2021, Number 2
Incidence of endodontic emergencies during SARS-CoV-2 confinement in Mexico City
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ABSTRACT
Descriptive study was carried out in a dental office specialized in endodontics, with patients who requested an emergency appointment to r relief a dental pain or infection during the COVID-19 pandemic, between July 2020 to June 2021. The office and staff were adapted with the protective equipment and physical barriers recommended by WHO. 178 patients were, interviewed by phone triage questionnaire and informed about COVID-19 and its risks, all the patients were questioned regarding their pain requesting a pain measurement on the visual analogue scale (VAS), we gave him an appointment a validly informed consent of COVID-19 was obtained, the diagnostic methodology was applied to determine its pulp and periapical pathology, performing endodontic treatment in one session. Descriptive analysis is applied collecting and ordering the information through graphs and tables. Results: The average age of the patients was 58 years, corresponding to 65.7% women and 34.3% men, with an average body temperature of 36.4 oC. The most frequent pulp and periapical diagnosis was acute (symptomatic) periodontitis with pulp necrosis, 41%, followed by(symptomatic), irreversible pulpitis 34.8%. Patients with comorbidity were 89 cases, 50% of the sample, predominantly arterial hypertension in 36 cases, 20.2%, diabetes 15 cases, 8.4%, and heart disease, 11 cases, 6.2%. Two patients, 1.1%, reported suffering from COVID-19 between two and six days after treatment, no member of the team was infected. Conclusion: Despite the conflict generated by emergency pain patients in a COVID-19 pandemic, all measures and precautions must be taken for personal health care and avoid the potential risk of contagion of the team and their family to continue providing care to patients with endodontic emergence.INTRODUCTION
In dental emergencies, the elimination of pain of endodontic origin should be managed using various clinical procedures to provide real and lasting benefit to the patient. Some practitioners often recommend the use of medication for pain control, however, this treatment is palliative. Effective emergency endodontic treatment options aimed at eliminating operative and postoperative pain, reducing anxiety, which is undoubtedly an important factor for the patient, are pulpotomy, pulpectomy, necropulpectomy, transmucosal drainage, and occlusal adjustment.
The technique or procedures are not problematic in routine situations, but the appearance of the coronavirus (SARS-CoV-2) causing severe acute respiratory syndrome,1 in the world and Mexico has generated concern in the area of public health. Despite the efforts made by the World Health Organization to contain the spread of the disease, the outbreak is increasing in some countries due to the pattern of contagion and spread of this infection in the community. Once established in the human body, SARS-CoV-2 aggressively invades the nasopharyngeal and salivary secretions of those infected and spreads predominantly through saliva droplets and respiratory secretions. Dental health care professionals, including endodontists, could be infected and spread the infection when caring for patients with suspected or unconfirmed SARS-CoV-2 infection.2 Considering the risk of contagion to which dental health professionals are exposed, in March 2020 the dental service for regular and emergency dental treatments offered by the federation and the Faculty of Dentistry of the UNAM was suspended, including those related to inflammation and infections of endodontic origin that are regularly associated with acute pain.3,4
Objective: The objective of this study was to apply the methods of diagnosis and endodontic treatment in emergency patients with pain and/or infection of pulpo-periapical origin,5 to know the incidence and characteristics of pulpo-periapical diseases in 12 months (1/6/2020-31/5/2021) in a dental office dedicated exclusively to endodontics.
