European Archives of Paediatric Dentistry (2020) 21:543–556

https://doi.org/10.1007/s40368-020-00547-5

INVITED REVIEW

Assessment of paediatric dental guidelines and caries management

alternatives in the post COVID‑19 period. A critical review and clinical
recommendations
M. Al‑Halabi1   · A. Salami1 · E. Alnuaimi1 · M. Kowash1 · I. Hussein1

Received: 22 April 2020 / Accepted: 7 June 2020 / Published online: 16 June 2020
© European Academy of Paediatric Dentistry 2020

Abstract
Purpose  The first aim of this paper is to provide dental professionals caring for children and adolescents during and after
the COVID-19 pandemic with a reference to international dental guidelines. The second aim is to suggest minimally inva-
sive treatment alternatives for caries management, minimising the risk of viral cross-infection and offering a safer clinical
environment.
Methods  An evidence-based pertinent literature search of different electronic databases was performed in addition to leading
global dental authorities, royal colleges, and programmes.
Results  All guidelines released in response to COVID-19 centred around minimising Aerosol Generating Procedures (AGP)
impacting the provision of regular dental treatment of paediatric patients. There was an emphasis on triaging and only treat-
ing emergency and urgent cases. Special attention was given to medically compromised children in the guidelines. Detailed
guidelines for the dental environment and equipment were given. This paper also summarised the relevant evidence-based
guidelines for the use of non-invasive and minimally invasive caries management techniques.
Conclusion   Specific recommendations for dental management of paediatric patients during and in the post-COVID-19 era
are suggested. Minimisation of AGP procedures, and case-based selection of biological, non-invasive or minimally invasive
methods are recommended.

Keywords  COVID-19 · Paediatric dentistry · Aerosol generating procedures · Biological caries treatment · Atraumatic
restorative treatment · Non-restorative caries control

Introduction including the global paediatric population (Rabaan et al.

2020; Yang et al. 2020; Choi et al. 2020; Cao et al. 2020;
In December 2019, “COVID-19” originated in China as a Cruz and Zeichner 2020; Dong et al. 2020).
result of a novel Corona RNA virus (Dong et al. 2020). It has COVID-19 is a Severe Acute Respiratory Syndrome
exposed 7 billion humans on our planet to one of the worst (SARS) caused by SARS-CoV-2 virus (Rabaan et al. 2020;
and most rapidly expanding pandemics known to the global Yu et al. 2020). It is believed to be transmitted via droplet
population since the Spanish Flu pandemic in 1918–19 (Sny- infection or contact with contaminated surfaces (Rothan
der and Ravi 2018). The global spread of COVID-19 has and Byrareddy 2020). After a period of incubation of up to
led to mass gathering controls (Ebrahim and Memish 2020; 14 days, patients may experience a range of no symptoms,
McCloskey et al. 2020), severely slowed down countries’ or mild symptoms of pyrexia (85%), dry cough (68.6%) and
economies, as it infected more than 6.3 million patients general malaise, myalgia or fatigue (35.8%), expectoration
(28.2%), headache or dizziness (12.1%), diarrhoea (4.8%),
* M. Al‑Halabi nausea and vomiting (3.9%), dyspnea (21.9%) anosmia
[email protected] and general malaise. Severe symptoms includerespiratory
1
distress and ultimate death (Jiang et al. 2020; Wu et al.
Department of Pediatric Dentistry, Hamdan Bin Mohammed 2020). The latter mainly affects those with co-morbidities
College of Dental Medicine (HBMCDM), Mohammed
Bin Rashid University of Medicine and Health Sciences of all age groups. Detection is achieved by assessment of
(MBRU), P.O. Box 35701, Dubai, UAE

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544 European Archives of Paediatric Dentistry (2020) 21:543–556

