Abstract
The Severe Acute Respiratory Syndrome (SARS) caused by SARS-CoV-2 virus has quickly spread all over the world, directly affecting the dentistry practice. This study aimed to perform a literature review about the current evidences on biosafety practices and clinical recommendations regarding the return to the elective dental care in the practice of Pediatric dentistry. An electronic search was performed in PubMed, Scopus, Web of Science and Grey literature databases using the terms “Pediatric dentistry” and “COVID-19”. Initially, 38 studies were retrieved. After title and abstract were read, it was identified that 22 studies referred specifically to children's dental practice. A total of 19 studies were included in this study. The COVID-19 pandemic will imply significant changes in the reorientation of dental practices, from biosafety issues to technical procedures. Greater rigor in the use of Personal Protective Equipment (PPE) may cause strangeness for children. Consequently, an improvement in the management of patient's behavior before and during the treatment and new approaches to perform the procedures will be demanded. Non-aerosol techniques and minimally invasive procedures will be preferable whenever possible. Professionals will need to be constantly updated based on what the scientific literature recommends. The moment is suitable for the use of preventive practice and minimally invasive techniques.
Keywords: Pediatric dentistry, Dentistry, SARS-CoV-2 virus, Containment of biohazards, Behavior, Evidence-based dentistry
1. Introduction
The first semester of 2020 was marked by the quick spread of the new coronavirus all over the world. This virus causes the Severe Acute Respiratory Syndrome 2 (SARS-CoV-2). The SARS-CoV-2 transmission among humans has been characterized by air droplets or direct contact with contaminated objects and surfaces [[1], [2], [3], [4], [5], [6]]. Although the whole world is working to stop the viral spread, the outbreak has not stopped yet [4]. The number of deaths is still a distressful reality. Given the widespread transmission of the novel coronavirus, healthcare professionals are at a high risk of contracting the infection and becoming potential carriers of the disease [[6], [7], [8]].
The disease that the virus causes is called COVID 19. The impact of this infection on dentistry practice has been too strong [9]. Dentistry is placed at a very high exposure risk category, due to the possibility of exposure to biological infectious materials disseminated as droplets and aerosols and the high viral load present in the upper airways and saliva [6,[9], [10], [11], [12]], as well as the close proximity to the patient's oral cavity [6,7]. This situation becomes even worse when treating children and adolescents. Recent studies have shown that most of children remain asymptomatic despite having contracted the disease and may contribute significantly to transmission [1,13].
Given the aforementioned information, this study aimed to perform a literature review of the available evidence about the Pediatric dental practice related to biosafety and clinical recommendations in order to guide Pediatric dentists regarding dental approaches post-COVID-19 still without the vaccine.
2. Literature review
An electronic search was performed in PubMed, Scopus and Web of Science databases until September 21st, 2020. The search strategy involved a combination of controlled vocabulary (MeSH) and free terms, as shown in Table 1 . No filters or limits were applied. There were no date or language restrictions. Articles in more than one data base were considered just once. Additionally, grey literature was also consulted via Open Grey database. A manual search was also performed by reading the reference list of the selected articles to identify any other eligible studies.
Table 1.
Search strategy.
Pub Med | #1 ((pediatric dentistry [MeSH Terms]) OR (pediatric dentistry [Title/Abstract])) OR (pediatric dentistry [Title/Abstract]) |
#2 ((SARS-CoV-2 [Title/Abstract]) OR (coronavirus [Title/Abstract])) OR (COVID-19 [Title/Abstract]) | |
#1#2 (((pediatric dentistry [MeSH Terms]) OR (pediatric dentistry [Title/Abstract])) OR (pediatric dentistry [Title/Abstract])) AND (((SARS-CoV-2 [Title/Abstract]) OR (coronavirus [Title/Abstract])) OR (COVID-19 [Title/Abstract])) | |
WoS | # 1 TOPIC: (pediatric dentistry) |
# 2 TOPIC: (COVID-19) OR TOPIC: (coronavirus) | |
#2 AND #1 | |
Scopus | TITLE-ABS-KEY (pediatric AND dentistry) |
(TITLE-ABS-KEY (covid-19) OR TITLE-ABS-KEY (coronavirus)) | |
(TITLE-ABS-KEY (pediatric AND dentistry)) AND ((TITLE-ABS-KEY (covid-19) OR TITLE-ABS-KEY (coronavirus))) |
The inclusion criteria were articles that assessed Pediatric dentistry dental practice and COVID-19.
