UNIVERSIDADE FEDERAL FLUMINENSE
FACULDADE DE ODONTOLOGIA
AVALIAÇÃO DO PROTOCOLO DE ATENDIMENTO FRENTE AOS CASOS DE
AVULSÃO E INTRUSÃO EM DENTES DECÍDUOS E PERMANENTES JOVENS
NAS UNIVERSIDADES PÚBLICAS DO BRASIL
Niterói
2015
UNIVERSIDADE FEDERAL FLUMINENSE
FACULDADE DE ODONTOLOGIA
AVALIAÇÃO DO PROTOCOLO DE ATENDIMENTO FRENTE AOS CASOS DE
AVULSÃO E INTRUSÃO EM DENTES DECÍDUOS E PERMANENTES JOVENS
NAS UNIVERSIDADES PÚBLICAS DO BRASIL
DÁRIA GLÁUCIA RANGEL DA CRUZ BUSQUET FERREIRA
Dissertação apresentada à Faculdade de
Odontologia da Universidade Federal
Fluminense, como parte dos requisitos
para obtenção do título de Mestre, pelo
Programa
de
Pós-Graduação
em
Odontologia.
Área de Concentração: Clínica
Odontológica.
Orientador: Prof. Dr. Gustavo Oliveira Dos
Santos.
Co-Orientadora: Profa. Dra. Tereza
Cristina Almeida Graça.
Niterói
2015
F 383 Ferreira, Dária Gláucia Rangel da Cruz Busquet
Avaliação do protocolo de atendimento frente aos casos de avulsão e intrusão em dentes decíduos e permanentes jovens nas universida- des públicas do Brasil / Dária Gláucia Rangel da Cruz Busquet Ferreira; orientador: Profº Drº Gustavo Oliveira dos Santos, coorientadora: Profª Drª.Teresa Cristina Almeida Graça. – Niterói: [s.n.], 2015.
64 f.
Inclui tabelas.
Dissertação (Mestrado em Clínica Odontológica) – Universidade Fe- Federal Fluminense, 2015.
Bibliografia: 29-34.
1.Traumatismo dentário. 2. Avulsão dentária. 3. Movimentação den- tária. I. Santos, Gustavo Oliveira dos [orien.].II. Graça, Teresa Cristina Almeida. III.Título.
Prof. Dr. Gustavo Oliveira dos Santos
Instituição: Universidade Federal Fluminense
Decisão: _________________________Assinatura: ________________________
Profª. Dr.ª Tereza Cristina Almeida Graça
Instituição: Universidade Federal Fluminense
Decisão: _________________________Assinatura: ________________________
Prof. Dr. Sileno Corrêa Brum
Instituição: Universidade Severino Sombra
Ao meu maravilhoso Deus, autor e consumador da minha fé. Agradeço pelo dom da vida e por todas as bênçãos que me tem concedido. As suas misericórdias não tem fim,
renovam-se a cada manhã. Obrigada Senhor, pela realização deste sonho!
Ao meu querido Avô Mario Cruz que sempre me incentivou e me tem sustentado com suas orações. O seu exemplo de fé e amor a Deus tem marcado a minha vida. Sinto uma imensa paz quando estou ao seu lado. É uma honra ser a sua neta! Te amo muito meu vovozinho!
AGRADECIMENTOS
Sinto-me privilegiada por estar cercada de pessoas tão especiais que me amam e me apoiam incondicionalmente. Agradeço a cada um que de uma forma singular me apoiou neste momento tão feliz, mas ao mesmo tempo tão dificil da minha vida. Só voces sabem de cada detalhe. Muito obrigada meu amor, Felipe, minha preciosa filha Ana Carolina e meus amados pais Dário e Jacira. Vocês são a minha segurança e a minha fortaleza! A razão da minha vida! Amo vocês para SEMPRE!
Aos meus orientadores. Agradeço à minha Professora Tereza Graça que acreditou no meu sonho e por ter viabilizado a sua realização. Obrigada por sempre confiar em mim e me compreender admiravelmente! Agradeço muitíssimo ao Professor Gustavo Santos que de uma forma acolhedora me recebeu como sua orientada me proporcionando a oportunidade de fazer o mestrado. Sem vocês jamais teria chegado aqui. Tenho uma grandiosa admiração por vocês! Serei eternamente grata por tudo que fizeram por mim!
Ao meu amado irmão Christiano, por saber que posso sempre contar com você. Te amo e te admiro demais!
Ao meu tio preferido, Lúcio Rangel, muito obrigada por estar sempre presente e torcendo por mim!
Agradeço aos meus amigos e às famílias Rangel-Cruz e Busquet-Ferreira. A cada um que tem se alegrado comigo e orado por mim, muito obrigada!
À Professora Maria Elisa Santos, que tem me dado oportunidades para crescer na odontopediatria e na iniciação à carreira docente. Sou muito grata pelo seu apoio e carinho.
À Camila Borges, a nossa amizade foi mais do que um presente que ganhei neste mestrado!
Aos professores que aceitaram participar da pesquisa por terem dispensado um pouco de seu precioso tempo para responderem ao questionário.
dinâmica.
Agradeço a minha querida Faculdade de Odontologia-UFF e ao PPGO-UFF. A Professora Coordenadora Mônica Diuana e aos queridos João Carlos e Lucy. Vocês são muito dedicados e amam o que fazem! Muito obrigada por tudo! Se Deus permitir, me aguardem...
...e a todos aqueles que de uma forma direta ou indireta contribuíram para a execução deste trabalho.
AGRADECIMENTO ESPECIAL
À querida Tereza Graça, minha orientadora, minha professora, minha amiga.
Obrigada por fazer parte de toda a trajetória da minha formação profissional desde a graduação. Foi maravilhoso te reencontrar na especialização e vibrei muito quando fui sorteada para ser sua orientada. Sei que Deus coloca as pessoas certas pertinho de nós! Você acreditou em mim, mesmo numa fase tão difícil da minha vida e mudou a minha história por permitir que eu esteja realizando um sonho antigo que é concluir o mestrado. Muito obrigada por seu carinho e dedicação!
