Impact of COVID-19 on the self-esteem,psychological and dental esthetics of dental students

1 Introduction

The sudden outbreak of coronavirus disease 2019 (COVID-19) has badly affected the lives of people all over the world [1]. Due to the rapid increase in the number of COVID-19 affected cases, various countries implemented forced lockdown, which helped saved lives of millions of people [2]. Moreover, in Pakistan, after the first COVID-19 patient was identified, a country-wide lockdown was implemented on 1^st April 2020. This lockdown assisted in restricting the spread of disease [3]. Nevertheless, this strict countrywide closure proved effective in controlling the virus, but at the same time it had negative impact on the psychological health of the individuals, which not only caused increased level of apprehension, despair, anxiety, but also affected the quality of life [4–6]. In the same perspective, quality of life of dental students worldwide also got affected [7], while a study from China reported higher incidence of depression in the students [8].

Due to the pandemic, all education continued online, and various video applications were used which included Microsoft Teams, Zoom, and Google Meet [9]. Aside from the advantages of online sessions, studies identified negative effects of how individuals perceived their image during those online sessions [10, 11]. It has been identified that during the video sessions participants’ attention shifted towards their appearance, and consequently generated a mirror effect, where users stared at themselves for a long period of time [12]. Mirror gazing had been associated with focused attention which increased the likelihood of being dissatisfied with their appearance which also affected their self-esteem [9, 13]. Moreover, perceptions regarding dental aesthetics are one of the crucial elements involved in the development of the personality [14]. The presence of malocclusion especially on anterior part, is quite noticeable, which could lead to negative social reaction and low self-esteem. [15]. Self-esteem reflects how one is perceived by others, especially the younger individuals who depends on others’ opinions and thoughts throughout their entire lives [16]. According to the World Health Organization, a person’s view regarding their state of life in relation to their culture, expectations, values, goals, standards, and priorities constitutes their quality of life [17]. The living condition of an individual along with the apprehensions faced, socioeconomic and the health status are few of the factors which can impact the quality of life [18, 19].

Various tools have been designed and developed which help evaluate the quality of life [20, 21]. These includes OHIP-14 [22] GOHAI [23] OIDP [24], PIDAQ [25], Rosenberg self-esteem scale [26]. All these tools differ with respect to the content of the item. OHIP-14 measures the effect of oral conditions on the quality of life, which includes physical pain, emotional discomfort functional limitation, physical, psychological, and social disability [22]. The GOHAI tool analyses several factors, including physical functioning related with eating and speaking, psychosocial dimension, oral health concern, dissatisfaction with appearance, and pain or discomfort in the mouth [23]. OIDP assessed an individual’s performance on daily activities based on their behaviors, some of which were eating, sleeping, laughing, and expressing their emotions [24]. PIDAQ “Psychosocial Impact of Dental Aesthetics Questionnaire measures four aspects, which includes “Dental self-confidence”, “Social Influence”, “Psychological Effect”, and “Aesthetic concern” [27]. Other than this Rosenberg self-esteem scale, which evaluates the self-esteem of an individual by identifying both negative and positive emotions associated with them [26]. OHIP-14 detected depression, GOHAI evaluates the masticatory efficacy, while OIDP assessed the daily routine [28]. Hence PIDAQ and Rosenberg self-esteem scale are two scales suitable for this study, as the study aimed to evaluate the psychological concerns associated with dental aesthetics and self-esteem.

PIDAQ was originally developed to identify orthodontic treatment needs, but it has also been used to measure the quality of life of participants related to dental esthetics [29]. Maligned teeth influence the masticatory efficiency and the orofacial esthetics but can also negatively affect the mental and emotional health of individuals [30].

According to MacDonald and Leary, self-esteem is a person’s opinion regarding their self-worth. It is based on an individual’s belief regarding their abilities which depends on their thoughts, life experiences faced by them, and effects their psychological health and well-being [31]. Choi et al. identified a link between self-esteem and depression; henceforth individuals with lower self-esteem are more likely to be subjective to feeling of despair, anguish [32].

Understanding and evaluating the psychosocial influence of dental esthetics and self-esteem amongst young adults is quite complex. Although various studies have examined the psychosocial impact of oral esthetics among adolescent patients [30, 32]. Similarly, in Pakistan previously conducted studies by Khan and Fida and Haq et al. only evaluated the psychological impact of participants using PIDAQ questionnaire [33, 34]. Another recent study by Azmi et al. assessed the anxiety and depression amongst the Saudi university students using Rosenberg scale and Self-Rating Depression scale by Zung, during the COVID-19 pandemic [35].

