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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 225-230

Management of endodontic emergencies at a tertiary care hospital during the lockdown phase of the COVID-19 pandemic


Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India

Date of Submission14-Jun-2020
Date of Decision28-Oct-2020
Date of Acceptance07-Dec-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Prof. Ajay Logani
Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_79_20

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  Abstract 


Context: Coronavirus disease 2019 (COVID-19) is declared as a global pandemic by the WHO. Due to lack of proper vaccine, social distancing and restriction of movement in the form of“lockdown” have been implemented to curb the spread. This has crippled dental care in the country.
Aims: The aim of this article is to highlight the management of endodontic emergencies during the COVID-19 lockdown phase.
Settings and Design: Retrospective analysis of patient's data at a tertiary care center
Materials and Methods: The data of 247 patients referred to the specialty clinic between March 23 and May 31, 2020, were retrospectively analyzed. COVID-19 risk assessment was performed for all the patients. Based on the diagnosis, the cases were classified as emergency, urgent, or nonemergency. The endodontic intervention was performed for all the emergency cases. Minimally invasive dentistry and pharmacotherapy were provided for urgent and nonemergency cases.
Results: One hundred and seventeen patients presented with true endodontic emergencies (symptomatic irreversible pulpitis with or without apical periodontitis [80%], pulp necrosis and acute apical abscess [18%] or traumatic dental injury [2%]). About 82% of the emergency cases were managed by nonsurgical endodontic therapy, and vital pulp therapy was performed in 15.4% of the cases.
Conclusions: Management of most of the endodontic emergencies required the use of aerosol-generating procedures. Irreversible pulpitis was the most common cause for the patients seeking emergency endodontic treatment.

Keywords: Acute apical abscess, coronavirus disease-2019, endodontic emergencies, irreversible pulpitis


How to cite this article:
Sharma S, Logani A, Chawla A, Kumar V, Gill S. Management of endodontic emergencies at a tertiary care hospital during the lockdown phase of the COVID-19 pandemic. Endodontology 2020;32:225-30

How to cite this URL:
Sharma S, Logani A, Chawla A, Kumar V, Gill S. Management of endodontic emergencies at a tertiary care hospital during the lockdown phase of the COVID-19 pandemic. Endodontology [serial online] 2020 [cited 2021 Mar 2];32:225-30. Available from: https://www.endodontologyonweb.org/text.asp?2020/32/4/225/307318




  Introduction Top


Coronavirus disease-2019 (COVID-19) is a respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] This highly contagious disease which originated in Wuhan, China, has spread rapidly across many countries around the world. The WHO declared this outbreak as a public health emergency of international concerns on January 30, 2020, and global pandemic on March 11, 2020. SARS-CoV-2 is mainly transmitted through respiratory droplets from coughing and sneezing.[2] Symptoms of COVID-19 vary in patients from mild upper respiratory tract infection (like fever, cough, sore throat), pneumonia to acute respiratory distress syndrome.[3] Because of the high virulence of SARS-CoV-2 and the absence of any drug or vaccine against it, hand hygiene, respiratory etiquette, and social distancing are the recommended methods to prevent the disease transmission.[4] Many countries followed“lockdown” as an additional preventive measure for mass transmission.

Endodontists, due to the nature of their work, are at a higher risk of getting exposed to SARS-CoV-2.[5] The fact that routine endodontic procedures generate a significant amount of bio-aerosols and spatter, and it is suspended in the environment for as long as 3 h, amplifies biological risk to the concerned dental health-care personnel (DHCP).[6] In the absence of proper precautions and infection control measures, a dental operatory can become a source of cross-contamination. Various statutory bodies have issued advisories for restriction of dental services to emergency or urgent procedures only, to minimize this risk of cross-infection.[7],[8] This has severely crippled dental care in India. The Department of Conservative Dentistry and Endodontics at the Centre for Dental Education and Research, All India Institute of Medical Sciences (AIIMS), New Delhi, continued to provide emergency endodontic care. This article highlights the management of endodontic emergencies tactfully, efficiently, and safely during the COVID-19 lockdown period.


  Materials and Methods Top


The data of 247 patients referred to the specialty clinic between March 23 and May 31, 2020, were retrospectively analyzed for demographic details, preoperative diagnosis (emergency/urgency/non-emergency), and type of intervention performed (aerosol-generating/non-aerosol-generating/pharmacotherapy). The ethical clearance for this retrospective study was not sought from the institute's review committee because the demographic details of the subjects were not divulged, and all treatment procedures performed were evidence based. Patient management involved the following steps:

Patient hygiene and coronavirus disease 2019 risk assessment

All patients were instructed to perform hand hygiene with soap and water for 20 s and subsequently with propanol-based hand rub (Raman and Weil Private Limited, Mumbai, Maharashtra, India). Further, they were requested to wash their face before entering the reception area. It was ensured that patients had donned their face masks, and the same was provided when necessary.

