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Management of Dental Avulsion Injuries: a Survey of Dental Support Staff in Cairns, Australia

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Management of Dental Avulsion Injuries: a Survey of Dental Support Staff in Cairns, Australia dentistry journal Article Management of Dental Avulsion Injuries: A Survey of Dental Support Staff in Cairns, Australia Yannis Abraham 1,*, Roshini Christy 1, Americo Gomez-Kunicki 1, Ting Cheng 1, Silvia Eskarous 1, Verona Samaan 1, Ahsen Khan 2 and Amar Sholapurkar 1,* 1 College of Medicine and Dentistry, James Cook University, Cairns, QLD 4870, Australia; [email protected] (R.C.); [email protected] (A.G.-K.); [email protected] (T.C.); [email protected] (S.E.); [email protected] (V.S.) 2 Private Practice, Corrimal, NSW 2518, Australia; [email protected] * Correspondence: [email protected] (Y.A.); [email protected] (A.S.) Abstract: Background/Aim: The aim of this study was to assess the knowledge of dental support staff in providing appropriate first-aid advice regarding dental avulsion emergencies. Methods: This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. Dental support staff (includes dental assistants, administrative staff and other non-clinical staff) were contacted and data were collected from 50 private dental clinics across the Greater Cairns Area, Queensland, Australia. These data were collected through an online survey throughout 2020. Descriptive statistics and Pearson’s Chi-squared test was used to analyze the data and any associations between categorical outcomes. Results: This survey yielded a response rate of 34.1% with a margin of error of 10.3%. More than four-tenths of participants (42%) reported that they had received some form of dental avulsion management training previously. All but five participants (92%) denoted that they would immediately replant an avulsed permanent tooth. More than half of all participants would choose to rinse a soiled avulsed tooth with fresh milk (55%) and transport that tooth in fresh milk (65%) should they not be able to replant the tooth at the site. Almost nine in every ten participants (85%) expressed willingness to further their Citation: Abraham, Y.; Christy, R.; Gomez-Kunicki, A.; Cheng, T.; training in this area. Knowledge in replanting avulsed permanent teeth was found to be significantly Eskarous, S.; Samaan, V.; Khan, A.; impacted by gender, age, years of experience and participation in formal avulsion training. Male Sholapurkar, A. Management of participants were found to be significantly more likely (p = 0.025) to replant a permanent avulsed Dental Avulsion Injuries: A Survey of tooth than their female counterparts. Participants who were 40 years of age and above were found Dental Support Staff in Cairns, to be significantly more likely to choose fresh milk to transport avulsed teeth (p = 0.0478). Older Australia. Dent. J. 2021, 9, 4. participants (p = 0.0021), alongside those who had greater years of experience (p = 0.0112) and https://doi.org/10.3390/dj9010004 those who had undertaken formal avulsion training (p = 0.0106) were all significantly more likely to express greater confidence in their ability to manage dental avulsion injuries. Participants who Received: 21 November 2020 had previously received some form of education regarding avulsion injury management were also Accepted: 26 December 2020 most likely to warrant further education and training in this area (p < 0.0001). Conclusion: This Published: 30 December 2020 study demonstrated that dental support staff in the Greater Cairns Area seem to have a fair grasp of first-aid knowledge regarding the management of dental avulsion injuries. This result indicates Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- that this knowledge has been picked up through years of experience, rather than a formal education. ms in published maps and institutio- Despite this, one would expect people who work in the dental industry to be able to provide accurate nal affiliations. and appropriate assistance during dental emergencies, hence, further training is warranted to ensure optimum patient outcomes. Keywords: avulsion; dental trauma; emergency management; pediatric dentistry; public health Copyright: © 2020 by the authors. Li- dentistry censee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and con- ditions of the Creative Commons At- 1. Introduction tribution (CC BY) license (https:// creativecommons.org/licenses/by/ Avulsion is a critical dental injury in which a tooth is completely removed from 4.0/). its socket due to trauma, making up 0.5–3% of all dental injuries [1]. In an avulsion Dent. J. 2021, 9, 4. https://doi.org/10.3390/dj9010004 https://www.mdpi.com/journal/dentistry Dent. J. 2021, 9, 4 2 of 13 injury, damage occurs to the periodontal ligament, the neurovascular bundle, cementum, alveolar bone and gingiva [1,2]. Complex treatment is therefore necessary as multiple components of the tooth are affected. Moreover, instant action taken at the site of incident will improve overall tooth prognosis [1]. If immediate action is not taken, long-term