Você é a minha inspiração e um exemplo de profissional e professora a ser seguido! Muito obrigada por me incentivar na carreira docente e por todas as dicas, orientações, indicações e por literalmente torcer por mim!
Que este momento tão especial seja precursor de muitas outras realizações e que venhamos a fazer juntas muitos trabalhos, pesquisas, artigos, aulas, congressos, passeios, enfim, que possamos continuar a cultivar a amizade tão especial que nos une e a experimentar momentos fabulosos que certamente Deus já nos tem preparado!
RESUMO
(Ferreira DGRCB). Avaliação do protocolo de atendimento frente aos casos de avulsão e intrusão em dentes decíduos e permanentes jovens nas universidades públicas do Brasil [dissertação]. Niterói: Universidade Federal Fluminense, Faculdade de Odontologia; 2015.
Esta pesquisa objetivou avaliar o protocolo de atendimento das faculdades de odontologia públicas do Brasil frente aos casos de intrusão e avulsão de dentes decíduos e permanentes jovens. Buscou também verificar a existência de centros especializados no atendimento de traumatismo dentário, comparar as condutas clínicas, medicamentosas e preventivas adotadas e verificar a indicação de reforço da vacina antitetânica e do uso de protetores bucais. Um questionário com 15 perguntas fechadas foi enviado a todos os coordenadores de odontopediatria das 55 faculdades públicas através do Software (Sphinx Lexica). Foram respondidos 83,6% dos questionários. Possuíam centro especializado na Instituição 34,8%. Na dentição decídua, 71,7% sugeriram aguardar a re-erupção passiva com determinação de prazo nos casos de intrusão sem invasão do germe do sucessor. O pronto atendimento e a manutenção de espaço foi a conduta de escolha para 91,3% dos casos de avulsão. Quando da intrusão de dente permanente jovem, 80,4% preferiram aguardar a re-erupção passiva com determinação de prazo e nos casos de avulsão todos realizaram o reimplante quando o meio de conservação do dente foi adequado, sendo 47,8% apenas até 60 minutos e 43,5% mesmo após 60 minutos do traumatismo. A amoxicilina foi o antibiótico de escolha de 100% dos respondentes, porém indicado por 69,2% somente quando o local favorece o processo infeccioso em ambas as dentições. Os anti-inflamatórios foram prescritos por 73,9% e 78,3% somente nos casos de edema intenso na dentição decídua e permanente respectivamente. Somente 28,3% recomendaram o reforço da antitetânica. As condutas preventivas foram indicadas por 78,3% das faculdades e 89,1% recomendaram o uso dos protetores bucais. Concluiu-se que existem divergências nos protocolos adotados, devendo-se incentivar a adoção de medidas uniformes e de prevenção ao traumatismo dentário.
Palavras-chave: traumatismo dentário, avulsão dentária, intrusão dentária, dentição decídua, dentição permanente.
ABSTRACT
(Ferreira DGRCB). Evaluation of the treatment protocol taken by public dental schools in Brazil in the cases of avulsion and intrusion of primary and young permanent teeth. [dissertation]. Niterói: Universidade Federal Fluminense, Faculdade de Odontologia; 2015.
This research aimed to evaluate the treatment protocol of public dental schools in Brazil compared to the cases of intrusion and avulsion of deciduous and young permanent teeth. It also sought to verify the existence of specializing centers in dental trauma care, to compare the clinical, therapeutical and preventive measures adopted, to verify about the indication of tetanus booster and the use of mouthguards. A questionnaire with fifteen closed questions was sent to all coordinators´ professors of the pediatric dentistry department of the 55 public colleges through a Software (Sphinx Lexica). 83.6% of the questionnaires had been answered. 34.8% of the institutions had specialized traumatic injuries care center. In the deciduous dentition, 71.7% suggested to await the passive re-eruption with a period determinated in cases of intrusion without invasion of the permanent successor tooth germ. The prompt service and maintenance of space was the behavior chosen for 91.3% of the cases of avulsion. When there is a young permanent tooth intrusion, 80.4% preferred to await a passive re-eruption with a period determined and in the avulsion cases all performs a replantation of the tooth when the storage medium is suitable, wherein 8.7% only perform if immediately, 47.8% in 60 minutes and 43.5% after 60 minutes from trauma. Amoxicillin was the antibiotic of choice of 100% of respondents but indicated by 69.2% only when the local site favors the infectious process of both dentitions. Anti-inflammatory drugs were prescribed for 73.9% and 78.3% only in cases of severe swelling in the primary dentition and permanent dentition respectively. Only 28.3% recommended the reinforcement of tetanus vaccine. The preventive measures were carried out by 78.3% of colleges and 89.1% recommended the use of mouthguards. It was concluded that there are differences in the protocols used, and one should encourage the adoption of uniform measures and prevention of dental trauma.
Keywords: dental trauma, dental avulsion, dental intrusion, primary dentition and permanent dentition.
1 – INTRODUÇÃO
A mudança de paradigmas na Odontologia há muito vem transformando o conhecimento a respeito de etiologias e decisões de tratamento na prática clínica. A busca por evidencias científicas que sustentem os melhores prognósticos embasa os profissionais na busca da qualidade de atendimento, refletindo na saúde do paciente.
Os traumatismos dentários sempre foram encarados como fatalidades, onde o profissional procurava prestar o melhor pronto atendimento e proservação. Sua alta prevalência na população infantil e suas consequências constituem uma questão de saúde pública. O impacto negativo sobre o acidentado e sua família repercute negativamente tanto física quanto psicossocialmente (1/1, 3/2, 14/1, 15/ 1).
As peculiaridades pertinentes à dentição decídua, além de seu íntimo contato com os dentes permanentes são por si só objeto de controvérsia em relação à decisão de tratamento. Possíveis repercussões sobre o dente permanente devem ser consideradas para evitar danos adicionais (24/1). Também fundamental para o melhor prognóstico para o dente traumatizado e a saúde sistêmica do paciente é o conhecimento das manobras relativas ao tratamento dos dentes permanentes jovens.
