Guidelines for the management of avulsion

IADT guidelines for management of avulsed teeth

1. Guidelines for the Management of Traumatic Dental Injuries: 2 . Avulsion of Permanent Teeth Presented By : Rahaf Najjar

2. This paper Andersson et al Authors literature review Type International Association of Dental Traumatology, Journal 2013 Date

3. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

4. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

5. Introduction Avulsion of permanent teeth is seen in .5-3% of all dental injuries. It is one of the most serious injuries , and the prognosis is very much dependent on: Action taken at the place of injury And promptly after the avulsion.

6. Situation when replantation is NOT indicated: Severe caries Severe periodontal disease Non cooperative patients Severe medical condition ( immunosuppression and sever cardiac conditions)

7. An appropriate diagnosis and treatment plane are important for good prognosis

8. Guidelines should assess dentist, other healthcare professionals and patients in decision making The should be credible, readily understandable, and practical with the aim of delivering appropriate car as effectively and efficiently as possible.

9. Guidelines are to be applied with judgment of:

10. It is including but not limited to compliance , finances and understanding of immediate and long term of treatment alternative vs no treatment.

11. IADT cannot and dose not guarantee favorable outcomes from strict adherence to the guideline but believe that their application can maximize the chance of favorable outcome. The final decision regarding patient care remains primarily in the hand of the hand of treating dentist.

12. For ethical reasons the dentist should inform the patient and the guardians with all the information needed so the patient and the guardians has as much influence in decision making

13. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

14. First aid for avulsed teeth at the place of accident

15. Dentist should be prepared to give advices about first aid for avulsed teeth to public. Avulsed teeth is on of a REAL EMERGENCY situation in dentistry. Instruction may be given by phone to people at the emergency site.

16. USE STORAGE MEDIA

17. INSTRUCTIONS: Make sure that the avulsed tooth is a permanent tooth. Keep the patient calm. Fined the tooth and pick it up from the crown Not the root. If the tooth is dirty , wash it briefly ( MAX 10 s) under cold running water and reposition it.

18. Try to encourage the patient/ gardens to replant the tooth. Once the tooth is in place bite into a napkin to hold the tooth in position. If it is not possible ( e.g. pt unconscious ), place the tooth in a glass of storage media (e.g. Milk) and bring with the patient to emergency clinic .

19. The tooth can be transported in the mouth, by keeping the tooth inside the lip or cheek if the patient is conscious.

20. If the patient is very young, he/she may swallow the tooth, therefore it is advisable to ask the patient to spit in a container and place the tooth in it ( AVOID WATER )

21. Storage media ( if available) is advisable ( tissue cutler / transport medium, Hanks balanced storage media ( HBSS or saline)

22. Seek emergency dental treatment IMMEDIATLY

23. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

24. It is important to asses the condition of the PDL cells, by classifying the avulsed tooth into one of the following: 1) The PDL cells are more likely viable Tooth replanted immediately Short time after the accident

25. 2) The PDL cells may be viable but compromised Tooth kept in storage media Total dry time < 60 min

26. 3 ) The PDL cells are non viable Storage medium non physiologic Total dry time >60 min

27. 1) Treatment guidelines for avulsed permanent teeth with closed apex:

28. 1A ) The tooth has been replanted before the patient’s arrival at the clinic : Leave the tooth in place. Clean the area with water spray, saline, or chlorhexidine. Suture gingival lacerations, if present. Verify normal position of the replanted tooth clinically and radiographically.

29. Apply a flexible splint for up to 2 weeks . Antibiotic and antitetanus therapy Patient instructions. Initial RCT 7-10 day after replantation and before splint removal

30. 1B ) The tooth has been kept in a physiologic storage medium and/or stored dry, the extra-oral dry time has been <60 min: Clean the root surface and apical foramen with a saline and soak the tooth in saline . LA Irrigate the socket with saline. Examine the alveolar socket. If fractured, reposition it with suitable instrument .

31. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations, if present. Verify normal position of the replanted tooth clinically and radiographically. Apply a flexible splint for up to 2 weeks , keep away from the gingiva.

32. Antibiotic and antitetanus therapy Give patient instructions Initiate root canal treatment 7–10 days after replantation and before splint removal.

33. 1C) Dry time >60 min or other reasons suggesting non-viable cells : Remove attached non-viable soft tissue carefully. Root canal treatment to the tooth can be carried out prior to replantation or later . In cases of delayed replantation , root canal treatment should be either carried out on the tooth prior to replantation or it can be carried out 7–10 days later. LA

34. Irrigate the socket with saline. Examine the alveolar socket. If fractured, reposition it with a suitable instrument. Replant the tooth . Suture gingival lacerations, if present. Verify normal position of the replanted tooth clinically and radiographically .

35. Stabilize the tooth for 4 weeks using a flexible splint . Antibiotic and antitetanus Patient instructions To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2% sodium fluoride solution for 20 min)

36. Follow-up : In children and adolescent ankylosis is frequently associated with infra position Carful follow up is required Good communication to insecure the patient and the guardians with this possible outcome Decoronation may be necessary later when infraposition is seen ( > 1mm)

37. 2 ) Treatment guidelines for avulsed permanent teeth with an open apex

38. 2A) The tooth has been replanted before the patient’s arrival at the clinic : Leave the tooth in place. Clean the area with water spray, saline, or chlorhexidine. Suture gingival lacerations, if present. Verify normal position of the replanted tooth clinically and radiographically . flexible splint for up to 2 weeks .

