Diogo Magalhães

Germano Rocha

JIBM

Journal of Anesthesia & Clinical Research

Open Repository of the University of Porto

Accidental Dental Avulsion Caused by Direct Laringoscopy
Joana Barros Mourão*, Diogo Magalhães and Germano Neves Pinto Rocha
Anesthesiologist, Centro Hospitalar São João, Anesthesiology, Alameda Professor HernaniMonteiro Oporto, Portugal
*Corresponding author: Joana Barros Mourão, Anesthesiologist, Centro Hospitalar São João, Anesthesiology, Alameda Professor HernaniMonteiro Oporto, Portugal,
Tel: 00351966312610; E-mail: joanamourao1@sapo.pt
Copyright: © 2014 Mourao JB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received date: February 20, 2014; Accepted date: April 07, 2014; Published date: April 18, 2014
Abstract
Background: Damage to the teeth is one of the most common complications of tracheal intubation. The aim of
this study is to provide the knowledge on how anesthesiologists should act when faced with dental avulsion.
Methods: A multiple choice survey made up of eleven questions was delivered at a Portuguese Anesthesiologist
meeting. Statistical analysis was performed using the spss17.0 software and all the answers were expressed in
descriptive frequency distributions and percentages.
Results: The sample consisted of 65 anesthesiologists, 37 specialists (56.9%) and 28 internees (43.1%). In
response to, what to do if a tooth came out of its socket, only 13.8% would put it back. The majority (86.2%)
preferred taking it out despising the possible conditions of the tooth and bone. From the latter group, 90.1% chose to
preserve the tooth and send the patient to a dentist. When reimplantation was considered, a small percentage
(10.8%) chose to do it immediately. Also 32.3% decided to reimplant the tooth in the recovery room and the other
32.3% admitted not knowing when. As to the splinting of the anterior teeth, just 26.2 % of the respondents would
consider using it. The others wouldn't, either because it would be their decision (33.8%) or because they wouldn't
know how to do it (40.0%). In order to determine the evaluation of periodontal conditions, most anesthesiologists
confirmed not to use any guidelines (69.2%) and 84.6% of the respondents denied having been taught anything in
this particular area.
Conclusion: The majority (86.2%) confirmed not having been given such information. To help prevent and treat
dental avulsion, having knowledge in this area is essential.
Keywords: Dental avulsion; Laringoscopy; Anesthesia complications
Introduction
During general anesthesia the airway’s patency has been the main
care given by anesthesiologists. From all available techniques, the
tracheal intubation by direct laryngoscopy continues to be the most
efficient and fastest technique. It guarantees not only success, but also
safety to mechanically maintained airway ventilation [1]. Although it
is a tool of great benefit, the technique itself could cause severe dental
trauma.
The direct laryngoscopy technique consists of inserting a blade of
the laryngoscope, moving the tongue of the patient to his left side [2].
Upon visualization of the epiglottis the laryngoscope is then pulled
antero-superiorly to expose the glottis cleft where the orotracheal tube
is then inserted. It is during this last step that the majority of dental
traumas occurs.It is expected, however, that no pressure should be
applied to the teeth, lips and mucosa as well [3]. In a study by Taeko et
al. the maximum peak force applied to the superior incisors was 40.2N
[4]. Bucxand Snijders have also shown that the force transmitted while
using the superior incisors as a lever was much higher than normal [5]
making it easier to gain access to the glottis. Despite traditional advice
to the contrary, the levering movement of the laryngoscope, using the
maxillary incisors (or gums), is common practice [6]. From all possible
traumas, dental trauma variesfrom 1:1000 to 1:10 [7], being the central
maxillary incisors the most struck.
It is of great importance to understand that, oral trauma, due to an
unsuitable technique, can cause not only transient lesions (oedema
and haemorrhage) but also permanent damage [8], being avulsion the
most traumatic one. In a study by Hoffman et al. 20.8% of all dental
trauma were avulsions [9]. This is such a relevant problem that the