Como centros formadores de profissionais, as Instituições de Ensino Superior podem contribuir para que medidas preventivas e decisões de tratamento clínico sejam adotadas de maneira mais uniforme, proporcionando com base nas evidencias científicas, as condutas que vêm apresentando melhor prognóstico de acordo com as situações apresentadas.
A luxação intrusiva e a avulsão constituem os traumatismos mais frequentes na dentição decídua devido a maior elasticidade do osso alveolar. Quanto mais precoce ocorrer o traumatismo na dentição decídua, maiores as consequências na dentição permanente, pois esta ainda encontra-se em formação (4/1).
A resiliência das estruturas periodontais é um fator significativo para determinar a extensão e o tipo de traumatismo. Na dentição permanente jovem, a presença de um ligamento periodontal mais frágil devido ao processo de erupção em desenvolvimento, favorece a maior prevalência de avulsão que pode variar de 0,5 a 16% (11/1).
O tecido dentário e o osso de suporte podem ser afetados de diferentes formas pelos traumatismos dentais. As injúrias mais frequentes são as fraturas dentárias simples sem envolvimento pulpar (6/1, 7/1). Por outro lado, apesar de menos frequentes, os traumas aos tecidos periodontais são considerados os de maior gravidade, principalmente a luxação intrusiva e a avulsão (8/1, 9/1). Esses dois tipos de injúria causam um maior dano ao feixe vásculo-nervoso, um dano direto as fibras do ligamento periodontal, além do deslocamento dentário em si, que pode facilitar a entrada de micro-organismos presentes na cavidade bucal pelo sulco gengival, aumentando o potencial de infecção e influenciando negativamente no prognóstico (10/1).
Há muitas controvérsias a respeito das condutas a serem adotadas frente aos casos e avulsão e intrusão tanto de dentes decíduos como permanentes jovens. Além disso, os conhecimentos adquiridos no ensino odontológico nem sempre são utilizados durante o atendimento clínico dos pacientes que sofreram traumatismo dentário. Existe uma baixa incidência de traumas dentoalveolares na prática clinica e como resultado, a consolidação dos conhecimentos técnico-científicos fica prejudicada. Segundo Pedrini et al. (7/2) é importante o desenvolvimento de campanhas de educação continuada para divulgação dos protocolos baseados em evidências que indiquem os mais adequados tratamentos para cada tipo de injúria a fim de manter os cirurgiões-dentistas atualizados sobre esse tão importante assunto.
Buscou-se através desta pesquisa avaliar o protocolo de atendimento das faculdades de odontologia públicas do Brasil frente a essas injúrias e traçar um comparativo das condutas clínicas, medicamentosas e preventivas adotadas. Além de verificar se as instituições contam com centros especializados no atendimento de traumatismo dentário e se medidas de prevenção ao trauma dental e orientação quanto ao uso de protetores bucais são realizadas na disciplina de odontopediatria.
O tratamento de dentes decíduos e permanentes jovens traumatizados representa um grande desafio para o cirurgião-dentista, em especial os casos de avulsão e intrusão. Desta forma, trabalhos que visam avaliar as melhores condutas de atendimento dessas injúrias dentárias traumáticas e que ofereçam o melhor prognóstico, são perfeitamente justificáveis e contribuirão para o debate e reflexão dos profissionais em relação à adoção de um protocolo de atendimento mais uniforme, que privilegie a saúde e a qualidade de vida do paciente infantil.
2 - METODOLOGIA
Trata-se de uma pesquisa descritiva prospectiva realizada com as 55 faculdades de odontologia públicas brasileiras cadastradas e reconhecidas pelo Conselho Federal de Odontologia (CFO). Foram convidados a participar da pesquisa os professores coordenadores da disciplina de odontopediatria. Os endereços eletrônicos das unidades de ensino foram obtidos inicialmente no site do CFO e confirmados posteriormente através de busca ativa na internet. A partir deste primeiro contato com as universidades foram obtidos o nome e o contato dos professores e solicitado aos mesmos a sua contribuição ao estudo.
A abordagem dos coordenadores foi realizada através da internet, utilizando-se um e-mail, onde uma justificativa da pesquisa precedeu o convite para que o mesmo participasse da pesquisa (ANEXO A). Após este primeiro contato foi enviado através do Software Sphinx Léxica, um e-mail com o TCLE (ANEXO B) e o questionário contendo 15 perguntas fechadas (ANEXO C), cujas respostas permitiram as avaliações contidas nos objetivos geral e específicos. Todas as questões foram embasadas no protocolo recomendado pela “International Association of Dental Traumatology” (29/1, 38/1, 41/1) e no livro “Manual de Referência para Procedimentos Clínicos em Odontopediatria”, 2ª edição (22/2). Os questionários foram enviados nos meses de outubro de 2014 a janeiro de 2015. A pesquisa foi devidamente aprovada pelo Comitê de Ética em Pesquisa (Parecer: 458.855), conforme o ANEXO D.
O Software Sphinx Léxica permite a realização de pesquisas em todas as suas etapas desde a concepção e edição do questionário, entrada das respostas, apuração e análise estatística dos dados. Após a criação do questionário da pesquisa no software, o mesmo foi hospedado na internet através do uso do servidor Sphinx na Web. O processo de publicação transporta o arquivo editado pelo Software Sphinx Léxica para um Servidor onde há o Software Sphinx Web Server, que cria automaticamente os links de acesso ao formulário e aos relatórios. Ao publicar o TCLE e o questionário na web, um link foi gerado e enviado por e-mail aos participantes da pesquisa cadastrados. O uso dos recursos do software favoreceu o acompanhamento do desenvolvimento da pesquisa em tempo real por propiciar que os dados e relatórios fossem atualizados automaticamente após cada participação dos respondentes. Um vantajoso benefício adicional da utilização do software foi garantir o monitoramento da pesquisa através da verificação das taxas de resposta, de
abandono e de não-recebimento e a programação de reenvios o que colaborou grandemente para alcançar o máximo de participações. Após a coleta das respostas, o software permitiu a análise estatística consolidada dos dados e a aplicação de estratos (considerando os critérios de segmentação da amostra estabelecidos) para a obtenção das respostas aos objetivos propostos na pesquisa. Os resultados foram finalmente dispostos em gráficos e tabelas.