seroprevalence of SARS-CoV-2 antibodies from a naso- checklist to help prepare paediatric dental practices to start
pharyngeal swab (Rubino et al. 2020). seeing patients (American Academy of Pediatric Dentistry
Paediatric COVID-19 infection is reported to be relatively 2020).
mild in symptoms when compared to adults and adolescents, Given the aforementioned information and the fact that
and children are also reported to have a better prognosis (Su the literature concerning the impact of COVID-19 on paedi-
et al. 2020; Shen et al. 2020). Mortality in children appears atric dentistry is quite limited, this critical review aimed to
rare, but those with co-morbidities remain a concern (Dong summarise the international guidelines issued by different
et al. 2020; Sinha et al. 2020). authorities regarding the management of the dental envi-
Clinical features of COVID-19 in children include fever ronment and patients during the COVID-19 pandemic. The
and cough, but a large proportion of infected children review also aimed to provide a summary of the available
appears to be asymptomatic and may contribute significantly non-invasive or minimally invasive caries management strat-
to transmission (Qiu et al. 2020; Dong et al. 2020; Frauen- egies that can be utilised by paediatric dentists to minimise
felder et al. 2020). A specific concern for children is the AGP in the immediate and near future while dealing with
uncertainty of their infection status; a clinical history may the COVID-19 pandemic.
not be as suggestive of the infection as it is in adults (Xia
et al. 2020). According to Cruz and Zeichner (2020), 4% of
virologically confirmed cases in children had an asympto- Materials and methods
matic infection (Cruz and Zeichner 2020).
SARS-CoV-2 infection seems to have a more benign Search strategy
evolution in children and the infection runs in three major
stages: a mild cold-like illness, a moderate respiratory syn- An evidence-based pertinent literature search of the elec-
drome and a severe acute interstitial pneumonia (Pavone tronic database; PubMed (MED-LINE), Scopus and Google
et al. 2020). They found that the median period of viral shed- Scholar was performed to identify the relevant articles and
ding of COVID-19 was 15 days as measured from illness guidelines. The search was conducted up to 6th May 2020
onset to discharge. This period was shorter in asymptomatic using free text and controlled vocabulary (MeSH) terms.
patients compared with symptomatic patients (11 days vs. The following keywords were used: “COVID-19,” “Corona
17 days). Thus the prolonged duration of viral shedding in virus and dentistry,” “COVID-19 and Paediatric dentistry
children with COVID-19 was associated with symptomatic guidelines,” “Dental management during COVID-19 Pan-
infection, fever, pneumonia and high lymphocyte count demic,” “Minimal Intervention Dentistry,” “Atraumatic
(Zimmerman et al. 2020). Restorative Treatment,” and “Post-corona dental manage-
Therefore, it can be assumed that, at this stage in the pan- ment.” The electronic search was complemented with a hand
demic, all children and their parents/carers are potentially search of the following websites: American Dental Associa-
infective (Royal College of Surgeons England 2020) with the tion, American Academy of Pediatric Dentistry, European
potential of cross-infection to healthcare workers, parents Academy of Paediatric Dentistry, British Society of Paediat-
and the public. This has, in theory, an impact on medical and ric Dentistry, British Society of Periodontology, Australian
dental procedures that are Aerosol Generating Procedures Dental Association, International Association of Paediatric
(AGP) (Cook 2020; Sundaram et al. 2020), necessitating Dentistry, Scottish Dental Clinical Effectiveness Program,
healthcare workers in all disciplines to wear full enhanced Royal College of Surgeons, Centers for Disease Control and
Personal Protective Equipment (PPE) during treatment pro- Prevention-USA, and Google Scholar.
cedures (Heij et al. 2020).
As most dental procedures are elective ones, health Inclusion and exclusion criteria
authorities around the globe [American Dental Association
(ADA), Centers for Disease Control and Prevention (CDC), The studies were selected if they met the following inclu-
Royal College of Surgeons of England (RCS), Scottish Den- sion criteria: studies in the English language up to 22nd
tal Clinical Effectiveness Programme (SDCEP) Australian April 2020, randomised or non-randomized clinical trials,
Dental Association (AusDA), and the Ministry of Health prospective or retrospective studies as well as in vivo and
and Dental Council New Zealand (NZMOH)] have recom- in vitro animal studies that reported on the Minimal Inter-
mended suspending these procedures (American Dental vention Dentistry (MID) as a tool of atraumatic and bio-
Association 2020; Centers for Disease Control and Preven- logical caries management in both primary and permanent
tion 2020; Royal Collge of Surgeons England 2020; SDCEP dentitions and clinical guidelines on the dental manage-
2020; Australian Dental Association 2020; New Zealand ment of paediatric patients during and after the COVID-
Ministry of Health, 2020). The American Academy of 19 pandemic. Exclusion criteria included: studies that used
Pediatric Dentistry (AAPD) issued re-emergence practice other techniques to treat carious lesions (such as adhesive

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European Archives of Paediatric Dentistry (2020) 21:543–556 545

restorations, conventional crowns, pulp therapy) as well as 2020; Australian Dental Association 2020; New Zealand
case reports, case series, and review of literature papers. Ministry of Health 2020). The RCS guidelines included a
There were no restrictions regarding the date of publica- ‘red flag’ list comprising children with underlying medical
tion in regards to papers related to MID treatment, but the conditions making them more prone to complications if any
clinical guidelines on the management of children during dental infection is not promptly treated. Consequently, these
COVID-19 were searched between 1st January–6th May children should be prioritised for urgent treatment (Royal
2020 and selected the most updated edition. College of Surgeons England 2020). The CDC recom-
mended telephone triage of all patients in need of emergency
Data extraction dental care. When possible, assessment of patient’s dental
condition using teleconferencing or tele-dentistry options
A data extraction form was adopted to collect the follow- have been suggested as alternatives to in-office care. If dental
ing study information: (1) title, (2) authors/guideline, (3) treatment can be delayed, offer patients with detailed home
year/month of publication, (4) technique of MID, and (5) care instructions and any appropriate medications (Centers
subject of the guideline. Papers found in the database and for Disease Control and Prevention 2020). The ADA stated
hand searches underwent three rounds of screening before that dentists must “make every effort to interview the patient
they were included in this update. The first round was a title by telephone, text monitoring system, or video conference
screen where papers that obviously did not meet the inclu- before the visit” (American Dental Association 2020).
sion criteria were excluded. The second was an abstract
screen where papers that did not meet the inclusion crite- Definition of urgent and emergency cases
ria based on the information provided in the abstract were
excluded. These first two stages were carried out by two of Table 1 summarises the recommendations in terms of the
the authors. Finally, a full-text screen with a critical appraisal urgency of the oral health conditions and their management.
was carried out by all five authors of the manuscript. The ADA guidance was based on the presence/absence of
COVID-19 infection symptoms. If an emergency dental
patient does not have symptoms consistent with COVID-
Results 19 infection, they can be seen in dental settings with suit-
able protocols and PPE in place. However, if there are signs
The recommendations from the ADA, CDC, RCS, SDCEP, and symptoms of respiratory illness, the patient should be
AusDA, NZMOH and AAPD will be summarised in this referred for emergency care where appropriate transmission-
section (American Dental Association 2020; Centers for based precautions are available.
Disease Control and Prevention 2020; Royal Collge of
Surgeons England 2020; SDCEP 2020; Australian Dental Medically compromised and special needs children
Association 2020; New Zealand Ministry of Health 2020;
American Academy of Pediatric Dentistry 2020). Dental management of medically compromised children
and children with special needs requires special considera-
Triaging dental patients with COVID‑19 (phone, tion of their underlying health condition. Dental pain may
tele‑health conferences) have a severe impact on these children and their families
with evidence of adverse behaviours such as self-harming.
The recommendation from all global healthcare authori- Furthermore, children with underlying medical conditions
ties is to triage dental patients either by phone or any other should have special consideration due to the increased risk
means of tele-health conferencing. The purpose of these of developing complications arising from any subsequent
triaging procedures is to verify the COVID-19 risk status infection if the tooth is not treated. These conditions include
of the patients and to decide on the urgency of the dental those with an increased risk of bleeding from medications
condition. In addition, specific advice for the management of or health conditions, increased risk of infection (e.g., any
any presenting dental problem and general advice for proper immunocompromised state, transplant patient, diabetic, chil-
maintenance of oral health can be given. dren on immunosuppressants/steroids/chemotherapy), and
The AusDA, NZMOH, RCS and SDCEP recommended children at risk of infective endocarditis. Additionally, there
triaging patients by telephone. Analgesics or antimicrobials, are children who are identified as being at a significantly
or referral for urgent dental care or emergency care would increased risk from COVID-19. These are children with long
be recommended as appropriate. Furthermore, the SDCEP term respiratory conditions, including chronic lung disease
and the RCS, divided dental cases into three categories: (1) of prematurity with oxygen dependency, cystic fibrosis with
urgent, (2) emergency and (3) an “advice and self-help” cat- significant respiratory problems, childhood interstitial lung
egory (SDCEP 2020; Royal College of Surgeons England disease, severe asthma, and respiratory complications of

