Dentistry, Faculty of
DSpace
UBCV
Kumar, Smita
Master of Science - MSc
University of British Columbia
Objectives: Our objective is to measure the effect of the pandemic on the frequency and types of dental emergencies. We hypothesized there will be no difference in the number of visits during the most extreme phase of the lock-down. We also hypothesized that trauma and dental infections would remain the same as in prepandemic times. Methods: Retrospective chart review of dental emergencies from 2018-2021, that required dental staff to attend and treat the patient after hours. The data was anonymized, entered into REDCap, and exported to Prism v10.0 for statistical analysis. Results: A total of 283 patients were in the study, 131 were recruited from Jan. 2018-March 15, 2020, and 152 were recruited from March 16, 2020, to December 31 2021. The proportion of trauma versus non-trauma associated visits to the ED (78% were due to trauma and 22% from other causes) was unchanged compared to prepandemic. The following significant differences were found: During the pandemic there was a higher proportion of (A) bike and hit injuries, (B) outdoor injuries, (C) Photographic records taken during the visit, (D) cases treated directly by the attending pediatric dentist, and (E) use of sedation. Note there were no significant differences in types of injuries within the different phases of the pandemic. Conclusions: There was no significant change in the total number or proportion of visits due to trauma or non-trauma related emergencies due to the pandemic. Interestingly, the prepandemic period used in this study had different proportions of emergency visits compared to 2009-2013. In the historical period there were more non-traumatic emergencies than traumatic injuries. Therefore, emergency treatment has evolved, and it was critical that our comparison period be as close as possible to the study period (pandemic). Emergency care is dynamic and during the pandemic, there was a big shift towards taking photographs of the face and teeth. Photographs help the attending dentist to prepare for the emergency visit and are the standard of care up to the present day.
COVID-19 IMPACT ON DENTAL EMERGENCIES AT BC CHILDREN’S HOSPITAL by Smita Kumar D.D.S, University of Minnesota, 2014 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) July 2024 © Smita Kumar, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Covid-19 impact on Dental Emergencies at BC Children’s Hospital submitted by Smita Kumar in partial fulfillment of the requirements for the degree of Master of Science in Craniofacial Science Examining Committee: Dr. Joy Richman, Professor and Director, Oral Health Sciences, UBC Supervisor Dr. Jennifer Park, Chief of Dentistry, BC Children’s Hospital Clinical Assistant Professor, Faculty of Dentistry, UBC Supervisory Committee Member Dr. Ahmed Hieawy, Associate Professor, Department of Endodontics, UBC Supervisory Committee Member Dr. Ran Goldman, Professor, Department of Emergency Medicine, BC Children’s Hospital Supervisory Committee Member Dr. Gabriela Garisto, Director of Dental Education, The Hospital for Sick Children, Toronto Additional Examiner DD iii Abstract Objectives: Our objective is to measure the effect of the pandemic on the frequency and types of dental emergencies. We hypothesized there will be no difference in the number of visits during the most extreme phase of the lock-down. We also hypothesized that trauma and dental infections would remain the same as in prepandemic times. Methods: Retrospective chart review of dental emergencies from 2018-2021, that required dental staff to attend and treat the patient after hours. The data was anonymized, entered into REDCap, and exported to Prism v10.0 for statistical analysis. Results: A total of 283 patients were in the study, 131 were recruited from Jan. 2018-March 15, 2020, and 152 were recruited from March 16, 2020, to December 31 2021. The proportion of trauma versus non-trauma associated visits to the ED (78% were due to trauma and 22% from other causes) was unchanged compared to prepandemic. The following significant differences were found: During the pandemic there was a higher proportion of (A) bike and hit injuries, (B) outdoor injuries, (C) Photographic records taken during the visit, (D) cases treated directly by the attending pediatric dentist, and (E) use of sedation. Note there were no significant differences in types of injuries within the different phases of the pandemic. Conclusions: There was no significant change in the total number or proportion of visits due to trauma or non-trauma related emergencies due to the pandemic. Interestingly, the prepandemic period used in this study had different proportions of emergency visits compared to 2009-2013. In the historical period there were more non-traumatic emergencies than traumatic injuries. Therefore, emergency treatment has evolved, and it was critical that our comparison period be as close as possible to the study period (pandemic). Emergency care is dynamic and during the pandemic, there was a big shift towards taking photographs of the face and teeth. Photographs help iv the attending dentist to prepare for the emergency visit and are the standard of care up to the present day. v Lay Summary This study focuses on pediatric patients who need urgent dental care at a hospital after regular hours. During the early days of COVID-19, there was a significant reduction in emergency cases in BC hospitals. We wanted to see how the pandemic affected the number and types of dental emergency cases and how they were handled. Our findings show that the overall number and types of dental emergencies didn't change much, but where and how kids got injured did change. Also, more photographic records were collected, and sedation was used at a higher frequency during the pandemic which are still being used to the present day. Analyzing these details helps figure out how to improve healthcare delivery for dental emergencies. We will also use the findings to tailor messages for caregivers on the most common reasons for dental injuries in kids and how to prevent them. vi Preface This thesis is the original, unpublished, independent work by the author. The identification and design of this research project were by the author under the direction of her research supervisor, Dr. Joy Richman. Data collection was conducted by the author with assistance from The Office of Pediatric Surgical Evaluation and Innovation (OPSEI) co-op student, Mr. Jack Hu. Data analysis was conducted by the author with the guidance of Dr. Richman and statistical consultant, Mr. Akshdeep Sandhu from BCCH Research Institute. Regular committee meetings were held with the supervisory committee, consisting of Drs. Joy Richman, Jennifer Park, Ran Goldman, and Ahmed Hieawy. Ethical approval for the study was granted by the UBC Children’s & Women’s Clinical Research Ethics Board [H21-03957]. The online ethics training module Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans Course on Research Ethics (TCPS2: CORE) was issued and completed by the author on August 14, 2021. vii Table of Contents Abstract ............................................................................................................................... iii Lay Summary........................................................................................................................v Preface ................................................................................................................................. vi Table of Contents ............................................................................................................... vii List of Tables .........................................................................................................................x List of Figures ..................................................................................................................... xi List of Abbreviations ......................................................................................................... xii Acknowledgements ........................................................................................................... xiv Dedication ............................................................................................................................xv Chapter 1: INTRODUCTION ........................................................................................... 1 1.1 COVID-19 Pandemic .......................................................................................... 1 1.2 COVID-19 in Canada ......................................................................................... 1 1.2.1 Canada’s response to COVID-19 .................................................................. 1 1.2.2 COVID-19 in British Columbia .................................................................... 2 1.2.3 Dental clinic shutdowns ................................................................................ 2 1.3 BCCH Introduction ............................................................................................. 4 1.3.1 Dental services at BCCH ............................................................................... 5 1.3.2 Dental Emergencies at BCCH (How the ED triages) .................................... 5 1.4 Dental Home ....................................................................................................... 7 1.5 Emergencies in pediatric dentistry ...................................................................... 7 1.5.1 Traumatic Dental Injuries .............................................................................. 7 viii 1.5.2 Non-traumatic dental conditions ................................................................... 8 1.5.3 Miscellaneous reasons for attending the emergency department ................ 10 1.6 Dental emergencies during COVID-19: A Global Perspective ........................ 11 1.6.1 Decreases and increases in the number of dental emergencies during the pandemic…………. .......................................................................................................... 12 1.6.2 Rise in non-traumatic dental emergencies versus traumatic dental emergencies………........................................................................................................... 14 1.6.3 Substitution of non-aerosol generating procedures ..................................... 14 1.7 Gaps in the recent literature .............................................................................. 15 Chapter 2: Purpose .......................................................................................................... 17 2.1 Research Problem ............................................................................................. 17 2.2 Research Objectives .......................................................................................... 19 Chapter 3: Methods ......................................................................................................... 20 3.1 Inclusion criteria ............................................................................................... 20 3.2 Exclusion criteria .............................................................................................. 20 3.3 Study Procedures .............................................................................................. 