Com a finalidade de avaliar o questionário em relação à compreensão foi realizado um pré-teste. Deste participaram nove professores de odontopediatria de quatro Faculdades de Odontologia privadas dos Estados do Rio de Janeiro e de São Paulo (Faculdades São José, Universidade Salgado de Oliveira, Universidade Estácio de Sá e São Leopoldo Mandic). Por tratar-se de uma pesquisa voltada para a especialidade de odontopediatria foi sugerida a especificação de dentição permanente jovem no titulo da pesquisa e nas questões do questionário pertinentes a dentição permanente enfatizando se tratar de dentes com rizogênese incompleta, o que nas situações pesquisadas, interfere diretamente na decisão da conduta clinica.
3 - ARTIGOS PRODUZIDOS
Artigo 1
Avulsion and intrusion in primary and young permanent teeth: clinical
and preventive measures taken by public dental schools in Brazil.
Dária Gláucia Rangel da Cruz Busquet Ferreira1*, Master Student Gustavo Oliveira dos Santos2, Adjunct Professor
Tereza Cristina Almeida Graça3, Associate Professor
1DDS, Master student, School of Dentistry, Universidade Federal Fluminense, Niterói, RJ,
Brazil.
2DDS, MSD, PhD, Adjunct Professor of Integrated Dental Clinic, School of Dentistry,
Universidade Federal Fluminense, Niterói, RJ, Brazil.
3DDS, MSD, PhD, Associate Professor of Pediatric Dentistry, School of Dentistry,
Universidade Federal Fluminense, Niterói, RJ, Brazil.
*Correspondenting author: Dária Gláucia Rangel da Cruz Busquet Ferreira Praça dos Expedicionários, nº 4, Bl 1, Aptº1002. Centro, Niterói, RJ, Brazil. CEP: 24030-270 - Phone: 55 21 97320-7450 - e-mail: dariaglaucia@hotmail.com
ABSTRACT
This research aimed to evaluate the treatment protocol of public dental schools in Brazil compared to the cases of intrusion and avulsion of deciduous and young permanent teeth. It also sought to verify the existence of specializing centers in dental trauma care, to compare the clinical and preventive measures adopted, and the indication of the use of mouthguards. A questionnaire with eight closed questions was sent to all pediatric dentistry coordinators of 55 public colleges through a Software (Sphinx Lexica). 83.6% of the questionnaires had been answered. 34.8% of the institutions have specialized traumatic injuries care center. In the primary dentition, 71.7% suggested to await the passive re-eruption with a period determinated in cases of intrusion without invasion of the permanent successor tooth germ. The prompt service and maintenance of space was the behavior chosen for 91.3% of the cases of avulsion. When there is a young permanent tooth intrusion, 80.4% preferred to await a passive re-eruption with a period determined and in the avulsion cases, all performs a replantation of the tooth when the storage medium is suitable, wherein 8.7% only perform if immediately, 47.8% in 60 minutes and 43.5% after 60 minutes from trauma. The preventive measures were carried out by 78.3% of colleges and 89.1% recommended the use of mouthguards. It was concluded that there are differences in the protocols used, and one should encourage the adoption of uniform measures and prevention of dental trauma.
Keywords: dental avulsion, dental intrusion, primary dentition and permanent dentition, prevention.
INTRODUCTION
Dental injuries have a high prevalence in the Brazilian and world child population, thus becoming a public health problem. The dental trauma gives a negative impact on the child's quality of life and their family members, either at the time of its occurrence or in the preservation period, which triggers often anxiety and emotional changes especially when there is the aesthetic involvement (1).
In deciduous teeth, trauma requires a differentiated approach held in permanent by the fact that there is a close relationship between the tooth apex deciduous affected by trauma and the tooth germ. So the likely implications about the permanent tooth should be considered to prevent further damage (2).
Dental trauma are common in childhood and may occur from 4-30%, been more common dislocations, since the alveolar bone has broader marrow spaces and therefore greater flexibility. The force of the trauma against these teeth can often cause more displacement than fractures (3). Regardless of the development stage of the successor, the types of trauma that cause most sequelae are dislocations, especially intrusive, and avulsion. The most prevalent sequelae are the discoloration of the enamel and hypoplasia (4, 5).
The dental tissue and the bone support may be affected in different ways by dental trauma. The most frequent injuries are simple dental fractures without pulp involvement (6, 7). On the other hand, although less frequent, trauma to the periodontal tissues are considered the most serious (8, 9) by cause damage to the neurovascular bundle and the periodontal ligament fibers. Dental displacement may facilitate the entry of microorganisms presents in the oral cavity by the gingival sulcus, increasing the potential for infection and influences negatively the prognosis (10).
The resilience of the periodontal structures is a significant factor in determining the extent and type of injury. In young permanent teeth, the presence of a weaker periodontal ligament due to eruption developing process, favors higher prevalence avulsion which may range from 0.5 to 16% (11).
Treatment and prognosis of primary and young permanent teeth traumatized is a major challenge for the dental surgeon, in particular the cases of avulsion and intrusion. Therefore, the objective of this research was to evaluate the treatment protocol of public dental schools in Brazil compared to the cases of avulsion and intrusion deciduous and young permanent teeth. It was also examined the differences between the protocols used and if the colleges have specialized centers in dental trauma care. Furthermore, it was verified if the educational measures regarding the prevention and prompt service to dental trauma are held in the institutions surveyed.
MATERIAL AND METHODS
This prospective descriptive study was conducted with the 55 colleges of Brazilian public dental schools registered and recognized by the Federal Council of Dentistry (CFO). Were invited to participate in the study all coordinators ‘professors of the department of pediatric dentistry. The email addresses of teaching units were initially obtained in the CFO's website and confirmed later by active search on the internet. From this first contact with universities were obtained the professors’ name and email.
