Traumatic dental emergencies are common worldwide and affect various age-groups. Dental trauma accounts for 5% of the injuries for which patients seek emergency treatment.1 Idzik and Krauss report an estimate of 0.3% of outpatient primary care visits were related to dental complaints, whereas the number of pediatric ED visits related to dental emergencies has steadily increased over the past two decades.2,3 Dental injuries can affect primary (deciduous) teeth as well as permanent teeth. Such injuries cause esthetic, psychological, social, and therapeutic problems.4
One particular type of dental injury is tooth avulsion, which is a complex traumatic injury to periodontal and pulpal tissue.5 Tooth avulsion, or exarticulation, is a dentoalveolar injury that occurs when the tooth is completely displaced from the alveolar socket, commonly due to various traumatic etiologies.6 Avulsion interrupts the periodontal ligament (PDL) cells (the neurovascular bundle at the root apex), the blood supply to the dental pulp, the alveolar bone, and the gingiva.7,8 The avulsion injury ruptures or splits the PDL cells away from the alveolar bone, and without sufficient treatment, rapidly threatens viability of the cells (see Dental avulsion). Such interruption is a well-recognized threat for tooth and cellular viability.9 Recommendations for management of avulsion injuries target both the diagnosis and treatment plan, as both contribute to the viability of the disarticulated tooth.1,8
The purpose of this article is to identify some of injuries leading to tooth avulsion, review evidence that documents a lack of knowledge in nondental providers, and then describe the assessment, diagnosis, and treatment plan for tooth avulsion injuries. A summary of recommendations for NP education as well as for those in clinical practice will be provided. Outside the scope of this article are other dental injuries or issues, such as tooth pain or infection.
Avulsion injuries are the result of trauma. While dental injuries can occur at any location, between 20% and 30% occur in the school setting.4 Pediatrics (children between birth and 18) represent the largest age-group of patients who sustain an avulsion injury. School nurses from New York reported seeing more than 250 cases per year.4 Data from a 10-year retrospective analysis of children and adolescent injuries suggested that the most commonly reported sources of trauma included falls (36.4%), traffic accidents (22.7%), bicycle accidents (18.2%), collisions (9.1%), and other nonspecified causes (13.6%).7
This same study identified that the average number of avulsed teeth were 1.4 per incident (69.7% had one avulsion; 19.7% had two; 10.6% had three) and were more likely to affect either maxillary central or lateral incisors.7 Ram and Cohenca added skateboards to the list of causes of injury.8 In preschool-age children, the incidence of injuries does not vary by gender, however during adolescence, more males reported injuries than females. School-age children were more likely to sustain a fall, while adolescents more likely experienced sports-related injuries or altercations.10 Dental avulsions may also be the result of physical child abuse, as many abuse cases have injuries in the orofacial region.1,10
The causes of tooth avulsion in adult patients are less established but share similar characteristics as those of children. In an Australian review article, researchers identified several studies involving adults with tooth avulsion injuries. Sports-related injuries (handball, ice hockey, basketball, soccer) were cited, of which many of the injured individuals were not wearing mouth guards.11 Slips and falls, in either the workplace or home setting, also contributed to dental avulsions.12 Laryngoscope blades used during endotracheal intubation have also been associated with dental avulsion.13
Need for knowledge
There is a need to increase NP knowledge as a resource for managing tooth avulsions.8 Several researchers have established the gap in medical care providers' knowledge related to tooth avulsions. Skapetis and colleagues identified that dental emergencies often present to the ED or for primary care consultation.11 NPs in these settings are sometimes ill equipped to manage the conditions due to a lack of education regarding dental injury management options and the limited occurrence of such events.
The authors recommended that interprofessional collaboration would lead to better patient outcomes. In a U.S. study, investigators tested ED physicians' knowledge of managing dental traumas.3 While limited to Massachusetts, the findings suggested that only half of the EDs had onsite dental coverage; therefore, half relied on the use of outside consultants. Formal policies on managing dental emergencies were nonexistent. Based on the surveys returned, the authors concluded that more than half of the participants lacked formal, dental injury-specific knowledge; furthermore, half felt that the tooth should not be replanted, and only 4% would provide treatment targeted to saving the tooth. An interesting finding was that those participants who had significant others in the dental profession had relevant knowledge of the subject. Emergency dental trauma knowledge is not limited to physicians. From a study examining New York school nurses, nearly 75% reported high self-confidence in the management of injury, but slightly more than half responded incorrectly to the information about replanting an avulsed tooth.4
A collective review of literature performed by the Association of periOperative Registered Nurses showed there was moderate evidence pertaining to the value of education and competency verification related to best practices for management of avulsed teeth.14 Such education and competency evaluation should be available to healthcare personnel involved in caring for patients with avulsed teeth.10 The benefits of providing such education outweigh the potential harms.10 Educational activities should also be extended to the community.