Bahador et al.5 report that in normal conditions in a room between three to 45 species of bacteria were detected at rest at 0.5 m, predominantly Staphylococcus aureus, Staphylococcus epidermis, and Streptococcus oral species at 2 m, so the authors conclude that the spread of microorganisms is low. In pandemic (SARS-CoV-2) the concept of viral spread, under conditions of endodontic emergencies and non-surgical root canal therapy, is different since the droplets and aerosol generated during the treatment time and the proximity to the patient's mouth determine the level of contamination. Therefore, it is very likely that in these cases there is a higher risk of transmission of the acute respiratory syndrome (SARS-CoV-2) due to the high amounts of aerosols generated by the work in the mouth and the transmission through the saliva of infected individuals who are asymptomatic or who present symptoms of the disease.6-8
In a review of the literature6-9 it was reported that the levels of anxiety expressed by the members of the working staff were due to the high risk of contagion and the protective measures during the first weeks of the pandemic. This resulted in increased stress affecting their heart rate and blood pressure since there are many questions to be answered about SARS-CoV-2 concerning its association with systemic diseases (diabetes mellitus, hypertension, and patients with heart disease) since after root canal treatment, the resistance of these patients to bacterial infection is decreased and the potential for repair of the tissues involved after non-surgical root canal treatment is lower. Therefore, the risk of reinfection is latent.7,8
MATERIAL AND METHODS
This descriptive study was conducted in a dental office specializing in endodontics and included only emergency patients who called the office requesting an appointment for relief of dental pain and/or infection. To determine what was an emergency, a telephone triage questionnaire was used as a structured system with five priority levels that were included to differentiate between emergency and routine appointments. The patient was debriefed and informed of the risks involved during their dental visit using the following questions:
- 1. Have you been confirmed to be a suspect or to have COVID-19?
- 2. Are you a patient who has recovered from COVID-19?
- 3. Have you recently exhibited COVID-19 symptoms such as fever, dry cough, fatigue, vomiting, etc.?
- 4. Have you been in contact with persons confirmed or in confinement for COVID-19?
Once the questionnaire was completed, questioning was continued to distinguish between emergency and routine treatment, including the patient's health status to offer an effective approach to the problem, without exposing staff and patient unnecessarily.10,11 Following the protocol suggested by Eleazar and Rosenberg.12 To detect a true emergency case using the following telephone interrogation:
- 1. Does your pain interfere with your sleep, eating, work, concentration, or other daily activity?
- 2. How long has the symptomatology been present?
- 3. Have you taken any medication? If yes, was the medication effective?
The patient was asked to define the intensity of his pain according to the visual analog scale (VAS). The VAS consists of a horizontal line of 10 centimeters, at the ends of which are the 0 and 10 which represent the extremes of a symptom. The patient is instructed that the pain intensity is classified between 1 and 3 (mild pain), between 4 and 7 (moderate pain), and between 8 to 10 (severe pain) so that it is possible to give specific information.
Once the evaluation is finished, it is determined if it is an emergency and an appointment is made. Once in the office, the patient fills out a questionnaire where the information is collected and organized electronically according to the date of visit, sex, age, and history of systemic diseases, the patient is informed about the risks of contagion and spread of COVID-19, a respiratory triage is performed, body temperature is measured and the patient is asked to sign a validly informed consent form. Once this preliminary information is gathered, diagnostic tests are applied to determine the pulpo-periapical pathology, and the treatment, the patient signs the validly informed consent, the patient is informed that the purpose of the data obtained is to be used in an epidemiological investigation of the COVID-19 coronavirus disease. As well as the indicated treatment, biopulpectomy or necropulpectomy, which is performed in one visit.
In this study 178 cases with emergency dental pathology were included during the period from July 2020 to June 2021; the time that the emergency or urgent dental care clinics, public or educational, remained closed, with the sole purpose of knowing the incidence of pulpo-periapical diseases. The data obtained for this purpose included affected tooth, age, sex, body temperature, comorbidities paying special attention to patients with diabetes mellitus, arterial hypertension and cardiopathies, pulp and periapical diagnosis related to pain, infection, and inflammation, dental emergency, and treatment. This study was carried out strictly following the protocols and recommendations of international sources of guidance documents for the reopening of dental services9 constantly avoiding the substantial risk of contamination and cross infection and spread of the virus to the patient and/or dental staff.
