Dental Emergency Management Techniques in Medical Practice during the COVID 19

Pandemic

Dr Jacqueline Stuart BDSc, PhDAdjunct Lecturer JCU James Cook University, College of Medicine and DentistryT: 0419112769E: jackiestuart64@gmail.com

Presentation Outline

1. Dental Practice limitations imposed during Co-Vid 19

2. Prevalence of Dental Presentations to the Medical Practitioners.

3. The Importance of Improving Interprofessional communications.

4. Dental Anaesthetic Techniques.

5. Antibiotic Use in Dental Emergency Management.

6. Common Emergency Dental Presentations and their Treatment Options.

Dental professionals are reported to be at very high risk of COVID-19 infection due to the close face-to-face patient contact required during patient care (Peng et al., 2020).

Studies suggest that COVID-19 may be airborne through aerosols formed during dental and medical procedures or indirectly through saliva (Wax et al., 2020., Tsang et al., 2020)

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Campaign/COVID-19/Managing-COVID-19/Practice-Resources/Dental-restriction-Levels/ADA-dental-restriction-levels-in-COVID-19-Publishe.aspx

ADA Dental Service Restrictions in COVID 19

Five restriction levels for dental practice during the pandemic exist. These are based on published triaging systems in Australia for Dentistry and take into consideration the following key objectives:

1. A proportionate, pre-planned response to the possible escalation of COVID-19 based on the evolving community context.

2. Staged restrictions of dental services to reduce transmission risks for COVID-19

3. Avoidance of likely burden on medical primary care and emergency services should access to urgent dental care cease.

• Patients confirmed with COVID-19 may either be a hospital in-patient or being managed by ‘hospital in the home’.

• Dental treatment will be provided with transmission based, contact and airborne precautions. Airborne precautions include the need for the patient to be treated in a negative pressure room, with dental staff wearing P2/N95 respirators which have been previously fit-tested, and then fit checked at time of use.

• All confirmed coronavirus cases will only have dental treatment as an in-patient or within a hospital setting by appropriately trained and credentialled dental personnel.

Management of Patients Confirmed with COVID-19 who Require Urgent Dental Care

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide

A patient with a significant dental emergency who is at risk of COVID-19 infection or with a confirmed diagnosis, will most often be able to be managed with analgesics until the patient has reached the end of any mandatory quarantine period, or is no longer at risk of being infectious.

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide

Services that can be performed Restricted services, defer treatment

No restrictions

All dental services No restrictions apply

Level 1 Restrictions

All dental treatments using standard precautions for people who do not meet epidemiological or clinical risk factors for COVID-19 infection transmission

Defer non-urgent treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk.

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Campaign/COVID-19/Managing-COVID-19/Practice-Resources/Dental-restriction-Levels/ADA-dental-restriction-levels-in-COVID-19-Publishe.aspx

Services that can be performed Restricted services, defer treatment

Level 2 Restrictions

Provision of dental treatments that are unlikely to generate aerosols or where aerosols generated have the presence of minimal saliva/blood due to the use of rubber dam.

• Examinations and hand scaling• Restorative procedures using high

speed handpieces only provided with the use of rubber dam

• Non-surgical extractions• Denture procedures• Orthodontic treatment

Defer all treatments that are likely to generate aerosols

Services that can be performed Restricted services, defer treatment

Level 3 Restrictions

Only urgent dental treatments that do not generate aerosols, or where treatments generating aerosols is limited to management of;

• Acute dental pain e.g. endodontic treatment under rubber dam

• Non-Surgical Extractions• Dental tooth trauma performed under rubber

dam

Defer all routine recall examinations and non-urgent dental treatments.

Services that can be performed Restricted services, defer treatment

Level 4 Restrictions

Very limited urgent dental treatments which include management of the following :

• Swelling of the face, neck or mouth• Dental trauma causing change in the

position of teeth, soft tissue damage and/or significant pain

• Significant bleeding

Defer all dental treatments for patients not fitting the risk categories identified on the left.

Level 5 Restrictions

No routine dental treatment provided. All patients with acute dental concerns to be directed to emergency care centres.

Any dental treatment without expressed permission from the public health authorities.

