Complications and survival rates of teeth after dental trauma over a 5-year period.

OBJECTIVES: The purpose of this study was to evaluate whether the current guidelines of the International Association of Dental Traumatology (IADT) for emergency care of traumatised teeth result in lower complication rates. MATERIALS AND METHODS: Therapeutic strategies of 361 dental injuries in 291 patients treated at a university dental hospital over a 5-year period were investigated by evaluating the patients' records. Adherence to the guidelines of the IADT (Flores et al. Dent Traumatol 17:1-4, 2001; 49-52, 2001; 97-102, 2001; 145-148, 2001; and 193-196, 2001; Flores et al. Dent Traumatol 23:66-71, 2007; 130-136, 2007; and 196-202, 2007) was evaluated. Complications were also recorded according to the patients' records and analysed relative to the treatment and injury pattern. During follow-up visits, the teeth were inspected regarding pulp vitality and overall function of the injured tooth. The Kaplan-Meier survival analysis of pulps and teeth was performed for different injury categories. RESULTS: The majority of injuries (322/361; 89.2 %) were treated according to the guidelines. When IADT guidelines were followed, complication rates were significantly lower than for cases treated without adherence to the guidelines. The most frequent complication was the loss of restoration, followed by pulp necrosis, abnormal mobility, and tooth loss. The overall survival analysis showed that in the permanent dentition, the loss of pulp vitality and tooth occurs within the first 6 months but may also occur later. CONCLUSIONS: The results of this study indicate that traumatised teeth that were treated according to the recommendations had a lower complication rate. In addition, the majority of pulp necrosis and tooth losses in the permanent dentition occurred within the first 6 months after trauma. These results indicate that early follow-up visits are essential to promptly treat complications. CLINICAL RELEVANCE: Adherence to the IADT guidelines for treatment of dental trauma may lead to more favourable outcomes when compared to cases treated without compliance to the guidelines.

Three year retrospective analysis of computer-assisted emergency dental triage in Tasmania, Australia.

INTRODUCTION: Tasmania is Australia's smallest state measuring approximately 68,000 km2 and separated (by approximately 240 km of ocean) from the mainland of Australia, at the south-east corner of the continent. The total resident population of Tasmania is approximately 500,000 people with the greatest population density in the capital city, Hobart. Adult dental care is subsidised for socioeconomically disadvantaged people and are provided through the State government dental clinics. Emergency demand for adult dental care is rationed through a triage system (mainly by telephone contact with trained receptionists), applied across the State based on universal clinically agreed criteria. The aim of this study was to analyse the outcomes of this triage system in delivering effective public emergency dental care services in Tasmania. METHODS: The study population consisted of all patients who approached the dental services in Tasmania for emergency care over a period of 3 years. The data were collected from all four major fixed public dental clinics for the calendar years 2009, 2010 and 2011. RESULTS: A total of 56,298 triage events were analysed over the 3 years (2009-2011) of the study. The proportion of each triage outcome category (ie speed to needing to be seen) was stable. Regarding month-to-month variation, December had the lowest overall number of events (n=3921) and August had the greatest (n=5237). There was a tendency mid-year (winter in the southern hemisphere) for triage events to be above the baseline, while in summer (December to February) there were fewer events. Most triage events occurred on the first day of the working week (Monday), and the least occurred on Fridays. Over half the events were driven from two patient symptom sets: (1) pain that woke patients at night; and (2) pain that required analgesics. CONCLUSION: In order to deal with the current workforce shortage and funding constraints in the public health sector, the peri-operative workforce such as receptionists can be utilized in innovative ways such as triage, and in particular clinical-based systematic telephone-based assistance.

Effectiveness of a brief educational workshop intervention among primary care providers at 6 months: uptake of dental emergency supporting resources.