consequences, including post-operative treatment complications and inflammatory or replacement root resorption, may occur [2]. Injuries sustained to permanent anterior teeth occur frequently during childhood between the ages of 7 and 10, in which facial growth and psychosocial development is of utmost importance [2]. The teeth most commonly affected are maxillary central incisors, followed by maxillary lateral incisors and then mandibular central incisors [1,3]. Avulsion injuries are often a result of falls, sometimes during sporting activities or traffic accidents. Malocclusions such as increased overjet, protrusion and poor lip coverage of the maxillary anterior dentition can also predispose one to higher risk of dental trauma injuries [4]. According to the International Association of Dental Traumatology (IADT), avulsion management in the clinic should strive to prevent infection of the pulpal tissues [5]. Teeth that reside extra-orally for longer than 60 min usually have a poor long-term prognosis [6]. Thus, all permanent avulsed teeth should be re-implanted almost instantaneously [5,6]. If immediate reimplantation of the tooth is not achievable, the avulsed tooth should be stored in milk, a saline or sodium fluoride so as to preserve the biological components of the tooth [5–7]. It was noted that refrigerated milk is a suitable medium, due to its ideal pH (6.5–7.2), temperature (<25 ◦C) and availability [7]. A study by Khinda et al. discussed other liquid mediums including, Hank’s balanced salt solution (HBSS), tooth rescue box (Dentosafe) and coconut water. They found that all these liquids were superior storage medium for avulsed teeth than dairy milk [6]. However, these products are not as practical due to lack of availability at the time of tooth avulsion injury [6]. Storage mediums such as tap water, saliva, alcohol and saline solution have non-ideal pH, thus are not recommended [6]. Furthermore, the vessel that encloses the storage medium is an additional factor which contributes to the preservation of the avulsed tooth [8]. This vessel should possess the following characteristics: sterile, resistant to cracks/fractures, provide a tight seal and made of biocompatible material [9]. Additionally, all avulsed teeth should be handled with care and held only from the crown of the tooth [7–9]. If the avulsed tooth is held from the root tip, then damage to the periodontal ligament cells may ensue [7–9]. According to a study conducted by Cvek et al., [7] the prognosis of an avulsed tooth is largely determined by the preservation of the periodontal ligament fibers as this component serves as the connection between the avulsed tooth and the bony socket [7]. Therefore, the preservation of the periodontal ligament cells residing on the root surface of the tooth is of utmost importance [10]. They begin to disintegrate as early as 5 min after an avulsion injury [11]. If an avulsed tooth is not replanted before 60 min, the viability of the peri- odontal ligament cells greatly diminishes, and the chance of survival reduces [9–11]. This will then produce an avenue for unwarranted complications such as root resorption [12]. Despite this, it should be noted that most dental practitioners experience considerable difficulty replanting avulsed teeth upon immediate clinical presentation [13]. Additionally, replantation without sufficient anesthesia has shown to be distressing for the affected patient, particularly if patient cooperation is unachievable [11–13]. According to the American Dental Association, to ensure the survival of an avulsed tooth, avulsion management in the clinic should be segregated into three main cate- gories [7]: 1. Reimplantation of the avulsed tooth promptly. 2. A subsequent appointment involving a comprehensive clinical and radiographic assessment of the tooth in question. 3. Root canal therapy if indicated. Furthermore, the way in which the avulsed tooth is re-implanted is highly important, as incorrect placement can increase the risk of root resorption [14]. The type of splint used Dent. J. 2021, 9, 4 3 of 13 must be carefully considered as an inflexible splint can warrant unfavorable outcomes such as ankylosis [15]. It should be noted that with all avulsion injuries the risk of aspiration of the avulsed tooth is probable and thus it is pertinent that general dentists refer the patient for chest and bowel X-rays, as a precautionary measure [16]. An investigation was conducted in Pub-Med, Ovid databases and through hand search to explore existing literatures; the key words ‘dental staff’, ‘avulsion injury’ and ‘avulsion management’ were utilized. Only one study about dental avulsion injuries was conducted in Australia; however, this study targeted primary school teachers [17]. Furthermore, it was clear that there has been very minimal research conducted globally in evaluating the knowl- edge of dental staff with regards to avulsion injuries. One study carried out by Halawany et al. [18] in Saudi Arabia assessed the knowledge of dental assistants with regards to avul- sion management.
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