key: cord-0836616-leym1jwf authors: Guo, Hua-Qiu; Xu, Tao; Pan, Jie; Ji, Ai-Ping; Huang, Ming-Wei; Bai, Jie title: A retrospective study of oral emergency services during COVID-19 date: 2021-09-28 journal: Int Dent J DOI: 10.1016/j.identj.2021.09.004 sha: 426170f022e4f9e0bd289ba851230746d7345c3c doc_id: 836616 cord_uid: leym1jwf OBJECTIVES: This study was performed to examine changes in the number of patient visits and types of oral services in an oral emergency department from the beginning to the control stage of the coronavirus disease 2019 (COVID-19) outbreak in Beijing. METHODS: The numbers of daily oral emergency visits from January 20 to March 24, 2020, at a dental university hospital in Beijing and daily newly confirmed COVID-19 cases in Beijing during the same period were collected and analysed. All oral emergency patient information (including sex, age, and oral diagnosis) was collected and analysed. Patients with incomplete medical data were excluded. RESULTS: In total, 12,416 patients were included in this study. The number of daily emergency visits was negatively correlated with the number of newly confirmed local COVID-19 cases in Beijing (P < 0.001). The number of daily emergency visits during the COVID-19 stable period in Beijing was greater than that during the outbreak period (P < 0.001). Compared to those in the COVID-19 outbreak period, the percentages of females, children and adolescents, acute toothache patients, and nonurgent patients were higher in the stable period, and the numbers of patients with toothache, trauma, infection and nonemergency conditions increased in the COVID-19 stable period (P < 0.001). CONCLUSION: COVID-19 significantly influenced the number of patient visits and the percentages of patients with oral emergency diseases in the oral emergency department. There were obvious differences in treatment-seeking for oral emergencies between the COVID-19 periods in Beijing. There was an inverse relationship between daily oral emergency visits and daily confirmed COVID-19 cases in Beijing. The common transmission routes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include direct transmission (coughing, sneezing, and inhalation of respiratory secretion droplets) and contact transmission (contact with oral, nasal, or eye mucous membranes) 5 . There is also a possibility for aerosol transmission in a relatively closed environment in which there is exposure to high concentrations of aerosols. During oral examination and treatment, there is a high risk of transmission between doctors and patients. At the beginning of the outbreak, more patients chose not to see a dentist, even for oral emergencies 6, 7 . With the effective control of the pandemic in Beijing and China, the number of newly confirmed COVID-19 cases per day in Beijing has shown a downward trend since February 17, 2020 , and people's fear of transmission has decreased. However, has their willingness to seek dental treatment increased? To analyse the impact of COVID-19 on oral emergency services during the ongoing pandemic, we conducted a retrospective study in an oral emergency centre by analysing data from the beginning stage to the control stage of the COVID-19 outbreak in Beijing. A retrospective analysis was conducted in the present study, which retrieved patients seeking oral and dental emergency services in a public tertiary stomatological hospital that functions as one of the two 24-h emergency dental centres in Beijing, Dental departments in hospitals and private dental clinics were closed from January 20 to March 24, 2020, in China. We retrospectively reviewed the files of the patients seen in the oral emergency centre during this period, eliminating the confounding impact of the availability of other dental clinic services, to determine the exact impact of COVID-19 on oral emergency services. Hospital of Stomatology from January 20 to 24 March 2020 were included in the study. All medical information relating to the patients (including sex, age, and diagnosis) was collected. Patients with incomplete medical data were excluded. To avoid duplicating data, only the first visit was recorded when the same patient visited multiple times on the same day. We divided the patients into three groups according to age: children and adolescents (0-17), youth and middle-aged individuals (18-65) and elderly individuals (over 65). According to the common chief complaints of oral emergency patients, diagnoses were classified into groups for analysis. The diagnoses were coded using the International Classification of Diseases and Related Health Problems, 10th Revision, Beijing clinical Edition (ICD-10-BJ). Postoperative complications were diagnosed according to the ICD-10 codes of the original diseases and postoperative symptoms (e.g.: pain after treatment of acute pulpitis (K04.002)). We divided the oral emergency types into six groups (Table 1) (Table 2 ). There were 5445 patients who visited the department during the stable period, with a median of 314 patients per day. Of these, 2765 were males and 2680 were females, with a male to female ratio of 