TRAUMA/CASE REPORT

Use of 2-Octyl Cyanoacrylate for the Repair of a Fractured Molar Tooth

Lisa M. Hile, MD Derek R. Linklater, MD
From the Department of Emergency Medicine, Darnall Army Community Hospital, Fort Hood, TX (Hile, Linklater); Texas A&M College of Medicine, College Station, TX, and Uniformed Services University of the Health Sciences, F. Edward Hbert School of Medicine, Bethesda, MD (Linklater). The views expressed in this case study are those of the authors and do not reect the ofcial policy or position of the Department of Defense, the Department of the Army, or the United States Government.

Odontalgia in association with an acutely fractured tooth is a frequent reason for emergency department presentation. We describe the case of a patient who presented with a painful fractured molar tooth and was treated with topical application of 2-octyl cyanoacrylate tissue adhesive, resulting in prompt relief of her discomfort and a good temporary functional and cosmetic outcome. This product may prove useful in treating similar dental emergencies when access to emergency dental care is unavailable. [Ann Emerg Med. 2006;47:424-426.]
0196-0644/$-see front matter Copyright 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2005.12.026

INTRODUCTION
Fractured teeth and the associated odontalgia are a common complaint encountered by emergency physicians who practice amid patient populations that include large numbers of adolescents and young adults. Tooth fractures can occur in a variety of clinical circumstances, including athletic injuries, blunt facial or intraoral trauma, or simply chewing or biting hard foods with teeth affected by dental caries. In the current emergency department (ED) environment of on-call specialist shortages and the chronic lack of insurance coverage experienced by a substantial percentage of ED patients, rapid access to urgent dental care is frequently unavailable. Emergency dental care is also unavailable in a variety of austere environments, including wilderness expeditions, military operations, and humanitarian relief efforts. The dental literature is replete with examples of the use of cyanoacrylates. These compounds have been used to seal the remaining dentin of endodontically treated teeth because they were found to control microleakage of oral uid at the tooth-lling interface. Cyanoacrylate also has applications in periodontics, such as desensitizing teeth, and is used by oral surgeons as a tissue adhesive for surgical procedures in the mouth. In preventive dentistry, cyanoacrylate was also the rst material modied for use as a pit and ssure sealant to help prevent dental decay, especially on the occlusal surfaces.1 We present the case of a patient who presented to the ED in the middle of the night with a painful fractured molar tooth and 424 Annals of Emergency Medicine

was treated with the topical application of 2-octyl cyanoacrylate (2-OCA) tissue adhesive (Dermabond; Ethicon Products, Somerville, NJ) in an effort to provide immediate analgesia and temporary restoration of normal tooth architecture and function. This type of treatment has never been previously reported in the medical literature.

CASE REPORT
A 40-year-old black woman presented to our ED at 2 AM with a chief complaint of breaking her tooth. The patient stated that she had been eating a piece of hard candy approximately 1 hour before her presentation, felt a cracking sensation, and now experienced moderate to severe pain in her right jaw. Drinking cold liquids exacerbated her discomfort. She denied any bleeding and stated that the tooth still seemed intact in her mouth. The patients review of systems revealed otherwise negative results. She denied any other pertinent medical history but admitted to smoking a half a pack of cigarettes per day. She had no allergies and was not taking any long-term medications. The pain did not respond to usual doses of acetaminophen and ibuprofen taken at home. Physical examination revealed a well-nourished black woman in mild distress as a result of her pain. Her initial vital signs were blood pressure 135/85 mm Hg, pulse rate 85 beats/min, respiratory rate 16 breaths/min, and temperature 37.1C (98.8F). Her oropharynx was moist and revealed no lesions or erythema. Her gums were pink and moist without evidence of infection or trauma. The patient had several dental caries that
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Hile & Linklater had been restored with llings; she otherwise had fair dentition. Physical examination of the right lower rst molar (#30) tooth revealed an oblique linear vertical fracture extending through the crown of the tooth from the lingual to the buccal aspect, creating 2 major pieces from this tooth. Although there were 2 distinct parts of the tooth, the crown remained attached to the root within each part. Neither part of the tooth was avulsed, but both parts were subluxed and mobile. The tooth was rst dried with a surgical towel. Approximately 0.1 mL of 2-OCA was applied to the fractured tooth using the standard Dermabond applicator. The adhesive was applied directly to the fracture, resulting in direct bonding of the fractured edges. The patient experienced some initial warmth and a mild burning sensation for approximately 15 to 20 seconds while pressure was applied to either side of the fractured tooth. After pressure was held for approximately 2 minutes, the patients tooth was reexamined. The fracture line appeared much smaller, and the fragments were no longer mobile. The patients pain rapidly subsided, and she required no further medication for analgesia. She began eating a soft diet and was told to consult her dentist within 48 hours. The patient was treated by her dentist 2 days later. Her tooth remained intact, and she reported that she had not experienced any recurrent pain. Hot and cold liquids no longer bothered her, and she demonstrated no signs or symptoms of infection. Her dentist elected to extract the tooth because of the extent of the underlying damage but reported to the patient that the tooth would have to have been removed whether or not the tissue adhesive had been applied.

