{"id":15430,"date":"2020-04-02T11:41:34","date_gmt":"2020-04-02T16:41:34","guid":{"rendered":"https:\/\/www.aae.org\/specialty\/?page_id=15430"},"modified":"2021-12-10T09:56:13","modified_gmt":"2021-12-10T15:56:13","slug":"characteristics-of-endodontic-emergencies-during-covid-19-outbreak-in-wuhan","status":"publish","type":"page","link":"https:\/\/www.aae.org\/specialty\/clinical-resources\/characteristics-of-endodontic-emergencies-during-covid-19-outbreak-in-wuhan\/","title":{"rendered":"Characteristics of Endodontic Emergencies during COVID-19 Outbreak in Wuhan"},"content":{"rendered":"\r\n

Jingjing Yu, DDS1<\/sup>, Tian Zhang2<\/sup>, Dan Zhao, DDS, PhD1,3<\/sup>, Markus Haapasalo, DDS, PhD2<\/sup>, Ya Shen, DDS, PhD2<\/sup><\/p>\r\n

1<\/sup>The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China; 2<\/sup>Division of Endodontics, Department of Oral Biological & Medical Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada; 3<\/sup>General and Emergency Department, School and Hospital of Stomatology, Wuhan University, Wuhan, China.<\/p>\r\n

Journal of Endodontics<\/em> 46(6): in press, June 2020<\/p>\r\n

Acknowledgement: The authors deny any conflicts of interest.<\/em> This work was partly supported by grants from the National Natural Science Foundation of China (grant no. 81901000).<\/p>\r\n

Corresponding author:<\/strong>
Dr. Dan Zhao
State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine Ministry of Education
School and Hospital of Stomatology
Wuhan University
237 Luoyu Road
Wuhan 430079, P.R. China.
Email: wb003211@whu.edu.cn<\/a><\/p>\r\n

Abstract:<\/h3>\r\n

Introduction<\/strong>: In late 2019 an outbreak of a new coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in Wuhan, China. A great percentage of patients with this disease developed symptoms of dry cough, malaise and high fever. During this time several patients requiring assessment and treatment of endodontic emergencies were directed to the School and Hospital of Stomatology at Wuhan University (WHUSS). Here, we examined the characteristics of these patients. Methods<\/strong>: A total of 96 patients with mean age of 42.24 \u00b1 18.32 years visited General and Emergency Department of WHUSS due to endodontic emergencies during the peak period of February 22 to March 2, 2020. Patient information was collected and organized by date of visit, gender, age, systemic diseases history. Body temperature was measured and acquired for each patient, a coronavirus disease 2019 (COVID-19) epidemiological investigation questionnaire was given to each patient, endodontic diagnosis determined for the offending tooth and verbal numerical rating scale (VNRS) was used to record pain levels. Results<\/strong>: Of total patient visits during this period, 50.26% of visits were for endodontic treatment. No patients had fever (>37.2\u2103). One patient with a confirmed COVID-19 history was admitted after recovery. Three admitted patients had been exposed to confirmed or suspected COVID-19 patients. Twelve admitted patients (12.5%) with mean age of 62.42 \u00b1 13.77 years had a history of systemic diseases. The most common age group for endodontic emergencies was 45-64 years (30.21%) and patients of this group showed significantly higher mean VNRS score compared with that of the 6-19 years group and 20-34 years group (p<0.05). The majority of endodontic emergency diagnosis was diseases of symptomatic irreversible pulpitis (53.10%). Patients who were diagnosed with symptomatic irreversible pulpitis, symptomatic apical periodontitis and acute apical abscess showed significantly higher mean VNRS Score than that of other groups (p<0.05). Conclusion<\/strong>: Endodontic emergencies, with symptomatic irreversible pulpitis being the most common, consist of a much higher proportion of dental emergencies in a COVID-19 high risk area than normally. Vital pulp therapy can advantageously reduce treatment time resulting in reduced risk of infection for vital pulp cases. Rubber dam, personal protective equipment and patient screening are of great importance during the COVID-19 outbreak in protecting clinicians.<\/p>\r\n

Keywords<\/h5>\r\n

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COVID-19 outbreak; endodontic emergency; epidemiological investigation; VAS score; vital pulp therapy<\/p>\r\n

