Remote management of dental problems in children during and post the COVID-19 pandemic outbreak: A teledentistry approach

The recent pandemic outbreak of coronavirus disease 2019 (COVID-19) has created a helpless situation in healthcare systems worldwide. The disease can be transmitted in different ways, e.g., through contact, droplets, fomites, and aerosol-generating procedures. Subsequently, the World Health Organization (WHO) released recommendations regarding precautions to be taken by all healthcare workers, including dentists, in order to avoid the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 indeed has become a pandemic, and there is a need for an innovative method to continue providing dental care to children with a minimal risk of cross-infection. The objective of this short communication was to draw special attention to the teledentistry model in pediatric dentistry and to guide the management of children with dental problems during the COVID-19 pandemic. Teledentistry is a feasible method and its use can overcome challenges in the present situation. The teledentistry approach enables providing guidance, treatment plans and follow-up with remote-assistance dental care through the use of information technology instead of face-to-face contact with patients.


Introduction
Teledentistry is a form of telemedicine explicitly dedi cated to dentistry. Teledentistry utilizes electronic den tal records, information and communication technology (ICT), digital dental photography, and the Internet for consultation, supervision as well as continuing dental education. The usage of mobile phones in teledentistry has become an attractive innovation due to an increase in availability, and improved digital photography capa bilities and data processing of smartphones, which allows users to multitask, having access to affordable and secure cloud storage. The smartphone camera can be useful in dental photography, in recording the baseline preoperative oral health status, and in facilitating dia gnoses and appropriate treatment plans. Since smart phones can be easily carried and used at any time, they are useful in improving patientcentered care delivery as pointofcare testing (POCT) devices. The teleden tistry model can facilitate screening, data collection and primary prevention. 1 With minimal training, parents, teachers or other caregivers can collect and share the required digital data from children at home or school, using userfriendly mobile technology for remote evalu ation by a pediatric dentist. 2 After the recent outbreak of the coronavirus disease 2019 (COVID19) pandemic, the World Health Orga nization (WHO) released recommendations regard ing precautions to be taken by all healthcare workers, including dentists, in order to avoid the transmission of severe acute respiratory syndrome coronavirus 2 (SARSCoV2). 3 These refer to different transmission modes, such as contact, droplets, fomites, and aerosol generating procedures. 3,4 As dentistry is a profession that involves facetoface contact with patients and atten dants in a closed setting, as per the current information, there are high chances of contracting this disease. 5 Fur thermore, almost all dental procedures involve aerosols in the dental operatory. 4 The WHO also makes it clear that, based on the available data and experience, the key is to limit close contact between the infected people and others in order to break the chain of COVID19 trans mission. 3 This risk is higher in pediatric dentistry, as the affected children are usually asymptomatic or have mildtomoderate clinical symptoms of viral infection. 4 Hence, communitybased COVID19 transmission may involve children from different age groups. As there are no available universal guidelines for pediatric dental pro cedures during the COVID19 pandemic, routine dental procedures should be deferred, and only acute dental emergencies should be treated. In acute emergencies, pediatric dentists should be aware of the recommended protocols for managing children's dental problems. It is essential to adopt these protocols to protect themselves as well as children and their parents, at the same time preventing viral transmission. 6 One of the best options to prevent viral transmission is teledentistry. It has been reported that there is high acceptance for teledentistry among patients and oral healthcare professionals. 1,7 Teledentistry saves time, and shortens the distance be tween the dental operatory and children and their pa rents. Teledentistry possibly allows dental teams to exa mine children in their most accustomed environments, and significantly diminishes dental anxiety and fear of children and their parents or caregivers. 7,8 This type of approach is very much required now to overcome the present COVID19 pandemic crisis. Therefore, this nar rative review was planned to outline the use of teleden tistry in managing children's dental problems, both dur ing and after the COVID19 pandemic.

Literature search
An extensive search of the literature reported from December 2019 to December 2020 was conducted using the PubMed database. The keywords used in the search stra tegy were "COVID19", "teledentistry", "children", "dental problems, " and "management" in various combinations. In order to identify additional data published on the use of teledentistry to manage dental problems in children during COVID19, a hand search was performed. The electronic search yielded 35 citations, and with regard to the details of the search words, the retrieved citations included: "COVID19" AND "teledentistry" AND "children" -1; "COVID19" AND "teledentistry" -30; and "teledentistry" AND "children" -4. The hand search did not reveal any additional data. From the retrieved data, essential articles were utilized for this narrative review.

Teledentistry for pediatric dental practice
During this COVID19 pandemic, pediatric dentists may consider the use of teledentistry for the remote consultation, triage and delivery of dental care when ever possible and applicable. Teledentistry (virtual den tal visits or dental care at a distance) enables pediatric dentists to meet various dental care requirements while avoiding close contact with their pediatric patients. However, teledentistry can only be practiced accord ing to the respective national or state authorities'/asso ciations' guidelines. 8 Teledentistry encompasses various components, such as consultation, diagnosis, triage, and monitoring. Teleconsultation is the most common form of teledentistry through which parents, caregivers or school teachers can seek advice for children who require a dental appointment. It may also help with the continua tion of the treatment plan and followup advice during the quarantine or lockdown period. Teletriage consists in the safe, correct and timely evaluation of the child's symptoms through remote consultation, using the pedi atric dentist's smartphone or laptop computer. Similarly, parents can also use their smartphones to take pictures of their children's teeth and to provide information to the pediatric dentist. Triage involves distinguishing be tween emergency and nonemergency dental needs, and between those that require prioritization or deferment. In telediagnosis, the smartphone can be utilized to ex change information and photographs taken as directed by the pediatric dentist, thereby facilitating the diagnosis of emergencies related to early childhood caries (ECC), dental pain, traumatic dental injuries (TDI), and facial swelling. Telemonitoring (virtual visits) can substitute regular physical visits in routine monitoring of disease progression or treatment outcomes. 9