2-Octyl Cyanoacrylate for Fractured Tooth Repair unfounded, given the widespread availability of newergeneration products with longer alkyl chains. 2-OCA (Dermabond; Ethicon Products) is a synthetic tissue adhesive approved for use in the United States in August 1998 for skin closure. Several clinical studies have compared the use of 2-OCA with 5-0 and 6-0 sutures.3-5 In all the studies, the 3-month cosmetic outcome, short-term rate of infection, and rate of wound dehiscence were similar. The time to wound closure was reduced by more than 50% in the group treated with the tissue adhesives.6 The use of 2-OCA for skin closure after elective facial plastic surgical procedures produced better long-term results than sutures.7 In vitro and in vivo studies have found that cyanoacrylate tissue adhesives have Gram-positive antimicrobial properties.8,9 Application of tissue adhesives is rapid and relatively painless. Tissue adhesives do not require suture removal. They usually slough off in 5 to 10 days as the keratinized layer of epithelium sloughs.10 Although the oral use of cyanoacrylate adhesives is relatively commonplace in general and cosmetic dentistry, its use is uncommonly reported in the medical literature. The few reported cases include patients reattaching broken crowns,11 reimplanting avulsed teeth,12 and afxing articial ngernails led into the shape of teeth for cosmesis.13 Intraoral uses of tissue adhesives are becoming more common, and in 1999 the US Food and Drug Administration (FDA) approved a novel 2-OCA formulation (Colgate ORABASE Soothe-N-Seal Liquid Protectant, Colgate Oral Pharmaceutical, Canton, MA) for over-the-counter use in the treatment of aphthous ulcers, mouth sores, and traumatic ulcerations. Although the FDA approval for Colgate ORABASE Soothe-N-Seal Liquid Protectant lends credibility to the idea of safe intraoral uses of 2-OCA, this formulation has much less tensile strength than Dermabond. Colgate ORABASE Soothe-N-Seal Liquid Protectant is designed for temporary use as an oral bandage and will slough off in only 6 to 10 hours; thus, it would likely prove to be less useful for the temporary repair of fractured teeth. There are many ways of denitively restoring a fractured tooth, depending on the type of crack and the degree of damage to the tooth. The treatment and prognosis for each of the 5 classications of longitudinal tooth fractures is variable. According to one dental journal, 75% of cracked teeth will have viable pulp. In these situations, a cast restoration providing cuspal coverage will possibly inhibit crack progression. For cases in which the pulp has been diagnosed as necrotic, root canal treatment is indicated, along with cuspal coverage restoration.14 For virtually all dental emergencies, the goal of the emergency practitioner should be to provide necessary analgesia, minimize the risk of infection, preserve function, and ensure timely dental follow-up. Many times, however, this follow-up cannot occur quickly or when the emergency practitioner is practicing under austere conditions. 2-OCA is lightweight, selfcontained, easily portable, and relatively inexpensive; these factors make it ideal for individuals practicing medicine during a military deployment or in a wilderness environment.
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DISCUSSION
Fractured teeth are difcult to repair in the ED. Usual treatment involves enamel bonding material or dental cement; these materials are somewhat costly and messy, have a limited shelf life, and frequently cannot be located when they are needed. In practice, the functional outcome of using such materials is marginal and can result in a subluxed or fractured tooth falling apart, which subsequently increases the risk of recurrent odontalgia and infection. Other materials that are classically used include calcium hydroxide pastes and foil, but they share many of the disadvantages mentioned above, as well as being cumbersome and difcult to apply. All these treatments require dental care within 24 hours, which may not be feasible for uninsured patients or patients in an austere environment. Cyanoacrylates were rst synthesized in 1949, and secondgeneration (butyl-) cyanoacrylates were used clinically during the Korean and Vietnam wars as agents to approximate skin wounds and assist in wound hemostasis. These products had signicant tissue toxicity, resulting in acute and chronic inammation. With the longer alkyl chains found in currentgeneration tissue adhesives, the toxicity decreases as a result of slower degradation and limitation of the accumulation of byproducts.2 Initial concerns about the potential tissue toxicity of early cyanoacrylate-based adhesives have not been prospectively validated in the medical literature and may be
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2-Octyl Cyanoacrylate for Fractured Tooth Repair Given the overall condition of the patients dentition, the absence of bleeding from this signicant fracture, and the moderately severe (rather than excruciating) pain that the patient experienced, the tooth that we treated may not have been fully viable to begin with. Alternatively, the patients tooth may have undergone a root canal that we were unaware of at treatment. These characteristics represent a potential limitation to our case report in that the treatment may not have been so successful if the patients tooth had completely normal underlying architecture. Our case demonstrated that 2-OCA may be an effective way to temporarily repair a fractured tooth, pending denitive dental care, but further research is necessary to truly measure the efcacy and safety of this therapy.
Supervising editor: Steven M. Green, MD Funding and support: Dr. Linklater owns 10 shares in Johnson & Johnson. Publication dates: Received for publication October 13, 2005. Revision received December 21, 2005. Accepted for publication December 22, 2005. Available online February 21, 2006. Reprints not available from the authors. Address for correspondence: Derek R. Linklater, MD, Department of Emergency Medicine, Darnall Army Community Hospital, 36000 Darnall Loop, Fort Hood, TX 76544; 254-288-8302; E-mail derek.r.linklater@us.army.mil. REFERENCES
1. Leggat PA, Kedjarune U, Smith DR. Toxicity of cyanoacrylate adhesives and their occupational impacts for dental staff. Ind Health. 2004;42:207-211.