For our research, the study participants were dental students, who have more knowledge and awareness regarding dental conditions as compared to general population, despite not having completed their degree. Hence, we wanted to evaluate their responses with respect to self-esteem and dental esthetics concerns when the mode of education was online during the pandemic. In Pakistan, due to strict lockdown, on-campus education was conducted online, and at the same time the students were subjected to anxiety and uneasiness [4]. None of the studies conducted so far have analyzed the psychological aspects of dental students using PIDAQ scale and Rosenberg self-esteem scale during the pandemic. This study intended to evaluate the psychological impact and self-esteem of dental students using PIDAQ and Rosenberg self-esteem scale during the COVID-19 pandemic.

2 Materials and methods

For this cross-sectional study, 332 dental students enrolled in various dental colleges in Karachi, Pakistan were included. This study was conducted from January to May 2022. The main theme of the study was explained to all the study participants, and students’ perception regarding dental self-confidence, self-esteem along with other factors will be evaluated during the pandemic with the help of a questionnaire. This survey required approximately 10 mins to complete. Students were informed regarding maintaining full confidentiality of the information provided. All participants gave their consent before completing the survey forms.

3 Results

3.3 Correlation of PIDAQ and self-esteem (RSS) with gender

Association of PIDAQ and Rosenberg self-esteem scores with students from different age groups could be seen from Table 2. Statistically significant association can be seen between social effect, and gender (p = 0.000). Psychological impact (P = 0.000) and aesthetic concerns (p = 0.011) showed statistically significant correlation with students from both genders. However, self-esteem did not demonstrate a positive association with gender (Fig. 1).

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Table 2

Linear regression analysis for the different variables

Parameters	Questionnaire	Unstandardized		Standardized	t	P-value	95% Confidence
	Scoring	Coefficients		Coefficients			Interval for B
		B	Std. Error	Beta			Lower Bound	Upper Bound
Age	Dental Self Confidence	0.041	0.010	0.216	4.046	0.000	0.021	0.060
	Social Impact	0.025	0.010	0.199	2.508	0.013	0.005	0.044
	Psychological Impact	0.008	0.014	0.049	0.598	0.551	-0.019	0.036
	Aesthetic Concern	0.041	0.025	0.135	1.624	0.105	-0.009	0.090
	Rosenberg Total Score Achieved	0.029	0.007	0.208	3.995	0.000	0.015	0.044
Gender	Dental Self Confidence	0.004	0.006	0.046	0.787	0.432	-0.006	0.015
	Social Impact	-0.018	0.005	-0.284	-3.283	0.001	-0.028	-0.007
	Psychological Impact	-0.002	0.008	-0.028	-0.317	0.752	-0.018	0.013
	Aesthetic Concern	0.016	0.014	0.106	1.173	0.242	-0.011	0.043
	Rosenberg Total Score Achieved	-0.007	0.004	-0.096	-1.699	0.090	-0.015	0.001

*Dependent Variable: Age & Gender. Linear Regression Analysis applied to see significance at P-value≤0.05.

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Fig. 1

Correlation of scoring of PIDAQ and self-esteem with gender.

3.4 Correlation of PIDAQ and self-esteem (RSS) with age of participants

Statistically significant correlation of dental self-confidence was identified with the age groups of students (p < 0.001). Social impact and psychological impact also demonstrated significant association with the age (p < 0.001). While the aesthetic concern also exhibited significant association with the different age groups (p = 0.015). Rosenberg total score also showed significant association with the age, identifying the impact of self-esteem (Fig. 2).

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Fig. 2

Correlation of PIDAQ and self-esteem (RSS) with age of participants.

4 Discussion

It has been found that throughout the pandemic, students experienced psychological stress, which led them getting worried about their self-esteem, owing to the burden of their coursework, and fear for the future [36]. Various previously reported studies have evaluated the psychological health of the students during the pandemic [37, 38]. The present study aimed at highlighting the effect of dental aesthetics on the psychological wellbeing and on self-esteem of dental students during the COVID-19 pandemic.

This study identifies that, for young adults, physical characteristics of the face play a fundamental role which has a substantial effect not only on the self-perception but also on their quality of life, confidence, and dignity [39–41]. Being physically attractive has a substantial influence on the above-described factors, which also impacts the psycho-social working [42]. In line with the previous literature, findings from current study showed that dental aesthetics had a higher impact on the mental health of the students, with significant implications on the body image [43, 44]. Bucchianeri et al. identified a direct relationship between age and body image in young individuals [45]. This could be attributed to the fact that during lockdown most of the individuals were forced to stay indoors, due to stress and anxiety many could have started binge eating which could have raised their weight and BMI and could have affected their self-confidence.

