Dental Emergency Management Techniques in Medical Practice during the COVID 19 Pandemic Dr Jacqueline Stuart BDSc, PhD Adjunct Lecturer JCU James Cook University, College of Medicine and Dentistry T: 0419112769 E: [email protected] 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) 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. 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 Management of Patients Confirmed with COVID-19 who Require Urgent Dental Care • 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. 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 All dental services No restrictions apply restrictions Level 1 All dental treatments using Defer non-urgent treatment for Restrictions standard precautions for people people who DO meet who do not meet epidemiological epidemiological or clinical or clinical risk factors for COVID-19 symptom criteria for COVID-19 infection transmission 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 Provision of dental treatments Defer all treatments that are Restrictions that are unlikely to generate likely to generate aerosols 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 Services that can be performed Restricted services, defer treatment Level 3 Only urgent dental treatments that do Defer all routine recall Restrictions not generate aerosols, or where examinations and non-urgent treatments generating aerosols is dental treatments. limited to management of; • Acute dental pain e.g. endodontic treatment under rubber dam • Non-Surgical Extractions • Dental tooth trauma performed under rubber dam Services that can be performed Restricted services, defer treatment Level 4 Very limited urgent dental Defer all dental treatments for Restrictions treatments which include patients not fitting the risk management of the following : categories identified on the left. • 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 Level 5 No routine dental treatment Any dental treatment without Restrictions provided. All patients with acute expressed permission from the dental concerns to be directed to public health authorities. emergency care centres. 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) Potentially Preventable Hospitalisations in Regional Queensland 2012-2014 UTI Convulsions ENT Infections DentalDental Conditions Conditions Cellulitis Gangrene Pelvic Inflammatory Disease Perforated or Bleeding Ulcer Pneumonia Number of Indigenous and Non-Indigenous Hospitalisations 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 One in 10 potentially preventable hospitalisations in Australia from 2015-2016 were for conditions of dental origin (Australian Institute of Health and Welfare, 2019) (AIHW,2017) 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.......OPG The 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 Dental Abscess Odontogenic Ameloblastoma Dentigenous Cyst OPG of a 7 year old with a mixed dentition Anatomy of the Normal Healthy Tooth Enamel Crown Dentine Pulp Periodontal Root ligament Alveolar bone Tooth apices (Douglass & Douglass, 2003) Australian tooth numbering system: Permanent Dentition 13 12 25 22 23 11 21 24 46 37 45 36 44 35 43 42 33 34 41 31 32 Australian tooth numbering system: Deciduous Dentition 54 53 62 63 52 51 61 85 84 74 83 73 82 81 71 72 Eruption Times for Deciduous and Permanent Teeth 16 mo 29 mo 8 mo 7-8 yr 17-21 yr 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 Submucosal injection of local Infiltration anaesthetic directly into an area of terminal nerve endings. This typically provides pulpal anaesthesia for 1-2 teeth. Injection of the local anaesthetic Peripheral Nerve solution into the vicinity of a peripheral nerve to anaesthetize that nerve’s Block entire area of innervation. Maxillary Infiltration Injection This involves the extravascular placement of the local anaesthetic in the region to