20 3.3.1 Variables measured ..................................................................................... 21 3.4 Data Analysis .................................................................................................... 22 Chapter 4: Results............................................................................................................ 23 4.1 Relative rate of dental after-hours emergencies per year .................................. 23 4.2 Demographic characteristics ............................................................................. 24 4.3 Details of the emergency cases ......................................................................... 26 4.4 Traumatic dental injuries versus non-traumatic emergencies ........................... 28 ix 4.5 Age of patient and types of emergencies .......................................................... 32 4.6 Time of occurrence of Traumatic Dental Injuries............................................. 33 4.7 Characteristics of Non-traumatic emergencies ................................................. 35 Chapter 5: Discussion ...................................................................................................... 37 5.1 Effects of the pandemic on pediatric dental emergencies in BC ...................... 38 5.2 Evolution of dental emergency treatment at BCCH ......................................... 40 5.3 Worldwide effects of the pandemic on types of dental emergencies................ 43 5.4 Study Strengths and Limitations ....................................................................... 46 Conclusions .........................................................................................................................48 Knowledge transfer ............................................................................................................50 Bibliography ........................................................................................................................51 x List of Tables Table 4.1 Patient Demographics.......................................................................................... 25 Table 4.2 Characteristics of the emergency visits ............................................................... 28 Table 4.3 Types of traumatic injuries, causes, location and treatment................................ 35 Table 4.4 Characteristics of non-traumatic dental emergencies .......................................... 36 Table 5.1 Number of patients seen for emergency treatment at BCCH in the dental clinic 41 xi List of Figures Figure 4.1 Number of emergencies by year ........................................................................ 23 Figure 4.2 Distance travelled ............................................................................................... 25 Figure 4.3 Wait times for all types of dental emergencies .................................................. 26 Figure 4.4 Traumatic versus non-traumatic injuries............................................................ 29 Figure 4.5 Interrupted time series analysis - monthly counts of dental emergencies .......... 30 Figure 4.6 Interrupted time series analysis - weekly counts of dental emergencies ........... 31 Figure 4.7 Proportion of cases due to trauma versus non-trauma ....................................... 31 Figure 4.8 Proportions of cases according to age bracket ................................................... 32 Figure 4.9 Time of day when traumatic injuries occurred before or during the pandemic . 34 xii List of Abbreviations ADA – American Dental Association AGP – Aerosol Generating Procedure AGMP – Aerosol Generating Medical Procedure BC – British Columbia BCCDC – British Columbia Center for Disease Control BCCH – British Columbia Children’s Hospital CDC – Center for Disease Control CDHBC - College of Dental Hygienists of British Columbia CDSBC - College of Dental Surgeons of British Columbia COVID-19 – Coronavirus Disease of 2019 DD-BCCH – Department of Dentistry at British Columbia Children’s Hospital E2i – Evidence to Innovation ED – Emergency Department ED-BCCH – Emergency Department at British Columbia Children’s Hospital GPR – General Practice Resident IADT – International Association for Dental Traumatology MSP – Medical Services Plan NHANES - National Health and Nutrition Survey NTDC – Non-Traumatic Dental Condition NTDE – Non-Traumatic Dental Emergencies OMFS – Oral and Maxillo-Facial Surgeon OPSEI – The Office of Pediatric Surgical Evaluation and Innovation xiii OR – Operating Room PaedCTAS - Canadian Triage and Acuity Scale Paediatric Guidelines PDC – Pacific Dental Conference PHSA – Provincial Health Services Authority PPE – Personal Protective Equipment SARS – Severe Acute Respiratory Syndrome TDI – Traumatic Dental Injury UK – United Kingdom xiv Acknowledgements To Dr. Joy Richman, my research supervisor - this endeavor would not have been possible without your guidance, support, and patience. Your enthusiasm about the topic and your belief in me was crucial to the success of this project. I would like to express my deepest gratitude to my committee member Dr. Jennifer Park. You always made yourself available and offered invaluable insight regarding this topic. I truly appreciate your time and attention. Many thanks to my committee member, Dr. Ahmed Hieawy. Thank you for your support. Special thanks to Mr. Damian Duffy for providing research space and co-op students for all important data entry. Thank you for also including me in research events sponsored by the E2I group. I am also grateful to my wonderful co-residents – Kevin, Michael, and May. You three have been the best cheerleaders one could ask for and I consider myself very fortunate to go through this residency program with you. Finally, I would be remiss in not mentioning my husband, Nishant, whose unconditional love, and unwavering faith in me makes me a better person. xv Dedication To my wonderful parents and sisters – thank you for supporting me and always believing in me. 1 Chapter 1: INTRODUCTION 1.1 COVID-19 Pandemic The World Health Organization (WHO) on March 11,2020 declared the novel SARS-CoV-2 a worldwide pandemic. The disease caused by this virus, COVID-19, was first recognized in December 2019 and quickly became a global threat as a highly contagious respiratory disease. SARS-CoV-2 is structurally related to the virus that causes severe acute respiratory syndrome (SARS). This global pandemic has posed critical challenges for the public health, research, and medical communities (Fauci et al. 2020). 1.2 COVID-19 in Canada The first COVID-19 case in Canada was reported on January 25, 2020 (CIHI). As of April 16, 2024, a total of 4,949,441 cases of COVID-19 have been reported in Canada, of which 384,078 cases affected patients under the age of 20 years (BCCDC 2023). 1.2.1 Canada’s response to COVID-19 A study comparing Canada’s response to the initial 2 years of the COVID-19 pandemic with peer countries (G10 countries) revealed that Canada had the second-highest stringent measures. Italy had the highest and Japan the lowest (Razak et al. 2022). Life in the community in Canada was significantly affected by public health mitigation strategies that recommended social distancing, stay-at-home orders, closure of non-essential services closure of playgrounds, cessation of competitive sports and restrictions on gatherings of people (Goldman et al. 2020). 2 1.2.2 COVID-19 in British Columbia The first case of COVID-19 in BC was recorded on 28 January 2020 and involved a traveler returning from Wuhan. By 13 March 2020, international travel was deemed unsafe and advised against by the Canadian government. On 17 March 2020, a BC public health emergency was declared, and a province-wide state of emergency was declared the next day (Thiara et al. 2020). The initial three waves of the pandemic, encompassing the complete lockdown from March 16 to May 13, 2020 (with restrictions lifted in the summer of 2020), the second wave spanning October 30, 2020, to December 15, 2020, and the third wave occurring from April 12, 2021 to June 15, 2021, were notably significant due to the limited availability of vaccines to the general public. During this period, public health guidelines and stay-at-home orders were consistently evolving and undergoing revisions (BCCDC 2023). 1.2.3 Dental clinic shutdowns The nature of dental procedures is such that many droplets and aerosols could be generated. COVID-19, as we found out very early, spread via droplet and aerosols hence the standard dental precautions were deemed ineffective against protecting the dental providers and patients from spread of infection. The major concern was the inadvertent spread of this potentially deadly virus through asymptomatic patients or those concealing their diagnosis and hiding their symptoms (Meng et al. 2020). A systematic review accessed the published literature to assess COVID-19 transmission risk and protective protocols in dentistry (Banakar et al. 2020). Dentistry was widely recognized as a possible workplace for hazardous transmission of the SARS-CoV-2 virus. It was hypothesized that due to the nature of dental procedures and the proximity of the dental team to their patients during 3 treatment, the virus could rapidly spread from the team to the patient or vice versa, if appropriate precautions were not taken. Clinical organizations such as the American Dental Association (ADA) and the Centre for Disease Control (CDC) recommended regular hand hygiene, antiseptic oxidative mouth rinses prior to and after treatment, masks with pores of less than 50µm, use of goggles or face shields, delaying non-urgent dental services, using teledentistry when possible, etc., to minimize spread of COVID-19 in dental offices (Banakar et al. 2020). Throughout the pandemic, there were distinct periods during which dental services faced mandated shutdowns. The most noteworthy and stringent closure spanned from March 16, 2020, to May 2020, prompted by the Pacific Dental Conference (PDC) in Vancouver, which resulted in a significant super-spreader event from March 5 to 7, 2020. In response, the Chief Public Health Officer of BC, Dr. Bonnie Henry, directed an immediate cessation of all dental office operations until a reassessment could be conducted. During this closure, the College of Dental Surgeons of British Columbia (CDSBC) and the College of Dental Hygienists of British Columbia (CDHBC) recommended suspending all non-essential dental services in the province (CIHI 2022). The British Columbia Centre for Disease Control (BCCDC) advised the use of N95 respirators or equivalent protective gear, along with gowns, gloves, and eye protection (face shields or goggles) for aerosol-generating medical procedures (AGMP) on patients suspected or confirmed to have COVID-19 (BCCDC 2023b). BC Children's Hospital (BCCH) dental clinic took the lead by reopening on March 31, 2020, following hospital guidelines. While private offices gradually resumed non-aerosol generating procedures (non-AGPs) such as extractions, the postponement of most urgent treatments occurred due to patient reluctance and fewer dental providers willing to work under restricted conditions. BCCH dental department continued supporting dental offices during the initial pandemic phases, 4 progressively incorporating AGPs, facilitated by the hospital's provision of advanced personal protective equipment (PPE), including N95 masks. The scarcity of PPE led healthcare workers, including dentists, to ration equipment, sanitize items for reuse, and, in some cases, resort to homemade solutions. Dentists in the community played a significant role in contributing their PPE stocks to hospitals and frontline workers, a selfless act that, while commendable, further delayed the reopening of dental offices after the provincial order to provide emergency dental services only was lifted in May 2020. A study from the US showed that dentists adhered to enhanced infection control procedures and concomitant low infection rates with COVID-19 (Araujo et al. 2021). Additionally, up to November 2020, there were no confirmed cases of COVID-19 transmission in patients after their dental appointments (Araujo et al. 2021). A more recent survey of dentists in Japan also found that there was no transmission from patients to staff or the reverse (Sakai et al. 2023). Therefore, the PPE and infection control procedures were sufficient to prevent transmission in dental offices. 