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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 50-55

Pediatric dentistry post coronavirus disease 2019: Changing treatment paradigms in the pandemic setting

1 Department of Paediatric Dentistry, INHS Sanjivini, Kochi, Kerala, India
2 Department of Orthodontics, Army Dental Centre (R and R), New Delhi, India
3 Department of Paediatric Dentistry, Fd Hosp, Manipur, India
4 Dental Officer,MDC, Gopalpur, Odisha, India

Date of Submission26-Dec-2020
Date of Acceptance04-May-2021
Date of Web Publication04-Jan-2022

Correspondence Address:
Rahul Kaul
House No. 150, MH Road, EktaVihar, Udhampur - 182 101, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jorr.jorr_55_20

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Coronavirus disease 2019 (COVID-19) pandemic has had a great impact on the practice of dentistry. Dental setups are potential focal points for cross-infection, and utmost care must be taken to reduce the risk of infection to, from, or among dentists, paradental staff, and patients. A specific concern for children is the uncertainty of their infection status; a clinical history may not be as suggestive of the infection as it is in adults. This makes pediatric dentists more prone to getting infected by the disease. The present review is aimed to provide an overview of potential dental emergencies in pediatric dental practice and a summary of the available treatment strategies that can be utilized by pediatric dentists with an aim to minimize aerosol generation to reduce chances of transmission during and after COVID-19 pandemic.

Keywords: AGPs, children, coronavirus disease 2019, dental emergencies, pandemic

How to cite this article:
Dempsy Chengappa M M, Bali A, Kaul R, Koul R. Pediatric dentistry post coronavirus disease 2019: Changing treatment paradigms in the pandemic setting. J Oral Res Rev 2022;14:50-5

How to cite this URL:
Dempsy Chengappa M M, Bali A, Kaul R, Koul R. Pediatric dentistry post coronavirus disease 2019: Changing treatment paradigms in the pandemic setting. J Oral Res Rev [serial online] 2022 [cited 2023 Jan 27];14:50-5. Available from: https://www.jorr.org/text.asp?2022/14/1/50/334835

  Introduction Top

A new type of virus that causes pneumonia was first reported from Wuhan, China, in December 2019. It got the name 2019 novel coronavirus.[1] It was later renamed as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), by the International Committee on Taxonomy of Viruses in February 2020, and the WHO declared the official name of disease as coronavirus disease 2019 (COVID-19).[2] COVID-19 is a SARS caused by SARS-CoV-2 virus.[3] It is believed to be transmitted via droplet infection or contact with contaminated surfaces.[4] Detection is achieved by assessment of seroprevalence of antibodies obtained from either oropharyngeal or nasopharyngeal swab. Real-time polymerase chain reaction test which mainly makes use of a nasopharyngeal swab is still the only confirmatory test.[5],[6]

COVID-19 was seen to spread rapidly across the globe and was declared as pandemic by the World Health Organization. As on October 10, 2020, 1900 h the total number of confirmed cases worldwide was 37.2 million and deaths were 1.07 million. The statistics in India were 7.07 million confirmed cases and reported deaths were 1.08 lakhs.[7] As per the American Academy of Pediatrics, children accounted for 10.6% of all cases of COVID19 reported in the United States with a mortality rate of 0%–0.24%.[8] Similarly, a lower mortality rate and better prognosis among children in India was also observed. Most of the children were observed to be asymptomatic carriers, thereby posing a higher risk to both the health-care provider and their parents. The mortality rate of COVID 19 among health-care providers ranged from 4% to 44%.[9] In India, so far, there have been 196 deaths out of 1000 doctors who tested positive for COVID 19; two of them were dentists.[10]

After a period of incubation of up to 14 days, COVID 19 manifests in the form of either an asymptomatic disease or mild symptoms of pyrexia, dry cough and general malaise, myalgia or fatigue, expectoration, headache or dizziness, diarrhea, nausea and vomiting, dyspnea, anosmia, and general malaise. Severe symptoms include respiratory distress and ultimate death. The latter mainly affects those with comorbidities of all age groups.[11],[12]

A specific concern for children is the uncertainty of their infection status; a clinical history may not be as suggestive of the infection as it is in adults.[13] Therefore, it can be assumed that all children and their parents or caretakers are potential source of infection to health-care workers, other parents, and the public in general unless proved otherwise. This makes pediatric dentists more prone to getting infected by this disease. To ensure that pediatric dentist does not fall under the receiving end of infection and acts as further source of infection to his patients, their parents, paradental staff, and his own family, it is mandatory to bring about certain changes in daily practice.