Psychological impact had statistically significant association with self-esteem, social and aesthetic concerns. These findings are in line with research led by Kavaliauskiene et al. who found an association between oral and psychosocial health. As a result, having good oral health can reduce the likelihood of experiencing anxiety, apprehension, and despair, demonstrating the existence of a link between the aforementioned variables [42]. Another study by Saladino also identified drastic impact of the pandemic on the social and psychological health of the population, which had significantly affected the college going students [46]. Moreover, this could also be because of the different economic status of students, which has been reported in previous literature [47]. It has been observed that students belonging to a lower socioeconomic background are greatly affected by dental appearance [48, 49] signifying that income has a direct effect on health care facilities and personal grooming. Lastly it can be seen that students from both genders were affected.

Social influence highlights the presence of an inverse relationship that existed between social influence and dental confidence. Also, it has been recognized that individuals who are quite mindful socially seem more cautious of their smile and looks. These outcomes are in agreement with the research led by Taghavi et al. which showed that individuals refrained from laughing in public to not show their teeth and isolated themselves from the crowd [50]. Furthermore, another study from Italy found that approximately 30% of the study participant’s physical appearance affected their frame of mind significantly during the pandemic, and this approach was more common within the female participants [51]. This is because females generally are more demanding and concerned regarding their dental aesthetics as compared to males.

Self-esteem can be described as the ability to understand the value of oneself. Furthermore, it was positively correlated with dental aesthetics, self-confidence, social and psychological influence. It has been known that individuals considering oneself as ‘less attractive’ generally have a lower self-esteem as compared to those who find themselves as ‘attractive’. This shows that self-thought aesthetics may have an impact on how one feels about themselves [52]. Our study findings are consistent with the studies conducted by Claudino and Traebert [53] and Badran [17]. Furthermore, findings from the study by Azmi et al. also showed that the self-esteem of 41% of the students was quite low during the pandemic, which had affected their quality of life [35]. Also, as our study participants were dental students, who basically have higher dental knowledge than public, in case of maligned or crooked teeth may get more conscious which could affect their self-esteem.

With respect to regression analysis, it was revealed that age of the participant affected the self-esteem and facial confidence. These outcomes are convergent from the study by Klages where no significant difference between age groups could have been identified [54]. Gender showed significant association with social impact and self-esteem. However, these findings are in contrast from a study done in Nepal, where gender did not have significant impact on social impact. Various researchers have stated higher level of self-esteem in males [43] whereas our finding is in line with the study of Azmi et al. where females had a higher level of self-esteem during the pandemic as compared to the males [35].

A statistically significant association was seen between students’ ages and the variables. Findings from the current study showed positive association of age with dental self-confidence, self-esteem, aesthetic, and psychological concerns. However, these findings are in contrast from the study by Hassan et al., who identified a direct association of social concerns with the lower dental confidence level, which was seen in young individuals [55]. However, our study participants aged 18 and above. This can be attributed to the fact that young children are more susceptible to teasing by their classmates in case of any visible dental malocclusion. Lastly self-esteem was also affected, as identified by the current study findings.

Our study’s main strength was being the first study to be carried out amongst the dental students after the COVID-19 pandemic using the Rosenberg scale and PIDAQ scale which have been identified as reliable indicator. This study could be helpful in understanding the dental students’ viewpoints and thoughts regarding the self-esteem and dental aesthetics as dental students have more awareness about the dental aesthetics as compared to the general public.

5 Conclusion

It has been identified that COVID-19, apart from affecting the health of individuals worldwide, also badly affected the quality of life, psychological health, and self-esteem of the dental students. Dental aesthetics played a crucial role in the mental wellbeing and self-esteem of the students. Moreover, for individuals who were already unhappy with their dental appearance, the pandemic further affected them psychologically and made them more conscious. The self-esteem of the students was also affected, which had further impact on their quality of life and well-being. Lastly, this study suggests use of PIDAQ and Rosenberg scale as useful tools to evaluate the psychosocial impacts of poor self-esteem and dental esthetics on young adults.

Ethical approval

The study was approved by the ethics committee of Bahria University Medical and Dental College, Karachi, Pakistan (ERC# 22/2021).

Informed consent

All participants were informed regarding the study design and provided informed consent.

Conflict of interest

Not applicable.