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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 4-10

Institutional approach for the management of patients in orthodontic office during COVID-19 pandemic

1 Department of Orthodontics and Dentofacial Orthopedics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Conservative and Endodontics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Submission01-Jun-2020
Date of Decision22-Jun-2020
Date of Acceptance25-Jun-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Lakshman Chowdary Basam
Department of Orthodontics and Dentofacial Orthopedics, Sibar Institute of Dental Sciences, Takkellapadu, Guntur - 522 509, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sidj.sidj_21_20

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COVID-19, the current pandemic has created a fearful scenario for health-care professionals. Being the frontline warriors, we need to have sound knowledge about the transmission of SARS-CoV-2 and protect ourselves during this pandemic. According to the published literature, ins pite of following possible precautionary measures against transmission of disease, there is an increased number of infected health-care workers with COVID-19. The purpose of this review is to provide the information for the postgraduates, faculties, orthodontic practitioners, and to some extent, guidance on possible transmission routes, patient assessment, laboratory investigations, various radiographic imaging techniques, proper disinfectant protocol in handling the patients, orthodontic emergency management, and elective orthodontic treatment.

Keywords: Coronavirus, COVID-19, infection control, orthodontic practice management, orthodontics, SARS-CoV-2, transmission

How to cite this article:
Basam LC, Peddu R, Tamineedi S, Basam RC. Institutional approach for the management of patients in orthodontic office during COVID-19 pandemic. Saint Int Dent J 2020;4:4-10

How to cite this URL:
Basam LC, Peddu R, Tamineedi S, Basam RC. Institutional approach for the management of patients in orthodontic office during COVID-19 pandemic. Saint Int Dent J [serial online] 2020 [cited 2022 Jan 24];4:4-10. Available from: https://www.sidj.org/text.asp?2020/4/1/4/291029

  Introduction Top

Postgraduate students and faculty inside the orthodontic profession during the COVID-19 pandemic are in a major dilemma. It may be a big undertaking in attempting to provide the quality treatment these days. The attitude and knowledge about the personal-protective protocol against the dreadful diseases are mandatory. Although in delivering quality care in the orthodontic specialty, it is a necessary to follow the standards all the time due to pandemic, it dictates that one should have sound knowledge of the precautions to be taken in the management of orthodontic emergency patients during and after the pandemic. In orthodontic practice, COVID-19 transmission routes are mostly through airborne spread,[1],[2] contact spread, and contaminated surface spread.[3],[4] There is a greater risk of exposure in the institute while treating the patient by orthodontic through patients' salivary bioaerosols, splatter, droplets nuclei, and high-potential infectious aerosols while performing various procedures such as banding, polishing, and bracket debonding, causing a greater chance of spread of infection transmission.[1],[5],[6] The aim of the present review is to provide an orthodontics perspective for the postgraduates, faculty, orthodontic practitioners, and to some extent, guidance on possible transmission routes, patient assessment and laboratory investigations, various radiographic imaging techniques, a proper disinfectant protocol for patient handling, orthodontic emergency management, and elective treatment for orthodontic patients.

