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Avulsed Teeth
APRIL 1991, VOL. 53, NO 4
AORN JOURNAL
Avulsed Teeth MANAGEMENT DURING ANESTHESIA INDUCTION, SURGERY Paul R. Krasner, DDS
T
eeth that are inadvertently avulsed (ie, knocked out) during endotracheal intubation or surgery can be stored, preserved, and replanted following the surgery. The long-term success of the replanted teeth depends on how the teeth are handled by operating room personnel before the replantation. Extensive research has determined the optimal factors necessary to sustain avulsed teeth. This article explains how operating room personnel should preserve avulsed teeth so optimum success of replanted avulsed teeth can be achieved. More than 90% of avulsed normal teeth can be retained long term with the correct treatment.' The proper treatment consists of the following:' immediate replantation or storage,
alignment into proper tooth relationship, fixation to the adjacent teeth, and 0 root canal treatment. Research has shown that a critical factor in saving these teeth is the length of time that the teeth are out of the mouth. A success rate of more than 90% is possible if the teeth are replanted within 15 to 30 minutes following an avulsion.' Laboratory experiments have shown that after 15 to 30 minutes, the success rate drops drastically (Table 1).4 This time limitation is related to the viability of the periodontal ligament (PDL) cells that surround the tooth root. The longer the PDL is cut off from its blood supply and the more storage trauma it sustains, the more cells necrose. A tooth that is replanted with necrotic periodontal ligament cells is more likely to be resorbed or fused to bone and be lost prematurely.
Storwge Media
U Paul R , Krasner, DDS, is u clinical assoc iufe professor a t T e m p l e U n i v e r s i t y , School of Dentistry, Philadelphia, and a Diplomatc of the Aniericun Board of Endodontics. H e receiivd his doctoiute in deiital surgery fimn Temple University, School id Dentistiy, Philadelphia. 998
'nder many circumstances, an avulsed tooth should be replanted immediately or stored in a safe biologic environment until it can be replanted. It is not advisable, however, to replant a tooth immediately in the patient in the operating room because the tooth cannot be splinted into place, 0 it could become dislodged again and be aspirated, 0 it could move out of its proper position and require orthodontic movement at a later time, and
APRIL 1991, VOL. 5 3 , NO 4
AORN JOURNAL
Table 1
Replantation Success vs Extra-Oral Time 100
90 80 70
Percentage 60 of success 50 40
30 20 10 0
0
I
I
I
I
I
15
30
45
60
75
’
‘ P
90
Time (minutes) Without use tooth preserving ---
120
135
150
of a fluid With use of an optimal preserving fluid
it could be placed back into position in an improper angle. The additional manipulation required to correct these procedures can increase the chances of losing the tooth. Studies have shown that an avulsed tooth can be preserved for longer than 30 minutes outside of the mouth and still have a 90% postreplantation retention rate if it is kept in a proper storage medium.’ The PDL of the tooth must be bathed in a medium with a biocompatible osmolality, pH, and ingredients necessary to maintain cell metabolism (eg, glucose, magnesium [Mg++], calcium [Ca++], amino acids, vitamins).h Storage in a medium that is not compatible (eg, dry tissue, handkerchief) will diy the periodontal ligament cells excessively and cause degeneration (Table 2). Water is as damaging to the PDL as dry storage because it has an incompatible osmolality. In addition, the viability of the PDL can be nurtured or hindered by the physical characteristics of the fluid environment in which it is stored.
