REVIEW ARTICLE


https://doi.org/10.5005/jp-journals-10062-0115
Journal of Oral Health and Community Dentistry
Volume 15 | Issue 3 | Year 2021

Evolving Perception of a Pediatric Dentist Post-COVID-19

Sakshi Jain1https://orcid.org/0000-0002-3703-0372, Tanya Batra2, Shivani Mathur3, Vinod Sachdev4

1–4Department of Pediatric and Preventive Dentistry, ITS Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India

Corresponding Author: Sakshi Jain, Department of Pediatric and Preventive Dentistry, ITS Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India, Phone: +91 9560509262, e-mail: sakshi.jain7@gmail.com

How to cite this article: Jain S, Batra T, Mathur S, et al. Evolving Perception of a Pediatric Dentist Post-COVID-19. J Oral Health Comm Dent 2021;15(3):156–159.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Everything in the world was going beautifully until the arrival of coronavirus in December 2019, which marked the beginning of reshaping the world. Dentistry is greatly affected during this pandemic as dentist and dental assistant are at greater risk of coronavirus disease-19 (COVID-19) infection because they deal with the oral fluids. Pediatric dentists are at even higher risk as the rate of transmission from children to adults is more than that of transmission from adults to adults. There is a change in practice of pediatric dentistry that will soon be considered as the new normal. Sterilization and disinfection was done before COVID also, but now protocols will have to be followed even strictly. Although the treatment remains the same, approach toward it has to be changed.

Keywords: COVID-19, New normal, Pediatric dentistry.

INTRODUCTION

Everything in the world was going placidly until a pneumonia like disease started infecting citizens of Wuhan, China, in December 2019. What seemed like an outbreak in early 2020 rapidly escalated to a worldwide pandemic creating health and an economic crisis globally. On January 30, 2020, the novel coronavirus disease-19 (COVID-19) was declared as Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) eventually resulted in the biggest global pandemic disease known to the history of mankind.1,2

COVID-19 currently designated as severe acute respiratory syndrome (SARS-CoV-2) is a human novel virus, which is considered to be similar yet distinct from SARS-COV and MERS-CoV belonging to subgenus sarbecovirus, with Chinese horseshoe bats (Rhinolophus sinicus) being said to be the most probable origin.

The human–human transmission of COVID-19 occurs either through direct or through indirect contact from the respiratory droplets of infected individual (symptomatic/asymptomatic) suspended in air and aerosols or in close contact (within 1 m) with the infected person having respiratory symptoms (during sneeze, cough, talking loudly).

This virus has been seen to affect the human race unprejudiced, be it the rich and the poor, the healthy or those with comorbidities, the elderly as well as the children.

It seemed that the entire world has come to a standstill and so has dentistry. Like other professions, there were many nags and hitches to the revival of dental services. A kin to the healthcare professionals, DHCP (dentist, dental hygienist as well as dental assistants) are at greater risk of COVID-19 infection as they deal with the major culprit of transmission of virus/pathogens—the oral fluids. Moreover, basic dental procedures that include high-speed handpieces and scalers are potential way of spreading infection as they generate large quantities of aerosols which stay in air for quite a longer period of time.2,3

Though these problems are customary with all the dentist, pediatric dentist have added risks also. Children do not effectively ensure their personal protection and are mostly accompanied by their parents. Also, the modalities required for behavior management add to the potential way of spreading the infection to both the dental staff and the patient.2

COVID-19 is predicted to reshape the world in general. The world of dentistry is no such exception. Although the end of COVID-19 seems to be indefinite, the perception toward pediatric dental practice post-COVID needs a reform, which shall soon be considered as the “NEW NORMAL.”

A well-delineated step-by-step approach needs to be formulated for working during this pandemic that starts from the pre-appointment session, patient scheduling, behavior management, examination, treatment, post-procedural patient exit.

PRE-APPOINTMENT MEASURES

An elaborate pre-appointment discussion through phone or preferably video conference should be planned before the actual visit. This shall include a complete medical history of the patient especially of any symptom in the family over the past 14 days (Flowchart 1).

Flowchart 1: Medical history questions to be asked on call

Dental pain can be effectively managed by the analgesics and/or antimicrobials. During isolation, patients might have tried self-management at home before the pre-appointment discussion; thus, a proper up-to-date drug history should also be taken before prescribing any medication to avoid over-dosage of a drug.4

Paracetamol and/or ibuprofen is effective in relieving most of the odontogenic pain. Although there are concerns raised for the use of ibuprofen in COVID-19 patients, due to lack of evidence to establish a link between the use of ibuprofen and worsening of COVID-19, it could be considered appropriate for the management of dental pain. SDCEP Drug Prescribing for Dentistry guidance recommends a 5-day regime for children suffering from dental pain4 (Box 1).