Patient assessment and laboratory investigations

  • Patients visiting the institute for emergency orthodontic management should not right way requested for laboratory investigations earlier to the completion of clinical history. Much of the signs of this pandemic illness are close to seasonal flu, and hence, the subsequent criteria have to be checked before treatment or sending the patient to COVID-19 designated hospitals
  • Usage of the preformed COVID-19-based standard questionnaires in the form of “Declaration/Screening form for the screening of Patients entering the institute, to identify and access the risk of COVID-19 infection [proposed [Table 1][7]
  • The patient should be given to fill out the declaration/screening form with detailed symptomology questionnaires such as the occurrence of intermittent cough, trouble swallowing inflammation through nostrils, discomfort in breathing, and occurrence of fever ≥37.8°C, [record by using noncontact infrared thermometers][8]
  • Information on any social contacts with persons traveling in extremely infected COVID-19 areas should be collected.
  • In cases of negative history, orthodontic treatment could be delivered as long as the adequate guidelines for infection control are executed [Chart 1]
  • In the case of recovered COVID-19-positive patients, the CDC (Center for Disease Control and Prevention) recommends that they can be treated for orthodontic emergencies if the following criteria are met:
  • If the history of COVID-19 positive at least 72 h have passed since recovery and at least 14 days have passed since initial symptoms; or
  • The patient should have at least two negative COVID-19 laboratory tests 24 h apart, has no fever (without the use of fever-reducing medications), including other improved symptoms.[9]
  • In the case of positive history or symptoms of the points mentioned above, a laboratory examination based on (pharyngeal swabs, sputum samples, and alveolar lavage) nucleic acid testing (real-time polymerase chain reaction) should be done [Chart 2].[10] After positive laboratory confirmation, it is recommended that not to perform treatment procedures, and he/she should be referred to COVID-19 designated centers for needful.[11],[12]
Table 1: Declaration/screening form For COVID-19 infection (From ios Guidelines for the ios members on COVID 19)

Click here to view

Depending on the severity of the emergency, treatment should be carried out in hospitals where airborne infection isolation rooms (AIIR) facilities with negative suction and air purifiers with high-efficiency particulate air filters are available along with the judicial use of personal-protective equipment (PPE) such that they will considerably limit the chance of transmission.[13],[14],[15],[16]

  Infection Control Measures Top

Hand hygiene

Orthodontic offices should keep an eye on stringent hand hygiene procedures to avoid coronavirus contamination.[17],[18] Orthodontists should not touch their personal belongings such as cell phones and also should avoid the contact of the nonclean hands with mouth, nose, and eyes throughout the orthodontic diagnosis and treatment process. Implement strict hand hygiene after the completion of orthodontic procedures using the seven-step handwashing procedures and should dispose of the PPE in a designated area as per sterilization and disinfection protocols for COVID-19.

Oral examination

Patients are encouraged to use povidone-iodine (1%), cetylpyridinium chloride (0.05% ~ 0.10%), or mouthwashes comprising essential oils to efficiently decrease microbes in the droplets and aerosols formed by dental procedures. Studies showed that the number of microorganisms is decreased after mouth rinsing.[17],[19]

Personal protective equipment

Orthodontic personnel and dental assistants should be appropriately trained and qualified to use the PPE kit appropriately and even to dispose of after treatment procedures. All the staff involved in the treatment procedures should wear protective masks, gloves, goggles, shields, and protective dressing, etc., and are intended to avoid the skin, mucous membranes of the mouth, nose, eyes, and other parts from contacting the patient's saliva, blood, or other body fluids.

According to the WHO's endorsements, if a patient who comes into contact with the coronavirus and in need of immediate orthodontic emergency treatment should use N95 masks or masks of the EU FFP2 standard.[20] Hands should be cleaned thoroughly before wearing a protective mask, and the mask must entirely shield the nose and chin. The mask time should not reach 4 h. The requirement for a complete PPE kit is follows:

  • Should protect from the droplet and contact
  • Should protect from the airborne infections
  • Should be comfortable for health-care workers.

Once the PPE is soiled with blood, body fluids, secretions, etc., in the course of the orthodontic diagnosis and treatment procedures, it should be changed or disinfected immediately. Do not touch the mask, goggles, protective mask, and nontreatment area with your bare hands throughout the treatment.

  Orthodontic Emergency Treatments during the Pandemic of Covid-19 Top

Orthodontic emergencies

Although orthodontic emergencies are relatively uncommon, they do occur. Most of the orthodontic complications are sensed to come back from 10% of patients seeking orthodontic therapy. If a patient makes an unexpected visit to the orthodontic department to complain of orthodontic appliance damage, it is necessary to adopt the COVID-19 preventive protocol and guidelines.

