There has been calls to enhance the evidence-base of the management of OFDP . We assessed patient-reported OFDP during the first 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 findings with previous research.
The main finding was that TT decision to remotely manage or to refer the caller for face-to-face management was significantly associated with OFDP severity. An increase in pain score was associated with increased odds of face-face referral, however, other covariates were also associated with such decisions. Most significant 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/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 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 . 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.
Hight levels of pain severity 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 . For instance, we observed that TMD was the second most painful condition. This supports that the pandemic adversely effected peoples' psycho-emotional status and intensified their bruxism and TMD symptoms . However, during tele-triage, patients may provide inaccurate history  as TMD is difficult to be described by the patient. In addition, it could be an early symptom of an underlying cardiac problem . 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 , 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 . All cellulitis were categorized by the HDC tele-dentists as emergency and referred to hospital emergency for intravenous antimicrobials and analgesics .
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 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 OFDP was the driver of urgent care . 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 . The present report showed that PS indeed influenced 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 first dental pain encounter. Hence, generalizability of the findings 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 , while the current report explored the influence of PS on TT 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 OFDP related emergencies and similar epi/pandemics, or where resources are significantly limited in rural areas and underdeveloped regions.