2.1. Studies selection
The electronic search was performed in the databases by two independent reviewers (SM and AS). Initially, 38 articles were retrieved. After reading title and abstract, 22 studies were selected. The inclusion criteria were applied and 19 articles were included in this study. Fig. 1 shows the flow diagram of the literature search.
Fig. 1.
Flow diagram of literature search.
The selected articles had their text read in full and the following data were extracted: author, date, type of paper and content/considerations. Table 2 shows the characteristics of the included studies.
Table 2.
Characteristics of the included studies (n = 19), in alphabetical order.
Author | Date | Type of paper | Content/Considerations |
---|---|---|---|
Acharya et al. [27] | Sep | Interdisciplinary update |
|
Achmad et al. [29] | Jun 18th | Literature review |
|
Al-Halabi et al. [13] | Jun 16th | Critical review Clinical recommendations |
|
Amorim et al. [5] | Jun 22nd | Critical review |
|
Bahramian, Gharib, Baghalan [18] | Jul 14th | Review |
|
BaniHani et al. [19] | Jul 28th | Perspective |
|
Bhardwaj et al. [28] | Jun 30th | Review |
|
Cagetti & Angelino [24] | May 20th | Short communication |
|
Casamassimo, Townsend, Litch [20] | Mar 15th | Guest editorial |
|
Cianetti et al. [21] | May 26th | Narrative overview |
|
Ferrazzano et al. [4] | May 22nd | Short communication |
|
Ilyas et al. [9] | Jun 26th | Highlights |
|
Jayaraman et al. [12] | May 15th | Letter to the Editor |
|
Jurema et al. [14] | Jun 1st | Literature review |
|
Mallineni et al. [22] | Apr 16th | Editorial |
|
Oliveira et al. [15] | Sep 9th | Survey questionnaire |
|
Paglia [11] | Jun | Editorial |
|
Shah [23] | Aug 8th | Narrative review |
|
Yang et al. [16] | Sep 18th | Retrospective study |
|
For better understanding, the literature review was divided into four topics, as follows: 1. Protocols or clinical pathways; 2. Aspects related to biosafety; 3. Clinical practice – dental procedures and 4. Child behavior management.
2.2.1. Protocols or clinical pathways
To avoid the risk of virus transmission, the American Dental Association has developed guidance to categorize emergency, urgent and non-urgent or routine dental procedures. Dental conditions that can be potentially life-threatening and require immediate treatment are considered emergencies, such as hemorrhage, dental trauma and cellulitis that compromise a patient's airway. Non-life-threatening dental problems presenting pain or localized cellulitis are considered urgent [12].
Although some countries have been limiting dental care to emergency procedures only, using teledentistry as alternative to in office care, caregivers must inform in advance, during the virtual consultation, if the child has been unwell and feverish for the last 24 h and should be informed about the use of a face mask on the day of the appointment [5,14,15].
Fig. 2 illustrates scheme considering the practice of Pediatric Dentistry post-COVID, i.e, indicating the procedures in the phases with their marking.
Fig. 2.
Illustrative scheme considering the practice of Pediatric Dentistry post-COVID. (OSHA - Occupational Safety and Health Administration; CDC - Centers for Disease Control and Prevention; PPE - Personal Protective Equipment; ART - Atraumatic Restorative Treatment; SDF - Silver Diamine Fluoride; AGP - aerosol Generating Procedure).
