Emergency Management During

Pandemic For Dentists:

what to do and not to do
Mayang Indah Lestari
The 5 Questions

▪ What’s the background behind the topic?

▪ What are the things called emergency in dentistry,
esp. during COVID-19 pandemic?
▪ How can we protect ourselves to get infected by
COVID-19?
▪ How to assess and treat the emergencies?
▪ What’s to conclude?

2
 1.
What’s the background
behind the topic?

The background of present day

 Pathogenesis of COVID-19

▪ A respiratory tract infection caused by

SARS-CoV-2
▪ The transmission is still debatable,
but the latest and strongest suspect is
by aerosol (droplet nuclei)
▪ The virus was inhaled by the potential
host

4 4
 Pathogenesis of COVID-19

▪ SARS-CoV-2 has spike

protein which acts as RBD
▪ Entry receptor is ACE-2
▪ Found to be very abundant
in oral cavity and
respiratory tract mucous
membrane

5 5
Recent update of COVID-19

▪ COVID-19 pandemic has been around for almost 2 years

▪ Since the horrible global ‘third wave’ back in July-August, the rate has
continued to a downward trend. However, there is a sign of a possible
fourth wave in many western countries
▪ Indonesia is epidemiologically in a second wave but could possibly move
to the third wave
▪ Meaning, all health services must prepare for the worst once again,
especially in management of patients admission

6
Recent update of COVID-19

▪ Oral and dental department is one of the essential health practices that
is greatly hampered by the pandemic
▪ In oral and dental health, there is lack of global consensus concept on
practice during pandemic, including in emergency setting
▪ Per September 2021, data from PDGI showed that 369 dentists has
suffered from COVID-19, and 1 of 4 dentists died from it

7 7
What can be inferred?

▪ Dentists’ work involves oral examination because they can be exposed

with a great source of droplets from patients’ saliva and exhalation, and
their procedures
▪ Scaling or handpiece turbines may produce aerosol and splatter blood
and saliva, which is high in viral load

Dentists have an extremely high risk of infected by SARS-CoV-2!

8 8
 2.
What are the things called
emergency in denstistry?
The principles for present times
Definition

10
Definition

11
 Emergencies in dental and oral health
Oral surgery Prosthodontic Oral disease Orthodontic Pediatric Periodontology Dental General
and dentistry conservation emergency
maxillofacial

Dental TMJ Oral cavity Pain Oral cavity Periodontal Infected Anaphylaxis
fracture or dislocation bleeding associated bleeding in abscess caries and
extraction with children pulpitis
orthodontics
and braces

Oral cavity Implant- Hypersensitiv Dental Occlusion Tooth decay Syncope

abscess associated oral ity and fracture or trauma and necrosis
abscess autoimmune extraction
oral disease

Severe dental Oral and Dental pain Gum bleeding Cracked tooth Surgery-
pain dental or resection syndrome associated
infection adrenal crisis

Maxillofacial Mucosal burn Hopeless teeth Seizures

fracture

Alharbi et al. (2020). Guidelines for dental care provision during the COVID-19 pandemic.
Saudi Dental Journal; 32:181-6 12
“New Emergence Emergency”

COVID-19 Pandemic!

13
 3.
How can we protect ourselves to get
infected by COVID-19?
The principles for present times
“New Normal”

▪ Pandemic makes all medical practices more complicated,

especially dentistry
▪ Effective preparation (precaution, triage, and
prioritization) is mandatory for dentists in this darkest
hour!
▪ Still no global consensus and depends on each countries’
dentistry association for guideline

15
Precaution

A. Workplace setting
B. Personal protection equipment
A. Level 1
B. Level 2
C. Level 3
C. Teleconsultation

Alharbi et al. (2020). Guidelines for dental care provision during the COVID-19 pandemic.
Saudi Dental Journal; 32:181-6 16
Workplace setting

▪ Ventilation
▫ WHO recommends hourly average ventilation rate of 160 l/s/patient
for airborne precaution rooms
▫ Using non-permeable barrier on consultation desks
▪ Sterilization
▫ UVC disinfection of viral aerosols effectively inactivate coronavirus
▪ Disinfection
▫ After every procedures, all physical matters should be sprayed using a
0.5% concentration of chlorine-based disinfectant

Alharbi et al. (2020). Guidelines for dental care provision during the COVID-19 pandemic.
Saudi Dental Journal; 32:181-6 17
PERSONAL
PROTECTION
EQUIPMENT
Before assessing ANY patients,
make sure to wear your PPE
altogether!