Hile & Linklater

2. Toriumi DM, Raslan WF, Friedman M, et al. Histotoxicity of cyanoacrylate tissue adhesives: a comparative study. Arch Otolaryngol Head Neck Surg. 1990;116:546-550. 3. Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatr. 1998;132:1067-1070. 4. Quinn JV, Wells GA, Sutcliffe T, et al. Tissue adhesive vs suture wound repair at one year: randomized clinical trial correlating early, three-month, and one year cosmetic outcome. Ann Emerg Med. 1998;32:645-649. 5. Singer AJ, Hollander JE, Valentine SM, et al. Prospective randomized controlled trial of tissue adhesive (2octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Acad Emerg Med. 1998;5:94-99. 6. Barefoot J, Toriumi D, Thorn M, et al. Food and Drug Administration Physician Advisory Panel on General and Plastic Surgery Devices presentation. January 31, 1998; Gaithersburg, MD. 7. Toriumi DM, Ogrady K, Desai D, et al. Use of 2-octylcyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg. 1998;102:2209-2219. Available at: http://www.fda.gov/ohrms/ dockets/ac/98/transcpt/3371t2.rtf. Accessed January 29, 2006. 8. Quinn JV, Maw JL, Ramotar K, et al. Octylcyanoacrylate tissue adhesive wound repair versus suture wound repair in a contaminated wound model. Surgery. 1997;122:69-72. 9. Quinn JV, Osmond MH, Yurack JA, et al. N-2-butylcyanoacrylate: risk of bacterial contamination with an appraisal of its antimicrobial effects. J Emerg Med. 1995;13:581-585. 10. Capellan O, Hollander J. Management of lacerations in the emergency department. Emerg Med Clin North Am. 2003;21:205231. 11. Winkler S, Wood R, Facchiano AM, et al. Esthetics and super glue: a case report. J Oral Implantol. 2003;29:286-288. 12. McCabe MJ. Use of histoacryl tissue adhesive to manage an avulsed tooth. BMJ. 1990;301:20-21. 13. Leyland JT. Amateur dentistry and the anesthesiologist. [letter to the editor]. Anesthesiology. 2004;101:1051. 14. Rivera EM. Diagnosis and treatment planning: cracked tooth. Tex Dent J. 2003;120:278-283.

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