2.2.2. Aspects related to biosafety
With a gradual and programmed return to activities, dentists and their professional team will need to have an extra care regarding the suitable use of the Personal Protective Equipment (PPE) to minimize the risk of contamination and cross-infection during dental care [5,11,13]. They will also need to update their knowledge and skills regarding infection control and follow the protocols [7,14]. Considering the virus incubation period, the asymptomatic course of the disease observed in children, or even mild and unspecific symptoms, all patients and caregivers must be considered potential carriers of COVID-19 [1].
Administrative, educational and preventive training measures should be used to avoid the infection [1]. The intervals between the appointments should be longer and patients and dentist should respect the scheduled time. A longer interval is important to carry out all recommendations for disinfection of the dental office and to avoid agglomeration of patients in the waiting room. Patients and caregivers should be wearing facial masks [6]. Sink with soap and water for hand washing and hand sanitizer (70% alcohol gel) should be easily available. Handwashing, the use of PPE, sterilization of instruments, proper waste disposal and safe anesthesia practices must be accomplished [1].
In cases of known or suspected COVID-19 positive patients, the use of N95 or a higher-level respirator, eye protection, face shield, gloves, and a gown are recommended to carry out aerosol generating procedures (AGP) [12]. Due to the high transmissibility and permanence of the virus in the environment, the last hours of appointments should be reserved for children infected by COVID-19 [6,13]. For non-AGP dental procedures on a healthy patient, a combination of appropriate surgical mask, face shield, gloves, and a gown are recommended [12]. Elective treatments should be avoided whenever possible, prioritizing urgent procedures. Visual alerts, such as signs and posters, at the main entrance and in the waiting room should be placed to reinforce biosafety measures [5].
2.2.3. Clinical practice – dental procedures
Due to the enormous varied situations that may present to dental offices, it is difficult to give specific recommendation for each one. Dentists must rely on their clinical judgment, factoring in the acuity of the symptoms, possible alternative procedures that may provide relief, and the quality of protective equipment available [12].
Aerosol generating procedures and the use of air syringe must be avoided whenever possible [11,16,17], aiming at the reduction of cross-infection during the treatment [1]. When the use of high speed drills are necessary, previous mouth rinse or impregnated gauze with substances capable of reducing the infectious load of SARS-CoV-2 and the use of rubber dam are strongly recommended [1,18,19]. Thus, the non-invasive and the minimally invasive treatments are desirable [1,9,11,13,20,21,[23], [24], [25]].
Additionally, considering SARS-CoV-2, there is not a specific guideline for anesthesia in pediatric patients, so when necessary, the AAPD 2017 [26] guide should be considered. Similarly, X-ray examinations should be considered based on AAPD 2017 [27]. Both do not produce aerosol and therefore are not considered at risk.
2.2.4. Behavior management
Behavioral management in pediatric patients is necessary in contexts of fear, anxiety and pain, aiming the humanization of care and gaining the patient's trust and collaboration during treatment. Calm children spread less aerosol compared to restless and crying children [13,21]. The added anxiety that child might have due to dental healthcare providers having to follow enhanced PPE protocols including face mask, face shields, gowns and coveralls must be taken into consideration. Whenever possible, it is helpful to put this protective equipment on while the child is watching, and while we explain to them in simple words the value and use of this equipment. The child might be encouraged to fantasize that the dentist is putting on special power suits. Last but not least important, making the child dress like the dental staffs could decrease the fear and anxiety seeing everyone in gowns, masks and coveralls [20].
In addition, it is possible to consider the possibility of contacting the family by phone (from conversation to video call) to guide them on how the office environment (without recreational spaces), the professional and team will be different [20].
Taking into consideration the challenges of dealing with children, the need of additional pharmacological behavioral management techniques may be necessary. If non-pharmacological behavioral management techniques alone are insufficient, inhalation sedation (IHS) can be offered as an alternative [9].