Medical Defence Union has already named it the most frequent cause
of compensation during general anesthesia (63%) [10].
The aim of this study is to evaluate the level of knowledge that
Anesthesiologists have towards an accidental dental avulsion and how
they act when faced with one.
Material and Methods
After approval of The Ethic Council of the Faculty of Dental
Medicine of Porto’s University, a survey was delivered at a Portuguese
Anesthesiologist meeting. The main objective of the questionnaire was
to understand how they would act when faced with an accidental
avulsion. The survey consisted ofeleven questions presented on Table
1.
1) If a tooth came out of its socket, what would you do?
2) How would you pick the tooth up?
3) If taken out should it be cleaned and with what?
4) If preserved in any liquid which would you use?
Anesthesia & Clinical Research Mourão et al,, J Anesth Clin Res 2014, 5:4http://dx.doi.org/10.4172/2155-6148.1000400
Research Article Open Access
J Anesth Clin Res
ISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400
5) What would you do with the avulsioned tooth?
6) If reimplantation was an option, when would it be done?
7) Before reimplantation, which liquid would you irrigate it with?
8) Regarding dental splinting, what would you use?
9) During the pre-surgery consultation, do you do dental/periodontal
evaluation?
10) Were you at any time of your medical training instructed in this area?
11) If yes, when
Table1: Questionnaire
Statistical analysis was performed using thespss 17.0 software
package by IBM (SPSS Inc., Chicago, IL, USA) and all the answers
were expressed in descriptive frequency distributions and percentages.
Results
The sample was made up of 65 anesthesiologists, 37 specialists
(56.9%) and 28 internees (43,1%). 23.1% were male and 72.3% female,
with an overall average of 10.8 years of experience (n=64, σ=8.33) as
shown in Table 2.
N Minimum Maximum Mean Std. Deviation
Years/experience 64 1.00 34.00 10.8047 8.33220
Table 2: Descriptive statistics of answers about the years of experience
In response to the first question, what to do if a tooth came out of
its socket, only 13.8% would put it back. The majority (86.2%)
preferred to take it out ignoring the possible conditions of the tooth
and bone (Table 3a). From this group, 90.1% chose to preserve the
tooth and send the patient to a dentist (Table 4).
Question 1
Take it out, n (%) 56 (86.2)
Put it back in the socket, n (%) 9 (13.8)
Question 2
Root, n (%) 5 (7.7)
Crown, n (%) 27 (41.5)
Any position, n (%) 33 (50.8)
Question 3
Don’t clean it, n (%) 32 (49.2)
water or other, n (%) 16 (24.6)
with a gauze, n (%) 17 (26.2)
Question 4
Water, n (%) 6 (9.2)
Serum, n (%) 51 (78.5)
Saliva, n (%) 3 (4.6)
Other, n (%) 1 (1.5)
Don’t know, n (%) 4 (6.2)
Question 5
Reimplant , n (%) 7 (10.8)
Won’t reimplant, n (%) 3 (4.6)
Preserve/contact dentist, n (%) 54 (83.1)
Don’t know, n (%) 1 (1.5)
Table 3a: Percentage distribution of answers about tooth avulsion
knowledge and procedure
When reimplantation was considered, only a small percentage
(10.8%) would choose to do it immediately and 15.4% during the
maintenance of the anesthesia. Also 32.3% would decide to reimplant
the tooth in the recovery room and the other 32.3% admitted not
knowing the procedure. As to the splinting of the anterior teeth, only
26.2% of the respondents would consider using it. Most wouldn’t,
either because they wouldn’t find it appropriate (33.8%) or because
they wouldn’t know how to (40.0%) as shown in Table 3b.
Question 6
Immediately after avulsion, n (%) 7 (10.8)
During anaesthesia, n (%) 10 (15.4)
During emergency of anaesthesia, n (%) 1 (1.5)
Recovery, n (%) 21 (32.3)
Other, n (%) 5 (7.7)
Don’t know/ contact dentist, n (%) 21 (32.3)
Question 7
Serum, n (%) 41 (63.1)
Hydrogen peroxide, n (%) 2 (3.1)
Alcohol, n (%) 2 (3.1)
Other, n (%) 4 (6.2)
Don’tknow, n (%) 16 (24.6)
Question 8
Don’t use splint, n (%) 22 (33.8)
Resin, n (%) 12 (18.5)
Rigidsplint, n (%) 2 (3.1)
Flexible splint, n (%) 3 (4.6)
Don’t know, n (%) 26 (40.0)
Table 3b: Percentage distribution of answers about tooth avulsion
knowledge and procedure
In order to determine the evaluation of periodontal conditions
before surgery, most anesthesiologists confirm not having used any
guidelines (69.2%) in comparison to 27.7% that actually use them.
Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.
