Background
As COVID-19 affected the world, it was soon classified as a pandemic by the World Health Organization [
1], and nationwide complete lockdown became the sole option [
2]. This affected all aspects of healthcare care, including oral health. A complete move from the traditional care became critical, and virtual health technologies came to the forefront out of necessity to continue patient care and reduce the risk of transmission [
3]. In line with recommendations of the World Health Organization [
4], Hamad Dental Center (HDC), the sole public tertiary dental services provider in Qatar, initiated changes related to all aspects of dental services. These included patient triage for COVID-19 symptoms, operatory preparation, infection control, and selection of low-risk interventions. HDC also initiated a dedicated teledentistry (TD) hotline to ensure the continuity of care to patients including triage, consultation, identification of oral diseases, and treatment and/or referral according to the urgency of oral/dental condition [
5]. TD applies to the remote provision of dental care without physical contact using a variety of technologies [
6], including synchronous real-time communication like audioconferencing, videoconferencing, instant messaging communication software [
7], or asynchronous store-and-forward communication. Tele-triage applies to the use of TD to interview callers, assess urgency and sort patients by priority and level of care required [
8,
9]. The aim was to maintain the continuity of services and to avoid missing serious or emergency dental conditions.
As part of the COVID-19 measures, the American Dental Association (ADA) published guidelines with definitions for different categories of dental conditions [
6]. Dental pain was a fundamental component in these definitions as it is a highly prevalent and significant health problem that reduces quality of life and well-being [
10‐
13].
Pre-pandemic literature suggested that patients seek emergency appointments in dental practices, and to a certain extent in general medical practices and emergency departments because of ease of access, anxiety from dental intervention, or the notion that a course of antibiotics will treat the condition [
14]. COVID-19 pandemic influenced the utilization of emergency dental services [
15], and its impact on patterns of dental emergencies was evident in the increased prevalence of dental pain compared to other oral health related problems [
16‐
21]. It has also been suggested that during the pandemic, only patients with acute pain remained constant [
22], while the less acute but nevertheless existing dental problems were neglected [
23]. Such actions might have led to the worsening of overall health, triggering infections with local and systemic complications, compromising general health, and forcing at risk patients to visit hospital emergency rooms [
16,
24]. These complications were attributed to using the recommended 'advice, analgesics and antibiotics' (AAA) strategy to manage dental pain which has significant limitations with severe pain-related conditions, where face-to-face dental procedures are necessary to achieve symptomatic relief [
25].
While TD offers acceptable reliability for the tentative diagnosis [
26], the literature on tele-triage during the pandemic reveals knowledge gaps [
16,
17,
21,
22,
27]. No previous research objectively reported whether tele-triage decisions were driven by the severity of pain. Likewise, to our knowledge, no studies compared the reported pain severity (PS) in relation to the associated symptoms and tentative tele-diagnosis. Studies have examined selective conditions e.g., dental-facial trauma [
28], or pain, swelling and trauma [
16], with less attention to other conditions associated with orofacial/dental pain e.g., loose/broken dental restorations, orthodontic appliances, oral ulcers, or bleeding. In addition, many reports focused on paediatric populations [
28,
29], where PS cannot be objectively determined remotely.
Therefore, the current study assessed whether the severity of reported pain (exposure, continuous variables) affected the tele-triage decisions (binary outcome of whether the patient was managed remotely or referred for face-to-face management). PS was appraised across its associated tele-triage categories, dental history, and tentative tele-diagnosis to analyse their associations with tele-triage decisions. The emerging findings provide important information to a non-existent evidence base on the management of orofacial/dental pain during pandemics. The findings will provide practitioners and policy makers with information necessary to better manage reported orofacial/dental pain-related emergencies during situations like those experienced during the COVID-19 pandemic, or where resources are significantly limited for managing such emergencies.
Discussion
There has been calls to enhance the evidence-base of the management of orofacial/ dental pain [
38]. The main objective of the current study was to explore whether PS was associated with tele-triage decisions (remote management of caller vs referral for face-to-face management). To our knowledge, no previous research undertook such task. Hence, it was not straightforward to directly compare our findings with previous research. The main finding was that tele-triage decision to remotely manage or to refer the caller for face-to-face management was significantly associated with the severity of the orofacial/ dental pain. An increase in the pain score was associated with increased odds of face-face referral, however, other covariates were also associated with such decisions. The most significant associations were whether the caller had a history of a chronic illness, and whether the discipline that was needed operated aerosol generating procedures. This indicates that management decisions at HDC were highly individualized, taking into account the tripartite considerations of the reported pain, clinical judgement, and the high transmission characteristics of COVID-19.
For instance, for callers with high PS, in terms of dental history, those with problems related to tooth cavity/filling, temporo-mandibular joint, wisdom tooth, and swellings had the highest PS. However, more than two thirds of these patients were managed remotely. In terms of tele-diagnosis, we observed that pulpitis was not only associated with high PS, but it was also the most frequent tele-diagnosis (31.77%), concurring with the range of 22.5–46% pulpitis rates reported by other studies as the origin of orofacial/ dental pain during the pandemic [
16,
19,
20]. Despite that endodontic root canal treatment (RCT) is the gold standard treatment for pulpitis, > 75% of our pulpitis were managed remotely, because RCT generates aerosols. Hence RCT was restricted during the pandemic and reserved for when the tooth was restorable and strategically important, otherwise extraction was favoured. This supports a UK study where 65% of clinical consultations resulted in extractions to avoid aerosol generating procedures [
17]. This also explains the increased odds of the patients being seen at the clinic for surgical and orthodontic procedures (OR = 1.9 and 7.016 respectively) compared to that of aerosol generating restorative procedures.