1.3 BCCH Introduction British Columbia Children’s Hospital (BCCH) is the only tertiary level hospital in British Columbia. It is devoted exclusively to serving a population of close to a million children in all of BC (0-19 years). Besides being the province’s major treatment facility, it is also a valuable teaching and research facility for pediatric health. On an annual basis, about 93,000 children receive care at BCCH. Sunny Hill Health Centre is a part of BCCH providing specialized developmental assessments and rehabilitation services for children, youth, and their families. Both BCCH and Sunny Hill Health Centre are closely affiliated with University of British Columbia (PHSA). 5 1.3.1 Dental services at BCCH The Department of Dentistry at BCCH (DD-BCCH) provides consultation and comprehensive dental treatment for healthy young children and children/adolescents diagnosed with a medical diagnosis or behavioral complexity. A referral from a physician, a nurse practitioner, or a dentist, is needed to be seen at the BCCH dental clinic. The eligibility criteria for treatment in the dental clinic and OR are as follows: • Children under four years of age with severe dental decay. • Children/adolescents under 17 years of age with a significantly compromising medical condition, such as: cancer, organ transplant, congenital heart disease, cleft lip/palate, craniofacial anomaly, severe bleeding disorder. • Children/adolescents under 17 years of age medically diagnosed with a behavior management issue, such as autism or severe developmental delay. The staff at DD-BCCH include eleven pediatric dentists who supervise trainees - dental fellows (pediatric dentistry graduate students) and general practice residents (GPRs) in the provision of dental care to the pediatric patients. Other specialty consultants such as oral surgeons and endodontists are also part of the dental staff and are available for emergency consultation and treatment as well as treatment under General Anesthesia in the OR (PHSA). 1.3.2 Dental Emergencies at BCCH (How the ED triages) Clinic hours for DD-BCCH are Monday through Friday from 8:00am to 4:00pm. The clinic also provides round the clock coverage for emergency dental services. Trainees are responsible for providing after-hours emergency calls on a rotating basis in pairs. The ‘third call’ will normally be the attending pediatric dentist who in times of shortage of trainees, will be second call and is 6 expected to assist with treatment. There is also an oral and maxillofacial surgeon (OMFS) assigned to each week of call. An endodontist is also available for phone consultation (UBC Faculty of Dentistry 2022-2023). Patients can present directly to the Emergency Department (ED) or can be referred to emergency by a physician or a dentist. In the current after-hours service model, a child presenting to BCCH with an urgent dental concern is directed to the emergency department (ED), where (s)he is quickly assessed by a trained triage nurse stationed at the “Emergency Report Here” desk. The emergency is triaged in accordance with the Canadian triage and Acuity Scale Paediatric Guidelines (PaedCTAS) (Yates et al. 2016). The scale ranges from 1 to 5. Those that need resuscitation are highest priority and require immediate attention, emergent cases (emergencies) must be seen in 15 minutes, urgent cases should be seen in 30 minutes, less urgent cases should be seen in 60 minutes and non-urgent cases should be seen in 120 minutes. The dental cases are classified as urgent to non-urgent. This information is passed on to the “Urgent Care” section of the ED for review by an attending physician. The patient is examined by an ED physician, or a medical resident supervised by an attending staff physician. A dental concern may be managed in one of three ways: 1. In the case of a permanent tooth avulsion with less than two hours extraoral time, the patient is sent directly to the “Critical Care physician” who will replant the tooth, then advise the Dentistry department (8am-4pm) or page the dentist on call (after 4pm). 2. One-third of cases are directed to DD-BCCH (8am-4pm) or dentist on call (after 4pm) for further assessment/management. 3. Two-thirds of cases are deemed non-urgent and discharged with appropriate supportive care instructions/information, such as a list of local dentists, pain management instructions, or a prescription for oral antibiotics. In some cases, if the attending physician feels the case 7 may meet hospital criteria, a non-urgent consultation request will be faxed to the Dentistry Department to initiate further review (Park 2015). 1.4 Dental Home The American Academy of Pediatric Dentistry (AAPD) defines dental home as “the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a safe, culturally sensitive, individualized, comprehensive, continuous, accessible, coordinated, compassionate, and patient- and family-centered way regardless of race, ethnicity, religion, sexual or gender identity, medical status, family structure, or financial circumstances.” Establishing a dental home by 12 months of age is advised to ensure both routine and emergency oral care for optimal dental health. 1.5 Emergencies in pediatric dentistry 1.5.1 Traumatic Dental Injuries An injury to the primary or permanent teeth of a young child or permanent teeth in an adolescent can have far-reaching consequences. The immediate sequelae are often pain, disfigurement, and emotional impact on wellbeing. Long term effects may include pain, infection, discoloration of the tooth, damage to underlying permanent teeth and sometimes loss of permanent teeth (Flores and Onetto 2019). Prompt treatment of dental TDIs can prevent loss of teeth and possibly minimize long term consequences associated with the injury. Dental TDIs can present as hard tissue, soft tissue or supporting tissue injuries (McTigue 2019). Hard tissue injuries may include fractures of supporting structures such as alveolar bone, fracture of facial bones including jaw bones or fracture of the condyle. Injuries to dental hard 8 tissues include luxation or avulsion of teeth. Fractures of the crowns may affect enamel only, enamel and dentin (simple fracture) or enamel dentin and pulp (complicated fracture). Soft tissue injuries may include abrasions and laceration of the extraoral or intraoral tissues. Supporting tissue injuries are most often seen in luxation injuries where the periodontal ligament is crushed or torn and there are sometimes small fractures of the alveolar bone. Many TDIs present as a combination of injuries which further complicates their management (McCann and Welbury 2017). Management of TDIs can range from no treatment which includes but is not limited to, monitoring the injury in a clinical setting to restorative treatment, endodontic treatment, repositioning of teeth with or without splinting, suturing, or extraction of teeth (McCann and Welbury 2017). According to the most recent trauma guidelines published in May 2020 by IADT, 25% of all school children experience dental trauma with luxation injuries being most common in the primary dentition while crown fractures are more common in the permanent dentition (Levin et al. 2020). 1.5.2 Non-traumatic dental conditions Non traumatic dental conditions (NTDCs) includes diseases affecting the teeth and supporting structures that do not have a traumatic origin (Akinlotan and Ferdinand 2020). Dental caries is the most common non-traumatic dental condition, commonly observed in the pediatric population. It continues to be a major health problem in high-income countries and is increasing in many low- and middle-income countries. The consequence of untreated dental caries is most often pain and sensitivity which may lead to loss of school days, reduced quality of life and in some cases hospitalization and emergency department visits (Friedman et al. 2018; Krol and Nedley 2007). 9 When addressed promptly, dental caries can be effectively managed through conservative restorative treatment. However, if left untreated, it can lead to infections that vary from localized dentoalveolar abscesses to severe facial cellulitis of odontogenic origin, which pertains to acute inflammation and infection of subcutaneous tissue caused by an infected tooth (Ritwik et al. 2020). The infection spreads through tissue spaces and fascial planes in the head and neck area. Odontogenic cellulitis is caused by a combination of multiple bacteria, often highly virulent in nature. Facial cellulitis has the potential to result in systemic issues, including sepsis, dehydration, central nervous system infection, and obstruction of the airway. Children who experience facial cellulitis may exhibit a range of clinical symptoms, including variations in severity, the extent of involvement in fascial planes, the presence of fever, difficulties with swallowing (dysphagia), restricted mouth opening (trismus), and dehydration (Ritwik et al. 2020). Children with facial cellulitis often require hospitalization to manage this serious dental emergency. Emergency management of facial cellulitis often includes antibiotics (oral or intravenous), analgesics, and/or extraction of offending tooth with or without incision and drainage of the affected tissues under general anesthesia. Caries is one of the most common, noncommunicable diseases (affects more than 3.5 billion people globally (Collaborators et al. 2020). Data from the 1999–2002 National Health and Nutrition Survey (NHANES) indicated that 41% of children aged 2 to 11 had caries in their primary teeth, with 21% having untreated decay. Among children and adolescents aged 6 to 19, 42.0% had caries in permanent teeth, and 14% had untreated decay in these teeth (Krol and Nedley 2007). Overall, there has been a decline in the incidence of dental caries and untreated dental decay in both primary and permanent dentitions. According to the National Institute of Dental and Craniofacial Research (NIDCR 2022) – between 2011 and 2016, 23% of children between the ages 10 of 2 and 5 years, have had dental caries in their primary teeth. 