Introduction More than 50% of all European children suffer a dental injury DI , for which the emergency treatment is usually carried out by a general dentist. The aim of this survey was to assess the management of avulsions in Switzerland as the common treatment procedures used by Swiss dentists in such cases. As yet there are no published data on the treatment of DI in Switzerland. On average, two avulsions per practitioner had been seen in the past 3 years. The dental practitioners who encountered cases of tooth avulsion treated an average of 2. Most dentists applied conventional intraoral root canal treatment, which was performed on average 9 days after replantation. As the intracanal dressing, calcium hydroxide was used by 69. The favorite splint after replantation was the Titanium Trauma Splint®, followed by the wire composite splint and the bracket splint, while the aligner was used very rarely. The average splinting time was 11. Dental injuries are a severe problem of public health , not only because of their high prevalence - but also because they have a considerable impact on the quality of life of the mostly young patients ,. An avulsion represents a complex injury, causing considerable damage to the periodontal ligament PDL and to the pulp. Vitality of the PDL cells is of great importance to the prognosis of replanted teeth. There are several treatment guidelines which promote appropriate treatment Table , but unfortunately, this information gained from research may not always reach every practitioner. In relation to a variety of countries, several studies have been published - that assess the knowledge of dentists regarding the treatment for avulsions. However, as yet there are no published data for Switzerland. If a tooth is avulsed make sure it is a permanent tooth primary teeth should not be replanted First aid Immediate replantation is the best treatment at the place of accident. Find the tooth and pick it up by the crown. Avoid touching the root. If the tooth is dirty, wash it briefly max. The tooth can also be transported in the mouth, keeping it inside the lip or cheek if the patient is conscious. Avoid storage in water. If there is access at the place of accident to special storage or transport media such media can preferably be used Splinting of the replanted tooth It is considered best practice to maintain the repositioned tooth in correct position, provides patient comfort and improves function. Replanted permanent teeth should be splinted up to 2 weeks Endodontic considerations If root canal treatment is indicated teeth with closed apex , the ideal time to begin treatment is 7—10 days postreplantation. Calcium hydroxide is recommended as an intracanal medication for up to 1 month followed by root canal filling with an acceptable material. For very immature teeth, root canal treatment should be avoided unless and there is clinical or radiographic evidence of pulp necrosis Antibiotics Antibiotics are in most situations recommended after replantation of teeth. For systemic administration, tetracycline is the first choice in appropriate dose for patient age and weight the first week after replantation. Topical antibiotics appear experimentally to have a beneficial effect in increasing the chance of pulpal space revascularization and periodontal healing and may be considered in immature teeth The aim of this survey was to evaluate how Swiss dentists proceed in avulsion cases. Materials and methods In March 2010, a total of 3288 questionnaires were distributed to all members of the Swiss Dental Society. In line with the three languages spoken in Switzerland, the questionnaires were sent 2514 times in German, 629 times in French, and 145 times in Italian. The dentists were also asked to name their treatment of choice, the products needed to treat avulsions which they had available in their office and whether or not they had completed postgraduate dental trauma education PDTE at least one continuing education course in dental traumatology in the last few years Table. This included mean and standard deviation SD for continuous parameters. For comparison of categorical variables, cross tables were reported as counts and percentages. To study the behavior of the continuous variables, logistic regression models were performed. The Kruskal—Wallis rank sum test was used to study the overall effect of the categorical variables between the tested groups. The comparison of ordinal variables between the groups was carried out using the Wilcoxon rank sum test. All analyses were performed using r version 2. Results A total of 1350 of the 3288 questionnaires were returned. The overall response rate was 41% 42. Approximately 21% had a specialist title Table. Dentists without a specialist title had received PTDE slightly more often 79. Not every returned questionnaire was filled out completely. On average two avulsions 0—11. Dentists without a specialist title encountered two avulsions 0—12. Dentists without a specialist title treated 2. This frequency distribution did not vary, regardless of specialist title. The respondents who experienced at least one avulsion and performed conventional intraoral root canal treatment started endodontic therapy on average 9. There was no difference in the time until pulp extirpation between dentists with a specialist title 9. Dentists who had received PDTE 8. The respondents were allowed to name multiple dressings, which they have in their offices. Calcium