18
19
Teleconsultation or tele-triage

▪ Schedule patient appointments, can by voicemail, SMS, email, or telephone.

▪ At the initial tele-triage before the patient came, they were also asked about the
patient's disease status and the possible risk factors that the patient had to get
infected by COVID-19

• By using appointment
previously, there is a pause
between patients, to prevent
transmission through aerosols.
• Team can be given time for
room disinfection.

20
COVID-19 Triage

Gurzawa-Comis et al. (2020). Recommendations for Dental Care during COVID-19 Pandemic. J. Clin. Med; 9: 1833 21
COVID-19 Triage

Gurzawa-Comis et al. (2020). Recommendations for Dental Care during COVID-19 Pandemic. J. Clin. Med; 9: 1833 22
Prioritization

A. Emergency management of life-threatening conditions.

B. Urgent conditions that can be managed with minimally invasive
procedures and without aerosol generation.
C. Urgent conditions that need to be managed with invasive and/or aerosol-
generating procedures.
D. Non-urgent procedures.
E. Elective procedures

Alharbi et al. (2020). Guidelines for dental care provision during the COVID-19 pandemic.
Saudi Dental Journal; 32:181-6 23
24
RUBBER DAM
Effectively prevent splash of
saliva or aerosol from
procedures

25
 4.
How to assess and treat the
emergencies?

Take home messages

Step-by-step approach

The purpose is to identify and deal with life-threatening injuries

▪ Triage (Pain, swelling, bleeding, trauma, obvious sign of infection)
▪ Airway Maintenance
▪ Breathing and Ventilation
Simultaneously,
▪ Circulation and Bleeding Control if medical team is
available
▪ Disability Orderly, if short-
handed!
▪ Exposure
▪ Re-evaluation

27
AIRWAY MAINTENANCE
Situation that may compromise
▪ Altered mental status
▪ Inhalation trauma
▪ Maxilofacial injury
▪ Cervical injury
▪ Larynx injury
Clinical sign(s) and symptom
▪ Agitated (hypoxic!) or
lethargic (hypercarbic)
▪ Cyanosis on nails and lips
▪ Chest-wall retraction
▪ Additional breath sound
(Stridor, gurgling, snoring)
28
PEARLs AND PITFALLs

Always assume there is cervical Evaluate patency

injury in maxillofacial trauma
▪ Return head to natural position,
but with the most minimal
manipulation!
▪ Protect neck (CC, your forearms)
▪ Radiography to exclude the
assumption
▪ Chin-lift/Jaw-thrust
▪ Listen to additional breath
sounds
▫ Gurgling  Suction
▫ Snoring  Extraction
▫ Stridor  OPA
▪ Unconscious patients 
OPA

29
BREATHING AND VENTILATION
Situation that may compromise
▪ Direct injury to chest wall
▪ Brain or spinal injury
▪ COVID-19 related
respiratory compromise
Clinical sign(s) and symptom
▪ Assymetric chest movement
▪ Diminished or absence of
vesicular sound in
auscultation
▪ Increased or absence of RR
▪ Declining SpO2
30
PEARLs AND PITFALLs

Examination is key Simultaneously manage Is Pulse Oximetry legit?