Introduction<\/h5>\r\n

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Cases of the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), the causative agent of the coronavirus disease 2019 (COVID-19) disease, were first reported in Wuhan, Hubei, China in December 20191<\/sup>. Ever since the emergence of these first cases, COVID-19 has become a public health crisis globally. As of March 2, 2020, National Health Commission of China reported 49,426 cumulative cases and 2,251 deaths in the city of Wuhan2<\/sup>. To halt transmission, Hubei Province activated its Level 2 response to public health emergencies on January 23, 2020, and the city of Wuhan with a population exceeding 11 million was under lockdown and remains under lockdown at present3-5<\/sup>. In consideration of the risk dental treatment may pose during the outbreak, the Hubei Province government suspended regular dental treatments allowing only emergency treatments4<\/sup>. Endodontic infections can cause serious pain6<\/sup>, and endodontic emergencies are considered to be an important category of dental emergencies7<\/sup>. From January 24, 2020, all patients receiving emergency dental treatment were directed to the School and Hospital of Stomatology, Wuhan University\u2019s (WHUSS) General and Emergency Department, which remained the only hospital open within Wuhan for emergency dental treatments until March 2, 2020. Since February 22, 2020, the General and Emergency Department began administering a COVID-19 epidemiological investigation questionnaire, which was of particular interest for the purposes of this study. This study aimed to analyze the characteristics of endodontic emergency patients at WHUSS between February 22 and March 2, 2020 and is the first descriptive study that examines endodontic emergency dental patients at the epicenter of the COVID-19 outbreak. Here, we also provide suggestions for endodontic practice and infection control strategies based on these novel observations.<\/p>\r\n

Materials and Methods<\/h5>\r\n

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Selection of Subjects<\/h4>\r\n

The study has been approved by the Ethics Committee of the School and Hospital of Stomatology at Wuhan University (project number: 2020B08). Patients who visited the General and Emergency Department at WHUSS due to endodontic emergencies from February 22 to March 2, 2020 were reviewed. Body temperature was acquired for each patient, and a COVID-19 epidemiological questionnaire was given before dental treatment.<\/p>\r\n

The questionnaire consisted of the following four questions:<\/p>\r\n

    \r\n
  1. Are you a confirmed or suspected COVID-19 patient who has recovered after treatment?<\/li>\r\n
  2. Are you a confirmed or suspected COVID-19 patient with no symptoms?<\/li>\r\n
  3. Have you recently been showing COVID-19 symptoms? (optional) Such as: fever, cough, fatigue, vomiting, et cetera.<\/li>\r\n
  4. Have you been in contact with confirmed or suspected COVID-19 patients recently?<\/li>\r\n<\/ol>\r\n

    Patients were asked to describe their level of pain using the verbal numerical rating scale (VNRS)6<\/sup>.<\/p>\r\n

    Only patients that had answered the questionnaire, described their level of pain, had their body temperature measured and received an endodontic diagnosis were included in this study.<\/p>\r\n

    Evaluations of Subjects<\/h4>\r\n

    Patient information such as date of visit, gender, age, systemic disease history and VNRS score were included in the study. Acquired body temperature and the COVID-19 epidemiological investigation questionnaires were reviewed. Diagnoses were based on the recommended consensus by the American Board of Endodontics and American Association of Endodontics8<\/sup> . The number of total patient visits and type of visits at the General and Emergency Department, WHUSS during the dates studied were compared to past statistics corresponding to these same dates in 2018 and 2019.<\/p>\r\n

    Statistical Method<\/h4>\r\n

    The characteristics of patients with endodontic emergency were stratified by subgroups including sex, age group and diagnosis by multivariate Poisson regression. Independent sample t-test or one-way analysis of variance (ANOVA) was performed to compare mean VNRS score. VNRS scores with p set to < 0.05 for statistical significance. All statistical analyses were performed with the SPSS 20.0 software (IBM Corp, Armonk, NY).<\/p>\r\n

