Two areas of particular importance for our pediatric dental practices are 1. treating emergencies and 2. managing hospital and office-based general anesthesia cases. Both require triage and possible re-prioritization in this time of limited access and potential infectivity.
1. Emergency care of patients. Pediatric dentists around the country have taken different approaches to the management of dental emergencies in children. An algorithmic approach to determining medical and dental emergencies is one proposed by Meyer et al and may be helpful to pediatric dentists seeking to provide humane care in this time of crisis, yet minimize possible exposures to the COVID-19 virus. View the article here.
We suggest that each practice determine the best approach to emergency management and take into consideration the needs of children, the health and safety of staff, and their own safety and that of loved ones. No one size fits all. In addition, local and state health authorities may provide guidance for management and or referral and members are encouraged to check those sources for advice. (See the section on “Office Re-opening” for links to local and state information.)
2. General anesthesia cases. Hospitals across the country are looking at elective surgeries and encouraging or mandating providers to triage those cases so that operating room resources are not stressed and OR personnel are not unnecessarily exposed to COVID-19. Pediatric dentists are encouraged to review pending cases to determine if children can be delayed access to the operating room until this crisis abates. Clearly, children in pain, with acute facial swelling, or with significant traumatic injury may require treatment under general anesthesia. Again, the decision to provide care is dependent on patient need, local restrictions, and available alternative care approaches such as antibiotics and pain medication.
You can read the ADA guidance as to what constitutes emergency/urgent procedures here.
Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:
- Uncontrolled bleeding
- Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient's airway
- Trauma involving facial bones, potentially compromising the patient's airway
Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.
- Severe dental pain from pulpal inflammation
- Pericoronitis or third-molar pain
- Surgical post-operative osteitis, dry socket dressing changes
- Abscess, or localized bacterial infection resulting in localized pain and swelling
- Tooth fracture resulting in pain or causing soft tissue trauma
- Dental trauma with avulsion/luxation
- Dental treatment required prior to critical medical procedures
- Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
- Biopsy of abnormal tissue
An ADA patient flyer on managing dental emergencies can be found here.
ADA Emergency Care Q & A. On April 7, 2020, the American Dental Association recorded answers to questions submitted by dentists regarding the ADA’s interim guidance for minimizing the risk of COVID-19 transmission while performing emergency and urgent dental care. The discussion covers a range of topics including the use of personal protective equipment, coordinating care with other members of the medical community and the future of infection control in dentistry. View the discussion here.
You will find guidance for establishing crisis standards of care for in disaster situations from the National Center for Biotechnology Information here.