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Table 1  Summary of the dental treatment guidelines during COVID-19 for urgent, emergency and seeking-advice conditions
546

Guideline* Emergency dental conditions Urgent dental conditions Seeking advice Conditions

13
American dental association Fever strongly associated with a dental diag- Did not distinguish urgent and emergency N/A
nosis (e.g., pulpal and periapical dental pain conditions
and intraoral swelling is present)
Management Management Management
Definitive,conservative treatment (i.e., pul- N/A Interview patient by telephone, text monitoring
potomy, pulpectomy, RCT, abscess incision system, or video conference before the visit
and drainage if available Ibuprofen for management of pulpal- and
Use antibiotics for immunocompetent adult periapical-related pain and intraoral swelling
patients As per 2019 ADA clinical practice in immunocompetent adults
recommendations
Centers for disease control and prevention, N/A The urgency of a procedure is a decision N/A
USA based on clinical judgement and should be
made on a case-by-case basis
Management Management Management
Patient without COVID-19 symptoms: Avoid N/A Use teledentistry as alternatives to in offce care
AGP whenever possible. Avoid handpieces, If dental treatment can be delayed, provide
air–water syringe, ultrasonic. Prioritize patients with detailed home care instructions
minimally invasive/atraumatic restorative and any appropriate pharmaceuticals
techniques (hand instruments only)
COVID 19 suspected or confirmed patient: If
emergency dental care is medically neces-
sary, airborne Precautions (an isolation room
with negative pressure
The minstry of health and dental council New Trauma-including facial/oral laceration and/ Oal infections without systemic involvement N/A
Zealand or dentoalveolar injuries (avulsion of a Severe pain not relieved by medication
permanent tooth) Tooth fracture
Oro-facial swelling that is serious and worsen- Adjustment or repair of dental appliances in
ing patients with health issues
Uncontrolled post-extraction bleeding
Dental infections with acute systemic illness
acute infections likely to exacerbate systemic
conditions (diabetes)
Management Management Management
Invasive emergency treatment MUST be Patients should have access to dental emer- Patients should have access to advice via
DEFERRED where possible, if not, aerosol gency triage and advice via telephone and telephone
generating procedures should be avoided should only be seen in person if their pain
where possible cannot be controlled by medication, or if
they have orofacial trauma requiring urgent
management
European Archives of Paediatric Dentistry (2020) 21:543–556
 Table 1  (continued)
Guideline* Emergency dental conditions Urgent dental conditions Seeking advice Conditions

Australian dental association Uncontrolled bleeding Acute dental pain If the patient is not in pain and does not have an
Severe or systemic symptoms of odontogenic Sgnificantly damaged upper front teeth infection or dental concern with serious medi-
infection (e.g., facial swelling) Soft tissue pathology (ulcers) cal implications
Facial trauma (particularly that may compro- Medically compromised patients
mise the airway) Patients socioeconomic or cultural factors
Systemic health issue increasing risk of rapid progression of dental
disease
Management Management Management
If the patient fits the hospital admissions Defer physical appointment for unknown risk All non-urgent/elective treatment should be
criteria, provide emergency treatment if you until status can be confirmed deferred
can implement the protective measures in Non-aerosols generating procedures (extrac- Provide advice, analgesics or antimicrobials
the AUSDA COVID-19 Guidelines, which tion), or where treatments generating aero- (where appropriate) via teledentistry
includes droplet-based precautions sols are provided for the listed conditions
Scottish dental clinical effectiveness pro- Apical/periodontal abscess with spreading Acute apical/periodontal abscess with spread- Mild and moderate symptoms of the below:
European Archives of Paediatric Dentistry (2020) 21:543–556