Liquid storage media (eg, saliva, saline solution), although moist and better than a dry environment, lack a compatible periodontal ligament cell osmolality and cause cell death.7 The most biologic storage medias are pH balanced, buffered, cell culture fluids.x Storage in a biologic fluid, known as Hank’s solution, can maintain t h e P D L cells in a viable state for at least 12 to 24 hours.’ In addition, Hank’s solution can reconstitute metabolized cell nutrients; PDL cells that are partially degenerated can be returned to normal function by being soaked i n Hank’s solution for 30 minutes. Any tooth that has been out of the mouth for 15 minutes should be soaked in the solution.“’ This permits adequate storage time until replantation can be accomplished without sacrificing long-term success. A fluid such a s Hank’s solution can be obtained from medical research supply houses. It also comes packaged in pre-made avulsed tooth preserving systems. This solution is very sensitive to bacteria, and it must be packaged under strict sterile conditions. Once the seal is removed, it must be discarded after 24 hours. 999
APRIL 1991, VOL. 53, NO 4
AORN JOURNAL
Table 2
Success Rate of Replanted Teeth - Soaking vs Nonsoaking
Percentage ofsuccess following replantation
60
-
50
-
4~
-
20
-
10
-
0
\
I
I
I
I
I
Minutes after avulsion accident
OR Handing, Preservation
T
he physician who is present at the time of the avulsion often does not have the knowledge, equipment, or time to perform the treatment properly. A dentist can most effectively treat the avulsion. When the surgery is completed and the patient is stable, a dentist can replant and splint the tooth. The time factor (ie, 15 to 30 minutes) is critical in replanting the tooth, but a dentist is rarely able to be located in time to replant, align, and splint the tooth. The best course of action for operating room personnel is biologic storage of the avulsed tooth until the surgery is complete. This environment should protect the tooth from being crushed, replenish depleted nutrients, and provide easy removal at the time of replantation. The tooth should not be wrapped in anything and should be suspended in a Hank's cell preserving solution to protect the PDL cells on the tooth root from being crushed. Dry gauze is contraindicated. Wet gauze should be avoided because it is abrasive and will crush the PDL cells. The avulsed tooth should be handled gently so a s not t o crush t h e cells of the PDL." Placing an avulsed tooth in a glass container can result in the PDL cells being damaged if
the tooth strikes the walls of this container. The operating room personnel can use t h e Emergency Tooth Preserving System to overcome this problem (Fig 1).'* This system is specifically designed for the proper storage and transportation of avulsed teeth. It is a self-contained and complete system that consists of a scientifically designed container, Hank's solution that can rejuvenate partially degenerated cells that have been out of the mouth for up to one hour following the accident, and a suspension netting that holds the tooth in a safe and nurturing environment (ie, Hank's solution) for 12 to 24 hours without sacrificing long-term success. If a tooth is preserved in the appropriate environment, the surgery can proceed while a dentist is being located. T h e tooth can be replanted by the dentist either in the operating room, the postanesthesia care unit, or when the patient is back in his hospital room.
Replantation
I
f a physician chooses to replant immediately, the tooth should be carefully placed back in the socket. A blood clot may impede complete seating of a tooth so the socket is gen-
F i g I . The Emergency Tooth Preserving System is designed for storing and transporting avulsed teeth.
tly flushed with isotonic saline. The tooth should then be properly aligned into the occlusion and fixed to the adjacent teeth with a semirigid fixation technique. Senii-rigid fixation permits functional movement of the tooth. An example of this fixation would b e 0.20 orthodontic wire connected to three orthodontic bonded brackets. Functional (ie, some tooth movement) is better than rigid (ie, no tooth movement) fixation because less fusion occurs with some functional tooth movement.” This splint should remain in place for no longer than two weeks.13 The possibility of stiffness or fusion to the bone increases after that time. The next phase of the treatment consists of root canal extirpation (ie, cleaning). This phase should occur within the first week following the avulsion. It should never be done while the tooth is out of the mouth.15 Exposure to the air and any increase in extra-oral time causes added cell nutrient depletion. The cells of the tooth also become crushed during this manipulation. If the root canal treatment is not done within a week, severe root resorption can rapidly occur resulting in the tooth loss despite any additional procedures.“
