What are emergencies? And the need for PPE?

by KEVIN KUO DDS, MMSc | March 22, 2020

OVERVIEW. Last week, on March 15th, we discussed a likely large spike in cases. It did happen, in an enormous way. We went from 3,400 cases to 34,000 cases today, March 22nd, in the United States in one week. Previously, we discussed how keeping offices open for emergencies is still important. Today, we will discuss how to define emergencies a bit more. We also will discuss how the definition is still hard to define despite some recommendations from national and state organizations. Additionally, we will discuss more about how to make the best decision for the future. We talk about PPE and aerosols, as well.

I have publicized the main points on my Instagram and Facebook stories already. So make sure you follow me on those platforms for quicker updates. Subscribe to my YouTube as well, of course.

Emergency or not?

The first wave of dental-related recommendations has been made. They happen to mirror what was stated in the previous article. Dental offices should postpone elective care but should still see emergency patients. The primary question now is, what should be considered a dental emergency? 

The ADA put out a statement earlier in the week clarifying emergency versus non-emergency treatments. The statement includes examples of dental emergencies, like uncontrolled bleeding, cellulitis, and trauma involving facial bones. It also lists examples of urgent dental care needs like severe dental pain, pericoronitis, osteitis, abscess, tooth fracture, and dental trauma. Other urgent dental care needs also include extensive dental caries causing pain, suture removal, and denture adjustments when function is impeded. The ADA includes both emergency and urgent needs as cases to be treated right now to prevent hospital overload. 

Overall, the statement is similar to my sentiments about the COVID-19 situation. The ADA needed to recommend a guideline that would relate to most states, doctors, and patients. It is extremely difficult to carry through with such a large variety of practice differences, the number of infections in a given area in the United States, and many more factors. In the end, the ADA stated that they also defer to state governments and state dental associations to make their recommendations to their specific locations and situations given the fluidity of the situation. I very much agree with the overall statement. 

Some states, like Oregon and California, have followed suit with their own, more stringent recommendations. Oregon has recommended emergency only into June. California has recommended only life-threatening dental conditions to be seen, and only with N95 masks. Since the situation is so fluid, I recommend everyone to just follow their specific state guidelines, whether from the state governor or state dental association or boards. There are just not enough tests done to accurately collect the data needed to be more specific with regulations and recommendations. The federal government and state governments just need to do their best. And so do we. More on data...

Future progress and recommendations

With that said, I do want to comment more on how we could potentially deal with this pandemic better in the future and help dental offices figure out what to do in future situations. The key to the future will be for recommendations and regulations to be driven more with data. 

As far as the number of infections, we need to have more tests. That testing limitation is the United States’ biggest issue right now, aside from lack of preparation and materials to treat patients. We really do not know how many people are actually infected. And, we do not know where they are exactly located. Knowing the number of infected people in a given area and population is important to the solutions we make without having to make umbrella blanket recommendations or mandates. Without valid testing, we also do not know how easily spreadable a disease is to the public and how deadly. For instance, if a virus is not easily transmissible, then the community spread is less likely. And so, the solutions to combat a disease is less stringent and urgent. 

The other data points we need to evaluate are the number of dental-related emergencies present at hospitals and urgent care centers. First, we can look at the number of dental-related patients already presenting to emergency rooms on a typical day. According to the ADA, there are more than 2 million visits every year to hospital emergency rooms for dental pain. This statistic does not include dental infections nor trauma. These patients are typically without dental insurance and have trouble accessing dental care. This is the baseline statistic for the number of dental-related ER visits. Additionally, the closure of private practice offices likely will contribute to additional emergency patients—people who normally carry dental insurance and routinely see their dentists. The question is, by how much is this increase in ER burden? This statistic will be difficult to calculate as there is not one consensus EHR used by dental offices. In other words, if complete dental office closures do significantly increase the number of dental-related emergency room visits, then closing dental offices ultimately would not be a reasonable option. But with better data, blanket closures can also be avoided, even if somehow dental office closures do not affect dental-related patient loads in the ER.

There are obviously many statistical scenarios and plans. The main point is: recommendations for dentists can be more specific and more specific to a given area with better data.

Current treatment precautions for emergencies

In order to present the best infection control guidelines for COVID-19, we need to understand more about how SARS-CoV-2 transmits and survives outside of the body. Like other respiratory viruses, SARS-CoV-2 is transmitted commonly through close exposure with a person infected with COVID-19. Respiratory droplets from the infected transmit to nearby people via mouths, noses, and eyes. Aerosols transmission is actually debatable. Transmission via dental treatment is often quoted as a high-risk means to become infected. This portrayed elevated risk is reasonable. But it is important to keep in mind that it is theoretical and not backed by clinical evidence. Coughing and extended close contact with infected patients during treatment are more likely to cause transmission in the dental office than aerosols from high-speed handpieces or ultrasonics. With this in mind, prevention of transmission during treatment would include using rubber dams and providing some sort of barrier from the patient’s open mouths and the provider. Of course, minimizing aerosols should be done as much as possible, just to be safe.

Another commonly asked question regarding treatment at this time is personal protective equipment (PPE). N95 masks are often recommended at this time for dentists. However, it is important to keep in mind that N95 is primarily recommended outside of dentistry for healthcare providers when treated COVID-19 test-confirmed patients or likely COVID-19 positive patients. With a shortage of N95 globally, these respirators should be reserved for healthcare providers treating COVID-19 confirmed patients. In other words, the likelihood of dentists actually treating a COVID-19 patient is significantly lower than front-line medical personnel. Some may argue that dentists need N95 masks due to the possibility of an asymptomatic patient carrying COVID-19. If there were no shortage of N95, then the recommendation to only wear N95 respiratory would be more reasonable.

These crisis-altered recommendations are also important subjects to discuss as well. Some dentists and dental hygienists have cried foul when re-using surgical masks, let alone not using N95 masks. These concerns are reasonable at times of conventional treatment. But in times of crisis, recommendations are often loosened given the situation. If there are shortages of N95, it is reasonable to use surgical masks. If there are also shortages of surgical masks, it is reasonable to use surgical masks for multiple patients.

The CDC actually has a list of strategies for optimizing the supply of PPE depending on availability.

SUMMARY

1. The definition of emergency dental treatments depends on many factors.

2. Due to the lack of data, we can only follow state government or dental association recommendations.

3. Future preparation will rely on data, which would allow more specific recommendations for each unique location.

4. Aerosol transmission is theoretical and likely plays a smaller role in transmission than currently perceived.

5. N95 respirators should not be mandatory to see dental patients due to limited supply.

6. Surgical masks can be reused if the current supply is low as well.