gramme infection ing infection without airway compromise Acute apical/periodontal abscess, necrotising
Post-extraction haemorrhage that fails to stop Irreversible pulpitis with severe pain ulcerative gingivitis/periodontitis
or patient under anticoagulant Post-extraction haemorrhage that fails to stop Reversible/irreversible pulpitis
Oral ulceration in a severely dehydrated but is not brisk or persistent Post-extraction haemorrhage
patient Oral ulceration 3 weeks or more Oral ulceration
Inhaled tooth/tooth fragment, restoration or Avulsed permanent tooth Uncomplicated crown fracture, avulsed primary
fractured appliance Displaced or fractured teeth affecting the bite tooth or displaced without affecting the bite
Severe bleeding that does not stop within Broken restorations
15–30 min or loss of consciousness follow-
ing facial trauma
Management Management Management
Refer immediately for emergency care Extraction or drainage Advice and self-help, analgesics, antibiotics,
Refer to urgent dental care centre soft diet, the use of chlorhexidine mouthwash,
Encourage parents/carers to replant an avulsed application of local pressure (bleeding) or ice
permanent tooth then refer to urgent dental packs (soft tissue injury and swelling)
care centre

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Table 1  (continued)
548

Guideline* Emergency dental conditions Urgent dental conditions Seeking advice Conditions

13
Royal college of surgeons of England N/A Swelling compromising swallowing and/or N/A
breathing, extending to the eye or associated
pyrexia
Complex traumatic dental injuries in perma-
nent dentition resulting in pulp exposure or
severe luxation in primary dentition
Uncontrolled bleeding not responded to self-
care measures
Severe dental pain not responding to analge-
sics and impacting on eating and sleeping
Management Management Management
N/A Avulsed teeth: likely prognosis, extra-oral dry N/A
time, total extra-oral time, tooth maturity,
co-operation,time until extirpation can be
performed, place a bracket and wire type
splint to minimise AGP for removal. Use of
self-etching adhesive, using a slow hand-
piece for splint removal, removal of compos-
ite following the pandemic
Children with pulpal symptoms (excepting
permanent anterior teeth), extarction
Inhalational sedation as alternative to GA
If parent/legal guardian is not present, consent
for urgent treatment verbally over the phone
Responsibilities to safeguard children con-
tinue during the pandemic

*For references see text

European Archives of Paediatric Dentistry (2020) 21:543–556
European Archives of Paediatric Dentistry (2020) 21:543–556 549

neurodisability. These children should not attend a hospital • Compromised swallow and are at risk of aspirating a
or dental clinic environment unless the dental condition is tooth which cannot be removed under local anaesthetic.
considered ‘life-threatening’ (RCSENG 2018).
The AAPD recommended that to start seeing children Dental environmental and equipment guidelines
with compromised immune illness or with complex medical for COVID‑19
care needs back in the dental offices, protocols and referral
sources should be prepared with hospital protocols readily The guidelines issued by the AAPD, ADA, CDC and
available. Consultation with the child’s physician about the NZMOH have all included detailed instructions stressing the
safety of being seen in the dental office or consideration importance of minimising cross-infection, maintaining the
should be given to hospital-based dental clinics if available. safety of dental healthcare providers, paediatric patients and
Additionally, special consideration should be given to the their guardians, and the proper use of PPE. The ADA guide-
timing of the appointment in the schedule (1st appointments lines had detailed guidance that should be followed before,
or special hours/days). If possible, consider building a room during and after the dental care is provided. These guidelines
that meets hospital standards for infection control and air are summarised in Table 2. In addition, Table 2 includes
turnover (American Academy of Pediatric Dentistry 2020). further recommendations for NZMOH regarding the same
(American Academy of Pediatric Dentistry 2020; American
Access to urgent dental care under general Dental Association 2020b; Centers for disease control and
anaesthetic Prevention 2020; New Zealand Ministry of Health 2020).
A recent Cochrane “rapid’ review of international recom-
Providers have been advised to cancel all elective proce- mendations for the re-opening of dental services from 11
dures, including dental treatment under general anaesthesia countries reported some common key messages intended to
(GA). It is very crucial to minimise the risk of cross-infec- assist policy and decision-makers to produce comprehen-
tion and transmission of the disease. Protocols have been put sive national guidance for their own settings. It was noticed
in place for operating room requirements and preparation that in the majority of the sources, there was no referenced,
for confirmed or suspected COVID-19 patients. The AAPD underpinning evidence with some areas unlikely to ever
encouraged to develop a risk-based scale for scheduling gen- have strong (or any) research evidence. Furthermore, there
eral anaesthesia patients (American Academy of Pediatric was a highly variable level of detail given across interna-
Dentistry 2020). Where possible, limited emergency provi- tional sources. Filtering facepiece class 2 (FFP2, equivalent
sion should be maintained on a regional basis with the fol- to N95) masks are recommended by the majority of inter-
lowing children prioritised for urgent treatment under GA: national sources for both COVID-19 and non-COVID-19
(RCSEng 2018; Royal College of Surgeons England 2020). confirmed cases irrespective of the use of AGPs. A minority
of sources recommend the use of a filtering facepiece class
• Sustained trauma to the primary dentition where the child 3 (FFP3, equivalent to N99) mask for AGPs (Clarkson et al
is symptomatic (pain not managed with analgesics, infec- 2020).
tion not managed with antibiotics or interference with All the guidelines highlighted that during this period,
eating), and treatment under local anaesthetic is not pos- AGP use should be kept to a minimum. Dental caries is best
sible. managed by prevention (Toumba et al. 2019). Non-restora-
• Trauma to the permanent dentition which needs interven- tive treatment and minimally invasive restorative techniques
tion and treatment under local anaesthetic or sedation is that generate minimal aerosol are presented in Table 3 and
not possible. discussed in details in the "Discussion" section.
• Acute dental infection that is not responsive to antibiot-
ics.
• Intractable pain or discomfort which cannot be managed Discussion
under local anaesthetic.
• Facial swelling as a result of dental disease and treatment Dentistry involves many procedures that are, for the most
under local anaesthetic is not possible. part, AGP and might lead to the spread of the COVID-19
• Poor dental health is impacting on or is highly likely to virus to dental healthcare workers and other patients and
impact on, their medical health and a decision is made families. In addition, the wide-spread epidemic has resulted
that the benefits of surgery outweigh the risks of bringing in shortages or critical need for the healthcare PPE (Centers
a child into the hospital during the COVID-19 pandemic. for Disease Control and Prevention 2020). Guidelines issued
• Additional needs such as those with learning disability by different dental and medical organisations attempted to
or autism, where dental pain is resulting in self-harm or provide clear instructions to dental practitioners regarding
other disruptive or detrimental behaviours. prioritising cases seen in the clinics, communicating with