10% of these children had untreated dental caries. However, the percentage of children with untreated dental caries increased to 16% in the 6–8-year age group, in the same report. For permanent teeth, only 5% of children between the ages of 6 and 11 had untreated dental decay. Children belonging to Black and Mexican American families and those belonging to low-income families, were more likely to have dental caries (Prevention 2019). Nevertheless, there are still children presenting to the emergency department with acute odontogenic infections, many of whom have become unresponsive to antibiotics due to resistance from previous rounds of treatment. It is important to continue the care for the tooth as soon as possible after the prescription has been taken. Otherwise, the source of the infection remains, and residual bacteria will acquire resistance. With exponential growth, the resistant bacteria will soon replace all of the drug-susceptible microbes. Patients end up in emergency after taking multiple courses of antibiotics and then the cellulitis becomes unresponsive to most of the commonly used drugs. 1.5.3 Miscellaneous reasons for attending the emergency department The other reasons that bring children and adolescents to emergency departments are much less common than trauma or odontogenic infections with some studies estimating them at less than 10% of the total dental emergencies (Lewis et al. 2003). Eruption-related problems commonly occur in children with mixed dentition. Occasionally cysts form around the erupting teeth that are large and painful. Other times primary teeth fail to shed quickly. Retention of exfoliating primary teeth may cause pain, especially in children with a lower pain threshold. Wisdom tooth impaction may also cause pain, but this is restricted to children over age 16. Typically, the population seen at a children’s hospital is not one where the wisdom teeth have erupted. There may be other natal 11 or neonatal abnormalities including growths that interfere with eating and swallowing (de Oliveira et al. 2019). Teeth that are very mobile may need to be extracted. Rarely problems with orthodontic appliances require emergency visits. This can be mucosal injuries due to broken wires or appliances that are loose but still in the mouth. Finally, other soft tissue pathologies such as excessive bleeding, gingival inflammation, primary herpes (Huang et al. 2020) or widespread Aphthous ulcers (Messadi and Younai 2010) are some of the more common soft tissue concerns. Often these conditions are urgent rather than emergent, so appointments are made during regular business hours. A study completed in 2015 at BCCH examined factors influencing the decision to attend a pediatric ED for non-emergent complaints. Although they did not separate medical complaints from dental, the reasons seem to align with what dentistry sees in the ED with such cases. Top factors were identified as having more faith in a dedicated pediatric hospital than their primary care provider, child having medical issues that were previously managed at the hospital, geographic proximity, being specifically told to go to BCCH, not knowing their child could be seen elsewhere, wait time felt to be shorter at BCCH and easy access to BCCH. (Smith et al. 2015) 1.6 Dental emergencies during COVID-19: A Global Perspective Numerous studies around the world have been completed regarding the nature of dental emergencies during COVID-19. A multinational, cross-sectional study by Davis et al, (Davis et al. 2021) looked at pediatric emergency departments in the USA, Canada, Israel, Spain, and Switzerland. They found that one in five caregivers reported delaying treatment for their ill or injured child due to fear of contracting COVID-19 while in the hospital (Davis et al. 2021). This 12 is just a report on caregivers. The actual statistics on numbers of emergency visits is needed to understand the true impact of the pandemic on caregivers seeking treatment for their children. 1.6.1 Decreases and increases in the number of dental emergencies during the pandemic The date of the first COVID-19 lockdown occurred between March to May or as far as June 2020 depending on the location. China was the first country where the government imposed strict restrictions in movement outside the home. There was increased public perception of the dangers of visiting public spaces such as hospitals or dental centers. Chinese researchers noted a 38% decrease in dental emergencies at a tertiary level hospital in Beijing, China. Their test period was between February 1 and Feb 10, 2020, while the control period was between January 1 and January 10, 2020 (Guo et al. 2020). These are the earliest dates of the start of the pandemic in any Covid-19 study. In the middle east, emergency government dental centers in Saudi Arabia reported a decrease in number of pediatric dental emergencies during a six-week investigated period between March 26 to May 7, 2020 (Alzahrani et al. 2021). However, this period of reporting is very short relative to the length of the pandemic which we know did not normalize until the summer or fall season of 2021 (Salam et al. 2021). In the UK, overall number of maxillofacial emergencies diminished significantly in the six-week initial lockdown which started on March 24, 2020, (Blackhall et al. 2020). This study did not have a specified control period. In another UK study, there was a decrease in number of emergency visits of 38% in the initial lockdown (Diskin et al. 2023). There are several reports from European countries showing similar decreased utilization of emergency services. In the Netherlands, the first lockdown was between March 11 and May 10, 2020. A single-center 13 retrospective cohort study at a level 2 trauma center noted a 32% decrease in TDIs at the ED compared with the previous years 2019 and 2018 (van Aert et al. 2021). A study conducted in Northern Italy at an urgent care center at a hospital revealed a significant reduction in dental emergencies for all ages coinciding with periods of national lockdown and a surge in numbers after re-opening, especially for their pediatric patients. Northern Italy (Milan) was at one point in the early pandemic the hardest hit region in all of Europe and had the highest mortality of any country in the world (Cagetti et al. 2021). Another Italian study noted a decrease in dental emergencies but only during the second wave from October to December 2020 (Carmagnola et al. 2022). A Romanian study which looked at dental ED visits in 2019, 2020 and 2021 noted a decline in visits in 2020 and a surge in numbers in 2021 (Moca et al. 2023). Unlike the other European studies, a German study that noted an increase in emergency dental treatment during the initial lockdown period from March 17 to April 30, 2020. The need for emergency dental treatment was 45% higher when compared to the 2019 cohort (Al Masri et al. 2021). The reasons for these differences were not discussed in the study. Finally in the US, there was a study showing an increase in dental emergencies during the pandemic carried out at a hospital in Delaware, US which noted a 41% drop in total pediatric admissions but a significant increase in dental emergencies from March to August 2020 (Fleagle et al. 2022). The reasons were thought dental office closures, cancellation of all elective general anesthesia cases and pre-appointment screening questionnaire which recommended referral to the ED for oral infections with systemic involvement. A recent study also reported more dental emergencies seen in Seattle during the pandemic than before (Whyte et al. 2023). The reason for the rise in trauma cases was thought to be children with increased time at home for unstructured play and for caries emergencies – dental offices operating at limited capacity or staying closed. 14 Another US study from San Diego reported an increase in traumatic dental emergencies during the initial lockdown period (Whyte et al. 2023). They too cited the reason to be closure of pediatric dental offices because of the pandemic. The effect on the pandemic on dental emergencies in Canada has not been reported yet. 1.6.2 Rise in non-traumatic dental emergencies versus traumatic dental emergencies Typically, during prepandemic times, there were fewer non-traumatic dental emergencies than those resulting from trauma (Jung et al. 2016; Oliva et al. 2008; Rowley et al.). Several studies noted a rise in NTDEs as the reason for presentation to the ED or dental clinic during the pandemic. Multiple reasons were cited for this rise in NTDEs - closure of dental practices during the lockdown period or limited PPE availability (Al Masri et al. 2021), suspension of non-emergency dental treatment leading to delay in timely and effective treatment and less TIs due to social distancing, quarantine, and school closure. (Alzahrani et al. 2021; Eggmann et al. 2021; Goswami et al. 2021). Other studies speculated that existing poor oral health status and oral health behavior habits led to a rise in NTDC while limited outdoor activities reduced the incidence of TIs (Guo et al. 2020; Kumar et al. 2021). One of the UK studies cited limited access to general anesthesia as the reason for increasing the burden of dental caries. Meanwhile, Moca et al noted that the increase in presentation of NTDEs reflects the high incidence of untreated dental caries among children and adolescents in Romania (Moca et al. 2023). 1.6.3 Substitution of non-aerosol generating procedures Dentistry is prone to aerosol generating procedures from scaling with an ultrasonic scaler, use of handpieces and suction. During the pandemic however, dentists were discouraged from 15 performing AGPs. As a result, more non-AGP procedures were carried out such as simple extractions or pharmacological management in the form of prescriptions for analgesics and antibiotics (Al Masri et al. 2021; Bauer et al. 2023; Eggmann et al. 2021; Kumar et al. 2021; Tong et al. 2021). Hospitals were the only places in BC with sufficient PPE and good ventilation to allow AGPs to be performed at the start of the pandemic. 1.7 Gaps in the recent literature The studies on dental emergency visits specifically for children are fewer in number and many are just reports without statistical analysis. Several studies were completed in pediatric dental departments rather than EDs (Al Masri et al. 2021; Alzahrani et al. 2021; Eggmann et al. 2021; Goswami et al. 2021; Kumar et al. 2021). The lack of a comparison period and small study samples could be the main reasons for lack of statistical analyses. Most studies include short study periods focusing on only the initial lockdown period in 2020, a period of six to seven weeks (Al Masri et al. 2021; Alzahrani et al. 2021; Eggmann et al. 2021; Goldman et al. 2020; Goswami et al. 2021; Guo et al. 2020; Irvine et al. 2021; Kumar et al. 2021; Patel et al. 2021; Tong et al. 2021; van Aert et al. 2021). Several studies included both pediatric and adult dental emergencies which made it difficult to separate children from the group and we are not able to assess the variability of patients with different reasons to present to the department (Blackhall et al. 2020; Blackhall et al. 2021; Cagetti et al. 2021; Eggmann et al. 2021; Guo et al. 2020; Rodriguez et al. 2022; van Aert et al. 2021). In studies completed in British Columbia, medical and dental emergencies were grouped together, and it was not possible to extract information specific to dental emergencies (Goldman et al. 2020; Irvine et al. 2021). 