Relationship Between Patient-reported Orofacial-dental Pain Severity and Tele-triage Decisions During COVID-19 Pandemic-Does the Severity of Pain Drive Tele-triage Decisions?

BACKGROUND Globally, withCOVID-19 pandemic, elective dental services were stopped, and only urgent/ emergency conditions were managed face-to-face after tele-triage(TT). However, no previous researchexploredwhetherthe severity of orofacial/ dental pain (OFDP)drivesthe TT decisions.The current report undertook this task. METHODS This retrospective cross-sectional reportanalyzed the pain severity (PS) reported byhotline callers during the first COVID-19 lockdownand its association with patient's age,sex, history of chronic illness,and dental discipline required. PS was also compared across triage categories, associated dental history and tentative tele-diagnosis. PS was measured using self-reported numerical rating scale (NRS-11).Binomial logistic regression assessed the associationbetweenthe PS (exposure) and likelihoodof being referred for face to face management, controlling for age, sex, history of chronic illness, and dental discipline needed. ANOVA compared pain severity (PS) across dental history and tentative diagnosis. RESULTS PS was significantly associated with TT decisions (p<0.05). An increase in pain score by 1 unit was associated with 1.4 times increased odds of face-face referral. Pediatric/ adolescent patients (9-18 years) were 2.1 times more likely, and those with chronic illness were 2.12 times more likelyto be referred for face-to-facemanagement.Among the dental specialties, surgical and orthodontic specialties were each associated with increased odds of referral (1.9 and 7.016 respectively) compared to restorative specialties.The highest PS was highest for the emergency triage category (8.00 ± 2.83, P< 0.0001),adults (6.29 ± 2.1819, P< 0.0001),and the tentative tele-diagnosis of cellulitis (7.75 ± 2.872, P< 0.0001). CONCLUSIONS TT decisions were significantly influenced by severity of patient-reported OFDP, adjusting for a range of variables. However, acute dental conditions were not referred when they were judged to be manageable remotely;and conversely, less acute dental conditions were given the attention they required and referred when they hadpotential life threating or quality of life implications. Consideringsuch tele-approach after the pandemic has subsided might be safe and useful in a range of scenarios and healthcare facilities.

As part of the COVID-19 measures, the American Dental Association (ADA) published a guidance with de nitions for different categories of dental conditions [6]. Dental pain was a fundamental component in these de nitions as it is a highly prevalent and a signi cant health problem that reduces quality of life and well-being [9 -12].
Pre-pandemic literature suggested that there is an elevated demand of emergency appointments in dental practices and in a certain proportion of general medical practices and emergency departments due to high level and frequency of orofacial/ dental pain (OFDP) [13]. Correspondingly, the pandemic literature suggests that the COVID-19 pandemic in uenced the utilization of emergency dental services [14], and its impact on patterns of dental emergencies was shown in the high prevalence of dental pain compared to other oral health related problems during the pandemic [15 -20]. It has also been suggested that during the pandemic, only patients with acute pain remained constant [21], while the less acute but nevertheless existing dental problems were neglected [22]. 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 hospitals emergency rooms [15,23]. These complications were attributed to the use of the recommended advice, analgesics and antibiotics (AAA) strategy in dental pain management which has signi cant limitations with severe pain-related conditions where face-to-face dental procedures are necessary to achieve symptomatic relief [24].
While TD offers acceptable reliability for the tentative diagnosis [25], the literature on TT during the pandemic reveals knowledge gaps [15,16,20,21,26]. No previous research objectively reported whether TT decisions were driven by severity of pain. Likewise, according to our knowledge, no studies compared the pain severity (PS) across its associated symptoms, and tentative tele-diagnosis. Studies examined selective conditions e.g., dentalfacial trauma [27], or pain, swelling and trauma [15], with less attention to other conditions associated with OFDP e.g., loose/broken dental restorations, orthodontic appliances, oral ulcers, or bleeding. In addition, many reports focused on paediatric populations [27,28] where PS cannot be objectively determined remotely.
Therefore, the aim of the current report is to assess whether tele-triage decisions were driven by severity of pain.
PS was appraised across its associated dental history, and tentative tele-diagnosis to analyse their in uence on tele-triage decisions. The emerging ndings provide important information to a non-existent evidence base on the management of OFDP during pandemics. Findings will provide practitioners and policy makers with information necessary to better manage OFDP related emergencies during situations like those experienced during COVID-19 pandemic, or where resources are signi cantly limited for managing such emergencies.

