Pediatric dentistry: between invasiveness and less access

In a world where some dentists make future plans independent of their honorary profession and others are thinking of retiring early – for the most optimistic in Pediatric Dentistry – who still believe in the stenic value of exceptional pandemic challenges – it’s time to reorganize, reset and reflect on day-to-day care protocols. It is no longer a novelty that Dentistry is placed by OSHA (Occupational Safety and Health Administration Inspections) among the professional categories exposed to high infectious risk. Guides based on scientific evidence, expert recommendations, the experience of other countries and/or other epidemics informed Dentistry (with particularities for Pediatric Dentistry) on the conditions for minimizing the risk of transmission and contamination for both medical staff and patients – whether adult or pediatric.

Despite all these measures – given the prolongation and worsening of pandemic health conditions – what kind of dentistry is still recommended during a pandemic? Are the same selective emergency treatments recommended? After 8 months of lock-down and military and/or legal constraints and limitations – can the minimum set of oral health care treatments be maintained at the same – Middle Ages Level? Which means that after years of discouraging on-demand and emergency dental treatments – now we only recommend treatments for borderline diagnoses accompanied by extreme pain, infection, bleeding and endangering – no, no, not the quality of life – but life itself! A parent’s reply – requesting an appointment for a 3-year-old with two painful initial caries to food stimuli – in the face of refusing and postponing the appointment on the grounds that a simple caries is not a real emergency – according to the March Military Ordinance – was an ethical challenge for me:  … but what is not urgent today will be urgent tomorrow! I confess that throughout my career I have been ashamed – professionally speaking – twice: once thanks to a parent who reproached me in the 2000s that I did not have enough preventive approach for new caries (why does his child have new caries although he regularly brings the child to the dentist…?) and another time in 2020 – thanks to the pandemic aftershocks mentioned above.

The ethical discomfort felt in the two critical situations above is actually due to the same dogma with which traditional dentistry was indoctrinated both in principle and de facto: invasive restorative dentistry – the younger sister of previous extractionist dentistry. Stomatology of milling cutter and high rotation speeds! In Western countries and in private dentistry it is called Drill-Fill-PIN! In other words… if it’s not a milling cutter… it’s not dentistry either! Indeed – in the traditional dental health system – not only in Romania – it is generally accepted as – the best practice – for the management of dental caries – is the complete surgical removal of degraded tissues from caries with the help of rotating instruments (low or high speed) and replacement of missing tissues by placing a plastic seal in their place. Rotary milling in hard dental tissues – it is considered a surgical act and by virtue of it – not accidentally – the title of the French dentist is not that of a medicine dentist but of a chirurgien dentist!

But if the invasiveness of milling dentistry is not yet an argument for restructured decisions and applications, then the potential for transmitting the infection via aerosols produced by rotary instruments that usually work with water – for cooling – can be an edifying argument. Therefore – in the version in which we do not renounce this profession as a group – a profession of excellence but of great complexity even in normal conditions – nowadays we have to adapt our protocols and to select therapeutic procedures while taking into account the risk of aerosol transmission produced by the high-speed instrumentation traditionally used and which obliges us – in addition to the precautions Standard Infection Control (SICPs) to measures based on the mode of transmission (TBPs) (see tab 1).

To summarize – from national and international guidelines result in

4 main lines of restructuring and reorganization of Dentistry

1. Remote consultation and triage service: Minimizing the number, frequency and duration of face-to-face consultations through online scheduling management: triage and remote documented consultation.
2. One stage/day dentistry: If the patient is selected and scheduled in the office: (multiple treatments to be initiated and completed in the same session)
3. Innovative Minim invasive and preventive dentistry upgrading: Revaluation of non-procedural and/or minimally invasive preventive dentistry that do not require high-speed instruments and that is aerosol-free and NO SARS-CoV-2 friendly.
4. Infection Control Precautions: Precautions for infection transmission through SICPs and TBPs. (see tab.1)

Tab 1. Infection Control Measures in Dentistry

Tab 2. Dental procedures and their ability to produce droplets and aerosols