doi:10.4172/2155-6148.1000400
Page 2 of 4
J Anesth Clin Res
ISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400
Finally, 84.6% of the respondents denied having been taught anything
in this particular area (Table 3c).
Question 9
Guidelines, n (%) 18 (27.7)
No guidelines, n (%) 45 (69.2)
Don’t evaluate, n (%) 2 (3.2)
Question 10
Yes, n (%) 9 (13.8)
No, n (%) 56 (86.2)
Question 11
Medical school, n (%) 0 (0)
Internee, n (%) 9 (13.8)
Without answer, n (%) 56 (86.2)
Table 3c: Percentage distribution of answers about tooth avulsion
knowledge and procedure
Question 5/
Question 1
Reimplant Won’t
Reimplan
t
Conserve Don’t
Know
Total
Take the tooth
out
1 (1.8%) 3 (5,3%) 51
(90,1%)
1 (1.8%) 56 (100%)
Put it back 6 (66, 7%) 0 3 (33, 3%) 0 9
Table 4: Crosstab relationship between Question 1 and 5
Discussion
Understanding and knowing the conditions and protocols for a
viable reimplant of an avulsioned tooth is of great importance.
Although time is crucial for the success of reimplantation, doing this
procedure after its avulsion is often not possible during laryngoscopy.
As shown, 86.2% of the anesthesiologists prefer to take the tooth out
and preserve it (90.1%). Even when the reimplantation option was
given, the majority (83.1%) still preferred to preserve it and later send
the patient to a dentist. This would reduce drastically the chances of
viable tooth reimplantation. Even so, all the respondents were asked
when a tooth should be reimplanted. Only 10.8% would do it
immediately and 15.4% during the maintenance of the anesthesia.
According to Adersson and when indicated, reimplantations within 15
min after avulsion have a favorable long-term prognosis [11].
Assuming it is not a minor intervention, this makes of the option
chosen the best time approach for reimplantation in the surgery room.
Still, most respondents would choose to do it after that time (41.5%) or
wouldn’t know when to carry it out (32.3%).
Immediate reimplantation is, most of the times, impossible and the
condition of the cells of the periodontal ligament is of utmost
importance. After a dry time of 60 min or more, all periodontal
ligament (PDL) is non-viable [12] and, therefore, a compatible
physiologic storage medium should be used [12-14]. The majority of
the respondents (78.5%) answered correctly, selecting a saline solution
(Serum). Only 9.2% chose water as its storage, which should also be
avoided, since it causes rapid cell lysis and inflammation on
reimplantation due to the hypotonic environment. Therefore it is not
advisable to use it as a storage medium [14].
Knowing how to handle a tooth correctly is also important in order
to reduce the probability/risk of root absorption and/or ankylosis [15].
If a tooth, after avulsion, is picked up by the root, as seen in 7.7% of
the answers, the chances of damaging the PDL are high and should
hence be avoided. Even so, 50.8% would pick it up in any convenient
position. Almost half of the respondents wouldn’t clean it (49.2%),
Cleaning should be refrainedsince the surgery room is already sterile.
This action will further damage the PDL, not so much if water is used
(24.6%) but drastically if cleaned with a gauze (26.2%), increasing the
chances of akylosis and root absorption.
A Flexible splint for the avulsioned teeth is recommended within
7-14 days [12,16] or 4-8weeks if alveolar fracture is visible [13]. When
using flexible splints, it is possible for a tooth to have a slight motion,
promoting periodontal healing [12] with less ankylosis [15]. In the
present study, the lack of such information is obvious, considering this
choice was only made by 4.6% of the respondents. The majority chose
either not to use it [8], or didn’t know how to (40%).
Anesthesiologists also need to take into account that not all teeth
are viable for reimplantation (e.g. advanced periodontal disease,
immunosuppression and severe caries) [12], hence the importance of
knowing how to make a correct periodontal evaluation before surgery.
It is expected that a majority of these avulsions should occur in
patients with grade 2 and 3 mobility, in which replantation isn’t
advised. Nevertheless, young permanent teeth with open apex still
remain a risk group where this treatment is necessary as well as in
other particular cases. This way, guidelines could help anesthesiologist