Summary
I
t is not known how often teeth are inadver-
tently knocked out in the operating room during intubation o r surgery. When it occurs, it can be very disturbing to the operat100.2
ing room personnel and the patient when he or she recovers from the surgery. Research has shown that most avulsed teeth can be saved by replanting them within 15 to 30 minutes, aligning and splinting them into proper position, and instituting appropriate follow-up care. Because a dentist cannot easily be found in this time period, a system designed specifically to preserve the teeth can be used to provide optimum care in these situations. By using such a system, the physician can proceed with the surgery knowing that all the appropria t e measures have been taken to save t h e knocked-out tooth. L Notes 1 . J 0 Andreasen, E Hjorting-Hansen, “Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss,” Acra Odontologica Scandinavica 24 (November 1966) 263-286; J 0 Andreasen, E Hjorting-Hansen, “Replantation of teeth. 11. Histological study of 22 replanted anterior teeth in humans,” Acru Odontologica Scandinuvica 24 (November 1966) 287-306. 2. Ad Hoc Committee on Treatment of the Avulsed Tooth, American Association of Endodontists, “Recommended guidelines for the treatment of the avulsed tooth,” Journal o,f Endodontics 9 (October 1983) 571; Council on Dental Therapeutics, Accepted Dental Therapeutics (Chicago: American Dental Association, 1984) 72. 3. Andreasen, Hjorting-Hansen,“Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss,” 263286; Andreasen, Hjorting-Hansen, “Replantation of teeth. 11. Histological study of 22 replanted anterior
AORN JOURNAL
teeth in humans,” 287-306; L Anderson, I Bodin, “Avulsed human teeth replanted within 15 minutes-a long-term clinical follow-up study,” Endodontics and Dental TvaumutoIog+y6 (February 1990) 37-42. 4. J 0 Andreasen, “The effect of pulp extirpation or root canal treatment on periodontal healing after replantation of permanent incisors in monkeys,” Journal of Endodontics 7 (June 1981) 245-252; J 0 Andreasen, L Kristerson, “The effect of extra-alveolar root filling with calcium hydroxide on periodontal healing after replatation of permanent incisors in monkeys,” Journal of Endodontics 7 (August 1981) 349-354. 5. L Blomlof, P Otteskog, “Viability of human periodontal ligament cells after storage in milk or saliva,” Scandinavian Journal of Dental Research 88 (October 1980) 436-440. 6. L Blomlof, P Otteskog, L Hammarstroni, “Effect of storage i n media with different ion strengths and osmolalities on human periodontal ligament cells,” Scandinavian Journal of Dental Research 89 (April 198 1 ) 180-187. 7. P Soder et al, “Effect of drying on viability of periodontal membrane,” Scandincrvian Journal of Dental Research 85 (March 1977) 164-168. 8. Blomlof, Otteskog, “Viability of human periodontal ligament cells after storage in milk or saliva,” 436-440; L Blomlof, Milk and Saliva a s P os si h 1e S t o r a
APRIL 1991, VOL. 53. NO 4
after replantation of mature permanent incisors in monkeys,” 43-53. 16. J 0 Andreasen, “Relationship between surface and inflammatory resorption and changes in the pulp after replantation of permanent incisors in monkeys,” Journal of Endodontics 8 (July 1981) 294301; J 0 Andreasen, “Analysis of pathogenesis and topography of replacement root resorption (ankylosis) after replantation of mature permanent incisors in monkeys,” Swedish Dental Journal 4 no 6 (1981) 23 1-240.
Preemployment Drug Screens Controversial Preemployment drug screens may identify risks of employee accident rates and poor performance, but they may indicate exaggerated facts, according to a study in the Nov 28, 1990, issue of the Journal of the American Medical
Association. Drug users have been reported to be involved in 200% to 300% more industrial accidents, sustain 400% more compensable injuries, and use 1,500%more sick leave. A recent study indicates such statistics may be exaggerated. From Sept 24, 1986, to Jan 6 , 1989, researchers performed urine drug screens
on nearly 5,000 job applicants at the US Postal Service Boston Management Sectional Center. Marijuana tests were sensitive for up to four weeks after use; cocaine tests were sensitive for up to 72 hours after use. Only confirmed positive tests were reported. Of 2,537 people who were hired, 2,229 (87.9%) tested negative, 198 (7.8%) tested positive for marijuana, 55 (2.2%) tested positive for cocaine, and 55 (2.2%) tested positive for other nontherapeutic drugs or multiple drugs. Researchers tracked new hires, examining the time until termination, absence rates, time until first work-related accident, and time until first report of disciplinary action. Those who had tested positive for marijuana had 55% more industrial accidents, 85% more injuries, and a 78% increase in absenteeism. Those positive for cocaine had a 145% increase in absenteeism and an 85% increase in injuries.
