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Pandemic-Minded Endodontics: Clinical Tips and Considerations

May 10, 2021
by Manor Haas, DDS, MSc(D), Cert. Endo.


INTRODUCTION

The need for endodontic care during the COVID-19 pandemic has remained as important as ever. But as we face unprecedented clinical challenges due to this ongoing pandemic, we must adjust our practice by adopting certain protocols. This article will discuss how to adapt to COVID-related considerations that centre around efficient and effective endodontic treatment and reduction of viral transmission risks in the dental office.

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COVID-related patient management and facility considerations should be followed as per your regulatory body’s guidelines. This should include considerations of the Centers for Disease Control and Prevention (CDC) and American Dental Association (ADA) guidances.1,2

Mitigating transmission risks obviously includes the use of barriers such as personal protective equipment (PPE), as per current guidelines.1,2 But it may also include enhanced patient screening, triage, and diagnosis, reducing the number of visits required to perform endodontic treatment, reducing patient time in the office by means of improved efficiency, and reduced production of contaminated aerosols and air droplets.

PRE-TREATMENT (covid-related screenings and diagnosis):
Added patient visits may increase the risk of transmission of the coronavirus and also use up precious, costly and possibly limited PPE resources. In turn, you should attempt to remotely and virtually, “tele-screen” and triage patients when they contact your office with a tooth ache. For instance, try to rule out non-endo related symptoms such as dentin hypersensitivity (ie: momentary sharp pain to sweets or brushing ) or parafunction (ie non-localized pressure tenderness waking patients up at night or present upon waking up in the mornings). Encourage patients to send you intra-oral and extra-oral photos taken on their smart-phones.1,2 See Figs. 1, 2&3

Fig. 1

Photograph taken by patient’s family showing a labial abscess over tooth #7.

Photograph taken by patient’s family showing a labial abscess over tooth #7.

Fig. 2

Photos emailed by patient with a buccal swelling and vestibular infection.

Photos emailed by patient with a buccal swelling and vestibular infection.

Fig. 3

Photos emailed by patient with a buccal swelling and vestibular infection.

Photos emailed by patient with a buccal swelling and vestibular infection.

Whenever possible, incorporate more extra-oral imaging such as CBCT or panorex for diagnosis. This helps reduce the need for intra-oral radiographs which entail an increased risk of patients coughing or gagging which may produce contaminated droplets.3 A CBCT scan can often replace the need for an invasive exploratory endodontic access and/or surgery that would inherently involve contact with contaminated saliva and/or blood. See Figs. 4 & 5

Fig. 4

 Buccal swelling over tooth #14.

Buccal swelling over tooth #14.

Fig. 5

Extra-oral imaging with CBCT clearly shows site of pathology (yellow arrows) and reduces need for intra-oral imaging or surgery.

Extra-oral imaging with CBCT clearly shows site of pathology (yellow arrows) and reduces need for intra-oral imaging or surgery.

TREATMENT PLANNING
In order to reduce the number of patient visits, be prepared to treat a patient that may have presented for a consultation only. This preparation should start prior to the appointment. Administrative staff should educate patients as to why limiting excursions out of their “safe” homes and accepting same day treatment, if determined to be necessary, benefits their safety during a pandemic. Hence, if it’s determined that a patient requires emergency or non-emergency treatment, you and your staff should be prepared to provide immediate treatment. This includes front desk staff re-arranging the schedule to accommodate the unscheduled treatment and even calling and moving the following scheduled patients a “few minutes” later, as you might be running late with the unscheduled emergency. It also includes having logistical clinical systems in place that enable immediate treatment. Such reduction of patient visits would benefit the patients’ and staff’s safety and the practice’s efficiency and production. A win-win during a pandemic.

When treatment planning, keep in mind the importance of definitive treatments. When presenting patients with treatment options, explain that during a pandemic, it’s certainly not the time for heroic endodontics. Treatments with lower prognosis are more likely to require follow up visits due to post-op complications or failures. For instance, retreatment of a complex molar case that has guarded restorability may have a poor prognosis versus extraction and implant replacement. See Figs. 6 & 7

Fig. 6

Consider very guarded endodontic and/or restorative prognosis for tooth #14

Consider very guarded endodontic and/or restorative prognosis for tooth #14

Fig. 7

Consider very guarded endodontic and/or restorative prognosis for tooth #14

Consider very guarded endodontic and/or restorative prognosis for tooth #14

TREATMENT CONSIDERATIONS
Once it is determined that endodontic treatment is necessary, you should keep the following in mind.

Reduce the airborne spread of the virus by decreasing and possibly eliminating, the production of contaminated aerosols and droplets by using rubber dam isolation.3,4

It should be noted that rubber dam isolation is an unequivocal standard of care in North America, and must be incorporated during all non-surgical root canal treatments. A COVID-related benefit of its use is the elimination of contact with contaminated saliva during drilling and file handling, and prevention of air droplets in case patients cough during the procedure. (See Figs. 8, 9 & 10) So, not only do we have to use rubber dam isolation, but it could be argued that its may make non-surgical endodontic treatment one of the least likely procedures to produce contaminated aerosols and air droplets. Prior to endodontic access preparation, oral rinse with an anti-viral solution is encouraged, along with bathing the isolated tooth’s crown with an anti-viral solution.3

Fig. 8

Endodontic treatment without isolation will result in contact with contaminated saliva and blood.