The aim of the present review is to provide an overview of dental emergencies in children and a summary of the available treatment strategies that can be utilized by pediatric dentists to minimize generation of aerosols during dental treatment in the immediate and near future when dealing with the COVID-19 pandemic.

  Coronavirus Disease 2019 Manifestations In Children Top

SARS-CoV-2 infection seems to run a milder course in children. The symptoms observed in children include a dry cough usually accompanied by fever, difficulty in breathing, and fatigue, and other less typical symptoms might also be observed over a course of time. Infection runs in three major stages: a mild cold-like illness, a moderate respiratory syndrome, and a severe acute interstitial pneumonia.[14] It has been observed that the median period of viral shedding of COVID-19 was 2 weeks as measured from illness onset to discharge. A curtailed period (11 days) was observed in asymptomatic patients compared to symptomatic patients (17 days).[15]

Seasonal flu and upper respiratory tract infection are commonly observed in children and with winter season around the corner; cough and cold will become more prevalent in children. The matter of concern here is that these symptoms might overlap with symptoms of COVID-19, thereby affecting dental treatment procedures both elective and emergency. Not only does it have an adverse psychological impact on patients; it affects pediatric dentists negatively as well.

COVID-19 is known to be transmitted via direct and indirect contact, mainly through respiratory droplets and splatter from saliva and blood through contact with mucous membranes and contaminated surfaces and inanimate objects.[16],[17] Dental clinics have a high number of potentially contaminated surfaces such as chair handles, lights, and spittoon used for carrying out a treatment, which may be the possible routes of transmission.[18] SARS-CoV-2 virus can persist on these surfaces for up to 3 days as per available literature.[19]

Universal precautions should be strictly adhered to in dental clinics. They play a pivotal role in preventing the transmission of SARS-CoV-2 virus to children from health-care professionals and vice versa. At present, the prevailing condition calls for maintenance of social distancing, hand hygiene, respiratory hygiene/cough etiquette, use of personal protective equipment (PPE), sterilization and disinfection of instruments and surfaces, environmental infection prevention, and maintenance of dental unit water quality.

  Dental Environmental And Equipment Top

Dental environment is unique because of proximity of the dentist to the patient and the potential of exposure to both bloodborne pathogens and aerosols. Emphasis should be laid on minimizing cross-infection, maintaining the safety of dental health-care providers, pediatric patients, and their guardians. Proper use of PPE and filtering facepiece Class 2 (FFP2, equivalent to N95) masks have been recommended.[20] In addition to handwashing when hands are visibly dirty, alcohol- based hand rub should be encouraged amongst all patients and should be provided in appropriate areas close to the health workers. Treatment of any suspected COVID-19 patient if required must preferably utilize a negative pressure/airborne infection isolation room.[21] Furthermore, a portable high-efficiency particulate air filter with negative ion generator may also be considered.[22] Use of rubber dam should be mandatory in every case. A preprocedural mouthrinse of 0.23% povidone-iodine mouthwash for at least 15 s or 0.5%–1% hydrogen peroxide mouthrinse is advisable.[23] Use of extraoral radiographs rather than intraoral radiographs should be encouraged. In a recent study, after SARS-CoV-2 application on copper and only cardboard, no live viable SARS-CoV-2 was observed after 4 h and 24 h, respectively. Cardboard used as barriers and the use of copper-coated instruments instead of stainless steel may be considered as a substitute, but further scientific evidence is necessary.[19]

  Communication And Tele-Triaging Top

The initial control measure before treating any patient is establishment of proper communication. Proper screening of children, their parents, and members of dental team needs to be done. Patient history should be taken about any close contact with a known COVID-19 patient or symptoms including fever, flu, breathing problem, and dry cough over the phone augmented with a photograph/video and preferably over a video call. The purpose of these triaging procedures is to ensure the COVID-19 risk status of the patients, thereby deciding the urgency of the dental condition. In addition, specific advice for the management of any presenting dental problem and general advice for proper maintenance of oral health can be given. This practice of communication has to be repeated even after completion of treatment. Patients also need to inform the pediatric dentist, if they subsequently develop such symptoms within 14 days of receiving emergency treatment.

Dental cases can be divided into three categories:

  1. Emergency Cases
  2. Urgent cases
  3. Scheduled cases.

[Table 1] shows a list of emergency and urgent cases that can report to a pediatric dentist. It is always advisable to delay urgent treatment for further 2 weeks and simultaneously offer patients with detailed home care instructions and any appropriate medications.[24]
Table 1: Potential emergency and urgent cases

Click here to view

  Medically Compromised And Special Needs Children Top

Emphasis needs to be given to underlying health condition. Underlying medical conditions might further aggravate risk of developing complications arising from any subsequent infection if the tooth is not treated. These conditions include those children who are in an immunocompromised state, transplant patients, diabetics, children on immunosuppressants/steroids/chemotherapy, and children at risk of infective endocarditis. In addition, children who are suffering from long-term respiratory conditions such as cystic fibrosis, asthma, and chronic lung disease are at a significantly higher risk from COVID-19. Dental pain may have a severe impact on these children and their families with evidence of adverse behaviors such as inflicting self-harm, thereby affecting their overall quality of life.