Considering that the treatment presented by the patient is an endodontic emergency and cannot be postponed, the personnel prepared the materials and equipment to be used during each treatment under strict aseptic measures. Before the patient's admission, the staff changes clothes, the waiting room and the offices are disinfected with a 5th generation quaternary ammonium ammonium-based fume chamber (SteelPro 900-FG and Protect 4000 SteelPro Mex.), the dental instruments are disinfected in the autoclave (Midmark M9 Autoclave USA), the work equipment (unit) is disinfected with a contact antiseptic of 2% benzalkonium chloride, 1% ethyl alcohol, surfactant and EDTA (Lysol Reckitt Benckiser Mex.), and the staff is equipped with N95 masks, gloves, caps, shoe covers, face shields, and disposable gowns. The installation of physical barriers in the waiting room, removal of objects, and disinfection of the patient by nebulization of clothing and belongings with 5th generation quaternary harmonium (San-100 Prolimp Mex.), as aseptic precautionary measures for the work team, rapid COVID-19 antigen testing of the nasal swab was performed periodically.
The patient's body temperature, which should not exceed 37.2 oC,13,14 was taken using a frontal thermometer with infrared temperature sensors (Henan Yobekan Medical Equipment Ltd. China). The patient washed his hands with alcohol hand sanitizer at 60-95% (Protex Colgate Palmolive Mex) and performed a 0.2% chlorhexidine mouth wash (Lacer Brasil), the patient was offered the use of eye protection supplies to reduce the risk of cross-infection.
A safety period was also implemented between patients and between dental appointments to minimize possible contact between patients and avoid overcrowding. Only if strictly necessary, if more than one patient remains in the waiting room, a minimum distance of 1.5 m between them will be respected.13,14 Indoor air renewal is essential to minimize the spread of SARS-CoV-2 as well as other microorganisms. This is possible in a well-ventilated place, or its case by placing air purification units with HEPA type filters, (Nakomsa, Mod. Hunter HEPA tech 30057, Mex.), of negative pressure, filtered before recirculation. The use of a high-efficiency particulate air filtration unit avoids airborne particles spreading in the service unit and allows a unidirectional airflow, usable in the case of not having air purifiers or being able to open a window.13,15
The diagnoses and treatments were based on the consensus recommended by the American Association of Endodontics,16 by the classification suggested by the college of professors of endodontics of the Faculty of Dentistry of the UNAM.
Descriptive analysis was applied, collecting and ordering the information using graphs and visual aids.
RESULTS
The data obtained were collected during the pandemic due to COVID-19, from July 2020 to May 2021, a period in which the public and private dental schools in the metropolitan area did not offer emergency endodontic services. In the private practice, we received only patients with signs and symptoms qualified during a telephone interview as an emergency. In this period 178 patients were seen with endodontic emergencies, the composition of the population according to the number and proportion of males and females was 65.7% of females and 34.3% of males. The most common pulpo-periapical pathology was pulp necrosis with symptomatic acute periodontitis, with 73 cases (41%), followed by symptomatic irreversible pulpitis with 62 cases (34.8%) which were also assessed and diagnosed according to the visual analog pain scale (VAS) with severe pain, higher than 8 (Figure 1).
The average age was 58 years (min. 18 and max. 94 years), the distribution by age range was < 18, 2%; 18-50, 24%; 51-60, 25%; ≥ 60, 49%. Two patients developed COVID-19 disease between two and six days after emergency treatment (1.1%) and five (2.8%) reported having had COVID-19 before the consultation. No staff members were infected with COVID-19.
In this study, 89 patients (50%) of the sample reported having some comorbidity, with arterial hypertension being the most common comorbidity with 36 cases (20.2%), followed by diabetes mellitus with 15 cases (8.4%), heart disease 11 cases (6.2%), thyroid gland disease 10 cases (5.6%) and hypercholesterolemia seven cases (3.9%); lupus two cases (1.1%) and COPD one case (0.6%).
