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© Borgis - Nowa Stomatologia 3/2018, s. 121-125 | DOI: 10.25121/NS.2018.23.3.121
*Aleksandra Malinowska
Complete permanent tooth avulsion – current therapy concept and prognosis
Zwichnięcie całkowite zęba stałego – aktualna koncepcja terapii oraz rokowanie
Medicine and Dentistry Practice Aleksandra Malinowska
Head of Practice: Aleksandra Malinowska
Streszczenie
Zwichnięcie całkowite zęba stałego jest urazem, który dotyczy zarówno zębów z niezakończonym rozwojem, jak i tych dojrzałych. Etiologia bywa różna, jednak najczęściej nie determinuje wyboru metody leczenia.
Aktualna koncepcja terapii zębów stałych zwichniętych całkowicie opiera się na decyzji o celowości replantacji zęba i jeśli są do niej wskazania, jak najszybszym jej wykonaniu. Ma to na celu utrzymanie zęba w jamie ustnej jak najdłużej lub w czasie potrzebnym do rozpoczęcia dalszych etapów leczenia. Bardzo istotne jest określenie dokładnego czasu wystąpienia urazu i ustalenie, czy zostały wykonane czynności pierwszej pomocy w obrębie jamy ustnej oraz jakie to były czynności. Postępowanie w gabinecie stomatologicznym zależy od czasu przebywania zęba poza zębodołem, dojrzałości zęba oraz środowiska, w którym ząb był przechowywany. Rola lekarza dentysty poza profesjonalną terapią zaistniałych już urazów polega również na profilaktyce oraz edukowaniu i promowaniu odpowiednich postaw pacjentów. Rokowanie w przypadku zwichnięcia całkowitego jest również ściśle uzależnione od tych czynników, a wystąpienie powikłań ma często związek ze zbyt późnym rozpoczęciem leczenia lub brakiem wiedzy osób obecnych przy urazie odnośnie postępowania z wybitym zębem. W celu promowania odpowiednich zachowań w społeczeństwach International Association of Dental Traumatology (IADT) udostępnia poprzez stronę internetową, plakaty czy aplikację mobilną, zalecenia dla pacjentów dotyczące urazów zębów.
Summary
Complete permanent tooth avulsion is trauma relating both to teeth not fully developed and the mature ones. The aetiology may vary, but usually it does not determine the choice of treatment method.
The current concept of avulsed permanent teeth is based entirely on the decision on the expediency of tooth replantation and its possibly swift performance, as long as there are indications for it. This is aimed at maintaining the tooth in the oral cavity for as long as possible, or as long as it takes to start the further stages of the treatment. It is important to determine the exact time of injury and to establish whether any first-aid operations in the mouth were performed and what they were. The course of action in the dental office depends on the time the tooth spent outside the socket, its maturity and the environment in which the tooth was stored. The role of the dental practitioner, in addition to the professional treatment of the injuries which have already occurred, consists in the prevention, education and the promotion of appropriate attitudes in the patients. In complete avulsion, the prognosis is strictly dependent on these factors and the occurrence of complications is often associated with late treatment initiation or lack of knowledge among the persons present at the injury with respect to the way in which an avulsed tooth should be handled. In order to promote the appropriate behaviour in the society, the International Association of Dental Traumatology (IADT) provides recommendations for patients concerning trauma to the teeth via its website, posters and a mobile application.
Słowa kluczowe: zwichnięcia, uraz, replantacja.
Introduction
Complete dental avulsion, or, in other words, dislocation of a tooth, consists in a complete loss of contact between the tooth and the alveolar socket as a result of the interruption of all the ligaments of the periodontium. This type of trauma occurs mostly in patients aged 7-10 years and consists 0.5-16% of all the traumatic injuries of the teeth. Front teeth are the most common to sustain the trauma – mainly maxillary incisors, less frequently mandibular ones. This injury is often associated with damage to the soft tissue and the fracture of the alveolar process (1).
The aetiology of avulsion, similarly to other tooth trauma, is varied. However, falls, sports practice and – at the later age – fights are among the main causes. It should also be noted that children with malocclusion, such as complete or partial distal occlusion, distal occlusion with protrusion or apertognathia, are more vulnerable to tooth injuries (2). Children with impaired muscle coordination and nervous system diseases, such as epilepsy, as well as suffering from other conditions affecting their physical fitness, are also predisposed to such events.
Therapy of complete permanent tooth avulsion consists in its replantation or the abandonment of the procedure and the activities accompanying the chosen course of action. The decision on the selection of the method of treatment is difficult because of the complexity of the injury and the possible complications connected with the medical activities. It is also dependent on many factors, and often must be taken very quickly. The prognosis in the case of a permanent tooth avulsion is not only the consequence of the proceedings in the dental office. The time spent outside of the tooth socket is currently considered the most important factor here. Also, factors such as the medium in which the dislocated tooth is transported and the first aid procedure undertaken are significant.
The chances for a good prognosis are currently increasing, owing to the more structured indications for a particular therapy, depending on the co-existing factors. Unfortunately, lack of public awareness, resulting mainly from too little information, frequently worsens the prognosis of treatment in such serious tooth injuries.
The article below aims at demonstrating that the treatment of total tooth dislocation is strictly dependent on the factors described above and that nowadays, in many situations, it is possible to preserve the tooth, maintaining it in the mouth, even as a temporary measure, necessary for further treatment.
Treatment of complete tooth avulsion – first aid
The current concept of the treatment of complete permanent tooth avulsion is based on the knowledge that the most important factor increasing the chance of maintaining a tooth is its immediate replantation if there are no contraindications. Long-term prognosis worsens significantly when replantation is postponed for longer than 10 minutes after the injury (3).
The indications concerning the course of action to be taken immediately after the injury before going to the dental office (according to IADT) assume instant replantation, that is, re-insertion of the tooth into the socket, held by the crown, oriented according to the location of a neighbouring tooth. If the tooth is contaminated, it should be briefly rinsed with running cold water. Once the tooth is in the right place, the patient should be advised to bite on a tissue paper and go to the dentist as soon as possible (preferably within 60 mins). It should be remembered that only permanent teeth are replanted. If immediate replantation is not possible, it is recommended that the tooth, held by the crown, should be placed in a container with a suitable transporting medium. Special transport solutions available at the pharmacy – such as Save-A-Tooth – or milk can be used for this purpose. Currently, pasteurised milk is most commonly recommended due to its availability. A tooth may also be kept in the mouth, between the molars and the cheek. However, choking hazard should be considered here in the case of a restless patient (4). Water should not be used for this purpose as it causes the lysis of the cells of the periodontium, while it is important for the further treatment process that they are preserved.
Treatment – the role of the dental practitioner
The procedure at the dental office begins with the physical examination and interview. It is crucial that during the dental and general medical interview the exact circumstances of the event are determined – what happened and where, what actions were taken at the accident scene and whether any general symptoms occurred, for example, loss of consciousness. In the physical examination, apart from the rigorous evaluation of the injured tooth, alveolus and their surroundings, the condition of all the remaining teeth, soft tissues, the alveolar process of the jaw and the alveolar part of the mandible should be checked in order to rule out fractures.
The choice of the type of therapy used depends on whether immediate replantation has been performed outside the dental office or whether deferred replantation should be considered. In the case of the deferred procedure, it is important to determine whether the injury took place less than 60 minutes ago or whether the tooth has stayed outside the socket a for longer time than that.
If the tooth has been immediately replanted, it should be left in the current position and the operating field should be cleaned, for example, with chlorhexidine solution. If there is damage to the soft tissue, sutures should be applied. The position of the tooth should be checked radiologically and flexible splints should be applied for 14 days. Adequate antibiotic cover must be prescribed and the first follow-up visit scheduled.
A tooth remaining outside the oral cavity for up to 60 minutes in a wet or dry environment requires replantation in the dental office. If there are impurities on the surface of the tooth, it should be rinsed gently with saline. In this situation, the examination of the alveolus must also be performed, that is, rinsing the clot with saline and a gentle review aimed at determining whether or not a fracture of the alveolar process has occurred. Typically, these activities are preceded by anaesthesia. Following the tooth replantation, an evaluation is necessary and, if necessary, suturing of the soft tissues. If there is no doubt at to the position of the tooth in the radiographic examination, flexible splinting is recommended for 14 days, an antibiotic cover and the arrangement of the first follow-up appointment. If a tooth not fully developed has been subject to the injury, it is recommended that its root surface should be covered with minocycline hydrochloride microspheres or soaked with a doxycycline solution of 1 mg/20 ml of saline (5).

