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dentalcorp COVID-19 Emergency Guidelines

Providing Safe Emergency Dental Treatment During COVID-19

dentalcorp is providing the following information for members to use as a resource in addition to good clinical judgment on making decisions to provide care for emergency dental treatment.


We want to stress again that it is appropriate to provide emergency care, that if left untreated, becomes a more significant burden on our health care resources and significantly compromises patient health. A primary goal of providing “emergency only care” is to prevent patients with dental emergencies from becoming a strain on limited hospital resources at a time when doctors and beds are expected to be in short supply. At the same time, the patient’s need for this urgent care must be weighed against the risk of exposure to patients, staff and dentists.

Once again, good clinical judgement during this time period will allow dentists and their teams to care for patients and alleviate the burden that dental emergencies would place on hospital emergency departments.

In this context, Continuity of Care means that patients of record have access to their primary care provider for guidance on emergency care. Primary care providers are best situated to determine whether and how a patient’s medical or dental history may inform what, if any, emergency treatment should be provided. Even where the primary treating dentist is not currently able to see the patient, he or she remains an important link in the screening and referral process.

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Guidelines

In the interest of the health and safety of both patients and providers, the following guidelines are provided.

  • Section 1: Assessment of office and clinic staff

    Practice managers and HR team members should be aware of employees who may be at an elevated risk to COVID19 (e.g., due to diabetes, heart disease, lung diseases, a compromised immune system, age, etc.) and perform a risk assessment concerning whether the employee should continue to attend the clinic during the pandemic crisis.

    If staff members are unable to wear appropriate PPE, for whatever reason, they should not report to work.

    Each office/clinic staff member should self-assess their health daily before reporting to work.

    They should say “No” to all the following questions:

    • Fever
    • Cough
    • Sore throat
    • Shortness of breath
    • Flu-like symptoms
    • Close personal contact (without PPE) with a suspected or lab confirmed COVID-19 patient within the past 2 weeks
    • Travel to an affected area in the past 14 days
    • Airline travel in the past 14 days
  • Section 2: Symptomatic patients This means patients responded ‘YES’ to one or more of the above screening assessment questions

    Symptomatic patients who indicate they have emergency or painful conditions need to be treated in facilities equipped with the proper PPE (fitted N95 mask, eye protection, face shield, protective gown, gloves).

    If your dental practice does NOT have required safety precautions in place to manage emergency cases in person, you are still responsible to triage emergency care via telephone first and then by referral to a nearby dental or specialty practice or hospital that can provide such care.

    Contact your regulatory body website for a list of qualified practices.

  • Section 3: Asymptomatic, healthy patients This means patients responded ‘NO’ to the screening assessment questions in the assessment section

    Asymptomatic, healthy patients who request treatment due to an emergency or painful condition, need to be pre-screened via telephone to protect dental staff and patients from possible virus transmission.

    If, after appropriate telephone screening, it is ascertained that the patient has no symptoms, and they require emergency dental treatment (see definitions/examples listed below) then follow the below guidelines to provide the necessary treatment.

  • Section 4: How to determine what is an emergency versus non-emergency

    The following should be helpful in determining what is considered “emergency” versus “non-emergency.”

    This guidance may change as the COVID-19 pandemic progresses, and dentists should use their professional judgment in determining a patient’s need for emergency care.

    1. Dental emergency procedures

    Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:

    • Uncontrolled bleeding
    • Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient’s airway
    • Trauma involving facial bones, potentially compromising the patient’s airway
    • Dental trauma with avulsion/luxation  
    • Surgical post-operative osteitis, dry socket dressing changes
    • Tooth/crown/bridge fracture resulting in severe pain or causing significant soft tissue trauma
    • Suture removal
    • Replacing temporary filling on endo access openings in patients experiencing significant problems 
    • Snipping or adjustment of an orthodontic wire or broken appliances piercing or ulcerating the oral mucosa
    • Denture adjustments or repairs when necessary for patients to maintain adequate nutrition (e.g. chemotherapy and oncology patients)
    • Abscess, or localized bacterial infection resulting in localized pain and swelling *
    • Severe dental pain from pulpal inflammation *
    • Pericoronitis or third-molar pain *
    • Denture management on radiation/oncology patients *

    * Most of these cases can be managed by telephone with guidance from the dentist (e.g. removing dentures that are causing irritation) or pharmacotherapy for infection/pain management.