▪ Take-off the patients’ with airway ▪ Represents peripheral
upper apparel ▪ Check on patency, artery oxygenation
▪ while also monitor ▪
Inspect for chest Our aim: 95% or
with SpO2
injuries, bruises, higher
wounds, chest ▪ Give oxygen therapy
▪ Not getting better?
movements, whatever the case
Consider definitive
auscultate ▪ No spontaneous airway!
breathing  Assist!

31
32
DEFINITIVE AIRWAY?

Insertion of tube for respiration into the trachea with its cuff
positioned below the vocal cord
▪ Inability to sustain patent airway
▪ Failure to reach adequate oxygenation even after maximum
supplementation
▪ Persistent apnea
▪ Decreased consciousness (GCS ≤8) because of hypoperfusion or brain
injury

33
CIRCULATION AND BLEEDING CONTROL

▪ Consists of 2 things: Cardiac Output and Bleeding

▪ Cardiac Output: Stroke/Blood volume and Heart rate
▪ A definitive bleeding control > Fluid resuscitation
▪ In dentistry emergency, pain and bleeding are two
most common, so act fast!

34
PEARLs AND PITFALLs

Shock
▪ Consciousness  GCS
▪ Blood pressure  Hypotension; Exclude
tension pneumothorax origin
(Obstructive), then blood loss
(Haemorrhagic)
▪ Tissue Perfusion
▫ Pulse  Rapid and weak
▫ Skin  greyish skin on face or
distal extremities
▫ Acral Coldness  Compare on
both sides
Management
▪ Intravenous access for fluid
resuscitation and blood
samples
▪ Urine catheter for monitoring
UO
▪ Crystalloid resuscitation
▫ Initial 500 cc  vital
sign  add 500 cc
▫ Up to 2 L

35
PEARLs AND PITFALLs
Bleeding
▪ Identify possible source of
bleeding, especially visible
ones!
▪ Tranexamic acid may improve
life expectancy if administered
in 3 hours after haemorrhagic
trauma
Management
▪ Apply direct pressure
▫ On the oral or tooth wound, by
dabbing with gauze
▪ Does the fluid resuscitation work?
▫ Responsive  Continue
▫ Partial or no respond  Consider
using blood transfusion,
determining other cause, or
referring to surgeon
36
37
DISABILITY

AVPU GCS EMV (3-15)

▪ Alert ▪ 14-15 Mild
▪ Respond to ▪ 9-13 Moderate
Verbal ▪ 3-8 Severe
▪ Respond to
Pain
▪ Unresponsive

38
Following examinations

Secondary Survey Tertiary Survey

▪ History ▪ Radiologic and other modality
▫ AMPLE mnemonic ▫ X-ray
▪ Head-to-Toe Examination ▫ Panoramic?
▫ Comprehensive oral and ▫ CT-scan
dental examination ▪ Depend on the suspected injuries
only, don’t waste resource!

39
WHEN TO CONSULT SPECIALISTS

▪ Failure to administer definitive airway  Anesthesiologist

▪ Open or closed maxillofacial fracture  Oral and dental surgeon

40
TRANSFER OF PATIENTS

▪ The principles of referring

▫ Know your (you and your hospital’s) capabilities
▫ Know the referred hospital’s capabilities
▫ Good communication between doctors in each hospital
▫ The ambulance must have adequate facilities
▫ The patient’s ABCDE is stable!

41
 5.
What’s to conclude?

Take home messages

CONCLUSION

▪ Avoid impromptu admission, make appointments first with patients as much as

possible
▪ Prepare our consultation room for aerosol procedures and design a proper triage
▪ Always assume our patients may be contaminated with COVID-19
▪ Always equip your Personal Protective Equipment while on duty!
▪ Initial survey and management is a mandatory to stabilize patients’ vital signs. No
difference between pre-pandemic and post-pandemic, however we should be most
careful that everyone might be a SARS-CoV-2 carrier during this COVID-19
pandemic.

43
THANKS!
“Jika anda tidak belajar, maka anda
tidak akan berubah. Dan jika anda
tidak berubah, maka anda akan mati
digilas perubahan”
-An Obstetrician

44