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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 80-84

Managing pediatric dental patients during the SARS-CoV-2 pandemic

Department of Paediatric Dentistry and Dental Public Health, Kulliyyah of Dentistry, International Islamic University Malaysia, Pahang, Malaysia; Department of Dental and Maxillofacial Surgery, Sultan Ahmad Shah Medical Centre (SASMEC), Pahang, Malaysia

Date of Submission09-Jul-2020
Date of Decision20-Aug-2020
Date of Acceptance16-Sep-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Ahmad Faisal Ismail
Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM), Kuantan Campus, 25200 Pahang.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_234_20

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The coronavirus disease 2019 (COVID-19) represents one of the major medical challenges that the World Health Organization (WHO) had to declare the situation as a pandemic and public health emergency. As the virus spreads very rapidly across the world through droplets and direct contact, dental professionals are at the highest risk of exposure to the infection. The emergence of COVID-19 has totally changed the way we practise dentistry. However, the true impact of COVID-19 towards pediatric dental practice is under-reported. Literature search was conducted through PubMed, CINAHL, and SCOPUS databases using the combination of terms such as “Covid19,” “coronavirus,” “pediatric dentistry,” and “paediatric dentistry” to identify relevant documents. This review was written around the impact of COVID-19 on scheduling appointments, infection control practices, and clinical settings and impact on dental care practices. With limited available sources, recommendations were summarized from included guidelines and clinical recommendations. Pediatric dentists are advised to remain vigilant to recent international and local institutional guidelines; appropriate professional clinical judgment should be considered when making decisions.

Keywords: COVID-19, Dental Practice, Pediatric Dentistry

How to cite this article:
Ismail AF. Managing pediatric dental patients during the SARS-CoV-2 pandemic. J Int Oral Health 2020;12, Suppl S2:80-4

How to cite this URL:
Ismail AF. Managing pediatric dental patients during the SARS-CoV-2 pandemic. J Int Oral Health [serial online] 2020 [cited 2021 Jan 24];12, Suppl S2:80-4. Available from:

  Introduction Top

Coronavirus disease 2019 (COVID-19), which was first reported to emerge in Wuhan, China has been declared a global pandemic by World Health Organization (WHO). The infection is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] Children has been accounted for 1–5% of diagnosed COVID-19 cases globally; however, they appear to be less affected and at lower risk than adults.

Children tend to have a better prognosis and present with milder symptoms than adults. It is hypothesized that these differences may be related to children having less-developed angiotensin-converting enzyme (ACE) 2, limited available reports on affected children having exaggerated inflammatory response and healthier respiratory tracts.[2],[3],[4] A recent meta-analysis reported that fever, cough, sore throat, and diarrhea are among the most frequent clinical characteristics that can be observed in children and/or adolescents with COVID-19.[5] However, there are emerging concerns regarding the existence of hyper-inflammatory syndrome among children, characterized by fever, rashes, gastrointestinal symptoms, and multi-organ failures.[6]

Several medications are currently being investigated as treatment for COVID-19 infection; however, none has been approved for use in children. To date, there are no effective therapies reported in both adult and children against this novel coronavirus and there is insufficient data to guide therapy.[7] Since the illness in children is known to be milder and less severe, they are commonly managed at home. The principle of care is generally centered around prevention of transmission, personal hygiene, and physical distancing.

In the dental setting where potentially anxious children are seen, dental professionals will need to engage in close communication with patients and parents, which could possibly expose them to droplets generated from an unprotected cough or sneeze. As children can be asymptomatic, it is best to assume all children attending dental clinic as potential carriers of COVID-19 unless proven otherwise. This mini-review aims to summarize the management of pediatric dental patients during the SARS-CoV-2 pandemic and its impact towards the pediatric dental practice.

  Materials and Methods Top

A literature search was conducted in June 2020 using PubMed, CINAHL, and SCOPUS databases. A combination of the following keywords was used: “Covid19,” “coronavirus,” “paediatric dentistry,” and “pediatric dentistry.” Documents that reported relevant data and written in English were included in this review. The included articles are summarized in [Table 1].
Table 1: Included articles

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  Impact on Appointment Scheduling Top

Most global authorities recommended triaging dental patients using tele-medicine platform, such as telephone, prior to attending dental clinic. The advantages of using this platform are that dental professionals can verify the COVID-19 risk status of the patient, assess the urgency of the dental condition, and provide self-care advice when appropriate.[8],[9] Upon telephone triage, if there is no urgency and dental treatment can be delayed, patients and parents should be advised with self-care instructions and appropriate medication, if required.[10]