People who have difficulty in accessing dental services frequently present to:

• Hospital Emergency Departments (Cohen, Bonito, Akin, Manski, & Macek, 2008; Cohen et al., 2011)

• Private Medical Practices (Britt et al., 2000)

• Pharmacists (Cohen, Bonito, et al., 2009)

• Aboriginal Health Centres (Tennant et al.,2014:Walker et al., 2013)

When restrictions are placed on accessing routine oral health care, a significant concern exists for overall patient dental/medical care. During this Pandemic, more patients than usual may access Accident and Emergency Hospital Departments. These patients may potentially need hospital admission for the management of acute dental infections that may threaten the airway and require intensive care (Manus et al., 2020).

• From 2016-2017 there were 70,200 avoidable hospital admissions for dental conditions (Australian Institute of Health and Welfare, 2019)

• It is estimated that there were 750,000 consultations with medical practitioners in 2011 for dental-related issues in Australia (National Advisory Council on Dental Health, 2012).

Medical practitioners generally lack substantive training in dentistry (Cohen, Harris, et al., 2009; Skapetis, Gerzina, & Hu, 2011)

Very few doctors at the Emergency Hospital Departments have been trained in the management of dental problems

(Skapetis, Gerzina, & Hu, 2011)

Pneumonia

Perforated or Bleeding Ulcer

Pelvic Inflammatory Disease

Gangrene

Cellulitis

Dental Conditions

ENT Infections

Convulsions

UTI

Number of Indigenous and Non-Indigenous Hospitalisations

Potentially Preventable Hospitalisations in Regional Queensland 2012-2014

Dental Conditions

Harriss et al, (2019). Preventable hospitalisations in regional Queensland; potential for primary health? Australian Health Review, 43, 371-381.

Dental Conditions

Number of Potentially Preventable Hospitalizations due to Dental Conditions 2016-2017

(Australian Institute of Health and Welfare, 2019) (AIHW,2017)

One in 10 potentially preventable hospitalisations in Australia from 2015-2016 were for conditions of dental origin

Patients with substantial facial swellings may progress to life-threatening emergencies. For such patients, extractions of the causative pathogenic teeth should be prioritised over restorative rescue, and input from dedicated oral surgery and maxillofacial services and close follow-up is indicated (Manus et al., 2020).

Improving interprofessional communications will ensure better patient outcomes

• OPG Interpretation

• Basic Dental Anatomy

• Australian Tooth Numbering System

Orthopantomogram.......OPGThe image provides an overview of the state of the dentition as well as information regarding the mandible, maxilla, sinuses and the temporomandibular joints.

Dental Pathology on OPG

AmeloblastomaOdontogenic Dentigenous Cyst

Dental Abscess

OPG of a 7 year old with a mixed dentition

Anatomy of the Normal Healthy Tooth

Tooth apices

Periodontalligament

Alveolarbone

Pulp

Dentine

Enamel

(Douglass & Douglass, 2003)

Crown

Root

11 2112

22 23

13

31 324142

4333

Australian tooth numbering system: Permanent Dentition

24

4434

4546

35

3637

25

51 6162

5253 63

71 7273

74

818283

84

85

54

Australian tooth numbering system: Deciduous Dentition

Eruption Times for Deciduous and Permanent Teeth

16 mo

8 mo

7-8 yr

17-21 yr

29 mo

Dental Anaesthesia

Although the efficacy of using a mouth rinse before commencing dental procedural treatments cannot be guaranteed to have a significant effect on viral load in a patient with COVID-19, it is recommended by the ADA that all patients should be asked to undertake a 20-30 second pre-procedural mouthrinse with either: 0.2% povidone iodine, 1% hydrogen peroxide or 0.2% chlorhexidine rinse (alcohol free).

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide

Provide Dental Anaesthetic pain relief and refer.

The Trigeminal Nerve

Different Dental Anaesthesia Techniques

InfiltrationSubmucosal injection of local anaesthetic directly into an area of terminal nerve endings. This typically provides pulpal anaesthesia for 1-2 teeth.

Peripheral Nerve Block

Injection of the local anaesthetic solution into the vicinity of a peripheral nerve to anaesthetize that nerve’s entire area of innervation.