39. Antibiotic and antitetanus therapy Give patient instructions . The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization ( apexogenisis ) of the pulp space. If that does not occur, root canal treatment may be recommended

40. 2B) The tooth has been kept in a physiologic storage medium and/or stored dry, the extra-oral dry time has been <60 min Clean the root surface and apical foramen with a stream of saline. Topical application of antibiotics has been shown to enhance chances for revascularization of the pulp and can be considered if available . LA Examine the alveolar socket . If fractured, reposition it with a suitable instrument.

41. Remove the coagulum in the socket and replant the tooth slowly with slight digital pressure . Suture gingival lacerations, especially in the cervical area. Verify normal position of the replanted tooth clinically and radiographically. Apply a flexible splint for up to 2 weeks

42. Antibiotic and antitetanus therapy. Give patient instructions . The goal for replanting (immature) teeth in children is to allow for possible revascularization ( apexogenisis ) of the pulp space. If that does not occur, root canal treatment may be recommended.

43. 2C) Dry time >60 min or other reasons suggesting non-viable cells Remove attached non-viable soft tissue carefully. Root canal treatment to the tooth can be carried out prior to replantation or later. Administer local anesthesia. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument .

44. Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. Stabilize the tooth for 4 weeks using a flexible splint . Antibiotic and antitetanus therapy

45. Give patient instructions . To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation (2% sodium fluoride solution for 20 min)

46. Follow-up: In children and adolescent ankylosis is frequently associated with infra position Carful follow up is required Good communication to insecure the patient and the guardians with this possible outcome Decoronation may be necessary later when infraposition is seen ( > 1mm)

47. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

48. Anesthetic Patient / guardians instructed to do replantation of avulsed tooth at the place of accident without anesthesia . In the clinic, there is no need to omit local anesthesia, especially as there are often contamination injury. U sing vasoconstrictors in the anesthesia may compromising the healing  WEAK EVIDANCE Block anesthesia maybe considered as an alternative to infiltration.

49. Antibiotic The value of systematic antibiotic after replantation is still questionable as clinical studies have not demonstrate its value. Experimental studies have demonstrate + ve effect on pulpal and periodontal healing specially when demonstrated topically.

50. Antibiotic For systematic administration : Tetracycline is the 1 st choice in appropriate dose the first week after replantation The risk of permeant teeth pigmentation must be considered in young patients ( it is not recommended in patients under 12. A penicillin phenoxymethylpenicillin ( pen V) or amoxicillin the first week after replantation can be given as an alternative to tetracycline.

51. Antibiotic Topical antibiotic: ( Minocycline or doxycycline 1mg/ 20 ml of saline for 5 min soak ) appear experimentally to have + ve effect on pulpal space revascularization and periodontal healing in immature teeth ( 2B)

52. Tetanus Refer to patient physician to evaluate the need of tetanus booster

53. Splinting of replanted tooth It is considered best practice to maintain the repositioned tooth in correct position. Current evidence supports short term flexible splint for replanted teeth.

54. The splint should be placed into the buccal surface of maxillary anterior teeth

55. Patient instructions Avoid participation in contact sports. Soft diet for up to 2 weeks. Thereafter normal function as soon as possible. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

56. Endodontic consideration: If RCT needed ( in tooth with closed apex) the ideal time for Tx is 7-10 days after replantation Calcium hydroxide is recommended as intra canal medication for up to 1 month followed by root canal filling with an acceptable material.

57. Endodontic consideration: Alternatively: If antibiotic-corticosteroid past is chosen to be used as anti- inflammatiory , anti-clastic intra-canal medication, it may placed immediately or shortly after replantation and left for at least 2 weeks If the tooth has been dry for > 60 min before replantation, RCT may carry out prior to replantation.

58. In teeth with open apexes, which replanted immediately or kept in appropriate storage media: revascularization is possible. For very immature teeth, root canal treatment should be avoided .

59. Outline Introduction First aid for avulsed teeth at the place of accident Treatment guideline for avulsed permeant teeth Additional consideration Follow up

60. Follow-up procedures Replanted teeth should be monitored by clinical and radiographic control after 1month, 3 months, 6 months, 1 year, and yearly there after. Clinical and radiographic examination will provide information to determine outcome

61. Favorable outcome Open Apex Closed Apex Asymptomatic Normal mobility Normal percussion sound Radiographic evidence of arrested or continued root formation Pulp canal obliteration is expected Asymptomatic Normal mobility Normal percussion sound No radiographic evidence of resorption or periradicular osteitis Lamina dura should appear normal

62. Unfavorable outcome Open Apex Closed Apex Symptomatic Excessive mobility or normal mobility ( ankyloses) with high pitched percussion sound ( infraposition ) Radiographic evidence of resorption Absence of continued root formation Symptomatic Excessive mobility or normal mobility ( ankyloses) with high pitched percussion sound Radiographic evidence of resorption

63. Loss of tooth If tooth lost during emergency phase or later after trauma. Appropriate treatment options includes: Decoronation Autotransplantation Resin retained bridge Denture Orthodontic space closure with composite modification and sectional osteotomy After growth is completed implant treatment is considered