INTRODUCTION: Dental emergencies often present to primary care providers in general practice and Emergency Departments (ED), who may be unable to manage them effectively due to limited knowledge, skills and available resources. This may impact negatively on patient outcomes. Provision of a short educational workshop intervention in the management of such emergencies, including education in supporting resources, may provide a practical strategy for assisting clinicians to provide this aspect of comprehensive primary care. METHODS: This descriptive study used a validated questionnaire survey instrument to measure the effectiveness of a short multimodal educational intervention through the uptake and perceived usefulness of supporting resources at 6 months following the intervention. Between 2009 and 2010, 15 workshops, of which eight were for regional and rural hospital ED doctors, were conducted by the same presenter using the same educational materials and training techniques. A sample of 181 workshop participants, 63% of whom were in rural or remote practice and engaged in providing primary care medical services, returned responses at 6 months on the perceived usefulness of the dental emergencies resource. RESULTS: Thirty percent of clinicians had used the dental emergencies resource within the six-month follow-up period. Significance was demonstrated between professional category and use of the resource, with emergency registrars utilising this resource most and GPs the least. The Dental Handbook, specifically designed for ED use, and tooth-filling material contained within this resource, were deemed the most useful components. There were overall positive open-ended question responses regarding the usefulness of the resource, especially when it was made available to clinicians who had attended the education workshops. CONCLUSION: Utilisation and perceived usefulness of a supporting resource at 6 months are indicators of the effectiveness of a short workshop educational intervention in the management of dental emergencies by primary care providers. This education may have greater relevance to rural and remote practice where dental services may be limited.

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition.

Traumatic injuries to the primary dentition present special problems and the management is often different as compared with the permanent dentition. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialities were included in the task group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care for management of primary teeth injuries. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the guidelines, but believe that their application can maximize the chances of a positive outcome.

A program to improve the quality of emergency endotracheal intubation.

OBJECTIVE: To assess the results of a quality improvement (QI) project designed to improve safety of emergency endotracheal intubation (EEI). DESIGN: Single center prospective observational. SETTING: 16-bed intensive care unit. PARTICIPANTS: Nine pulmonary/critical care fellows. INTERVENTIONS: For 3 years, EEI performed by the medical intensive care unit team were analyzed to identify interventions that would improve quality of the procedure. By segmental process analysis, the procedure of EEI was subjected to iterative change. Major components of process improvement were development of a combined team approach, a mandatory checklist, use of crew resource management (CRM) tactics, and postevent debriefing. Quality analysis and improvement included training of fellows using scenario-based training (SBT) with computerized patient simulator (CPS) to improve mechanical skills of intubation and team leadership. Fellows received 15 sessions of SBT with CPS using a combined checklist and team approach before assuming team leadership position during real-life EEI. MEASUREMENTS: For a 10-month period, fellows carried digital voice recorders to EEI; which, when combined with recording of continuous oximetry and BP monitoring were used to assess the quality of EEI. MAIN RESULTS: 128 EEI were performed of which 101 had full data recorded. Complications were 14% severe hypoxemia (<80% saturation), 6% severe hypotension (SBP<70 mm Hg), 1% death, 20% difficult EEI (≥ 3 attempts), 11% esophageal intubations, 2% aspiration, and 1% dental injury; 62% EEI were successfully achieved on first attempt, 11% required >3 attempts. CONCLUSIONS: EEI may be performed by pulmonary/critical medicine (PCCM) fellows with safety comparable to that described in other studies on EEI. Important parts of the program included the use of formal iterative QI approach, the use of intensive SBT with CPS, basic CRM, a comprehensive checklist, and a combined team approach. A key benefit of the program was to make the process of EEI fully transparent for ongoing quality and safety improvement.

Dental Emergencies: Management Strategies That Improve Outcomes [Digest].

Points & Pearls is a digest of Emergency Medicine Practice. Acute dental emergencies are a common chief complaint presenting to emergency departments, and they are increasing substantially in frequency. The diagnosis and management of dental emergencies is a core competency of the emergency clinician, and proper therapeutic strategies can significantly improve cosmetic and functional outcomes for patients. This issue provides a systematic review of the literature on common acute traumatic and atraumatic dental emergencies with a focus on the historical and physical examination findings that must be understood to identify life-threatening infections, relieve pain, salvage natural teeth, and communicate with specialists in the further management of patients after emergency treatment.

