Sir, we are already seeing the effects of a 'tsunami' of treatment need with a transference of most hospital resources to managing COVID-19 patients and a consequent diminution of resources for even the most urgent dental, medical and surgical conditions.1
One significant finding about the virus' behaviour is that health professionals, notably those working in ITU, dentistry, oral and maxillofacial surgery, ophthalmology and ENT, are particularly susceptible to severe infections which, in combination with a lack of protective equipment, reduces the active NHS workforce. This knowledge has been synthesised into position statements on NHS staff protection and working practice in the time of COVID-19. The British Oral and Maxillofacial (BAOMS) and oral surgeons (BAOS) have produced didactic guidance about risk and protection (https://www.baoms.org.uk).
At present there is no certainty about the pandemic timescale and the ability of NHS services to manage patients with COVID-19 and patients with other serious problems such as facial injuries. Also, in OMFS practice we must minimise cross infection from COVID patients to facial injury patients. The management of facial injuries has evolved over the last 100 years to our current evidence-based practice of anatomical reduction and internal fixation of complex facial injuries. This allows early mobilisation and rapid return to full jaw function, without the historical obligatory four to six weeks' rigid intermaxillary fixation (IMF) with wires.
However, cross-infection risk and the BAOMS and BAOS guidance about avoiding exposure, rapid hospital discharge, and simplifying and shortening surgical procedures has already resulted in abbreviated surgical treatment with older techniques such as IMF and potentially with follow-up delegated to the patient's dentist or doctor.2 There are three problems with GP or GDP follow up. Firstly, primary care practitioners must know how to manage the patient during the recovery period and remove intra-oral wires when the fractures have healed; they must also have the equipment and lighting to do this. They must also be remunerated satisfactorily for this work. Many dentists have closed their practices but it is likely that they will reopen once they are given proper protective equipment.
The wires around the teeth and jaws (IMF) remain until the jaw has healed.3 They make tooth cleaning difficult causing poor periodontal health. The GDP's weekly follow-up should include jaw fracture assessment and care of the periodontium. GDPs may need new skills and regular advice so we will provide learning and advice modules at: https://www.baoms.org.uk/professionals/omfs_and_COVID-19.aspx.
References
Hunter D J. COVID-19 and the stiff upper lip - the pandemic response in the United Kingdom. N Engl J Med 2020; DOI: 10.1056/NEJMp2005755.
Blitz M, Notarnicola K. Closed reduction of the mandibular fracture. Atlas Oral Maxillofac Surg Clin North Am 2009; 17: 1-13.
Thor A, Andersson L. Interdental wiring in jaw fractures: effects on teeth and surrounding tissues after a one-year follow-up. Br J Oral Maxillofac Surg 2001; 39: 398-401.
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Holmes, S., Hutchison, I. & Chatzopoulou, D. Broken jaws in the COVID era. Br Dent J 228, 488 (2020). https://doi.org/10.1038/s41415-020-1486-x
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DOI: https://doi.org/10.1038/s41415-020-1486-x
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