key: cord-0866098-f9dxlmu1
authors: Wang, Tim T.; Moon, Hwi Sean; Le, Anh; Panchal, Neeraj
title: Proceedings of the OMS COVID-19 Response Conference
date: 2020-05-11
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2020.05.003
sha: 6f7582b9769bdb8d67fa6b0da50a6f5ae946fc8e
doc_id: 866098
cord_uid: f9dxlmu1

The CoronaVirus Disease 2019 (COVID-19) pandemic has impacted the world in unprecedented ways. It is clear that this pandemic, unlike any public health challenge in recent memory, has the potential to fundamentally alter the delivery of many healthcare services, including the practice of oral and maxillofacial surgery. In response to this global health crisis, the Oral and Maxillofacial Surgery (OMS) COVID-19 Response Conference was held virtually on April 9, 2020, organized by oral and maxillofacial surgeons (OMSs) and administrators from multiple institutions to provide a forum for OMSs to discuss how COVID-19 has impacted the specialty. As evidence-based information on COVID-19 continues to emerge, this manuscript serves as a means to disseminate the current opinions and management strategies of a variety of experts in OMS.

The CoronaVirus Disease 2019 (COVID-19) pandemic has impacted the world in unprecedented ways. As of May 6, 2020, there were over 1.1 million confirmed cases and over 60,000 deaths in the United States. 1 While there is still much unknown about the clinical and epidemiological characteristics of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is clear that this pandemic, unlike any public health challenge in recent memory, has the potential to fundamentally alter the delivery of many healthcare services, including the practice of oral and maxillofacial surgery. [2] [3] [4] [5] [6] In response to this global health crisis, a Oral and Maxillofacial Surgery (OMS) COVID-surgeons (OMSs) and administrators from multiple institutions to provide a forum for OMSs to discuss how COVID-19 has impacted the specialty. The conference aimed to help OMSs gain an overall understanding of COVID-19 and its impact on the field. Second, it disseminated strategies to protect OMS staff, residents, and faculty. Third, it provided sessions focused on how the pandemic alters the management of various areas of OMS: head and neck trauma, dentoalveolar surgery, head and neck cancer surgery, craniofacial surgery, cosmetic surgery, and trigeminal nerve surgery. Fourth, it highlighted the impact that OMSs can make on their local health system to aid with the COVID-19 response. Fifth, the conference examined how COVID-19 affects OMS resident education. Finally, the conference outlined the initiatives by the American Association of Oral and Maxillofacial Surgeons (AAOMS) to support OMSs during this crisis.

As evidence-based information on COVID-19 continues to emerge, this manuscript serves as a means to disseminate the current opinions and management strategies of a variety of experts in OMS. Each expert was given the opportunity to speak for 15-minutes with a moderated question and answer (Q&A) session. The following is a summary of the pertinent opinions and strategies recommended by speakers. they have had two negative COVID-19 tests separated by at least 24 hours, due to the possibility of false negative results. More specific recommendations can be made since late March, with increased availability of testing both symptomatic and asymptomatic patients and improvements in COVID-19 testing. When treating asymptomatic patients who are COVID-19 testing negative, standard precautions maybe appropriate dependent on local conditions. The chance of an occupational exposure in an asympomatic patient who has a negative COVID-19 test can be calculated by multiplying the local rate of a positive COVID-19 test in an asymptomatic patient by the false negative rate of the COVID-19 test in an asymptomatic patient and by the risk of the viral particle exposure based on the particle filtration efficiency of the mask ( Figure 1 ). If symptom or test status cannot be ascertained, additional special precautions to avoid exposure to coronavirus are indicated. This recommendation, however, should be based on local conditions and be situationally appropriate.