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Table 2  Dental environmental and equipment guidelines for COVID-19
Treatment phase Patient Dental healthcare personnel (DHCP) Dental office

Before dental care starts Schedule appointments apart to minimise contact in Seasonal Flu vaccination Conduct an inventory of available PPE supplies
the waiting room DHCP experiencing influenza-like-illness should All unnecessary items should be removed from the
No accompanying persons except if assistance not report to work waiting room and surfaces kept clear
needed or a child patient Protocol for staff testing positive for COVID-19 Clean and separate waiting room chairs by 2 m
If patients wish to, or if the waiting room does not Providers perceived at a lower risk of contracting Signage in the dental office for standard respiratory
allow for appropriate “social distancing”, they may COVID-19 should be prioritised to provide care hygiene/cough etiquette and social distancing
wait in their personal vehicle or outside the facility DHCP should self-monitor any respiratory symp- Alcohol-based hand rub with 60–95%, and no-touch
toms and check their temperature twice a day receptacles
Providers contracted and recovered from a COVID- Consider leaving front door to office open or installa-
19 infection should be the preferred personnel tion of electronic door openers
providing care Single treatment rooms with door closed and negative
pressure if available for high risk patients, normal
pressure only with low and medium risk patients for
non-AGP only
Consider air purifiers in high volume/traffic areas?
During dental care Use 1.5% hydrogen peroxide or 0.2% povidone as a DHCP should adhere to standard precautions, Consider using disposable or steralisable nitrous
preprocedural mouthrinse regardless of infection status of the patient oxide tubing
Use “extraoral dental radiographs, (panoramic Surgical mask and eye protection with solid side Adequate room ventilation
radiographs or cone beam CT) as alternatives” to shields or a face shield during procedures likely to Isolated-based patient room placement
intraoral dental radiographs generate splashing or spattering of blood or other High-volume evacuators. Backflow could occur with
Reduce AGP. Use rubber dams for AGPs. AGPs body fluids a saliva ejector. “[minimise] the use of a 3-in-1
should be scheduled as the last appointment of the Surgical masks are one use only syringe
day Adhere to the standard sequence of donning and Disinfectants in the handpiece and 3-in-1 syringe
Resorbable sutures doffing of PPE water supplies after each patient
After dental care is provided Change from scrubs to personal clothing before Clean and disinfect reusable facial protective equip-
returning home ment between patients
Upon arriving home, take off shoes, remove and Non-disposable equipment (e.g., handpieces) should
wash clothing [separately from other household be disinfected according to manufacturer’s instruc-
residents], and immediately shower tions
All PPEs must be discarded as clinical waste
Door handles, chairs, desks, elevators, and bathrooms
should be cleaned and disinfected frequently
After treating suspected or COVID-19-positive
patient and aerosol generating procedures have
occurred, the room should remain closed for a
stand-down period of 20 min prior to cleaning

AGP Aerosol generating procedures, PPE personal protective equipment

European Archives of Paediatric Dentistry (2020) 21:543–556
European Archives of Paediatric Dentistry (2020) 21:543–556 551

Table 3  Summary of proposed biological caries management techniques and their grade of evidence
Biological Caries Cavitated/non- Primary/Permanent Symptomatic/ Proximal/Occlusal Grade of evidence Grade of rec-
Management Tech- cavitated lesion tooth Asymptomatic lesion quality ommendation
nique tooth quality

Fluoride varnish Non-cavitated Primary and per- Asymptomatic Proximal Low to very low conditional
manent
Resin infiltration Non-cavitated Primary and per- Asymptomatic Proximal Low to very low conditional
manent
Sealant Non-cavitated Primary and per- Asymptomatic Occlusal Moderate Strong
manent
SDF Cavitated Primary Asymptomatic Occlusal and proxi- Moderate Strong
mal
Cavitated Permanent Asymptomatic Occlusal and proxi- Low Conditional
mal
Hall PMC Cavitated and non- Primary Asymptomatic Occlusal and proxi- High* Strong
cavitated mal
Cavitated Permanent Asymptomatic Occlusal and proxi- Low Conditional
mal
ART​ Cavitated Primary Asymptomatic Occlusal and proxi- Low to very low Conditional
mal
Cavitated Permanent Asymptomatic Occlusal and proxi- Low to very low Conditional
mal
ITR Cavitated Primary Asymptomatic Occlusal and proxi- Low Conditional
mal
ITR/diagnostic Cavitated Primary Symptomatic Occlusal and proxi- Low Conditional
(reversible pulpi- mal
tis symptoms)
IPC Cavitated Primary and per- Symptomatic Occlusal and proxi- Low Conditional
manent (reversible pulpi- mal
tis symptoms)

