Progress in Orthodontics ( IF 4.8 ) Pub Date : 2020-04-07 , DOI: 10.1186/s40510-020-00310-y Alberto Caprioglio 1 , Giulia B Pizzetti 1 , Piero Antonio Zecca 1 , Rosamaria Fastuca 1 , Giuliano Maino 2 , Ravindra Nanda 3
The coronavirus (COVID-19) epidemic is a public health worldwide problem for which specific guidelines are published, constantly updated by the World Health Organization (WHO) and, in Italy, by the Italian National Institute of Health. The competent ministries and the regions directly or indirectly contribute to risk management through the identification of suspected cases and the activation of containment and quarantine measures for people who have had contact with suspicious cases.
In the dental field, for the purpose of controlling COVID-19 infection, the fundamental preventive measure lies in the filter of patients who come to the ambulatory. Therefore, a questionnaire should be used to screen patients with potential infection of 2019-nCoV before they could be led to the dental chair-side, as recently suggested [1].
Another fundamental aspect is the correct use of personal protective equipment (PPE) and the strict compliance with the behavioral guidelines at the dental office established by the competent authorities and recently published [1].
Given that the professional can assess whether to stay open or manage emergencies only, common sense must prevail during a quarantine period.
One choice that can be made is to postpone routine orthodontic appointments, according to the guidelines of the single Nations, but patients need to be assured and followed, especially if they are experiencing discomfort or problems related to the orthodontic appliance they are using.
An orthodontic emergency might be described as a problem arising from an orthodontic appliance, where an unscheduled appointment is required to resolve the issue. When a patient has such an issue, a timely additional appointment may need to be arranged with a specialist. Patients who present with an orthodontic emergency may be experiencing pain or discomfort. It can also be inconvenient for the patient and parents in attending for an additional, unexpected appointment due to pre-existing school or work commitments. Consequently, repeated breakages prolong treatment time and can lead to decreased patient motivation due to a loss of confidence in the appliance or the operator. By providing appropriate timely management, inconvenience and distress to both the patient and parents may be minimized with the efficacy of the appliance still being maintained [2].
According to single Nations guidelines during COVID-19 pandemic, dentists should accept in the private practice only non-deferrable urgencies, such as an abscess or irreversible pulpitis. Orthodontic problems, like general dentistry problems, represent urgencies, not true emergencies, so a video call or message with a photo might be the best options to evaluate the case.
A brief summary of guidelines on the management of orthodontic patients during COVID-19 emergency is proposed as follows focusing on virtual assistance devices and classification of emergencies.
WhatsApp Messenger (Facebook Inc., Mountain View, California) is an instant messaging application developed in 2009 and quickly spread among users of all ages, for personal relationships, as entertainment, as an aid to the study, and as a virtual place of contact with their group. The international scientific literature on the use of this application in the health sector, identified by the major database, on-line, reports only a small number of publications. Although its impact in the clinical setting has been poorly investigated, WhatsApp is among the most widely used communication tools, which may also be valuable in favoring the communication and relationship between patients and physicians. Healthcare providers should be trained to use modern web-based communication systems with accurate assessment of indications and contraindications [3, 4].
Clement has recently published some data about the most popular global mobile messenger apps based on the number of monthly active users on Statista (https://www.statista.com/statistics/258749/most-popular-global-mobile-messenger-apps/), which is a German web portal for statistics. The most popular messenger app turns out to be WhatsApp, with 1.6 billion users on a monthly basis.
Nowadays, WhatsApp is the largest messaging app, and therefore, it is the most widespread and most usable even by inexperienced audiences.
The best way to manage orthodontic emergencies is to decide step by step. The first step should always be virtual assistance, and WhatsApp may be considered a good tool to do that. The virtual assistance might be performed by using photos, videos (better if with additional light source), or video call.
In particular, we recommend the business version of WhatsApp to link it to the firm’s fixed number, activating the verification on call.
We recommend doing a triage via WhatsApp to skim the real urgencies to be managed in the private practice in person from remotely manageable situations. It is recommended for large offices or hospital departments to activate WhatsApp Web and have the QR code sent by the dental office staff on duty in order to manage problems on two users.
We can classify orthodontic emergencies on the basis of the type of the appliance used by the patient: removable appliance or fixed appliance.
Removable appliances
Removable appliances can be classified into the following:
Functional
Aligners
Retainers (for example Essix appliance)
Functional appliances are used by growing patients to guide the correct growth of the dento-alveolar complex and the jaws [5].
If the patient breaks the appliance or has noticeable discomfort by wearing it, we suggest suspending the use of the appliance for the moment, in order to reduce emergencies that cannot be managed directly.