raise questions to whether reimplantation should be practiced in case
of avulsion, and even take measures to avoid this trauma. Prevention
should always be mandatory, either to prevent dental avulsions or
dental fractures. After being asked, 69.2% of the respondents affirm
not using any guidelines for a pre-surgical consultation and 3.1% don’t
do dental checkup at all. This is worrying in a way that patients with
moderate to severe periodontal disease are highly likely to suffer from
traumatic dental avulsion where previous dental splinting could help
lower or even prevent it from happening [12]. However, even if
damage to the tooth cannot be prevented, it is of great importance that
when faced with an unexpected avulsion, the anesthesiologist knows if
the reimplantantion option is viable or not.
Overall, as seen in this study, knowledge of this practice is somehow
unknown to anesthesiologists. This becomes a problem in a way that
anesthesiologists cannot guarantee, whenreimplantation is indicated, a
good outcome from the procedure itself leaving the patient with a
severe dental mutilation. This will not only affect the aesthetics and
difficulty to speak, as it will also become a reason for social
segregation. The majority (86.2%) of the respondents confirm not
having been given any information on this particular area.
Conclusion
To treat dental avulsion, anesthesiologists need such knowledge
that must be undertaken during their internship. It’s mandatory using
guidelines for dental and oral evaluation and to replantation of
accidental avulsed teeth duringlaryngoscopy.
Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.
doi:10.4172/2155-6148.1000400
Page 3 of 4
J Anesth Clin Res
ISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400
References
1. Nouruzi-Sedeh P, Schumann M, Groeben H (2009) Laryngoscopy via
Macintosh blade versus GlideScope: success rate and time for
endotracheal intubation in untrained medical personnel. Anesthesiology
110: 32-37.
2. Scott J, Baker PA (2009) How did the Macintosh laryngoscope become so
popular? PaediatrAnaesth 19 Suppl 1: 24-29.
3. Janeway HH (1913) Intratracheal anesthesia from the standpoint of the
nose, throat and oral surgeon with a description of a new instrument for
catheterizing the trachea. Laryngoscope 23: 1082-1090.
4. Fukuda T, Sugimoto Y, Yamashita S, Toyooka H, Tanaka M (2011)
Forces applied to the maxillary incisors during tracheal intubation and
dental injury risks of intubation by beginners: a manikin study.
ActaAnaesthesiol Taiwan 49: 12-15.
5. Bucx MJ, Snijders CJ (1996) Force, torque, and stress relaxation with
direct laryngoscopy. AnesthAnalg 83: 1130-1131.
6. Bucx MJ, Snijders CJ, van Geel RT, Robers C, van de Giessen H, et al.
(1994) Forces acting on the maxillary incisor teeth during laryngoscopy
using the Macintosh laryngoscope. Anaesthesia 49: 1064-1070.
7. Lockhart PB, Feldbau EV, Gabel RA, Connolly SF, Silversin JB (1986)
Dental complications during and after tracheal intubation. J Am Dent
Assoc 112: 480-483.
8. Aromaa U, Pesonen P, Linko K, Tammisto T (1988) Difficulties with
tooth protectors in endotracheal intubation. ActaAnaesthesiolScand 32:
304-307.
9. Hoffmann J, Westendorff C, Reinert S (2005) Evaluation of dental injury
following endotracheal intubation using the Periotest technique. Dent
Traumatol 21: 263-268.
10. Aitkenhead AR (2005) Injuries associated with anaesthesia. A global
perspective. Br J Anaesth 95: 95-109.
11. Andersson L, Bodin I (1990) Avulsed human teeth replanted within 15
minutes--a long-term clinical follow-up study. Endod Dent Traumatol 6:
37-42.
12. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, et al. (2012)
International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 2. Avulsion of permanent
teeth. Dent traumatol 28: 88-96.
13. Trope M (2002) Clinical management of the avulsed tooth: present
strategies and future directions. Dent Traumatol 18: 1-11.
14. Blomlöf L (1981) Milk and saliva as possible storage media for
traumatically exarticulated teeth prior to replantation. Swed Dent J Suppl
8: 1-26.
15. Andreasen JO, Andreasen FM, Andersson L (2007) Textbook and color
atlas of traumatic injuries to the teeth. (4thedn), Wiley-Blackwell,
Oxford, UK, 444-488.
16. Maria AMA (1999) TratamentoClínico dos TraumatismosDentários.
(1stedn), São Paulo: ArtesMédicas, 223-265.
 
Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.
doi:10.4172/2155-6148.1000400
Page 4 of 4
J Anesth Clin Res
ISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400


English

Accidental Dental Avulsion Caused by Direct Laringoscopy

Repositório Aberto da Universidade do Porto

Accidental Dental Avulsion Caused by Direct LaringoscopyJoana Barros Mourão*, Diogo Magalhães and Germano Neves Pinto RochaAnesthesiologist, Centro Hospitalar São João, Anesthesiology, Alameda Professor HernaniMonteiro Oporto, Portugal*Corresponding author: Joana Barros Mourão, Anesthesiologist, Centro Hospitalar São João, Anesthesiology, Alameda Professor HernaniMonteiro Oporto, Portugal,Tel: 00351966312610; E-mail: joanamourao1@sapo.ptCopyright: © 2014 Mourao JB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.Received date: February 20, 2014; Accepted date: April 07, 2014; Published date: April 18, 2014AbstractBackground: Damage to the teeth is one of the most common complications of tracheal intubation. The aim ofthis study is to provide the knowledge on how anesthesiologists should act when faced with dental avulsion.Methods: A multiple choice survey made up of eleven questions was delivered at a Portuguese Anesthesiologistmeeting. Statistical analysis was performed using the spss17.0 software and all the answers were expressed indescriptive frequency distributions and percentages.Results: The sample consisted of 65 anesthesiologists, 37 specialists (56.9%) and 28 internees (43.1%). Inresponse to, what to do if a tooth came out of its socket, only 13.8% would put it back. The majority (86.2%)preferred taking it out despising the possible conditions of the tooth and bone. From the latter group, 90.1% chose topreserve the tooth and send the patient to a dentist. When reimplantation was considered, a small percentage(10.8%) chose to do it immediately. Also 32.3% decided to reimplant the tooth in the recovery room and the other32.3% admitted not knowing when. As to the splinting of the anterior teeth, just 26.2 % of the respondents wouldconsider using it. The others wouldn't, either because it would be their decision (33.8%) or because they wouldn'tknow how to do it (40.0%). In order to determine the evaluation of periodontal conditions, most anesthesiologistsconfirmed not to use any guidelines (69.2%) and 84.6% of the respondents denied having been taught anything inthis particular area.Conclusion: The majority (86.2%) confirmed not having been given such information. To help prevent and treatdental avulsion, having knowledge in this area is essential.Keywords: Dental avulsion; Laringoscopy; Anesthesia complicationsIntroductionDuring general anesthesia the airway’s patency has been the maincare given by anesthesiologists. From all available techniques, thetracheal intubation by direct laryngoscopy continues to be the mostefficient and fastest technique. It guarantees not only success, but alsosafety to mechanically maintained airway ventilation [1]. Although itis a tool of great benefit, the technique itself could cause severe dentaltrauma.The direct laryngoscopy technique consists of inserting a blade ofthe laryngoscope, moving the tongue of the patient to his left side [2].Upon visualization of the epiglottis the laryngoscope is then pulledantero-superiorly to expose the glottis cleft where the orotracheal tubeis then inserted. It is during this last step that the majority of dentaltraumas occurs.It is expected, however, that no pressure should beapplied to the teeth, lips and mucosa as well [3]. In a study by Taeko etal. the maximum peak force applied to the superior incisors was 40.2N[4]. Bucxand Snijders have also shown that the force transmitted whileusing the superior incisors as a lever was much higher than normal [5]making it easier to gain access to the glottis. Despite traditional adviceto the contrary, the levering movement of the laryngoscope, using themaxillary incisors (or gums), is common practice [6]. From all possibletraumas, dental trauma variesfrom 1:1000 to 1:10 [7], being the centralmaxillary incisors the most struck.It is of great importance to understand that, oral trauma, due to anunsuitable technique, can cause not only transient lesions (oedemaand haemorrhage) but also permanent damage [8], being avulsion themost traumatic one. In a study by Hoffman et al. 20.8% of all dentaltrauma were avulsions [9]. This is such a relevant problem that theMedical Defence