Recommendations on occupational exposure risk changes as testing is more available and accurate, local prevalence of COVID-19 changes, and protection measures are more readily available. To limit the spread of COVID-19 and to limit the consumption of PPE, non-essential procedures should be deferred. In addition, non-essential clinic locations should be closed in order to simplify the organizational process and number of staff needed on-site at clinical practices. To ensure appropriate scheduling of patients, all care providers should review their schedules and appropriately reschedule patients. Practitioners must change their mindset to pandemic mode. A decision tree regarding consultation, pre-operative, and post-operative actions can be created for different OMS procedures during this pandemic. Such a decision tool can set guidelines for which events could be done through telemedicine or postponed.

At institutions, OMS service lines can be organized into teams to reduce the risk of COVID-19 spread or necessity for quarantining large numbers of individuals from a single COVID-19 exposure. To illustrate this with an example from the University of Pennsylvania, providers are divided into teams of 2 attending OMSs, 1 chief resident, 1 mid-level resident, and 2 interns. The teams rotate through different service locations for one week each at the primary two locations and then go off-service to recover, do telemedicine, advance academic endeavors, and teach students via virtual means for the next two weeks. These rotations allow the team to maintain service efficiency while building in time for surgeons to self-isolate in the event of COVID-19 exposure and be available for backup if others have a COVID-19 exposure.

It is important to standardize treatments and guidelines with other medical specialties in the health system, such as otorhinolaryngology, plastic surgery, and ophthalmology. This helps the emergency departments and trauma teams to standardize expectations and processes for managing patients with similar acuity levels of care. Decisions on which patients can be managed via tele-consults should be made collectively.

During this uncertain time, the famous adage that "there are no emergencies in a pandemic" certainly rings true. Providers should not rush into treating a COVID-19 positive patient without the proper safety infrastructure in place, because a provider cannot treat anyone if they are on a ventilator themselves. that there may be a 6 to 9 month of window of opportunity to operate for many trigeminal nerve injuries. 10 Past this date, nerves can undergo Wallerian degeneration, in which the axons distal to the injury fibrosis and will decrease the chance of neurosensory recovery. 11 It will be important to keep in mind and discuss the management of patients with nerve injuries as the COVID-19 pandemic continues to progress, especially in the case where elective surgeries remain postponed for several months. Early diagnosis and early time to treatment of oral cancers have been associated with improved survival; delayed diagnosis from stage 1 to 2 cancers is more detrimental to survival than the delay from stage 3 to 4. 12 In addition, tumors that undergo primary surgery or primary radiotherapy are more greatly impacted by delays in initiation of treatment than tumors that are planned for primary concurrent chemoradiotherapy. 12 Treatment planning should be supported with evidence-based guidelines whenever possible and compatible with the resources available.

To this end, OMS managing cancer patients should reference national guidelines, such as those from the National Comprehensive Cancer Network (https://www.nccn.org/).

In terms of best patient care practices during this pandemic, video telemedicine can be helpful for consultations and initial treatment planning. The video component, along with home photos of any lesions, is crucial to having a productive appointment. Surgical treatment plans should be adjusted to favor oncologic and reconstructive procedures that minimize aerosolization, need for ventilator/intensive care support, need for transfusion of blood products, while also minimizing length of hospital stay. Furthermore, serious consideration should be given prior to initiation of immunosuppressive therapies due to the increased susceptibility to COVID-19 while patients are on such therapies. Despite staff furloughs, it is important to communicate with them regularly, such as through video conferencing, to keep up team spirits. It may also be helpful to offer patients free virtual consults, along with the option to get back their deposits for planned procedures without penalties.

Despite the disruption, there are a few ways that private practice OMSs can use the COVID-19 associated hiatus to better themselves and their practices. Providers can participate in webinars, continuing education (CE) courses, and read or write academic work to gain new knowledge. It is also a suitable time to refine one's digital marketing strategies and social media presence.

Going forward, disruptions to cosmetic surgeries will likely extend beyond the pandemic itself. Many patients will have less disposable income and may elect to defer surgeries.

Nevertheless, providers should remain firm and plan to extend working times after the pandemic to recoup the productivity lost during this pandemic. Cardiac Life Support (ACLS) certification are also all delayed, affecting the ability for incoming residents, who start at the end of June 2020, to provide patient care.

