Evaluation of characteristics and clinical implications of endodontic emergencies during COVID-19 pandemic

Seema Chaudhary; Sonali Sharma

doi:10.4103/jodd.jodd_33_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 16 | Issue : 1 | Page : 30-35

Evaluation of characteristics and clinical implications of endodontic emergencies during COVID-19 pandemic

Seema Chaudhary, Sonali Sharma
Army Dental Centre (Research and Referral), New Delhi, India

Date of Submission	25-Jul-2021
Date of Acceptance	21-Jan-2022
Date of Web Publication	05-Apr-2022

Correspondence Address:
Seema Chaudhary
Army Dental Centre (Research and Referral), New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodd.jodd_33_21

Abstract

Background: The spread of a new coronavirus named Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) was detected in China in late 2019, which later spread to other parts of the world. Affected persons present with symptoms such as dry cough, malaise, and a high fever. During the various phases of the pandemic, patients presented with the symptomatology of a plethora of dental emergencies including endodontic emergencies to the dental institute.
Aim: The present study aimed to analyze the nature and characterize endodontic emergencies.
Materials and Methods: Patients reporting with pain and swelling of endodontic nature were included in the study. Information about patients was collected and systematized by date of visit, gender, age, and diagnosis. Only the patients exhibiting emergencies of endodontic origin were included in the study. Emergencies were divided into three groups: Group I: Preoperative, Group II: Intraoperative and Group III: Postoperative. These groups were further stratified according to the final diagnosis. A numerical rating scale (NRS) was used to record pain levels.
Results: A total of 4274 patients were attended for endodontic emergencies. The age group which presented with maximum number of endodontic emergencies was 30–39 years (37%). The majority of endodontic emergency diagnoses were diseases of symptomatic irreversible pulpitis (57%). Patients who were diagnosed with symptomatic irreversible pulpitis showed higher mean verbal NRS scores than that of other groups although the difference was statistically nonsignificant.
Conclusion: The type of endodontic emergencies varies depending on the inflammatory status of the pulp. Keeping in mind the characteristics of endodontic emergencies, treatment protocols can be formulated and patients can be managed taking care of all due precautions to reduce the risk of infection transmission.

Keywords: Coronavirus disease 2019, endodontic emergency, pandemic, verbal numerical rating scale, vital pulp therapy

How to cite this article:
Chaudhary S, Sharma S. Evaluation of characteristics and clinical implications of endodontic emergencies during COVID-19 pandemic. J Dent Def Sect. 2022;16:30-5

How to cite this URL:
Chaudhary S, Sharma S. Evaluation of characteristics and clinical implications of endodontic emergencies during COVID-19 pandemic. J Dent Def Sect. [serial online] 2022 [cited 2023 Mar 23];16:30-5. Available from: http://www.journaldds.org/text.asp?2022/16/1/30/342642

Introduction

The novel coronavirus was identified in Wuhan, China, in December 2019, and later in March 2020, coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO).^[1] Severe acute respiratory disease corona virus-2 (SARS CoV-2) is transmitted mainly via the respiratory route when people inhale droplets that infected people release as they breathe, talk, sneeze, and cough.^[1] Clinical symptoms of COVID-19 disease include cough, fever, and shortness of breath. In over 80% of the patients, the infection is mild.^[2] About 15% of patients develop severe illness and 5% might need critical care treatment. COVID-19 can affect multiple organs and can lead to severe respiratory distress, renal failure, and even death. The primary source of transmission is symptomatic patients although findings suggest that asymptomatic individuals also act as a carrier.^[3] To control the community spread, strategies include physical distancing, wearing masks, avoiding crowded places, and prompt isolation along with treatment of COVID patients.

COVID-19 is a challenge to dentists as well as patients, as there is a high risk of transmission owing to the generation of aerosols while carrying out dental procedures and its evidence of being harbored in the salivary glands, both major and minor.^[4] In consideration of the high risk, during the first and second wave of COVID-19 disease in India, initial lockdown measures were implemented on March 24, 2020, soon after the declaration of a pandemic by WHO. Most of the routine dental practices were deferred and only emergency treatments were being done at the dental centers during this time.

