Advice on Emergency Dental & Orthodontic Treatments During COVID-19

 BOS Covid-19 Orthodontic Emergencies Protocol 

In light of the most recent evidence on the spread of covid-19 in relation to AGPs, the PPE available and to prevent transmission of the disease, we have created an emergency orthodontic protocol to deal with all but the most urgent orthodontic problems. 

Most orthodontic appliances can be left in situ for some months without detriment to the patient if the patient continues with the usual after care instructions; 

• • Exemplary oral hygiene – brushing 3 times a day with their standard toothbrush, followed by interproximal brush use. As an adjunct, use of a fluoride mouthrinse eg. Fluoriguard (225ppm), once a day. 
• • Low sugar diet – Where possible avoid all snacking on sugars and drinks with ADDED SUGAR. Fizzy drinks should be avoided in particular. 
• • Avoid hard, sticky and hard foodstuffs that could break the brace wire or fracture brackets (debond) off a tooth. 

Patients may ring in the coming weeks with pain, problems and loose wires. At present, the best advice is to avoid all but the most essential mouth procedures to limit spread of the disease to the wider population. 

In the event of a patient needing to attend with an orthodontic emergency, the following protocol has been put together to help best treat the patient and keep staff members safe. 

Upon receiving a call it would be wise to have a member of the orthodontic team speak to the patient or parent (either immediately or at a later agreed time) to identify the problem and determine if a visit to the practice is essential; 

• 1. Are they in pain? 
• 2. What is the problem? 
• 3. Identify if it is something the patient can deal with at home? 
• 4. Verify that they have an acute orthodontic problem that is affecting lifestyle? 

If the practice/unit member contacting the patient is not a clinician and is in doubt about the triaging of the urgency a suitably qualified health care professional (HPC) should be informed to assist the decision making. 

The following information should be obtained 

• 1. A summary of the issue 
• 2. Any medical issues that may impact on the decision making 
• 3. Photos of the problem taken on a smartphone and sent to the team by the route determined by that unit. 

Once the appropriate information is received 

• 1. Advice should be given over the phone (+/- video calling) where possible 
• 2. Arrangements made to see patients where necessary (see justifiable issues below) 

Please refer to your local area arrangements regarding emergency care. This may be local or in secondary care units BOS Emergencies protocol v5 25th March 2020 

Common ‘emergency’ brace problems and solutions: 

If you are an orthodontic patient following the advice contained here PLEASE where possible contact your orthodontic HCP first to ensure that you are carrying out procedures safely and not preducing other aspects of your orthodontic appliance 

If you are a dental health practitioner seeing a patient please consider these guides for safe practice 

• o Full PPE is advised (see link here) 
• o Patients only attend at the time of their appointment 
• o Patients must not bring other family members with them 
• o Patients should wait outside the practice until their appointment can commence 
• o Patients should leave the unit immediately after their appointment 
• o Units must make all emergency appointments long enough to ensure there is adequate time for cleaning and management of clinical waste 
• o Patients should wash their hands or use of hand sanitiser on entering the unit. 

Wires Digging in 

Home advice ○ If a thin wire, it may be possible for the patient or family member to use tweezers to replace wire in the tube/band or tweezers and a nail clipper/scissors to shorten the long end 

○ It may be that a thin wire is the correct size but may have rotated round the teeth so that it is short on one side and long on the other. Using tweezers a pencil with a rubber on the end or a teaspoon, it may be possible to push the wire back round to prevent the long end digging in. 

○ If the wire is very thick and stiff (discuss with your HCP) it may not be possible to cut the wire with home instruments. If this is the case it may be necessary to cover the wire to prevent it being sharp. Relief wax/silicone may be sent to you or you can buy it online (Orthodontic Wax) Failing that using a wax covering from hard cheese (baby-bell, cheddar), Blue tack or even chewing gum may help 

● In clinic advice ○ Trim and adjust as simply as possible. (Distal end cutter if available – wire cutters and forceps to hold the loose end if not) 

Broken Bonded Retainers 

• Home advice ○ Push wire back down towards the tooth as much as possible. (Fingers or tweezers) 
• Cover with best medium available (Ortho wax, Cheese wax, Blu tack, chewing gum) 
• Cut the exposed unbonded wire using tweezers and nail clippers/scissors 
• Gently pull the wire to remove the whole retainer 
• Advise greater use of removable retainers if present 

BOS Emergencies protocol v5 25th March 2020 

• In clinic advice ○ Trim wire 
• Remove wire 
• Advise greater use of removable retainers if present 

Lost Retainers 

Home advice ○ Contact HPC – it may be that your unit has access to your final moulds and can make a new retainer remotely which can be posted out to you 

If it is not possible to get a replacement retainer you could consider ordering online a ‘boil in the bag’ (heat mouldable) gumshield to use and wear at night to reduce the risk of relapse (unwanted tooth movement). It should be noted that these appliances aren’t specifically designed to hold teeth in position so the manufacturer cannot be held responsible for any relapse. Please contact your HCP before investing in this strategy to ensure all aspects of this compromise for retention are understood 

In clinic advice ○ Do not visit unit 

Gold Chains 

If the gold chain was recently place and is now dangling down, it may be possible to cut it short. Gold is quite a soft metal and it may be possible to cut the chain using some nail scissors or nail clippers. Always hold the loose end with tweezers or similar item. If possible leave at least 5 links through the gum so it can used later by your orthodontic team 

If you have a none dissolvable coloured stitch discuss with your HPC about the feasibility of removing it at home using nail scissors to prevent a minor infection in the gum. 