    Results<\/h5>\r\n

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    Demographic patient information is shown in Fig. 1 along with cumulative COVID-19 cases in Wuhan2<\/sup>. The percentage (50.26%) of endodontic emergency patients (n=96) among all dental emergency patients (n=191) is shown in Fig. 2, as well as that at the corresponding period in 2019 (13.47%, 141\/1047) and 2018 (17.96%, 178\/991). Endodontic emergency patients that were included in the study had a mean age of 42.24 \u00b1 18.32 years, of which 52.08% of patients (n=50\/96) were male and 47.92% (n=46\/96) were female. Twelve admitted patients with a mean age of 62.42 \u00b1 13.77 years had a history of systemic diseases, including diabetes, cardiovascular disease, hypertension. Fever (>37.2\u00b0C) was not detected in any of the patients presented due to endodontic emergencies and the results of the COVID-19 questionnaires are presented in Table 1. One admitted patient (1.04%, 1\/96) had a confirmed COVID-19 history and was recovering at the time of treatment. Three admitted patients (3.13%, 3\/96) had history of exposure to confirmed or suspected COVID-19 patients recently. Two of the three were health care workers, and one of which was the child of a suspected COVID-19 positive patient. No patients reported history of confirmed or suspected asymptomatic COVID-19 or showing symptoms of COVID-19.<\/p>\r\n

    VNRS scores by gender, age, and endodontic emergencies are summarized in Table 2. Patients in the 45-64 years group accounted for 30.02% of total endodontic emergency patients and showed significantly higher VNRS scores compared to those of patients in the 6-19 years group and 20-34 years group (p<0.05). Among the patient population in this study, 97.90% were first-visit patients and the most common endodontic emergency diagnosis was symptomatic irreversible pulpitis (53.1% or 51\/96 patients). In addition, patients with symptomatic irreversible pulpitis, symptomatic apical periodontitis and acute apical abscess had significantly higher reported VNRS scores than any other diagnosis (p<0.05).<\/p>\r\n

    Discussion<\/h5>\r\n

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    The total number of patients attending General and Emergency Department at WHUSS during the COVID-19 outbreak (n=191) in our study was 18.24% of that of corresponding periods in 2019 (n=1047) and 19.27% of that in 2018 (n=991). These results are consistent with that of a previous study9<\/sup> that examined patient visits at the Prince Philip Dental Hospital in Hong Kong 10 working days after the severe acute respiratory syndrome (SARS) outbreak in 2003, during which visits dropped to less than one-fifth. The percentage of endodontic emergency patients has increased from 13.47% in 2019, and 17.96% in 2018, to 50.26% during the COVID-19 outbreak in the study. This observed increase could be accounted for by the closing of other facilities that were available to treat endodontic patients under normal operations and possibly by the reduction of trauma as an indirect result of the lockdown. Reduction of outdoor activities by the lockdown may consequently result in a decrease in trauma occurrences, which was reportedly the chief complaint among patients who visited the dental emergency room of a dental hospital in Korea10<\/sup>. These results highlight patient needs for endodontic treatment even under public health emergencies.<\/p>\r\n

    In this study, there was nearly the same ratio of male to female patients for both endodontic emergency patients (1.1:1) and all dental emergency patients (1.2:1), in contrast to other studies11-15<\/sup> that have shown a greater percentage of male patients presenting with dental emergencies. However, this discrepancy may be due to the higher proportion of endodontic emergency patients in our patient population. The largest age group for endodontic emergencies was 45-64 years (30.21%, 29\/96) in our study. Importantly, older age and the existence of underlying comorbidities are associated with poorer COVID-19 prognosis4, 16, 17<\/sup>. Since patients older than 65 years represented approximately 15% of all patients, care should be exercised to avoid cross contamination.<\/p>\r\n

    Patient screening was crucial during the SARS epidemic in 2002 and 200318<\/sup>. An important tool in patient screening is the use of disease-specific questionnaires, which can differ depending on the location at which they are employed, for example, epicenter versus other sites. In this study, four patients with a previous COVID-19 history or possible COVID-19 cases were identified using the questionnaire. Fever was reported to be the most common clinical symptom (98%) for 41 patients diagnosed with COVID-19 in a previous study19<\/sup>. No patient with fever presented to the WHUSS due to endodontic emergencies\u201d. Conversely, a patient with pyogenic osteomyelitis of the jaw was found to have fever (>37.2\u2103), but tested negative for COVID-19 by a series of diagnostic tests. Notably, several infections of the oral cavity could present with fever that could confound the diagnosis of COVID-19; thus fever alone should not be the only sign and symptom of COVID-19 to be evaluated and oral disease needs to be accurately diagnosed. The diagnosis of COVID-19 is currently based on a combination of epidemiologic information, clinical symptoms, chest CT imaging findings, and laboratory tests such as on RT-PCR respiratory tract specimens4<\/sup>. Sabino-Silva et al.20<\/sup> has raised important questions about the role saliva plays in the human-to-human transmission of diseases, in particular respiratory coronaviruses21, 22<\/sup>.<\/p>\r\n