Despite the high risks, acute pain of dental origin necessitates urgent treatment. The most common cause of dental pain is that of endodontic origin. Endodontic conditions ranging from irreversible pulpitis, apical abscess formation, and traumatic fractures of teeth can cause severe pain and compel patients to seek emergency aid. Thus, endodontic emergencies are an integral and major component of dental emergencies.

This study aimed to evaluate the nature and characterization of endodontic emergencies attended at Army Dental Centre, Research and Referral (ADC R and R) between April 1^st, 2020, and May 31^st, 2021.

Materials and Methods

Selection of study subjects

The present study was approved by the Institutional Ethical Committee. Patients who visited the outpatient department (OPD) at ADC R and R between April 1^st, 2020, and May 31^st, 2021 were managed based on the emergency severity assessment of the associated dental condition. Body temperature was measured using a handheld infrared thermometer for each patient, and a COVID-19 questionnaire was given before dental treatment. Patients fulfilling the emergency of endodontic origin were included in the study.

Evaluation of study subjects

The case history was recorded and examination was done based on oral health assessment and review of 2013. As per Paul Abbott's revised classification of pulpoperiapical diseases, the patients were segregated into different endodontic entities.^[5] The definitive diagnosis was arrived at by a comprehensive clinical evaluation, clinical tests including pulp sensibility testing and radiographic examination. Patients were asked to record their pain levels using a 0-10 verbal numerical rating scale [Figure 1].

Figure 1: The 11-point numeric scale range from '0' representing one pain extreme (e.g., “no pain to '10' representing to other pain extreme (e.g., pain as bad as you can imagine” or worst pain imaginable”)

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Patients were segregated and analyzed under 3 Groups [Figure 2] based on characterization of endodontic emergencies:-

Figure 2: Overview of study with segregation of endodontic emergencies to different groups

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Group I: Preoperative,
Group II: Intraoperative (while undergoing root canal treatment) and
Group III: Postoperative (Post endodontic treatment).

Each group was further subdivided into subgroups which constituted the following emergencies:

Group I: Subgroup IA: Acute reversible pulpitis, Subgroup IB: Acute irreversible pulpitis, Subgroup IC: Primary acute apical periodontitis, Subgroup ID: Acute apical abscess, Subgroup IE: Facial Cellulitis/space infection (of endodontic origin) and subgroup IF: Complicated crown fracture.

Group II: Subgroup IIA: Endodontic flareup and IIB: Fractured tooth while undergoing endodontic treatment.

Group III: Subgroup IIIA: Pulpless and infected root canal system and Subgroup IIIB: Fractured tooth post endodontic treatment.

Based on the pulpal status the patients were divided into different groups as appended in [Figure 2]. The aim of the characterization and segregation was to have a varied and need-based endodontic protocol in place during the COVID pandemic. Thus, on evaluating the pulpal status, the treatment procedures were performed. The treatment options which were embraced were: Direct pulp capping for reversible pulpitis, Partial (Cvek) or complete pulpotomy for cases in which just partial inflammation was seen clinically. In other words, cases with Irreversible pulpitis in which the pulp was vital and bleeding could be controlled were the candidates for pulpotomy. Acute apical periodontitis or infected pulpless teeth with acute symptoms were managed by pulpectomy. Endodontic therapy was initiated in such cases and cleaning and shaping was done till 25/30 with the master apical file. Infected cases or retreatment cases were all prepared till 25/30 and the intracanal medicament of choice was chlorhexidine gel. For cases having periapical pathology, the intracanal medicament of choice was calcium hydroxide. Irrigation in between instrumentation was done using 2.5% sodium hypochlorite solution. In retreatment cases, 2% chlorhexidine solution was used in addition to 2.5% sodium hypochlorite solution. Seventeen percent ethylenediamine tetraacetic acid (EDTA) was used as a final rinse in all the cases. Copious irrigation with normal saline was carried out after the change of irrigating solution.