Maxillary Infiltration Injection

This involves the extravascular placement of the local anaesthetic in the region to be anaesthetised. Infiltration injections are most routinely used to anesthetise the maxillary nerve supplying these teeth. Xylocaine (Lignocaine) is the most common anaesthetic choice but Marcaine is often used for longer duration anaesthesia.

Topical Anaesthetic and pressure at injection site reduce discomfort.

Injection site directed at the tooth root tip at a 45 degree angle.

Inferior Alveolar Block aims at the deepest part of ascending ramus parallel to the occlusal

plane and lateral to the raphe. The needle tip will hit bone with the bevel aimed away to assist in needle deflection and direction of local anaesthetic solution. Aspirate so as not to inject into the blood vessel. Deposit 1.8-2.2 ml.

The introduction of Articaine has allowed success rates of mandibular buccal infiltration anaesthesia of 64%- 70% in adult mandibular first molar with almost 100% success rated in anterior permanent and deciduous mandibular anaesthesia.

Jung et al (2008) Corbett et al (2008)

Mandibular Infiltration Injection

Commonly used Dental Local Anaesthetics

Vasoconstrictors should be included in dental local anaesthetic solutions unless specifically contraindicated by the medical status of the patient or by the duration of the planned treatment. (Said Yekta-Michael, Stein, & Marioth-Wirtz, 2015)

• Lidocaine........”Xylocaine”• Prilocaine........”Citanest”• Bupivacaine....”Marcaine”

• Articaine.........”Septocaine/ Septonest”

Contraindications to Vasoconstrictors and/or Local Anaesthetic Agents

• Recent myocardial infarction (<1 month or symptomatic)• High risk Arrhythmia• Uncontrolled or severe Hypertension• Patients taking digoxin• Uncontrolled diabetes mellitus• Uncontrolled hyperthyroidism• Documented allergy• Drug abuse (Cocaine, Methamphetamine- known use within past 6-24

hours)

(Daublander et al., 2012)

SEPTANEST 1:100,000Articaine Hydrochloride 4% with adrenaline (epinephrine) Injection

Dental Conditions that may present to the Emergency Department or to the

Medical Practitioner

Oral Pain

•Dental Caries

•Dental Abscess

•Gingivitis

•ANUG

•Periodontal Disease

•Perichoronitis

•Dry Socket

Dental Trauma

Hard Tissue Injuries:•Jaw Fracture

•Tooth fracture

•Avulsed Tooth

•Tooth Intrusion

Soft Tissue Injuries:•Degloving

•Tongue piercing

•Lacerations

•Aspirin/ Chemical Burn

• Post extraction haemorrhage

• Denture related issues

• Lost or broken restorations or crowns

• Broken orthodontic brackets

Common Emergency Dental Presentations

Other Emergencies

Dental Caries Cause Odontogenic PainCarious lesionencroachingon pulp

Pulp becomingseverely inflamed,causing acutepain because ofconfined space

(Douglass and Douglass 2003) Silver Diamine Fluoride 37%? (Hendre, Taylor, Chavez, & Hyde, 2017)

Aetiology of Dental Caries

A dental abscess is pus enclosed in the periapical tissue of an infected tooth. Usually the abscess originates from a bacterial infection in the dead pulp of the tooth caused by dental caries, broken teeth or extensive periodontal disease.

Aetiology of the Dental Abscess

The Dental Abscess

Antibiotics are not an effective treatment for most dental emergencies!

The principles of managing infection, such as, remove the cause, drain the pus and support the host, have been known since the time of Hippocrates.

“Antibiotics should not be used for dental pain, pulpitis or infection localised to the teeth, or to delay providing dental treatment”.

Oral and Dental Expert Group. Therapeutic Guidelines - Oral and Dental, version 2. Therapeutic Guidelines Limited; Melbourne 2012.

• Antibiotic prophylaxis is no longer required for patients with orthopaedic joint replacements.

• Antibiotic prophylaxis is no longer required for patients with mitral heart valve prolapse or structural or valvular heart disease.

