to COVID-19 . According to recent studies, people with serious medical conditions such as diabetes, According to recent studies, people with serious medical conditions such as diabetes, heart diseases, lung or kidney chronic disease, and older persons were at high risk for de- heart diseases, lung or kidney chronic disease, and older persons were at high risk for veloping more severe COVID-19 infection. On the other hand, poor oral health and hygiene developing may increase more the severe risk ofCOVID-19 developinginfection. On the other hand, the abovementioned medical poor oral health problems. and hy- Therefore, giene may increase the risk of developing the abovementioned improving oral health among the whole population may lead to a lower risk of developing medical problems. There- fore, improving oral health among the whole population may systemic diseases and, in this way, reduce the morbidity due to COVID-19 [9,23]. In lead to a lower risk of the de- veloping study among systemic a groupdiseases of 568and, in thisthe patients, way, reduce higher riskthe of morbidity intensive care dueunit to COVID-19 admission[9,23]. with In the study among a group of 568 patients, the higher the need for assisted ventilation and worse disease outcomes, leading even risk of intensive care unit toadmission the death with the needpatients, of COVID-19 for assisted wasventilation associated and withworse disease outcomes, periodontitis. Similarly, leading COVID-19 even to the patients death of COVID-19 patients, was associated with periodontitis. with periodontitis had significantly higher blood levels of D-dimer and C-reactive protein Similarly, COVID-19 pa- tients with periodontitis had significantly higher blood levels of D-dimer and C-reactive
J. Clin. Med. 2021, 10, 3532 9 of 12 and white blood cells . After a lower level of interest in oral health was detected in the number of queries asked in GT during the hard lockdown, in the conducted study, we detected a peak in periodontitis questions and about a 15% interest growth in the subject. During the pandemic, telemedicine represented an opportunity to improve accessibil- ity to medical treatments. According to some studies, teledentistry could be comparable to face-to-face visits for oral screening, especially in areas with limited access to oral health care. In fact, the identification of oral pathologies via teleconsultations is widely possible and valid . The online examination using intraoral scans may become helpful in de- tecting dental problems. The remote assessment of intraoral scans can allow an efficient screening and the correct triage of patients. Improved intraoral scans can provide even three-dimensional images with true colors . Nowadays, to minimize contact with the patient and to ensure patient safety clinicians may follow up with patients online, for example, through video calls. In the present study, a 5-time increase in query rates for teledentistry during the COVID-19 pandemic was detected because of the anxiety to visit the dentist. The query “is it safe to go to the dentist” increased the question rate during the pandemic almost 40 times. It may indicate the usefulness of such a digital tool during epidemiological threats. The screening for other chronic viral infections was previously conducted in dental offices, for example, for HCV virus ; such easy, free-of-charge prevention campaigns may use teleconsultation in the post-pandemic time. In addition, specific recommendations and lots of preventive measures against COVID-19 were undertaken in dental offices with infection control strategies. The urgent need for den- tal emergency care required fast delivery of the appropriate PPE. The initial shortage and distribution challenges of PPE was seen globally [11,28], as well as the large interest in PPE connected with dentists was observed in our study, with a 30-time increase of requests mean rate. The patient management protocols were applied to reduce the risk of infection and to prevent the spread of the cross-infection, for example, clinical triage for patient screening with a questionnaire on recent disease symptoms, body temperature measurement, avoiding crowding in the waiting room, a hand sanitizer available to patients before entering the oper- ating rooms, and the use of PPEs and oral rinses with hydrogen peroxide before the dental treatment [29–32]. The WHO recommended the use of FFP3 masks according to the European terminology or N100, according to the United States nomenclature . Members of the oral healthcare team should be acquainted with the COVID-19 transmission and preventive measures, as the oral cavity is an important site for COVID-19 infection and a potential route of virus transmission . Cross-infection control measures should be applied to all patients because asymptomatic COVID-19 persons may also need emergency dental treatment . This study has some limitations. Firstly, the analyzed data were collected from one search engine; nevertheless, Google engine has nearly four billion users worldwide and covers more than 90% of all queries on the internet, with near 7 billion queries per day. With 4.39 billion internet users worldwide, the number of Google users is globally nearly four billion . In our study, the GT request sample size