The coordinators approach was conducted through the internet, using an e-mail, where a justification of the research preceded the invitation to participate in the same research. After this first contact, was sent through Software Sphinx Lexica, an e-mail with the Informed Consent Form (ICF) and the questionnaire (Figure 1). The data was collected from
October 2014 to January 2015. The survey was duly approved by the Institution`s Research Ethics Committee (Approval number: 458,855).
An advantageous benefit of the use of the software was to ensure the monitoring of research by checking the response, abandonment and non-receipt rates and the resend programming which helped greatly to achieve maximum participation. The data collected were processed and statistically analyzed descriptively and arranged in graphics and tables relying on the support of the Software Sphinx Lexical.
In order to evaluate the questionnaire in relation to the understanding, we conducted a pretest. Participated from this, 9 pediatric dentistry’s professors from 4 private dental schools in the states of Rio de Janeiro and Sao Paulo. Since it is a research aimed at pediatric dentistry specialty was suggested the young permanent dentition specification in the title of the research and in the relevant survey questions about young permanent teeth emphasizing the case of teeth with incomplete rhizogenesis, which in the studied situations, interfere directly in the clinical decision conduct.
RESULTS
Were received 83.6% of the questionnaires sent to the coordinators of pediatric dentistry department (Table 1), being 6.5% of the Northern Region colleges, 26.1% of the Northeast, 4.3% of the Midwest, 41.3% of the Southeast and 21.7% of the South (Table 2). 16.4% of public dental schools of Brazil did not answer the questionnaire.
The total participants colleges of the study, 34.8% had a center dedicated to treat dental trauma (Table 3) of which 43.8% of these centers were active for more than 10 years, 25% between 5 and 10 years and 31.3% less than five years (Table 4).
In the primary dentition in relation to the clinical management of treatment after the intrusion without the germ of the permanent tooth is reached, 71.7% suggested to await for the passive re-eruption with the determination of time and 28.3% without the determination of time.
No college indicated as an immediate protocol, the tooth extraction or surgical repositioning (Table 5).
In the case of primary tooth avulsion, only 8.7% of the participating colleges suggested replantation while 91.3% do not conduct replantation, but only emergency care and maintenance of the space (Table 6).
In the permanent dentition, were found the following conducts: When there is tooth intrusion with incomplete rhizogenesis, the treatment regimen adopted by 80.4% was waiting for the passive re-eruption with determination of time. Only 6.5% awaited the re-eruption without determination of time and 2.2% stated to the immediate surgical repositioning. 10.9% referred the patient for endodontics discipline (Table 7).
Regarding the permanent tooth replantation with incomplete rhizogenesis, whereas the avulsed tooth storage has been adequate, 47.8% (22) of pediatric dentistry coordinators opted for replantation if performed within 60 minutes after the trauma, 43.5% performed the replantation even 60 minutes after the trauma and 8.7% (4) only made immediate replantation (Table 8).
The prevention of dental trauma through a work with the parents or caregivers of the patients is an important initiative undertaken in 78.3% of the dental schools (Table 9). Regarding the indication of the use of mouthguards in patients practitioners of contact sports, 89.1% said guide on the importance of its use in preventing the occurrence and traumatic dental injuries severities (Table 10).
DISCUSSION
Dental injuries have become the subject of great interest and attention from health professionals not only for its high prevalence, but also because it significantly affects the quality of life of patients committing them socially, physically and psychologically (1, 12, 13). Affect mainly children and adolescents (14-17) affecting differently dental hard tissue, dental pulp, periodontal ligament and the supporting bone (10).
The avulsion and tooth intrusion are the most serious and complex injuries, considering the clinical management in the emergency room, the post-trauma monitoring and the consequences caused, either in primary teeth as in the permanent. Many complications of the healing process can trigger in pulp necrosis and root resorption, and may lead to tooth loss (2, 10, 18).
It is observed that the knowledge of dentists about the measures to be adopted in cases of dental trauma is still precarious and a reason of doubt and controversy. Surveys that sought to assess the degree of knowledge of dentists on emergency management of dental trauma showed that the vast majority would not follow the approaches recommended in the literature. (19-21).
The prompt adequate care and the observation period are crucial for successful treatment. Dental surgeons must be able to make the right decisions and thus collaborate to achieve the best prognosis. Therefore, they represent professional education centers where surveys are developed in order to reach excellence in all procedures aimed to investigate the clinical and preventive measures taken by public dental schools in Brazil ahead of avulsion injuries and intrusion deciduous and young permanent teeth.
Of the 55 colleges, were obtained the participation of 83.6%. From these institutions, only 34.8% had a center dedicated to meet dental trauma. From the 16 existing centers, 31.3% were created less than five years ago which suggests the recent increase in awareness of the importance of these centers in universities.
The specialized centers in dental trauma primarily constitute a reference to the search for better care before the trauma situations, meeting the demand which is often not accepted in the clinics or dental emergencies in public or private hospitals. On the other hand, they constitute major research centers where the best conduct of care are developed in the best possible prognosis of these frequent injuries.
The intrusion of primary teeth is considered one of the most serious dental traumatic injuries, either by sequelae in primary teeth as in the permanent successors. The pulp necrosis is the most common sequelae found in post-intrusion deciduous teeth in the permanent successors while there is a predominance of enamel hypoplasia (22,23). Considering the tooth intrusion deciduous without the successor of the germ has been affected, the clinical approach adopted by 71.7% of pediatric dentistry coordinators was waiting for the passive re-eruption with the determination of time. Approximately 28.3%of teachers didn’t stipulated the determination of time and this condition should be reassessed considering the risk of the development of ankylosis which can lead to non-physiological resorption of deciduous tooth and consequent delayed or ectopic eruption of permanent tooth (24). If in up to 8 weeks there is no re-eruption of intruded tooth, the extraction is indicated (25, 26).
