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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 3  |  Page : 132-138

Emergency management of symptomatic children with severe early childhood caries in the time of COVID-19 - Protocols and procedures - A case series

1 Dental Centre, INHS Sanjivani, Naval Base, Kochi, Kerala, India
2 Military Dental Centre, Base Hospital, Delhi Cantt, New Delhi, India

Date of Submission30-Jan-2022
Date of Decision01-Feb-2022
Date of Acceptance17-Mar-2022
Date of Web Publication27-Aug-2022

Correspondence Address:
M M Dempsy Chengappa
Dental Centre, INHS Sanjivani, Naval Base, Kochi - 682 004, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijds.ijds_14_22

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Severe early childhood caries (S-ECC) is a health concern which can lead to reduced overall quality of life. In most cases, due to the extent of rehabilitation required and difficulty in obtaining cooperation of the patient due to their age necessitates management under general anesthesia (GA). However, the COVID-19 pandemic limited dental treatment to emergency procedures only. The objective of this study was to report two cases of emergency management of S-ECC, under GA, emphasizing on the protocols and procedures required to be followed to safely deliver treatment in the background of the pandemic. Two children aged 3.5 years and a 5 years, respectively, were brought to the department by their parents due to severe pain, difficulty in chewing, and disturbed sleep. They were taken up as emergency cases for rehabilitation to alleviate pain and restore function. Protocols and procedures to prevent transmission of COVID-19 during treatment were followed stringently. In emergency management to rehabilitate patients suffering from S-ECC, care should be taken to follow all protocols instituted to prevent transmission of COVID-19 infection. This is highlighted in the oral cavity due to an increased chance of transmission during aerosol-generating procedures.

Keywords: Severe early childhood caries, COVID-19, full mouth rehabilitation, GA management, personal protective equipments, severe acute respiratory syndrome coronavirus 2 viruses, TrueNat test, stainless steel crowns

How to cite this article:
Dempsy Chengappa M M, Kumar AN, Sharma D, Kaul R. Emergency management of symptomatic children with severe early childhood caries in the time of COVID-19 - Protocols and procedures - A case series. Indian J Dent Sci 2022;14:132-8

How to cite this URL:
Dempsy Chengappa M M, Kumar AN, Sharma D, Kaul R. Emergency management of symptomatic children with severe early childhood caries in the time of COVID-19 - Protocols and procedures - A case series. Indian J Dent Sci [serial online] 2022 [cited 2022 Dec 9];14:132-8. Available from: http://www.ijds.in/text.asp?2022/14/3/132/354891

  Introduction Top

Severe early childhood caries (S-ECC) is a chronic disease affecting infants and children having multifactorial etiology, regarded as a symptom of deterioration of a child's health due to inadequate care. Any sign of smooth surface caries in children younger than 3 years of age and one or more cavitated, missing due to caries or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of >4 at age 3, >5 at age 4, or >6 at age 5 surfaces describes S-ECC.[1] Its management positively impacts the quality of life of the child and also positively impacts the family.[2] However, due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which represents one of the major medical emergencies recorded in history; most elective interventions not requiring emergency management have been curtailed.[3] Various measures have been instituted to avoid the spread of SARS-CoV-2 virus from patient to health-care professionals and vice versa and are applicable to dentistry being one of the most at-risk medical disciplines.[4] Hence, safe protocols and procedures have been developed and applied for emergency management of children with S-ECC to aid in the reduction of transmission while restoring oral health.[5] The management of all pediatric dental emergencies during this pandemic must be done by adopting protective measures for health-care personnel and the young patients as per the latest guidelines for prevention and control of infections. Gathering detailed history of travel and contacts, diagnostic test for SARS-COV-2 virus before procedure, utilization of personal protective equipment (PPE), and minimizing aerosol generation by use of appropriate equipment and procedures such as minimal intervention dentistry.[6] As dental emergencies can occur in children with S-ECC requiring urgent attention, these measures are critical in ensuring the safety of the patient and health-care provider.[7] This case series aims to put forth protocols and procedures followed during emergency management of two highly uncooperative children requiring extensive oral rehabilitation for S-ECC under general anesthesia (GA) during the COVID-19 pandemic restoring function and quality of life.

