Table 2. .

Advice That Can Be Provided to Patients for the Short-Term Management of Orthodontic Emergencies at Home^a–c

Orthodontic Emergency	How the Patient Can Attempt to Handle it at Home
Irritation of lip and/or cheek from the brackets	- Push/pinch a small piece of rolled relief waxd over the bracket or long wire that is causing the irritation. - Orthodontic wax that is accidentally swallowed is harmless. - Mouth sores can be relieved by applying a small amount of topical anesthetic (eg, Orabase, Colgate-Palmolive, New York, New York; or Orajel, Church & Dwight, Ewing, New Jersey) directly to the ulcerated surface using a cotton swab (reapplication might be needed).
Elastic ligature has come loose from a bracket during eating or tooth brushing.	- The ligature can be placed back around the bracket using a sterile tweezer. - If the patient is anxious about debonding the bracket or cannot place the ligature back in place, then a sterile tweezer can be used to remove the ligature.
Metallic ligature has come loose from a bracket or is irritating the lips and cheeks.	- If the ligature is loose, a sterile tweezer can be used to remove it. - If the ligature is not loose but is sticking out, a cotton swab/cotton bud or a clean pencil eraser can be used to bend the ligature back down.
Broken or loose elastic chain	- The extra segment can be removed with a sterile tweezer or cut with a sterile clipper.
Loose orthodontic attachment (bracket, tube, or band)	- If the patient cannot be seen in person by the orthodontist and the loose bracket is flipping (rotating) around on the wire and causing discomfort, a sterile tweezer can be used to correct this problem. First the bracket is moved along the wire so that it is in between two teeth. The bracket is then rotated back (unflipped) to its proper relation (as noted from the other brackets, which are not loose) and is then moved along the wire back to the center of the tooth. - If the bracket is used as an anchor for wearing elastic rubber bands, elastic wear should be stopped. - If the loose bracket is the last attachment in the arch, it can be slid off the wire if it is safe for a care provider to do so. The bracket can also be held securely and the wire with the loose bracket can be cut at the point of the last tooth that has a secure orthodontic attachment on it (see the following material). The cut end of the wire with the loose bracket attachment should be carefully removed from the mouth.
Protruding wire at the end of the braces	- A cotton swab/cotton bud or clean pencil eraser can be used to push the wire so that it flattens against the tooth. - A protruding wire can sometimes result from the archwire slipping away from one side and extruding past the other side, and if so, using a sterile tweezer, the wire can be gripped and moved back so that it is equally secure on both sides, and comfortable. - If the wire cannot be moved to a comfortable position, the wire can be covered with relief wax (see the entry on “Irritation of lips and/or cheeks”). - If the wire is extremely irritating, and the patient cannot be seen in person by the orthodontist, the patient or care provider may use a sterile nail clipper to cut the wire. Folded tissue or gauze should be used around the area while cutting the wire to reduce the possibility of swallowing of the snipped piece of wire. Relief wax may still be needed to provide comfort to the irritated area.
Piece of appliance or a bracket is swallowed	- Most small orthodontic appliances (eg, brackets) that are swallowed will pass through the digestive tract uneventfully. - If an object is swallowed, it should be confirmed that the patient did/does not have difficulty breathing or experience sudden coughing after the object was swallowed. In the case of sudden difficulty breathing or sudden coughing following ingestion of the broken appliance or bracket, the patient should go to an emergency department of a hospital. - The orthodontist may advise the patient to seek clinical examination and or radiographic assessment in the emergency department of a hospital.
Broken bonded retainer	- If the whole bonded retainer is loose and the patient cannot be seen in person by the orthodontist, the retainer should be left outside of the mouth. The patient should be advised to wear their removable retainer (if provided) until their next visit with the orthodontist when the clinic/practice reopens for routine treatment. - If only one or two teeth have resin pads that are loose and the patient cannot be seen in person by the orthodontist, the patient can: - attempt to push the loose retainer wire back towards its tooth as much as possible, or - cut the exposed unbonded part of the retainer using a sterile clipper (see previous example of protruding wire). - If only a small portion of the retainer is still bonded, a sterile tweezer can be used gently to pull and remove the whole retainer. If too much force is required to remove the retainer, then it should be cut with a sterile clipper.
Long, hanging gold chains that are severely irritating	- If the patient cannot be seen in person by the orthodontist, if possible, a piece of dental floss can be threaded through or tied around the last link at the loose end of the chain by the care provider at home, and then tied to a bracket so that it is no longer hanging and causing severe irritation. - It is not advised to cut the hanging long chain, as there is a risk of aspiration.
Broken or loose fixed expander or a lingual/palatal arch	- If the expander/lingual/palatal arch is partially glued and still present in the mouth, it can be placed back in position, and any remaining screw activations should be stopped until the patient can be seen in-person by the orthodontist. - If the expander has fallen out completely it should be kept in a safe place until further instructions are received from the orthodontist.
Broken intermaxillary spring, eg, Class II corrector appliance	- If completely broken (and the spring cannot be reattached to the rod) the patient or home care provider can use a piece of dental floss to secure the loose end of the appliance to the remaining archwire and brackets.
Part of orthodontic appliance embedded in the gingiva leading to severe pain and or infection	- This would represent a true emergency that could be seen by the orthodontist in office, provided that the patient has cleared the triage questions with respect to COVID-19 and the orthodontist has suitable PPE and if this is permitted by the local health regulatory bodies, or should be seen in a hospital setting. - If the patient cannot be seen in person by the orthodontist, the patient or home care provider can use a sterile clipper to cut the wire if it is attached to the broken or loose part and remove the broken part from the mouth using sterile tweezers. However, this may not be possible to do with large diameter wires.

^aAdapted from online resources posted on the websites of the American Association of Orthodontists, the British Orthodontic Society, and the Canadian Association of Orthodontists.

^bIn all emergencies, patients should first consult their orthodontic care provider and follow the recommendations provided by their orthodontic care provider. Orthodontists should consider the jurisdictional requirements and permissions of regulatory professional bodies of the area in which their practice is located. In-person emergency dental treatment, including handling of orthodontic emergencies may also be undertaken by general dental practitioners or other dental specialists in accordance with the jurisdictional requirements and permissions of regulatory professional bodies of the area in which their practice is located.

^cThese should be attempted only if it is safe for the patient to do so, or by a care provider who is capable of undertaking these steps at home, who should wear gloves if possible. Some of the methods and steps described here may not be possible for patients or care providers to perform if they have COVID-19 or are quarantined.

^dWax provided by the orthodontist or purchased from the drug store/pharmacy.