Could COVID‐19 change the way we manage caries in primary teeth? Current implications on Paediatric Dentistry

Abstract

SARS-CoV-2 is a new and an unpredictable virus that is rapidly transmitting from one country to another, and unfortunately as of today, there is no effective medication or vaccine for the disease control. This virus has gone on to cause one of the most rapidly expanding pandemics we have known since the Spanish Flu pandemic in the early 1900s, with over 9 million people being infected worldwide including the paediatric population.1 In response to the pandemic, governments introduced lockdown measures, significantly affecting the daily lives of its citizens, including the provision of dental care. In order to reduce the spread of the virus, routine dental treatment was suspended in many countries across the globe, causing significant disruption to the provision of oral health services since the beginning of the pandemic.1 Historically, infected aerosols and splatter droplets generated from dental procedures have been implicated in the transmission of diseases known to be spread via an airborne route including pneumonic plague, tuberculosis, influenza, and Legionnaires' disease; therefore, COVID-19 could be perceived as no different.2 The virus is believed to be transmitted via droplets and aerosol released from an infected person's mouth or nose as they breathe, talk, sneeze, or cough.3 The infected aerosol can remain airborne for a few hours as well as landing on and contaminating surfaces for up to 72 hours.3 The mouth is part of the oronasal pharynx and harbours bacteria and viruses from the nose, throat, and respiratory tract mainly in the saliva and oral fluids.2 Common dental procedures including the use of high-speed handpiece, 3-in-1 syringe, ultrasonic scalers, air polishers, and air abrasion units generate large quantities of aerosols and splatter from the patient's saliva and blood which can remain suspended in the air for approximately 30 minutes before settling on the environmental surfaces, medical instruments, or entering the respiratory tract through the nose and mouth.2 Aerosols also have the potential to enter ventilation systems and spread to areas of buildings where barrier protection is not used.2 Thus, contributing to the spread of the infection to the dental staff, patients, and public eventually. These dental procedures are known as Aerosols Generating Procedures (AGPs). The novel virus presents unprecedented challenges to the paediatric dentists. Children under the age of 16 make up around 2% of total COVID-19 cases worldwide and are mainly asymptomatic, therefore contributing to the transmission and presenting a significant concern for dental care providers due to the uncertainty of their infectious status.1, 4 In addition, managing children during dental treatment can be challenging as they may cough, sneeze, and cry which can theoretically generate more natural aerosols when compared to treatment in adults or a child requiring dental treatment under general anaesthesia (GA). Access to the latter has significantly reduced during the pandemic for the foreseeable future to reduce the stress on the operating rooms.1, 4, 5 In addition, in several countries during the peak of the pandemic, AGPs were suspended and were only provided to patients requesting urgent care as per advice by many health authorities around the world (Royal College of Surgeons of England, Scottish Dental Clinical Effectiveness Programme, German Dental Association-Bundeszahnärztekammer, the American Dental Association, Centers for Disease Control and Prevention, Australian Dental Association, the Ministry of Health and Dental Council New Zealand, and the Brazilian National Health Surveillance Agency).1 If AGPs are to be provided, a proper personal protective equipment (PPE) should be used by dental care providers which is limited due to the high demand, and a fallow period of up to 60 minutes is required post-treatment. As a result of this, the number of patients being seen is much lower.5 The fallow period is the time required to allow for clearance of infectious aerosols after a particular procedure before decontamination of the surgery can begin, and it mainly depends on the ventilation and air change system within the room.5 These implications have resulted in a significant increase in the suffering of the paediatric patients in need of dental care and have placed a large burden on the dental health services due to increasing waiting lists for both routine and urgent dental care in chair and under GA for the post-COVID era. It is futile to imagine that COVID-19 will just suddenly disappear; rather, it is likely to remain an issue in the long term with a second wave of COVID-19 cases already being reported in some countries. Given the high proportion of children with dental caries worldwide and the negative impact this has on their quality of life,6 during the course of this pandemic, alternatives to conventional dental treatment of carious primary teeth including non-selective removal of dental caries, traditionally known as complete caries removal and pulp therapy using high-speed handpiece, and 3-in-1 syringe should be reconsidered to minimise the amount of aerosols produced to maintain a healthy environment for the patients and the dental staff. Minimal Intervention Dentistry (MID) is a biological approach to treat carious lesions, which covers a spectrum of techniques ranging from no carious tissue removal to selective carious tissue removal.7 These techniques aim to control the progression of carious lesion by isolating the cariogenic bacteria from dental plaque.8 Several MID techniques provide a safe, decreased aerosol-generating procedure with high-quality treatment approaches that are