Each patient was asked a set of questions [Table 1]. Their body temperature was measured using a thermal scanner, and the status on Arogya Setu application in their mobile phones was checked. The patients were graded as at low- and high-risk for COVID-19.[4] The latter was referred to the COVID-19 screening facility at AIIMS, New Delhi, for further evaluation. All patients were advised to follow the social distancing norms and were asked to wear shoe covers before entering the dental operatory.
Table 1: Coronavirus disease-2019questionnaire

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Oral examination

All patients were requested to rinse the oral cavity with 0.2% povidone-iodine solution for 1 min. Specialty consultant donning a Level I personal protective equipment (PPE) (Head cap, N95 mask, face shield, nitrile examination gloves, and surgical gown) carried out the diagnostic examination. A detailed history and complete clinical examination of intraoral hard and soft tissue was performed. A pulp sensibility test was carried out if required. Orthopantomogram was preferred for radiographic evaluation. However, in case an intra-oral periapical X-ray was required, a double-barrier technique (latex finger cot and plastic sleeve) was used to protect the sensor and prevent cross-infection.[9] The cases were classified as emergency, urgent, or nonemergency based on diagnosis [Table 2]. The endodontic intervention was performed for all the emergency cases. Minimally invasive dentistry and pharmacotherapy were provided for urgent and nonemergency cases.
Table 2: Categorization of cases based on diagnosis

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Intervention

All the procedures were performed in an operatory fitted with HEPA 14 filters and complying with recommendations given in the Indian Endodontic Society (IES), International Federation of Endodontic Associations (IFEA), and Indian Dental Association (IDA) joint position statement.[4] Before commencing the treatment, the necessary equipment, instruments, and materials were arranged on the assistant trolley. Four-handed dentistry was practised. Both the operator and the assistant were provided with level II PPEs (Coverall bodysuit, long shoe cover, N-95 mask, goggles/face shield and sterile surgical gloves). Before starting the procedure, the patient was given a head cap, and the face was scrubbed with povidone-iodine solution. A nerve block was administered to anaesthetize the offending tooth. An electric pulp test was performed at 15-min time interval. A negative response indicated complete pulpal anesthesia. The rubber dam was applied to isolate the tooth. However, it was extended to cover the nostrils. This acted as a physical barrier for nasopharyngeal secretions [Figure 1]. This did not hamper the breathing of the patient and was well accepted. Subsequently, a round diamond bur operated in a high-speed air rotor handpiece under water coolant was used to remove caries and achieve access to the pulp chamber. High vacuum suction was used to control the aerosol spread. Use of three-way air-water syringe was minimized, and the cotton pellet was preferred to dry the area. In teeth with symptomatic irreversible pulpitis (SIP), vital pulp therapy (VPT), i.e., complete pulpotomy, was the preferred option. It entailed removal of the coronal pulp and control of pulpal bleed with pressure cotton pellet moistened with 3% sodium hypochlorite. Teeth in which hemorrhage control was achieved within 10 min, a layer of three mm mineral trioxide aggregate (MTA) (Dentsply DeTreY GmbH, Konstanz, Germany) was placed over the orifices, followed by type II glass ionomer cement (GC Fuji Type 2 Restorative Cement Gold Label, GC Corporation, Tokyo, Japan). The tooth was restored with posterior composite resin (Tetric N Ceram Bulk Fill, Ivoclar Vivadent) in the same visit. Teeth with inflamed pulp where bleeding could not be controlled, complete pulpectomy with completion of endodontic therapy in a single visit was done. Electronic apex locators for working length determination, rotary NiTi instruments for canal preparation, and sonic irrigation agitation devices for enhancing disinfection were used. This ensured maximum efficiency and minimize treatment duration. In teeth with pulp necrosis, the chemomechanical preparation was completed, calcium hydroxide intracanal medicament was placed, and the access was sealed with type II glass ionomer cement. The recall appointment was scheduled after 2 weeks. Teeth with luxation dental injury were immediately splinted following the International Association of Dental Traumatology guidelines. Complicated crown fractures were managed by pulpotomy or pulpectomy in teeth with immature or mature root apices, respectively. Care was taken to minimize cross-infection during prescription writing. After the procedure, hand hygiene was carried out by the operator and prescriptions were written on a new paper after wearing a sterilized pair of gloves. Pens used for prescription writing were also cleaned with alcohol-based disinfectant after every use. Tablet ibuprofen 600 mg was prescribed to all patients and were instructed to take it in case of postoperative pain. Antibiotics (capsule amoxicillin 500 mg TDS/tablet metronidazole 400 mg TDS × 3 days) was prescribed whenever indicated. To manage the urgent endodontic and restorative needs, nonaerosol-generating procedures (n-AGP) were performed. Cotton rolls and high vacuum suction were used to isolate the operating field during n-AGP procedures. In teeth with deep carious lesions or dislodged restorations, caries removal was performed with hand excavators. Intermediate restorative material (IRM, Dentsply International Inc., U.S.A) was placed. In cases where Class II intermediate restoration was not possible without performing an AGP, patients were advised to use an interdental brush dipped in chlorhexidine mouthwash to keep the area clean. In patients categorized as having nonemergency endodontic or restorative needs, no active intervention was performed. The importance of good oral and respiratory hygiene and maintenance of social distancing was reinforced before the discharge of patients.
Figure 1: Rubber dam application to prevent aerosol inhalation by patient