1.03:1. The youngest patient was 9 months old, and the oldest was 95 years old, with a median age of 38 years ( Table 2 ). More patients visited the oral emergency department during the stable period than during the outbreak period (P<0.001). The percentage of female patients was higher and that of male patients was lower in the stable period than in the outbreak period (X 2 =7.101, P<0.001) ( Table 2 ). During the stable period, the percentage of children and adolescent patients increased, and the percentage of patients in the 18-to 64-year-old age group decreased compared with that in the outbreak period (X 2 =38.429, P<0.001) (Table2). The most common emergency problems among patients in both the outbreak and stable periods were acute toothache, infections, and oral and maxillofacial trauma (including dental trauma, soft tissue injury and jaw fracture; Table 3 ). Compared with the outbreak period, the daily visits associated with different oral emergency types, except for postoperative complications, increased in the stable period, and the differences were statistically significant (P<0.001) ( Table 3 ). The percentages of acute toothache and nonurgent cases increased in the stable period, while the percentages of others decreased, and the differences were statistically significant (Table 4 ). COVID-19 is caused by a coronavirus similar to the SARS virus that circulated in 2003 8 . The virus can be spread through saliva, bodily fluids, and airborne droplets when people cough or sneeze, which is the major route of transmission 5, 9 . Since dental treatment can induce considerable saliva splatter from the patient, it carries a high risk of virus transmission 10, 11 . Since the outbreak of COVID-19, several dental practice guidelines have been published, and the suspension of nonemergency dental treatment while providing only emergency dental services was initially recommended 12, 13, 14 . According to previous studies, the number of oral emergency department visits decreased at the beginning of the pandemic 6, 7, 15 . Similar results were found in our study; there was a negative correlation between the number of oral emergency visits and newly confirmed COVID-19 cases in Beijing. During the outbreak period of COVID-19, the number of daily oral emergency visits decreased as the number of new daily confirmed COVID-19 cases increased. This might be due to the government's implementation of prevention and control measures, such as a limiting traffic during the epidemic, which decreased participation in outdoor activities, various sports and group activities, including visits to hospitals for nonurgent reasons. In addition, the decrease in the use of various forms of transportation might have reduced traffic accidents, including those resulting in oral and maxillofacial damage. Sun's questionnaire study results revealed that a considerable percentage of patients thought that the dental environment was more dangerous and there was a higher risk of infection in dental environments than in other medical departments or other places 16 ; therefore, the number of dental visits was reduced. Moreover, the number of oral emergency patients increased gradually after the pandemic was effectively controlled. On 4 March 2020, the Chinese government loosened restrictions and isolation requirements and allowed work resumption. With the lifting of lockdown measures and changes in the understanding of infection risk at dental visits, an increased number of people visited the oral emergency department. Previous studies found that compared with that in the nonpandemic period, the percentage of women seeking dental services decreased in the pandemic period 6, 7, 15 . As shown in previous studies, females have a higher degree of self-oral service than males, and a higher percentage of females visit dentists 17, 18 . However, female patients may be more concerned than male patients about being infected with COVID-19 during oral treatment and outdoor activities. According to the current results, the number of female patients seeking dental services was less than that of male patients during the outbreak period. After COVID-19 was controlled effectively, the percentage of female patients seeking dental services increased significantly, which demonstrates that the dentist-visiting behaviour of females was greatly impacted by COVID-19. The percentage of children and adolescents (<18 years old) seeking dental services during the COVID-19 outbreak period was relatively low. This may be related to concern by parents or guardians about children being infected with COVID-19 in the hospital. Sun et al. found that the fear of COVID-19 and the presence of toothache greatly affected the quality of life of children 16 . When the COVID-19 situation in Beijing was under control, parents were more willing to seek treatment for a child's toothache. Therefore, the percentage of children and adolescents increased significantly after COVID-19 was effectively controlled in Beijing. Previous studies found that due to the lockdown and isolation policy during the outbreak period, after the