Emergency Orthodontic Protocol in the context of Covid-19

• The information in this orthodontic protocol is for informational purposes only, and the patient should discuss it with the orthodontist in order to be guided to the correct course of action. Under no circumstances should patients wearing braces act without the supervision of the orthodontic specialist;
• In the context of Covid-19, please adhere strictly to the personal hygiene recommendations of the authorities, especially as it is known that SARS-COV-2 virus remains on surfaces, devices etc;
• Blunt objects such as box cutters, nail or tweezers can create serious injuries if not properly handled and can be a source of illness if not sufficiently or properly disinfected;
• DENT ESTET does not encourage or support approaches that could jeopardize patients' health.
   

In light of the latest evidence on the spread of Covid-19, to prevent disease transmission, we have created an emergency orthodontic protocol to deal with all orthodontic problems at home, except in situations that cannot be handled at home.

Most orthodontic appliances can be left in place for several months with no harm to the patient if they continue with regular care instructions:

• Strict oral hygiene - brushing 3 times a day with a standard toothbrush, followed by interdental brushing. As an addition, mouthwash once a day.
• Low-sugar diet. If possible, avoid all sugar-based snacks and drinks with ADDED SUGAR. Avoid fizzy drinks in particular.
• Avoid sticky and hard foods, which could break the arch wire or detach the bracket from the tooth.
   

Patients may call in the following weeks with pain or various other problems related to braces. Currently, the best advice is to avoid all dental procedures, except emergencies, to limit the spread of the disease throughout the community.

In case a patient has an orthodontic emergency, the following protocol has been created to help treat the patient while keeping the patient and staff members safe.

Upon receiving a phone call, it would be best to have a member of the orthodontic specialist team speak with the patient or parent (either immediately or later at an agreed upon time) to identify the problem and determine if an office visit is essential:

1. Are you in pain?
2. What is the problem?
3. Identify if it is something the patient can manage at home.
4. Check if they have an acute orthodontic-related problem that is affecting their lifestyle.

The following information is mandatory:

5. A summary of the problem;
6. Any medical issues that may impact decision making;
7. Photographs illustrating the situation taken with a smartphone as directed by the doctor and sent to the medical team.

Once the information has been received:

8. If possible, advice should be given over the phone (+/- video call);
9. Arrangements made to see patients where necessary (see below for situations requiring patient encounter).

Common "emergency" problems and solutions:

If you are a patient undergoing orthodontic treatment follow the advice contained here but PLEASE, if possible, contact your orthodontist first to ensure that you are performing the procedures safely and fully understand all aspects of the worn braces.

If you are a dentist, please consider these guidelines for your and your patient's safety:

• Full PPE is recommended (see link - here);
• Patients come at the exact appointment time;
• Patients should not bring other family members;
• Patients must wait outside the clinic until their appointment begins;
• Patients must leave the facility immediately after the procedure;
• Units must allow sufficient time between emergency appointments to allow for disinfection of the cabinet and disposal of waste;
• Patients must wash their hands or and use the disinfectant provided to them

1. The spring (wire) of the appliance got detached:

• Homecare tips:
  • If it's a thin wire, the patient or a family member might use tweezers to reinsert the wire into the tube, or tweezers and a nail clipper/scissors to shorten the long end;
  • It is possible for a thin wire to be the correct size, but it might wrap around the dental arch so that it is short on one side and long on the other. Using tweezers, a pencil with an eraser on the end, or a teaspoon, it may be possible to push the wire back so both ends will be short and won't cause injury;
  • If the wire is very thick and stiff (discuss this with your orthodontist), it may not be possible to cut the wire with household instruments. In this case, you may need to cover the wire so that it is not sharp. Orthodontic wax can be sent from the office or purchased online. Otherwise, using a piece of hard cheese wax (baby-bell, cheddar) or even chewing gum may help.
• In the clinic:
  • Adjust the arch as simply as possible.

2. Broken fixed retainers

• Homecare tips:
  • Push the cord back toward the tooth as far as possible (use your fingers or tweezers);
  • Coat with whatever you have available (ortho wax, cheese wax, chewing gum);
  • Cut the stripped wires using tweezers and nail clippers/scissors;
  • Gently pull on the wire to remove the entire containment device;
  • Advise the predominant use of mobile restraints, such as removable mouth guards, if the patient has one.
• In the clinic:
  • Cut the wire;
  • Remove the wire;
  • Advise to predominantly use mobile retainers, if the patient has one.

3. Lost retainers:

• Homecare tips:
  • Contact your orthodontist - they may have your final moulds in the clinic and may be able to make a new retainer for you and send it to you;
• In-clinic:
  • Do not visit the clinic, it is not an emergency.

