COVID-19 Implications for Emergency Dental Care

COVID-19 has had a profound impact on dentistry, with all elective treatment initially coming to a halt and a slow, gradual return to normal services. The available guidance on the treatment of dental emergencies is currently advice, analgesia and antimicrobials, where indicated in the first instance.

Some patients cannot be successfully treated with this approach and require in-person consultations.

Unless dental offices have appropriate personal protective equipment and follow strict infection prevention and control guidelines, in-person consultations may not be possible.

If treatment is required, it is based on minimal intervention and avoidance of aerosol-generating procedures (AGP) in COVID-19-free patients. Positive or suspected COVID-19 patients still require treatment at designated urgent dental care centers.

The purpose of this article is to provide insight into the COVID-19 pandemic and its implications on current emergency dental care. Commonly occurring dental conditions requiring endodontic treatment will be discussed.

Finally, an endodontic management protocol is suggested. The intent of the protocol is to describe practical techniques to minimize potential viral load and reduce the risk of COVID-19 transmission when AGPs are instigated.

Primary care dentistry

On 25 March 2020, the Chief Dental Officer (CDO) advised that the provision of all non-urgent dental treatments would be postponed or stopped entirely. 

On a no further treatment basis, patients would be managed remotely via telephone triage and treated for acute problems where possible on the basis of counselling, analgesia and antimicrobials (AAA), if possible in the first instance.

If the physician, through telephone triage, feels that the condition warrants an in-person consultation and additional treatment, then the patient should be referred to urgent dental care centers (UDCC). Any treatment would be provided with the goal of reducing or avoiding aerosol generating procedures (AGP) unless absolutely necessary.

Additional guidance published in May recommended that dental practices could reopen from 8 June 2020. This was a gradual transition towards a return to normal service and a number of key principles were outlined .

Initially, remote consultations should be provided and AAA should continue to be adopted in the first instance.

Patients who do not show symptoms of COVID-19 may be offered in-person appointments, and a variety of treatments may be offered on the condition that appropriate personal protective equipment is available and in accordance with prevention and treatment guidelines. infection control (IPC).

If treatment is planned, then AGPs should be avoided if possible and intervention should be reduced to a minimum.

If patients are confirmed or suspected to have COVID-19, they should still be referred to UDCC.

Acute dental presentation and management

If patients have pain , the recommendations mentioned above should be adopted. The AAA principle discussed above should be provided in the first instance where appropriate. This may be successful in a portion of the short-term cases that are handled by telephone triage.

In areas where systems and services are available, dental practices can promote face-to-face consultations and subsequent treatment if IPC guidance and appropriate PPE are available; However, this may not be the case for a number of dental practices.

Commonly occurring conditions are briefly discussed below:

Irreversible pulpitis : lasting, stabbing pain of spontaneous onset. It is aggravated by heat and relieved by cold, and is generally poorly localized. Patients with irreversible pulpitis would have previously received appropriate analgesic advice. Typically, people who came for treatment would not have been able to control severe pain with painkillers alone. Sometimes antimicrobials may have been prescribed, which of course will not be effective for pulpitis. Reversible pulpitis should be treatable with analgesia and appropriate triage advice.

Symptomatic apical periodontitis : dull, stabbing, constant pain that worsens when biting the affected tooth. The patient can locate a single tooth. These patients often have severe pain and, unfortunately, analgesia may have been ineffective. Typically, these patients may have been prescribed one or more antimicrobials that have previously resolved the pain.

Acute apical abscess : spontaneous, intense pain with swelling and usually discharge of pus. The tooth is well located as it can be sensitive when biting. If these patients present with severe symptoms, soft tissue inflammation and disseminated infection, appropriate hospital referral may be required for management by the oral and maxillofacial surgery team.

General considerations for the management of endodontic emergencies

Due to the need for social distancing measures and minimization of transmission risk, specific considerations for patient flow and management are required. For example, a waiting room full of patients increases the risk, as do areas where patients with and without COVID-19 symptoms could come into contact.