Oral and Dental Expert Group. Therapeutic Guidelines - Oral and Dental, version 2. Therapeutic Guidelines Limited; Melbourne 2012

Emergency Drainage of the Dental Abscess

A piece of sterile rubber glove is inserted into the incision site to keep the wound open to allow drainage until definitive dental treatment can occur.

Cut drainage insert shape this way……

Referral to the Dentist is Vital

Only Dental Abscess causing Acute Oral, Medical and Surgical Conditions with Facial Swelling requires Antibiotics

Ludwig’s Angina

• Ludwig’s Angina is a rare but life threatening

infection with mortality close to 100%

• Dental infection is the cause in 90% of cases

• Bilateral infection of sublingual and

submandibular glands and facial tissues

Gingivitis

Acute Necrotising Ulcerative Gingivitis (ANUG)

Can be easily identified by the involvement of the interproximal papillae and the presence of a pseudomembranous necrotic covering of the marginal tissue

Periodontal Disease

(Douglass and Douglass 2003)

Pericoronitis• Pericoronitis associated with wisdom tooth

eruption causes the formation of operculum which can be very painful and cause swelling.

• Treatment is irrigation under the operculum flap with saline or chlorhexidine and supportive medication such as anti-inflammatory medications and pain killers.

• Antibiotics are rarely required ...

Operculum

Alvogyl

(eugenol, iodoform and butamen)

Treatment• Chlorhexidine rinse • Alvogyl placement in some instances• Analgesics • Antibiotics are not indicated

Dry SocketDry socket following a tooth extraction is caused when the post operative blood clot is prematurely lost. This may be due to vigorous rinsing, interference with the extraction site, smoking or idiopathic origins.

Dental Trauma

Consider other issues related to dental trauma

1. Other injuries- Head injury/ concussion- Jaw/ facial bone fracture

2. Social issues.- Who can give consent for treatment if a child patient? -Third parties involved ?-Records need to be kept for 25 years.

3. Trauma History .... suspected child abuse, insurance claims -When...timing essential for re-implantation success-Where.....-How....-Who....

Injuries to hard dental tissues -Jaw fracture-Crown fracture with/without pulpal involvement-Root fracture-Avulsions/Intrusions

Injuries involving soft dental tissues-Degloving-Tongue Piercing-Lacerations- Aspirin/Chemical Burns

Hard Tissue Injuries: Jaw Fractures

Fractured MandibleSigns of a fractured mandible include inability to open the mouth, sideways canting of the jaw upon opening, uneven teeth that appears different from before the accident, and inability to close the teeth together properly.

Reduce the fracture by wiring the jaw with fine gauge wire .

Simple Jaw Stabilisation

https://youtu.be/s3DrqQrAhi4

Locked Jaw

Tooth Fracture with no pulpal involvement

TREATMENT

The patient should be advised to eat soft food till seen by dentist – 48 hrs. If a tooth fragment is available, it can be bonded to the tooth. Otherwise perform a provisionaltreatment by covering the exposed dentin with glass-ionomer. Then referral to a dentist.

Involvement of the nerve causes pain and the possible eventual death of the tooth. Pain Relief with dental analgesia or medication must be administered.

In the ED department, in the absence of a dentist, the application of a sedative dressing with calcium hydroxide and glass ionomer to cover exposed dentine will seal the tooth till a dentist can see it.

Tooth Fracture with pulpal involvement

Dental Trauma Kits

• If the root tip is not fully formed then the prognosis for survival is possible if it is not left out for longer than 15-60 minutes.

• If the root is fully formed and reimplantation rapid, vitality may be maintained but is not predictable.

The Avulsed Tooth

Treatment for an avulsed permanent tooth

Calm the patient downHave the avulsed tooth with them in either a glass of room temperature milk or in their own mouth in the buccal sulcus

Clean debris from tooth as gently as possible without touching the root surface. Use milk or sterile saline not tap water. Reimplant the tooth making sure it is not back to front!

Apply a temporary splint.Refer to the dentist immediately to splint the tooth in place ideally using fishing line and glass ionomer cement

Avulsed baby teeth should not be replanted.

