Changes in the characteristics of dental emergencies under the influence of SARS-CoV-2 pandemic: a retrospective study

BACKGROUND: Further understanding of the distribution and changing characteristics of dental diseases is of great significance for all dental emergency centers for strengthening the medical staff's treatment knowledge abilities and effective use of emergency resources in the face of public health emergencies involving highly infectious respiratory diseases. METHODS: The medical records of 4158 dental emergency patients in 2019 and 2020 were retrospectively analyzed and divided into pre-SARS-COV-2 group and SARS-COV-2 group according to time. The demographic data, date and time, diagnosis, and treatment methods of the two groups were statistically described, and the chi-squared test was used to analyze the differences. The medical records of 4158 dental emergency patients during the same period of two years in 2019 and 2020 were retrospectively analyzed and divided into SARS-COV-2 pre-group and SARS-COV-2 group according to time. The demographic data, date and time, diagnosis and treatment methods of the two groups were statistically described, and the chi-square test was used to determine the differences. RESULTS: During the SARS-COV-2 pandemic, the number of dental emergency visits increased by 29.7%. During the pandemic, males (n = 286, 58.1%) were more likely to visit dental emergency centers for trauma than females (n = 206, 41.9%) (P < 0.05); females (n = 242, 60.8%) were more likely to visit dental emergency centers for acute gingivitis and acute pericoronitis than males (n = 156, 39.2%) (P < 0.05). A major change in diagnosis was related to acute pulpitis (K04.0) and acute apical periodontitis (K04.4), which increased by 9.2%; acute gingivitis (K05.0) and acute pericoronitis (K05.2) increased by 3.5%; open wound of the lip and oral cavity (S01.5) decreased by 17.9%; other conditions (non-emergency diseases) increased by 6.8%, compared with the pre-SARS-COV-2 period. Among the treatment modalities, during the pre-SARS-COV-2 period, 304 patients (17.7%) received a prescription for antibiotics and analgesics, and 1485 (86.5%) received a prescription for local treatment. During the SARS-COV-2 period, 958 (39.2%) received a prescription for antibiotics and analgesics, and 1636 (67.0%) received a prescription for local treatment. CONCLUSION: SARS-COV-2 pandemic led to changes in the characteristics of dental emergency patients. Trauma, acute pulpitis, and acute periodontitis are the leading reasons patients refer to dental emergency centers. Dental emergency centers should optimize treatment procedures, optimize the staff, and reasonably allocate materials according to the changes to improve the on-site treatment capacity and provide adequate dental emergency care.


Background
Emergency dental patients often need emergency treatment because of acute facial or dental pain,bleeding,trauma and other conditions [1].Dental emergencies progress quickly because of the acute and complex nature of the conditions in patients.The composition and epidemiological characteristics of dental diseases in the emergency center vary from region to region [1,2],Previous studies have summarized the characteristics of visits to emergency dental patients.For example,in terms of time distribution,the number of visits to emergency dental patients at weekends is more than that in weeks [3],and night is the peak of visits to emergency dental patients [3,4].Gender and age show different features in all kinds of emergency visits [3,4,5],and the main reasons for visits are Pulpitis, trauma and bleeding [5].
The composition and characteristics of emergency dental care are in uenced by environmental changes,lifestyle,economic and sociocultural in uences [6].With the spread of SARS-COV-2 around the world,people adopt home isolation to reduce going out and gathering,resulting in changes in the living environment,psychological status and lifestyle of the population [7].The composition of dental emergency diseases also presents different changes and characteristics.Most of the risk factors associated with dental emergencies are considered to be preventable [6,8].Characteristics of dental emergency patients under the in uence of SARS-COV-2 have been reported,There is a lack of comparison with the situation before the SARS-COV-2 [9].To analyze the incompleteness of the types of emergency diseases [1,9].
Hospitals and clinics choose to reduce or stop visits in order to ensure the safety of doctors and patients under the impact of the SARS-COV-2,At the same time,the dental treatment process has also changed accordingly [1,9,10],dental protection needs to be strengthened during treatment,reduced use of some dental appliances that cause spatter,changes in treatment choices and drug use all in uence the effective operation of dental emergencies [10,11].So master dental emergency diseases distribution and the change law of demographic characteristics for dental emergency center in the face of strong public health emergencies of infectious respiratory disease,can not only improve the e ciency of treatment of dental emergency patients,at the same time can provide dental emergency personnel,supplies, and emergency technical expertise to provide important reference data [12].
In this study,through retrospective analysis,we selected the Demographic data,day and time,diagnosis,treatment method data of patients who visited the dental emergency center during the SARS-COV-2 from January 20 to March 8, 2020.At the same time,patients in the emergency cneter in the same period of 2019 were selected as the control group to compare and analyze the demographic characteristics and disease composition of emergency dental patients and the trend of changes in treatment methods before and during the SARS-COV-2,.In order to explore the characteristics of the composition of dental emergency diseases,provide references for the diagnosis and treatment of critical illnesses in dental emergency departments,and provide scienti c basis for the organization and management of equipment,materials,technology and personnel in dental emergency center.

