This study is one of the first to explore the prevalence rates of anxiety, sleep bruxism, TMD and changes in dietary/brushing habits and its possible association with the social restrictions imposed by the COVID-19 pandemic within a cohort of children and adolescents. The main finding of this study is the presence of elevated levels of overall anxiety in approximately one-third of the included participants, with no previous history of such concerns prior to the pandemic. This finding is consistent with other studies showing increased anxiety symptoms in children and adolescents during the current pandemic (Khan et al. 2021; Kostev et al. 2021; Śniadach et al. 2021). In addition, elevated levels of overall anxiety were shown to be more prevalent in younger (≤ 9-year old) compared to older (≥ 10-year old) aged children. In terms of specific anxiety domains, this study reports a high prevalence of social phobia, which is in keeping with established literature (Cartwright-Hatton et al. 2006; Franz et al. 2013). We surmise that this could indicate the fear of the pandemic itself due to the associated social restrictions, and the fear of the risk of getting infected.

Results of this study report sleep bruxism in 5.7% of the children and adolescents which is towards the lower end of those reported in previous literature (3.5% to 40.6%) (Manfredini et al. 2013). This wide range of prevalence rate is possibly related to the differences in the age range of included participants, study design and instrument used. The variability of parental access to their children during their sleeping hours is also difficult to standardise resulting in an unintentionally introduced bias. In the current study, access of parents to their children during sleep time was limited by a number of factors, such as infrequent parental checking, which could have underestimated the prevalence rates of reported sleep bruxism in this study. Therefore, this specific result should be interpreted with caution since no pre-pandemic baseline sleep bruxism prevalence rates amongst the Qatari population are available. Nevertheless, this data can act as a comparator for future studies.

In addition, this study reported symptoms of TMD in almost a quarter of participating children and adolescents, who otherwise suffered no previous history of TMD. In similarity to sleep bruxism, a wide variability of TMD prevalence ranging between 7.3 and 30.4% is reported in the literature (Christidis et al. 2019). Such variability could be related to the multiple assessment tools used and the lack of standardised examination protocols. The prevalence rates of TMD, shown in this study, are towards the higher end of the reported prevalence range in the literature. Although the lack of local pre-pandemic TMD data precludes linking such higher prevalence to the COVID-19 pandemic, TMD in this study was found to be associated with increased social phobia, therefore indicating a possible relationship with the COVID-19 pandemic social restrictions. Of interest, in a recent study involving adults participants, an increase in psychosocial distress was linked to an increase in bruxism and TMD symptoms during the COVID-19 pandemic (Colonna et al. 2021). Although the FAI is a validated self-rated questionnaire, used for screening children/adolescents with TMD (Rigoldi Bonjardim et al. 2008; de Santis et al. 2014), some concerns have been raised in relation to its accuracy when used in different languages, and with young children (de Santis et al. 2014). To overcome such limitations, the questions were read and explained to the parents during a face-to-face or telephone interview by dental specialists.

Furthermore, this study highlighted worrying changes in children’s and adolescents’ dietary and brushing habits over the course of the recent COVID-19 pandemic, which is in line with the negative impact of COVID-19 on the dietary habits reported globally (Campagnaro et al. 2020; Bennett et al. 2021). An increase consumption of food, specifically sweets, was apparent in a large proportion of participants. A higher consumption of sweets and the reduction in tooth brushing habits in the younger children were evident. Such changes, specifically if combined, could most likely result in an increased risk of dental caries and periodontal disease which warrants better communication between dental health services during any pandemic-related restrictions.

This study sets out one of the first reports in the Middle East and North Africa (MENA) region of how COVID-19 has impacted children’s and adolescents’ oral health when analysed in the context of higher anxiety and social phobia due to the social restrictions. This is a critical finding that should inform public health policy and health care delivery during the current late stage of the pandemic and future possible pandemics. Measures aimed at early identification and management of anxiety and oral health in children within the specific context of pandemics need to be further developed. Qatar was reasonably successful in delivering virtual mental health care through telephone and video consultations; however, there is little data to suggest whether these measures were ever designed for children and whether children benefited (Karim et al. 2020). Qatar also developed an online dental patient advice website created to help patients identify and possibly manage the most common dental emergencies with a helpline for those requiring further assistance. However, the abovementioned website did not include advice on identification and seeking help for sleep bruxism, TMD or change in diet/brushing habits and did not link social restrictions with psychological anxiety and its impact on oral health.

Results of this study further aim to inform a better designed and accessible information campaign. There is merit in utilising information technology and virtual dentistry clinics that are not limited by the quarantine restrictions for early identification of dental problems associated with psychological distress in children (Ali et al. 2022). In addition, the utilisation of mHealth (in means of text messages and phone applications) is regarded as a promising adjunct clinical tool for spreading awareness and health education aiming at preventing and promoting oral health during the pandemic (Luzzi et al. 2021). Although currently, most countries have lifted the COVID-19 restriction-related measures, such as social distancing, the pandemic continues to infect people in new waves of infection as new variants of the coronavirus evolve. It follows that health systems should support health action plans that recognise the, yet to be fully understood impact, of this waxing and waning pandemic and focus on general advice, early identification and measures supporting mental health and oral health in the young generation.

This study was subjected to some unavoidable limitations due to the nature of the pandemic and its subsequent restrictions to patient recruitment and examination. The recruitment of patients followed a convenient sampling technique of those attending two specific dental centres within the State of Qatar which might have affected the generalisability of the results. Such design was performed due to the applied lockdown restrictions and inability to conduct the study in a wider random setting. In addition, data collected relied on parental questioners and specific assessments tools which, whilst possessing advantages, have inherent limitations such as their overall reliability and sensitivity that are acknowledged by the authors. In addition, in this study, the prevalence of sleep bruxism and TMD relied solely on history taking; however, adjunct clinical examination would have been beneficial to further affirm these results. Unfortunately, due to the pandemic restrictions, clinical examination was not performed due to restrictions applied in the dental office. Although well-designed large multi-centre clinical studies are required to ascertain the impact of pandemic restriction-related measures on the mental and dental health of children and adolescents, such studies are not easily planned and executed due to the level of restriction of such unprecedented global pandemic.