(Resource Centre for Rare Oral Diseases and Department of Oral and Maxillo-Facial Surgery at the University Hospital of Copenhagen, 2010)

Use the patients mouthguard as a splint

Emergency temporary splint options for the GP

Use patients existing orthodontic splint or night guard

A good temporary splint can be made using Al Foil and Blu-Tac

Final Splinting by a dentist as soon as possible

Use ConvaTec Stomahesive® wafer for provisional splinting

Post operative instructions afterre-implantation of avulsed tooth

1. Tetanus immunisation if necessary

2. Oral Doxycycline ( 100mg for adults) 2x/day for 7 days if >12 years.

If < 12 years give penicillin V.

3. Chlorhexidine mouth rinse 2x/day for 7 days

4. Soft diet for 2 weeks

5. Follow up with dentist as soon as possible

(Skapetis, 2012)

TREATMENT

The treatment of choice for permanent teeth with incomplete root formation with minor or moderate intrusion is to allow spontaneous eruption. If no movement within a few weeks, the dentist will initiate orthodontic or surgical repositioning before ankyloses can develop.

(Resource Centre for Rare Oral Diseases and Department of Oral and Maxillo-Facial Surgery at the University Hospital of Copenhagen, 2010).

Tooth IntrusionThis tooth is pushed up into the socket.

It is different for Deciduous Teeth

Don’t re-implant avulsed deciduous teeth or extract intruded deciduous teeth as this may inadvertently damage the developing

permanent tooth germ apically.

DENTAL TRAUMA

Permanent Teeth

Deciduous Teeth

Avulsed

Intruded

Fractured Tooth

Crown with exposed pulp

Crown with no exposed pulp

Root fracture

Store tooth in UHT milk and refer to dentist

Rinse crown with milk or sterile saline and re-implant

SPLINT and REFER to DENTIST ASAP

Extract if tooth is an inhalation risk, otherwise DO NOTHING!

Dry and cover pulp with CALCIUM HYDROXIDE PASTE

Dry and cover fracture with

GLASS IONOMER CEMENT

Intrusion < 3mm do nothing

Intrusion >3mm reposition under LA

Adapted from Skapetis et al 2012

Soft Tissue Injuries

(The Royal Dental Hospital of Melbourne, 2014)

De-gloving Injuries

TREATMENT: Requires anaesthetic and suturing of soft tissue back into position.

Complications of Tongue Piercing Infections

• Bleeding and swelling• Fractured teeth• Abscesses of brain, liver, inner lining of heart due to normal mouth flora

(Streptococcus intermedius)• Ludwig’s Angina

Soft Tissue Lacerations

Cheek biting Tongue bitingLip Laceration

This may occur as a post operative sequaele to an anaesthetised lip. Suture where necessary or offer palliative support such as saline mouth rinses and topical anaesthesia.

Aspirin/ Chemical Burn

Turpentine Burn

• Mucosa in direct contact with aspirin becomes necrotic and painful.

• Contact stomatitis may occur with some other allergens causing intra-oral erythema, ulceration or a lichenoid mucositis

Aspirin Burn

Other Emergency Dental

Presentations

• Post extraction Haemorrhage• Denture related issues • Lost or broken restorations or

crowns• Broken orthodontic brackets

Post operative Haemorrhage after dental extractions

• Normal oozing of nutrient canal : apply pressure, suture and do not rinse.

• Severed inferior dental vessel: administer a local haemostatic such as thrombin and insert fibrin foam, gelatin foam or oxidized cellulose into the socket.

• Systemic disease: treatment is directed towards managing that underlying condition by doing the required investigations and local haemostatic, primary closure, sutures and tranexamic acid (Svensson, Hallmer, Englesson, Svensson, & Becktor, 2013)

Denture Related Issues

Denture Related Issues

• Pain on eating from ill fitting or chipped dentures. • Underlying pathology beneath the fitting surfaces. • Dry mouth due to medications.• Excessive dental plaque accumulation due to poor oral hygiene.

The lost crown, bridge or restoration

Broken arch wires or brackets on orthodontic brackets

Dental Wax is used to cover sharp edges on braces

Death by Power Point Presentation

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• Harriss et al, (2019). Preventable hospitalisations in regional Queensland; potential for primary health?Australian Health Review, 43, 371-381.