Data sources and grouping
All patients that presented to the dental emergency service of National Clinical Research Center for Oral Diseases,Department of Dental Emergency,West China Hospital of Stomatology,Sichuan university.Located in Chengdu,Sichuan,China.it is an important dental emergency center in western China. The emergency center is open from Monday to Sunday from 1:00 to 24:00 every day.According to the SARS-COV-2 epidemic,Collected during the outbreak on January20,2020March8(7weeks),dentalemergency patients'Demographicdata,Diagnoses,Treatment methods and the use of Antibiotics and Analgesics,as the during SARS -COV -2 group.In order to better compare the changes and avoid the in uence of time,season and other confounding factors,The pre-SARS-COV-2 group was selected as the data of dental emergency patients from January 21 to March 10, 2019 (7 weeks) during the same period in the pre-SARS-COV-2.Screening criteria included data from 4158 visitors with clear disease diagnosis and complete medical records in the dental emergency center.

Classi cation
A retrospective investigation of the patients was carried out analysing demographic data: sex (male, female);age (0~18 years old in the juvenile group,19~45 years old in the youth group,46~65 years old in the middle-aged group,66 years old and above in the elderly group);the time period (weekly trend changes,daily trend changes);the dental emergency treatment approaches(including drug use(Antibiotics/Analgesics)and local treatment.

Diagnoses
According to the standards of the International Classi cation of Diseases,10th edition (ICD-10) [13,14],the following seven categories of dental emergencies preliminarily diagnosed by pre-hospital physicians were included into this study: Group7: others (non-emergency diseases,including diagnoses related to prosthesis, aesthetic, recall or maintenance).

Statistical methods
The statistical analysis was performed using the SPSS(version 20.0)software.Data were normally distributed,shown as mean ± standard deviation.Chi-square testswas used for analying distribution between groups.A p-value less than 0.05 was set to declare statistical signi cance.

Demographic Data
A total of 4158 cases of emergency patients were included in the study,which consisted of 1716 patients in the pre-SARS-COV-2 group and 2442 patients in the during SARS-COV-2 group.There were males(n=873;50.9%) and females(n=843;49.1%) in the pre-SARS-COV-2 group,with a male to female ratio of 1.04:1.In terms of age composition,564(32.9%) patients were aged 0-17 years in the juvenile group,832(48.5%) were aged 18-45 years in the youth group,189(11.0%) were aged 46-65 years in the middle-aged group,and 131(7.6%) were aged over 65 years in the elderly group.The mean age was 24.7±16.7 years.In the during SARS-COV-2 group,there were males(n=1236;50.6%) and females(n=1206,49.4%),with a male to female ratio of 1.02:1.Among the age groups,535(21.9%) were 0-17 years old in the juvenile group,1299 (53.2%) were 18-45 years old in the youth group,468(19.2%) were 46-65 years old in the middle-aged group,and 140 (5.7%) were over 65 years old in the elderly group.The mean age was 33.0± 19.4 years. (Figure 1 a and b).