Union has already named it the most frequent causeof compensation during general anesthesia (63%) [10].The aim of this study is to evaluate the level of knowledge thatAnesthesiologists have towards an accidental dental avulsion and howthey act when faced with one.Material and MethodsAfter approval of The Ethic Council of the Faculty of DentalMedicine of Porto’s University, a survey was delivered at a PortugueseAnesthesiologist meeting. The main objective of the questionnaire wasto understand how they would act when faced with an accidentalavulsion. The survey consisted ofeleven questions presented on Table1.1) If a tooth came out of its socket, what would you do?2) How would you pick the tooth up?3) If taken out should it be cleaned and with what?4) If preserved in any liquid which would you use?Anesthesia & Clinical Research Mourão et al,, J Anesth Clin Res 2014, 5:4http://dx.doi.org/10.4172/2155-6148.1000400Research Article Open AccessJ Anesth Clin ResISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 10004005) What would you do with the avulsioned tooth?6) If reimplantation was an option, when would it be done?7) Before reimplantation, which liquid would you irrigate it with?8) Regarding dental splinting, what would you use?9) During the pre-surgery consultation, do you do dental/periodontalevaluation?10) Were you at any time of your medical training instructed in this area?11) If yes, whenTable1: QuestionnaireStatistical analysis was performed using thespss 17.0 softwarepackage by IBM (SPSS Inc., Chicago, IL, USA) and all the answerswere expressed in descriptive frequency distributions and percentages.ResultsThe sample was made up of 65 anesthesiologists, 37 specialists(56.9%) and 28 internees (43,1%). 23.1% were male and 72.3% female,with an overall average of 10.8 years of experience (n=64, σ=8.33) asshown in Table 2.N Minimum Maximum Mean Std. DeviationYears/experience 64 1.00 34.00 10.8047 8.33220Table 2: Descriptive statistics of answers about the years of experienceIn response to the first question, what to do if a tooth came out ofits socket, only 13.8% would put it back. The majority (86.2%)preferred to take it out ignoring the possible conditions of the toothand bone (Table 3a). From this group, 90.1% chose to preserve thetooth and send the patient to a dentist (Table 4).Question 1Take it out, n (%) 56 (86.2)Put it back in the socket, n (%) 9 (13.8)Question 2Root, n (%) 5 (7.7)Crown, n (%) 27 (41.5)Any position, n (%) 33 (50.8)Question 3Don’t clean it, n (%) 32 (49.2)water or other, n (%) 16 (24.6)with a gauze, n (%) 17 (26.2)Question 4Water, n (%) 6 (9.2)Serum, n (%) 51 (78.5)Saliva, n (%) 3 (4.6)Other, n (%) 1 (1.5)Don’t know, n (%) 4 (6.2)Question 5Reimplant , n (%) 7 (10.8)Won’t reimplant, n (%) 3 (4.6)Preserve/contact dentist, n (%) 54 (83.1)Don’t know, n (%) 1 (1.5)Table 3a: Percentage distribution of answers about tooth avulsionknowledge and procedureWhen reimplantation was considered, only a small percentage(10.8%) would choose to do it immediately and 15.4% during themaintenance of the anesthesia. Also 32.3% would decide to reimplantthe tooth in the recovery room and the other 32.3% admitted notknowing the procedure. As to the splinting of the anterior teeth, only26.2% of the respondents would consider using it. Most wouldn’t,either because they wouldn’t find it appropriate (33.8%) or becausethey wouldn’t know how to (40.0%) as shown in Table 3b.Question 6Immediately after avulsion, n (%) 7 (10.8)During anaesthesia, n (%) 10 (15.4)During emergency of anaesthesia, n (%) 1 (1.5)Recovery, n (%) 21 (32.3)Other, n (%) 5 (7.7)Don’t know/ contact dentist, n (%) 21 (32.3)Question 7Serum, n (%) 41 (63.1)Hydrogen peroxide, n (%) 2 (3.1)Alcohol, n (%) 2 (3.1)Other, n (%) 4 (6.2)Don’tknow, n (%) 16 (24.6)Question 8Don’t use splint, n (%) 22 (33.8)Resin, n (%) 12 (18.5)Rigidsplint, n (%) 2 (3.1)Flexible splint, n (%) 3 (4.6)Don’t know, n (%) 26 (40.0)Table 3b: Percentage distribution of answers about tooth avulsionknowledge and procedureIn order to determine the evaluation of periodontal conditionsbefore surgery, most anesthesiologists confirm not having used anyguidelines (69.2%) in comparison to 27.7% that actually use them.Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.doi:10.4172/2155-6148.1000400Page 2 of 4J Anesth Clin ResISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400Finally, 84.6% of the respondents denied having been taught anythingin this particular area (Table 3c).Question 9Guidelines, n (%) 18 (27.7)No guidelines, n (%) 45 (69.2)Don’t evaluate, n (%) 2 (3.2)Question 10Yes, n (%) 9 (13.8)No, n (%) 56 (86.2)Question 11Medical school, n (%) 0 (0)Internee, n (%) 9 (13.8)Without answer, n (%) 56 (86.2)Table 3c: Percentage distribution of answers about tooth avulsionknowledge and procedureQuestion 5/Question 1Reimplant Won’tReimplantConserve Don’tKnowTotalTake the toothout1 (1.8%) 3 (5,3%) 51(90,1%)1 (1.8%) 56 (100%)Put it back 6 (66, 7%) 0 3 (33, 3%) 0 9Table 4: Crosstab relationship between Question 1 and 5DiscussionUnderstanding and knowing the conditions and protocols for aviable reimplant of an avulsioned tooth is of great importance.Although time is crucial for the success of reimplantation, doing thisprocedure after its avulsion is often not possible during laryngoscopy.As shown, 86.2% of the anesthesiologists prefer to take the tooth outand preserve it (90.1%). Even when the reimplantation option wasgiven, the majority (83.1%) still preferred to preserve it and later sendthe patient to a dentist. This would reduce drastically the chances ofviable tooth reimplantation. Even so, all the respondents were askedwhen a tooth should be reimplanted. Only 10.8% would do itimmediately and 15.4% during the maintenance of the anesthesia.According to Adersson and when indicated, reimplantations within 15min after avulsion have a favorable long-term prognosis [11].Assuming it is not a minor intervention, this makes of the optionchosen the best time approach for reimplantation in the surgery room.Still, most respondents would choose to do it after that time (41.5%) orwouldn’t know when to carry it out (32.3%).Immediate reimplantation is, most of the times, impossible and thecondition of the cells of the periodontal ligament is of utmostimportance. After a dry time of 60 min or more, all periodontalligament (PDL) is non-viable [12] and, therefore, a compatiblephysiologic storage medium should be used [12-14]. The majority ofthe respondents (78.5%) answered correctly, selecting a saline solution(Serum). Only 9.2% chose water as its storage, which should also beavoided, since it causes rapid cell lysis and inflammation onreimplantation due to the hypotonic environment. Therefore it is notadvisable to use it as a storage medium [14].Knowing how to handle a tooth correctly is also important in orderto reduce the probability/risk of root absorption and/or ankylosis [15].If a tooth, after avulsion, is picked up by the root, as seen in 7.7% ofthe answers, the chances of damaging the PDL are high and shouldhence be avoided. Even so, 50.8% would pick it up in any convenientposition. Almost half of the respondents wouldn’t clean it (49.2%),Cleaning should be refrainedsince the surgery room is already sterile.This action will further damage the PDL, not so much if water is used(24.6%) but drastically if cleaned with a gauze (26.2%), increasing thechances of akylosis and root absorption.A Flexible splint for the avulsioned teeth is recommended within7-14 days [12,16] or 4-8weeks if alveolar fracture is visible [13]. Whenusing flexible splints, it is possible for a tooth to have a slight motion,promoting periodontal healing [12] with less ankylosis [15]. In thepresent study, the lack of such information is obvious, considering thischoice was only made by 4.6% of the respondents. The majority choseeither not to use it [8], or didn’t know how to (40%).Anesthesiologists also need to take into account that not all teethare viable for reimplantation (e.g. advanced periodontal disease,immunosuppression and severe caries) [12], hence the importance ofknowing how to make a correct periodontal evaluation before surgery.It is expected that a majority of these avulsions should occur inpatients with grade 2 and 3 mobility, in which replantation isn’tadvised. Nevertheless, young permanent teeth with open apex stillremain a risk group where this treatment is necessary as well as inother particular cases. This way, guidelines could help anesthesiologistraise questions to whether reimplantation should be practiced in caseof avulsion, and even take measures to avoid this trauma. Preventionshould always be mandatory, either to prevent dental avulsions ordental fractures. After being asked, 69.2% of the respondents affirmnot using any guidelines for a pre-surgical consultation and 3.1% don’tdo dental checkup at all. This is worrying in a way that