These are purely suggestions for the management of patients in pain and in an emergency requiring extirpation. As aseptic technique as possible and the least aerosol production should be the aim with optimal extirpation. I have not outlined any procedures associated with triaging, PPE and anaesthesia.

These are my own suggestions with some snippets from the AAE. They do not represent the opinions of my employer or any of my affiliations and associations with societies and groups.

  • Ensure your diagnosis is correct and that the tooth definitely requires extirpation

  • Some form of mouthwash could be considered-some organisations (AAE) have suggested gargling with povidine-iodine or Betadine

  • As aseptic technique as possible should be utilised. Consider ‘scrubbing’ the patients lips and surrounding area with povidine-iodine, iodine or chlorhexidine if available

  • Single use instruments to be used wherever possible

  • Reduce the need to utilise intra-oral radiographs wherever possible-this is unlikely to be practical for an extirpation unfortunately. Refer to old x-rays wherever possible

  • Rubber dam is imperative. The AAE have suggested fitting the dam over the nose to reduce transmission

  • Ideally load the dam with the appropriate clamp prior to placing into the mouth to reduce potential for aerosol

  • Utilise sealant materials to optimise fit around the dam

  • Scrub the tooth with hypochlorite/iodine-povidine/chlorhexidine utilising a cotton wool pledget and tweezers. In comparison prophying the tooth is likely to result in aerosol. Do this as optimally as possible prior to instrumenting the tooth

  • Avoid the use of ultrasonics which have a high chance of aerosol production

  • To begin your access cavity utilise a fast handpiece without water to reduce aerosol production.This is an escape for normal practice in abnormal circumstances

  • Tungsten Carbide cuts more efficiently than diamond burs and hence are less likely to result in haphazard debris

  • There is only a need to remove the enamel within the ideal access cavity-once the dentine is breached switch to the use of slow handpiece

  • Make use of gates gladden burs and or goose neck burs to improve access depending on the depth of the dentine overlying the pulp roof and the proximity of the canal orifices

  • 5% hypochlorite should be utilised to fully dissolve any organic tissue to the best possible level and minimise constant need for irrigation and re-irrigation

  • Dress the pulp system

  • Consider restoring the access cavity with a material that is easy to identify and remove such as IRM

Without prejudice. AA.