In this regard, scheduled appointments with appropriate staggering of clinic hours are needed. Waiting rooms can be divided into zones with adequate spacing between seats. When waiting rooms are small, the doctor may decide to have only one patient waiting at a time to further minimize risk.

Depending on symptoms, confirmed or potentially positive COVID-19 patients should ideally wait and be treated in areas other than those who are asymptomatic.

More attention should be paid to patients who are in vulnerable groups (those who are 70 years or older, pregnant, obese, diabetic, suffering from lung or heart diseases and patients taking medications that affect the immune system), who should also be treated in different areas if possible.

The dentist and nurse should not leave the office during an AGP procedure due to droplet contamination and therefore all necessary equipment should be arranged in the best possible way to avoid unnecessary stocking of items.

A "runner" nurse should remain outside the surgery to provide any additional supplies needed during the operation. These materials can be transferred via cart from outside the office.

Prior to any AGP, appropriate PPE should be donned (put on) in a separate area/surgery. In practice, the nurse and operator can assist each other in putting on PPE to ensure it is fitted correctly, or the ’runner’ nurse can be used as a ’buddy’.

PPE should be removed in reverse order and ideally in a separate dedicated area if available. If a dedicated area is not available, then removal can be completed in the patient’s treatment room, with the exception of respiratory masks which must be removed outside the room.

After completing any AGP, the aerosol cloud must be cleaned prior to any further use of the room.

Aerosols can commonly remain in dental surgeries for 10 to 30 minutes before dissipating.

Current recommendations indicate that surgical rooms should be left empty for 20 minutes in a negative pressure room and for one hour in neutral pressure rooms. After aerosol dispersion and settling, meticulous cleaning should be performed before any further treatment of the patient in the same surgery.

For this reason, it is recommended that several surgeries be available for use during AGPs. Doctors and nurses can use free rooms while waiting for terminal cleanings from previously used surgeries. This should increase efficiency and could reduce the number of patients gathering in waiting rooms.

Most commonly, doctors use optical magnification when performing endodontic procedures; They are usually in the form of dental loupes or microscopes. This can pose a problem when using enhanced personal protective equipment and in particular a full face visor. If the visor does not sit vertically, some have advocated creating holes inside the visor to accommodate magnifying glasses, but this unfortunately creates a path for the aerosol to travel.

If dental microscopes are to be used, then proper barrier wrapping and protection may be more of a challenge. Recommended full face scopes can be inverted and tethered to the eyepiece. The operator’s chin can rest on the visor to provide some protection; While placing your eyes near the microscope eyepiece, a form of eye protection should be worn . Both techniques rely heavily on initiative, as they do not provide the same protection as full-face visors.

Suggestions for managing acute endodontics during the COVID-19 crisis

These are suggestions for managing patients in pain and in an emergency requiring endodontic intervention.

The goal should be as aseptic a technique and as little aerosol production as possible. Another goal is optimal and efficient endodontic access and instrumentation. This would be in the hope that any further intervention or acute symptoms would be prevented or negated, especially during the period when services are not at normal operating capacity.

What is vitally important is that the diagnosis is clear, the tooth can be restored predictably, and the need for endodontic treatment is appropriate. The patient should also be aware that the tooth will require completion of endodontic treatment. If a tooth is accessed and then deemed unrestorable or the patient’s tooth is extracted, an AGP may have been started unnecessarily.

Preoperative

• Consider ’swabbing’ the patient’s lips and surrounding area with povidone-iodine (PVP-I) or chlorhexidine if available to maintain as aseptic technique as possible, similar to other dental procedures that require aseptic technique.
   
• A form of mouthwash may be considered preoperatively: gargling with PVP-I or hydrogen peroxide has the potential to reduce salivary viral load.
   
• In practice, hydrogen peroxide mouthwash may be most available in concentrations ranging from 1.5 to 9%. This can be rinsed around your mouth for a minute.
   