  Presentation of Case Top

Protocol and procedure

In this case series, two children were managed with full mouth rehabilitation under GA. These protocols and procedures were followed in the backdrop of the COVID-19 pandemic:

  • Initial screening of the parents and the child was done at the reception. This included recording of temperature using a contactless IR thermometer and recording of contact and travel history by administering a questionnaire from behind a glass barrier [Figure 1] and [Figure 2], The questionnaire was formulated originally in the Department of Dentistry of the Hospital to help triage the cases coming for treatment.
  • The children were brought to the dental operatory, which was properly disinfected using 70% isopropyl alcohol for the dental chair along with its accessories and 1% sodium hypochlorite for other working surfaces [Figure 3]. The dental operatory was well ventilated, and the central air conditioning was switched off. Fumigation of the dental operatory using sterisol solution was carried out in between the patients
  • A designated zone for donning/doffing of PPE was established for the dental team [Figure 4]
  • The caregivers provided restraint during the examination as both children were highly uncooperative
  • The children were examined following all preventive protocols including PPE kits for the operator and the assistant
  • On examination, it was found that both children had an extremely high caries load that required extensive oral rehabilitation
  • Extraoral radiographs (OPG's) were preferred to reduce chances of transmission.
  • After completion of the examination, all sterilizable instruments were autoclaved, biomedical waste was disposed as per guidelines, surfaces were disinfected using 70% isopropyl alcohol and the surgery was fumigated using sterisol solution [Figure 5]
  • On the evaluation of the behavior of the children, it was decided to carry out the rehabilitation under GA
  • The children were sent with their respective caregivers to provide swabs for a baseline TrueNat test (chip-based reverse transcription–polymerase chain reaction [RT-PCR]) for COVID-19 before admission
  • The results of the TrueNat test were available after 4 h. As both caregivers and children tested negative, they were admitted to the family ward of the hospital and kept in isolation
  • The preanesthetic checkup was conducted which included a chest X-ray and test for viral markers. They were classified as American Society of Anesthesiology I
  • Informed consent was obtained from the parent before the procedure. In addition, a COVID-19 consent form was introduced as part of the protocol for the pandemic [Figure 6]. The children were kept nil per oral from midnight and taken up for the procedure in the morning.
Figure 1: COVID-19 protocol: Reception area, receptionist uses the personal protective equipment kit along with N95 mask and face shield

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Figure 2: COVID-19 protocol: COVID-19 questionnaire

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Figure 3: COVID-19 protocol: Disinfection with 70% isopropyl alcohol after each patient

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Figure 4: COVID-19 protocol: Designated personal protective equipment donning area

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Figure 5: COVID-19 protocol: Surgery fumigation using sterisol solution

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Figure 6: COVID-19 protocol: COVID-19 consent form

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Case report 1

A 3.5-year-old male child was brought to the department of dentistry of the hospital by his parents after they had sought teledentistry consultation. They complained that the child was not eating properly, had disturbed sleep due to pain. After initial clinical examination as per the COVID-19 protocol, the child was sent for an OPG radiograph [Figure 7]. The radiograph showed extensive destruction of tooth structure. Deep dental caries with pulpal involvement was observed in relation to 51, 52, 53, 54, 55, 61, 62, 64, 75, 84, and 85 [Figure 8] and [Figure 9]. Multi-surface dental caries without pulpal exposure were seen on 74. The child had undergone some dental treatment 3 months ago; however, due to behavioral constraints, only glass ionomer restorations on 64, 73, 74, and 75 could be done. On the day of the procedure, the child was brought to the preoperative room by the mother and was given preanesthetic medication. He was subsequently brought to the operation theater (OT), laid supine, and intubated orally uneventfully; throat pack was placed by the anesthesiologist who was draped in full PPE kit. The child was scrubbed and draped by the pediatric dental surgical team who were also draped in the full PPE kits. After oral hygiene measures were carried out; pulpectomy was done on 51, 52, 53, 54, 55, 61, 62, 63, 75, 84, and 85. During the procedure, a micromotor was used for access opening and an extraoral suction was used to reduce the spread of the aerosols generated. The anterior teeth were restored with fiber posts and composite restorations [Figure 10]. Stainless steel (SS) crowns were placed on 54, 55, 64, 74, 75, 84, and 85 [Figure 11] and [Figure 12]. As a part of the preventive protocol, the application of topical fluoride gel (2% sodium fluoride) was done on both the upper and lower arches using disposable trays [Figure 13]. The patient was extubated uneventfully after administration of reversal agent and the throat pack was retrieved. All waste generated during the procedure were disposed as per the biomedical waste management protocol for COVID-19. The child was handed over to his parents in the recovery area and shifted to the ward after monitoring the vitals. The child was kept nil per oral for the next 6 h and introduced to liquid and semisolid food subsequently. Since the recovery was uneventful, the child was discharged the subsequent day after counseling the parents about home care measures and follow-up. A postoperative OPG was taken at the 1-week postprocedure follow-up appointment [Figure 14].
Figure 7: Case 1 - Preoperative Radiograph