Hight levels of PS were observed with conditions that could precede a serious medical emergency or are caused by odontogenic infections. Our management decisions considered the risk of systemic life-threatening complications in tandem with PS, as recommended by the ADA [
6]. For instance, we observed that TMD was the second most painful condition. This concurs with that the pandemic adversely effected peoples' psycho-emotional status and intensified their bruxism and TMD symptoms [
39]. However, during tele-triage, patients may provide inaccurate history [
40] as TMD is difficult to be described by the patient. In addition, it could be an early symptom of an underlying cardiac problem [
41]. Given such uncertainties combined with the fact that our TD was largely limited to telephone consultations during the pandemic's initial stages like other places worldwide [
39], half of our TMD cases were referred. Likewise, although we found that cellulitis had the highest PS, pain was not the sole reason for referral. It is recognized that cellulitis of odontogenic infection origins can be life threatening [
42]. All cellulitis were categorized by the HDC tele-dentists as emergency and referred to hospital emergency for intravenous antimicrobials and analgesics [
42].
For callers with low PS, the individualized approach after careful weighting of the reported pain and clinical picture was also evident. For instance, those with history of orthodontic appliance problems experienced the least pain, but the majority were referred. The majority of orthodontic patients typically fell in the pediatric/ adolescent group (9–18 years), and this could explain the 2.1 times increased odds of face-to-face referral for patients of this age group. Orthodontic appliance related problems may not be life threatening or severely painful; nevertheless, they challenge daily activities (speech, mastication, sleep), quality of life, and could lead to significant consequences if left unattended.
At the height of a rapidly changing pandemic, HDC management decisions provide positive lessons for future 'normal' times after the pandemic. On the one hand, during the pandemic, severe orofacial/ dental pain was the driver of urgent care [
22]. On the other hand, pre-pandemic literature suggests that the high orofacial/ dental pain results in an elevated demand of emergency appointments at dental practices, some general medical practices and emergency departments [
14]. The present study showed that PS indeed influenced the tele-triage decisions of orofacial/ dental pain (remote management or referal). However, a main observation is that not all our cases with higher severity of pain were referred; and conversely, not all cases with low pain severity were managed remotely. Such discrepancies might seem odd. However, when dental history, tentative tele-diagnosis, discipline required and face-to-face procedure at point of referral were considered, other factors like clinical judgment, risk of disease transmission, potential life-threatening systemic complications, possible diagnostic uncertainty, and probable challenges with daily activities/ deteriorated quality of life if the condition is left unattended contribute to explain such discrepancies. The approach used at HDC during the pandemic led to the remote management of 31 cases triaged as urgent (5.8% of the total callers) and 331 cases triaged as non-urgent (62.2% of the total callers). During 'normal' (non-pandemic) times, these combined 68% of the patients would have otherwise physically presented themselves at our clinics.
The current study has limitations. HDC is a tertiary dental services provider, and patients in the current study probably had previous dental experiences or persisting symptoms. Such patients are different than those who present at primary dental care centers experiencing their first dental pain encounter. The current cross sectional design does not allow any inferences of causal relationships between pain severity and triage decision decisions, rather only associations and should be interpreted as such. We encountered 40% missing data regarding the outcome during the early phase of the study when the dentists were home-working during the lockdown. This influenced the effective sample size used in the analysis. Others have similarly reported that the 'helpline was developed and implemented while many people were working from home during shelter-in-place restrictions, making training, calibration on information entry, and supervision more difficult. Despite conducting training sessions, initially there was inconsistent or incomplete recording of information in the spreadsheet for administrative calls and in the newly adopted Epic' [
21, p. 833]. For the current study as well as for other studies, such missing data could influence the robustness of the findings as it could over or under estimate the findings. The confidence intervals we observed were rather wide in some instances e.g., for the odds ratio of the orthodontics category of the dental specialty needed (Table
2); larger sample size would have been useful. Hence, generalizability of the findings needs to exercise caution, and future research would benefit to address these points. Despite this, the study has strengths. Previous work on patient-reported orofacial/ dental pain during the pandemic lockdown focused on the association between worsened socioeconomic conditions and pain severity [
43], while the current study explored the influence of PS on tele-triage decisions, and appraised PS across triage categories, demographic variables, dental history, discipline required, and tele-diagnosis related factors. These findings provide policy makers with information necessary to better manage orofacial/ dental pain related emergencies and similar epi/pandemics, or where resources are significantly limited in rural areas and underdeveloped regions.
The main public health implication of this study is that extending the application of teledentistry, tele-triage, tele-consultation, and tele-therapy to after the pandemic is over might offer a promising and useful approach if practiced with the same level of individualization and driven by considerations of both, the reported pain and clinical judgement. Such continuation of tele-services after the pandemic would lead to the freeing of healthcare resources that could be used elsewhere, shortening of long waiting lists, alleviation of over-crowded walk-in clinics, and reserving the chairside appointments to conditions that truly require such management.
Future research should aim at larger sample sizes and less missing values. There is also a need for evidence premised on different demographic profiles and countries to better define dental characteristics that fall in the basic, urgent, or emergency categories of essential oral health care and the best route of action, in terms of remote or face-to-face management for each of these categories.
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