Ethics, Design and Participants
The institutional research board (IRB) at Hamad Medical Corporation (HMC) granted permission for this service evaluation project to proceed. This is a retrospective analysis of information routinely collected for clinical audit and service evaluation. We analyzed patient, and triage data of all hotline calls during the rst wave of Covid-19 lockdown (N= 1239 for 5 months, 23 March -31 August 2020). We excluded callers with incomplete records where outcomes were not reported (n= 389), and children ≤ 8 years old (n= 125) as the numeric pain scale is not applicable to patients at this age [29,30]. We excluded patients who were not exposed to pain (0 pain score) (n= 193). The inclusion of those with no pain could bias the results, as patients who did not report pain would be referred for face-to-face management for a reason other than the pain itself.
After exclusions, the sample comprised 532 callers who reported various extents of pain. We. analyzed pain severity (PS) reported by callers and its association with patient's age, sex, history of chronic illness, and dental discipline required. We also assessed the association between the PS and likelihood of the TT decision of being referred for face to face management, controlling for the same variables. Data were extracted from the electronic health records and the TD data collection forms. The forms were completed by each tele-dentist for every caller, as part of an ongoing service audit.

Setting and Procedures
HDC set up a dental emergency services hotline managed by a team of quali ed dentists to remotely consult, diagnose oral/ dental diseases, and undertake urgent TT decisions. TD policy and guidelines were formulated to guide the categorization of triage levels (emergency, urgent or non-urgent) and assist the team in the management of self-reported pain, swelling, bleeding, trauma, and oral-mucosal ulceration (Fig. 1). These guidelines were not binding but indicative, leaving some freedom of interpretation to the tele-dentists, who had been trained to ensure consistency of the service in arriving at triage and management decisions while observing caller privacy.
The recommended policy and guidelines, based on American and British recommendations [6, 31,32], helped to triage the call, arrive at a tentative diagnosis, and accordingly offer appropriate care and/or referral. The guideline document was available to each practitioner and posted near the telephone set. In addition, as part of the service, dentists administered a TD data collection form (Fig. S1) for each call. The form collected information on: 1) call (frequency, time, duration); 2) patient (demographics, medical/ allergy history, relationship of caller to patient, chief complaint, severity of pain on scale from 0-10); and 3) triage (specialty required, management, referral to emergency/ dental facility undertaken, medications prescribed, procedure performed at point of referral). The focus of the current report is on the pain.

Pain
The numerical rating scale (NRS-11) is a simple and easy to score pain assessment tool [30] that consists of a total of 11 numbers, ranging from 0 to 10, representing no pain to the worst possible pain, respectively [33]. NRS-11 is reliable and valid as a self-report scale of pain intensity in many populations including children and adolescents as young as 8 years old, however it is not suitable for very young children as certain cognitive skills are required for children to understand the meaning of the numbers of the NRS-11 and provide accurate ratings of PS [34]. Hence, callers ≤ 8 years old were excluded.
Tele-dentists categorized the condition into emergency, urgent or non-urgent and managed the condition accordingly. AAA strategy was utilized as appropriate, and medications were home delivered to patients using courier service. Callers who were referred to hospital emergency or dental facility to receive face-to-face interventions were tele-triaged for COVID-19 symptoms and directed accordingly to either HDC or COVID-19 dedicated facilities.

Statistical Analysis
Descriptive and inferential statistics characterized the sample. Categorical variables are reported as frequencies and percentages and differences TT decisions compared using Fisher's Exact test (Monte Carlo test with 99% CI) due to relatively small sample size. Continuous variables are reported as mean ± standard deviation and PS compared using t test if comparisons were between two groups or Analysis of variance (ANOVA) if > 2 groups. Binomial logistic regression assessed the association between the PS (exposure) and likelihood of being referred for face to face management, adjusted for age, sex, history of chronic illness, and dental discipline needed.
Adjusted odds ratios are reported. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp., USA). P <0.05 (two-tailed) was considered statistically signi cant. Table 1 illustrates that majority of callers were adults (68.61%), while there was almost equal proportions of males and females. About three quarters of the sample had no history of chronic illness. More than half of the callers needed restorative specialties that operate mainly aerosol generating procedures. The mean PS for the whole sample was moderate/ high (6.05 ± 2.284), with adults reporting signi cantly more severe pain than other age groups (p < 0.0001). Likewise, callers who needed restorative and surgical specialties reported moderate/ high PS, while those who needed orthodontic procedures demonstrated signi cantly less PS. PS did not differ by caller sex or history of chronic illness. Association between pain severity and tele-triage decisions