In clinic advice ○ Do not visit unit 

Orthognathic Post-Op 

• ● Home advice ○ Discuss with your local hospital team your specific concern/problems for the best advice 
• ○ Consult yourjawsrugery.com for general post op advice (Here) 
• ○ Stop or reduce post surgery elastic wear as advised by your HPC. 
• ● In clinic advice ○ Ensure patient doesn’t have acute infection/swelling/infected plate. 
• ○ Stop or reduce post op elastic wear as you see fit. 
• ○ Reassure patient about continuity of treatment at next visit. 
• ○ Do not provide any active orthodontic tooth movement 

Aligner therapy 

Home advice 

BOS Emergencies protocol v5 25th March 2020 

• ○ If your current aligner is in good order keep wearing it as much as possible 
• ○ If your current aligner is broken or ill fitting, step back to your previous aligner 
• ○ If neither option is open to you, ring you HPC for advice ■ It may be possible to have a new aligner at the correct stage made for you and sent out to you 

Or with advice from your HPC a ‘boil in the bag’ (heat mouldable) gumshield to use and wear at night to reduce the risk of relapse (unwanted tooth movement). It should be noted that these appliances aren’t specifically designed to hold teeth in position so the manufacturer cannot be held responsible for any relapse. Please contact your HCP before investing in this strategy to ensure all aspects of this compromise for retention are understood 

● In clinic advice ○ Do not visit unit 

Bracket off 

This is not urgent unless it is causing trauma to the soft tissues. 

• Home advice ○ It may be possible your HPC can guide the you on how to remove the bracket from the wire via video if it is causing trauma. 
• It may be the possible to leave the bracket if it is not causing any problems at present. Consider contacting your HPC for advice. 
• In clinic advice ○ Do not visit unit 

Elastic Bands 

• Home advice ○ At this time if you run low or out of elastics your HPC may either send you a some more out via the post or advice cessation of wear. 
• In clinic advice ○ Do not visit unit 

Band off 

• Home advice ○ If band is very loose your HPC may be able to talk you through removal of the band and trimming of the wire depending upon your stage of treatment. 
• It may also be also be the case your HPC advises you to leave the band in place. If this occurs please ensure you adhere to good oral hygiene and a low sugar diet to prevent decay under the band and around your tooth. 
• In clinic advice ○ Remove band and trim any excess wire to the distal aspect of the last back tooth with a bracket or band on. 

Band off Quadhelixes, RME, TPA +/- Nance 

Home advice ○ Discuss with your HPC about the nature of the looseness and take advice accordingly. 

BOS Emergencies protocol v5 25th March 2020 

• Push band back onto tooth if it will locate and ensure you adhere to good oral hygiene and a low sugar diet to prevent decay under the band and around your tooth. 
• Remove appliance 
• In clinic advice 

Removable/Functional appliances 

• Home advice 
• Check for comfort and retention 
• If unsure about how much to continue to wear the appliance discuss with your HPC 
• If fractured or ill fitting do not wear the appliance 
• In clinic advice o Do not visit unit 

Separators 

• Home advice 
• These should be removed at the earliest opportunity – Attempt removal with end of safety pin, small paper clip or wooden tooth pick 
  • • In clinic advice o Do not visit unit 

Lost module(s) 

• Home advice 
• No action required – try and make wire where the module has been lost secure with dental wax, cheese wax or blu tack and chewing gum 
• In clinic advice ○ Do not visit unit 

Temporary anchorage Devices TADS 

1. Home advice 
2. HPC may assist you in removing and springs or elastic chain moving the teeth 
3. In clinic advice 
4. Remove 

Headgear 

• Home advice 
• Stop wear 
• In clinic advice ○ Do not visit unit 

Lost spring 

1. Home advice 
2. No treatment required 
   • • In clinic advice o Do not visit unit 

Fractured/Frayed power chain BOS Emergencies protocol v5 25th March 2020 

• Home advice o Accept situation– most powerchain will denature in 4-6 weeks and become passive 
• Remove powerchain with tweezers if necessary 
• Cut fayed end as short as possible to improve comfort 
• In clinic advice o Do not visit unit 

• Exposed end of wire tie – long ligature or short ligature. 

• • Home advice o Re-tuck sharp end under wire/bracket using tea spoon or tweezers 
• o Remove wire if broken with tweezers if possible 
• o Cut fayed end as short as possible to improve comfort with nail cutters or scissors 
• o Cover for comfort using Ortho wax, Cheese wax, Blu tack, chewing gum 
• • In clinic advice o Do not visit unit