highly accepted by children.1, 8, 9 MID has several advantages which are of significant importance during the COVID era; besides maintaining tooth structure and reducing the risk of pulp exposure, it is potentially considered low-risk Aerosols Generating Exposures (AGEs) and requires less need for local anaesthetic, thus reducing the child's discomfort, which contributes to a decreased spread of natural aerosols. In addition, most of the MID procedures can be completed in a short period of time, therefore requiring a shorter fallow period and reduce the number of patients in waiting room waiting to be seen.1, 5 These techniques involve sealants, resin infiltration, silver diammine fluoride (SDF) application, the Hall Technique, Atraumatic Restorative Technique (ART), and selective removal of carious tissue to soft and firm dentine. They are indicated in asymptomatic dentine carious lesions and in teeth with no clinical or radiographic signs of irreversible pulpitis, dental infection, pulp exposure, or pathology.1, 7 The following is a summary of these techniques. Fissure sealants can seal and inhibit further progression of carious lesions in pits and fissures by isolating the carious lesion from the surface biofilm, thus delaying or preventing the need for AGPs,10 whereas resin infiltration fills and reinforces demineralised enamel and dentine with a low-viscosity resin creating a diffusion barrier inside the lesion rather than on the surface facilitating its clinical application especially in interproximal lesions without the need for temporary tooth separation.11 Both techniques are indicated in initial non-cavitated carious lesions in both primary and permanent teeth.10, 11 Silver diammine fluoride is a topical colourless ammonia liquid containing silver and fluoride. Silver is antibacterial, whereas fluoride enhances remineralisation of dental hard tissue. Both act synergistically to arrest dental caries and prevent new lesions forming on remaining tooth surfaces. SDF does not require carious dentin excavation prior to its application; therefore, it is considered a low-risk AGEs. In addition, SDF helps with desensitising of non-carious tooth lesions, and it might be an advantage particularly in molar incisor hypominerlisation (MIH), by occluding dentinal tubules. The main drawback of the treatment is that it leaves carious teeth black, thus thorough discussion with parents prior to its use is paramount.12, 13 Hall Technique (HT) is another method for managing carious primary molars during the COVID-19 era where caries is sealed under a preformed metal crown (PMC) without local anaesthesia, tooth preparation, or any caries removal. It is also indicated in primary teeth with enamel and dentine defects such as primary molar hypomineralisation, amelogenesis imperfecta, and dentinogenesis imperfecta. It is quick, easy for the child to cope with and is considered a low-risk AGEs. Care, however, should be taken when separators are used to create interproximal space between primary molars, careful removal (with high volume suction) should be ensured to reduce the risk of splatter. Also, the technique should be avoided in children where airways cannot be managed safely, or very anxious children who might struggle to cope with biting down on the Hall crown.8, 9, 14 Atraumatic Restorative Technique is also an alternative approach for managing dental caries during the pandemic, and it involves preventive and restorative measures. This involves removal of caries using hand instruments usually without local anaesthesia, and the intact fissures are sealed with High Viscosity Glass Ionomer Cement (HVGIC) and therefore carries low-risk AGEs. The technique was first developed as a treatment approach in developing countries where routine dental treatment cannot be performed because of a lack of facilities or accessibility to dental clinic. It, however, has received increased interest in the past few years. HVGIC has improved properties including wear resistance, compressive strength, and marginal adaptability, contributing to ART success rates.7, 15, 16 Selective removal of carious tissue to soft and firm dentine, known as partial or incomplete caries removal, includes selective removal of carious tissue pulpally until either soft dentine, where caries is easily scooped up with little force being required, is reached or firm dentine, which is resistant to hand excavator, is reached to avoid exposure and stress to the pulp. Periphery of cavity should be cleaned to hard dentine that is similar to sound dentine to allow a tight seal and placement of a durable restoration. The former is indicated in deep cavitated lesions where caries is extending to the pulpal third where the latter is indicated in shallow or moderately deep cavitated dentinal lesions in asymptomatic both primary and permanent teeth.7, 8 In conclusion, COVID-19 has and will continue to have significant impacts on the practice of paediatric dentistry. As a result, some traditional approaches used for the management of carious primary teeth prior to the COVID-19 pandemic will need to be adapted during the COVID-19 era and more minimally intervention techniques in caries management will need to be utilised in order to minimise the risk of spreading the infection to patients, dental staff, and public posed by the dental procedures. We have described many professional techniques for dealing with carious lesions. Still, it is also important to emphasise the importance of the application of all oral health preventive and therapeutic measures during this time to control the disease. The views expressed in this editorial represent the views of the authors. It has not been peer-reviewed, and it does not replace the clinical judgement of the professional.

Topics & Concepts