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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 21-26

Oral health management of children during coronavirus disease 2019 pandemic

1 Department of Pediatric Dentistry, Government Dental College and Hospital, Aurangabad, Maharashtra, India
2 Department of Mechanical Engineering, Government College of Engineering, Aurangabad, Maharashtra, India

Date of Submission21-May-2021
Date of Acceptance20-Jun-2021
Date of Web Publication23-Aug-2021

Correspondence Address:
Chaitali Hambire
17, Shreekunj, Samadhan Colony, Behind Sessions Court, Aurangabad - 431 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jssrp.jssrp_7_21

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Coronavirus disease 2019 pandemic has affected more than 200 countries worldwide. It has caused complete lockdown in most of the countries due to its highly contagious nature. Aerosol generated during dental treatment can be a major source of human-to-human transmission. Management of oral health of pediatric population should address emergency as well as nonemergency dental problems. This article attempts to provide possible approach on identification and management of emergency, urgent, and nonemergency dental conditions. It also suggests various preventive measures toward the maintenance of oral health and hygiene of children.

Keywords: Communicable disease, coronavirus disease 2019, infectious disease, oral health, pediatric dentistry

How to cite this article:
Hambire C, Hambire UV. Oral health management of children during coronavirus disease 2019 pandemic. J Surg Spec Rural Pract 2021;2:21-6

How to cite this URL:
Hambire C, Hambire UV. Oral health management of children during coronavirus disease 2019 pandemic. J Surg Spec Rural Pract [serial online] 2021 [cited 2023 Mar 31];2:21-6. Available from: http://www.jssrp.org/text.asp?2021/2/2/21/324483

  Introduction Top

Coronavirus disease 2019 (COVID-19) pandemic was initially identified in Wuhan, China. According to the World Health Organization (WHO), there are 164,523,894 confirmed cases of COVID-19, including 3,412,032 deaths globally, as of May 20, 2021. More than 227 countries have been affected by the coronavirus.[1] As per the Centers for Disease Control and Prevention (CDC), the number of cases reported of COVID-19 in children (age: 0–17 years) is fewer as compared with adults in the United States and globally.[2],[3] It is difficult to estimate the correct incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children because of lack of widespread testing and the prioritization of testing for adults and those with severe illness. Hospitalization rates in children are significantly lower than hospitalization rates in adults with COVID-19, suggesting that children may have less severe illness from COVID-19 compared to adults.[4] Recent evidence suggests that children carry the same or higher viral loads in their nasopharynx compared with adults[5] and that a child can spread the virus effectively in households and camp settings.[6] The low incidence of COVID-19 in children could be due to school closures and community mitigation measures.[7]

Guidelines for dental professionals are provided by CDC, WHO, and the American Dental Association.[8],[9],[10] They have recommended that urgent and emergency dental conditions should be given priority. Nonemergency and elective dental procedures are to be delayed in order to protect the dentist and his staff. Another major objective is to preserve personal protective equipment (PPE) and patient care supplies for future emergencies. Dental treatment involves close contact with patient, face-to-face communication, and exposure to saliva and blood, along with aerosol generation.[11]

The Indian Society of Pedodontics and Preventive Dentistry, a national society, believes that "Every child in India has a fundamental right to total oral health."[12] It is, therefore, very important that measures are taken to manage the emergency and nonemergency oral health conditions of pediatric population. Education and motivation of parents and caregivers in maintenance of good oral hygiene is significant during this pandemic. Emphasis should be given on development of healthy dietary habit and strengthening of their immune system. In case of nonemergency dental conditions, the parents should be educated to relieve the symptoms at home. Teledentistry and good communication with dentist would play a crucial role in this regard. In case of dental emergencies such as cellulitis, maxillofacial trauma, and acute pulpitis, the parents and children should visit dental hospitals under appropriate personal protection.[13]

Primary care physicians have significantly more visits than dentists by the parents of the children before they are 3 years old. Therefore, it is very important that the primary care physicians should be well educated and aware of the oral health screening and counseling. They should be trained for providing appropriate primary preventive oral health care. Primary care physicians can improve the parental knowledge and practices related to the oral health of their children. In addition to it, they can refer the children with early childhood caries (ECC) to the dentist for its early management. The objective of this paper is to provide the dentist as well as the primary care physicians the knowledge related to oral health care of pediatric patients.