History. The injured patient, and often with family members, seek treatment for tooth avulsion injuries at a variety of locations. NPs should determine the cause and mechanism of injury, and establish the time that has lapsed since tooth avulsion, as these first steps in the management define the risk of associated injuries and begin to outline the treatment options available.6,15 The history of the chief complaint, therefore, focuses on these elements, and the practitioner should also review vital signs, including temperature and the need for tetanus and bacterial endocarditis prophylaxis.6,16
Clinical exam. NPs should be able to correctly identify normal findings. Identifying the avulsed tooth (or teeth) by number is generally the standard used in documentation (see Identifying avulsed teeth by number). The NP may need to make a determination if the injured tooth is primary (baby) or permanent (secondary), as primary teeth are not often reimplanted. The oral cavity is examined, and the NP should note the presence of bruising, lacerations, and confirm the absence of facial fractures.6,16 The exam should account for all tooth positions as well as any missing teeth or fragments.
It may be necessary to have the patient rinse the mouth with water in order to have a clear visual field.1 The assessment includes an evaluation of bite, occlusion, and mobility. A chest X-ray is warranted should there be a suspicion of accidental inhalation of the tooth. The practitioner may also consider head and abdomen films if the tooth is not accounted for. The avulsed tooth is also inspected with care given not to touch the roots.6,16
Treatment options. Avulsed teeth should be reimplanted as soon after injury as possible, as the PDL cells lose viability. 6,8 When in doubt, if the tooth is a primary or permanent tooth, the NP should reimplant and refer to the dental provider. The period between the injury (knocking out the tooth/teeth) and reimplantation is critical and must be adequately documented. NPs should have access to an established network for emergency dental referrals and to dental providers who have panoramic equipment to rule out other injuries. Some federally sponsored health centers have onsite dental services, and these referrals are equal to community-based dental providers. The time between the initial evaluation by the practitioner and entrance into an emergency dental network should be as minimal as possible. When necessary to remove debris, the provider can hold the tooth by the crown (avoiding touching the roots) and can then rinse the tooth with saline.6 If the socket has formed a clot, the practitioner should not remove it. Rather, the tooth should be seated back into the socket. The patient, if cooperative, should be advised to keep the tooth in place by biting gently on gauze during the transport time.6
If the tooth cannot be immediately reimplanted (in less than 20 minutes), it must be stored in an appropriate medium to preserve PDL viability.8 The NP must ensure the avoidance of a dry medium (wrapped in gauze for transport to the emergency dental center), as any period of greater than 15 minutes in a dry environment is associated with poor outcomes through cell necrosis.9 Avoid storing avulsed teeth in tap, distilled, or sterile water due to rapid cell lysis.9
An appropriate medium, such as a physiological solution that closely replicates the natural oral environment, is essential, and researchers have studied a wide breadth of transport mediums. Udoye and colleagues published a review of 17 various types of media and discussed practicalities, costs, and the lack of readily available options for consumers and NPs.9 From the perspective of consumers, milk remained the most practical storage medium of choice given its wide availability and the conclusion that PDL cells can remain viable for a period of up to 2 to 3 hours.
In the clinical setting, Hank's balanced salt solution (HBSS) at room temperature is a suitable medium, as the solution has electrolytes and a compatible osmolality. HBSS is asserted to have the ability to replenish metabolites in depleted PDL cells while preserving the avulsed tooth for a period of up to 24 hours.9 There are drawbacks to HBSS, including the cost and the availability. To overcome these barriers, one commercial product (Save-A-Tooth by Phoenix Lazerus, Inc.) has brought a special kit designed for public and provider use to the common marketplace. Isotonic, or 0.9% sodium chloride solution, has also been used. This solution has a maximum storage period of 1 hour but fails to provide any nutrients to the PDL. Saliva is another alternative media intended for temporary storage.14 (See Comparison of selected media associated with care of avulsed teeth.)
NPs should consider pharmacologic options as part of the treatment plan. Antimicrobial coverage can be achieved through the use of doxycycline, penicillin-based products, or metronidazole with dosages based on the patient's weight and allergy status.2,6,8,15 Consideration may also include the use of nonaspirin analgesic products. When appropriate, tetanus prophylaxis must be given and documented. In many states, dental providers are not authorized to order and administer tetanus vaccines. Therefore, it is important to communicate the treatment plan between all involved and identify which provider will take responsibility for the various components.
Prognosis of avulsion cases has wide variation. Under ideal diagnosis and treatment conditions, up to 75% of the teeth remain viable; there is no guarantee that even with prompt intervention all teeth can be saved.7 Therefore, all patients with dental avulsions should receive follow-up care with a dentist, as long-term sequelae may range from pulp death, root resorption, displacement, or other defects.15 The dental provider will establish the follow-up schedule, which may include weekly dental office visits up to 4 to 6 weeks post injury; then, a more relaxed biannual schedule for up to 5 years may be implemented.8
NPs are in a position to influence positive outcomes related to tooth avulsion. From a community perspective, NPs must advocate that emergency dental kits be more widely included in first-aid stations in gymnasiums, schools, playgrounds, ambulances, sports complexes, and hospitals.8 Additional education regarding the care of avulsed teeth should be widely available to lay individuals as well as healthcare providers. NP educators should examine curricula for such content and consider developing simulation or other competency measures. Practicing NPs should have an established network with dental providers for consultation, follow-up, and collaboration.
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