16 In all these studies, we are not able to assess the variability of patients with different reasons to present to the department. Only absolute numbers of cases were reported, and the authors speculate that there was a decrease in cases seen during lockdown. An editorial published early in the pandemic noted that more research was needed on the effects of the pandemic on dentistry (Paglia 2020). We are now in a different COVID-19 landscape where 48% of 5-11 year-olds and 78% of 12-17 year-olds have had at least one dose of the vaccine (Public health agency of canada: Vaccination coverage by age, sex, and province or territory 2024). Typical injuries to the primary teeth in children 3 and under occur at home and thus there would be no change in the prevalence of dental trauma to preschool age children (Anderson et al. 2021; Choi et al. 2010; Mitchell et al. 2014; Ozgur et al. 2021). In contrast to trauma, the proportion of children that experienced severe infections would be increased. The reasons for increased infections are that dental neglect had taken place or that treatments were suspended when dental offices had to shut down. Definitive dental care could not be provided for 3-4 months during the pandemic. Even when care resumed, patient numbers were greatly restricted causing a lag in treatment.17 Chapter 2: Purpose The purpose of this study was to evaluate the traumatic and non-traumatic dental emergencies treated at BCCH dental department, focusing specifically on after-hours visits, and the effect that the pandemic had on the types of emergencies encountered and treatments provided. 2.1 Research Problem Our question is whether there was an overall decrease in the number of emergency visits due to the pandemic compared to prepandemic times. The decrease would be a measure of how many patients could not get care for pain, infection, and TDIs. We also want to find out whether there were differences in the patient demographics and causes of emergency visits compared to pre-pandemic data. We hypothesized that TDIs would sharply decrease whereas the incidence of pain and infection would increase. The city playgrounds and schools were closed from March until late June 2020. There were no organized sports for children until fall of 2020 but even then, there were no competitions and no travel between health authorities. During this time, children who would normally be engaged in sports and outdoor play would be at home and thus would have lower prevalence of dental trauma. Typical injuries to the primary teeth in children 3 and under occur at home and thus there would be no change in the prevalence of dental trauma to preschool age children (Anderson et al. 2021; Choi et al. 2010; Mitchell et al. 2014; Ozgur et al. 2021). In contrast to trauma, the proportion of children that experienced severe infections would be increased. The reasons for increased infections are that dental neglect had taken place or that treatments were suspended when dental offices had to shut down. Definitive dental care could not be provided for 3-4 months during the 18 pandemic. Even when care resumed, patient numbers were greatly restricted causing a lag in treatment.19 2.2 Research Objectives Primary • To describe the effect of the pandemic on the frequency of dental emergencies presenting to BCCH Department of Dentistry after hours. • To describe the effect of the pandemic on the type (traumatic versus non-traumatic) of dental emergencies presenting to BCCH Department of Dentistry after hours. Secondary • To describe the effect of the pandemic on - The characteristics of traumatic and non-traumatic dental emergencies - The types of treatment provided - Changes in treatment for dental emergencies that occurred across the period of study 20 Chapter 3: Methods A retrospective chart review of patients January 1, 2018- December 31, 2021, was conducted. These patients were those that had been referred to BCCH dentistry by the emergency department, after normal clinic hours. 3.1 Inclusion criteria • Patients that were referred to DD-BCCH for emergency care from ED-BCCH. • Patients aged 0-17 years. • Patients treated after 4:00 p.m. on weekdays, or on weekends and holidays. 3.2 Exclusion criteria • Patients who were referred to the dental department during normal working hours and therefore not considered emergencies. 3.3 Study Procedures A list of patient numbers, name, and procedure dates for all cases, fitting the eligibility criteria for the period of January 1, 2018, to Dec. 31, 2021, was obtained from reviewing dental records within Cleardent dental software and Accuro dental software. Each chart was assessed for eligibility, and ineligible cases were rejected. The dental record number was linked to a subject ID in an encrypted Excel spreadsheet. The subject ID from the excel sheet was then used to enter data on REDCap, physically separating RedCap from any personal identifying information. The principal investigator and research supervisor only had access to the anonymized data. 21 3.3.1 Variables measured 1. Patient demographics: a. Record ID (auto generated by RedCap, linked to Chart ID or Cleardent ID in an encrypted Excel spreadsheet). b. Age c. Sex d. Postal code (only the first 3 digits/letters) e. Healthy kids f. Dental home g. Medical diagnosis 2. Visit details: a. Date of emergency b. Date of onset of symptoms c. Day of presentation to the ED d. Time of injury e. Time of dental intervention f. Affected teeth g. Treatment provided by h. Records taken i. Location of treatment j. Sedation used for treatment k. Follow up plan 22 3. Traumatic dental emergencies: a. Diagnosis b. Place of injury c. Cause of injury d. Treatment performed 4. Non-trauma dental emergencies: a. Diagnosis b. Treatment performed 3.4 Data Analysis Data was analyzed using GraphPad Prism statistical software. Descriptive statistics were first completed for the overall sample. Pearson’s Chi-squared Tests and Fisher’s exact test were used for bivariate analysis. p value of <0.05 was used to indicate statistical significance. Parts of whole data was analyzed with the Binomial test and confidence intervals were calculated using the Wilson-Brown test when comparing historical data with data from our study. R Core Team (2022) was used to generate figures for time series analysis. 23 Chapter 4: Results 4.1 Relative rate of dental after-hours emergencies per year Patients for our study were collected from January 2018 through December 2021. This period included a prepandemic sample of 26.5 months (January 1, 2018-March 16, 2020) and a pandemic sample of 21.5 months (March 17, 2020 – December 31, 2021). We excluded 12 patient charts from our 2018 study sample due to incomplete clinical documentation. Only emergency visits that were referred to dentistry by the BCCH emergency department out of normal clinic hours were included in the study. Rarely are emergencies seen during the workday since most are treated by dentists in the community. The true emergencies are those that come to the ED after 4 p.m. or are referred in from surrounding hospitals. The absolute number of patients in the pre-pandemic study sample is 142 while the pandemic study sample is 153. The frequency of dental emergencies seen by dentistry, after-hours, is 5.3 patients per month pre-pandemic and 7.1 patients per month during the pandemic. The number of out of hours dental emergencies was significantly lower in the year 2018 when compared to the years 2019, 2020 and 2021 (Fig 4.1). The reasons for these differences were not visible in the Figure 4.1 Number of emergencies by year. There were significantly fewer dental emergencies in 2018 than other years. However, 2019 which was prepandemic numbers were similar to the pandemic 24 patient demographics (Table 4.1). To compare the data in 2018 to other periods we converted the absolute values into percentages (Fig. 4.7). 4.2 Demographic characteristics To assess potential differences brought on by the pandemic, the patient files were separated into two groups, prepandemic and during the pandemic. Throughout the period of study between 2018 and 2021 there were similar age distributions of the patients, similar increased prevalence of male versus female patients and a similar proportion with other medical diagnoses (Table 4.1). Healthy children made up the majority of cases in both time periods (pre-pandemic: 80.1%; pandemic: 81.5%). Regarding the dental home, the highest frequency was noted for children who were being seen regularly by the community general dentists (pre-pandemic: 43.4%; pandemic: 50%) while the proportion of patients being seen by specialists was increased during the pandemic (not significant). BCCH dental clinic patients were the lowest frequency (pre-pandemic: 3.10%; pandemic: 1.3%) suggesting the urgent needs were being handled during normal clinic hours. 25 Most patients seen by DD-BCCH for after-hours emergencies, lived within 15km of BCCH (Table 4.1; pre-pandemic: 43.07%; pandemic: 44.4%; Fig. 4.2). Table 4.1 Patient Demographics + BCCH and Community pediatric dentist categories merged to do a 2-way Chi-squared test. Still the data are not significant. Pre-pandemic “n” (percentage “% out of 131 cases) Pandemic “n” (percentage “% out of 152 cases) p-value Age (in years) 0.9921 0-3 42 (32.06) 48 (31.5) 4-7 39 (29.7) 45 (29.6) 7-11 30 (22.9) 37 (24.3) 12+ 20 (15.2) 22 (14.4) Sex 1.000 Male 81 (62.8) 97 (63.0) Female 48 (37.2) 57 (37.0) Medical Status Healthy 105(80.1) 124 (81.5) Co-morbidities 26 (19.9) 28 (18.5) Dental Home 0.0761+ None 44 (34.1) 34 (22.1) BCCH dental clinic 4 (3.10) 2 (1.30) Community Pediatric Dentist 25 (19.4) 41 (26.6) Community General Dentist 56 (43.4) 77 (50.0) City of Residence 0.79 Within 15km 56 (43.07) 68 (44.4) 16-30km 29 (22.3) 34 (22.2) 31-45km 22 (16.9) 30 (19.6) >45km 23 (17.6) 21 (13.7) Figure 4.2 Distance travelled. Majority of patients lived within the lower mainland or 15 km of BCCH. This indicates regional hospitals also treat dental emergencies in children 26 4.3 Details of the emergency cases The time of week when emergencies were seen did not change during the pandemic. Significantly more patients were treated on weekdays than weekends in both time periods (pre-pandemic: 67.94%; pandemic: 61.18%). The wait time (difference in time of injury and time of intervention) was not significantly affected by the pandemic. Most patients were treated within 300-600 minutes of their dental injury (Fig. 4.3; pre-pandemic: 43.9%; pandemic: 53.3%). These waiting times far exceeded the goal of 120 minutes for non-urgent cases as listed in the PaedCTAS triage scale (Gravel et al. 2013). There were also no differences in frequencies of emergency visits across the calendar. A significantly higher proportion of emergencies were treated by the attending pediatric dentist during the pandemic (Table 4.2; pre-pandemic: 1.52%; pandemic: 9.86%). In the lockdown period, Attendings came in to treat the patients. Another interesting finding was that a significant proportion of patients had photos taken during the pandemic (pre-pandemic: 5.18%; pandemic: Figure 4.3 Wait times for all types of dental emergencies. There are no significant differences between the wait times 27 28.28%). The photographs were necessary to make a more accurate determination of whether a patient needed an in-person examination. The aim during