Distribution of day and time
The number of dental emergency patients during the SARS-COV-2 increased by 29.73% compared with the number of patients admitted to the emergency center before the SARS-COV-2,with the average daily emergency visits increasing from 35.0 to 49.8.According to the date distribution,the highest number of dental emergency cases in the pre-outbreak period was on Sunday (n=383;22.3%).The minimum day is Tuesday (n=178;10.4%),the highest number of dental emergency cases during the outbreak was on Saturdays(n=402;16.5%)and the lowest was Tuesdays (n=298,12.2%).Compared with the during SARS-COV-2,patients were more concentrated in weekend visits.During the visit period,both groups of patients in emergency dental care had a visit peak from 19:00 to 24:00,among which the pre-SARS-COV-2 group (n=567;33.0%),the during SARS-COV-2 period group Moreover,it was found that during the epidemic period,female(n= 242,60.8%)were more likely to visit the emergency center due to Acute gingivitis and Acute pericoronitis than male (n=156,39.2%),while male(n=286,58.1%)were more likely to visit the emergency center due to the Open wound of lip and oral cavity than female(n=206,41.9%).The low age group(19.8±17.9)was prone to Open wound of lip and oral cavity,while the middle age group (40.7±19.4) was more prone to visit because of Cellulitis and abscess of mouth.(Table1)   Table2   Table 2 Use of antibiotics and treatment by diagnosis