  Primary Prevention Top

Education and motivation

Dental caries is an infectious disease that can be prevented. Effective oral hygiene can be maintained with correct brushing technique, fluoridated toothpaste, and dental floss.[14] The pediatric dentists and the general dental practitioners can circulate educational and motivational oral hygiene programs to follow during this pandemic. Its major objective would be to prevent the onset of dental caries and maintain the health of dental and oral tissues. This can be achieved with the use of social media platforms for digital communications and teledentistry.[15]

Diet plays an important role in maintaining a healthy stomatognathic system. Parents should be made aware of the caries-promoting and protective diet. A good diet would maintain oral and digestive system healthy as well as boost the immune system. A balanced diet consisting of fruits, vegetables, carbohydrates, and proteins would provide the body the essential micro- and macronutrients to function correctly. During this pandemic, the children would be at home, hence it is important to limit their consumption of junk food, aerated soft drinks, and sweets. The aerated soft drinks contain a large amount of sugar and acids which could result in erosion of enamel, thus making it porous and susceptible to the attack by the oral pathogenic bacteria.[16]

Children should be motivated for physical workouts and exercises. This would help to boost up their immune system to fight against all infections. Good physical activities would help in their growth and development. Along with these measures, adequate sound sleep is needed.[17] Preschool children are most commonly affected by ECC. It is important to educate parents regarding the etiology and pathogenesis of ECC. ECC has early onset and rapid spread affecting almost the entire primary dentition. Considering the age of the child and infectious complications associated with it, the prevention of ECC becomes utmost important. Parents and caregivers should be cautioned against the incorrect feeding practices. They should be educated regarding mother–child transmission of oral cariogenic bacteria.[18]

  Coronavirus Disease 2019 and Pediatric Dental Health-Care Management Top

Coronavirus disease 2019 transmissions

The COVID-19 is a highly communicable infectious disease caused by coronavirus 2 (SARS-CoV-2, Coronaviridae family, order – Nidovirales, size - 65–125 nm in diameter). The direct transmission of virus between humans occurs through close contact of healthy individuals with droplets from an infected person during talking, coughing, sneezing, or aerosols generated during dental procedures.[19] The studies have shown that angiotensin-converting enzyme 2 (ACE2) is the main host cell receptor of SARS-CoV-2 and plays a crucial role in the entry of virus into the cell. The ACE2 is highly expressed on the epithelial cells of oral mucosa, salivary gland duct, and other cells in the lungs. Hence, it has been suggested that the salivary gland epithelial cells may be infected in vivo after entry of the virus and the saliva produced by the infected salivary glands could be an important source of virus, particularly in early infection.[20]

Studies have shown that the aerosols generated during endotracheal intubation or in combination with other procedures such as cardiopulmonary resuscitation or bronchoscopy increase the risk of SARS transmission.[17] A recent study conducted on the saliva samples of COVID-19 positive showed that SARS-CoV-2 could be detected in 91.7% of the saliva samples, indicating that saliva is a potential source of SARS-CoV-2 spreading. Aerosols are liquid and solid particles (<50 μm diameter) suspended in air for protracted periods. Splatter is a mixture of air, water, and/or solid substances (50 μm to several millimeters diameter).[21] Dental drills generate aerosol and splatter commonly contaminated with bacteria, viruses, fungi, and blood. Oral surgery drills also produce aerosol in addition to splatter. Rotary dental and surgical instruments, such as handpieces or ultrasonic scalers, are associated with generations of large quantities of aerosols and droplets from the saliva and blood of the patient. Both are a health risk to the dental team. These can enter the human body through the nose or mouth via inhalation acting as a potential source of transmission of virus to the dentist and his staff.[20] Regular surgical face masks used in dentistry when correctly worn and frequently changed offer around 80% filtration rate. The COVID-19 measures around 120 nm (0.12 μm) and aerosol particle sizes range from 3 to 100 nm. The use of a FFP3 respirator offers a filtration rate of 99% of all particles measuring up to 0.6 μm.[22]

Pedodontist, his clinical assistant, staff, and other patients are at risk of cross infection. The virus can be transmitted indirectly when the heavy droplets carrying the virus settle down on the surface of dental chair, instruments, and equipment and remain suspended in the air after the dental procedures.[23] Dental treatment of children during this pandemic can be risky. Children can have fear and anxiety associated with PPE worn by the pedodontist and his assisting staff. Cooperation of children during dental treatment can be difficult. Finally, the presence of parent or caregiver in the dental operatory during the child's dental treatment increases the risk of transmission.[24]

Pediatric dental setup

Provide instructions regarding hand hygiene, respiratory hygiene, and cough etiquette via signs and posters in local languages [Table 1]. Paste them at all the strategic locations. Ask all the children and visitors to wear face mask during their entire visit in your dental setup. Keep the alcohol-based hand rub (ABHR) with 60%–95% alcohol, disposable tissues, and no-touch dustbins for disposal at health-care entrances, waiting rooms, and operatory. At your reception area, install physical barriers made of glass, acrylic, or plastic to minimize the contact between your staff and patient. Keep six-foot distance between the chairs in the waiting room. In the waiting area, do not keep toys, magazine, newspapers, etc., which cannot be disinfected. Do not keep many patients waiting in the waiting room. Ask the parent to wait with their child outside your dental clinic or facility and contact them when their turn comes. The number of patients appointed in a day depends upon the number of rooms, dental chairs, and time required to clean and disinfect the dental operatory. At least 15 min is required for the droplets to fall sufficiently from the air after a dental procedure. Only after this duration, you can start the cleaning and disinfection of the room.[25]
Table 1: Pediatric dental setup