AORN JOURNAL
Avulsed Teeth MANAGEMENT DURING ANESTHESIA INDUCTION, SURGERY Paul R. Krasner, DDS
T
eeth that are inadvertently avulsed (ie, knocked out) during endotracheal intubation or surgery can be stored, preserved, and replanted following the surgery. The long-term success of the replanted teeth depends on how the teeth are handled by operating room personnel before the replantation. Extensive research has determined the optimal factors necessary to sustain avulsed teeth. This article explains how operating room personnel should preserve avulsed teeth so optimum success of replanted avulsed teeth can be achieved. More than 90% of avulsed normal teeth can be retained long term with the correct treatment.' The proper treatment consists of the following:' immediate replantation or storage,
alignment into proper tooth relationship, fixation to the adjacent teeth, and 0 root canal treatment. Research has shown that a critical factor in saving these teeth is the length of time that the teeth are out of the mouth. A success rate of more than 90% is possible if the teeth are replanted within 15 to 30 minutes following an avulsion.' Laboratory experiments have shown that after 15 to 30 minutes, the success rate drops drastically (Table 1).4 This time limitation is related to the viability of the periodontal ligament (PDL) cells that surround the tooth root. The longer the PDL is cut off from its blood supply and the more storage trauma it sustains, the more cells necrose. A tooth that is replanted with necrotic periodontal ligament cells is more likely to be resorbed or fused to bone and be lost prematurely.
Storwge Media
U Paul R , Krasner, DDS, is u clinical assoc iufe professor a t T e m p l e U n i v e r s i t y , School of Dentistry, Philadelphia, and a Diplomatc of the Aniericun Board of Endodontics. H e receiivd his doctoiute in deiital surgery fimn Temple University, School id Dentistiy, Philadelphia. 998
'nder many circumstances, an avulsed tooth should be replanted immediately or stored in a safe biologic environment until it can be replanted. It is not advisable, however, to replant a tooth immediately in the patient in the operating room because the tooth cannot be splinted into place, 0 it could become dislodged again and be aspirated, 0 it could move out of its proper position and require orthodontic movement at a later time, and
APRIL 1991, VOL. 5 3 , NO 4
AORN JOURNAL
Table 1
Replantation Success vs Extra-Oral Time 100
90 80 70
Percentage 60 of success 50 40
30 20 10 0
0
I
I
I
I
I
15
30
45
60
75
’
‘ P
90
Time (minutes) Without use tooth preserving ---
120
135
150
of a fluid With use of an optimal preserving fluid
it could be placed back into position in an improper angle. The additional manipulation required to correct these procedures can increase the chances of losing the tooth. Studies have shown that an avulsed tooth can be preserved for longer than 30 minutes outside of the mouth and still have a 90% postreplantation retention rate if it is kept in a proper storage medium.’ The PDL of the tooth must be bathed in a medium with a biocompatible osmolality, pH, and ingredients necessary to maintain cell metabolism (eg, glucose, magnesium [Mg++], calcium [Ca++], amino acids, vitamins).h Storage in a medium that is not compatible (eg, dry tissue, handkerchief) will diy the periodontal ligament cells excessively and cause degeneration (Table 2). Water is as damaging to the PDL as dry storage because it has an incompatible osmolality. In addition, the viability of the PDL can be nurtured or hindered by the physical characteristics of the fluid environment in which it is stored.