for 5 years period is about big data collections. Thus, the nature of the data and sample size is appropriate for the purpose and nature of the study. Moreover, when considering the overlapping of expressions meaning, in a small sample, it might be discussed as a limitation; however, the sample of expressions gathered in the presented study is huge, the time of observation is long, and therefore, it should not induce significant changes in results. Secondly, the study was carried out globally, in order not to add too much manual categorization, by providing expressions in different languages. When adding queries in many languages across countries, it becomes more difficult to choose the best fitting expression used in a specific country. Finally, there are no strict rules on how to analyze the GT in health care research ; on the other hand, the GT data are recognized by the scientific community as a reliable source on the basis of which scientific papers in various fields are published [38,39]. Because of the anonymized approach of data collection, GT enables the analysis and forecasting of sensitive topics especially in medicine [37,40–43]. Because of using the revealed and not stated users’ preferences, it is possible to obtain information that would be otherwise impossible to
J. Clin. Med. 2021, 10, 3532 10 of 12 collect. Moreover, GT offers a substantial promise for the global monitoring of diseases in countries that lack clinical surveillance but have sufficient internet coverage to allow for surveillance via digital epidemiology . 5. Conclusions 1. Firstly, according to the search queries analysis from GT, the COVID-19 pandemic had a large impact on oral health problems; 2. Moreover, emergency dental care became more required during the onset of pandemic and hard lockdown than regular dental care; 3. Finally, teledentistry gained in popularity during the lockdowns according to globally asked questions in GT service. Author Contributions: Conceptualization, M.S.-D. and G.S.; methodology, M.S.-D.; software, M.S.- D.; validation, M.S.-D. and M.M.; formal analysis, M.S.-D.; investigation, M.S.-D.; resources, M.S.-D.; data curation, M.S.-D.; writing—original draft preparation, M.S.-D.; writing—review and editing, M.S.-D., K.W., M.M., and G.S.; visualization, M.S.-D. and M.M.; supervision, G.S. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Conflicts of Interest: The authors declare no conflict of interest. References 1. Worldometer—COVID-19 Coronavirus Pandemic. Available online: https://www.worldometers.info/coronavirus/?utm_ campaign=homeAdvegas1 (accessed on 28 June 2021). 2. Barca, I.; Novembre, D.; Giofrè, E.; Caruso, D.; Cordaro, R.; Kallaverja, E.; Ferragina, F.; Cristofaro, M.G. Telemedicine in Oral and Maxillo-Facial Surgery: An Effective Alternative in Post COVID-19 Pandemic. Int. J. Environ. Res. Public Health 2020, 17, 7365. [CrossRef] 3. Beauquis, J.; Petit, A.; Michaux, V.; Sagué, V.; Henrard, S.; Leprince, J. Dental Emergencies Management in COVID-19 Pandemic Peak: A Cohort Study. J. Dent. Res. 2021, 100, 352–360. [CrossRef] 4. Cagetti, M.G.; Balian, A.; Camoni, N. Guglielmo Campus Influence of the COVID-19 Pandemic on Dental Emergency Admissions in an Urgent Dental Care Service in North Italy. Int. J. Environ. Res. Public Health 2021, 18, 1812. [CrossRef] 5. Guo, H.; Zhou, Y.; Liu, X.; Tan, J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J. Dent. Sci. 2020, 15, 564–567. [CrossRef] 6. Yu, J.; Zhang, T.; Zhao, D.; Haapasalo, M.; Shen, Y. Characteristics of Endodontic Emergencies during Coronavirus Disease 2019 Outbreak in Wuhan. J. Endod. 2020, 46, 730–735. [CrossRef] [PubMed] 7. Chakraborty, T.; Jamal, R.; Battineni, G.; Teja, K.; Marto, C.; Spagnuolo, G. A Review of Prolonged Post-COVID-19 Symptoms and Their Implications on Dental Management. Int. J. Environ. Res. Public Health 2021, 18, 5131. [CrossRef] [PubMed] 8. Soltani, P.; Baghaei, K.; Tafti, K.T.; Spagnuolo, G. Science Mapping Analysis of COVID-19 Articles Published in Dental Journals. Int. J. Environ. Res. Public Health 2021, 18, 2110. [CrossRef] [PubMed] 9. Campisi, G.; Bizzoca, M.E.; Muzio, L.L. COVID-19 and periodontitis: Reflecting on a possible association. Head Face Med. 2021, 17, 1–6. [CrossRef] [PubMed] 10. Echeverría, J.J.; Echeverría, A.; Caffesse, R.G. Adherence to supportive periodontal treatment. Periodontology 2019, 79, 200–209. [CrossRef] 11. Mandrola, J. COVID-19 e dispositivi di protezione individuale: Qualcuno di noi morirà per la loro carenza. Recent. Prog. Med. 2020. [CrossRef] 12. Campus, G.; Diaz-Betancourt, M.; Cagetti, M.G.; Carvalho, J.C.; Carvalho, T.S.; Cortés-Martinicorena, J.F.; Deschner, J.; Douglas, G.V.; Giacaman, R.A.; Machiulskiene, V.; et al. Study Protocol for an Online Questionnaire Survey on Symptoms/Signs, Protective Measures, Level of Awareness and Perception Regarding COVID-19 Outbreak among Dentists. A Global Survey. Int. J. Environ. Res. Public Health 2020, 17, 5598. [CrossRef] 13. Top 10 Search Engines In The World (2021 Update). Available online: https://www.reliablesoft.net/top-10-search-engines-in- the-world/ (accessed on 11 May 2021). 14. Google Trends. Available online: https://trends.google.com/trends (accessed on 20 August 2020).
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