DISCUSSION
The total number of patients attending for consultation (n = 178) during the pandemic in the period from July 2020 to May 2021 is similar to those reported by Yu et al.17 in the general and emergency departments in Wuhan (n = 191) during the COVID-19 outbreak. These results are also consistent with those of a previous study.18
Traditional approaches to pain measurement include numerical and verbal self-assessment scales. The primary goals of pain scales are to quantify pain severity and to determine changes in pain after treatment.19 The complex and subjective nature of the pain experienced is the reason that the quantification of pain with VAS and VNRS scales does not always show a high level of agreement. However, they have shown a consistent correlation of pain in the clinic.19
Similar to what has already been reported20 in this investigation in which the greatest number of patients with dental emergencies were female (67.5%); however, in other investigations it has been reported20,21 that the greatest number of patients with dental emergencies were male. This difference may be explained by the different types of populations investigated.
The age range in our study was between 18 and 94 years with an average of 58 years, while that reported by Yu et al17 was six to 95 years, and that patients older than 65 years represented approximately 15% of the investigated population. In this study, the population over 60 years of age was 49.4%, which gives us a guideline that the care of patients of this age should be exercised with extreme care to avoid cross-contamination.
Yu et al,17 reported that the most common pulp disease was symptomatic irreversible pulpitis (irreversible pulpitis; 53.13%), with a relatively high quantification of pain (VNRS). In this research, this disease had an incidence of 34.8% resulting in the highest quantification of pain in patients with acute alveolar abscess (AAL). In this study, the highest incidence in pulpo-periapical emergencies was pulp necrosis with acute periodontitis, (symptomatic apical periodontitis; 41%), while Yu et al.,17 using the (VNRS) report only 16.67% of patients with symptomatic apical periodontitis. These differences could be explained by the difference in idiosyncrasy of the investigated populations.
Another team of researchers22 agrees with the results obtained in this research on the management of emergencies during the COVID-19 pandemic, in which the highest incidence of emergency treatment are female patients and in which the incidence of pathologies are pulp necrosis, acute apical periodontitis (symptomatic apical periodontitis) and irreversible pulpitis (symptomatic irreversible pulpitis).
In this investigation, in addition to the pain emergency and performing the emergency endodontic treatment in the COVID-19 pandemic, 50% of the patients reported having some comorbidity such as hypertension, diabetes mellitus, and heart disease, which is consistent with the results reported by Wang et al.23
In planning and carrying out this study we followed the asepsis recommendations proposed by Meng et al.,2 who suggest that dental personnel should take adequate measures to avoid contracting COVID-19 during treatment. Therefore, the operator and assistants were at all times equipped with N95 masks, gloves, caps, shoe covers, face shields, and disposable gowns and the performance of rapid COVID-19 antigen nasal swab tests.
In addition to attending to emergencies, the operator and staff should take into account that patients present, apart from the normal alteration, altered by the anxiety generated by pain and especially by the emotional situation produced by the COVID-19 pandemic. However, it has been reported24 that a large majority of endodontists are aware of the COVID-19 pandemic, and are taking special precautions as preventive measures against the acquisition and spread of the virus.
CONCLUSIONS
Despite the conflict of dental care for patients in the COVID-19 pandemic and because of the high risk of exposure, aseptic measures must be taken to care for the health of dental personnel and their family members. Therefore, all recommendations for the care of dental personnel should be carefully considered and evaluated for implementation in order to continue to provide dental care and treatment for emergency endodontic patients and to reduce the risk of contamination to the lowest possible level.
ACKNOWLEDGMENTS
To Dr. Haroldo Elorza and Dr. Benjamín Briseño for their guidance in the development of this work.
REFERENCES
COVID-19 Dental Services Evidence Review (CoDER) Working Group. Recommendations for the re-opening of dental services: a rapid review of international sources [Internet]. [Accessed august 21st 2021]. Available in: https://oralhealth.cochrane.org/sites/oralhealth.cochrane.org/files/public/uploads/covid19_dental_reopening_rapid_review_13052020.pdf
AFFILIATIONS
1 Facultad de Odontología, UNAM. México.
CORRESPONDENCE
Raúl Luis García Aranda. E-mail: raulLuisgarciaaranda@gmail.comReceived: Septiembre 2020. Accepted: Octubre 2020.