*Cochrane reviews and RCTs

patients through telephone and tele-health conferencing for surgical centres will be scheduling elective dental patients
triaging and recommendation for self-administered actions (American Academy of Pediatric Dentistry 2020). Addition-
in cases that can wait to be seen. Guidelines also classified ally, the SDCEP issued a supplement to their COVID-19
cases into an emergency or urgent ones and “can wait” ones. dental guidelines, specifically discussing the pharmacologi-
The guidelines also provided instructions for office prepar- cal management of dental emergencies during the pandemic
edness and precautions required for treating patients. (SDCEP 2020).
It is appropriate to mention here that the only specific The content of guidelines appeared to be quite similar in
guidelines for the management of paediatric dental cases terms of triaging and classifying oral health care into seek-
were issued by the RCS ( Royal College of Surgeons Eng- ing advice, urgent, and emergency cases especially in the
land 2020). AAPD issued guidelines for the preparation of SDCEP, RCS, AusDA and the NZMOH guidelines (SDCEP
practice to resume clinical activities (American Academy of 2020; Royal College of Surgeons England 2020; Australian
Pediatric Dentistry 2020). Furthermore, the AAPD issued Dental Association 2020; New Zealand Ministry of Health
specific guidance for immediate care for high caries index 2020).
patients/emergencies encouraging maximising treatment per The guidelines of the AAPD, ADA, CDC and NZMOH
visit to reduce numbers of visits. However, considerations included the most details regarding the dental environmen-
pertaining to paediatric dentistry and guidance on the man- tal and equipment guidelines for dealing with COVID-19
agement under inhalation sedation or general anaesthetic pandemic. These guidelines went into details regarding the
was only discussed in details by the RCS recommendations office preparedness to deal with and receive patients during
for paediatric dentistry during the pandemic. (England Royal the pandemic compared to the other guidelines quoted in
College Of Surgeons 2020). The AAPD guidelines only this review (American Dental Association 2020; American
adviced to develop protocols for emergency cases requiring Dental Association 2020; Centers for Disease Control and
general anaesthesia and to determine when the hospitals/ Prevention 2020; New Zealand Ministry of Health 2020).

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552 European Archives of Paediatric Dentistry (2020) 21:543–556

Nevertheless, because of impacts on healthcare, poverty protective equipment. Having the parents in the dental clinic
and economy, the current practice state of only emergency during treatment might be restricted moving forward. Proper
dental care that many professional organisations have rec- coping techniques and communication between the paediat-
ommended or required in attempts to mitigate the spread of ric dentist and the parents and their child are very essential.
COVID-19 is unsustainable in the long term. For that reason, The AAPD recommends delaying seeing pediatric patients
the AAPD issued a checklist to address significant areas of who require physical behaviour management, considering
practice that may need attention prior to the resumption of treating patients while on parent’s lap with parent wearing
pre-pandemic levels of care, taking into consideration new a mask and having passed negative screening criteria, dedi-
and possible changes as a result of the pandemic and its cating special hours in the day for such patients (American
lingering effects (American Academy of Pediatric Dentistry Academy of Pediatric Dentistry 2020).
2020). Additionally, this review attempted to provide “safer”
options for paediatric dentists in dealing with their patients Prevention
during this transitional period.
A ‘rapid’ Cochrane review for re-opening of dental ser- Dental caries is largely preventable, and effective evidence-
vices recommendations from eleven countries noticed that in based strategies are available for caries prevention as well
the majority of the sources, there was no referenced, under- as management of the disease. Patient-centred enhanced
pinning evidence with some areas unlikely to ever have prevention plans tend to be more effective. (SDCEP 2018).
strong (or any) research evidence. Furthermore, there was Therefore, it is only logical to prioritise and emphasise all
a highly variable level of detail given across these sources. oral health preventive and therapeutic measure during this
Most sources recommend avoiding aerosol-generating pro- time (Toumba et al. 2019).
cedures (AGPs), if possible but still support high-quality
clinical care (Clarkson et al. 2020). Biological caries management techniques

Post‑COVID‑19 era clinical recommendations Using biological atraumatic, non-invasive or minimally

invasive treatment methods that require minimal or no
As presented above, the unpredictability of COVID-19 AGP would be more logical and safer given the high suc-
infection in children and the challenges in the diagnosis of cess rate of the biological approach in caries management
symptoms, in addition to the reports of carrier status of the (BaniHani et al. 2018). The use of evidence-based biologi-
SARS-CoV-2 will present a challenge for all paediatric den- cal approaches for caries management in both primary and
tists once normal function in the dental clinics is restored permanent dentition might be more appropriate under the
worldwide. Consequently, this may result in increased anxi- current and near-future circumstances of COVID-19.
ety for the dental healthcare providers, the parents and the A 2016 European Academy of Paediatric Dentistry policy
patients. Emphasis should be placed on minimising AGPs document regarding best clinical practice guidance for man-
as much as possible, and this section will present a summary agement of early caries lesions in children and young adults
of the non-restorative and the atraumatic restorative treat- concluded that non-cavitated caries lesions can be managed
ment alternatives for caries that are reported in the scientific non-invasively in the majority of cases. The spectrum of
literature. measures includes a low cariogenicity tooth-friendly diet,
daily and appropriate management of the biofilm, home and
Behaviour management within the dental office/surgery usage of fluorides as well as
sealing techniques. The policy emphasised on the impor-
The first and most important basic technique that all paediat- tance of performing caries risk assessment at a child’s first
ric dentists can utilise to minimise the probability of SARS- dental visit, and reassessments on a regular basis (Kühnisch
CoV-2 cross-infection is by appropriate and skillfull behav- et al. 2016).
iour management. Restless, crying children spread more Biological treatment alternatives for asymptomatic teeth
aerosol compared to calm children. We all need to keep in or teeth exhibiting signs of reversible pulpitis include seal-
mind the added anxiety that the child might have as a result ing non-cavitated caries, using fluoride varnish and resin
of the dental healthcare providers having to follow enhanced infiltration to arrest non-caviateted caries, atraumatic or
PPE protocols that may include a face mask. Whenever pos- alternative restorative technique (ART), interim therapeutic
sible, it is helpful to put this protective equipment on while restorations (ITR) indirect pulp capping (IPC), the Hall tech-
the child is watching, and while we explain to them in simple nique (HT); and the use of Silver Diamine Fluoride (SDF)
terms, the value and use of this equipment. Another sugges- (Slayton et al. 2018; Urquhart et al. 2019; Al Halabi et al.
tion is to have a pin or a sticker that can be disinfected eas- 2018; Tedesco et al. 2017; American Academy of Pediatirc
ily with the health provider’s photograph displayed over the Dentistry 2017a, b; Hussein et al. 2020; Seifo et al. 2018).