Apart from triaging, patients’ appointments should be scheduled apart from each other. Patients may be advised to wait in their vehicle or outside clinic facilities should recommended physical distancing is not achievable in the waiting area.[8] Clinical sessions should be scheduled in a manner that not more than one pediatric patient and one accompanying person may be present in the surgery room at a time.[9] To allow physical distancing and sanitization procedures before and after completion of treatment, it is expected that the total number of patients treated on a daily basis will be reduced, depending on the capacity of each dental office.[11] All these measures are taken to minimize the exposure to patients and dental staff, and to reduce waiting time prior to treatment [Figure 1].
Figure 1: Proposed flowchart for pediatric dental practice

Click here to view

Most dental procedures are considered as aerosol-generating procedures (AGPs), especially with the use of hand-piece, ultrasonic scaler, and triple-air syringe. Patients who require AGPs should be scheduled at the end of the session to allow appropriate ventilation and minimize exposure.[8]

Upon ease of practice restriction, treatment priority should be given to children with medical co-morbidities or complex medical issues through special dedicated sessions or an early appointment. This is because they are at increased risk of developing complications from untreated dental infections. Elective, non-urgent dental treatment for uncooperative children who require physical behavior management is recommended to be postponed. The American Academy of Pediatric Dentistry (AAPD) reminded dental professionals to have appropriate hospital protocol prepared and readily available upon reopening their practice.[12]

  Impact on Infection Control Practices and Clinical Settings Top

Since fever is the most common presentation of COVID-19 infection, upon arrival at dental clinic, all children and their accompanying person should be screened and checked for any increase in body temperature.[9] If body temperature exceeds 37.3°C (99.14°F), elective dental treatment is best to be postponed.[11] At the waiting area, patients and their accompanying person should be provided with disposable face masks and shoe cover and requested to wash or sanitize their hands.[9]

Dentists are expected to practice appropriate hand hygiene prior to examining the child, before, and after dental treatments.[9],[11] There is no standard consensus on the type of face mask one needs to wear when treating patients. Most international protocols recommended the use of filtering facepiece class 2 (FFP2, equivalent to N95) regardless of AGP procedures or not. However, some authors proposed surgical mask, eye protection, and facial shields while others suggested the use of filtering facepiece class 3 (FFP3, equivalent to N99) mask for AGP procedures.[8],[13-15] For non-AGP procedures on a healthy child, a combination of appropriate surgical face masks and face shields is recommended.[14],[15] Thus, it is difficult to propose a standard guideline on protective equipment; pediatric dentists are advised to use clinical judgment with reference to local protocols.[16] It is recommended whenever possible that some of the personal protective equipment (PPE) such as surgical gowns, gloves, surgical masks, eye protectors, or face shields are put on in the presence of the child to avoid feelings of insecurity in the child because the PPE can affect the child’s behavior and alter their cooperation.[8]

In order to reduce possible contamination from droplets and aerosols, all clinic surfaces and areas should be cleaned and disinfected after completion of every clinical session and dental health care personnel are advised to change the clinical wear or scrubs prior to returning home.[8],[9]

Clinic settings are also advised to be modified into having a single-entry point with designated screening areas and to ensure proper and adequate air ventilation.[12],[14] For high-risk patients and associated with AGP procedures, a single treatment room with a closed door and negative pressure is advisable.[8]

  Impact on Dental Care Top

Upon ease of practice restrictions, the management of dental diseases should be centered at non-AGP procedures, preventive concepts, and minimal intervention approaches, such as atraumatic restorative treatment, professional fluoride therapy, application of Hall technique, and sealing carious lesions.[9],[16],[17] To avoid contamination during treatment, staff should prepare all required instruments prior to the dental procedure.[9] It is vital that pediatric dentists communicate with the staff members regarding the proposed procedures to avoid any unnecessary contamination.

In order to reduce the viral load intraorally, some authors advocated the use of 0.5–1.5% hydrogen peroxide or 0.2% povidone as a preprocedural mouthwash prior to dental treatments.[8],[9] However, for children who are unable to spit, especially young children or children who are mentally challenged, oral mucosal surfaces can be disinfected using cotton rolls or gauze soaked in mouthwash.[11]

Al-Halabi et al.[8] proposed the use of extraoral dental imaging to intraoral imaging to reduce saliva contamination and the use of resorbable sutures in children to avoid additional appointment for suture removal. Whenever possible, the use of rubber dam isolation is highly advisable to reduce suspended particles especially in AGP procedures.[8],[11] Uncooperative patients that require emergency extraction are best managed in the hospital environment where the option of pharmacological behavior management is readily available.[14]

The COVID-19 pandemic not only affected the physical clinical setting but may eventually lead to increased costs of treatment. However, the economic effect varies depending on the healthcare system model in the country. From the perspective of the United States, Jayaraman et al.[14] suggested that patients need to get prior insurance verification due to the nature of healthcare policies.