the pandemic of all clinics was to decrease the number of people coming in. After strict triage criteria were followed, the number of family members allowed in with the patients was also controlled. The policy at BCCH was one caregiver per child for all of 2020 and extending into 2021. We were unable to assess whether treatment was provided in the ED or dental clinic from reading the records. However, the cases that were treated under general anesthesia could be identified. These cases represent a minority of all emergencies treated. Typical reasons for bringing the patient into the OR include incision and drainage tube placement, control of bleeding that requires cautery, complex closure of a degloving injury and jaw fractures requiring intermaxillary fixation. It is interesting that a significantly higher percentage of patients were treated under sedation during the pandemic (Table 4.2; pre-pandemic: 6.11%; pandemic: 18.42%). The reasons for this change are unclear but may be due to the fact these patients needed complex treatment involving splinting and were very anxious. A standard policy is for patients to follow up with either a community pediatric dentist (pre-pandemic: 45.80%; pandemic: 34.86%) or a community general dentist (pre-pandemic: 31.29%; pandemic: 33.55%). If they do not have a dental home, then patients are provided with a list of specialists in their area. 28 Table 4.2 Characteristics of the emergency visits 4.4 Traumatic dental injuries versus non-traumatic emergencies The null hypothesis was that there would be no change in the proportions of odontogenic infections and other types of non-traumatic dental emergencies versus traumatic injuries during the pandemic. We thought the hypothesis would be rejected since children were encouraged to stay home, not participate in group activities including organized sports and even not to play in playgrounds. Indoor play was thought to be safer in terms of risk of having a traumatic injury. Surprisingly, the proportion of TDIs versus NTDEs did not change due to the pandemic (Fig. 4.4). Pre-pandemic “n” (percentage “% out of 131 cases) Pandemic “n” (percentage “% out of 152 cases) p-value Day of week 0.2637 Weekdays 89 (67.94) 93 (61.18) Weekends 42 (32.06) 59 (38.82) Wait time (in minutes) 0.5935 0-300 22 (24.1) 16 (17.7) 301-600 40 (43.9) 48 (53.3) 601-900 13 (14.2) 15 (16.4) 901-1200 8 (8.7) 5 (5.5) >1200 8 (8.7) 6 (6.6) Provider 0.0130 (*) Specialty trainee 124 (94.65) 132(86.84) Attending pediatric dentist 2 (1.52) 15(9.86) Oral Surgeon 5 (3.81) 5(3.28) Records <0.0001 (****) Radiographs 107 (79.25) 129 (65.15) Photographs 7 (5.18) 56 (28.28) None 21 (15.55) 13 (6.56) Location of treatment NS Operating Room 8 (6.10) 5 (3.28) Sedation used 0.0021 (**) Yes 8 (6.11) 28 (18.42) No 123 (93.89) 124 (81.58) Follow-up 0.2498 BCCH dental clinic 25 (19.08) 39 (25.65) Community general dentist 41 (31.29) 51 (33.55) Community pediatric dentist 60 (45.80) 53 (34.86) Oral Surgeon 5 (3.81) 7 (4.60) Medical specialist 0 (0.00) 2 (1.31) 29 Prepandemic, DD-BCCH treated 103 traumatic dental emergencies and 28 non-traumatic dental emergencies. During the pandemic, 118 traumatic and 34 non-traumatic dental emergencies were treated. The interrupted time series analyses by weeks and months (Figs. 4.5 and 4.6), show all the data points and one standard deviation. The pandemic did not affect the number of traumatic and non-traumatic dental emergencies being treated by DD-BCCH. Thus, we accepted the null hypothesis. Figure 4.4 Traumatic versus non-traumatic injuries. While the number of traumatic injuries seen in the emergency department was higher than the non-traumatic injuries, this distribution was unaffected by the pandemic 30 Figure 4.5 Interrupted time series analysis - monthly counts of dental emergencies. The full dataset showing the weekly distribution of traumatic versus non-traumatic emergencies plus or minus 1 standard deviation (grey). There is a much more variable distribution to the traumatic injury cases per month which could explain why there are no differences between pre and during pandemic periods. 31 Figure 4.6 Interrupted time series analysis - weekly counts of dental emergencies. Similar results to weekly distribution of emergencies. Much greater variability is seen for the traumatic injuries so when data is collapsed into years this explains why there are no statistical differences. Grey area indicates plus or minus one standard deviation. Figure 4.7 Proportion of cases due to trauma versus non-trauma. A) Percentage of cases in each of the years of the study. There were no significant differences between the 3 years as shown with Fisher’s exact test. B) Separating the waves of the pandemic and comparing these to a similar interval prepandemic also did not show statistically significant differences with Fisher’s exact test. 32 We did not find significant differences between the proportion of traumatic dental injuries in the different years (Fig. 4.7A). Thus, even though the total number of cases in 2018 was small, the distribution between trauma and non-trauma emergencies was similar to 2019. We also broke the data down according to waves of the pandemic. There was no change in the proportion of traumatic and non-traumatic dental emergencies including during the first wave between March and May of 2020 (Fig. 4.7B). 4.5 Age of patient and types of emergencies We predicted that the age ranges of patients would be younger for those children seeking care for traumatic injuries. Indeed 0-3- and 4–7-year-old children had the highest frequency of traumatic injuries both pre and during pandemic. There were no significant differences in the proportions of traumatic and non-traumatic emergencies when broken down by age (Fig. 4.8). 0-34-78-11 12+050100150Age bracketsNumber of casesPre-Pandemic TIsPandemic TIsPre-Pandemic NTEsPandemic NTEsFigure 4.6 Proportions of cases according to age bracket. There was no significant change in the age brackets of patients seen pre and during the pandemic as well as by emergency type. 33 The proportion of dental hard tissue trauma (pre-pandemic: 33.47%; pandemic: 29.66%), soft tissue injuries (pre-pandemic: 29.75%; pandemic: 34.66%) and dental supporting tissue trauma (pre-pandemic: 36.77; pandemic: 35.66%) were not significantly different in the two study periods (Table 4.3). However, there was a significant change in the causes and locations of traumatic dental injuries according to whether these occurred prior to or during the pandemic. There were significantly more TDIs caused by bike accidents during the pandemic (pre-pandemic: 11.65%; pandemic: 24.57%) and a decrease in injuries involving hits during the pandemic (pre-pandemic: 22.33%; pandemic: 12.71%). Interestingly, significantly more TDIs were sustained outdoors during the pandemic (pre-pandemic: 59.80%; pandemic: 74.78%). For treatment provided, a significant proportion of injuries were treated with repositioning and splinting during the pandemic (pre-pandemic: 14.56%; pandemic: 29.66%) and fewer injuries received no treatment (pre-pandemic: 32.03%; pandemic: 17.79%). Extraction was the most common treatment provided but it did not change due to the pandemic (pre-pandemic: 34.95%; pandemic: 36.44%). 4.6 Time of occurrence of Traumatic Dental Injuries We confirmed that most of the traumatic dental injuries occurred during the afternoon and evening hours when children are more likely to be outdoors and riding bikes. This distribution was significant and did not change between prepandemic and pandemic periods. 34 12AM-6AM6AM-12PM12PM-6PM6PM-12AM0204060Time of occurrence of Traumatic InjuriesNumber of casesPre-PandemicPandemicFigure 4.7 Time of day when traumatic injuries occurred before or during the pandemic There are no significant differences between the prepandemic and pandemic data 35 Table 4.3 Types of traumatic injuries, causes, location and treatment Pre-pandemic “n” (percentage “% out of 131 cases) Pandemic “n” (percentage “% out of 152 cases) p-value Diagnosis 0.4360 Dental hard tissue trauma 81 (33.47) 89 (29.66) Soft tissue injury 72 (29.75) 104 (34.66) Dental supporting tissue trauma 89 (36.77) 107 (35.66) Cause of injury 0.0428 (*) Falls 62 (60.19) 66 (55.93) Bike accidents 12 (11.65) 29 (24.57) Hits 23 (22.33) 15 (12.71) Others 6 (5.82) 8 (6.77) Location of injury 0.0205 (*) Indoors 41 (40.20) 29 (25.22) Outdoors 61 (59.80) 86 (74.78) Treatment 0.0227(*) Extraction 36 (34.95) 43 (36.44) Repositioning and splinting 15 (14.56) 35 (29.66) Cvek pulpotomy 5 (4.85) 8 (6.77) No Treatment 33 (32.03) 21 (17.79) Others 14 13.59) 11 (9.32) 4.7 Characteristics of Non-traumatic emergencies The most prevalent diagnosis for non-traumatic emergencies pre-pandemic was odontogenic infection (Table 4.4; pre-pandemic: 40.47%; pandemic: 21.95%) and during the pandemic was pain (Table 4.4; pre-pandemic: 33.33%; pandemic: 34.14%). The most frequent treatment performed for infections was no treatment (pre-pandemic: 36.66%; pandemic: 29.41%). Extractions were the next most common treatment performed (pre-pandemic: 30.0%; pandemic: 26.47%). The sample size of these non-traumatic emergencies was too small to perform an accurate chi-square analysis. 36 Table 4.4 Characteristics of non-traumatic dental emergencies ++ Case numbers too small to perform an accurate chi-square analysis. Pre-pandemic “n” (percentage “% out of 131 cases) Pandemic “n” (percentage “% out of 152 cases) p-value Diagnosis ++ Pain 14 (33.33) 14 (34.14) NS Bleeding 2 (4.76) 3 (7.31) NS Odontogenic infection 17 (40.47) 9 (21.95) NS Non-odontogenic infection 4 (9.52) 3 (7.31) NS Other 5 (11.90) 12 (29.26) NS Treatment ++ Extraction 9 (30.0) 9 (26.47) NS Analgesics 1 (3.33) 2 (5.80) NS Antibiotics 5 (16.66) 6 (17.64) NS No treatment 11 (36.66) 10 (29.41) NS Other 4 (13.33) 7 (20.58) NS 37 Chapter 5: Discussion In the present study we carried out a thorough retrospective chart review of all patients that came to BCCH for treatment immediately prior to and during the major phases of the Covid-19 pandemic. We specifically looked at after hour emergencies as it was very difficult to track down emergencies treated by DD-BCCH during normal clinic hours due to the billing code being non-specific for emergencies. This project was born out of concern that patients may have been unable to receive care in a timely manner and more serious types of emergencies would have accumulated. We were also concerned that with an unprecedented shut down of dental offices and the specific directions to minimize aerosol generating procedures that there would only be hospitals such as BCCH providing care for children. Dentists were fearful because they could not purchase the PPE needed to safely provide care. There was mixed messaging about the mode of transmission of the virus, how long the virus would persist on surfaces or in the air, all of which made it difficult for private offices to reopen. Our study discovered that BCCH did provide a high level of care during the pandemic including the placement of more splints, the taking of photographs and provision of sedation to more patients. There was no major distortion of the types of dental emergencies that visited the ED. Children were experiencing similar risks of having a traumatic dental injury or developing an odontogenic infection as prior to the pandemic. The detailed examination of the charts revealed other unexpected findings. There were more children experiencing trauma outdoors than indoors which indirectly suggests that outdoor play (particularly bike riding) was promoted by parents during the pandemic. The causes of injuries were very commonplace activities where wearing a protective mouth guard would not be expected. 