• It is believed that chlorhexidine mouthwash may not be effective against COVID-19.

There is also potential for the use of PVP-I as a nasal spray and mouthwash for both patients and healthcare workers. A 10% PVP-I solution is diluted to a concentration of 0.5%. This solution is gargled in the mouth and held at the back of the throat for one minute and administered into the nostril with a spray device or syringe.

For healthcare workers, this can be repeated every two to three hours. A note of caution: PVP-I is for oral use, but in this case, it can be considered an ’off-label’ application. 28

Intraoperative

• Single-use instruments to be used whenever possible to reduce the need for sterilization and decontamination.
   
• Reduce the need to use intraoral radiographs whenever possible; This is unlikely to be practical for endodontics, as an adequate preoperative radiograph must be available.
   
• Isolation of the rubber dam is imperative; This should cover both the nose and oral cavity to reduce contamination with oral saliva and blood. Rubber dam isolation has been shown to reduce microorganisms by up to 98% when preparing teeth for direct restorations.
   
• Ideally, load the single-tooth dam with the appropriate clamp before placing it in the mouth to reduce the possibility of aerosol. Use sealant materials if necessary to optimize the seal between the tooth and the rubber dam. This can be accomplished with a caulking agent, liquid rubber dam sealants, or flowable compounds, which may be more readily available.
   
• After rubber dam isolation, the isolated tooth/teeth should be cleaned with sodium hypochlorite, hydrogen peroxide, or PVP-I using a cotton pad and tweezers for one minute. Classic endodontic microbiology studies have sterilized the crown of a tooth before access to prevent cross-infection of pulp microflora; This principle can be applied to the current situation. In comparison, tooth prophylaxis is likely to produce aerosol.
   
• Once the tooth has been disinfected, proceed to clean the rubber dam area local to the tooth in the same way.
   
• To start your access cavity, use a rapid handpiece with reduced or no water and high volume suction to reduce aerosol production. This is a deviation from normal practice in abnormal circumstances. Tungsten carbide burs cut more efficiently than diamond burs and are therefore less likely to produce random debris. It is only necessary to remove the enamel within the ideal access cavity; Once the dentin is broken, switch to a slow handpiece. The cavity can be excavated by hand if necessary.
   
• Be sure to use high volume suction as close to the tooth and handpiece head as possible during drilling to reduce aerosol contamination of the surface. The use of high volume suction has been shown to reduce aerosol surface contamination by 90-93%.
   
• Refrain from using 3-in-1 syringes as much as possible; Debris collected within the pulpal system can be removed by high volume suction. A fine surgical aspiration tip can be placed to aid delivery into the cavity.
   
• Avoid using ultrasonic scalers, which have high aerosol production.
   
• Use Gates Glidden burs and/or gooseneck burs to improve access depending on the depth of dentin overlying the pulp roof and the proximity of the canal orifices.
   
• Once the pulp has been accessed, the inflamed tissue in the pulp chamber can be removed, essentially a pulpotomy. 5% sodium hypochlorite can then be used to completely dissolve any organic tissue to the best possible level and minimize the constant need for irrigation and re-irrigation.
   
• An alternative to pulpotomy could be a ’pulpectomy’ if time and equipment permit. The root canal system can be mechanically instrumented to the extent necessary, with the goal of delivering intracanal irrigants and medications into the root canal system to eradicate bacteria.
   
• Pulpotomies may be considered for irreversible pulpitis as the root pulp is usually vital. In contrast, in necrotic cases, there is a well-established infection and the intention is to eliminate microorganisms within the root canal system.
   
• Whenever possible, a root canal treatment should be provided in a single visit. This will reduce the need for a new appointment as well as an increased risk of AGP.
   
• If the doctor is unable to complete the root canal treatment, which is likely to be the case in most acute cases, cover the pulpal system with an appropriate medication. Consider the use of unset calcium hydroxide for necrotic pulps and steroid/antibiotic pastes for cases of irreversible pulpitis.
   