Discussion
During the SARS-COV-2,the number of emergency dental patients increased by 29.73% compared with the pre SARS-COV-2 and the average daily visits increased by 14.8.This is mainly due to the high risk of dental treatment under the in uence of the SARS-COV-2,which leads to the decrease or closure of the general outpatient clinics of stomatological hospitals or clinics in China and the failure of regular examination and treatment of patients in a timely manner,which leads to the aggravation of the condition and aggravation of the pain,thus increasing the demand for dental emergency services,leading to the increase in the number of emergency visits [7,15].Regarding the weekly variation of the number of days visited,the number of patients visited on the weekend in the previous epidemic period was higher than the number of patients visited on the week,which was consistent with the distribution of dental emergency time in South Korea [16].With the outbreak,this difference becomes less pronounced and the distribution of daily and weekly visits after the outbreak decreases,which may be related to the increased demand for emergency dental services.In terms of visiting time,the pre-epidemic group in this study and another study on emergency visits in South Korea [16,17] showed a similar distribution of visiting time in dental emergency patients,both of whom had a peak visiting time at night.During the epidemic,the number of patients visiting during the daytime increased except for the night peak [2,18],which was related to the decrease of dental outpatient service during the SARS-COV-2 and patient's demand for medical treatment through emergency treatment.Therefore,dental emergency centers in a region should increase personnel and material support for dental emergency centers in the face of respiratory infectious disease emergencies, so as to cope with the increased emergency needs of dental emergency patients due to the closure of clinics [19].
In the gender our data show a rather balanced distribution of emergency visits between male and female. In contrast to other studies, other studies found that men are more likely to visit emergency centres [20]. Our study found that male are more likely to have trauma visits than female, while female are more likely to have acute gingivitis and acute periodontal disease visits than male. Such differences may be determined by the different social function roles of male and female, and male are more likely to engage in some more dangerous occupations [20,21],leading to a high incidence of trauma.Studies have shown that women pay more attention to oral health care than men [20,22].Therefore, when gingivitis and periodontitis occur, female are more likely to seek medical treatment. Meanwhile,female are less uncomfortable with pain than male, which may also increase the reasons for emergency visits [23].
By comparing the disease composition of oral emergency patients before and during the SARS-COV-2,Acute Pulpitis (K04.0),the Acute Apical Titis (K04.4),Acute Gingivitis (K05.0),the Acute oronitis(K05.2), Open Wound of lip and Oral cavity(S01.5) were all over 70% of the main types of dental emergency diseases,This result is basically consistent with Jingjing qiu and Jingjing's results against the Characteristics of Endodontic Emergencies during SARS-COV-2 [22].The main complaint was toothache,with its own characteristic nature of the pain,its location and duration.During the SARS-COV-2,admittance of patients with dental and trauma to the dental emergency center declined,but acute Pulpitis (K04.0) and acute apical periodontitis (K04.4) accounted for a signi cant increase.It may well be that during the outbreak,home quarantine and epidemic prevention measures let people stay at home more,thereby reducing the risk and occurrence of injury [20,23,24].The increase in the proportion of acute pulpitis has been related to the dietary habits of patients during the SARS-COV-2.In addition,there was a signi cant increase in the proportion of non-emergency cases during the SARS-COV-2,such as prosthesis, aesthetic,recall or maintenance,which resulted in rapid disease progression and unbearable pain in patients due to their inability to return to their scheduled treatments and ultimately seeking emergency treatment.This may be due to the closure of dental medical facilities during the SARS-COV-2,with patients unable to adhere to their scheduled follow-up treatments [25].
Due to the high risk of SARS-COV-2 transmissions via dental emergency treatments,the use of therapeutic instruments and equipment has been limited,such as high speed turbines used in pulp treatment,periodontal irrigation for the patientand.The selection of emergency treatment programs was also affected according to the change of the SARS-COV-2 situation.The selection of treatment instruments and equipment was mainly for the treatment of acute symptoms,and the principles of diagnosis and treatment during the SARS-COV-2 are mainly to relieve pain,eliminate in ammation, hemostasis,debridement and suture.In cases of acute Pulpitis (K04.0) and acute apical periodontitis (K04.4),the emergency treatments performed were pulp drainage,or dental pulp inactivation and pulpectomy,hence,these treatment measures as well as medullary pulp cavity disinfection and operation for pain treatments appeared to have increased during the SARS-COV-2.Acute pericoronitis(K05.2) mainly occurs in young people aged 18 to 30 years old [26].During an infection, tooth extraction may lead to the spread of infection and at the same time increases the risk of infection with SARS-COV-2.Therefore,the treatment of acute pericoronitis should be a local treatment,supplemented by Antibiotics and Analgesics drug therapy.For abscess,a small incision is needed for pus discharge and in case of space infection,systemic anti-in ammatory treatment may be necessary [27].The present study showed that trauma accounted for 20.1% during the SARS-COV-2 and although it had decreased from before the SARS-COV-2,it was still the main dental emergency among minors during the SARS-COV-2.Previous studies have shown that children are more likely to suffer trauma [15,28],Parents with children in emergency rooms are more anxious because of SARS-COV-2 [29],Therefore,dentists in charge of dental emergency rooms should be familiar with dental trauma in the primary and mixed dentition.In particular, behavior control is di cult in terms of children with trauma and since guardians can be sensitive and anxious,dentists should be well-trained for the behavioral control of the patient and guardian,their prognosis, and follow-up measures. If necessary,knowledge of drugs and emergency treatment is alsorequired,as pediatric patients may need to be sedated through medication [20,30].During the SARS-COV-2,the emergency treatment principle of trauma was to check the patient's overall condition,whether there was any injury to the brain,chest,abdomen and important organs and to conduct surgical suturing of the injury after excluding any life-threatening conditions [31].
The literature shwos an inappropriate use of antibiotics,especially in dental emergency centres.tulip et al reported that 50% of patients were treated with antibiotics alone without any local treatment [32].In our survey,before the SARS-COV-2,17.7% patients received a prescription for Antibiotics and Analgesics.During the SARS-COV-2,this data has reached 39.2%.If you only look at the data of antibiotics,this ratio will be even lower.Therefore,the data in this study can show that the use of antibiotics is relatively standardized.The reason for this change may be due to the impact of the epidemic.When patients are relatively optimistic,increase the use of antibiotics and analgesics,thereby shortening the time doctors can contact patients and reducing the risk of infection.But education abuot an appropriate use of antibiotics and an update of dentists knowledge is mandatory to avoid unnecessary apaplication of antibiotics [32,33].
During the SARS-COV-2,dental emergency services experienced an increase in their workload,re ecting the changes in the dental emergency spectrum as the pandemic progressed.The rational allocation of dental professional doctors could compensate for the experienced shortcomings in the dental emergency departments as well as more emergency resources of dental sub-professional doctors could be mobilized [12,15].It would also be necessary to train stomatologists to have solid professional knowledge and surgical skills in dental medicine,in order to meet the technical requirements of potentially encountered dental emergencies and ensure that all conditions can be dealt with quickly and effectively within the emergency department [2,19].At the same time,the dental emergency department should reasonably de ne and adhere to pandemic prevention measures and su ciently stock common anti-in ammatory and analgesic drugs to meet the patients' medical needs.The result may be an improvement in the operation e ciency of emergency treatments in terms of professional technology,personnel and material available[33]. Conclusion SARS-COV-2 led to changes in the characteristics of dental emergency patients.Trauma, Acute Pulpitis , Acute periodontitis Acute periodontitis is the leading reason why patients go to the dental emergency.The dental emergency department should optimize the treatment procedures, optimize the sta ng and reasonably allocate materials according to the changes, to improve the on-site treatment capacity and provide adequate dental emergency care. University. In addition, consent to participate form was signed by each participant in the study.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.