An aligner or a retainer appliance can be often broken or lost by the patient. For aligner treatment, the advice would be to remain on the current aligner if the patient does not have any more until the end of the emergency.
If there are no problems with the current aligner and subsequent aligners are in the patient’s possession, the suggestion is to continue with the subsequent aligner, up to the treatment phase prior to IPR, replacement of attachments, and introduction of elastic modules.
In the event that the current aligner is broken or lost, the advice would be to go on the previous aligner or to change to the next one depending on the percentage of usage of the broken/lost aligner.
As for the retainers or if there is a high risk of recurrence that irreversibly compromises the treatment, we suggest to buy an easy contenitive appliance, like hot customizable preforms, which can be found on e-commerce sites such as Amazon, which currently still allows fast shipments, so when the emergency will be finished, the clinician can take new impressions or scans.
Fixed appliances
Fixed appliances can be classified into the following:
Non-removable appliances
Non-removable appliances that can be activated by the patient
Pre-activated, non-removable appliances
For all emergencies, the patient should send photos or videos to confirm the accident.
The pre-adjusted edgewise appliance (straightwire appliance) is the most commonly used non-removable appliance [6]. It includes bands and brackets, archwires, and auxiliaries. The time elapsed since the previous activation is important in order to consider the appliance active or passive; normally, a time of 4 weeks indicates a passive appliance [7].
A bracket may become loose or lose its metallic or elastic ligature as a consequence of eating hard or sticky foods: if the bracket remains flush with the tooth, it can be left as it is, if it seems to fall from the archwire, the patient can carefully try to remove it with eyebrow tweezers.
If there is a metallic ligature that causes soft tissue trauma or pain, the patient should try to push it back with the small eraser on the back of a pencil. In the event that it is not possible, then orthodontic relief wax can be applied. If wax is not in possession of the patient, it might be found in pharmacies or on online stores such as Amazon. In case of an emergency, food wax can be used, since they are both made with micro-crystallized paraffin.
Another very frequent problem, especially during the first phases of the treatment, is protruding distal ends of archwire that can cause soft tissue trauma and large and painful ulcers. If the archwire has slid round to one side, then it may be possible to reposition it with the help of eyebrow tweezers. If the patient is not able to reposition the wire, the best option is to cut it. Thin wires can be cut using a nail clipper. Disinfection can be performed by boiling the instrument in 100 °C water for 30 min [8, 9]. If the wire is thick, it is recommended to try to cut it with a hardware cutter that could be ordered on e-commerce sites without concerns.
In any case of soft tissue trauma caused by sharp objects (end of the wire or ligatures), orthodontic relief wax is a good momentary solution. It can be found in drugstore, pharmacies, and e-commerce sites without problems.
Non-removable appliances that can be activated by the patient are for example the ones that use fixed molar bands but should be worn by the patient, such as face masks, headgears, or lip bumpers.
This type of appliances, and also elastics, should be suspended a priori to reduce the risk of emergencies until the patient can be referred back to the orthodontist.
If the patient feels pain, redness, and swelling near a fixed orthodontic appliance, we can ask him/her to take a photo and send it to the dentist: if a periodontal abscess is suspected, then it is suggested to visit him to remove the cause, for example, a band under the gum, and then to treat the infection with antibiotic therapy. Whether this is not immediately possible, we recommend prescribing a symptomatic therapy with FANS or paracetamol after properly asking for allergies [6, 10].
Fixed treatment can also enclose pre-activated appliances, such as Pendulum, Forsus, Distal Jet appliance, and transpalatal bar. In this case, it is recommended to take a picture every 3 weeks and eventually let the patient come to the office to remove it if it represents or could represent an emergency (for example, in the case of pain or swelling).
We must keep in mind that, in this case, the rationale is to prevent emergencies, not to cure them. Moreover, it would be useful to ask the patient to take careful notes on what he did and when. A summary of the possible scenarios and how to solve them is presented in Table 1.
In conclusion, a good method to manage emergencies, reassure, and follow patients remotely, while they are in their home, is via WhatsApp web.
The orthodontist should not let the patient use anything that could generate an urgency in the office such as appliances that can be activated by the patient (elastics, face masks, headgears, lip bumpers, or other non-removable appliances that can be activated by the patient).
At the moment, it is essential to manage in the office with the necessary PPE only the real cases of urgencies that cannot be resolved remotely by the patient, following the guidelines dictated by the WHO and local authorities.
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Affiliations
- Orthodontic Program, Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Alberto Caprioglio
- , Giulia B. Pizzetti
- , Piero Antonio Zecca
- & Rosamaria Fastuca
- Postgraduate School of Orthodontics, University of Ferrara, Ferrara, Italy
- Giuliano Maino
- Division of Orthodontics, University of Connecticut Health Center, Farmington, CT, USA
- Ravindra Nanda
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Correspondence to Ravindra Nanda.