Results

A total of 4274 patients presented with endodontic emergencies in the OPD at ADC R and R from April 1^st, 2020, to May 31^st, 2021. Characteristics of patients with an endodontic emergency were stratified by variables such as gender, age group, and diagnosis. Sociodemographic characteristics of the patients are shown in [Table 1]. Majority of the patients reporting for emergency were males (n = 2230, 53%) and belonged to Group I (Preoperative Endodontic Emergencies Group) (n = 3773, 88%) [Table 1]. Maximum cases (57%, n = 2152) were of subgroup IB, symptomatic irreversible pulpitis [Figure 3]. One-way analysis of variance and independent t-test was performed to compare the mean pain scores. Highest mean pain scores were observed in Group IB (7.32) as compared to others as shown in [Figure 4] although the difference was statistically nonsignificant (P > 0.05). Statistical analysis was performed using SPSS 20.0 software (IBM Corporation, Armonk, NY, USA).

Figure 3: Level of pain perception in the various endodontic emergency groups

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Figure 4: (a) Distribution of emergencies in group I. (b) Distribution of emergencies in group II. (c) Distribution of emergencies in group III.

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Table 1: The VNRS scores in males and females, various Age Groups, and groups

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Discussion

To curb the COVID-19 outbreak, lockdowns and calls for community discipline were enforced worldwide to prevent the spread of SARS CoV-2. Elective dental treatments were suspended in many countries around the world including India because of the risks dental procedures may pose due to the generation of aerosols.^[6] Only emergency and urgent care treatments were allowed at most of the places in the country. Huang et al. in a retrospective study observed that a substantial proportion of emergency dental visits are of endodontic origin.^[3] An endodontic emergency is defined as an “Unscheduled visit associated with pain or swelling ensuing from pulpo-periapical pathosis requiring immediate diagnosis and treatment.” No standard protocol exists about managing endodontic emergencies during pandemic outbreaks. Keeping this in mind, the present study was designed to characterize the nature of the endodontic emergencies attended to formulate a comprehensive need-based endodontic protocol in armed forces [Figure 2]. A patient exhibiting reversible pulpitis necessitated management with restoration or pulp capping. A patient exhibiting irreversible pulpitis symptoms warranted partial pulpotomy or complete pulpotomy. A case of apical periodontitis makes it mandatory to initiate root canal treatment. Thus, having a well-assessed data of nature and characteristics of the endodontic emergency enables a well-informed management strategy into place and results in predictable treatment outcome.

In the present study, the age Group, 30–39 years (37%) was reported to be having the largest number of endodontic emergencies followed by the age group of 40–49 years (29%) [Table 1]. The majority of patients who presented with endodontic emergencies were males (52%). These findings are similar to a retrospective study carried out by Huang et al. in which he observed that higher number of male patients reported to dental emergency department than females.^[3] Higher number of males visiting the emergency department in the present study could be attributed to the fact that an unprecedented number of people were forced to stay indoors, especially women who were home makers, teachers and working from home during the lockdown period. No significant difference was observed in pain levels between males and females (P > 0.05).

During the I^st and II^nd wave of COVID-19 pandemic, only emergency and urgent treatments were provided to the patients at ADC R and R. Elective dental treatments were postponed to a later date. Endodontic emergencies comprise a varied number of pulpal and periapical diseases such as acute reversible pulpitis, acute irreversible pulpitis, primary acute apical periodontitis, acute apical abscess, cellulitis, complicated crown fracture and endodontic flareups.^[5] The total number of patients visiting the OPD for endodontic emergencies during the study duration was reported to be 4274. To halt the spread of virus, the Government of India implemented lockdown measures in the country starting from March 24, 2020, to May 31^st, 2020. The total patient visits during this period was 426, out of which 223 cases were cases of endodontic origin [Figure 5]. After the relaxation of lockdown measures, there was an increase in patients visiting the dental center for elective dental treatments. During the second wave of COVID-19 pandemic in the country lockdown measures were put in place from April 19^th onward and continued till June 6^th. The number of endodontic emergencies attended during this period was 206. The total patient attendance during the entire study period was 23860. In the present study, the majority (57%) of patients presented with acute irreversible pulpitis. The second most common emergency observed in this study was primary acute apical periodontitis (27%). These results are in accordance with a study done by Yu et al. in which he observed that acute irreversible pulpitis cases comprise the major proportion of endodontic emergencies, followed by primary acute apical periodontitis.^[7]