    The incubation period of COVID-19 has been estimated to be between 2 to 14 days5<\/sup>. It has been shown that patients with no symptoms or during incubation periods may have the potential to infect others5<\/sup>. Positive RT-PCR test results have been reported in recovered patients23<\/sup>. Endodontists should take appropriate measures to stay safe. During the COVID-19 outbreak, dentists in WUHSS were equipped with disposable N95 masks, gloves, cap, shoe cover, face shield, and gowns4<\/sup>. From February 22, 2020, patients with fever, or who had answered \u201cyes\u201d to any of four questions on the questionnaire, or needing dental procedures producing droplets and\/or aerosols were required to undergo examination and treatment in an isolated clinic room with dentists equipped with protective suit instead of gowns4<\/sup>. To date, no cases of COVID-19 were reported among the twenty-six working staff of the General and Emergency Department at WHUSS working during the COVID-19 outbreak. RT-PCR findings for all working staff came back negative on March 24, 2020. Before the beginning of the study, nine working staff at the hospital level have been confirmed to have COVID-19, including three doctors, three nurses, two administrative staff, and one postgraduate student4<\/sup>. This suggests that the safety precautions and screening measures enforced since February 22, 2020, were effective in protecting working staff.<\/p>\r\n

    Symptomatic irreversible pulpitis was the most common endodontic emergency, with significant high VNRS score in our study. Treatments for endodontic emergency were challenging during the COVID-19 outbreak, since inhalation of airborne particles and aerosols produced during dental procedures on patients with COVID-19 could potentially expose dentists to the virus20<\/sup>, thus making them high-risk procedures. Reducing treatment time and exposure control are two ways the risk of infection for endodontic treatment could be reduced. For vital pulp cases such as pulpitis, vital pulp therapy including pulpotomy or pulp capping might be helpful in terms of shortening treatment time. Pulpotomy has been reported to reduce pain symptoms in nearly 90% of dental emergency patients 1 day after treatment24<\/sup>. Partial pulpotomy using mineral trioxide aggregate (MTA) sustained a good success rate (85%) over 3-year follow-ups in mature permanent teeth clinically diagnosed with irreversible pulpitis25<\/sup> and full pulpotomy using MTA demonstrated 92.7% success rate at 3-year follow-up for caries exposed pulps in mature permanent molar teeth26<\/sup>. Direct pulp capping with MTA showed a cumulative survival rate of 85% in adult molars with carious pulpal exposure at 36\u00a0months27<\/sup>. For cases that required root canal treatments, cone-beam computed tomography (CBCT) and single file systems should be considered. Besides the advantages of detecting root canal location and configuration28<\/sup>, CBCT examination could avoid nausea or vomiting for patients that may occur during intraoral x-ray examination and prevent exposure to patients\u2019 oral cavity4<\/sup>. During root canal preparation, single file nickel-titanium systems could be used to save working time29<\/sup>, as well as prevent the risk of re-sterilization. For any treatment that produces droplets and\/or aerosols, Dr. Hargreaves\u2019 group30<\/sup> suggested a number of preventative measures, such as the use of rubber dams. It has been reported that up to 70% airborne particles could be reduced around a 3-foot diameter of the operational field when a rubber dam was used31<\/sup>. In addition, rubber dam is not only able to limit the diffusion of the aerosol, but is also likely to dramatically reduce or even eliminate the presence of salivary components in the aerosol.<\/p>\r\n

    Only five cases of traumatic dental injury including two cases of \u201ccomplicated crown fracture\u201d and three cases of \u201cdislocation of tooth,\u201d respectively, were diagnosed in our study. Two patients made a subsequent visit for the completion of their root canal treatments. An online platform for patient consultations by the WHUSS was made available starting February 3, 20204<\/sup>. It was reported that more than 1,600 patients had used this consultation platform, and only dental emergency cases were suggested for treatment at the hospital4<\/sup>.<\/p>\r\n

    In addition to providing endodontic treatment, endodontists should pay attention to patients\u2019 psychological health during the COVID-19 outbreak32<\/sup>. Public health emergencies may negatively impact individuals\u2019 mental health33<\/sup>. For instance, one patient in our study had a diagnosis of reversible pulpitis with dentin hypersensitivity had a high VNRS score of 8. She demonstrated extreme anxiety and fear toward gaining a fever as a result of oral disease inflammation. During COVID-19 outbreak period, patients may suffer from psychological stress, endodontists should not only focus on the treatments of patients\u2019 endodontic diseases, but also their psychological state at times of emergency.<\/p>\r\n