    2. Dental non-emergency procedures

    These procedures are currently directed to NOT be performed and include but are not limited to:

    • Initial or periodic oral examinations and recall visits, including routine radiographs
    • Routine dental cleaning and preventive therapies
    • In-office consultations
    • Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)
    • Extraction of asymptomatic teeth
    • Restorative dentistry including treatment of asymptomatic carious lesions
    • Aesthetic or cosmetic dental procedures
    • Final crown/bridge cementation
    • Routine denture adjustments/delivery
    • Delivery of appliances (nightguards, TMJ appliances, orthodontic aligners) *

    * During a pandemic, delivery of certain appliances (e.g., nightguard or clear aligner) by mail with teleconference support by a dentist may be appropriate in limited urgent cases.

    3. Devices that may generate aerosols/splatter include but may not be limited to:

    • High-speed handpieces
    • Low-speed handpieces
    • Ultrasonic scalers
    • Air polishers
    • Air/water syringe
    • Electrosurgery units
    • Lasers
    • High volume suction
    • Low volume suction


      ONE OF THE BIGGEST CONCERNS TO YOU AND OTHERS IN THE OPERATORY IS AEROSOL PRODUCTION.*

      Remember the goal is to treat emergency cases only. By limiting chair time you limit exposure and opportunities for infection. Dentists are required to resort to pharmacotherapy to manage infection/pain whenever possible in order to minimize the number of patients seen in the dental office. Patients that walk in the door should have a true dental emergency that cannot be managed through a combination of consultation, OTC pain killers, and pharmacotherapy.

      As always, dentalcorp expects members to use clinical judgement.

    • Section 5: Considerations when providing treatment

      a) Waiting Room Guidance

      Prevent crowding of waiting areas and enforce social distancing practices:

      • Have patients wait in cars instead of waiting areas and call or text patients when the team and clinic are ready
      • Require patients to wash hands or use ABHR upon initial entry to the office
      • Consider staggering appointment times to reduce waiting room exposure
      • Allow only patients (and guardians or essential companions) to enter the clinic. All others to wait in their respective vehicles or outside the clinic
      • Remove magazines and toys etc. from waiting area to prevent contamination frequently wipe and disinfect high touch areas and object handled by patients, such as pens, etc.

      b) Considerations when providing treatment after proper screening

      • Use of 1% hydrogen peroxide 5cc to rinse for 30 seconds prior to examination of the oral cavity
      • Aerosol-generating procedures should be avoided wherever possible

      c) Follow-up procedures

      Contact with patients:

      • Contact patients 24 hours after providing emergency care
      • Confirm that emergency has resolved AND patients are not showing any signs of Covid-19 infection
      • Emergency patients may test positive for the virus some days after their dental visit, therefore you should contact the patients periodically up to 14 days after present in office

    Provincial Emergency Definitions and PPE Requirements

    • Alberta

      ADA&C Guidelines on Emergency Treatment | View »

      Emergency dental treatment includes treatment of oral-facial trauma, significant infection, prolonged bleeding or pain which cannot be managed by over-the-counter medications.


      PPE Required

      No aerosols used


      Guidelines on Emergency Treatment as of March 28, 2020

      "Current IPC standards apply and proper PPE." This includes PPE such as gloves, surgical masks, and protective eyewear.

      Aerosols are used


      Guidelines on Emergency Treatment as of March 28, 2020

      AGMPs require current IPC and enhanced PPE. This includes enhanced PPE such as protective clothing, gloves, fitted N-95, protective eyewear or face shield (due to the aerosol being created).

      Patient screened positive for COVID-19


      ADA&C Guidelines on Emergency Treatment

      Symptomatic patients must not be treated in a regular dental operatory

    • British Columbia

      CDSBC – March 19 Defining Emergent, Essential (Urgent), and Non-Essential (Elective) Care in Dentistry | View »

      Recommendations & Expectations for Clinical Care in the COVID-19 Pandemic (March 29, 2020) | View »

      Emergency dental care is defined as potentially life-threatening conditions requiring immediate management or treatment to stop ongoing tissue bleeding, alleviate severe pain or infection and include:

      1. Cellulitis as a result of an uncontrolled infection compromising the airway
      2. Severe uncontrolled hemorrhage (bleeding)
      3. Trauma to the orofacial complex especially to facial bones that potentially compromise the patient’s airway
      4. Uncontrolled severe pain
      5. Uncontrolled infection

      In BC, it appears that dentists may also treat "time sensitive treatment and essential (urgent) care" as minimally invasively as possible.