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Figure 8: Case 1 - Preoperative photograph Maxillary arch

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Figure 9: Case 1 - Preoperative photograph : Mandibular arch

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Figure 10: Case 1 - Intra operative: Fiber post placement

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Figure 11: Case 1 - Post operative photograph : Maxillary arch

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Figure 12: Post operative photograph: Mandibular arch

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Figure 13: Fluoride application: Topical fluoride application

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Figure 14: Post operative radiograph

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Case report 2

A 5-year-old male child came with his parents after medications administered through teledentistry failed to relieve the child's symptoms. The child was brought to the dental surgery by the mother after the initial screening procedure at the reception as per the COVID-19 protocol. Since the child was highly apprehensive (Frankl Behavior Rating Scale score 1), he was examined in the presence of his mother with all preventive measures for COVID-19 in place. An OPG was taken and it revealed multiple carious teeth confirming the diagnosis of S-ECC. The child had deep dental caries in relation to 54, 55, 52, 62, 64, 74, 75, 84, and dental caries without pulpal involvement in 65 [Figure 15] and [Figure 16]. Grade III mobile root stumps of 51.61 [Figure 17] were extracted using topical anesthetic spray and physical restraint during the initial examination. As the child was not amenable to further treatment in the dental clinic even after nonpharmacological behavior management and keeping in mind, the extensive treatment required it was decided to conduct the procedure under GA. After parental counseling, the mother and child were sent for a baseline TrueNat test. On obtaining negative results, they were admitted and kept in isolation. The preanesthetic checkup was carried out. The child was brought to the OT, laid supine, intubated nasally, and throat pack was placed. The surgical team was draped in full PPE kits, and extraoral suction for aerosol reduction was in use. The preparatory procedure of scrubbing, draping, and oral hygiene measures was carried out. Pulpectomy was carried out on 54, 55, 52, 62, 64, 74, 75, and 84. SS crowns were placed on 54, 55, 64, 74, 75, and 84 [Figure 18] and [Figure 19]. Sandwich restoration using glass ionomer cement and light cure composite resin was done on 65. Topical fluoride application using 2% sodium fluoride gel in disposable trays was done [Figure 20]. Extubation was carried out uneventfully, and nil per oral instructions for 6 h was given. Subsequently, the child tolerated oral feeds and his recovery was uneventful, he was discharged the following day. A postoperative OPG was taken, and regular follow-up schedule was instituted [Figure 21].
Figure 15: Preoperative photograph Maxillary arch

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Figure 16: Case 2 - Preoperative photograph Mandibular arch

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Figure 17: Case 2: Preoperative radiograph

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Figure 18: Case 2 - Post operative photograph : Maxillary arch

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Figure 19: Case 2 - Post operative photograph : Mandibular Arch

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Figure 20: Case 2 - Topical Fluoride application

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Figure 21: Case 2 - Postoperative Radiograph

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  Discussion Top

COVID-19 was declared a public health emergency of international importance by WHO on January 30, 2020, and all elective surgical procedures were advised to be curtailed.[3] It manifests with complete lack of symptoms to severe complications leading to multi-organ failure, septic shock, and systematic dysfunction.[8] Most children with COVID-19 have mild symptoms such as sore throat, headache, cough, and tiredness mimicking other common illnesses of childhood such as common cold, streptococcal throat infection, and allergies.[9] Average incubation period from exposure to virus to onset is 3–7 days. All dental professionals are at a risk of acquiring COVID-19 infection through contact with viral droplets from patients many of whom may be asymptomatic carriers, especially children. Considering the nature of dental restorative procedures and high possibility of transmission of disease through aerosols and proximity to the patient, it is prudent to institute appropriate preventive protocols for protection against infection from the patient and vice versa.[10]