38 5.1 Effects of the pandemic on pediatric dental emergencies in BC There were aspects of the data that did not change as a result of the pandemic and a few areas where significant change was observed. Consistent predominance of male patients was seen in both periods. In our study, the highest proportion of patients consulted by ED had a general dentist as their primary provider in the community and this did not change during the pandemic. Most of the emergencies in our study presented during weekdays. This contrasts with a large study conducted by Lewis et al, which found an estimated 2.95 million ED visits for dental-related complaints in the United States throughout a 4-year period. Most of the dental complaints occurred on weekends when dental offices are more likely to be closed (Lewis et al. 2003). The wait time before receiving dental treatment, which was calculated as the difference between time of injury and time of intervention by a pediatric dental provider, was not affected by the pandemic. Most of the emergencies were assessed between 300-600 minutes from the time of injury. Unfortunately, this wait time is far longer than the triage standards set forth for non-urgent cases (120 minutes) (Gravel et al. 2008). It is important to recognize that patients do not present to the ED immediately after the emergency was identified, which delays treatment even further. A major change was seen in the provider type during the pandemic as compared to the pre-pandemic period. There was a significantly higher proportion of patients treated by attending pediatric dentists. This was a result of two factors. First, the Faculty of Dentistry at UBC halted all clinical exposures to students between March 16th and June 1st 2020, whether at UBC or at BCCH. Students were prohibited from providing direct patient care during this time. Once clinic resumed "Waterfall scheduling" was adopted at DD-BCCH, with dentists working 1 week, including after-hour emergency calls, followed by three weeks off. These dentists would go in to 39 treat patients on call and the students did not initially accompany the dentist. This approach aimed to limit department-wide exposure and provide recovery time for exposed dentists (Park 2023). The current protocol is for pairs of students to attend emergencies in the ED. Once they assess the patient they provide photos and radiographs to the Attending over the phone and confirm the treatment plan. Trainees then provide follow up photos at the conclusion of treatment. The pandemic prompted a sharp shift towards using clinical photos to assess dental emergencies remotely. There are many emergencies that dentistry is consulted for and the dental on-call team decides is not a true emergency requiring an in-person consultation. The protocol is to discuss this with the ED physician over the phone. No clinical note is made in the patient’s chart by dentistry to document this discussion. Due to the lack of documentation by dentistry, we were unable to ascertain the true number of emergencies ED-BCCH actually consulted DD-BCCH for. Additionally, in the documentation made by ED-BCCH, dentistry is categorized as “other” and there is no separate CTAS code for dental issues. However, the usage of clinical photos streamlined triage and reduced unnecessary in-person consultations for non-emergencies. This positive trend persists to the present day, with clinical photos now serving as crucial records in patients' dental charts for tracking healing and progress. Sedation use increased significantly during the pandemic. The sedation committee at BCCH, which included the department head of dentistry, was redeveloped with new leadership. They recognized that using sedation facilitated the completion of full dental treatment in the ED, eliminating the need to transfer sedated children to the dental clinic. In addition, in 2021, the ED was for the first time fully equipped with an x-ray machine and dental clinic software so patients could remain in the ED during their treatment. Intranasal midazolam is offered by the nurses to reduce anxiety during procedures such as extractions since fasting is not required. BCCH's Child 40 Kind certification in January 2023 underscores its commitment to providing sedation for all children undergoing traumatic procedures (Park 2023). Similar increase in sedation usage was noted by the study on pediatric dental emergencies completed at Seattle Children's Hospital (Walsh et al. 2023). Our study also revealed a significant increase in providing definitive care for TDIs. This includes repositioning and splinting. Usually these patients are discharged from the ED and brought to the dental clinic since there is suction and air available. Overall there were significantly fewer TDIs that were not treated. The most likely reason is that triage was more efficient with photographs provided by the physicians. This helped trainees to identify true emergencies that required in-person consultation and treatment. Extraction was still the most prevalent treatment option for TDIs and NTDEs which aligns with the recommendation during the pandemic to provide non-AGP procedures. When examining the NDTEs, we noted that before the pandemic odontogenic infections were the most frequent reason for presentation to the ED whereas pain was the most frequent cause during the pandemic. This difference in frequency was not found to be significant. Interestingly, a 2016 study found that the majority of NTDEs seen by EDs across BC in all the hospitals, were non-urgent (Ahmed 2016). 5.2 Evolution of dental emergency treatment at BCCH A previous study completed by the current Chief of Dentistry, Dr. Jennifer Park, was carried out between 2013 and 2015 to identify any trends regarding dental emergencies that have changed over the previous 5 years (2009-2012) (Park 2015). In this retrospective chart review, they chose to review the first 5 patients from each month so that the full calendar year was sampled. There was a chance that 5 patients would not cover the full scope of emergencies however the authors 41 did a careful pilot study to determine whether this sampling was sufficient. They estimated that 300 patients spread out over 5 years would have sufficient power to analyze the trends including seasonal effects. Our study purposely took a different approach. We wanted to sample all the emergencies in part because the waves of the pandemic were relatively intense and lasted for short periods. There were also dramatic changes in dental care during the pandemic so we could not rely on punctuated sampling that might have worked well in stable, prepandemic or non-pandemic times. Another important difference in methodology between the Park study and ours is that they included dental emergencies referred by ED-BCCH during working hours. These cases would have been brought into the ambulatory clinic during the day. Our study only included after-hour emergencies which included periods during the day when the clinic was closed due to the pandemic. Interestingly, DD-BCCH has anecdotally reported a steady decline in dental emergencies between 2015 and 2017 (Table 5.1) however we still found a regular rate of emergencies in the study period 2019-2021. Table 5.1 Number of patients seen for emergency treatment at BCCH in the dental clinic Year Office hours After hours 2015 74 97 2016 48 88 2017 37 72 Both the Park study and ours have a similar weakness in that they do not capture all dental emergencies that were seen by ED-BCCH. A proportion of these emergencies are treated directly by the medical staff without paging dentistry. Dr. Park makes annual presentations to the ED to update the new residents and trainees on the classification of dental emergencies and how to identify those that require dental intervention. This training is reducing the number of times dentistry is paged, particularly for primary tooth injuries or infections. 42 We were interested to find out how similar our prepandemic data was compared to the data from Park. Like our study, the Park analysis noted a significant male predominance in the patients. There was also a predominance of younger children aged 0-3 and 4-7 years, living within a 15km radius of BCCH. The Park study found that emergencies were mainly on weekdays during afternoons and evenings. We were able to validate all these trends with more complete sampling. There were also some striking differences between our two studies. The most dramatic of these differences was the proportion of emergencies that were due to dental trauma compared to other causes (Fig. 5.1). In the recent data, there were significantly more traumatic injuries than in the historical data, whereas there were fewer odontogenic infections in the recent prepandemic data from 2018-2020 compared to the historical. The lower numbers in 2018 may be partially attributed to shorter wait times for dental surgeries in 2018. This meant that possibly patients receiving full mouth rehabilitation received treatment sooner, thus avoiding odontogenic infections (Park 2023). The dental department at BCCH has been under the direction of 4 different chiefs. In 2009-2012 the chief was Dr. Doug Johnson, from 2012-2018 it was Dr. Karen Campbell, from 2018-2019 it was Dr. Washam Cheung (interim chief) and from 2019-present the chief is Dr. Jennifer Park. Each chief has made improvements. There was certainly more detail available in the present electronic health record compared to the paper consultations sheets that were reviewed by Dr. Park. We were unable to expand the sample to prior years since charts for 2016-2017 had been moved offsite for storage. However, there may have been a benefit to not including these older records. An important finding is that the 2018-2020 prepandemic data was far more suitable as a comparison group than the historical data. Our results show extractions and repositioning and splinting to be the most prevalent treatment option whereas no treatment was the most prevalent 43 approach for traumatic injuries (Park 2015). Before year 2012, GPRs would be the solo on-call resident managing dental emergencies referred by ED-BCCH. Starting in 2011, pediatric dental trainees began handling calls alongside the GPRs. Since the Park study covered cases from 2009 to 2012, the shift in call responsibilities may also account for a change in delivering more conclusive treatments. Additionally, dentistry has been using a portable x-ray machine that was not available to trainees in the time period that the Park study was reviewing. This, along with more support from the ED staff, has made definitive treatment more possible. 5.3 Worldwide effects of the pandemic on types of dental emergencies Our hypothesis was that there would be fewer TDIs due to periods of strict lockdown in 2020 when access to playgrounds and public spaces was limited, schools were closed, and many parents Figure 5. 