Endodontic treatment without isolation will result in contact with contaminated saliva and blood.

Fig. 9

Rubber dam isolation eliminates contact with saliva and blood during endodontic treatment.

Rubber dam isolation eliminates contact with saliva and blood during endodontic treatment.

Fig. 10

Drilling alongside rubber dam isolation reduces (possibly eliminates) production of contaminated aerosols and meets standard of care.

Drilling alongside rubber dam isolation reduces (possibly eliminates) production of contaminated aerosols and meets standard of care.

Reduce the patients’ time in the chair by perform the procedure as efficiently as possible with the following protocols and armamentaria.

Use enhanced magnification and illumination to more efficiently locate canals, including calcified and MB2 canals. This is accomplished by using high-power loupes with an overhead light and/or dental microscope. Depending on the guidelines in your jurisdiction, face shields may be necessary. The use of a face shield with dental loupes might be easier than with a dental microscope. You might need some ingenuity to incorporate shields into your practice. See Figs. 11 & 12

Fig. 11

Face shield used overtop dental loupes with headlight with shield foam bumper positioned on forehead.

Face shield used overtop dental loupes with headlight with shield foam bumper positioned on forehead.

Fig. 12

Face shield inverted and foam bumper positioned on chin to accommodate longer loupes and/or larger headlight.

Face shield inverted and foam bumper positioned on chin to accommodate longer loupes and/or larger headlight.

Use a quality electronic apex locator to determine working lengths. Doing so will reduce the need for numerous intra-oral radiographs which expose you and your assistant to contaminate saliva, the risk of patient coughing while taking x-rays, and make the procedure more efficient overall.

Use endodontic NiTi filing systems that require fewer files and fewer steps than traditional NiTi filing systems. Doing so will in turn help make the procedure more efficient and enable you to accommodate endodontic emergencies and same day treatments.

Traditionally, multi-visit root canal treatments have been common for teeth with necrotic pulps. Yet, as previously mentioned and whenever possible, performing root canal treatments in a single visit is encouraged. This is possible by performing root canals more efficiently and by incorporating certain protocols. Studies show no difference in outcome between single and multi-visit root canals when certain protocols are incorporated. In part, they include enhanced intra-canal medication and activation. It’s also been shown that there may be no increased risk of post op pain with single visit root canal treatments, versus multi-visit treatments. The same was the case for the risk of post-operative flare ups following single visit root canal treatment, hopefully meaning no increased need for post-op visits.5,6,7,8

One should also attempt to permanently restore the endo treated tooth in the same visit. Especially while rubber dam isolation is still present and immediately after root canal treatment. Doing so helps improve outcome by reducing coronal bacterial micro-leakage. It also helps reduce the risk of tooth and/or temporary restoration fracture while the tooth is not permanently restored.9

This is all very important to keep in mind while providing treatment during a pandemic as patients need to reduce their excursions outside their homes. Table 1 sums up the considerations and protocols that help us adapt to practicing endodontics during the COVID-19 pandemic.

Table 1

SUMMARY
Providing endodontic care during a pandemic should entail protocols that reduce the risk of viral transmission amongst patients, staff and doctors. This means reducing unnecessary patient visits by means of tele-dentistry, being prepared to provide same day treatment, reducing treatment times and reducing the production of contaminated aerosols and air droplets. Doing so benefits and safeguards patients, dental staff and the viability of your dental practice.

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References

  1. Guidance for Dental Settings, www.cdc.org ,updated August 28,2020. American Dental Association online. Covid-19 Center. www.ada.org
  2. Harrel S, Molinari J, Aerosols and splatter in dentistry. A brief review of the literature and infection control implications, JADA, Vol 135, April 2004.
  3. Baumann K et al, Transmission precautions for dental aerosols, Decisions in Dentistry, 4(12), December 2018
  4. Schwendicke F, Gostemeyer G, Single-visit or multiple-visit root canal treatment: systematic review, meta-analysis and trial sequential analysis. MBJ Open. 7(2), 2017.
  5. Penesis VA, et. al., Outcome of one visit and two visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod Mar:34(3):251-7, 2008.
  6. Kalhoro F, Mirza A, A study of flare-ups following single-visit root canal treatment in endodontic patients. J Coll Physicians Surg Pak. Jul;19(7):410-2, 2009.
  7. Kurt M., Caliskan M, Efficacy of chlorhexidine as a final irrigant in one visit root canal treatment: a prospective comparative study, Int Endod J. Oct;51(10):1069-76, 2018.
  8. Goldfein J et al, Rubber dam use during post placement influences the success of root canal-treated teeth. J Endod, 39(12), 2013.

About the Author

Dr. Haas is a certified specialist in endodontics. He is extensively and passionately involved in continuing education to dentists and has lectured and provided workshops and webinars internationally. He is on staff at the Hospital for Sick Children. He maintains a full-time practice limited to endodontics and microsurgery in Toronto. He is a regular contributor to dental journals, websites and blogs. He may be reached via HaasEndoEducation.com


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