S-ECC is the 10th most prevalent chronic disease in children affecting 621 million children worldwide. It can cause pain, infection, destruction of tooth structure, improper development of speech, disturbed sleep, delayed growth, disruption in social and school activities necessitating urgent management. S-ECC is a serious oral health problem which begins early in life adversely impacting function and quality of life of the child. Early management of the condition is critical to restore function, quality of life, and to reduce social and economic consequences. These children are usually very young they often require extensive rehabilitation, making behavior management critical, be it nonpharmacological or pharmacological techniques.[11] In younger children with extensive rehabilitative needs and behavioral problems, pharmacological techniques such as GA may be the best option to restore oral health-related quality of life.[12]

In the background of COVID-19, only emergency cases were to be taken up after exhausting all other palliative options such as alleviating pain and discomfort through administration of medication based on teledentistry consultation to reduce exposure. These patients should be scheduled for treatment after through contact history recording and being tested (RT-PCR/TrueNat) to confirm they are not infected reducing chances of transmission.[13] During the course of the treatment, use of proper hand hygiene care, PPE and other preventive measures such as the use of extraOPG's, low-speed micromotors, antiretraction handpieces, and high-volume extraoral suction with HEPA filters are critical to the prevention of spread. Proper disinfection/fumigation of the operatory before and after the procedure and disposal of biomedical waste generated as per latest guidelines is critical.[14],[15]

  Conclusion Top

S-ECC is a public health problem which severely impacts the overall quality of life of a child. The pandemic has resulted in modification of the patient management, clinical protocols, introduction of newer equipment into the armamentarium, and changes in organizational practices to deliver quality care while ensuring measures are in place to reduce transmission of the virus. The procedures and protocols described in this article were based on the current scientific evidence that may be useful in delivering timely treatment to these children in a safe environment, thereby minimizing the chances of transmission of virus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Consequences and preventive strategies. In: The Reference Manual of Pediatric Dentistry. Chicago, Ill: American Academy of Pediatric Dentistry; 2021. p. 81-4.  Back to cited text no. 1
Corrêa-Faria P, Viana KA, Raggio DP, Hosey MT, Costa LR. Recommended procedures for the management of early childhood caries lesions – A scoping review by the Children Experiencing Dental Anxiety: Collaboration on Research and Education (CEDACORE). BMC Oral Health 2020;20:75.  Back to cited text no. 2
Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.  Back to cited text no. 3
Seto WH, Tsang D, Yung RW, Ching TY, Ng TK, Ho M, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361:1519-20.  Back to cited text no. 4
Cianetti S, Pagano S, Nardone M, Lombardo G. Model for taking care of patients with early childhood caries during the SARS-Cov-2 pandemic. Int J Environ Res Public Health 2020;17:3751.  Back to cited text no. 5
Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): Emerging and future challenges for dental and oral medicine. J Dent Res 2020;99:481-7.  Back to cited text no. 6
Peres MA, Daly B, Guarnizo-Herreno CC, Benzian H, Watt RG. Oral diseases: A global public health challenge. Lancet 2019;394:249-60.  Back to cited text no. 7
Suri S, Vandersluis YR, Kochhar AS, Bhasin R, Abdallah MN. Clinical orthodontic management during the COVID-19 pandemic. Angle Orthod 2020;90:473-84.  Back to cited text no. 8
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Banakar M, Bagheri Lankarani K, Jafarpour D, Moayedi S, Banakar MH, Mohammad Sadeghi A. COVID-19 transmission risk and protective protocols in dentistry: A systematic review. BMC Oral Health 2020;20:275.  Back to cited text no. 10
Knapp R, Gilchrist F, Rodd HD, Marshman Z. Change in children's oral health-related quality of life following dental treatment under general anaesthesia for the management of dental caries: A systematic review. Int J Paediatr Dent 2017;27:302-12.  Back to cited text no. 11
Chengappa DM, Kannan A, Jain P, Ghavri T. A comparative assessment of the changes in quality of life of children with severe early-childhood caries following comprehensive oral rehabilitation treated with or without general anesthesia. IJOCR 2019;7:46-9.  Back to cited text no. 12
Gupta R, Mohan B, Garg K, Taneja A, Virk SS, Grewal A, et al. A rational approach to manage surgical procedures in COVID Era – A perspective based on experience in a private referral hospital. J Anaesthesiol Clin Pharmacol 2020;36:325-30.  Back to cited text no. 13
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