      PPE Required


      No aerosols used


      CDSBC IPAC Guidelines

      Recommendations for appropriate PPE can be found through BCCDC, Health Canada, authoritative health agencies and governmental bodies and expert opinion.


      Aerosols are used


      Respiratory Protection for Health Care Workers Caring for Potential or Confirmed

      Ensure HCWs performing or assisting with AGMP wear appropriate PPE: gown, gloves, a fit tested N95 respirator and eye protection (i.e. face shield/goggles).


      Patient screened positive for COVID-19


      Recommendations & Expectations for Clinical Care in the COVID-19 Pandemic

      If the patient has suspected or confirmed COVID-19 disease, and if the appropriate treatment requires direct physical contact, appropriate personal protective equipment (PPE) and infection prevention and control practices must be used.

    • Manitoba

      MDA Statement to Members as of March 28, 2020 | View »

      Emergency treatment includes treatment due to a significant infection, acute pain that cannot be managed pharmacologically, oro-facial trauma or prolonged bleeding, all of which as a result require immediate care. The MDA strongly advises that the dentist exercise reasonable and prudent judgment for assessing risk in these circumstances.


      PPE Required


      No aerosols used


      IPC Guidelines related to COVID-19 management for asymptomatic patients (March 28, 2020)

      Non-Aerosolizing procedures: Gloves, ASTM Level 3 mask, Eye protection, (N95 mask if available)


      Aerosols are used


      IPC Guidelines related to COVID-19 management for asymptomatic patients (March 28, 2020)

      Potentially Aerosolizing procedures: Gloves, N95 Mask, fluid resistant gown, protective eyewear or face shield.


      Patient screened positive for COVID-19


      IPC Guidelines related to COVID-19 management for aymptomatic patients (March 28, 2020)

      For the protection of you, your staff, the patient and other patients, symptomatic patients should not be treated in a regular dental operatory.

    • New Brunswick

      NBDS Guidance on true emergency situations during COVID-19 pandemic | View »

      In dentistry, a “true emergency situation” includes oral-facial trauma, significant infection, prolonged bleeding or pain which cannot be managed by over-the-counter medications.


      PPE Required


      No aerosols used


      NBDS Guidance on true emergency situations during the COVID-19 pandemic

      Use routine practices and contact/droplet precautions (i.e. procedure/surgical mask, gloves and eye protection). Obtain a history of the patient’s condition and conduct an emergency clinical dental examination. Determine the nature of the emergency and provide care.


      Aerosols are used


      NBDS Guidance on true emergency situations during the COVID-19 pandemic

      Care may be provided using routine practices and contact/droplet precautions (i.e. procedure/surgical mask, gloves and eye protection).

      NBDS statement out of date, advise to follow current RCDSO standards—however, not yet officially adopted.


      Patient screened positive for COVID-19


      NBDS Guidance on true emergency situations during the COVID-19 pandemic

      If the patient screens positive for acute respiratory illness, including COVID-19, then care must be provided using enhanced precautions (i.e. N95 mask, gloves, eye protection, face shield and protective gown).

      To protect dentists, dental staff and conserve PPE supplies, aerosol-generating procedures should be avoided, if possible. Consider using pharmacotherapy instead.

    • Newfoundland and Labrador

      NLDA Pandemic Plan COVID-19 for Emergency Care | View »

      Dental Emergencies require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection. Visit the above link to view the full list of dental emergencies.


      PPE Required


      No aerosols used


      NLDA Pandemic Plan COVID-19 For Emergency Care

      Care may be provided using routine practices and contact/droplet precautions (i.e. procedure/surgical mask, gloves, gowns and eye protection and other standard precautions in the operatory).


      Aerosols are used


      NLDA Pandemic Plan COVID-19 For Emergency Care

      It is strongly recommended that care be provided using enhanced precautions (i.e. fit-tested N95 masks, gloves, eye protection, face shield and protective gown) in addition a rubber dam and high-volume suction should be used to minimize aerosols.


      Patient screened positive for COVID-19


      NLDA Pandemic Plan COVID-19 For Emergency Care

      If your patient screens positive for COVID-19 all treatment should be delayed until patient is determined to be viral free.

    • Nova Scotia

      PDBNS – Publications on COVID-19 | View »

      Emergency dental care is essential and is indicated for the treatment of infection, acute pain, trauma, bleeding and for necessary post operative follow up.


      PPE Required


      No aerosols used


      PDBNS – March 22, 2020

      Level 1 mask, eye protection, gown, lab coat, and gloves.


