American Journal of Advances in Medical Science www.arnaca.com eissn: 2347-2766 Review Article Tooth avulsion-a Dental emergency in children: A Review Debapriya Pradhan 1, Prasant MC 2, Varsha H Tambe 3 1 Dept of Pediatric Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences, Karad- 415539, Maharashtra, India 2 Dept of Oral & Maxillofacial Surgery, RKDF Dental College, Bhopal- 462026, Madhya Pradesh, India. 3Dept of Conservative Dentistry and Endodontics, SMBT Dental College, Sangamner Taluka, Maharashtra, India Abstract Traumatic dental injuries like tooth luxation, avulsion, fracture or laceration of soft tissue often occurs in the children and young adults due to various etiological factors. Out of these, tooth avulsion comprises which comprises of 12-16% of dental complications in children and are considered as dental emergency as the success of treatment and the survival of tooth depends on the extraoral time duration of the avulsed tooth. In the present review article, an attempt has been made to enumerate etiology of dental avulsion in children, its storage media and the systematic management protocol. Keywords: Tooth avulsion, children, etiology and management Cite this article as: Debapriya Pradhan 1, Prasant MC 2, Varsha H Tambe 3. Tooth avulsion-a Dental emergency in children: A Review.. American Journal of Advances in Medical Science. 2014; 2(3): 15-20. Source of Support: Nil, Conflict of Interest: None declared 15
Introduction Traumatic dental injuries are one of the emergency conditions in children and it is the dentist s responsibility to save the offending tooth[1]. Among the various traumatic injuries of the orofacial region, avulsion requires emergency management. According to the World Health Organization (WHO) classification system, later modified by Andreasen, avulsion is classified as an injury of periodontal tissue [2]. Tooth avulsion The traumatic dental injuries occur most commonly between the ages 8 and 11 years, as the falling accidents in a school environment are very common. Avulsion injuries occur at 7 to 9 years most commonly, when the when permanent incisors are erupting and also favored by the elasticity of alveolar bone. Tooth avulsion is defined as the complete displacement of a tooth from its socket due to accidental or nonaccidental injury [3,4]. Avulsion occurs in 0.5% to 16% of traumatic injuries in permanent dentition and 7 to 13% involving the primary dentition. Mostly, avulsion involves a single tooth but multiple avulsions can occur due to trauma. Avulsion injuries are three times more frequent in boys than girls because of their active participation in sports and games [4]. Although various emergency measures have been advocated for the management of avulsed permanent tooth, most commonly accepted treatment of choice is the immediate replantation. The success of replantation of the avulsed tooth depends upon several factors, such as storage of the tooth until replantation, extra-alveolar period, the type of retention employed, oral hygiene status, time of endodontic intervention, type of drug prescribed and the overall general health of the patient. Dental avulsion injuries are most commonly associated not only with the physical concern, but also social, psychological and esthetic trauma [4]. It is therefore necessary that the parents, school teachers and the general dentists should have basic knowledge of the emergency management of the tooth avulsion, so that it will improve the prognosis of the avulsed teeth. Management protocol Management of the avulsed teeth is very complicated because of the involvement of the several components like the periodontal ligament (PDL) fibers, the neurovascular bundle at the root apex, the cement layer of the tooth, alveolar bone and the gingival [5]. Various steps should be followed for the patient s esthetic, social and psychological benefit, and prognosis of the offending tooth. Clinical examination For the assessment of the patient s condition and to give the necessary treatment, detailed examination of the patient should be done about the history of injury, medical history, neurological evaluation, any extraoral swelling, and dental examination. All of these are helpful 16
in the future treatment planning of the patient [3,6]. Treatment of root In the immediate treatment, the avulsed tooth should be rinsed carefully with saline or milk or clean water to remove all the contaminants and also the socket should be flushed with saline. After the traumatic injury, the tooth should be located and carried up by the crown or enamel portion and not the root [1,7,8]. The maintenance of the vitality of the periodontal ligament is most important in the success of the replantation, which allows tooth to adhere to survive and recover their function. 2 therefore the extraalveolar drying time is most critical in the replantation procedure [1,7]. For the replantation of teeth in children with incomplete root formation, the critical period of drying is 20 min. Also, the dry time of 20 60 min is shown to have 15% chance of optimal periodontal ligament (PDL) healing. But, teeth with closed apices have a significantly lower chance of healing [1]. Management of adjacent soft tissues Dental avulsion injuries are most commonly associated with soft tissue lacerations, which are sutured. Help of plastic surgeon can be taken in the areas of aesthetic importance like the lips [9]. Radiological examination A detailed radiographic examination is essential to know the status of oot development and the relation to the permanent successors, also to establish the extent of the injury to the supporting tissues. The type of radiograph to be taken depends on the type of injury suspected and the extent of injury [10]. Storage media The ideal storage medium should preserve the majority of the functional capacities of the cells of the periodontal ligament. Various storage media that can be used are Hanks balanced salt solution, saliva, saline solution, tap water, endogain, propolis, egg white, contact lens solution, milk and viaspan. Out of these hanks balanced salt solution is the preferred storage media, which preserves the components of tissue in its normal physiological conditions [11,12]. Special considerations in primary teeth [10] 1. Treatment of primary teeth related problems are usually difficult to treat because of fear and lack of cooperation from child patients. 