Liquid storage media (eg, saliva, saline solution), although moist and better than a dry environment, lack a compatible periodontal ligament cell osmolality and cause cell death.7 The most biologic storage medias are pH balanced, buffered, cell culture fluids.x Storage in a biologic fluid, known as Hank’s solution, can maintain t h e P D L cells in a viable state for at least 12 to 24 hours.’ In addition, Hank’s solution can reconstitute metabolized cell nutrients; PDL cells that are partially degenerated can be returned to normal function by being soaked i n Hank’s solution for 30 minutes. Any tooth that has been out of the mouth for 15 minutes should be soaked in the solution.“’ This permits adequate storage time until replantation can be accomplished without sacrificing long-term success. A fluid such a s Hank’s solution can be obtained from medical research supply houses. It also comes packaged in pre-made avulsed tooth preserving systems. This solution is very sensitive to bacteria, and it must be packaged under strict sterile conditions. Once the seal is removed, it must be discarded after 24 hours. 999
APRIL 1991, VOL. 53, NO 4
AORN JOURNAL
Table 2
Success Rate of Replanted Teeth - Soaking vs Nonsoaking
Percentage ofsuccess following replantation
60
-
50
-
4~
-
20
-
10
-
0
\
I
I
I
I
I
Minutes after avulsion accident
OR Handing, Preservation
T
he physician who is present at the time of the avulsion often does not have the knowledge, equipment, or time to perform the treatment properly. A dentist can most effectively treat the avulsion. When the surgery is completed and the patient is stable, a dentist can replant and splint the tooth. The time factor (ie, 15 to 30 minutes) is critical in replanting the tooth, but a dentist is rarely able to be located in time to replant, align, and splint the tooth. The best course of action for operating room personnel is biologic storage of the avulsed tooth until the surgery is complete. This environment should protect the tooth from being crushed, replenish depleted nutrients, and provide easy removal at the time of replantation. The tooth should not be wrapped in anything and should be suspended in a Hank's cell preserving solution to protect the PDL cells on the tooth root from being crushed. Dry gauze is contraindicated. Wet gauze should be avoided because it is abrasive and will crush the PDL cells. The avulsed tooth should be handled gently so a s not t o crush t h e cells of the PDL." Placing an avulsed tooth in a glass container can result in the PDL cells being damaged if
the tooth strikes the walls of this container. The operating room personnel can use t h e Emergency Tooth Preserving System to overcome this problem (Fig 1).'* This system is specifically designed for the proper storage and transportation of avulsed teeth. It is a self-contained and complete system that consists of a scientifically designed container, Hank's solution that can rejuvenate partially degenerated cells that have been out of the mouth for up to one hour following the accident, and a suspension netting that holds the tooth in a safe and nurturing environment (ie, Hank's solution) for 12 to 24 hours without sacrificing long-term success. If a tooth is preserved in the appropriate environment, the surgery can proceed while a dentist is being located. T h e tooth can be replanted by the dentist either in the operating room, the postanesthesia care unit, or when the patient is back in his hospital room.
Replantation
I
f a physician chooses to replant immediately, the tooth should be carefully placed back in the socket. A blood clot may impede complete seating of a tooth so the socket is gen-
F i g I . The Emergency Tooth Preserving System is designed for storing and transporting avulsed teeth.
tly flushed with isotonic saline. The tooth should then be properly aligned into the occlusion and fixed to the adjacent teeth with a semirigid fixation technique. Senii-rigid fixation permits functional movement of the tooth. An example of this fixation would b e 0.20 orthodontic wire connected to three orthodontic bonded brackets. Functional (ie, some tooth movement) is better than rigid (ie, no tooth movement) fixation because less fusion occurs with some functional tooth movement.” This splint should remain in place for no longer than two weeks.13 The possibility of stiffness or fusion to the bone increases after that time. The next phase of the treatment consists of root canal extirpation (ie, cleaning). This phase should occur within the first week following the avulsion. It should never be done while the tooth is out of the mouth.15 Exposure to the air and any increase in extra-oral time causes added cell nutrient depletion. The cells of the tooth also become crushed during this manipulation. If the root canal treatment is not done within a week, severe root resorption can rapidly occur resulting in the tooth loss despite any additional procedures.“
