Could COVID-19 change the way we manage caries in primary teeth?

Current implications on
Accepted Article
Paediatric Dentistry.

1Alaa BaniHani, 1Collette Gardener, 2Daniela Prócida Raggio, 3Ruth M. Santamaría, 4 Sondos
Albadri
1 Department of Paediatric Dentistry, School of Dentistry, University of Leeds, UK.
2 Department of Orthodontics and Paediatric Dentistry, School of Dentistry, University of São
Paulo, Brazil.@
3Department of Preventive and Paediatric Dentistry, University of Greifswald, Germany.
4School of Dentistry, Institute of Life Course and Medical Sciences, University of Liverpool, UK.

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

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 part of the oronasal pharynx and harbours bacteria and viruses from the nose, throat and
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respiratory tract mainly in the saliva and oral fluids.2 Common dental procedures including the use
of high-speed handpiece, 3in1 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 to the 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 significantly 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 as well as 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 of the suffering of the paediatric patients in

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 need of dental care and has placed a large burden on the dental health services due to increasing
Accepted Article
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 3in1syringe 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 reinforce 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

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 temporary tooth separation.11 Both techniques are indicated in initial non-cavitated carious lesions
Accepted Article
in both primary and permanent teeth.10,11

SDF is a topical colourless ammonia liquid containing silver and fluoride. Silver is antibacterial
whereas fluoride enhances remineralization of dental hard tissue. Both acts 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, 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. However, care 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

ART 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, 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. However, it 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

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 caries is easily scooped up with little force being required, is reached or firm dentine, which is
Accepted Article
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.

References:
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 5. Faculty of General Dental Practice. Implications of COVID-19 for the safe management of
Accepted Article general dental practice-a practical guide June 2020. https://www.fgdp.org.uk/implications-
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Accepted Article
DISCLAIMER

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.

Corresponding Author:

Dr Alaa BaniHani

Clinical Lecturer and Specialist Registrar in Paediatric Dentistry, University of Leeds.

Email: A.BaniHani@leeds.ac.uk

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