Orthodontic emergencies requiring an immediate visit to orthodontist

  • Major trauma to the facial structures while using extraoral appliances such as headgears: Major eye trauma resulting in swellings and face laceration due to improper handling of extraoral headgears component will require immediate consultation with the orthodontist, through video/audio call and attend the clinic after the triage questionnaires have been completed. Such intense orthodontic emergency should be managed, with correct COVID-19 protocols, and then, it is recommended to perform debridement, cleaning, and suture of the wound accompanied by suction to prevent splashing. For those with oral and maxillofacial complex injuries such as intraocular damage due to extraoral components of headgears, they should be referred to a surgeon under COVID-19-designated centers. As it is rare and does not endanger health, the surgery can be delayed following emergency management
  • Piece of myofunctional appliance/removable appliance-habit-breaking appliances/components of fixed appliances are swallowed: Accidentally ingested orthodontic appliance components typically pass out from the body without any obstruction. If the patient is not having any difficulty in respiration due to swallowing of the appliance component, he/she can feel free to contact an orthodontist in a video call and take necessary instructions from him. If the situation needs emergency care after intake of a damaged component of the appliance, it is safest to move him/her to a local COVID-19 accredited hospital to undergo prompt treatment in terms of missing appliance components and retrieval of the same.

Orthodontic emergencies that can be managed by patients

  • Orthodontic tooth pain/pain in temporomandibular joint (TMJ): The prevalence of pain is common soon after initial archwire placement, and orthodontists should suggest the pharmacological and nonpharmacological pain management methods (e.g., chewing gums.) for the alleviation of pain. TMJ discomfort following the insertion of myofunctional appliances is common and includes hot fermentation on the TMJ and its surrounding muscles to reduce the pain
  • Oral mucosal damage due to the fixed appliance component: It is recommended to use orthodontic wax and pinch it on to the fixed appliance component such as sharp edges of tiewings of a bracket, sharp end of the archwire, or impinging wire component of debonded fixed retainer, metallic ligature which irritates. A vinyl eraser, sterilized cotton swabs can be used to alter the sharp edge of the wire on the tooth surface away from the oral mucosa. A sterile fingernail trimmer can be used to detach the impinging archwire. Ulcerations of the mouth can be cured by topical application of local anesthetic gels using a sterile cotton swab directly on the ulcerated surface
  • Hanging springs and detached, severely irritating attachments
  • Using telecommunication, i.e., video calling, an orthodontist can guide the patient by using dental tape to tie the spring or attach the adjacent wire component firmly bonded to the tooth surface.

Damaged or improperly attached bite plane/transpalatal arch

  • On telecommunications, the orthodontist can direct the patient concerning hanging bands bite plane/transpalatal bar, and it may be positioned in its original position with the help of patients' guardians at home. In emergency treatment, the patient should visit the orthodontist to apprehend the risk concerned with orthodontic appliances, their component, and what precautions to take if accidentally swallowed.

Precautions to be taken in routine orthodontic treatments

Four-handed emergency management in orthodontics

The fundamental tenets of four-handed surgeries during the COVID-19 pandemic can help manage orthodontic emergencies, improve treatment qualities, work efficiency, and help prevent infections. The four-handed approach in orthodontics can aid diagnosis and different treatment procedures such as emergency band cementation, which involves isolation, can assist in reduce aerosol development and avoid infection transmission.

Another means of spreading microorganisms in an orthodontic office is through the water of dental unit water lines. Small (saliva ejector) and large volume evacuator may be used to reveal moisture. Both should not be use concomitantly as this will create a pressure difference between them and leads to the backflow of the saliva from water lines into the oral cavity, which was previously suctioned by the low-volume evacuator. It mostly occurs because a partial vortex created near the suction edge as the patient covers the mouth slightly with the suction inside. Therefore, it should be used sequentially, or only high-volume evacuator can be advised to avoid cross-contamination.[17]