Box 1: 5-day analgesic regime for children

Paracetamol (500 mg tablets, or 120 mg/5 mL* or 250 mg/5** mL oral suspension), dose depending on age; up to four times daily (max 4 doses in 24 hours)

OR

Ibuprofen (200 mg tablets or 100 mg/5 mL oral suspension), dose depending on age, preferably after food, up to three times daily

*120 mg/5 mL paracetamol suspension is suitable for children 6 months to 6 years; **250 mg/5 mL paracetamol suspension is suitable for children 6 years plus.

In patients complaining of swelling and severe pain, antibiotics should also be prescribed. The most commonly prescribed antibiotic for dental pain is amoxicillin or phenoxymethylpenicillin. Metronidazole is either used as an alternative for patients who are allergic to penicillin or used as an adjunct with to penicillin in patients with spreading infection. A 5-day course is advised in cases of acute periapical abscess, and a 3-day course is advised in case of acute pericoronitis. SDCEP Drug Prescribing for Dentistry guidance recommended antibiotic doses for children4 (Box 2).

Box 2: Recommended first-line antibiotic doses for children

*Amoxicillin (250 mg capsules, or oral suspension 125 mg/5 mL or 250 mg/5 mL) dose depending on age; three times daily

*For severe infection in children aged 6 months to 11 years, increase the dose of amoxicillin up to 30 mg/kg (max 1 g) three times daily and for severe infection in children aged 12–17 years, double the dose of amoxicillin.

OR

**Phenoxymethylpenicillin (250 mg tablets, or oral solution, 125 mg/5 mL or 250 mg/5 mL) dose depending on age; four times daily

**For severe infection in children up to 11 years, increase the dose of phenoxymethylpenicillin up to 12.5 mg/kg four times daily and for severe infection in children aged 12–17 years, increase the dose up to 1 g four times daily.

OR

Metronidazole (200 mg tablets, or oral suspension, 200 mg/5 mL) dose depending on age; three times daily

After prescribing the medication, advise the patient to recontact if the symptoms still persist or worsen.

Paracetamol (500 mg tablets, or 120 mg/5 mL* or 250 mg/5 mL** oral suspension), dose depending on age; up to four times daily (max four doses in 24 hours).

If the answer to all the question asked is “NO,” the patient can be called for treatment with few mandatory extra protective measures. The clinician should prefer to give the set of instructions through call or via electronic mail. The instructions should include the following:

  1. Patients/parents should be informed that the questions will be again asked when the patient comes in the dental office to reassure that there is no change in the symptoms since the last conversation.

  2. To reduce the number of people in the dental office, only one parent/guardian should accompany the patient.

  3. Inform the patient to get their own story books, coloring books, and toys to keep the child busy. Also, inform the patients either to bring their own headphones or keep cartoon video in their phone.

  4. As modeling would not be possible in the dental office settings, so send some modeling videos and ask the parents to show those videos before their visit in the clinic.

  5. Dentist needs to develop a positive relationship with the child, so a prior video calling should be done with the child. Dentist can do modeling through video call as a behavior management protocol. Also, dentist can explain about patient interaction post COVID using euphemism (PPE) kits so that child does not get afraid when they see the dentist in PPE suit in the clinic.

PATIENT SCHEDULING

All the patients entering the dental clinic should be considered as a COVID-suspected patient. Therefore, all the precautions taken should be the same for all the patients. If a person contacts the corona-positive patient for less than 10 minutes, then chances of infection are very less.5 Therefore, time of appointment should be kept to the minimum.

IN-OFFICE PATIENT REGISTRATION PROCEDURES

Reception Area

As soon as patient enters the dental office, provide them with hand sanitizer before they enter into rest of the office. All patients must wear disposable shoe cover before entering the operatory. If possible, the chairs in the waiting area should be placed 6 ft apart. Patients’ initial screening should be done, which includes asking the questions which were asked previously on call and recording the temperature of the patient.6 Screening form issued by Indian Dental Association should be filled by the patient/guardian.

Chairside Checklist

Paper work in the operatory should be limited. No one should enter the dental operatory without mask as infected aerosols might be present. If possible, access to the dental operatory should be limited for parent/guardian.6

Behavior Management

When patient enters the operatory, the author advises that dentist should wear PPE kit in front of the child. By doing so, the patient will gain confidence in his dentist as the patient will be assured that this is the same person who was on video call. Also, dentist can use euphemism like space suit or superhero cape or costume for PPE kit. To make patient more comfortable, PPE-like suit can also be given to the child to make him feel like an astronaut.

Patient Examination

Before examination of the oral cavity, the patient should use mouthwash to reduce the bacterial load. The patient should rinse their mouth using 10 mL of 0.5% PVP-1 solution. The patient should thoroughly distribute the solution in the oral cavity for about 30 seconds and then should gargle at the back of the throat for another 30 seconds before spitting out.7 PVP-1 has proved to reduce SARS-COV virus infectivity;8 thus, rinsing mouth with PVP-1 will reduce both bacterial and viral loads in the patients’ mouth.

