Triaging Pediatric Dental Emergencies During COVID-19

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Dr. Reza Nouri, a pediatric dentist from Vancouver, gives a presentation on the management of pediatric emergencies during the Covid-19 pandemic.

Here are the key takeaways:

Purpose

• To help dentists triage dental emergencies during Covid-19 – especially pediatric cases.

Goals

• Minimize the number of patients sent to ER so as to minimize both patient risk and unnecessary burden on the hospital system.
• Minimize the need for emergency care within the dental office by planning periodic urgent care clinics for cases that are urgent but not emergencies. This will allow the dental office to be better prepared from an infection control point of view.

Based on a US study of pediatric dental emergencies presenting to the ER

• 51% are related to trauma
• 40% are related to caries
• 9% are related to soft tissue lesions

Many of these cases could be handled in the dental office, particularly during the Covid-19 epidemic when we are trying to lighten the load on healthcare systems.

When it comes to trauma, TIME is of the essence

• Important to get inflammation under control. In many cases this can be achieved by coaching the parent to take action at home.
• Important to assess quickly. If left unseen, trauma could turn into a significant emergency that would then need to be dealt with in a hospital setting.

So what do we consider to be an emergency?

Dr. Nouri takes us through a number of case examples:

• Avulsion – This is an emergency. Try to coach the patient over the phone to re-implant the tooth or put the tooth in medium. Get them to the office as soon as possible.
• Lateral Luxation – Like avulsion, you need to see this patient as soon as possible to reposition the tooth.
• Chipped or Fractured Tooth – Ask yourself, how bad is this? It could just be a chipped tooth but there is a possibility of root damage. To establish whether there is root damage, radiographs are required. This patient should be seen as soon as possible.
• Pulp Exposure – This is an emergency case, but to minimize aerosol production it may be best to temporize and leave the tooth alone until after Covid restrictions have been lifted.
• Severe Concussion – If it is a trauma that has just occurred, then you need to assess damage. If the trauma occurred days or weeks prior and discoloration has just shown, then this is not an emergency. The patient should be booked for your next urgent care clinic.
• Localized Abscess after Trauma – If the trauma occurred some time ago and there is no pain, fever or facial swelling, then this patient is not an emergency and can be booked into an urgent care clinic.
• Caries – This is not emergency and should be postponed until after Covid restrictions have been lifted, if possible. Important to avoid so as not to generate aerosols.
• Deep Carious Lesion – Not an emergency and do not want to generate aerosols. However, this could become an emergency and so should be booked into urgent care clinic.
• Chronic Extensive Caries – If caries have developed over time then, unless there is systemic involvement, this is not an emergency.
• Facial Cellulitis – This is an emergency. Must keep a close eye on the patient. Try to treat with oral antibiotics and monitor closely. Stay in touch with the patient. Make sure the parents can contact you if things get worse.
• Eruption Hematoma – Not an emergency. If pain, fever or swelling develop then you must deal with it.
• Self-inflicted Harm – Mostly self-resolving. Not an emergency. Be patient. Ice. Anti-inflammatories. Monitor.
• Over-retained Teeth with Gingival Infection – So long as there is no systemic involvement, this is not an emergency. Could treat with antimicrobial mouth rinse and oral hygiene. Keep inflammation down. If fever develops, deal with it as an emergency and extract teeth.
• Soft tissue lesions – Can be managed over the phone. Get patient to send you photos. Treat with antimicrobial mouth rinse.

Some Other considerations when Triaging Pediatric Emergencies:

• Get thorough medical and dental history.
• Consider using teledentistry to decide whether the patient needs emergency care or if they can be scheduled for an urgent care clinic.
• Important to screen parents/accompanying adults from an infection control point of view. Get parents and accompanying adults to fill in a Covid screening history.
• Include additional consent form to cover risk of contraction of Covid at the dental office.