In the four-handed approach, the use of micromotor is indicated; instead of using high-speed handpiece, if necessary, prefer those micromotors that come with anti-reflux valves or other anti-reflux designs. Such alternative designs considerably reduce the backflow of oral microbes into the water lines of the handpiece and dental device.[21]

  Radiographic Imaging Techniques in Orthodontics Top

In orthodontics, we use intraoral radiographic imaging and extraoral imaging for various procedures such as diagnosis, placement of temporary anchorage devices (TADs), etc., When using intraoral imaging techniques such as periapical radiographs, the film is positioned in the patient mouth. It can provoke the excess secretion of the patient's saliva. Some patients may have constricted dental arches, narrow mouths, and sensitive pharyngeal reflexes, which may result in uneasiness to the patient, producing nausea, coughing, and passing out droplets.[22] Therefore, during the COVID-19 epidemic, it is recommended that the situation be treated first without a radiograph; however, if the radiograph is required than extra-oral X-rays which includes orthopantomogram, lateral cephalogram, and cone-beam computer tomography should be given priority.

  Instructions for Postgraduate Students in Delivering of Appliances during Covid-19 Top

To prevent cross-infection and block transmission of pathogens through the oral cavity, an orthodontist should also advise postgraduate students to ensure hand hygiene, proper usage of instructions, and guidelines to maintain sterilization and disinfection procedures in the treatment of orthodontic emergencies and delivery of orthodontic appliances.

Parents should guide, supervise or assist children undergoing orthodontic treatment in developing good oral hygiene such as effective brushing and flossing, obsessive habits, and eating habits to avoid unnecessary breakage of orthodontic appliances, which can lead to specific orthodontic emergencies. Parents should teach, supervise children on how to protect themselves from any orthodontic emergencies or pain during COVID-19 by doing gargles to relieve symptoms, the use of chewing gums, and using nonpharmacological methods to manage orthodontic pain if necessary.

  Minor-Surgical Procedures during Covid-19 Top

For orthodontic emergency management, if required for orthodontic mini-implant or minimal surgical exposure under local anesthesia, caution should be taken not to spray the liquid rapidly, which may produce droplets mixed saliva that may contribute to infection transmission. Actions should be gentle during the operation to minimize the splashing of patients' blood and saliva. Before using TADs need to be sterilized with autoclave, and unused orthodontics mini-implants need to be resealed and sterilized to prevent cross-contamination.

  Documentation Photograph during Covid-19 Pandemic Top

Extra and intraoral photographs for documentation should be done with adequately disinfected (using 75%–90% alcohol) check retractors and intraoral mirrors following appropriate guidelines and instructions of COVID-19. This procedure shall be performed in a separate room with ambient light and airflow. While taking intraoral photographs in patients with a high gag reflex, it is advisable not to place an intraoral mirror deep in the oral cavity, which may increase gag reflex can lead to cough and sneezing.[22]

  Usage of Elastic Chains, Bonding Adhesives Top

Orthodontic materials such as elastic chains, intraoral elastics, extraoral elastics, elastic modules, bonding adhesives, are to be taken in required quantity for individual patient and to be maintained in separate pouches to minimize the cross infection. All these including the light curing units could be surface disinfected with 75%–90% alcohol before use.

  Disinfection of Orthodontic Impressions and Study Models Top

The orthodontic study models[23] have every risk of cross-infection if they are poured and processed from poorly disinfected dental impressions because these impressions may be contaminated with infected patient's body fluids resulting in the infection spreading from institute to wet laboratories.[24] In addition, models prepared from contaminated impressions of alginate results in the likelihood of transferring the virus to other noninfected institutes or labs.[25]

Etiqueting the grade (high, low, or intermediate) of disinfection on the covering of the impressions by the orthodontist is a suggested method to prevent infection before sending it to the lab.[26],[27] 0.5% sodium hypochlorite and iodophors can be used efficiently for the disinfection process of alginate impressions.[28]

  Sterilization and Disinfection of Dental Devices, Orthodontic Instruments, and Archwires Top

Used dental chairs, orthodontic instruments, archwires should sufficiently prepare and disinfect to avoid nosocomial contact transmission of COVID-19. For fabric masks that need to be reused, soak them with 500–1000 mg/L effective chlorine disinfectant, 62%–71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 30 min of exposure.[20] While treating suspicious or sick patients, it is recommended that the reusable orthodontic pliers and utensils should be stored in a chlorine-containing disinfectant container for 30 min at a concentration of 1000 mg/L.