2. As there is close relationship of the apex of primary tooth and the underlying permanent tooth germ, consequences like tooth malformation, impacted teeth and eruption disturbances in the developing permanent dentition can occur following severe injuries to primary teeth and/or alveolar bone. 3. Child s maturity, ability to cope with the emergency situation, occlusion and the time for 17
shedding of the injured tooth are all important factors that influence treatment selection in the child patient. 4. Also, most important factor that should be taken into consideration is frequency of repeated trauma episodes in children. It should be taken into consideration if planning endodontic treatment in an avulsed primary tooth. Replantation A. Primary teeth: Generally they are not replanted to avoid injury to the developing permanent tooth buds [13]. B. Permanent teeth: Treatment is usually complex, expensive, time consuming and often requires multidisciplinary approaches [6]. Tooth having closed apex Tooth with less than 60 min of First, tooth root is cleaned with saline and placed in the socket gently. Endodontic treatment is planned at the second visit [9]. Tooth with longer than 60 min of In this situation, the periodontal ligament is not expected to survive. Therefore, the root is prepared resist the resorption as possible. For the removal of necrotic tissue, the tooth is then soaked in acid for 5 min. Tooth is then placed in 2% sodium fluoride (NaF) for 20 min and then replanted. Endodontic treatment can be performed extraorally. 9 Tooth with open apex Tooth with less than 60 min of Tooth to be replanted is gently rinsed and then replanted. In this situation, endodontic treatment is not initiated until any signs of pathosis develop[9]. Tooth with more than 60 min of In these tooth, the periodontal ligament most becomes necrotic and healing is not expected to occur. Apexification procedure is started at the second visit after the tooth replantation[9]. Splinting Splinting procedures is usually done for the cases involving alveolar bone fractures or intra-alveolar root fractures [10,12]. Use of antibiotics Children s medical status and the severity of traumatic injury to soft tissues decide the use of antibiotics [10]. Complications Root resorption and ankyloses are the two most common complications observed in most of the replanted teeth, if the management protocols are not followed carefully [14,15]. Conclusion The avulsion of teeth should be considered as the dental emergency, as the length of extraoral time will affect the prognosis of the tooth. As the loss of teeth in the early age affect the patient s social, mental 18
status as well as self-confidence; avulsion should be treated as soon as possible. Thus every dental practitioner should know the management protocol and should be updated with the present treatment modality, so that it will be beneficial to the patient. References 1. Andreasen JO, Malmagren B, Barkland LK. Tooth avulsion in children: to replant or not. Endodon Topics. 2006;14: 28 34. 2. Singla A, Garg S, Dhindsa A, Jindal S. Re-implantation: Clinical implications and outcome of dry storage of avulsed teeth. J Clin Expt Dent. 2010; 2(1):38-42. 3. Fujita Y, Shiono Y, Maki K. Knowledge of emergency management of avulsed tooth among Japanese dental students. BMC oral Heal. 2014; 14(34):1-6. 4. Setty JV. Knocked-out tooth: Knowledge and attitudes of. J Den Res. 2009;3(3):9-16. 5. Karayilmaz H, Kirzioglu Z, Gungor OE. Aetiology, treatment patterns and long-term outcomes of tooth avulsion in children and adolescents. Pak J Med Sci. 2013; 29(2):464-468. 6. Hashim R. Physicians' knowledge and experience regarding the management of avulsed teeth in united arab emirates. J Int Dent Med Res. 2012; 5(2):91-95. 7. Verma L. Reimplantation of avulsed tooth A Case Study. J Exer Sci Physiother. 2010;6(2):126-129. 8. Ali FM, Bhushan P, Saujanya KP, Patil S, Sahane D. Dental trauma: Athletes, coaches, and school teachers must know-a brief review. Saudi J Sports Med. 2013; 13:7-9. 9. Hegd MN, Jain R. Tooth avulsion- A Dental emergency. Ind J Appl Res. 2013; 3(11):370-372. 10. Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: Dent Traumatol. 2012; 28:174-182. 11. Gomes MCB, Westphalen VPD, Westphalen FH, Neto UX, Fariniuk LF, Carneiro E. Study of storage media for avulsed teeth. Braz J Dent Traumatol. 2009;1(2):69-76. 12. Ali FM, Bhushan P, Khan MI, Ustad F. Attitude and knowledge towards tooth avulsion among sports teachers. Rev Progr. 2013;1(3):1-6. 13. Raina S. Traumatic injuries in children and management of avulsed tooth. Scien J. 2009;3: 23-28. 14. Singla M, Mittal N, Aggarwal R. Management of acute dental traumaavulsion and extrusive luxation: a case report. J Clin Diag Res. 2010;4:2596-600. 19
15. Rocha SRT, Moro A, Moresca RC, Sydney G, Fraiz F, Filho FB. Orthodontic treatment in patients with reimplanted teeth after traumatic avulsion: A case report. Dental Press J Orthod. 2010;15(4):40-2. 20