    In conclusion, endodontic emergencies consist of a much higher portion of dental emergencies in a COVID-19 high risk area than normally. Reducing treatment time and exposure control are two ways to significantly reduce the risk of SARS-CoV-2 virus spreading during endodontic treatment. Vital pulp therapy has the advantage of shortening the treatment time. Rubber dam, personal protective equipment and patient screening are of great importance during the COVID-19 outbreak in protecting clinicians. Dentists should focus not only on the dental treatment but also patients\u2019 psychological status during public health emergencies.<\/p>\r\n

    References<\/h5>\r\n

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      \r\n
    1. Zhu N, Zhang D, Wang D, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.<\/li>\r\n
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    22. Liu L, Wei Q, Alvarez X, et al. Epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques. J Virol 2011;85:4025-30.<\/li>\r\n
    23. Lan L, Xu D, Ye G, et al. Positive RT-PCR test results in patients recovered from COVID-19. JAMA 2020;in press.<\/li>\r\n
    24. Hasselgren G, Reit C. Emergency pulpotomy: Pain relieving effect with and without the use of sedative dressings. J Endod 1989;15:254-6.<\/li>\r\n
    25. Taha NA, Khazali MA. Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: A randomized clinical trial. J Endod 2017;43:1417-21.<\/li>\r\n
    26. Taha NA, Ahmad MB, Ghanim A. Assessment of Mineral Trioxide Aggregate pulpotomy in mature permanent teeth with carious exposures. Int Endod J 2017;50:117-25.<\/li>\r\n
    27. Kundzina R, Stangvaltaite L, Eriksen HM, Kerosuo E. Capping carious exposures in adults: A randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide. Int Endod J 2017;50:924-32.<\/li>\r\n
    28. Fan B, Ye W, Xie E, Wu H, Gutmann JL. Three-dimensional morphological analysis of C-shaped canals in mandibular first premolars in a Chinese population. Int Endod J 2012;45:1035-41.<\/li>\r\n
    29. Kuzekanani M. Nickel-titanium rotary instruments: Development of the single-file systems. J Int Soc Prev Community Dent 2018;8:386-90.<\/li>\r\n
    30. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:in press.<\/li>\r\n
    31. Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child 1989;56:442-4.<\/li>\r\n
    32. Qu X, Zhou X. Psychological intervention in oral patients in novel coronavirus pneumonia outbreak period. Chin J Stomatol 2020;55:in press.<\/li>\r\n
    33. Davidson JR, McFarlane AC. The extent and impact of mental health problems after disaster. J Clin Psychiatry 2006;67 Suppl 2:9-14.<\/li>\r\n
    34. \u00a0<\/li>\r\n<\/ol>\r\n
      Table 1<\/h5>\r\n

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      Table 1.<\/strong> Results of COVID-19 Epidemiological Investigation Questionnaires<\/p>\r\n

      \"Results<\/a>

      Click to enlarge.<\/p><\/div>\r\n

      Table 2<\/h5>\r\n

      Expand<\/i><\/a><\/p>\r\n

      Table 2.<\/strong> VAS Scores (Mean \u00b1 S.D.) in Different Gender, Age Groups, and Endodontic Emergency Diagnoses at 10 Working Days during COVID-19 Outbreak<\/p>\r\n

      \"VAS<\/a>

      Click to enlarge.<\/p><\/div>\r\n

      Figure 1<\/h5>\r\n

      Expand<\/i><\/a><\/p>\r\n

      Figure 1.<\/strong> Demographic information of patients who had visited the WHUSS due to dental emergencies and cumulative number of confirmed cases with coronavirus disease 2019 (COVID-19) in the city of Wuhan from February 22, to March 2, 2020.<\/p>\r\n

      \"Demographics<\/a>

      Click to enlarge.<\/p><\/div>\r\n

      Figure 2<\/h5>\r\n

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      Figure 2.<\/strong> Dental emergency patients at from February 22, 2020 to March 2, 2020 and in 2019 and 2018. (a) Total dental emergency visits by year and by type of visit. (b) Proportion of patients with endodontic emergency, including endo first visit and endo subsequent visit.<\/p>\r\n

      \"Dental<\/a>

      Click to enlarge<\/p><\/div>\r\n","protected":false},"excerpt":{"rendered":"

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