Unless the condition is life threatening, these children are advised not attend any hospital or dental clinic. These children should be preferably treated at hospital-based dental clinics if treatment is absolutely essential. Special consideration should be given when scheduling their appointment dedicating 1st appointments or special hours in the day for such patients.[24],[25]

  Behavior Management Top

An appropriate and skillful behavior management is the key to minimize the probability of SARS CoV-2 cross-infection. Noncooperative, anxious, and crying children spread more aerosols compared to cooperative and calm children. It is noteworthy that seeing a pediatric dentist wearing PPE kits and face masks may evoke anxiety in children. Whenever possible, it is advisable to wear these protective equipment when the child is watching and communicate with them in simple terms (the value and use of this equipment). Another suggestion is to have a sticker that can be disinfected easily with the health provider's photograph displayed over the protective equipment. Having the parents in the dental clinic during treatment should be restricted moving forward.[24] Proper coping techniques and communication between the pediatric dentist and the parents and their child are quintessential.

The AAPD recommends delaying seeing children who require physical behavior management, considering treating patients when on parent's lap with parent wearing a level 1 to level 3 surgical mask and having passed negative screening criteria, whenever deemed inescapable. Such children should be treated in operatory having negative air pressure rooms.[25] Objects such as magazines, other reading materials, and toys should be removed owing to their potential for cross-contamination.

  Urgent Dental Care Under General Anesthetic Top

Pediatric dentists are advised to cancel all elective procedures, including dental treatment under general anesthesia (GA). The AAPD encouraged to develop a risk-based scale for scheduling GA patients.[25] Where possible, limited emergency provision should be reserved for children prioritized for urgent treatment under GA. These include conditions that cannot be treated under local anesthesia, children with underlying medical conditions and special needs children wherein dental pain can result in self harm or other disruptive or detrimental behaviour.

  Biological Caries Management Techniques Top

Using biological atraumatic, noninvasive, or minimally invasive treatment methods that require minimal or no Aerosol generating procedures (AGP) would prove to be safer, given the high success rate of the biological approach in caries management. Various biological treatment alternatives are as follows.

  Preventive Dental Care Top

Dental caries is best managed using preventive protocols. The spectrum of measures includes a daily and appropriate management of the biofilm, home and within the dental office/surgery.[26] Preventive measures to be followed include:

  1. Brushing twice daily with fluoridated toothpaste
  2. Consumption of low cariogenicity diet
  3. Routine management of the biofilm by rinsing after every meal
  4. Usage of fluorides as well as pit and fissure sealents
  5. Consumption of fruits and healthy food in the diet.

  Chemomechanical Caries Removal Top

Chemomechanical caries removal is an excellent method for minimally invasive caries excavation, and the agents most commonly used are sodium hypochlorite-based agents such as Carisolv and Caridex or enzyme-based agents such as Papacarie and Biosolv.[27] Instead of using conventional burs, this method uses a chemical agent along with an atraumatic mechanical force for caries excavation, thereby reducing aerosol generation. Moreover, it is a readily acceptable technique for caries excavation by children.

  Atraumatic Restorative Technique Top

Atraumatic restorative technique (ART) is a time-tested, inseparable, effective evidence-based alternative to technique making restorative care accessible for pediatric patients. This technique has led to a high survival percentage in both dentitions compared to multiple-surface restorations. In addition, glass ionomer-based sealants can also be used as a treatment option. It has found special relevance in times of the pandemic as it does not produce aerosols. It is mainly indicated for small and shallow single surface caries.[28]

  Pit And Fissure Sealants Top

A quarterly or half yearly application of pit and fissure sealants has been found effective in arresting or reversing the noncavitated carious lesions on the occlusal surfaces of both primary and permanent teeth. In addition, sealing dental caries in permanent teeth where the carious lesion is partially removed or completely left has been employed as an accepted therapeutic technique by some researchers with success rates up to 10 years. Sealants can either be used alone or in combination with 5% NaF varnish and resin infiltration.[29]

