1 Volume 23 2024 e241764 Original Research Braz J Oral Sci. 2024;23:e241764http://dx.doi.org/10.20396/bjos.v23i00.8671764 1 Dentistry Faculty, Arthur Sá Earp Neto University Center, Petrópolis, Rio de Janeiro, Brazil. 2 Department of Periodontology, Federal University of Pelotas, Pelotas, Porto Alegre, Brazil. 3 Faculty of Medicine of Petrópolis, Petrópolis, Rio de Janeiro, Brazil. Corresponding author: Thayanne Brasil Barbosa Calcia. Faculdade de Medicina de Petrópolis/Centro Universitário Arthur Sá Earp Neto, Barão do Rio Branco Avenue, 1003, 25680-120, Petrópolis, Rio de Janeiro, Brazil. E-mail: thayannecalcia@gmail.com Editor: Dr. Altair A. Del Bel Cury Received: February 02, 2023 Accepted: February 29, 2024 Search for urgent dental care during COVID-19 pandemic: report of a university dental care setting experience Juliana de Oliveira Zóffoli1 , Francisco Wilker Mustafa Gomes Muniz2 , Vera Ligia Vieira Mendes Soviero1 , Thayanne Brasil Barbosa Calcia1,3* Dental emergencies may represent a challenge to clinicians, that sometimes may even need to treat patients with COVID-19. Aim: In this sense, we aim to report our experience in an urgent dental care setting during COVID-19 pandemic, providing a profile of patients and staff involved in attendance appointments. To address that, a retrospective analysis was conducted based on charts of the Urgent Dental Care Clinic. Data obtained from patients were extracted considering the period between July 2020 and December 2020. Final data were compiled, and continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as n (%). Results: A total of 92 patients (39 ±16.59 years) were attended with prevalence of female. Most patients (n = 83; 94.3%) answered that they did not have any symptoms since COVID-19 outbreak in March up to 21st day prior the appointment and searched for treatment with pain as the main complaint (n = 59; 64.1%). Drug prescriptions and advice were sufficient on several occasions (n = 19; 22.4%), eliminating the need for dental procedures. Recementation and temporary restorations were the most frequent clinical choice in this cohort (n = 19; 20.7). Regarding dental staff, COVID-19 symptoms after attendance were reported only seven times (3.4%) by 5 different persons. Conclusion: All patients treated in the emergency department during the COVID-19 pandemic were asymptomatic and pain was their main complaint. Importantly, occupational transmission was not detected during the study period, which highlights effectiveness of our prevention strategies. Keywords: Dental care. COVID-19. Dentistry. https://orcid.org/0000-0001-7681-3989 https://orcid.org/0000-0002-3945-1752 https://orcid.org/0000-0002-0572-3174 https://orcid.org/0000-0001-7641-2915 2 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 Introduction Late in 2019, a new and potentially lethal respiratory infection was reported by Chi- nese health authorities. This viral disease spread to European countries within few weeks1. Subsequently, in March 2020, a pandemic named Coronavirus Disease (COVID)-19 was declared by the World Health Organization (WHO), which led to several challenges in public health, due to its associated morbidity and mortality. As a result, there was an increase in Intensive Care Unit (ICU) hospitalization2. Cur- rent knowledge points to a human-to-human transmission of SARS-CoV-2 virus, due to droplets and aerosols, that can be expelled in coughing, sneezing, and even speaking3. Contribution of other transmission routes (such as contact with con- taminated surfaces) are under investigation, since the viability of this virus in dif- ferent materials4 remains unknown. Its impact on dental care was promptly perceived, due to the possible role of aerosols in virus spread and transmission, leading health agencies to point out several vul- nerabilities that could impair safe dental practice5,6. Faced with an unknown enemy, several dental offices remained closed until different guidelines were elaborated by regulatory authorities7. Dental education activities were profoundly impacted, which required a different organization of work, training and adaptation of facilities. Globally, undergraduate students had their practices discontinued and were promptly inserted in an online education effort8. In addition, a significant challenge in dental education was adapting clinical activi- ties in this new scenario, considering that clinical practice is extremely important in dental school. Therefore, as dental practical activities returned, new personal