  Conclusion Top

At the time of writing, most countries are still struggling to contain the spread, while only a few managed to enter the recovery phase. There is low prevalence of COVID-19 infection among children; however, the actual numbers are likely to be under-reported. Since countries experienced the pandemic at different stages, it is difficult to analyze the true impact of the pandemic towards pediatric dental practice. Thus, pediatric dentists are urged to update themselves with recent international and local institutional guidelines. Any practice modifications should be comprehended with professional clinical judgment.


Not applicable.

Financial support and sponsorship

This review was supported by IRF19-015-0015.

Conflicts of interest

There are no conflicts of interest.

Author contributions

Not applicable.

Ethical policy and institutional review board statement

No ethical approval required for this review.

Declaration of patient consent

Not applicable.

Data availability statement

Not applicable.

  References Top

Ramphul K, Mejias SG Coronavirus disease: A review of a new threat to public health. Cureus 2020;12:e7276.  Back to cited text no. 1
Brodin P Why is COVID-19 so mild in children? Acta Paediatr 2020;109:1082-3.  Back to cited text no. 2
Ludvigsson JF Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatr 2020;109:1088-95.  Back to cited text no. 3
Lee PI, Hu YL, Chen PY, Huang YC, Hsueh PR Are children less susceptible to COVID-19? J Microbiol Immunol Infect 2020;53:371-2.  Back to cited text no. 4
Mantovani A, Rinaldi E, Zusi C, Beatrice G, Saccomani MD, Dalbeni A Coronavirus disease 2019 (COVID-19) in children and/or adolescents: A meta-analysis. Pediatr Res2020; doi: 10.1038/s41390-020-1015-2. [Online ahead of print].  Back to cited text no. 5
World Health Organization [Internet]. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19 [cited 2020 June 12]. Available from: [Last accessed on 2020 Jun 12].  Back to cited text no. 6
Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB Pharmacologic treatments for coronavirus disease 2019 (COVID-19): A review. J Am Med Assoc 2020;323:1824-36.  Back to cited text no. 7
Al-Halabi M, Salami A, Alnuaimi E, Kowash M, Hussein I Assessment of paediatric dental guidelines and caries management alternatives in the post COVID-19 period. A critical review and clinical recommendations. Eur Arch Paediatr Dent2020;1-14. doi: 10.1007/s40368-020-00547-5 [Epub ahead of print].  Back to cited text no. 8
Ferrazzano GF, Ingenito A, Cantile T COVID-19 disease in children: What dentists should know and do to prevent viral spread. The Italian point of view. Int J Environ Res Public Health 2020;17:3642.  Back to cited text no. 9
Centers for Disease Control and Prevention [Internet]. Interim guidance for businesses and employers responding to coronavirus disease 2019 (COVID-19) [cited 2020 June 12]. Available from: [Last accessed on 2020 Jun 12].  Back to cited text no. 10
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:E3751.  Back to cited text no. 11
American Academy of Pediatric Dentistry [Internet]. New AAPD Re-emergence Pediatric Dentistry Practice Checklist [cited 2020 June 14]. Available from: [Last accessed on 2020 Jun 14].  Back to cited text no. 12
Cochrane Oral Health [Internet]. Recommendations for the re-opening of dental services: A rapid review of international sources [cited 2020 June 12]. Available from: [Last accessed on 2020 Jun 12].  Back to cited text no. 13
Jayaraman J, Dhar V, Moorani Z, Donly K, Tinanoff N, Mitchell S, et al. Impact of COVID-19 on pediatric dental practice in the United States. Pediatr Dent 2020;42:180-3.  Back to cited text no. 14
Centers for Disease Control and Prevention [Internet]. Infection control guidance for healthcare professionals about coronavirus (COVID-19) [cited 2020 June 10]. Available from: [Last accessed on 2020 Jun 10].  Back to cited text no. 15
Mallineni SK, Innes NP, Raggio DP, Araujo MP, Robertson MD, Jayaraman J Coronavirus disease (COVID-19): Characteristics in children and considerations for dentists providing their care. Int J Paediatr Dent 2020;30:245-50.  Back to cited text no. 16
Casamassimo PS, Townsend JA, Litch CS Pediatric dentistry during and after COVID-19. Pediatr Dent 2020;42:87-90.  Back to cited text no. 17


  [Figure 1]

  [Table 1]


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