Updated posters to help manage medical emergencies in the dental practice.

Medical emergencies can occur in the dental practice. Medical Emergencies in the Dental Practice and Emergency Drugs in the Dental Practice posters have been designed to help dental practitioners to respond effectively and safely to a medical emergency. These posters, endorsed by the British Dental Association, are included with this issue of the British Dental Journal. Further copies can be downloaded from: https://www.walsallhealthcare.nhs.uk/medical-education.aspx.

Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen?

HYPOTHESIS: Awareness of guidelines for damage control can improve patient outcomes after postraumatic open abdomen. DESIGN: Retrospective (November 1992 to December 1998), prospective (January 1999 to July 2001), 104-month study. SETTING: Los Angeles County and University of Southern California Medical Center, Los Angeles. PATIENTS: All patients undergoing damage control resulting in posttraumatic open abdomen. MAIN OUTCOME MEASURES: The main outcome measure was survival. Data were also collected on surgical findings and indications for damage control, including organs injured, intraoperative estimated blood loss, and intraoperative fluids, blood, and blood products administered. Postoperative complications, length of time patients had an open abdomen, and surgical intensive care unit and hospital length of stay were also recorded. RESULTS: No difference in mortality existed between patients admitted before awareness of guidelines (group 1; 21 [24%] of 86 patients died) and patients who underwent damage control following these suggested guidelines (group 2; 13 [24%] of 53 patients died) (P =.85). Of the 139 patients, 100 had penetrating injuries and 39 had blunt injuries. Estimated blood loss was 4764 +/- 5349 mL. Mean intraoperative fluid replacement was 22 034 mL. One hundred one patients (73%) experienced 228 complications, for a mean of 2.26 complications per patient. Group 1 patients spent a longer time in the operating room (mean, 4.09 +/- 1.99 hours; range, 0.4-9.5 hours) vs group 2 patients (mean, 2.34 +/- 1.50 hours; range, 0.3-6.2 hours; P<.001). The surgical intensive care unit length of stay was 23.5 +/- 18.3 days vs 8.7 +/- 14.9 days (P<.001), and the hospital length of stay was 37.4 +/- 27.5 days vs 12.4 +/- 21.0 days (P<.001) in survivors and nonsurvivors, respectively. CONCLUSIONS: We recommend close monitoring of intraoperative outcome predictors as validated within our guidelines and recommend following our model for early institution of damage control.

Ventilatory support in the field.

Ventilatory support during cardiopulmonary resuscitation can be accomplished with an array of methods and devices. These run the gamut from expired air resuscitation, including mouth-to-mouth and mouth-to-mask, to the use of ventilators including ventilator-to-mask and ventilator-to-artificial airway techniques. Appropriate application of these techniques depends on the clinical situation, rescuer training, and availability of equipment. This article discusses the proposed standards of emergency ventilatory support, the advantages and disadvantages of the techniques and devices used, and current controversies surrounding this topic.

Emergency department management of maxillofacial trauma.

This paper highlights critical aspects of examination, diagnosis and early management of the maxillofacial trauma patient.

[Accidental ingestion of cigarettes by children]. / Accidentele inname van sigaretten door kinderen.

Accidental ingestion of cigarettes (and butts) is mainly seen in young children. Nicotine in tobacco products is easily absorbed by the oral mucosa and intestines; absorption depends on nicotine content and pH of tobacco. Symptoms are caused by the nicotine component and usually develop rapidly (< 4 hours). The most common symptom is vomiting. Although cigarettes are potentially toxic, their ingestion by children is generally benign. Decontamination of the mouth with water may be useful. Induction of emesis is not advised. Gastric lavage is not needed in asymptomatic patients (with an unreliable history) or after vomiting. Children who ingested cigarettes should receive medical observation for four hours after ingestion. Children with significant symptoms should be admitted and eventually treated by supportive care. In symptomatic children or children with a reliable history of ingestion of large quantities who have not vomited gastric lavage with administration of activated charcoal has to be performed. When after vomiting other symptoms persist activated charcoal can be given via a nasogastric tube.