Avulsion of primary tooth mostly affects the upper central incisors and the early loss of this element greatly affects the child's quality of life for aesthetic, functional and emotional issues. The deciduous tooth avulsion may result in discoloration of the enamel and hypoplasia, eruptive disorders and lacerations in the successor teeth, wherein hypoplasia is the most often found sequel (27). In relation to clinical management in the face of primary
tooth avulsion, most of the answers (91.3%) converged to carry out the emergency care and maintenance of the space. The current guidelines of the International Association of Dental Traumatology (IADT) recommend against replantation of avulsed teeth (18, 28, 29). Despite the lack of scientific evidence indicating the successful replantation of avulsed deciduous teeth, it was found that 8.7% of respondents reported performing the replantation.
The replantation of primary tooth may be considered an additional trauma with sequelae even larger for permanent tooth development. The act of replantation can lead to clot compression formed in the socket against the tooth germ and the additional complications, such as pulp necrosis, abscess, mobility, advanced root resorption, resulting in some cases in early tooth loss (18, 30). The high risk of ankylosis development constitutes one of the main implications that lead to the contraindication of replantation of the primary tooth (31).
Some authors recommend replantation only in very young patients where the primary tooth still presents no initial sign of root resorption, it is essential that the replantation occurs within 30 minutes of the injury and that the avulsed tooth has been kept hydrated. Highlight the fact that in very young deciduous teeth with open apex, the pulp revascularization and healing are more likely, ensuring more favorable prognosis (32-35). However emphasize that the protection of the permanent tooth and child well-being are the priority. It is necessary to further scientific studies and evidence an increase favoring a new look at this type of procedure, since the literature does not present conclusive evidence on the safety of replantation of avulsed primary teeth.
When the traumatized tooth is lost prematurely, a major concern is the potential loss of space as a result of spontaneous movement of the adjacent teeth to the edentulous space, formerly occupied by the avulsed tooth. This migration is not necessarily related to the loss of space when avulsion occurs after the eruption of canine because there is evidence that the space between the mesial surfaces of deciduous canines remains the
same in case of premature loss of prior teeth. Borum and Andreasen (25) reported that the loss of space in the prior region affected only 2% of 167 cases of premature loss of primary teeth. However, even if there is no loss of space, other undesirable factors may occur as the eruption of disorders of the permanent teeth successor, changes in speech, swallowing and chewing and the possible installation of noxious oral habits, which in some cases indicates the installation of an equipment to maintain the previous space (27).
In the permanent dentition, the intrusive luxation is considered one of the most serious traumatic injuries supporting structures due to severe sequelae that can compromise the viability of the tooth, such as ankylosis, calcification and inflammatory or replacement resorption. (36). Intrusion is a rare injury, occurring more frequently in children aged 6-12 years and more prevalent in males (8.37).
The treatment of choice for cases of young permanent intrusion with incomplete root formation recommended by 80.4% (37) of the coordinators was waiting for the passive re-eruption with the determination of time according to the current guidelines suggested by IADT (38). The spontaneous re-eruption results in fewer complications in immature teeth (39, 40). If the tooth in 3-4 weeks show no movement is recommended perform the orthodontic repositioning. The importance of determining the deadline falls on the risk of the development of ankyloses and inflammatory root resorption, the latter being the most frequent sequel due to dental intrusion (36.41).
Only if the intruder is greater than 5 mm, a surgical or orthodontic repositioning must be performed promptly in cases of immature teeth (36; 38). Some authors found no superiority between the orthodontic repositioning and the surgical, but suggested that the first would be less traumatic to the tissues already damaged, compared to the second (39, 40). Despite this assertion, we found one respondent (2.2%) who adopted as a measure to choose the surgical repositioning.
According to Andreasen et al., (8), the reasons for surgical repositioning would be the immediate relief of nerve compression and the consequent reduction in activity of osteoclasts around the tooth. Moreover, the reduction of periodontal compression zone allows the creation of space between the root surface and promoting healing traumatized bone cement rather than the development of ankyloses. On the other hand, the surgical repositioning can be considered an additional trauma to the patient who has moved physically and psychologically.
Referral to endodontics discipline was suggested by 10.9% of the participants and is probably due to the great complexity involved in cases of intrusive trauma in young permanent teeth, requiring largely endodontic monitoring of affected elements. Therefore, the specialist in endodontics can greatly contribute to the better prognosis of these cases. The pulp vitality must be accompanied radiographically by ongoing training and through the apical pulp sensitivity tests. It should also be observed the occurrence of pulp necrosis, which can be caused by obliteration of large apical foramen of immature teeth alveolar bone due to intrusive forces, which prevents the pulp revascularization (41).
The avulsion of permanent teeth occurs most often between the ages of 7-10 years with an incidence varying from 0.5% to 16% of all traumatic injuries. In this group, the relative resilience of the alveolar bone offers less resistance to extrusive forces (42). The main factors contributing to the success of tooth replantation is the time past from trauma to the dental care and the storage medium of the avulsed tooth during the extra-oral period. Over 50% of schools replant only if immediately or within 60 minutes after the trauma, confirming further evidence favorable prognosis. The earlier is performed replantation, the smaller the chances of failure (8, 43).
Of the 46 colleges participating from the research, 43.5% suggest replantation of young permanent tooth even if the time between the trauma and the service is greater than 60 minutes. The restoration of the tooth in the mouth is a highly positive factor for
psychosocial condition of the traumatized patient (44). The prognosis is highly unfavorable, and in many cases, the result is the loss of the tooth. (43).
In order to modify this reality and that many teeth could be saved and retrieved, it is understood that health education could transform this scenario. Preventive and emergency care dental trauma measures need to be disseminated to the community, especially to the leaders and professionals who deal directly or indirectly with children and adolescents. Thus, these individuals will be able to make the right decisions ahead to dental trauma.
The poor knowledge of parents and caregivers regarding prevention and emergency treatment of dental trauma was found in a survey conducted by Oliveira et al. (45) where 83% had never received guidance on these issues. Santos et al. (46) evaluated the knowledge of parents and caregivers of children and found that only 44% had a good knowledge about the handling of cases of tooth avulsion.