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European Archives of Paediatric Dentistry (2020) 21:543–556 553

These aformentioned biological techniques are summarised Interim therapeutic restorations (ITR)
in Table 3, along with the strength of supportive evidence.
Another non-AGP method is the interim therapeutic resto-
Sealants ration as defined by the AAPD which utilises similar tech-
niques to ART but has different therapeutic goals. ITR more
To arrest or reverse the non-cavitated carious lesions on the accurately describes the procedure used in contemporary
occlusal surfaces of both primary and permanent teeth, the dental practice in the USA. It may be used to restore and
use of a combination of sealants and 5% NaF varnish (appli- prevent further decalcification and caries in young patients,
cation every 3–6 months) or sealants alone over 5% NaF var- uncooperative patients, or patients with special health care
nish alone (application every 3–6 months) is recommended needs. The technique can also be used when conventional
by the ADA (Slayton et al. 2018; Urquhart et al. 2019). cavity preparation and/or placement of conventional dental
In addition, sealing dental caries in permanent teeth restorations are not feasible and dental care needs to be post-
where the carious lesion is partially removed or completely poned (American Academy of Pediatric Dentistry 2017a).
left has been employed as an accepted therapeutic technique A suggested modified application of ITR is the step-wise
by some researchers with success rates up to ten years. excavation in children with multiple open carious lesions
Furthermore, in permanent teeth, the number of bacteria prior to definitive restoration of the teeth. (Coll et al. 2013)
detected after conventional complete caries removal was The ITR procedure involves removal of caries using hand
higher than that which remained in sealed carious lesions or slow speed rotary instruments with caution not to expose
(Maltz et al. 2012). Thus, this practice may be adopted in the pulp. Leakage of the restoration can be minimised with
the post-COVID-19 era. maximum caries removal from the periphery of the lesion.
For approximal surfaces, ADA suggests, to arrest or Following preparation, the tooth is restored with an adhesive
reverse non-cavitated carious lesions of primary and perma- restorative material such as self-setting or RM-GIC (Berg,
nent teeth, clinicians should use 5% NaF varnish (application 2002).
every 3–6 months), resin infiltration alone, resin infiltration Coll et al. (2013) investigated the use of ITR in deep
plus 5% NaF varnish (application every 3–6 months), or carious lesions as a diagnostic tool for pulpal status. They
sealants alone (Slayton et al. 2018; Urquhart et al. 2019). indicated that glass ionomer cement (GIC) used as an ITR
for a period of one to ≥ three months as a diagnostic tool on
Atrumatic restorative technique (ART) asymptomatic primary molars has significantly improved the
success rate of vital pulp therapy (Coll et al. 2013). The ITR
ART has been endorsed by the World Health Organization placed in proximal lesions significantly improved the suc-
(WHO) as a means of restoring and preventing caries in cess rate of vital pulp therapy done subsequently, while ITR
populations with limited access to traditional dental care placed in non-proximal lesions did not have any significant
(Tedesco et al. 2017). The use of ART for both primary effect on the success rate. No difference was found in the
and permanent teeth in children presents a valid option to success rate of indirect pulp capping and vital formocresol
manage caries successfully. In addition, glass ionomer ART pulpotomy treatment after the ITR. Therefore, one can see
sealants can also be used as a treatment option. A recent sys- that the use of ITR in the current COVID-19 pandemic and
tematic review and meta-analysis on survival percentages of beyond is a potential valid dental tool.
ART restorations and sealants in posterior teeth concluded
that ART single-surface restorations presented high survival The Hall technique
percentages in both dentitions compared to multiple-surface
restorations. In addition, ART sealants presented a high-car- The HT is a non-surgical/non-invasive method used to
ies-preventive effect (de Amorim et al. 2018). Thus, ART restore a carious but asymptomatic and non-septic primary
presents as an invaluable, effective evidence-based alterna- molar in a child using a child-friendly approach. As it is a
tive to conventional methods in the post-COVID-19 era for non-AGP procedure, it may be valid and relevant to report it
treating and preventing carious lesions in posterior teeth. here (Hussein et al. 2020). It relies on sealing non-pulpally
Nevertheless, a Cochrane Database of Systematic Review involved carious lesions on primary molars in situ using a
concluded that low‐quality evidence suggested that ART preformed metal crown (PMC) and GIC (Welbury 2017).
use may have a higher risk of restoration failure than con- The HT manual recommends crowning primary molars that
ventional treatment for caries lesions in primary teeth. The have no signs of irreversible pulpitis with clear radiographic
effects of ART using composite and resin-modified glass evidence of a band of normal dentine between the pulp space
ionomer cement (RM‐GIC) are uncertain due to the very low and the carious lesions. The PMC is placed on the affected
quality of the evidence, and we cannot rely on the findings molar after space is created using orthodontic spacers/sepa-
(Dorri et al. 2017). rators, which are applied for 3–5 days. No local anaesthesia