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Caprioglio, A., Pizzetti, G.B., Zecca, P.A. et al. Management of orthodontic emergencies during 2019-NCOV. Prog Orthod. 21, 10 (2020). https://doi.org/10.1186/s40510-020-00310-y
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DOI: https://doi.org/10.1186/s40510-020-00310-y
中文翻译：
2019-NCOV期间正畸紧急情况的管理。
冠状病毒 (COVID-19) 流行病是一个全球性的公共卫生问题，世界卫生组织 (WHO) 和意大利国立卫生研究院都针对该问题发布了具体指南，并不断对其进行更新。主管部委和地区通过发现疑似病例和对接触过疑似病例的人员启动遏制和隔离措施，直接或间接地为风险管理做出贡献。
在牙科领域，为了控制 COVID-19 感染，基本的预防措施在于对门诊患者进行过滤。因此，正如最近建议的那样，应使用问卷调查潜在感染 2019-nCoV 的患者，然后才能将其带到牙科椅侧 [1]。
另一个基本方面是正确使用个人防护设备 (PPE) 并严格遵守由主管当局制定并最近发布的牙科诊所的行为指南 [1]。
鉴于专业人员可以评估是保持开放还是仅管理紧急情况，因此在隔离期间必须以常识为准。
根据单一国家的指导方针，可以做出的一种选择是推迟常规的正畸预约，但患者需要得到保证和关注，尤其是当他们遇到与所使用的正畸矫治器相关的不适或问题时。
正畸紧急情况可能被描述为由正畸矫治器引起的问题，需要进行计划外的预约来解决问题。当患者有这样的问题时，可能需要与专家安排及时的额外预约。出现正畸紧急情况的患者可能会感到疼痛或不适。由于预先存在的学校或工作承诺，患者和父母参加额外的意外约会也可能不方便。因此，反复破损会延长治疗时间，并可能由于对器具或操作者失去信心而导致患者积极性降低。通过提供适当的及时管理，
根据 COVID-19 大流行期间的单一国家指南，牙医在私人诊所中应仅接受不可推迟的紧急情况，例如脓肿或不可逆的牙髓炎。正畸问题，如一般牙科问题，代表紧急情况，而不是真正的紧急情况，因此视频通话或带有照片的消息可能是评估病例的最佳选择。
建议对 COVID-19 紧急情况期间正畸患者的管理指南进行简要总结，重点关注虚拟辅助设备和紧急情况分类。
WhatsApp Messenger（Facebook Inc.，加利福尼亚州山景城）是 2009 年开发的即时通讯应用程序，并迅速在各个年龄段的用户中传播，用于人际关系、娱乐、学习辅助和虚拟联系场所与他们的小组。由在线主要数据库确定的有关在卫生部门使用该应用程序的国际科学文献仅报告了少数出版物。尽管它在临床环境中的影响尚未得到充分研究，但 WhatsApp 是使用最广泛的通信工具之一，它在促进患者和医生之间的沟通和关系方面也可能很有价值。应培训医疗保健提供者使用基于网络的现代通信系统，并准确评估适应症和禁忌症 [3, 4]。
Clement 最近根据 Statista 上的月活跃用户数发布了一些关于最受欢迎的全球移动通讯应用程序的数据（https://www.statista.com/statistics/258749/most-popular-global-mobile-messenger-apps /)，这是一个德国的统计门户网站。最受欢迎的即时通讯应用程序是 WhatsApp，每月有 16 亿用户。
如今，WhatsApp 是最大的消息传递应用程序，因此，即使是没有经验的受众，它也是最广泛和最有用的。
处理正畸紧急情况的最佳方法是逐步做出决定。第一步应该始终是虚拟协助，而 WhatsApp 可能被认为是一个很好的工具。可以通过使用照片、视频（如果有额外的光源更好）或视频通话来执行虚拟协助。
特别是，我们推荐商业版 WhatsApp 将其链接到公司的固定号码，激活待命验证。
我们建议通过 WhatsApp 进行分类，以便从远程可管理的情况中亲自在私人诊所中管理的真正紧迫性。建议大型办公室或医院部门激活 WhatsApp Web 并让牙科办公室值班人员发送二维码，以便管理两个用户的问题。
我们可以根据患者使用的矫治器类型对正畸紧急情况进行分类：可拆卸矫治器或固定矫治器。