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Disinfection of operatory after intervention

The operatory was left in“as in where” condition for 15 min and thereafter, the cleaning was performed following IFEA, IES, and IDA recommendations.[4] All the surfaces were disinfected at the end of the treatment session. The PPEs were doffed at a separate designated doffing area following the institute's infection control protocol.[10] The operatory was fogged with stabilized hydrogen peroxide (11%w/v) and silver nitrate solution (0.01%w/v) (Ecoshield, Sanosil Biotech Ltd., Mumbai, Maharashtra, India) as a terminal disinfection at the end of th e day.

Postoperative assessment

All the patients were telephonically contacted after 3 days of their visit to enquire about their pain status and also regarding the development of signs and symptoms suggestive of COVID-19. This was repeated over 14 days. They were requested to inform in case they developed symptoms of or tested positive for COVID-19.

Daily monitoring of dental team

All the DHCP involved in the patient care were asked to fill an online Google form every day morning before reporting to the work. They were asked to mention their general well-being, presence of any symptoms related to cough, fever, dyspnea, myalgia, lethargy, and the status of ArogyaSetu mobile application to assess their covid risk status. DHCP reporting any of the above-mentioned symptoms or high-risk status were asked to report to COVID screening facility at the institute and reverse transcription-polymerase chain reaction test for COVID-19 was performed. The DHCP with COVID-19 positive report was instructed for home or institutional isolation depending on the severity of symptoms.

All steps were taken to ensure strict compliance of Infection prevention and control guidelines for 2019-nCoV (COVID-19), issues by Hospital Infection Control committee, AIIMS, New Delhi.


  Results Top


Data of total 247 patients were recorded on a predesigned pro forma, managed on an excel sheet and analyzed using STATA 15.0 software (Stata Corporation, College Station, Texas, U.S.A.). Regarding the demographic profile of the subjects, the mean age of the patients who reported during the lockdown period was 37.5 years. 51.4% were males, and 48.6% were females [Table 3]. As the lockdown period continued, there was an increase in the number of patients attending the emergency specialty clinic, with the peak occurring in phase IV of the lockdown (May 18–31, 2020) [Figure 2]. 117 cases were diagnosed and categorized as endodontic emergencies (SIP 80%, acute apical abscess 18%, TDI 2%) [Figure 3]. Nonsurgical endodontic therapy (82%) was the most performed procedures in emergency cases, followed by a pulpotomy (VPT) (15.4%) [Figure 4]. One hundred thirty cases were classified as urgent/non-emergency cases. These primarily were class II fractured restoration or new class II cavities [Figure 5]. About 77% of these cases were treated with n-AGP [Figure 6]. The patients with previously initiated endodontic treatment, endodontic re-treatment and teeth with the diagnosis of chronic apical abscess were provided with pharmacotherapy. Patients having carious teeth without symptoms of pulpitis but having chief complaints of food impactions which cannot be managed by n-AGPs were instructed to follow oral hygiene measures.
Table 3: Demographic profile of patients

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Figure 2: Number of cases attended during the lockdown period

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Figure 3: Distribution of emergency cases based on diagnosis

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Figure 4: Distribution of emergency procedures performed

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Figure 5: Distribution of nonemergency cases based on diagnosis