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Management of patients before their dental treatment

Ask your staff to contact all the pediatric patients before starting their dental treatment. Ask them to screen the patients, on telephone, with respect to the symptoms associated with COVID 19. If any child's parent tests positively, avoid nonemergency dental treatment and delay the procedure until the patient has recovered. Teledentistry can be used to assess the child's dental condition. Advise the parents to minimize the number of people accompanying the child and request them to wear face masks during the appointments. Give appointments to patients with dental urgencies and emergencies. After arrival of child with his parent or caregiver, assess them systematically. Make sure that all of them are wearing mask, if not provide them with a surgical mask. Take detailed case history with stress on history of travel, contact with COVID-positive patient, presence of fever, and associated symptoms consistent with COVID-19. If the patient is asymptomatic and has negative history, provide dental treatment under proper infection control.[16],[24],[25]

Management of patients during their dental treatment

The pedodontist and his clinical assistant should always wear facemasks throughout their presence in the facility. They should follow strict hand hygiene guidelines issued by CDC. They should use ABHR when hands are not visibly soiled and soap when visibly soiled. While performing dental procedures, they should wear well-fitting respirators offering the highest level of protection, goggles for eye protection, face shield, and protective gown. All of them should be well trained in donning and doffing of PPE. Sterilized instruments should be used during child's dental treatment. Schedule the aerosol-generating procedures at the end of the day. Four-handed dentistry is recommended along with the use of rubber dam and high evacuation suction to minimize droplet spatter and aerosols [Figure 1].[16],[24],[25],[26],[27]
Figure 1: Flowchart for management of pediatric patients

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Recent studies have shown that the use of mouth rinse before the dental procedures can significantly reduce the load of oral microbes.[28] Evidence shows that 0.23%–1% of povidone solutions are effective against SARS-CoV, after 1-min in vitro incubation.[29] In an in vitro study, HCoV strain 229E was inactivated within 1 min by 0.5% of hydrogen peroxide.[30] Based on these studies, it is recommended to ask the child to gargle with antimicrobial mouthwash (0.12% chlorhexidine gluconate, 0.5%–1% hydrogen peroxide, essential oils, povidone-iodine, or cetylpyridinium chloride) to reduce the viral and bacterial load in the aerosol generated during dental procedures.[31] The prevention of dental caries can be accomplished by application of topical fluorides and pit and fissure sealants. Atraumatic restorative treatment, selective caries removal, and the Hall technique can also be considered.[32] The use of rubber dam along with high-volume evacuation with saliva ejector is recommended to decrease the droplets, splatters, and aerosols.[33] The application of a rubber dam has been shown to significantly reduce airborne particles in an approximately three-foot diameter of the operational field by 70%.[34] A study shows that the high-speed dental handpiece without anti-retraction function aspirates and expels debris and fluid during the dental procedures. This debris and saliva-borne microbes could contaminate the dental unit waterlines resulting in cross infection.[35] The splatter and droplet contamination can spread up to a range of three-foot diameter.[36] A recent study has shown that aerosol-generating dental procedures spread and contaminate various surfaces and equipment in the dental office, thereby producing long-lasting contamination and potential transmission of coronavirus.[37] Therefore, it is recommended that good ventilation of dental office along with strict and regular surface disinfection with sodium hypochlorite at 0.5% (equivalent 5000 ppm) be done. .[38] All the saliva-contaminated waste generated during the dental treatment procedures should be regarded as infectious medical waste and should be properly disposed accordingly.[39],[40],[41],[42],[43],[44]

  Conclusion Top

COVID-19 pandemic has a significant effect on the health-care delivery system. Most of the dental care facilities were either shut down or had reduced operations due to aerosol generation during dental procedures. Comparatively, the primary care physician's offices were more operational. Oral health care via telecommunication has increased. Primary care physicians can play an important role in building collaborative relationships with dentists for maintaining and managing the oral health of pediatric patients. Management of oral health of pediatric population during COVID-19 pandemic is challenging. We will have to consider the challenges provided by the present-day pandemic and re-evaluate our dental treatment protocols. We will have to put more stress on the preventive aspect for oral health maintenance. It is crucial to educate, motivate, and guide the primary care physicians as well as the parents to reduce the dental pathologies in children. It is important to inculcate good dietary and oral hygiene habits along with physical exercises to maintain the physical and emotional well-being of the child. We will have to adopt newer and smarter technologies in our dental practices along with strict infection control protocols. We have to adapt our dental practice and treatment guidelines according to newer infectious threats.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1]


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