• Ideally, the tooth should be definitively restored with a direct restoration under rubber dam isolation if endodontics has been completed. This may also provide the basis for extracoronal restoration at a later date and further reduce the burden of subsequent AGPs.

Management of dental trauma

Avulsion and dislocation injuries will require repositioning and treatment commonly in the form of a splint. Crown fractures complicated with pulp involvement will also require treatment.

If the teeth require splinting, then the use of a composite resin using a self-etching adhesive or a resin-modified glass ionomer cement may be considered. This would minimize the use of the 3-in-1 syringe and, in turn, reduce aerosol production.

Removal of the splint can be facilitated by sectioning the wire splint with pliers or pliers between the restorations. The composite buttons will remain on the tooth but can be removed at a later date; Remaining sections of wire or rough sections of composite material can be lightly polished with hand-held abrasive strips and discs or abrasive discs on a slow handpiece to remove sharp edges.

This would again negate the use of the high speed handpiece and, in turn, reduce aerosol generation. In other circumstances, the doctor may decide that the flexible splint can remain in situ for the time being.

Treatment of complicated crown fractures poses an additional challenge. A rubber dam should be applied and the tooth cleaned in the same manner as described above for endodontic treatment. Once isolated, the exposed pulp can be evaluated for a direct pulp capping (to minimize AGPs) or a partial pulpotomy.

The provision of a partial pulpotomy should limit the amount of aerosol generation, as it is unlikely to prolong the duration of instrumentation to reach healthy pulp tissue.

Once healthy pulp tissue is exposed, hemostasis can be assisted with a sterile cotton compress soaked in sodium hypochlorite or saline solution. If bleeding does not stop, more tissue may need to be removed until hemostasis is achieved.

The exposed healthy tissue can then be covered with non-setting calcium hydroxide or bioceramic materials such as mineral trioxide aggregates or calcium silicate-based materials. It can then be veneered with glass ionomer cement or a composite restoration using a self-etching adhesive without the creation of further aerosol.

More detailed guidance has been published regarding trauma management relevant to COVID-19, which recommends that if a patient is cared for, gold standard treatment should be provided, even if AGPs are likely to be involved. Where possible, this should be adhered to. a, otherwise it can lead to worse outcomes and recidivism.

Discussion

As dentistry is stripped back to essentials across the UK and the number of patients being seen is reduced, the initial approach of the AAA principle is useful for a large number of patients, with first contact being made through telephone classification.

The implications of this approach to emergency dental care are far-reaching and significant for patients and NHS dental services. Telephone triage by a professional through careful questioning of signs and symptoms, despite best efforts, may not provide a clear clinical picture of the problem without physical or radiographic investigation.

The concern is that antibiotics and painkillers may be prescribed to people who do not require them or that they may, in fact, be provided for conditions for which they may not be effective. A further consideration is what appears to be a complete change in approach to antibiotic prescribing at this clearly difficult time for the NHS.

The National Institute for Health and Care Excellence (NICE) has published guidelines aimed at controlling the overprescribing of antibiotics, with the aim of preventing antibiotic resistance and its implications. These practices can have unfortunate and unintended consequences for the patient in their future health management.

The problem and concern for patients where this is ineffective is that the result is repeated symptoms and morbidity. Antibiotics, without follow-up care such as providing root canal or extraction (if indicated), can result in antibiotic resistance, which could make any future treatment more challenging.

As such, we will likely be managing the legacy of this unfortunate period for many years to come. In fact, patients who go the AAA route for treatment are more likely to be interested in accessing endodontic treatment rather than extraction, in hopes of keeping the tooth.

Funding issues relating to NHS endodontics have long been cited. As a result of the widespread provision of antibiotics and the likely antimicrobial resistance that follows, we may see a large increase in the need for endodontic services and consequently an increase in pressure on the patient. already sporadic access to secondary care endodontics for teeth referred for new or de novo root canal treatment .