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Figure 6: Management of nonemergency cases

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  Discussion Top


An endodontic emergency is defined as“pain and/or swelling caused by various stages of inflammation or infection of the pulp and/or periapical tissues.”[11] These account for 60%–82% of all dental emergencies. An increase in the number of endodontic emergencies is reported during COVID-19 pandemic in Wuhan, China.[12] The authors attributed it to the closure of other endodontic facilities in the area during the lockdown. In India also, the government declared complete lockdown on March 23, 2020. Majority of dental clinics were shut in order to halt human-human transmission of COVID-19. Since the Department of Conservative Dentistry and Endodontics at AIIMS was one of the few hospitals providing emergency dental care, the burden of endodontic emergencies increased tremendously.

One hundred seventeen patients reported with the true endodontic emergencies (TEE), which include irreversible pulpits (80%), Pulp necrosis and acute apical abscess (18%) and traumatic dental injuries (2%). Since the majority of these were due to the pulp or periapical diseases, the appropriate treatment involved the removal of the cause by either endodontic therapy or extraction of the offending tooth. As a conservative dentistry and endodontics specialists, we are entrusted with the responsibility to salvage the tooth whenever possible. The recommended choice of endodontic treatment is complete pulpectomy/pulpotomy for irreversible pulpitis and root canal debridement for pulp necrosis.[13] In view of the COVID-19 pandemic, these endodontic emergencies were categorized under urgent dental care by the American Dental Association.[4] Their management has also been redefined as primary and secondary management in a recent article by Ather et al.[1] Pharmacotherapy, which was advocated only as an adjunct for the management of endodontic pain, has been proposed as primary management of irreversible pulpitis. However, nonsteroidal anti-inflammatory drugs can attenuate pain only for a limited time period, and evidence is lacking on the use of steroids for control preoperative pain in endodontics.[13] This deviation from evidence-based protocols for the management of endodontic emergencies is dictated by the efforts to minimize the AGPs in dentistry.

Bio-aerosol generation is expected during the routine use of the dental drill, ultrasonic instruments, and air-water syringe during endodontic procedures. These are composed of tooth particle, saliva, blood, nasopharyngeal secretions, and infectious microorganisms.[6] The particles of size <50 μm can remain suspended in the air for around 30 min before they sediment on the environmental surfaces such as the floor, dental chair, etc., in the dental operatory and can cause cross-contamination.[6] The reports of transmission of COVID-19 by asymptomatic carriers in the incubation period and detection of viral loads in saliva equivalent to nasopharyngeal swab potentiate the risk to dental health care providers.[14],[15] However, the airborne contamination has been reported to be reduced with the use of rubber dam and high vacuum suction.[6] Four-handed dentistry is a key point in reducing contamination and improves the efficiency and effectiveness of the dentist.[16] The joint position statement on“endodontic and dental practice during COVID-19” by IES. IDA and IFEA give useful recommendations for minimizing the risk of infection while performing AGPs.[4] All the infection control protocols to minimize the risk of COVID-19 were followed for the management of endodontic emergencies reported during the lockdown period. Full pulpotomy was preferred as a primary management option for SIP. It has the advantage of procedural simplicity and providing symptomatic relief quickly and effectively. None of the patients reported with pain after pulpotomy. These findings collaborate with the reported >95% success rate of emergency pulpotomy.[17] Since MTA has excellent biocompatibility and high success rate when used as a pulpotomy agent, it was the material of choice in the present study.[18] However, no significant difference was reported in the outcome when calcium hydroxide, platelet-rich fibrin, and MTA were compared as pulpotomy agents.[19] Hence, the use of calcium hydroxide in an emergency pulpotomy, as recommended by the British Endodontic Society, could be a cost-effective alternative with predictable outcomes during this ongoing COVID-19 pandemic.[20]

Decreasing the microbial burden is essential to minimize the spread of infection in cases of acute apical abscess that can lead to a life-threatening condition if not managed in time. A systematic review on the management of AAA concluded that abscess could be drained through a root canal or incision and drainage.[21] Antibiotics were reported to have no additional benefit in AAA except for immune-compromised patients or in the event of systemic complications.[21] Thus, complete root canal debridement followed by intracanal placement of a suitable medicament was the principal approach followed for such cases. Incision and drainage were only performed in patients with progressive swelling. Antibiotics were used as an adjunct only for the management of cases with systemic symptoms (fever, lymphadenopathy, cellulitis).