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554 European Archives of Paediatric Dentistry (2020) 21:543–556

is utilised, and no attempt to surgically remove the carious et al. 2015). They concluded that HT could be used even
tissue is made (Innes et al. 2015a). for anxious children because of its simplicity of avoiding
The evidence-based platform that rolled out the HT was injections and drilling. Although the data supporting the
clearly sound and was supported by a randomised controlled use of HT as a biological treatment option for FPMs is
trial and a Cochrane review (Santamaria et al. 2018; Innes scarce, we suggest its use as an option in post-COVID-19
et al. 2015b). Controversial issues like the effect of the PMC era to avoid drilling required for conventional restorations,
placed using the HT on the occlusion because of the slight thus reducing AGP.
initial opening of the bite was found to resolve spontane-
ously after a month (van der Zee V 2010). A recent pilot
study investigated the effect of the Hall technique crown Silver diamine fluoride (SDF)
application on the masseter muscle activity. The study con-
cluded that Hall technique crowns might affect masseter Non-restorative caries control has had its major supporters
muscle activity in children immediately post-treatment, but for a while now, but the new emphasis in the current and
the activity returned to and later exceeded baseline levels post-COVID-19 period is essential. The use of SDF should
at 2–6 weeks, respectively, while the rest masseter muscle be highlighted here (Kidd 2012; Seifo et al. 2020). SDF is a
activity remained unchanged (Abu Serdaneh et al. 2020). In clear, odourless liquid indicated for desensitisation of non-
addition, the HT was found to be more cost-effective than carious tooth lesions and molar incisor hypomineralisation
the conventional surgical method of treatment. It is now con- of FPMs. It can also be used for arresting carious lesions in
sidered in some circles “the golden standard” for managing high caries-risk children, children who are difficult to con-
the multi-surface non-pulpally involved carious primary trol, progressing carious lesions, unable to tolerate invasive
molars (Deery 2015). According to a review by Welbury treatment, and those who are medically compromised or
(2017), the HT is an ideal restoration for a primary tooth in a have additional care needs. (Innes et al. 2019). The ADA
young child as it is quick and easy for the child to cope with. recommends using SDF to arrest advanced cavitated carious
It does not require local anaesthesia and has proven efficacy lesions on any coronal surface of primary and permanent
by means of randomised clinical trials (Welbury 2017). teeth. Their expert panel suggests clinicians prioritise the
A published case series reported the success of combin- use of 38% SDF solution (biannual application) over 5% NaF
ing the use of GIC ITR as a diagnostic tool for teeth with varnish (Slayton et al. 2018; Urquhart et al. 2019).
deep caries that are asymptomatic or exhibiting symptoms According to the recent umbrella review by Seifo et al.
of reversible pulpitis with normal radiographic appearance (2019), systematic reviews consistently supported SDF’s
(Al Halabi et al. 2018; Coll et al. 2013). This was followed effectiveness for arresting coronal caries in the primary den-
by the use of the HT technique PMC after a period of time. tition. There is insufficient evidence to draw conclusions on
The confirmation of a diagnosis of reversible pulpitis is dem- SDF use in children for the prevention of caries in primary
onstrated by the absence of signs and symptoms. and permanent dentition. No serious adverse events were
Taking into account the methods highlighted above, a reported. (Seifo et al. 2019).
multicentre retrospective evaluation of outcomes of both the
biological method of treatment represented by the HT and
IPT and the conventional method of complete caries removal
and or pulpotomies concluded that both the conventional Conclusion
and biological treatment approaches had similar outcomes
and were equally successful for the management of cari- • COVID-19 has and will continue to have a major impact
ous lesions in the primary dentition (BaniHani et al. 2018). on the practice of paediatric dentistry. Traiging cases
Thus, this helps in supporting the debate that negates the use into advice only, urgent care and emergency cases should
of AGP wherever possible under the COVID-19 situation. become standard practice in the current pandemic.
What about permanent teeth? The HT is used mainly Avoidance of elective AGPs is recommended wherever
as a biological restoration for primary molars. However, it possible and management of emergencies should take
has been suggested by the caries management guidelines priority.
of the SDCEP as a treatment option to keep badly broken • Once the current worldwide restrictions are eased, we
down first permanent molars (FPMs) free from symptoms might modify some approaches in our practice of paedi-
until the ideal age for extractions (SDCEP 2018), although atric dentistry utilising more prevention-centred practices
there is no robust supportive evidence. Millar et al. (2015) and/or atraumatic non or minimally invasive techniques
stated that PMCs are beneficial for intermediate-term in caries management.
management of hypomineralised or hypoplastic FPMs
with enamel breakdown, caries and sensitivity (Millar

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European Archives of Paediatric Dentistry (2020) 21:543–556 555

Compliance with ethical standards  (ART) restorations and sealants in posterior teeth: an updated
systematic review and meta-analysis. Clin Oral Investig.
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Conflict of interest  The authors declare that they have no conflict of
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interest.
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