Benefits and barriers related to pediatric teledentistry
The benefits include the ability to provide primary and specialized dental care, improved communication between the dental team and children/parents, and the effective triage of patients. 2 Thus, teledentistry reduces inappropriate referrals and waiting time, aids in timely diagnoses, treatment provision and followup, and less ens the costs related to travel and accommodation. Tele dentistry might improve clinical outcomes and contribute to a reduction in pain and other comorbidities associated with delayed diagnosis and treatment. It supports moni toring a child's oral health and implementing preventive measures in such pandemic situations. 2 The possible barriers for teledentistry include the level of acceptance of its use by children, parents and pediatric dentists. The pediatric dentist may be concerned about making an in appropriate diagnosis and incurring additional expenses related to infrastructure, equipment and highspeed Internet. The issues related to poor Internet access, the lack of technical training and the lack of expertise can be causes for concern for the dental team and parents/care givers. As teledentistry is new to the healthcare system, the concerns related to insufficient financial reimburse ment, scanty guidelines, and the coordination between children, accompanying personnel and the dental team are other challenges. 10 The persons involved might have to depend on other people or government aid to utilize teledentistry in dental practice in communities without smartphones and Internet facilities. 2,9 Teledentistry could aid the dental community by cover ing a broader geographical area, enabling more efficient functioning and helping many people in need while maintaining social distancing. The most recent system atic review confirms that teledentistry is a viable option for remote consultation, screening, diagnosis, treat ment planning, and dentistry mentoring. 1 It also states that the rapidly developing ICT has greatly improved the costefficiency, precision and effectiveness of remote assistance for pediatric dentists. 1 There is high acceptance for teledentistry among clinicians and patients alike. 11,12 Parents have to be trained in video calling, taking the needed intraoral pictures and transferring them to the pediatric dentist by means of smartphones. Pediatric dentists have several possible approaches available for telecommunication with children and their parents, guardians and caregivers (Fig. 1). Through pediatric teledentistry, consultation with children and parents may be possible in 2 ways: realtime consultation (syn chronous) or consultation through the stored records (asynchronous). Teleconsultation and teledentistry will impact the way the insurance company and the patient are billed. One may also want to consider accessing patient management software to review the patient's chart and radiographs. Such a review can be done via the virtual remote login applications using the software, private telenetworks or social media, including Skype, WhatsApp, Instagram, and Messenger.
A systematic review by a Brazilian research group suggested that teledentistry could improve the quality of care related to the diagnosis and management of oral lesions, and shorten distances for patients who need specialized diagnoses and specialists providing care. 13 Another systematic review from the USA concluded that teledentistry could be comparable to onetoone dentistry for oral screening in remote areas, areas with limited access to care, longterm care facilities, and as part of schoolbased programs. 14 The authors also stated that teleconsultation was possible and valid in detect ing oral health issues. 14 Consequently, Daniel et al. per formed a systematic qualitative review and reported that the rapidly emerging communication technologies and information systems progressively revealed improve ment in the costeffeciency, precision and effectiveness of remote assistance for oral healthcare professionals. 15 Fig. 1. Pediatric dentist providing remote oral hygiene instructions to children through teledentistry Alabdullah et al. found that the exposure of pediatric den tal students to the teledentistry model increased. 16 Re garding the records used in teledentistry, an Australian group reviewed photographic examinations and found that the image analysis provided accuracy comparable to visual inspection in diagnosing dental problems. 17 The authors concluded that the results were least comparable between photographic and visual inspection techniques in the case of enamel defects. 17 In the present COVID19 pandemic situation, it is challenging to provide regu lar dental treatment to children. A Saudi Arabian cross sectional survey was performed on undergraduate students and it was found that the study subjects knew very little about teledentistry. 18 The author suggested the inclusion of teledentistry as a continuing dental education topic. 18 Pereira et al. reported that teledentistry was an emerging tool to help maintain contact with the patient without any risk of the transmission of infections such as COVID19. 19 A British study opined that healthcare professionals should consider adapting patient pathways and using telehealth as a consultation method to recover services and reduce the spread of COVID19. 20 A crosssectional survey by Surdu and Langelier found an increase in the utilization of oral health services for children, especially in rural areas. 21 Furthermore, various authors worldwide preferred utilizing teledentistry in this pandemic period. [22][23][24][25][26][27] There is a shortage of specialists and a lack of holistic oral healthcare for children due to the closure of aca demic institutes and private practices. Hence, through the pediatric teledentistry approach, the number of den tal consultations for children could be increased by en hancing specialists' accessibility to remote communities and otherwise inaccessible areas. The flowchart presented in Fig. 2 depicts a simple approach to teledentistry for children, including the use of various social media and communicators, decisionmaking for emergency vs non emergency dental needs, triage, decisions on home care instructions, and mobile or portable dentistry at home vs treatment at the dental operatory/dental clinic based on the needs of the individual child.

Conclusions
Teledentistry for children could be considered as pedi atric teledentistry. Pediatric dentists should train them selves and their teams also with regard to technical issues. Communication and the provision of treatment through teledentistry requires additional time and care to ensure proper advice to children and parents. Pediatric teleden tistry could be a viable option for managing dental pro blems in children during pandemics.