outbreak, the percentages of patients with traumatic diseases decreased significantly compared with those in 2019 6 . When the COVID-19 situation in Beijing was controlled and people gradually returned to work and production was restored, people's activities increased, resulting in an increase in the number of daily injuries compared with that in the outbreak period. According to previous studies, toothache is a common oral emergency 6, 19 . In both the outbreak stage and stable stage of COVID-19 in Beijing, the number and percentage of patients with acute toothache were the highest of all. Nontraumatic oral emergencies, such as toothaches and abscesses, are thought to be related to caries and periodontal disease that had not been effectively treated 20 . Oral health awareness and oral hygiene status are poor among people in developing countries, and the incidences of toothaches and infections caused by the development of caries or periodontal diseases are very high 21 . Acute toothache is, in many cases, debilitating and is often described as one of the most severe issues a person can experience in everyday life, resulting in a significant impact on quality of life. Patients often experience pain for over 2 weeks before seeking treatment, which may have a significant impact on their quality of life 22 . Because of COVID-19, patients may have suffered longer than they normally would. When dental clinics and departments were closed during the COVID-19 outbreak period, a large number of patients with toothache did not receive treatment. In addition, in the early stage of the pandemic, patients whose pain was relieved after initial pulp treatment often did not receive follow-up treatment and may have experienced recurrent pain due to the continuous closures of outpatient departments and clinics. Therefore, there was a substantial increase in treatment for toothache in the COVID-19 stable period. Many oral outpatient services and private dental clinics Some nonurgent patients visited the emergency room because although the cost of emergency treatment was the same as that of treatment in outpatient departments in public hospitals, registration was easier; others came to the emergency room due to an urgent need for treatment, such as the need to extract primary teeth. Azim therefore proposed that as the pandemic continues, strategies to manage patients will need to evolve from a palliative to a more permanent/definitive treatment approach 23 . During the different pandemic periods in Beijing, there were obvious differences in the number of oral emergencies. There was an inverse relationship between daily visits and daily confirmed COVID-19 cases in Beijing. After reaching the stable period, the percentages of females and children and adolescents increased compared with those in the outbreak period; the numbers of patients with toothache, trauma, infection and nonemergency conditions also increased. e. Non-parametric Mann-Whitney test Table 4 Proportions of different oral emergency types during the outbreak period and stable period. National Health Commission of the People's Republic of China. Epidemic Bulletin World Health Organization. Coronavirus disease (COVID-19) pandemic situation reports Beijing Municipal Health Commission. Epidemic Bulletin An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China 2019-nCoV transmission through the ocular surface must not be ignored Impact of COVID-19 on Oral Emergency Services The impact of the COVID-19 epidemic on the utilization of emergency dental services A new coronavirus associated with human respiratory disease in China Ocular Tropism of Respiratory Viruses Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Pathogenicity and transmissibility of 2019-nCoV-A quick overview and comparison with other emerging viruses COVID-19): Emerging and Future Challenges for Dental and Oral Medicine Recommendation: Postpone non-urgent dental procedures, surgeries, and visits. centers of disease control and prevention American Dental Association. ADA recommending dentists postpone elective procedures The impact of the COVID-19 epidemic on the utilization of dental services and attitudes of dental residents at the emergency department of a medical center in Taiwan Knowledge of and attitudes toward COVID-19 among parents of child dental patients during the outbreak Emergency care provided in a Greek dental school and analysis of the patients' demographic characteristics: a prospective study Incidence and factors associated with endodontic inter-appointment emergency in a dental teaching hospital in China Emergency department visits for dental problems not associated with trauma in Alberta Increasing prevalence of emergency department visits for pediatric dental care Oral health status of Chinese residents and suggestions for prevention and treatment strategies Pain and problems: a prospective cross-sectional study of the impact of dental emergencies Clinical endodontic management during the COVID-19 pandemic: a literature review and clinical recommendations The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.