patients withmoderate to severe periodontal disease are highly likely to suffer fromtraumatic dental avulsion where previous dental splinting could helplower or even prevent it from happening [12]. However, even ifdamage to the tooth cannot be prevented, it is of great importance thatwhen faced with an unexpected avulsion, the anesthesiologist knows ifthe reimplantantion option is viable or not.Overall, as seen in this study, knowledge of this practice is somehowunknown to anesthesiologists. This becomes a problem in a way thatanesthesiologists cannot guarantee, whenreimplantation is indicated, agood outcome from the procedure itself leaving the patient with asevere dental mutilation. This will not only affect the aesthetics anddifficulty to speak, as it will also become a reason for socialsegregation. The majority (86.2%) of the respondents confirm nothaving been given any information on this particular area.ConclusionTo treat dental avulsion, anesthesiologists need such knowledgethat must be undertaken during their internship. It’s mandatory usingguidelines for dental and oral evaluation and to replantation ofaccidental avulsed teeth duringlaryngoscopy.Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.doi:10.4172/2155-6148.1000400Page 3 of 4J Anesth Clin ResISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400References1. Nouruzi-Sedeh P, Schumann M, Groeben H (2009) Laryngoscopy viaMacintosh blade versus GlideScope: success rate and time forendotracheal intubation in untrained medical personnel. Anesthesiology110: 32-37.2. Scott J, Baker PA (2009) How did the Macintosh laryngoscope become sopopular? PaediatrAnaesth 19 Suppl 1: 24-29.3. Janeway HH (1913) Intratracheal anesthesia from the standpoint of thenose, throat and oral surgeon with a description of a new instrument forcatheterizing the trachea. Laryngoscope 23: 1082-1090.4. Fukuda T, Sugimoto Y, Yamashita S, Toyooka H, Tanaka M (2011)Forces applied to the maxillary incisors during tracheal intubation anddental injury risks of intubation by beginners: a manikin study.ActaAnaesthesiol Taiwan 49: 12-15.5. Bucx MJ, Snijders CJ (1996) Force, torque, and stress relaxation withdirect laryngoscopy. AnesthAnalg 83: 1130-1131.6. Bucx MJ, Snijders CJ, van Geel RT, Robers C, van de Giessen H, et al.(1994) Forces acting on the maxillary incisor teeth during laryngoscopyusing the Macintosh laryngoscope. Anaesthesia 49: 1064-1070.7. Lockhart PB, Feldbau EV, Gabel RA, Connolly SF, Silversin JB (1986)Dental complications during and after tracheal intubation. J Am DentAssoc 112: 480-483.8. Aromaa U, Pesonen P, Linko K, Tammisto T (1988) Difficulties withtooth protectors in endotracheal intubation. ActaAnaesthesiolScand 32:304-307.9. Hoffmann J, Westendorff C, Reinert S (2005) Evaluation of dental injuryfollowing endotracheal intubation using the Periotest technique. DentTraumatol 21: 263-268.10. Aitkenhead AR (2005) Injuries associated with anaesthesia. A globalperspective. Br J Anaesth 95: 95-109.11. Andersson L, Bodin I (1990) Avulsed human teeth replanted within 15minutes--a long-term clinical follow-up study. Endod Dent Traumatol 6:37-42.12. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, et al. (2012)International Association of Dental Traumatology guidelines for themanagement of traumatic dental injuries: 2. Avulsion of permanentteeth. Dent traumatol 28: 88-96.13. Trope M (2002) Clinical management of the avulsed tooth: presentstrategies and future directions. Dent Traumatol 18: 1-11.14. Blomlöf L (1981) Milk and saliva as possible storage media fortraumatically exarticulated teeth prior to replantation. Swed Dent J Suppl8: 1-26.15. Andreasen JO, Andreasen FM, Andersson L (2007) Textbook and coloratlas of traumatic injuries to the teeth. (4thedn), Wiley-Blackwell,Oxford, UK, 444-488.16. Maria AMA (1999) TratamentoClínico dos TraumatismosDentários.(1stedn), São Paulo: ArtesMédicas, 223-265. Citation: Mourão JB, Magalhães D, Rocha GNP (2014) Accidental Dental Avulsion Caused by Direct Laringoscopy. J Anesth Clin Res 5: 400.doi:10.4172/2155-6148.1000400Page 4 of 4J Anesth Clin ResISSN:2155-6148 JACR an open access journal Volume 5 • Issue 4 • 1000400

https://repositorio-aberto.up.pt/bitstream/10216/76118/2/88725.pdf

Accidental Dental Avulsion Caused by Direct Laringoscopy

Abstract

Similar works

Full text

Available Versions

Open Repository of the University of Porto

Repositório Aberto da Universidade do Porto