1 Historical versus present classification of emergencies. A historic study carried out by Park at BCCH sampled the first 5 patients of each month for 5 years between 2009 and 2013. The percentage of cases was significantly different compared to the present study. Parts of whole data was analyzed with the Binomial test and confidence intervals were calculated using the Wilson-Brown test. 44 were working remotely from their homes. It seems that children were playing at home or outside their homes and continued to sustain dental trauma that warranted a visit to the ED. Similar trends were found by studies completed at the Seattle Children’s Hospital (Walsh et al. 2023), Rady’s children’s hospital in San Diego (Whyte et al. 2023) and in an emergency department in a hospital in China (Wu et al. 2021). However, the Wu study (Wu et al. 2021) did not break down the data for pediatric patients less than 17 years of age. A UK study looking at patients of all ages found that most TDIs during the first lockdown were sustained at home while more TDIs occurred outside the home during UK’s second lockdown phase (Blackhall et al. 2020; Blackhall et al. 2021). One reason for fewer dental consultations for NTDEs compared to TDI is that ED physicians are more comfortable managing pain and infection in the orofacial region. They can treat these and discharge the patient without requesting dental consultation. When looking into the details of the traumatic emergencies, we found a significant increase in bike accidents as parents and children looked for ways to escape the four walls of their homes. The decrease in proportion of TDIs due to hits is in line with reduced contact sports during periods of lockdown. There were no statistically significant findings comparing the first wave which was a full lockdown to the later waves of the pandemic. Another study carried out in San Diego did compare the prepandemic period to the initial lockdown to a later period of the pandemic (Whyte et al. 2023). Their study included 1013 patients which increased the power to detect differences. There were significant changes in the types of treatment provided between the prepandemic, initial lockdown and later phase of the pandemic. A significant increase occurred in NTDEs and use of antibiotics during the lockdown and in the continuing phases of the pandemic compared to the prepandemic period. There were also a greater number of non-AGPs during the pandemic, a variable that we did not include in our 45 study (Whyte et al. 2023). These authors also provided positivity results for COVID-19 tests which was not available to us. They found only 4.3% of patients tested positive, which is reassuring for the healthcare provider. None of the other variables examined were changed in the different waves of the pandemic compared to prepandemic similar to our study including the relative frequency of TDI and NTDEs. The age group and gender that was most commonly seen at ED-BCCH was males aged 3 or under. This trend has been noted in other recent studies (Cully et al. 2019; Ozgur et al. 2021). Male children in this age group demonstrate risky behavior as they are learning to walk and exploring their surroundings while they’re still developing motor coordination. Additionally, young children have proportionally larger heads, hence, a higher center of gravity. This predisposes them to head and face injuries in the event of a fall. In contrast, other studies completed before the pandemic, focusing on TDIs, found that the mean age of most frequently injured boys ranged from 7-12 years (Anderson et al. 2021; Hall et al. 2016; Montero et al. 2019; Ritwik et al. 2015). This age group is engaged in more outdoor sports which predisposes them to falls, hits and contact injuries. We also observed boys aged 4-7 were more frequently attending the ED with dental emergencies and this trend was not significantly affected by the pandemic. No treatment or observation is the most common treatment for the following TDIs – concussion, subluxation, intrusive luxation (mild to moderate), uncomplicated crown fractures, avulsed primary teeth and some cases of root fractures in the primary dentition (Bourguignon et al. 2020). During the pandemic, pain was found to be the most frequent reason for presenting to the ED in some studies. In a study carried out in an Indian tertiary care hospital (Kumar et al. 2021) the, most common treatment during the pandemic was no treatment or advice/reassurance. Extractions were also completed frequently both during and before the pandemic for these 46 emergencies. A large study completed prior to the pandemic in Montreal, for dental conditions over a 10-year period (2004-2013), noted that dental pain due to caries was the most common reason for presentation to the ED of their pediatric hospital. They also found that females teenagers were more likely to present to the ED with NTDCs (Ferraz Dos Santos and Dabbagh 2020). Similar trend was noted in a study completed in the US looking at NTDC visits to EDs from 2010 to 2017 (Morgan et al. 2021). In our study males were more likely than females to present to our ED with NTDCs. We found there was no change in the rates of NTDEs presenting to the BCCH ED prior to or during the pandemic. This contrasted with the findings in several other studies completed during the early phases of the pandemic which noted an increase in the rates of infection during the pandemic (Alzahrani et al. 2021; Eggmann et al. 2021; Goswami et al. 2021; Guo et al. 2020; Patel et al. 2021). The BC population may have more access to dental care and thus serious odontogenic infections are relatively rare. 5.4 Study Strengths and Limitations According to a search of the medical literature, this study is the first to break down the data into the three major waves of the COVID-19 pandemic in BC, Canada and to the best of our knowledge, world-wide. Our control period preceding the pandemic is also quite robust and significant compared to most studies completed on this issue. Although there are plenty of studies looking at the effects of the pandemic on dental emergencies world-wide, a detailed study looking at the characteristics of dental emergencies in the Canadian healthcare landscape during COVID-19 was lacking. Although the patient numbers were sometimes too small to analyze when data was broken down into categories, the major trends could be analyzed with statistics. 47 Our study is not without limitations. Retrospective chart reviews are reliant on existing chart documentation. The records are completed by multiple dental trainees or attending pediatric dentists/oral maxillofacial surgeons. Fortunately, since 2019 all records in the dental clinic are electronic, including the records of the dental emergency patients. Going forward the dental and medical records will be harmonized and put onto the main medical health record so all physicians throughout the province can read about emergency visits. One area for improvement is to find out the true extent of all dental emergencies that are seen by the ED physicians. Currently there is no tracking of the dental complaints that come to the ED if the patients are not referred to dentistry. BCCH is not currently entering a specific CTAS code for dental complaints. It is possible that with improvements to the electronic health record additional codes for the type of visit and diagnosis could be entered by the attending physician. These codes would be captured in the discharge of the patient and put into the Canadian Institute of Health Information (CIHI) database. This is a national repository of discharge diagnoses with anonymized patient demographic information. Another limitation is that our study was carried out at one centre, BCCH. However, BCCH is representative of a typical Canadian children’s hospital and the Canadian public health measures which were more consistent nationally than in the USA. data will be applicable for planning other pandemic responses in the future. We did not find that the public health measures changed patients’ decisions about where and when to seek dental care in BC. 48 Conclusions ED-BCCH is uniquely positioned as the province’s only Level 1 pediatric trauma centre and provides care to more than 43,000 patients annually from across the province. It is the only emergency department in all of BC with 24/7 pediatric dental on-call coverage by specialty trainees supported by pediatric dentists. EDs serve as crucial care points for dental issues, especially for those without private dental insurance in BC, Canada. Medical Services Plan (MSP) covers the cost of consultation and dental extractions at hospitals, so finances are never an issue. EDs are relied upon for evaluating and treating a range of dental injuries, both simple and complex. The utilization of a multi-disciplinary team is vital, especially for pediatric oral and dental trauma care. In cases of traumatic injuries, often more than just the teeth and supporting structures are affected. Parents are concerned about the overall well-being of their children. Head trauma and neurological issues often needs to be ruled out prior to dental intervention. This can be accomplished by the ED physician who then consults with the on-call dentist, if deemed necessary. Our study showed that of those that dentistry did in person consultation for, the number of dental emergencies did not change due to the pandemic. We also found that the proportion of traumatic to non-traumatic injuries remained unchanged in favor of traumatic injuries. There was no significant drop in the number of dental emergencies in the first wave (March-May 2020) compared to the same period in 2019. Thus, the ED-BCCH continued to function as normal and dentistry received the usual number of calls. Our healthcare system was resilient and did provide a high standard of care. This level of care is impressive considering the reports of stress and burnout in hospital staff during the most intense parts of the pandemic, prior to vaccination (Diskin et al. 2023). Other reasons include better triaging by ED-BCCH due to continued efforts by the current chief in dentistry at educating them via presentations. In conclusion, our study sheds light 49 on the important role of ED-BCCH in serving the pediatric patients in BC and provides important guidance for the next pandemic. It is essential to maintain access to hospital emergency departments during a pandemic and it is very important to include dentistry as a vital service during these times of widespread health care disruption. It also important for community dental offices to stay open and handle emergencies definitively to avoid overloading ED. 50 Knowledge transfer The results of our study can allow ED-BCCH to plan better for future pandemics or other province-wide emergencies where access to care is blocked. The fall and early winter of 2022-23 presented a formidable period for pediatric hospitals in Canada, marked by a surge in Emergency Department admissions for RSV, Influenza, and COVID-19 concurrently. This confluence has been termed a "triple threat for kids," posing significant challenges for healthcare providers. High-quality research is crucial for the development of evidence-based injury prevention policy and programming. 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Thesis/Dissertation
eng
Craniofacial Science
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Richman, Joy M.
Covid-19 impact on dental emergencies at BC Children’s Hospital
Text