pro- tective equipment were incorporated in clinical settings in order to provide a safer practice to professionals and patients9. According to protocols, patients began to be submitted to an accurate screening, with body temperature measurement and a health questionnaire. Many procedures were unadvised, especially those related to aerosol spreading. Careful selection of cases, anti-retraction handpieces and rubber dam isolation were the recommended main measures to avoid virus spread and cross-infection in dental settings6. However, dental emergencies can present a challenge for doc- tors, who may sometimes need to treat patients infected with COVID-19. In this sense, the American Dental Association (ADA) published a guideline to a proper identification of emergency and urgent conditions10. Pain, trauma, and infections are among these urgent conditions, which can impair patient’s quality of life and need to be recognized and promptly treated early. Furthermore, the pandemic impaired the access of many patients to dental services, leading to a poorer health status, and a crescent demand for urgent services, changing the routine of den- tal services11. During this challenging period, dental care facilities had to develop strategies to adapt their routine and face the health crisis. Thus, considering the lack of consensus regarding the best strategy for organization, it opened space to different initiatives in the return to public attendance. In this sense, it was aimed 3 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 to report the experience of an urgent dental care during COVID-19 pandemic, pro- viding a profile of patients and staff involved in attendance appointments. Materials and Methods A retrospective analysis was conducted based on charts of the Urgent Dental Care Clinic, from a Faculty of Dentistry in Brazil. During the COVID-19 pandemic, a new biosafety protocol was implemented, and patients underwent symptom screen- ing prior to dental care (Figure 1). In case of possible COVID-19 related symptom, dental appointments were performed in an isolated setting. Complaints were classified as proposed by ADA guideline10, and symptomatic patients were up to be attended only in case of pain or bleeding. Furthermore, before in-person care, patients were contacted by telephone to receive guidance from a dentist. In case of persistence of complaint, dental appointment was scheduled. All charts were included, regardless age and sex. Data obtained from all patients were extracted considering the period between July 2020 and December 2020. Urgent visits were classified according to ADA guidelines10. The present study followed the STROBE checklist. COVID-19 symptoms screening temperature checking YES to any screening questions and ASSYMPTOMATIC YES to any screening questions and SYMPTOMATIC NO to screening questions and ASSYMPTOMATIC If possible, postpone dental attendance for at least 15 days. Refer the patient to medical attendance. If possible, postpone dental attendance for at least 15 days. Elective procedures are unadvised. In case of emergency (pain or bleeding), dental attendance must be performed in a special facility. Refer the patient to medical attendance. In case of emergency (pain or bleeding), dental attendance must be performed in a special facility, as may have COVID-19. Refer to dental attendance. Figure 1. Flowchart of dental urgent attendance during COVID-19 pandemic. This study was conducted in accordance with international ethical stan- dards and was approved by the local ethics committee under protocol number 35623820.3.0000.5245. Information regarding exposure to COVID-19 was extracted by one researcher from a chart containing the following questions: “Did you experience any symptom (fever, cough, fatigue, dyspnea, diarrhea, anosmia, ageusia) related to COVID-19 in the past 21 days?” “Do you have any symptom related to COVID at this moment?” “Did you have contact with a confirmed COVID-19 patient?” “Were you submitted to any COVID-19 test?”. Patients could respond “yes”, “no”, or “I do not know”. In addition, demographic 4 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 data (sex [male/female] and age [in a continuous fashion]) were recorded. Finally, the main complaint and clinical procedures were addressed. Data from staff was also recorded. In this sense, variables as a positive COVID-19 diagnosis and exposure to infection were considered. Final data were compiled, and continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as n (%). Results Demographic variables A total of 92 patients were attended between June 6th and December 14th, 2020, in the Urgent Care Service, and they were all included in the study. (Figure 2). 