Dealing with COVID-19 in the Dental Department of the Montreal Jewish Hospital

• All elective procedures should be terminated.
• Each dentist should be responsible for evaluating emergencies in their patient population.
• A list of key emergencies has been identified:

• • Evidence of dental trauma
  • Infection
  • Significant or prolonged bleeding
  • Acute uncontrolled pain

• Dental treatment that may be medically required as a pre-intervention to surgery needed in the short term
• If a patient identifies as Covid-19 positive, or is presumed Covid-19 positive, or if the management of the patient is unsuccessful in the community, then the dentist should refer the patient to a designated emergency care site.
• If a patient can be managed pharmacologically, the dentist should do so and follow up over time.

• The dental department has developed a flow sheet for ER physicians so that they can decide if a patient requires emergency dental care or not.
• The ER physician should contact dentistry if:

• • There is evidence of dentoalveolar trauma
  • Facial fracture
  • Facial abscess secondary to dental infection
  • Dislocated temporomandibular joint
  • Uncontrolled bleeding

• If the case is less serious, the ER physician is requested to try to address the emergency on their own.
• In addition to referrals from the ER, the dental department also receives emergency referrals directly from dental offices in the community. To facilitate this process, the dental department has produced a questionnaire template so that dentists can share important information on their patients, and thereby optimize the consult.

• We are still paying attention to medically compromised patients.
• The big issue is with aerosol generating procedures
• Operating on a case by case basis
• Good clinical judgement is important. If you have confidence that the patient is not Covid positive and that they have been self-isolating, then that patient can be addressed in a different way if they need an essential treatment.

• The clinic entrance is locked.
• If a patient arrives at the clinic, they have already passed through a security check at the hospital entrance.
• Patients are seen by appointment where possible
• Management of patients is taking much longer than usual. Instead of 18-20 patients a day it’s more like 6-8 patients a day.
• The patient goes through a thorough questionnaire regarding their history.
• The clinic evaluates if an intervention is necessary, or whether the patient can be managed pharmacologically or otherwise.

Not at this time. Despite best efforts there is a great demand for IPC and engineers within the hospital.

• One patient at a time is allowed in the waiting room. Only the person affected. If they have someone accompanying them, they must wait in the corridor.
• Every patient is required to wear a mask and wash their hands.

We have an oral and maxillofacial surgeon and support staff.

• We have not compromised our attitude towards the prescription of opioids
• A more liberal approach is being taken in the use of antibiotics. Although the first approach would be to remove the cause of infection, there is an increased reliance on antibiotics to avoid procedure.

• One operatory is being used at present.
• Operating on a skeleton staff so as to protect team from infection. If there are too many people on site and there is an unexpected situation, you could be depleted of staff very quickly.

• We have a number of staff we can count on who are prepared to come in.
• Another issue is staff being away from the hospital for a period of time who may not be getting all the information regarding risk. There is a lot of information and a lot of uncertainty amongst personnel.

We are assuming that we are following the appropriate measures. Just the fact that we perform a procedure on a Covid positive patient does not require us to be away for a 14 day period.

• We have had to hide the PPE because masks were disappearing.
• We developed our own intra-oral mouthwash which is hydrogen peroxide based.
• For the most part the operatory looks the same, except the area to dispose of PPE is a little closer to hand.

• It has a door that is closed and a window that can be left open.
• It has been suggested that, in the absence of a negative pressure room, you have a well-ventilated room.

• A combined face mask and visor – Level 3
• Head covering
• Yellow plastic gown
• No N95 masks. We would have to request them and we have not found them necessary.

Once the patient leaves, what is the protocol for the disposal of PPE?

• All PPE is removed inside the operatory to minimize the space we are occupying.
• Wash and clean yourself before leaving the operatory.

• Not doing any aerosol generating procedures
• Not using high speed hand piece
• Not using 3-in-1 syringe
• Not using cavitrons
• But you still have to evaluate the circumstances on a case by case basis. Where patient history is reliable, exceptions can be made. Especially if a conservative approach has already been tried and the emergency needs to readdressed.

• There are no particular new measures.
• To my knowledge we are using the same sanitizers as usual.

• We want to make certain the room that is being used is completely clean.
• Since there are no aerosol generating procedures done, it’s not as strict in terms of waiting time. Once the room is adequately cleaned, that should be sufficient.
• If there was an aerosol generating procedure performed you’d have to wait about 3 hours.
• Generally booking one patient per hour.

Ordinarily would follow up but because of the volume of activity and the limited staff on the ground, really only directing patient to get back in touch if there are complications.

We still don’t know when the peak is going to occur. Since we haven’t hit the peak, we’re not looking at the other side of the mountain yet.

It is important for all dentists to participate in this whole process. They have valuable information on their patients and must play a role in being available to triage emergencies and direct patients to the designated emergency care sites.