  Interim Therapeutic Restorations Top

Another non-AGP method is the interim therapeutic restoration (ITR) uses techniques similar to ART, but has different therapeutic goals. ITR not only aims to restore but also prevent further decalcification and caries in young patients, noncooperative patients, or patients with special health-care needs. The ITR procedure utilizes hand or slow speed rotary instruments with caution not to expose the pulp followed by restoration of tooth with an adhesive restorative material such as self-setting or resin-modified glass ionomer cement. The technique finds its use when conventional dental treatment is not feasible and dental treatment needs to be deferred.[30]

Coll et al. found that ITR placed in proximal lesions significantly improved the success rate of vital pulp therapy done subsequently, while ITR placed in nonproximal lesions did not have any significant effect on the success rate.[31]

  The Hall Technique Top

The HT is a nonsurgical, noninvasive method and nonaerosol-generating procedure used to restore a carious but asymptomatic primary molar without pulpal exposure. This technique involves sealing nonpulpally involved carious lesions on primary molars in situ using a preformed metal crown (PMC) and glass ionomer cement (GIC).[32] No local anesthesia is utilized, and no attempt to surgically remove the carious part of tooth is made, thereby reducing aerosol generation. The slight initial opening of the anterior bite due to the placement of PMC spontaneously resolves after a month.[33] The HT also has been suggested by the caries management treatment option to keep grossly decayed first permanent molars free from symptoms until the ideal age for extractions has reached. The rationale again for prevailing COVID era is nongeneration of aerosols.

  Silver Diamine Fluoride Top

Silver diamine fluoride (SDF) is a clear, odorless liquid that has remineralizing property of fluoride and the antibacterial effects of silver which can arrest dental caries and prevents its progression. It is also indicated for desensitization of noncarious tooth lesions and molar incisor hypomineralization of FPMs. Its use is limited due to its potential to cause tooth discoloration as well as gingival pigmentation later being reversible. Tooth discoloration can be overcome using GIC over SDF. Application time is 1 min, and it cannot be used in teeth in which caries has advanced to involve the pulp. It can also be used for arresting carious lesions in high caries risk children, children who are difficult to manage, progressing carious lesions, unable to tolerate invasive treatment, and those who are medically compromised or have additional care needs. The biggest advantage with SDF is that there is no cavity preparation; hence, it eliminates aerosol generation completely. There is control of pain, infection, with minimal use of armamentarium.[34]

  Management Of Carious Teeth With Pulpal Involvement Top

Pulpotomy procedure can be carried out using of low-speed micromotor handpiece in a deciduous tooth with reversible pulpitis without any evident radicular pathology. In young permanent tooth with reversible pulpitis, partial or Cvek's pulpotomy can be carried out. After hemorrhage control is achieved, pulp stumps should be covered preferably by MTA.

Pulpectomies in primary teeth should be avoided as much as possible during the pandemic. Rather extraction followed by custom-made space maintainers should be opted as treatment choice.[35]

  Management Of Traumatic Dental Injuries Top

Focus should be mainly on controlling bleeding through application of pressure pack and cold compression followed by pain management. Parents need to be reassured and counseled. Dental clinic should be visited only in case of uncontrollable bleeding, avulsion of permanent tooth, and facial injuries, that too after prior tele-consultation.

Management of orthodontic emergencies

The use of the appliance should be suspended if the appliance is causing discomfort to the child, loose fitting, and broken. Activation of removable appliances can be delayed for some time. A retainer appliance if lost or broken needs to be remade after taking new impressions. Preferably, a fixed retainer should be placed using self-etch composite resin material with minimal post procedure finishing. If the bracket remains flush with the tooth, it can be left as it is, and if it seems to drop from the archwire, the parents of child can cautiously try to remove using eyebrow tweezers. If a ligature wire is seen to causes soft tissue pain or injury, the patient should aim to push it back with the back of a pen/pencil. In case that it is not possible, orthodontic relief wax can be applied.[36],[37]

  Conclusion Top

Pediatric dentistry has been largely affected and will continue to be affected by the COVID-19 pandemic. Meticulous triaging, social distancing, use of PPE, hand hygiene, avoidance of any elective treatment, and abstaining from aerosol-generating procedures are the need of the hour. Pediatric dentists not only have the responsibility to guard the patient but also paradental staff and their own selves. This opportunity should also be utilized to promote preventive dentistry.

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Conflicts of interest

There are no conflicts of interest.

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Coronavirus Dise...
Dental Environme...
Communication An...
Medically Compro...
Behavior Management
Urgent Dental Ca...
Biological Carie...
Preventive Denta...
Chemomechanical ...
Atraumatic Resto...
Pit And Fissure ...
Interim Therapeu...
The Hall Technique
Silver Diamine F...
Management Of Ca...
Management Of Tr...
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