PS across selected sample characteristics
The logistic regression analysis showed that an increase of 1 unit in pain score was signi cantly associated with 1.4 times increased odds of referral for face-to-face management. Three out of the remaining four variables included in the logistic regression were also signi cantly associated with tele-triage decision of referral for face-toface management ( Table 2). The odds of face-to-face referral increased 2.1 times for patients of pediatric or adolescent age groups (9-18 years). Likewise, those with presence of chronic illness were 2.12 times more likely than those with no illness to be referred for face-to-face management. Among the dental specialties, surgical and orthodontic specialties were each associated with increased odds of referral of the patient for face-to-face management (1.9 and 7.016 respectively) compared to restorative specialties. Sex was not signi cantly associated with referral for face-to-face management.   In terms of dental history (Table 4), although tooth with cavity or lling were most frequent and most painful, only 21.78% were referred for face-to-face management. Similarly, jaw-related symptoms had the second highest PS, but only 40% of those callers were referred. Conversely, while orthodontic appliance problems had the lowest PS, 60% of these problems were referred for face-to-face clinical interventions.
As for tentative tele-diagnoses (Table 4), cellulitis was associated with the highest pain, and all cases were referred to a hospital emergency facility. Temporomandibular dysfunction (TMD) was also associated with high pain levels and 50% were referred for clinical management. Pulpitis was the most common tele-diagnosis (31.77%) and was signi cantly associated with high PS, however, 76.33% were managed remotely. While orthodontic problems were associated with lowest pain levels, more than half of the callers could not be managed remotely and were referred for chairside interventions.

Discussion
There has been calls to enhance the evidence-base of the management of OFDP [35]. We assessed patientreported OFDP during the rst wave of COVID-19 lockdown in terms of its differences in severity across demographic variables (age and gender), history of chronic illness, dental disciplines needed, dental history and tentative tele-diagnosis. The report's main objective was to explore whether TT decisions (remote management of caller vs referral for face-to-face management) were associated with the PS. To our knowledge, no previous research undertook such tasks. Hence, it was not straightforward to directly compare our ndings with previous research.
The main nding was that TT decision to remotely manage or to refer the caller for face-to-face management was signi cantly associated with OFDP severity. An increase in pain score was associated with increased odds of faceface referral, however, other covariates were also associated with such decisions. Most signi cant associations were whether the caller had a history of a chronic illness, and whether the discipline needed operates aerosol generating procedures. This indicates that management decisions at HDC were highly individualized, considering 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, callers with problems related to tooth cavity/ lling, 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 between 22.5% -46% pulpitis rates reported by others as the origin of OFDP during the pandemic [15,18,19]. Despite that endodontic 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 where 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 [16]. This also explains the increased odds of the patients being seen at the clinic for surgical and orthodontic procedures (1.9 and 7.016 respectively) compared to that of aerosol generating restorative procedures.  [39]. All cellulitis were categorized by the HDC tele-dentists as emergency and referred to hospital emergency for intravenous antimicrobials and analgesics [39].
For callers with low PS, the individualized approach after careful weighting of reported pain and clinical picture was also evident. For instance, those with history of orthodontic appliance problems experienced least pain, but the majority were referred. The majority of orthodontic patients typically fall in the pediatric or 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 signi cant 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 OFDP was the driver of urgent care [21]. On the other hand, pre-pandemic literature suggests that the high OFDP results in an elevated demand of emergency appointments at dental practices, some general medical practices and emergency departments [13].
The present report showed that PS indeed in uenced the TT decisions of OFDP (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. Hence, 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. This 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.
The current report has limitations. HDC is a tertiary dental services provider, and the patients in the current report are patients with previous dental experiences or persisting symptoms. Such patients are different than those who present at primary dental care centers experiencing their rst dental pain encounter. Hence, generalizability of the ndings needs to exercise caution. Despite this, the report has strengths. Previous work on patient-reported OFDP during the pandemic lockdown focused on the association between worsened socioeconomic conditions and pain severity [40], while the current report explored the in uence of PS on TT decisions, and appraised PS across triage categories, demographic variables, dental history, discipline required, and tele-diagnosis related factors. These ndings provide policy makers with information necessary to better manage OFDP related emergencies and similar epi/pandemics, or where resources are signi cantly limited in rural areas and underdeveloped regions.

Conclusion
During this phase of the pandemic, the most frequent symptom with most severe OFDP was decayed or lled tooth, and the most frequent tele-diagnosis was pulpitis. PS was signi cantly higher for emergency and urgent tele-triage categorization. TT decisions were signi cantly in uenced by severity of patient-reported OFDP, adjusting for a range of variables. However, acute dental conditions were not inevitably referred when they were judged to be manageable remotely; and conversely, less acute dental conditions were given the attention they required and referred when they were judged to have potential life threating or quality of life implications. Such measured actions could lead to sizeable savings of healthcare resources which could in future be used to reduce pressure on clinics overcrowded with conditions that could be remotely managed. Hence, maintenance of such tele-approach See image above for gure legend.

Supplementary Files
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