0 5 10 15 20 25 30 35 July Dental apointments during study period DecemberNovemberOctoberSeptemberAugust Figure 2. Dental appointments throughout the study period. Most of the patients were female (n = 62), and 30 were male. The youngest patient was 6 years old and the oldest was 73 years old, with a mean age of 39±16.59 years (Table 1). Table 1. Demographic variables of the patients included in this study. Sex Female 62 (67.4%) Male 30 (32.7 %) Age 39.5 ± 16.59 Sex data were expressed at absolute numbers and its percentage. Age-related data were expressed as mean and standard deviation. 5 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 COVID-related variables No patient had fever or main symptoms of COVID at the consultation (data not shown). Most patients (n = 83; 94.3%) responded that they had never presented any symptoms related to COVID-19 considering the period from March to the 21st prior to the consultation. Regarding COVID laboratory screening, only two patients (2.3%) reported a confirmed diagnosis of COVID-19. The majority of patients were not tested for COVID-19 diagnosis (n = 69; 78.4%). In addition, a higher percentage of patients reported that they did not have con- tact with a person with fever or diagnosis of COVID-19 (n = 84; 95.5% and n = 80; 90.9%, respectively). When asked about COVID-19 related symptoms, only few patients reported that had experienced fever (n = 2; 2,3%), cough (n = 2; 2,3%), intestinal discomfort (n = 2; 2,3%), or headache (n = 3; 3,4) in the past 21 days. Dyspnea, anosmia or ageusia were not reported in the present sample (Table 2). Table 2. COVID-related variables of the patients included in this study. Any possible COVID-related symptoms up to 21 days prior dental appointment? Yes 83 (94.3%) No 5 (5.7%) Missing data 4 Did you do any laboratorial exam to assess COVID? No 69 (78.4%) Yes, negative result 16 (18.2%) Yes, positive result 2 (2.3%) Yes, ignored result 1 (1.1%) Missing data 4 Did you have physical contact with a person with COVID in the past 21 days? No 80 (90.9%) Yes 8 (9.1%) Missing data 4 Did you have physical contact with a person with fever in the past 21 days? No 84 (95.5%) Yes 4 (4.5%) Missing data 4 Did you have any of the following COVID-related symptoms in the past 21 days: Fever No 86 (97.7%) Yes 2 (2.3%) Missing data 4 Continue 6 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 Continuation Cough No 85 (97.7%) Yes 2 (2.3%) Missing data 5 Respiratory distress No 87 (100.0%) Yes 0 (0.0%) Missing data 5 Anosmia and/or ageusia No 87 (100.0%) Yes 0 (0.0) Missing data 5 Headache No 84 (96.6%) Yes 3 (3.4%) Missing data 5 Intestinal discomfort No 85 (97.7%) Yes 2 (2.3%) Missing data 5 Values were expressed at absolute numbers and its percentage. Dental care variables Most patients searched for treatment with pain as the main complaint (n = 59; 64.1%). Among these, six patients (6.5%) had an associated swelling. Unsatisfac- tory restorations and/or dental fractures (n = 18; 19.6%), soft tissue lesions (n = 2; 2.2%) or trauma (n = 1; 1.1%) were others causes listed during anamnesis. Before dental appointment, a secretary contacted the patients by call or WhatsApp mes- sage. During this screening, two patients (2.4%) had their main complaints solved by remote professional orientations. Considering dental appointments, drug pre- scriptions and advice were sufficient on several occasions (n = 19; 22.4 %), and those patients did not receive dental procedures at that point. Recementation and temporary restorations were the most frequent clinical choice in this cohort (n = 19; 20.7). Similarly, dental extractions with forceps and endodontic access were fre- quently performed (n = 17, 18.5%, each), followed by extractions with high-speed turbine (n = 8; 8.7%) and biopsy (n = 1; 1.1%). No intercurrence was reported in analyzed charts. 