The success of replantation depends largely on the procedures performed in the emergency site. Frujeri & Costa Júnior (47) carried out a study on the evaluation of the effectiveness of educational lectures on prevention and emergency treatment of dental avulsion in five different professional groups. It was confirmed by comparing the 479 questionnaires before and after the lecture that there was a statistically significant difference in the increase of correct answers. Education is extremely important to promote awareness on prevention and emergency management of the avulsed tooth and can improve the prognosis.
The prevention work in relation to trauma is carried out in 78.3% of the surveyed institutions. This finding is of great importance because it demonstrates awareness of pediatric dentistry coordinators’ professors of these institutions in relation to the educational role that the profession requires. However, 21.3% of the participating colleges do not conduct an orientation work with those responsible for prevention of trauma. It is essential to break
the paradigm and the involvement of students from graduation with preventive activities in order to generate differentiated professionals who have experienced all scenarios where the dentist can and should act, highlighting the great difference that it can play in society to engage in preventive and educational campaigns that have the power to change not only the occurrence but the severity of injuries as dental trauma.
The prevalence of dental trauma either in the deciduous dentition (20.1%) or in the permanent (21%) is high and is largely triggered by falls, collisions and cycling and sports accidents. Research shows the low level of knowledge of parents and caregivers of children about the prevention and management on dental trauma. Thus, the guidelines offered in training centers that are universities may greatly contribute to change this reality (7, 45, 46, 48).
The best way to prevent the sequelaes caused by dental trauma is the dissemination of information through the training of those who are directly responsible for the children. The prompt adequate care is critical to successful treatment and therefore the implementation of educational activities on the prevention and correct management in dental trauma cases is essential (49).
Studies have shown the low identification of the occurrence of dental trauma in primary teeth by parents and caregivers, reflecting the failure by the search service. Concerning that, it reveals a lack of knowledge of the population about the importance of primary teeth and the possible consequences of trauma in the permanent dentition. Educational campaigns should also highlight these factors as well as emphasize the prevention of trauma (50, 51).
The main guidance on emergency treatment should emphasize on the importance of immediate referral of the patient and the appropriate means of tooth conservation when avulsed. Regarding prevention, the guidelines should emphasize the adoption of simple
measures in everyday life that can contribute to reduce the occurrence and severity of dental trauma. For example, the use of seat belt in baby strollers and baby/children car seats for transportation in cars, installation of protective corners on furniture and doors and use non-slip socks. In the practice of impact sports, those responsible should be warned about the use of safety accessories and individualized mouthguards, which reduces the risk of dental trauma in 80% (6, 52).
Regarding the indication of use of mouthguards, 89.1% of the coordinators recommend its use in detriment of only 10.9%. A study conducted in 80 children treated at Hadassah’s School of Dentistry, showed that there is great resistance by children as the acceptance of the use of this accessory while there is adequate knowledge of the parents about the importance of mouthguards in preventing dental trauma. In this study, we observed that after a year of manufacture of the mouthguards, two thirds of children still had them, but a third had never used, with as justification forgetfulness (45%) and discomfort (42%) (53).
An observational longitudinal study of two years was carried out in 208 pairs (sex-age) of adolescents. In each pair, one had had a previous dental trauma and the other not. The result showed a risk 4.85 times higher for the occurrence of new trauma in those ones who had had previous experience (54). Thus, in order to promote the prognosis of avulsed teeth replanted, the use of mouthguards is also indicated to avoid any additional trauma to the tooth during healing process after a trauma.
Much is said about the treatment of traumatic injuries, but prevention needs to be further addressed. It is understood that health education is the path to change the paradigm and the newest technologies should be used to attract the attention of patients and their caregivers about the importance of preventive measures that may reduce the occurrence of dental trauma, which impair physical, emotional and psychologically the children and all your household and demand long and expensive periods of follow up.
From the analysis of the results could be concluded that there are differences in the protocols used, and one should encourage the adoption of uniform measures and the prevention of dental trauma in universities that are the professional training centers and research publishers that can therefore have the transformative power of this reality.
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Artigo 2
Avulsion and intrusion in primary teeth: clinical and therapeutic measures
taken by public dental schools in Brazil.
Dária Gláucia Rangel da Cruz Busquet Ferreira1*, Master Student Gustavo Oliveira dos Santos2, Adjunct Professor
Tereza Cristina Almeida Graça3, Associate Professor
1
DDS, Master student, School of Dentistry, Universidade Federal Fluminense, Niterói, RJ, Brazil.
2DDS, MSD, PhD, Adjunct Professor of Integrated Dental Clinic, School of Dentistry, Universidade Federal Fluminense, Niterói, RJ, Brazil.
3DDS, MSD, PhD, Associate Professor of Pediatric Dentistry, School of Dentistry, Universidade Federal Fluminense, Niterói, RJ, Brazil.
*Correspondenting author: Dária Gláucia Rangel da Cruz Busquet Ferreira Praça dos Expedicionários, nº 4, Bl 1, Aptº1002. Centro, Niterói, RJ, Brazil. CEP: 24030-270 - Phone: 55 21 97320-7450 - e-mail: dariaglaucia@hotmail.com
ABSTRACT
This research aimed to evaluate the treatment protocol of public dental schools in Brazil compared to the cases of intrusion and avulsion of primary teeth. It also sought to compare the clinical and therapeutical measures adopted, and the indication of tetanus booster. A questionnaire with closed questions was sent to all pediatric dentistry coordinators of 55 public colleges through a Software (Sphinx lexica). 83.6% of the questionnaires had been answered. In the deciduous dentition, 71.7% waited the passive re-eruption with a period determinated in cases of intrusion without invasion of the permanent successor tooth germ. The prompt service and maintenance of space was the behavior chosen for 91.3% of the cases of avulsion. Amoxicillin was the antibiotic of choice of 100% of respondents, but indicated by 69.2% only when the local site of trauma may favor the infectious process. Anti-inflammatory drugs were prescribed for 73.9% just in cases of severe swelling in the primary dentition. Only 28.3% would recommend the reinforcement of tetanus vaccine. It was concluded that there are differences in the protocols used, and one should encourage the adoption of more uniform clinical and therapeutical conducts based on scientific evidences which favors a better prognosis, as well as the importance of a more holistic view of the patient.