Because OMS is primarily a dental specialty, the Commission on Dental Accreditation (CODA) standardizes and accredits all OMS programs. All regular (reaccreditation) site visits for the remainder of 2020 have been postponed and will be rescheduled to 2021. Special focused site visits have been postponed until the earliest opportunity to conduct the visit. According to the CODA Commissioner, all currently accredited programs will retain their accreditation. The commission is focused on residents and fellows finishing this academic year (2020). Currently, CODA requires 175 major OMS procedures and a cumulative anesthetic experience of 300 general anesthesia/deep sedation cases from each graduating resident. A minimum of 150 of the 300 cases must be ambulatory anesthetics for OMS and must involve care for 50 patients younger than age 13. Due to both surgical and anesthetic volumes being affected by the pandemic, CODA will allow temporary flexibility by evaluating each program's situation and response. The competency of each graduating resident will be determined by its own program.

More information regarding CODA guidance on accreditation and interruption of education related to COVID-19 can be found at the following website: https://www.ada.org/en/coda/accreditation/accreditation-news

Meadow, New York, USA AAOMS has been working to offer the best scientific evidence and to support OMSs during the ever-changing COVID-19 pandemic. The AAOMS leadership has reached out to the White House and Congress in Washington D.C. to advocate the role of OMSs as essential personnel and first responders in healthcare during the pandemic. In turn, it is crucial for public institutions, as well as state and local governments to support OMSs with allocation of resources, such as PPE, rapid COVID-19 tests, and telehealth. With these vital resources, hospital-based OMSs are able to provide service in a safer environment and community-based OMSs can continue to treat emergent patients while minimizing viral spread and keeping patients out of emergency rooms. In addition, AAOMS is constantly working to provide additional resources, ranging from information on small business loans to complimentary continuing education courses, to help OMSs get through the pandemic and facilitate re-opening of practices for OMSs following the pandemic.

More information regarding official AAOMS advocacy, statements, and guidance on OMSs practices related to COVID-19 can be found at the following website: https://www.aaoms.org/practice-resources/covid-19-updates It is critical to closely monitor the epidemiology of COVID-19 in your area. We must pay attention to the numbers and evaluate the appropriate projection to prepare the health system for upcoming challenges. One of the most valuable roles of OMSs during this pandemic is to manage patients in an outpatient setting or via telemedicine. This keeps many patients out of the hospital emergency departments, which can lighten the load on already strained medical resources. It is important to note, however, that the deferral of many dental treatments (i.e. using prescriptions to manage dental abscesses) is not sustainable in the long term. Many of these patients will eventually need emergency surgical care, such as dental extractions. Also, the COVID-19 pandemic may cause lingering disruptions for many health systems. It could be difficult to immediately ramp up operations post-COVID-19 because the workforce will likely be exhausted and burnt out. This can further increase unmet needs in the health system.

History provides a cautionary tale that illustrates the importance of maintaining physical distancing. During the 1918 Pandemic, a busy parade was held in the city of Philadelphia despite public health warnings. Tens of thousands of people subsequently died from the illness.

Learning from history can help us avoid similar missteps and protect the lives of our fellow citizens.

The OMS COVID-19 Response Conference provided a forum for OMSs to exchange ideas and share support for each other during this turbulent time. Moving forward, it will be critical to maintain open lines of communication and support within OMS and with the rest of the medical community in order to provide the best possible care to patients while protecting the safety of OMSs and staff.

Coronavirus Infections-More Than Just the Common Cold

Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. The Lancet

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany

Novel Coronavirus-Important Information for Clinicians

Transmission routes of 2019-nCoV and controls in dental practice

Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine

Governor Murphy Suspends All Elective Surgeries, Invasive Procedures to Preserve Essential Equipment and Hospital Capacity

Timing of trigeminal nerve microsurgery: a review of the literature

Wallerian degeneration, wld(s), and nmnat

Survival Impact of Increasing Time to Treatment Initiation for Patients With Head and Neck Cancer in the United States

We gratefully acknowledge funding from the Schoenleber endowment for educational activities