  Infection Control and Precautionary Care at the Orthodontic Office Top

Orthodontic offices can postvisual alerts, in the form of posters at the entrance and waiting room to provide patients with information on suitable sanitization methods, benefits from a social distance, usage, and proper disposal of medical waste. The orthodontic offices should include qualified hand sanitizers (liquid, gel, or foam) with ethanol and should be instructed to apply hand cream/moisturizer after hand washing to intact skin. The orthodontic office can be treated with ultraviolet rays (blue light-heliotherapy) two times daily for a period of ½ h each time; to hold accurate air ventilation (plasma air sterilizers can also be used) in the operating room. Wet mopping can be done on the floor twice a day with 1000–2000 mg/L chlorinated disinfectant (such as sodium hypochlorite, calcium hypochlorite, and chlorine dioxide) each time; in cases where COVID-19 is suspected or confirmed, the ground and objects in the operating room are subjected for disinfection with a disinfectant containing chlorine at a concentration of 1000–2000 mg/L.

  Maintenance of Orthodontic Office Following Covid-19 Exposure Top

Once an infected patient has been relocated to the orthodontic office, the room entrance door must be closed with opening windows, switching off the air conditioners, and the infected room should not be used for any other purpose. All the areas in the office, including the waiting area, toilets where the suspected case has spent time are should be immediately disinfected; these procedures should be carried out by wearing proper PPE equipment after the procedure, the discarding of PPE as clinical waste is mandatory.

  Waste Management Top

The disposal of all medical wastes should be carried out under the “COVID-19 medical waste management regulations” in different steps, including the classification of waste, sealing, transport, dispose, and disinfection of the transport vehicle in medical institutions.” Medical waste, including PPE, must be disposed of very cautiously on patients diagnosed with or without 2019-nCov and with very precautions after the completion of orthodontic emergency treatment procedures in a double-layer anti-leakage yellow bag with gooseneck ligation. The COVID-19 medical waste management, transport tool, and storage place can be disinfected by 1000 mg/L chlorine-containing disinfection solution (such as sodium hypochlorite, calcium hypochlorite, and chlorine dioxide) as per the guidelines of disposable of COVID-19 medical waste. During and after the outbreak of COVID-19 pandemic orthodontic personnel, postgraduates, dental staff should enthusiastically learn new preventive and control measures to do the worthy job inpatient management, offering quality orthodontic treatment, personal protection throughout diagnosis and management that will support health care workers and patient safety from the transmission of infection.

  Conclusion Top

  • Orthodontic professionals should develop skills based on evidence-based infection control and treatment strategies to protect patients and follow high-standard health-care protocols. Health-care recommendations for the prevention of infections as issues by the state/central regulatory authorities shall be followed by orthodontic professionals, postgraduate students, and all staff during the management of orthodontic emergencies in the institute
  • The guidelines and protocol for monitoring the spread of COVID-19 should be followed during the management of orthodontic emergencies, preliminary examinations, aerosol procedures, fabrication of customized archwire modifications, disposal of debonded brackets, maintenance of removable appliances, disinfection of reusable orthodontic pliers and bonding adhesives, including disinfection of orthodontic office after treatment
  • It is necessary to be conscious that asymptomatic patients who visit the orthodontic clinic for emergency treatment often have a risk of becoming infected. It is an essential responsibility of health-care professionals to educate the patients to maintain social distancing along with quality personal hygiene for the prevention of disease spread.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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