Updated guidance on medical emergencies and resuscitation in the dental practice.

This article outlines the updated guidance relating to the management of medical emergencies in the dental practice. The incidence of medical emergencies in the dental practice is discussed. The key recommendations from the Resuscitation Council UK on the treatment of medical emergencies in the dental practice are listed, with specific reference to oxygen therapy, medications and automated external defibrillators. An overview to the professional responsibilities of dental practitioners and dental care professionals is provided.

An assessment of the competence and experience of dentists with the management of medical emergencies in a Nigerian teaching hospital.

BACKGROUND: Previous reports show that medical emergency events have ocurred in Teaching Hospital Dental centres, with attendant mortality and morbidity. OBJECTIVES: (1) To study the pattern of medical emergencies encountered by clinical dental staff of Lagos University Teaching Hospital (2) To evaluate their training, perception of their training and competence as undergraduates and postgraduates to manage such events. METHODS: All the clinical staff viz: Dental surgeons of different cadres--consultants, registrars, house surgeons and dental nurses of Lagos University Teaching Hospital. A structured questionnaire requesting to know demographic data, respondents attendance of life support training viz: Basic life support (BLS), advanced trauma life support (ATLS), intensive care support (ICS). A self rating in the competence of management of medical emergencies and previous personal encounter with medical emergencies with success/failure in the management with/or without medical colleage assistance were sought. In addition adequacy of their dental clinic/centres for drugs, equipments and their perceived readiness to deal with emergencies were enquired. RESULTS: Among the dental surgeons, 20 (26.6%) were consultants, 40 (53.3%) were registrars and 35 (46.6%) were house-officers. Thirty five (43.7%) had previous knowledge of basic life support (BLS) training, while 45 (56.2%) denied such knowledge. The figures for other trainings such as advanced trauma life Support (ATLS) was 8 (10%) and intensive care support (ICS) 2 (2.5% 73.3% of the respondents felt inadequate in the management of cardiovascular emergencies, while only 15.4% felt adequately prepared. Similar ratings for respiratory emergencies are 63.1% inadequacy, 16.9% adequacy, and only 3.3% felt very adequate. The availability of oxygen extension tubing and ambu bag was nil in all departments. Emergency drugs were claimed to be present by 28.5% oral surgery respondents and, 34.7% Child Dental Health respondents. Most of the respondents felt their clinics are not adequately prepared to deal with medical emergencies. CONCLUSION: The study showed that syncope is the commonest medical emergency event in dental surgery practice in our teaching hospital, others are bleeding, seizure disorders and asthmatic attacks. The constitution of hospital emergency team (consisting of cardiologists, anaesthetists) as done in advanced countries is advocated and dentists should ensure that the departmental staff are adequately trained to provide basic life support.

A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract.

AIM: To investigate the clinical management of patients attending for emergency dental treatment. DESIGN: A retrospective analysis of clinical record cards. METHOD: Information was collected from patient record cards concerning the patient's reason for attendance and their management at an emergency dental clinic in South Sefton, Liverpool. RESULTS: Over a nine month period, 1,718 patients attended the clinic; 1,472 record cards were analysed. Over 80% of the patients attending the out of hours (OOH) clinic had pain associated with a localised dental infection or dental abscess. Where a diagnosis was recorded, only 67% of patients received appropriate treatment. Over 50% of patients received antibiotics alone with no other definitive treatment provided. The principal antibiotic prescribed for both adult and child patients was amoxicillin. CONCLUSION: The current study has highlighted that GDPs working within the OOH services are not adhering to current clinical and best practice guidelines with respect to patient examination, diagnosis, management, in particular the correct prescribing of antibiotics for dental infections, and clinical record keeping.

Guidelines for the management of traumatic dental injuries. III. Primary teeth.

Trauma to the primary dentition present special problems and the management is often different as compared with permanent teeth. An appropriate emergency treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this third article out of three, the IADT Guidelines for the management of traumatic injuries in the primary dentition, are presented.