key: cord-0810733-hpvm247b authors: Silva, Warley Oliveira; Vianna Silva Macedo, Renata Perez; Nevares, Giselle; Val Rodrigues, Renata Costa; Grossi Heleno, Juliana Francisca; Braga Pintor, Andréa Vaz; Almeida, Bernardo Mattos title: Recommendations for managing endodontic emergencies during covid-19 outbreak date: 2020-10-09 journal: J Endod DOI: 10.1016/j.joen.2020.09.018 sha: 065fdba2b6049b8b77ecae55665be8b65c8ac96d doc_id: 810733 cord_uid: hpvm247b INTRODUCTION: Management of endodontic emergencies has been particularly challenging during the COVID-19 outbreak due to the possible generation of airborne particles and aerosols. The aim of this report was to contribute to the practice of endodontics by proposing a general protocol for the management of emergencies showing the rationale for remote diagnosis, clinical procedures and use of personal protective equipment and barriers at the dental office, during the COVID-19 outbreak. METHODS: A review of the literature was conducted up to May 2020 on relevant institutional sites, aiming to retrieve the best updated evidence. The reporting considered the Reporting Tool for Practice Guidelines in Health Care (RIGHT) Statement. RESULTS: Recommendations from Cochrane Oral Health (CHO), the American Dental Association (ADA) and Centers for Disease Control and Prevention (CDCP) were included, besides the American Association of Endodontists (AAE) resources and scientific papers that addressed the issue. CONCLUSION: The proposed protocol could contribute to the management of endodontic emergencies at the dental office during the COVID-19 outbreak. (WHO) in March 2020 (1) . Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly contagious zoonotic virus, continues to escalate J o u r n a l P r e -p r o o f globally and has an incubation period of 1-14 days (2) (3) (4) . Although the latest findings indicate that asymptomatic infected patients are also carriers, symptomatic COVID-19 patients are the primary transmission source. Besides that, it remains to be established how long could patients be considered a possible source of transmission during the recovery process (3, (5) (6) (7) . To limit the community spread, strategies include avoiding human-to-human transmission and identifying, isolating and prompt treatment for COVID -19 patients (4). The live virus was detected in the saliva of 91.7% of asymptomatic infected patients (8) . Thus, direct contact with the mucosa during both diagnostic and therapeutic procedures require special care (9) . The virus can enter the saliva from the upper and lower respiratory tracts as well as from the gingival crevicular fluid and major and minor salivary glands (10) . Once the oral cavity is manipulated, viral particles have the ability to become aerosolized, can become airborne for 3 or more hours, and may spread to contaminate multiple surfaces in the surrounding area (11) (12) (13) . In this sense, currently, endodontists in private practice should accept only non-deferrable emergencies (14) . Aiming to address endodontic emergencies, a questionnaire should be used to screen the oral complaints and health conditions of patients, also considering special needs and the potential COVID-19 status (15, 16) . Interestingly, during the COVID-19 epidemic in Wuhan (China), the majority (50.6%) of dental emergencies were of endodontic origin (17) . These endodontic emergencies included symptomatic irreversible pulpitis, symptomatic apical periodontitis, acute apical abscess, and traumatic dental J o u r n a l P r e -p r o o f injuries. Therefore, it can be assumed that endodontists are on the front lines of this disease outbreak. Considering the pandemic, providing efficient emergency dental care and keeping the dental team and patients safe is a primary concern (9). Along with reinforced safety measures, minimally invasive treatment is recommended (18) . In this sense, protocols in endodontic practice would be relevant to endodontists and patients. Since there has been truly little published in the endodontic field regarding the management of endodontic emergencies during the COVID-19 outbreak, this study aimed to review the literature to compose a clinical protocol or recommendations about this theme. (20) . Contact between the patients and the dentist during endodontic therapy can create a substantial risk of contamination, crossinfection and spread the virus in dental practice (21) . A triage questionnaire should be performed to understand the chief complaint of the patient, distinguishing between emergency and urgency, including the general health status. This first contact aims to offer the best approach to the patient's problem, not exposing both parts without necessity (21, 22) . Questions used to detect a true emergency were proposed by Walton and Keiser in 2010 (23): 1. Does your pain interfere with your sleep, food, work, concentration or other daily activities? • A true emergency leaves the patient unbalanced, preventing them from performing routine activities. 2. How long has the problem been present? • Hardly a true emergency lasts for more than 2 to 3 days, the normal period for an acute inflammatory response. • Generally, the use of analgesics is not effective in the pain of a true emergency. (17, 22, 24) . It is worth mentioning that patients considered to be in a high-risk group should have priority for scheduling. The most common conditions reported as risk factors for COVID-19 were diabetes mellitus, chronic lung disease and cardiovascular disease (25) . When scheduled, the patient should be advised to come at the proper time, to wear a mask, to avoid wearing jewellery or accessories, to store mobile phone and, if possible, come alone (16) . Considering that the treatment of an endodontic emergency cannot be avoided, the staff should prepare in advance all the materials and equipment to be used in the appointment. The dental team should be equipped with disposable N95 masks, gloves, caps, shoe covers, face shields, and gowns, following national guidelines. The installation of physical barriers in the waiting room, the removal of magazines or other objects and the provision of supplies for the storage of the patient's personal belongings are also effective measures to prevent the permanence and spread of the virus during emergency dental care. Reception staff must be properly dressed, wearing masks, goggles and face shields before patients arrive. Practicing these