7 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 Table 3. Dental procedures and related complains of the patients included in this study. Main complaint Pain (tooth or soft tissues) 59 (64.1%) Pain and swelling 6 (6.5%) Soft tissue lesion 2 (2.2%) Trauma 1 (1.1%) Unsatisfactory restoration/ dental fracture 18 (19.6%) Others 6 (6.5%) Procedure Remote professional orientation 2 (2.2%) Drug prescription and/or exam 20 (21.7%) Recementation/ temporary restorations 19 (20.7%) Biopsy 1 (1.1%) Extractions with forceps 17 (18.5%) Extractions with high-speed turbine 8 (8.7%) Endodontic access 17 (18.5%) Others 8 (8.7%) Values were expressed at absolute numbers and its percentage. Staff variables Dental staff was formed by ten dentists, two dental assistants and 38 dental students (Table 4). During the study period, forms regarding COVID-19 related information were completed 208 times. Most respondents reported that they did not have con- tact with a COVID-19 infected person until 21 days prior attendance (n = 190; 94%). Furthermore, attending at other hospitals or clinics was the higher exposure reported by them (n = 85; 40.9). Restaurants, cafeteria, or pubs (n = 39; 18.8), public transport (n = 27, 13%), and supermarkets (n = 21; 10.1%) were also often cited among respond- ers. COVID-19 symptoms after attendance were reported only seven times (3.4%) by 5 different persons. There was no report of occupational transmission. Table 4. Information about exposure and COVID-19 symptoms of the clinical staff. Higher exposure in the past week: Stayed home 11 (5.3%) Visited some relative 11 (5.3%) Market 21 (10.1%) Barber shop/ Beauty saloon 13 (6.3%) Restaurant/Cafeteria/Pub 39 (18.8%) Other Health Service (Hospital or Clinic) 85 (40.9%) Public transport 27 (13.0%) Continue 8 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 Continuation Missing data 1 (0.5%) Did you have any COVID-19 symptom after your last clinical attendance? No 201 (96.6%) Yes 7 (3.4%) Did you have direct contact with a COVID-19 infected person in the past 21 days? No 190 (94.0%) Yes 12 (6.0%) Missing data 12 Values were expressed at absolute numbers and its percentage. Discussion Health care was profoundly impacted during COVID-19 outbreak, and dental prac- tices were specially affected due its proximity with aerosols and droplets5. There- fore, uncertainty about providing safe care was topic for several discussions and resulted in many direct strategies to mitigate risk of transmission12-15. In addition to lockdown, emergency and urgent dental care had often been provided in health facilities, due to its intrinsic nature10,11. Reporting on the efforts to organize atten- dance flow is of upmost importance to improve the response to a possible new health crisis16. The present study describes the profile of an urgent dental care service provided to community for a dental education school. Pain was the main complaint reported by the patients. Similar studies reported that symptomatic endodontic and periodontal complaints were main reported reasons for seeking dental care16. During the pan- demic period, telemedicine was a prolific discussion topic, and it was implemented in many health facilities. On our service, remote orientation was implemented as screening tool since dental appointments could not be entirely provided in a remote way. This strategy was efficient to identify the necessity of a dental appointment, eliminating unnecessary exposure and was enough in a few cases. Conversely, den- tal examination was necessary in most cases, due to uncertainty of diagnosis and necessity of intervention. In most cases, drug prescription and orientations, as self-care orientation were enough to solve a patient’s complaint. As expected, invasive procedures were fre- quently performed, what relates to reported complaints. Other experiences were similar in reporting needing for invasive procedures16-18. One study reported a sim- ilar proportion of dental extractions and restorative treatments. Furthermore, it highlighted the increase in need of surgical procedures in comparison to pre-pan- demic period, reflecting its urgent character17. According to Carter et al.16, (2020), dental extractions were necessary in 65% of attended patients over a six-weeks period of lockdown. This higher percentage, compared to pulp extirpation, was justified for the nature of the service. This may reflect deterioration of dental con- dition of patients. During the pandemic, reports of dental fractures, due to many 9 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 causes, such as dental caries or tooth clenching become more frequent, which relate with psychological features as stress and lack of access to dental care19,20. Since the dental service of the present study was a pioneer in providing urgent care during pandemic, our sample may represent a repressed demand in our city. It is important to highlight that our data represents dental appointments through- out 2020 2nd semester and, as elective dental procedures other than urgent