Post on 11-Oct-2020
transcript
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 .
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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