INTRODUCTION
The change of paradigms in Odontology has been transforming the knowledge regarding etiology and the decision making in clinical practice. The search for scientific evidence that corroborates the best prognostics is the starting point for professionals seeking to improve their performance, which positively affects the patient’s health.
Dental trauma has always been regarded as fatalities, in which the professional sought to provide the best emergency care and follow up treatment. Its high prevalence in children and its consequences are a matter of public health. The negative impact on the victim and their families negatively affects the patient both physically and psychosocially (1,2,3,4).
Trauma in deciduous dentition deserve special attention because they cause consequences not only to the primary teeth but also to those in developmentment, due to close relationship between the apex of the deciduous teeth and germs of the developing successor teeth(5).
Treatment and prognosis of traumatized deciduous teeth is a major challenge for the dental surgeon, especially in cases of avulsion and intrusion. One cannot overlook the existence of many doubts when the dental surgeon is faced with these injuries (6,7). To this end, an attempt was made to evaluate which clinical and drug practices are most often adopted by public dental schools in Brazil regarding cases of avulsion and intrusion of deciduous teeth, and verify the indication of the reinforcement of the tetanus vaccine.
MATERIAL AND METHODS
This prospective descriptive study was conducted with the 55 colleges of Brazilian public dental schools registered and recognized by the Federal Council of Dentistry (CFO). Were invited to participate in the study all coordinators’ professors of pediatric dentistry department. The email addresses of teaching units were initially obtained in the CFO's website and confirmed later by active search on the internet. From this first contact with universities were obtained the professors’ name and email.
The coordinators approach was conducted through the internet, using an e-mail, where a justification of the research preceded the invitation to participate in the same research. After this first contact, was sent through Software Sphinx Lexica, an e-mail with the Informed Consent Form (ICF) and the questionnaire (Figure 1). The data was collected from October 2014 to January 2015. The survey was duly approved by the Research Ethics Committee (Approval number: 458,855).
An advantageous benefit of the use of the software was to ensure the monitoring of research by checking the response, abandonment and non-receipt rates and the resend programming which helped greatly to achieve maximum participation. The data collected were processed and statistically analyzed descriptively and arranged in graphics and tables relying on the support of the Software Sphinx Lexical.
In order to evaluate the questionnaire in relation to the understanding, we conducted a pretest. Participated from this, 9 pediatric dentistry’s professors from 4 private dental schools in the states of Rio de Janeiro and Sao Paulo. Since it is a research aimed at pediatric dentistry specialty was suggested the young permanent dentition specification in the title of the research and in the relevant survey questions about young permanent teeth emphasizing the case of teeth with incomplete rhizogenesis, which in the studied situations, interfere directly in the clinical decision conduct.
RESULTS
Were received 83.6% of the questionnaires sent to the coordinators of pediatric dentistry department of public dental schools of Brazil. 16.4% did not answered the questionnaire (Table 1).
In the primary dentition in relation to the clinical management of treatment after the intrusion without the germ of the permanent tooth is reached, 71.7% suggested to await for the passive re-eruption with the determination of time and 28.3% without the determination of time. No college indicated as an immediate protocol, the tooth extraction or surgical repositioning (Table 2).
In the case of primary tooth avulsion, only 8.7% of the participating colleges suggested replantation while 91.3% do not conduct replantation, but only emergency care and maintenance of the space (Table 3).
Amoxicillin was the antibiotic of choice of 100% of respondents (Table 4) but indicated by 69.2% only when the place favors the infectious process (Table 5). Anti-inflammatory drugs were prescribed for 73.9% only in cases of severe swelling (Table 6). Only 28.3% would recommend the reinforcement of tetanus vaccine (Table 7).
DISCUSSION
Special attention needs to be done to the dental trauma in the primary dentition due to the close relationship between the apex of the deciduous tooth and the germ of the permanent. The earlier the dental trauma occurs, the more severe are the consequences in the odontogenesis. They can range from simple enamel defect to severe disturbances of development and eruption. It is very important that caregivers of patients be informed about
the importance of the long follow-up post-trauma until the complete formation and eruption of permanent teeth (5, 8, 9).
The intrusion of primary teeth is considered one of the most serious dental traumatic injuries, either by sequelae in primary teeth as in the permanent successors. The pulp necrosis is the most common sequelae found in post-intrusion deciduous teeth in the permanent successors while there is a predominance of enamel hypoplasia (10, 11). Considering the tooth intrusion deciduous without the successor of the germ has been affected, the clinical approach adopted by 71.7% of pediatric dentistry coordinators was waiting for the passive re-eruption with the determination of time. Approximately 28.3%of teachers didn’t stipulated the determination of time and this condition should be reassessed considering the risk of the development of ankylosis which can lead to non-physiological resorption of deciduous tooth and consequent delayed or ectopic eruption of permanent tooth (9). If in up to 8 weeks there is no re-eruption of intruded tooth, the extraction is indicated (12, 13).
Avulsion of primary tooth mostly affects the upper central incisors and the early loss of this element greatly affects the child's quality of life for aesthetic, functional and emotional issues. The deciduous tooth avulsion may result in discoloration of the enamel and hypoplasia, eruptive disorders and lacerations in the successor teeth, wherein hypoplasia is the most often found sequel (14). In relation to clinical management in the face of primary tooth avulsion, most of the answers (91.3%) converged to carry out the emergency care and maintenance of the space. The current guidelines of the International Association of Dental Traumatology (IADT) recommend against replantation of avulsed teeth (8, 15, 16). Despite the lack of scientific evidence indicating the successful replantation of avulsed deciduous teeth, it was found that 8.7% of respondents reported performing the replantation.
The replantation of primary tooth may be considered an additional trauma with sequelae even larger for permanent tooth development. The act of replantation can lead to clot compression formed in the socket against the tooth germ and the additional complications, such as pulp necrosis, abscess, mobility, advanced root resorption, resulting in some cases in early tooth loss (8, 17). The high risk of ankylosis development constitutes one of the main implications that lead to the contraindication of replantation of the primary tooth (18).