可移动电器
可移动设备可分为以下几类：
功能性
对准器
固定器（例如 Essix 设备）
成长中的患者使用功能性矫治器来指导牙槽复合体和颌骨的正确生长 [5]。
如果患者因佩戴而摔坏或有明显不适，建议暂时停止使用，以减少无法直接处理的紧急情况。
矫正器或固定器经常会被患者弄坏或丢失。对于矫正器治疗，如果患者在紧急情况结束前没有任何矫正器，建议继续使用当前矫正器。
如果当前的矫正器没有问题，并且后续矫正器在患者手中，建议继续使用后续矫正器，直至 IPR、更换附件和引入弹性模块之前的治疗阶段。
如果当前的对准器损坏或丢失，建议继续使用前一个对准器或根据损坏/丢失的对准器的使用百分比更改为下一个对准器。
至于保持器，或者如果复发风险高且不可逆转地影响治疗，我们建议购买易于竞争的器具，例如可在亚马逊等电子商务网站上找到的热可定制瓶坯，目前仍允许快速发货，因此当紧急情况结束时，临床医生可以进行新的印模或扫描。
固定电器
固定电器可分为以下几类：
不可拆卸电器
可由患者激活的不可拆卸器具
预激活的不可移动设备
对于所有紧急情况，患者应发送照片或视频以确认事故。
预先调整的边缘矫治器（直线矫治器）是最常用的不可拆卸矫治器[6]。它包括带子和支架、弓丝和辅助装置。自上次激活以来经过的时间对于考虑设备是主动还是被动很重要；通常情况下，4 周的时间表示被动器具 [7]。
由于吃了坚硬或粘稠的食物，托槽可能会松动或失去其金属或弹性结扎线：如果托槽仍然与牙齿齐平，它可以保持原样，如果它似乎从弓丝上掉下来，患者可以仔细尝试用眉毛镊子将其取下。
如果有金属结扎导致软组织创伤或疼痛，患者应尝试用铅笔背面的小橡皮擦将其推回。如果不可能，则可以使用正畸缓解蜡。如果患者没有蜡，可能会在药店或亚马逊等在线商店找到。在紧急情况下，可以使用食用蜡，因为它们都是用微晶石蜡制成的。
另一个非常常见的问题，尤其是在治疗的第一阶段，是弓丝远端突出，可能导致软组织损伤和大而疼痛的溃疡。如果弓丝滑到一侧，则可以在眉毛镊子的帮助下重新定位。如果患者无法重新定位导线，最好的选择是切断它。细线可以用指甲刀剪断。可以通过将仪器在 100 °C 水中煮沸 30 分钟来进行消毒 [8, 9]。如果电线很粗，建议尝试使用可以在电子商务网站上订购的硬件切割器来切割它，而无需担心。
在任何由尖锐物体（电线末端或结扎线）引起的软组织创伤的情况下，正畸缓解蜡是一个很好的临时解决方案。它可以在药店、药店和电子商务网站上毫无问题地找到。
可由患者激活的不可拆卸器具是例如使用固定磨牙带但应由患者佩戴的器具，例如面罩、头带或唇部缓冲器。
这种类型的矫治器和松紧带应该先暂停，以减少紧急情况的风险，直到患者可以被转诊给正畸医生。
如果患者在固定的正畸矫治器附近感到疼痛、发红、肿胀，我们可以要求他/她拍照并发送给牙医：如果怀疑是牙周脓肿，那么建议就诊于他/她去除牙周病。例如，在牙龈下形成一条带子，然后用抗生素治疗感染。无论这是否不可能立即实现，我们建议在正确询问过敏情况后使用 FANS 或扑热息痛进行对症治疗 [6, 10]。
固定治疗也可以附上预先激活的器具，例如 Pendulum、Forsus、Distal Jet 器具和经腭杆。在这种情况下，建议每 3 周拍一张照片，如果它代表或可能代表紧急情况（例如，在疼痛或肿胀的情况下），最终让患者来办公室将其移除。
我们必须记住，在这种情况下，基本原理是预防紧急情况，而不是治愈它们。此外，要求患者仔细记录他做了什么以及什么时候做的，这将是有用的。表 1 总结了可能的情况以及如何解决这些情况。
总之，通过 WhatsApp 网络是一种在患者在家时远程管理紧急情况、安抚和跟踪患者的好方法。
正畸医生不应让患者使用任何可能在办公室产生紧迫感的东西，例如可由患者激活的器具（松紧带、面罩、头带、唇部保险杠或其他可由医生激活的不可拆卸器具）。病人）。
目前，必须按照世卫组织和地方当局规定的指导方针，在办公室使用必要的个人防护装备管理患者无法远程解决的真实紧急情况。
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Caprioglio, A., Pizzetti, GB, Zecca, PA等。2019-NCOV期间正畸紧急情况的管理。前正教。 21 日， 10 日（2020 年）。https://doi.org/10.1186/s40510-020-00310-y
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