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Piśmiennictwo
1. Szpringer-Nodzak M, Wochna-Sobańska M (red.): Stomatologia wieku rozwojowego. PZWL, Warszawa 2006: 382-414.
2. Barańska-Gachowska M, Postek-Stefańska L (red.): Endodoncja wieku rozwojowego i dojrzałego. Czelej, Lublin 2011: 374-376, 383-387.
3. Cameron AC, Widmer RP, Kaczmarek U (red. pol.): Stomatologia dziecięca. Elsevier Urban & Partner, Wrocław 2013: 152-159.
4. https://www.iadt-dentaltrauma.org/.0.
5. Andreasen JO, Bakland LK, Flores MT et al., Kaczmarek U (red. pol.): Pourazowe uszkodzenia zębów, Elsevier Urban & Partner, Wrocław 2012: 18-27, 48-83.
6. Arabska-Przedpełska B, Pawlicka H (red.): Współczesna endodoncja w praktyce. Bestom DENTOnet.pl, 2011: 368-370.
7. Udoye CI, Jafarzadeh H, Abott PV: Transport media for avulsed teeth: A review. Aust Endod J 2012; 38: 129-136.
8. Sapir S, Kalter A, Sapir MR: Decoronation of an ankylosed permanent incisor: alveolar ridge preservation and rehabilitation by an implant supported porcelain crown. Dent Traumatol 2009; 25(3): 346-349.
9. Pazera R, Szczepańska J: Resorpcja jako powikłanie pourazowe – diagnostyka, leczenie. Nowa Stomatol 2016; 21(2): 135-146.
10. Dominiak M, Papiór P, Hadzik J: Koronektomia jako alternatywa wobec zabiegu ekstrakcji zęba trzeciego trzonowego w żuchwie – opis przypadku. TPS 2014; 11: 65-69.
11. https://www.iadt-dentaltrauma.org/polish%20save%20tooth%20poster.pdf.
otrzymano: 2018-07-16
zaakceptowano do druku: 2018-07-27

Adres do korespondencji:
*Aleksandra Malinowska
Praktyka Lekarsko-Dentystyczna Aleksandra Malinowska
ul. F.P. Schuberta 50c/2, 52-129 Wrocław
tel.: +48 668-027-159
malinowska.aleksandra@onet.pl

Nowa Stomatologia 3/2018
Strona internetowa czasopisma Nowa Stomatologia