Figure 5: Number of endodontic emergencies attended from April 2020 to May 2021

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Pulpotomy was performed in 12% of patients presenting with acute irreversible pulpitis. Remaining required root canal treatment. During the first visit, access opening was done and canals were enlarged to a minimum of 20/25 file sizes. Irrigation during instrumentation was performed using 2.5% sodium hypochlorite. In retreatment cases, initially, 2.5% hypochlorite was used in between instrumentation. Once the canal was sufficiently enlarged, irrigation was done with 2% chlorhexidine after rinsing with normal saline to further disinfect the canals. Seventeen percent EDTA was used as a final rinse in all the cases. Calcium hydroxide was used as the intracanal medicament because of its antibacterial and antifungal properties.^[8] It has an added advantage of minimizing inflammation by mediating neutralization of lipopolysaccharides and reducing the incidence of postoperative pain.^[9] In retreatment cases, chlorhexidine gel was used as an intracanal medicament. Patients were then recalled for subsequent visits after 2–3 weeks.

The management of endodontic emergencies is challenging during the COVID-19 outbreak because of the risk of transmission by inhalation of aerosols produced during dental treatment procedures on patients with COVID-19. It has been shown that asymptomatic COVID-19 patients as well as those under incubation period have the potential to spread infection.^[6] SARS CoV-2 has been reported to attach to angiotensin-converting enzyme 2 receptors found in structures of oral cavity and evidence suggests presence of SARS CoV-2 virus in saliva of infected patients thus making it a potential source of infection.^[10],[11] High-speed dental handpieces like the air rotor generate high amounts of bioaerosols containing contaminated fluids like blood and saliva. These bioaerosols carry the risk of transmission of COVID disease by direct inhalation and also by contamination of inanimate objects.^[12],[13]

Various strategies have been proposed to reduce infection transmission while treating endodontic emergencies. Proper triaging of patients should be done to minimize risk of infection to dental personnel as well as managing the cases using the suitable intervention. Procedures should preferably be performed in negative pressure rooms in a hospital environment.^[14] Preprocedural mouth rinses should be provided to patients to reduce microbial load. Treatment time can be reduced to decrease risk of infection by using vital pulp therapy procedures. Vital pulp therapy procedures can be used as an alternative to conventional root canal treatment in selected cases where pulp is vital and only coronal portion is inflamed sparing the radicular pulp.^[15] In the current study, 12% of the patients with symptomatic irreversible pulpitis were managed by pulpotomy. Aerosol management interventions like extraoral suction and air cleaning systems which contain high-efficiency particulate air filters should be used in the operatory to reduce aerosols.^[16] Rubber dam isolation should be used as it has been demonstrated to reduce aerosols and also eliminate or substantially reduce salivary contamination of aerosols generated.^[17],[18] All the endodontic emergency procedures in the dental center were performed under strict precautions which included the use of appropriately fitted personal protective equipment, use of rubber dam isolation, employing the use of extraoral suction apparatus in the operatory and use of aerosol minimizing instrumentation techniques like the use of retraction valve electric handpieces with high volume suction.

In the present scenario, instead of abandoning the dental care delivery at the dental center, patients with emergencies were attended to initially during the peak of COVID-19 disease in the country, and later urgency cases were also taken care of. Out of 23,860 who were managed during the entire period under consideration, only 4274 constituted an endodontic emergency. Thus a testimony to the fact that elective treatment was also carried out and there was no collapse of oral health care during the complete year under observation.

During the pandemic, providing effective dental care while keeping the patients and the dental staff safe is of utmost importance. Shutting down dental practices is not a solution and will only increase the suffering of the patients in need of dental care in addition to increasing the burden on emergency departments of hospitals. It is the need of the hour to formulate standard guidelines for dental care provision during pandemic outbreaks by analyzing the characteristics of emergencies that arise.

Choosing a single tertiary care center is a limitation of the study. In future, multicentric studies should be carried out to ensure universal validity of the results.

Conclusion

Endodontic emergencies vary widely ranging from reversible pulpitis to irreversible pulpitis and apical periodontitis to apical abscess. Characterization of nature of endodontic emergencies is important to determine the treatment protocol for a particular case. During COVID outbreak, the management of endodontic emergencies should be done keeping in mind the risks of infection transmission and a need-based treatment protocol should be formulated as per the changing situations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements:

The authors acknowledge with deep gratitude the guidance and help provided by Brig B Jayan, Commandant, ADC R and R.

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