Summary
I
t is not known how often teeth are inadver-
tently knocked out in the operating room during intubation o r surgery. When it occurs, it can be very disturbing to the operat100.2
ing room personnel and the patient when he or she recovers from the surgery. Research has shown that most avulsed teeth can be saved by replanting them within 15 to 30 minutes, aligning and splinting them into proper position, and instituting appropriate follow-up care. Because a dentist cannot easily be found in this time period, a system designed specifically to preserve the teeth can be used to provide optimum care in these situations. By using such a system, the physician can proceed with the surgery knowing that all the appropria t e measures have been taken to save t h e knocked-out tooth. L Notes 1 . J 0 Andreasen, E Hjorting-Hansen, “Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss,” Acra Odontologica Scandinavica 24 (November 1966) 263-286; J 0 Andreasen, E Hjorting-Hansen, “Replantation of teeth. 11. Histological study of 22 replanted anterior teeth in humans,” Acru Odontologica Scandinuvica 24 (November 1966) 287-306. 2. Ad Hoc Committee on Treatment of the Avulsed Tooth, American Association of Endodontists, “Recommended guidelines for the treatment of the avulsed tooth,” Journal o,f Endodontics 9 (October 1983) 571; Council on Dental Therapeutics, Accepted Dental Therapeutics (Chicago: American Dental Association, 1984) 72. 3. Andreasen, Hjorting-Hansen,“Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss,” 263286; Andreasen, Hjorting-Hansen, “Replantation of teeth. 11. Histological study of 22 replanted anterior
AORN JOURNAL
teeth in humans,” 287-306; L Anderson, I Bodin, “Avulsed human teeth replanted within 15 minutes-a long-term clinical follow-up study,” Endodontics and Dental TvaumutoIog+y6 (February 1990) 37-42. 4. J 0 Andreasen, “The effect of pulp extirpation or root canal treatment on periodontal healing after replantation of permanent incisors in monkeys,” Journal of Endodontics 7 (June 1981) 245-252; J 0 Andreasen, L Kristerson, “The effect of extra-alveolar root filling with calcium hydroxide on periodontal healing after replatation of permanent incisors in monkeys,” Journal of Endodontics 7 (August 1981) 349-354. 5. L Blomlof, P Otteskog, “Viability of human periodontal ligament cells after storage in milk or saliva,” Scandinavian Journal of Dental Research 88 (October 1980) 436-440. 6. L Blomlof, P Otteskog, L Hammarstroni, “Effect of storage i n media with different ion strengths and osmolalities on human periodontal ligament cells,” Scandinavian Journal of Dental Research 89 (April 198 1 ) 180-187. 7. P Soder et al, “Effect of drying on viability of periodontal membrane,” Scandincrvian Journal of Dental Research 85 (March 1977) 164-168. 8. Blomlof, Otteskog, “Viability of human periodontal ligament cells after storage in milk or saliva,” 436-440; L Blomlof, Milk and Saliva a s P os si h 1e S t o r a
APRIL 1991, VOL. 53. NO 4
after replantation of mature permanent incisors in monkeys,” 43-53. 16. J 0 Andreasen, “Relationship between surface and inflammatory resorption and changes in the pulp after replantation of permanent incisors in monkeys,” Journal of Endodontics 8 (July 1981) 294301; J 0 Andreasen, “Analysis of pathogenesis and topography of replacement root resorption (ankylosis) after replantation of mature permanent incisors in monkeys,” Swedish Dental Journal 4 no 6 (1981) 23 1-240.
Preemployment Drug Screens Controversial Preemployment drug screens may identify risks of employee accident rates and poor performance, but they may indicate exaggerated facts, according to a study in the Nov 28, 1990, issue of the Journal of the American Medical
Association. Drug users have been reported to be involved in 200% to 300% more industrial accidents, sustain 400% more compensable injuries, and use 1,500%more sick leave. A recent study indicates such statistics may be exaggerated. From Sept 24, 1986, to Jan 6 , 1989, researchers performed urine drug screens
on nearly 5,000 job applicants at the US Postal Service Boston Management Sectional Center. Marijuana tests were sensitive for up to four weeks after use; cocaine tests were sensitive for up to 72 hours after use. Only confirmed positive tests were reported. Of 2,537 people who were hired, 2,229 (87.9%) tested negative, 198 (7.8%) tested positive for marijuana, 55 (2.2%) tested positive for cocaine, and 55 (2.2%) tested positive for other nontherapeutic drugs or multiple drugs. Researchers tracked new hires, examining the time until termination, absence rates, time until first work-related accident, and time until first report of disciplinary action. Those who had tested positive for marijuana had 55% more industrial accidents, 85% more injuries, and a 78% increase in absenteeism. Those positive for cocaine had a 145% increase in absenteeism and an 85% increase in injuries.