care were gradually resumed at the university clinics, it may explain the decrease in the demand for dental urgencies. Aerosols and droplets generation were a main concern, and strategies of personal protection were strictly followed. Moreover, all patients attended during the study period were asymptomatic at dental appointment and did not report any recent pre- vious symptom related to COVID-19. This finding is similar to other studies, which found a major proportion of patients that did not report COVID-related symptoms (up to 99.4%)17,21. Finally, only a few patients related that ever performed some labo- ratorial exam to detect COVID-19 infection, and this finding may be related to sparse access to COVID-19 screening tools at that moment. It is well-known that many infected patients do not develop associated symptoms22. Therefore, we cannot rule out that these patients were COVID-positive at that point, due to lack of laboratorial test results. Symptoms among dental staff were infrequently related after dental appointment. More importantly, it did not register any occupational transmission, which reflects effectiveness of biosafety strategies. However, most professionals involved in dental care were not isolated and maintained some external activity as frequent visits to supermarkets or to relatives. It is important to highlight that personal protective equipment was reinforced to avoid crosslinked transmission. Based on several guidelines, our service developed an Institutional protocol for dental atten- dance during COVID-19 pandemic, establishing PFF2/N95 and face shield as clin- ical routine equipment and implementing intensive decontamination procedures. At that point, very few dental facilities were functioning, and fewer dental schools were providing dental care, even in an urgent fashion. Thus, mitigation of aerosols and droplets generation, attention to crosslinked infection and personal protective mea- sures were the pillars for services comeback. Since pandemic initiated, Brazil is struggling both in health assistance and strategies to limit the virus transmission. During the study period, the number of infected were still growing and strategies as lockdown were losing strength23. Until now, there are some concerns towards Brazil confrontation strategies, what still place us in a vul- nerable position when consider dental care what impute even more importance to our present data24. With more services functioning, it is crucial to develop strategies to provide safer dental care. In this sense, our findings reflect COVID-19 impact in a current discussion point, considering that prevention strategies remain necessary to mitigate occupational transmission in dentistry setting. It is important to emphasize that the present study involved only one dental care setting, which may be faced as a limitation of the present study. In addition, read- ers must be aware that filling the patients’ charts was performed by several dental 10 Zóffoli et al. Braz J Oral Sci. 2024;23:e241764 students, which does not allow a standardization of the data. However, to com- pensate for it, only one trained researcher was responsible for the data extraction of the present study. In conclusion, the present data provides additional information regarding urgent dental care, considering both patient characteristics and professional exposure. All patients attended were asymptomatic and pain was the main complaint. Occupational trans- mission was not detected during the study period, which highlights effectiveness of our prevention strategies. Acknowledgments This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 and for Faculdade de Medicina de Petrópolis/Centro Universitário Arthur Sá Earp Neto. Conflict of Interest The authors have no conflict of interest to disclose. Data Availability Datasets related to this article will be available upon request to the corresponding author. Authors Contribution Juliana Zóffoli: performed data collection, data compilation, revised and approved the final version of the manuscript. Francisco Wilker Mustafa Gomes Muniz: ana- lyzed data and revised and approved the final version of the manuscript. Vera Mendes Soviero: conceptualized study, analyzed data and revised and approved the final ver- sion of the manuscript. Thayanne Brasil Barbosa Calcia: conceptualized study, ana- lyzed data and revised and approved the final version of the manuscript. References 1. Checchi V, Bellini P, Bencivenni D, Consolo U. 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