hydroxide was the most frequently used intracanal dressing 69. An aligner removable splint appliance was used very rarely. This distribution did not vary according to the dentist's profile Table. Dentists with a specialist title 1. PDTE also led to a reduction in splinting time: dentists with PDTE splinted for an average of 1. Most of the dentists had a tooth rescue box. Dentists without PDTE had the tooth rescue box in their office less often 57. The same applied to tetracycline for local application and steroids. However, dentists without PDTE had Emdogain® available more often than dentists with PDTE Table. Dentists with less than 10 years' working experience had fewer therapy products than dentists with more working experience Table. Dentists Tooth rescue box % n Tetracycline for local application % n Steroids for local application % n Emdogain® % n All 81. This is consistent with the hypothesis that dentists who graduated recently have better knowledge of dental injuries ,. One reason might be that undergraduate education concerning dental injuries has improved in the last few years. Swiss dentists had encountered an average of two cases of tooth avulsion in the past 3 years. A fact that shows that some dentists either refer avulsion cases to specialized colleagues or they do not replant the avulsed teeth and they prefer a different therapy, for example, an implant. There are various explanations for the rather rare treatment for avulsions. One reason for this might be that general practitioners treat only a few dental injuries a year , , and therefore lack regular experience. However, these two findings are not significant. Most authors and endodontic societies recommend endodontic treatment after 7—10 days if revascularization cannot be expected. They also do not regard extraoral root canal treatment as a recommendable alternative -. Only if the tooth has been dry for more than 60 min before replantation, may root canal treatment be carried out extraorally prior to replantation. Conventional intraoral root canal treatment was chosen as the favorite therapy by the majority of the respondents in this study. The prognosis of traumatized teeth in general, and of avulsed teeth in particular, depends on prompt and appropriate treatment. Pulp extirpation is generally recommended within 7—14 days , -, 7—10 days , , or 10 days postreplantation. The respondents started endodontic therapy on average 9. Dentists with PDTE waited a shorter time until pulp extirpation, as this is consistent with the guidelines suggested in trauma education courses. The intracanal dressing most used in this study was calcium hydroxide, which is also consistent with recommendations found in the literature , -. It was used more often by dentists who had received PDTE. The chair time needed for splint application is significantly shorter for a Titanium Trauma Splint than for other adhesively attached splints. This might help to explain why the very flexible Titanium Trauma Splint was used most by the respondents. The average splinting time in this study was 11. This is consistent with the recommended splinting time of 1—2 weeks in the literature. Dentists with PDTE know that a maximum period of 2 weeks' splinting decreases the risk of ankylosis , which explains why this group splinted for shorter periods of time than dentists without PDTE. The latter explanation also applies to dentists with a specialist title. If immediate replantation is not possible, avulsed teeth should be stored in a physiologic storage medium because the storage medium and the duration of extraoral storage of an avulsed tooth are critical to periodontal healing , ,. A tooth rescue box consists of a cell culture medium which guarantees physiologic storage for at least 24 h. There was a high level of availability of such boxes in the dental offices, regardless of whether or not the dentists had a specialist title. This finding shows that most Swiss dentists are aware of the importance of the tooth rescue box. Less than half of the participants use Emdogain®. This enamel matrix derivative is mainly used in cases of regenerative periodontal therapy. Iqbal MK and Bamaas and Hamamoto et al. Having done PDTE meant that dentists had a tooth rescue box, tetracycline for local application, and steroids available with greater frequency. Only Emdogain® was found more often with dentists who had not received PDTE. Quite similar results were reported by Westphalen et al. Conclusion Treatment for avulsions by Swiss dentists with PDTE was close to the current guidelines. Although the level of knowledge is relatively high in Switzerland, there are a few dentists who are treating avulsions not in accordance with current guidelines and suggestions found in the literature. There are too few avulsions for every dentist to gain regular practice in treating avulsions, but a tooth rescue box should at least be available in every dental office. Westphalen, Analysis of the association of clinical factors and IL4 gene polymorphisms with root resorption in avulsed teeth after 1 year of replantation , International Endodontic Journal , 51 , 1 , 12-19 , 2017. Remus, Arun Khokale, Christian R. Habermann, Dirk Schulze, Jens Fiehler, Max Heiland, Jan Sedlacik and Reinhard E. Friedrich, Early detection of pulp necrosis and dental vitality after traumatic dental injuries in children and adolescents by 3-Tesla magnetic resonance imaging , Journal of Cranio-Maxillofacial Surgery , 10.