Hand hygiene protocol must be followed as it limits the spread of viral infection.9 WHO emphasizes that dentist should wash their hands before examining the patient, before dental procedures, after direct contact with the patient, after touching the environment without previous disinfection, and after touching the patient’s oral mucosa and skin or coming into contact with saliva and oral fluids.6,10

Patient Treatment

As the high-speed air-rotor creates aerosols so, it is time to shift to minimally invasive dentistry. A professional judgment should be employed to minimize the spatter of aerosols. Options that will reduce the use of air rotor should be considered (Box 3). In some situations, the use of air rotor cannot be avoided; therefore in such cases, a high-volume aspirator/air rotor with retraction valves/micromotor/electric motor can be used and operating field should be isolated with rubber dam so as to minimize droplets and aerosols produced during high-speed turbine operation. The high-speed turbines with anti-retraction valves should be used as they significantly reduce the return flow of oral bacteria. Four handed dentistry should be practiced, and preferably parents should not be present in the operating room. Dental office contains unhealthy air quality, which also increases the risk of infection. Thus, air purification should be done. Proper ventilation should be maintained in the operatory. Along with air conditioners, filters should be used. HEPA filters, carbon filters, UV light, or a combination of filter and UV light have been recommended.

Box 3: Alternative treatment approaches to reduce aerosols

  Conventional management Management during COVID
Preventive treatment •Fluoride application •Fluoride application
•Pit and fissure sealants application •Pit and fissure sealants application
•Silver diamine fluoride (SDF) application •Silver diamine fluoride application
Nonemergency treatment •SDF application •Silver diamine fluoride application
• Remineralizing agents •Remineralizing agents
•Restoration •Atraumatic restorative treatment (ART). It can be combined with the use of conditioners and chemomechanical agents (Papacarie, Carie-care)
•Ultrasonic scaling •Class II caries: Hall’s technique
  •Hand scaling
Nonemergency invasive treatment •Pulp capping •Selective caries removal using hand instruments
•Pulpotomy •Tooth preparation using air rotor with retraction valves/micromotor/electric motor
Emergency treatment •Pulpectomy •Treatment of choice should be extraction followed by space maintainer
•Extraction followed by space maintainer •In case of pulpectomy, tooth preparation using air rotor with retraction valves/micromotor/electric motor

USING NITROUS OXIDE INHALATION SEDATION IN THE ERA OF “NEW NORMAL”

If patient is treated under nitrous oxide inhalation sedation, disposable nasal hoods should be used and tubing should either be disposable or be sterilized according to the manufacturer’s instructions.

THE GROWING IMPORTANCE OF PREVENTIVE DENTISTRY

Emergency treatment interventions required would expose the child to potential risks of contagion from COVID-19. Therefore, dentist should emphasize on preventive dentistry and should tell the parents/guardians about the home care and application of use of fluorides and pit and fissure sealants placement.

Post-procedural Instructions

Patient should be given postoperative instructions and should include a reminder to report any signs or symptoms of COVID-19 within next 14 days.6

After Exit of the Patient

Operatory should be cleaned after every patient while wearing gloves, mask, and face shield. Suction pumps should be flushed with chemical cleaning solution as per the manufacturer’s instructions. Also, all suction and spittoon filters should be removed and cleaned after every patient. Fumigation should be done at the end of the day in clinical and high contact areas and biweekly in clinical or low contact areas.

For fumigation, clinic should be completely sealed and air conditioners should be switched on so that fumigant can reach the filter. Fumigation machine should be placed at one corner of the room and the fumigation solution is filled in it. The room should be left for the process for 30 minutes.11

CONCLUSION

We all know that COVID-19 is likely to stay for long and we as dentist have to adjust with living with the new normal. Dentist are at greater risk of COVID-19; therefore, new approach toward the treatment has to be inculcated by the dentist. The treatments remain the same, but the protocol may vary, and we as dentist need to change and mend ourselves with the new normal.

ORCID

Sakshi Jain https://orcid.org/0000-0002-3703-0372

REFERENCES

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5. European Centre for Disease Prevention and Control. Public health management of persons having had contact with cases of novel coronavirus in the European Union, 25 February 2020. Stockholm: ECDC; 2020.

6. American Dental Association. Return to work interim guidance toolkit; April 24, 2020.

7. Ministry of Health and Family Welfare. Guidelines for dental professionals in Covid-19 pandemic situation. May 19, 2020.

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9. Villani FA, Aiuto R, Paglia L, et al. COVID-19 and dentistry: prevention in dental practice, a literature review. Int J Environ Res Public Health 2020;17(12):4609. DOI: 10.3390/ijerph17124609.

10. Peng X, Xu X, Li Y, et al. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12(9):1–6. DOI: 10.1038/s41368-020-0075-9.

11. Dental Council of India. Dental advisory issued on 7th May 2020.

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