It is important to mention that social isolation and the disruption of children's routines may bring physical and psychological consequences that cannot be underestimated. According to Sprang & Silman (2013) [28], post-traumatic distress levels were four times higher in pediatric patients who were in quarantine during epidemic or pandemic events than those who were not in social isolation.
Most children and adolescents have never experienced a pandemic or even social distancing and a strict lockdown imposed by COVID-19. Thus, efforts must be redoubled in order to avoid the risk of physical and psychological repercussions, being parents, psychologists and teachers important allies in the maintenance of psychophysical health and well-being of these children [29].
3. Discussion
Although there is no evidence that aerosols generated from dental care lead to transmission of SARS-CoV-2, guidelines have been recommended given the urgency of the epidemic [30]. Thus, dental practices are being strongly affected by the current pandemic [9]. The pediatric dentistry approach is also being modified [13]. New features and ever-changing evidence-based guidelines have become part of the dental practice daily routine in order to contain the viral spread and the likelihood of a “second peak” [9].
The use of teledentistry is playing an important role in screening patients [1,31,32], enabling partial or complete management of dental clinics at a distance. Besides that, it as a tool for prevention of dental caries and the individual's engagement in health care, improving the quality of patient's management [7]. These new technologies can assist the diagnosis and help in the identification of cases that may or may not be a dental emergency [[14], [15], [16],25,32].
When the most important phase of the pandemic ends, dental clinical routine will not return immediately to what it was before [18]. With the restrictions mitigation on dental practices, a continuous management through minimally invasive concepts will be relevant [1]. Minimal Intervention Dentistry (MID) has several advantages, which are of significant importance during the COVID-19 pandemic, since it exposes patients to low risk aerosol, requires less need of local anesthesia and can be executed in a short period of time [16]. Atraumatic Restorative Technique (ART), resin infiltration, sealants, Silver Diamine Fluoride (SDF) application, selective caries removal and the Hall technique are examples of minimally invasive approaches [1,21,25].
By adopting all recommended measures for disease prevention and control, including the proper use of PPE, the risk of exposure to the pathogen must be minimized [1]. It is recommended that dentists wash their hands before children examination, as well as before and after dental procedures. Furthermore, at this moment, dentists should avoid touching their eyes, mouth and nose. In addition, according to the National Association of Italian Dentists the use of eyewear, masks, caps, gloves, face shields, surgical clothes, and shoe-cover are also recommended [4,19].
The pediatric dental care team must inform patients of all the changes in the dental office environment: that it will look different from usual, without toys in the waiting room, in addition to the vestment of the professional team in order to minimize patient's aversion and strangeness [5]. Managing children behavior during dental treatment is extremely important. Restless, crying children spread more aerosol compared to calm children [13]. In addition, handling techniques allow safe and quality treatment [25].
According to AAPD (American Academy of Pediatric Dentistry), it is recommended delaying seeing pediatric patients who require physical behavior management, also considering that treating them while on parent's lap would need special hours in the day dedicated for such patients [33].
The challenges in this new stage will be countless. However, with flexibility, knowledge, and a continuous adaptation process, pediatric dentists can face these challenges and strengthen even more the profession in the future [12].
The return to the elective procedures in Pediatric dentistry will demand the use of enhanced PPE during treatments [13,19,24,31]. It is believed that this new routine of dressing can cause strangeness to children demanding a humanized care of these patients and a behavior management before and during the procedure [20].
4. Conclusion
The Pediatric dentistry practice will require a thorough and explanatory approach with regard to the need for the professional to be dressed up so as to possibly be unrecognizable to that child. Non-aerosol techniques and minimally invasive procedures will be preferable whenever possible. The moment is suitable for the use of preventive practice and for minimally invasive techniques. Due to the constant scientific discoveries, professionals must remain attentive and updated based on the best scientific evidence.
Declaration of competing interest
The authors declare that they have no conflict of interest.
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