routines with employees to calibrate the entire care team should be considered (20, 26) . At the dental office, the patient's body temperature (<100.4°F) should be measured using a non-contact frontal thermometer or cameras with infrared temperature sensors. Patients should be instructed to wash their hands, preventing it from spreading in the service unit (28) . Additionally, for dental offices that do not have these equipments, it has been recommended to open the windows (27) . The proposed protocol is described in Figure 1 Reduce the water flow to avoid aerosol spread. Outline the ideal shape access cavity into dentine. Once through enamel move to speed increasing electric handpiece or low-speed handpiece to access and expose the entire pulp chamber. Ensure that high volume aspiration is used as close to the tooth as feasible, as noted in Figure 4 12. Once again clean and disinfect the operative field as described previously (32); 13 . The dental operating microscope should be used with all the barrier/protection covering the equipment. Acetate sheets could be used as a protective barrier and be adapted to the binocular of the dental operating microscope (Figure 4 ). In the case of using a dental loupe and headlight, it can be adapted onto a face shield, as also observed in The COVID-19 pandemic led to the need to postpone elective care for endodontic patients to help slow or prevent the spread of the coronavirus. Thus, in the health system, in the first phase of coping with the disease, only care for endodontic emergencies was advised by health authorities. Over time, each government will determine the best moment for the re-opening of dental services, with the proper biosafety criteria already incorporated into the clinical routine (2) . It is essential that endodontists are well-prepared for both phases (16, 20) . Overall, to date, no universal protocol or guideline is available to provide dental care to confirmed or suspected cases of COVID-19. Distinct governments have developed guidelines with their health authorities (16) . Certainly, endodontists should regularly consult their state dental boards or J o u r n a l P r e -p r o o f other regulatory agencies for specific requirements for their jurisdictions, as information is changing rapidly. Proposals for dental care protocols by the scientific community are extremely necessary so that professionals are more secure in providing dental care in the current adverse scenario. This proposed protocol aims to minimize the risks of spreading the virus, guiding professionals on their protection and that of the patient, with specific care for before, during and after clinical care. Dental management guidance documents from different countries provide information on how to group patients according to a risk assessment of the potential status of COVID-19 (e.g., positive for COVID-19, suspected COVID-19 or asymptomatic) (16, 36) . Alharbi, Alharbi and Alqaidib (2020) indicated that, in cases of endodontic emergency in a suspected or confirmed COVID-19 patient, they should be treated in isolation rooms for airborne infections or negative pressure rooms, preferably in a hospital environment (37) . The Directorate-General of Health of Portugal, however, recommends considering the patients symptoms, attending at the private office, scheduling the appointment at the end of the day and using adequate personal protective equipment (PPE) for high-risk procedures. In view of the above, it is imperative to keep in mind that scientific studies indicate that the COVID-19 incubation period can extend for 14 days, with an average time of 4-5 days from exposure to symptoms (38, 39) . It has been shown that the patient asymptomatic or during the incubation period may have potential for transmission (40) . Positive results of the RT-PCR test have also been reported in recovered patients (41) . WHO Director-General's remarks at the media briefing on 2019-nCoV on 11 How COVID-19 Spreads Transmission of 2019-NCOV infection from an asymptomatic contact in Germany Rapid detection of SARS-CoV-2 in saliva: can an endodontist take the lead in point-of-care COVID-19 testing? 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Recommendations for the re-opening of dental services: a rapid review of international sources. COVID-19 Characteristics of Endodontic Emergencies during Coronavirus Disease 2019 Outbreak in Wuhan ADA releases interim guidance on minimizing COVID-19 transmission risk when treating dental emergencies A reporting tool for practice guidelines in health care: The RIGHT statement ProMD Health Guidance for Minimizing Risk While Treating Patients During and After COVID-19. American Dental Association COVID-19: its impact on dental schools in Italy, clinical problems in endodontic therapy and general considerations Endodontic Emergencies of Infectious Origin Endodontic emergencies and therapeutics COVID-19): Implications for Clinical Dental Care Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus Disease 2019 -COVID-NET Q&A on coronaviruses (COVID-19 Standard operating procedure. 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Interim Infection Prevention and Control The Use of Mouthwashes against COVID-19 in Dentistry Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Infection control in retreatment cases: In vivo antibacterial effects of 2 instrumentation systems Effect of Different Concentrations of Sodium Hypochlorite on Outcome of Primary Root Canal Treatment: A Randomized Controlled Trial Diagnosis and management of endodontic emergencies, a British Endodontic Society position paper for primary dental care and other healthcare providers during the COVID-19 pandemic Recommendations for a safety dental care management during SARS-CoV-2 pandemic Management of Acute Dental Problems Guidelines for dental care provision during the COVID-19 pandemic Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Positive RT-PCR Test Results in Patients Recovered from COVID-19 This study was partially supported by grant from Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), number E-26/202-399/2017.The authors appreciate the authorization the use of images, kindly provided, by the manufacturers.The authors deny any conflicts of interest.J o u r n a l P r e -p r o o f the COVID-19 pandemic. The proposed protocol could contribute to the management of endodontic emergencies at the dental office during the COVID-19 outbreak.