      Aerosols are used


      PDBNS – March 22, 2020

      NSDA Infection Prevention and Control Guidelines

      Level 3 mask, face shield, eye protection, gown/lab coat, and gloves.


      Patient screened positive for COVID-19


      PDBNS – March 22, 2020

      Make appropriate dentist-dentist referral. Clinics provided in guidance document.

    • Ontario

      RCDSO – Dispatch News | View »

      In dentistry, a “true emergency situation” includes oral-facial trauma, significant infection, prolonged bleeding or pain which cannot be managed by over-the-counter medications.


      PPE Required


      No aerosols used


      RCDSO – Dispatch News - March 23rd

      Patient presents with an emergency that CAN be managed without generating an aerosol (i.e. high-speed handpiece and air-water syringe will NOT be used), routine practices and contact/droplet precautions (i.e. procedure/surgical mask, gloves and eye protection).


      Aerosols are used


      RCDSO – Dispatch News - March 23rd

      If an aerosol will be generated, then care MUST be provided using enhanced precautions (i.e. fit-tested N95 mask, gloves, eye protection, face shield and protective gown).


      Patient screened positive for COVID-19


      RCDSO – Dispatch News - March 23rd

    • PEI

      Following RCDSO – Dispatch News | View »

      In dentistry, a “true emergency situation” includes oral-facial trauma, significant infection, prolonged bleeding or pain which cannot be managed by over-the-counter medications.


      PPE Required


      No aerosols used


      RCDSO – Dispatch News - March 23rd

      Following RCDSO.


      Aerosols are used


      RCDSO – Dispatch News - March 23rd

      Following RCDSO.


      Patient screened positive for COVID-19


      RCDSO – Dispatch News - March 23rd

      Following RCDSO.

      For any AGMP, heightened PPE with N95, etc.

    • Quebec

      COVID-19 Dental Emergencies | View »

      In dentistry, an emergency can be defined as a clinical situation requiring an immediate intervention and one that cannot be managed with over-the-counter medications.

      Based on your clinical judgement, the following constitute an emergency:

      1. A major infection
      2. Acute pain
      3. Trauma requiring immediate intervention
      4. In addition, cases of prolonged bleeding and a dental treatment required prior to a surgery that must be done in a timely manner, can also be considered emergencies.


      PPE Required


      No aerosols used


      ODQ Decision Tree (Updated March 26, 2020)

      Single-use level 3 procedure mask (surgical mask) or level 2 mask. These masks must be changed when they are wt or visibly soiled, single-use gloves, protective glasses.


      Aerosols are used


      ODQ Decision Tree (Updated March 26, 2020)

      Properly fitted N95 mask, (fit test), single-use gloves covering the wrists, protective glasses, face shield, disposable surgical gown, cap and shoe covers.


      Patient screened positive for COVID-19


      ODQ Decision Tree (Updated March 26, 2020)

      Refer to designated dental clinics or hospital.

    • Saskatchewan

      Alert: Provision of Dental Emergency Services in Saskatchewan Update on Level 2 (March 26, 2020) | View »

      A dental emergency exists if a person needs immediate attention to address oral trauma, pain, infection, bleeding or other associated medical complications. Emergency cases should be managed via telephone screening risk assessment by taking a verbal history of the patient's condition and providing appropriate pharmacotherapy.

      "Level 1 - All CDSS members must maintain contact with their patients and manage emergencies using Pharmacotherapeutics. If patients cannot be managed at this Level 1, they must be referred to Level 2 providers. All CDSS members are requested to complete this form including all Level 1 providers which should include all CDSS members. If you have a patient that requires Level 2A or 2B emergency dental care and cannot currently provide that level of emergency care, please contact the CDSS at: tania@saskdentists.com."


      PPE Required


      No aerosols used


      Alert: Provision of Dental Emergency Services in Saskatchewan Update on Level 2 - March 25, 2020

      Current SOHP IPC standards apply and proper PPE. This includes proper PPE such as gloves, surgical masks, protective eyewear.


      Aerosols are used


      Alert: Provision of Dental Emergency Services in Saskatchewan Update on Level 2 - March 25, 2020

      Current SOHP IPC standards and proper PPE including properly fitting N95 masks, protective clothing, gloves, protective eyewear or face shield, fluid-resistant gowns and lab-coats.


      Patient screened positive for COVID-19


      ADA&C Guidelines on Emergency Treatment

      For the protection of you, your staff, the patient and other patients, symptomatic patients should not be treated in a regular dental operatory.

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