4. Traction Chains for pulling impacted/ectopic teeth:

• Homecare tips:
  • If the traction chain has been recently placed, is not fixed and presents a hazard, it is best to cut it short. Gold is a soft metal and it may be possible to cut the chain using nail scissors or nail clippers. Hold onto the released end with tweezers. If possible, leave at least 5 loops intact so that they can be used later by the orthodontist;
  • If the traction chain has been recently placed, is not fixed and presents a hazard, it is best to cut it short. Gold is a soft metal and it may be possible to cut the chain using nail scissors or nail clippers. Hold onto the released end with tweezers. If possible, leave at least 5 loops intact so that they can be used later by the orthodontist;
• In-clinic:
  • Do not visit the facility.

5. Post-operative care following orthognathic surgery:

• Homecare tips:
  • Talk to your local hospital team about your specific problems for the best advice;
  • Check yourjawsrugery.com for general post-op advice;
  • Stop or reduce the use of elastics post-surgery as recommended by your orthodontist.
• In-clinic:
  • Make sure the patient does not have an acute infection/tumour/plaque infection;
  • Stop or reduce the use of elastics as deemed appropriate;
  • Assure the patient of continued treatment at the next visit;
  • Do not activate the orthodontic appliance to induce tooth movement.

6. Orthodontic therapy with aligners (e.g. Invisalign®)

• Homecare tips:
  • If your aligner (mouthpiece) is in good condition, continue wearing it as long as possible;
  • If your current mouthpiece is broken or doesn't fit, go back to your previous mouthpiece;
  • If none of these are possible, call your orthodontist for recommendations (it may be possible to have a proper aligner made and sent to you).
• In-clinic:
  • Do not visit the facility.

7. Loose bracket:

This is not an emergency unless it causes soft tissue trauma.

• Homecare Tips:
  • It may be possible for your doctor to guide you on how to remove the bracket from the wire via videoconferencing if it is causing trauma;
  • It may be possible not to have to intervene if it is not currently causing problems. Call your orthodontist for advice.
• In-clinic:
  • Do not visit the facility.

8. Elastics

• Homecare tips:
  • If you run out of elastics, your orthodontist can send them to you by courier.
• In the clinic:
  • Do not visit the facility.

9. Loose molar band:

• Homecare tips:
  • If the band is loose, your doctor can help you remove it and cut the wire depending on the stage of treatment;
  • Your orthodontist may also recommend leaving the band in place. If this happens, please be sure to follow good oral hygiene and a low-sugar diet to prevent carious lesions under the band and around the tooth.
• In the clinic:
  • Remove the band and trim excess wire distal to the last tooth.

10. Loose Quad – helix Expanders, palatal arches +/- Nance devices

• Homecare Tips:
  • Talk to your orthodontist about the particular problem you are having so they can advise you accordingly;
  • Push the band back onto the tooth if you can, and make sure you follow good oral hygiene and a low-sugar diet to prevent cavities under the band and around the tooth.
• In the clinic:
  • Remove the appliance.

11. Removable/mobile/functional appliances

• Homecare tips:
  • Check for comfort and retention;
  • If you're not sure how much longer you need to wear the appliance, talk to your orthodontist;
  • If the appliance is fractured or defective, do not wear the appliance.
• In the clinic:
  • Do not visit the facility.

12. Separators

• Homecare tips:
  • These should be removed as soon as possible. Try removing with the end of a safety pin, small paper clip or toothpick.
• In the clinic:
  • Do not visit the facility.

13. Lost modules

• Homecare Tips:
  • No action necessary, try to secure the arch-wire with dental wax, cheese wax or chewing gum if the module has been lost.
• In the clinic:
  • Do not visit the facility.

14. TADS temporary anchorage devices

• Homecare Tips:
  • Your orthodontist can help with tips for removing the device or elastic chain that is moving your teeth.
• In the clinic:
  • Remove the elastic.

15. Headgear

• Homecare Tips:
  • Stop wearing the device.
• In the clinic:
  • Do not visit the facility.

16. Open Coil Spring

• Homecare Tips:
  • No treatment needed.
• In the clinic:
  • Do not visit the facility.

17. Fractured/worn-out elastic chain

• Homecare Tips:
  • No treatment required - most chains will wear out in 4-6 weeks and become passive;
  • If necessary, remove chain with tweezers;
  • Cut the end of the chain as short as possible to improve comfort.
• In the clinic:
  • Do not visit the facility.

18. Exposed end of a wire ligature - long / short ligature.

• Homecare Tips:
  • Reinsert the sharp end under the bracket/bow using a teaspoon or tweezers;
  • If broken, remove ligature with tweezers, if possible;
  • Trim the end as short as possible to improve comfort, using tweezers or scissors;
  • Cover the sharp end with orthodontic wax, cheese wax, or chewing gum for comfort.
• In the clinic:
  • Do not visit the facility.