Based on our experience, we are to the opinion that severe endodontic pain, although not life-threatening, should be primarily managed with a procedural intervention, which remains the gold standard. The clinician should not depend on preoperative pharmacotherapy as a primary pain relief measure. Long-term drug intake may result in systemic ill effects. The endodontist has been the front-line dental warrior during the COVID-19 pandemic, and we would encourage to provide only evidence-based treatment for TEE. However, this should be performed with universal precautions and adequate PPE. The message must be circulated for clarification. This only will do justice to our specialty.

Acknowledgment

We acknowledge the contribution of Senior residents Dr (s) Wasim Wani, Vijay Yadav, Krunal Tabiyar, Sarita Gill, Lekshmi, Divya Nangia for the management of patients with endodontic emergencies during COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-95.  Back to cited text no. 1
    
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WHO-2019-nCoV-Sci_Brief-Transmission_modes-2020.1-eng. Available from: https://apps.who.int/iris/bitstream/handle/10665/331601/WHO-2019-nCoV-Sci_Brief-Transmission_modes-2020.1-eng.pdf. [Last accessed on 2020 Jun 11].  Back to cited text no. 2
    
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Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554776/. [Last accessed on 2020 Jun 11].  Back to cited text no. 3
    
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Krithikadatta J, Nawal RR, Amalavathy K, McLean W, Gopikrishna V. Endodontic and dental practice during COVID-19 pandemic: Position statement from the Indian Endodontic Society, Indian Dental Association, and International Federation of Endodontic Associations. Endodontology 2020;32:55-66.  Back to cited text no. 4
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Izzetti R, Nisi M, Gabriele M, Graziani F. COVID-19 Transmission in Dental Practice: Brief Review of Preventive Measures in Italy. J Dent Res. 2020; 99:1030-1038.  Back to cited text no. 5
    
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Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc 2004;135:429-37.  Back to cited text no. 6
    
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DCI Guidelines on COVID-19. Available from: http://dciindia.gov.in/Admin/NewsArchives/DCI%20Guidelines%20on%20COVID-19.pdf. [Last accessed on 2020 Jun 11].  Back to cited text no. 7
    
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Dental Advisory. Available from: https://www.mohfw.gov.in/pdf/DentalAdvisoryF.pdf. [Last acessed on 2020 Jun 13].  Back to cited text no. 8
    
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Choi JW. Perforation rate of intraoral barriers for direct digital radiography. Dentomaxillofac Radiol 2015;44:20140245.  Back to cited text no. 9
    
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Infection Control Guidelines AIIMS Covid Information Portal. Available from: https://covid.aiims.edu/infection-control-guidelines/. [Last accessed on 2020 Jun 12].  Back to cited text no. 10
    
11.
Wolcott J, Rossman LE, Hasselgren G. Management of endodontic emergencies. In: Hargreaves KM, Cohen S, editors. Cohen's Pathways of the Pulp. 10th ed.. St. Louis, MO: Mosby; 2011. p. 40-8.  Back to cited text no. 11
    
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Yu J, Zhang T, Zhao D, Haapasalo M, Shen Y. Characteristics of Endodontic Emergencies during Coronavirus Disease 2019 Outbreak in Wuhan. J Endod 2020;46:730-5.  Back to cited text no. 12
    
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COL041Fall2017EndodonticEmergencies. Available from: https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/10/COL041Fall2017EndodonticEmergencies.pdf. [Last accessed on 2020 Jun 11].  Back to cited text no. 13
    
14.
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet Lond Engl 2020;395:514-23.  Back to cited text no. 14
    
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Comparison of SARS-CoV-2 Detection in Nasopharyngeal Swab and Saliva. Available from: https://www.medrxiv.org/content/10.1101/2020.05.13.20100206v2. [Last accessed on 2020 Jun 11].  Back to cited text no. 15
    
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Robinson R, McLaughlan A. Infection control in practice. Infection control and clinical efficiency: Are they compatible? Ann Royal Australasian Coll Dent Surg 1996;13:108-14.  Back to cited text no. 16
    
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19.
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[PUBMED]  [Full text]  
20.
Bhanderi DS, Lessani DM, Morgan DA, Tomson DP. Diagnosis and Management of Endodontic Emergencies, a British Endodontic Society Position Paper for Primary Dental Care and Other Healthcare Providers During the COVID-19 Pandemic. Available from: https://britishendodonticsociety.org.uk/wp-content/uploads/2020/03/BES-Emergency-Protocol-FINAL-DOCUMENT-29-MARCH-2020.pdf. [Last accessed on 2020 Jun 11].  Back to cited text no. 20
    
21.
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