How Do We Manage Tooth Avulsion?
As avulsion of permanent teeth is one of the most serious dental injuries, a prompt and correct emergency management is very important for a good prognosis. Tooth avulsion is a traumatic injury characterized as the complete displacement of the tooth out of its socket.
Trauma due to accidents, violence, full contact sports, and falls, especially in younger patients with poor balance are the most common causes of an avulsed tooth. The maxillary incisors are the most commonly affected teeth, and often more than one tooth is avulsed.
As dentist we should be well versed in such emergency cases we may experience from our own dental clinic. The success of the treatment varies on the survival of the viable periodontal ligament cells attached to the tooth root surface. The viability of the periodontal ligament cells is best preserved either when the tooth is immediately replanted into its socket or if it is stored in an appropriate storage /transport medium till a time, the tooth can be replanted into its socket.
Primary Teeth: Avulsed primary teeth are not required to be replanted (with the exception of open apex primary tooth) because of the potential for damage to the development of permanent tooth and may cause pulpal necrosis of the primary tooth. The dentist should emphasize to the parents of the child the advantages of sacrificing the primary teeth so as not to compromise the development of the permanent teeth.
Permanent Teeth: The sooner avulsed permanent teeth are replanted the greater chance for a favorable prognosis. However, before attempting replantation, one has to assess the patient's medical status. Replantation is contraindicated to the following:
- Immunocompromised patients
- Patients with uncontrolled seizure disorders
- Patients with severe mental disability
- Patients with congenital cardiac anomalies or severe cardiac diseases
- Patients with uncontrolled diabetes.
Assess also the integrity of the tooth and the supporting structures. Compromised integrity of the tooth (extensive decay) or supporting structures such as alveolar fracture or bone recession due to periodontal disease will also reduce success.
General Rule in Management of Avulsed Tooth:
- Radiographic examination is necessary to rule out intrusion and to determine the extent of the injury
- The antibiotic of choice is Amoxicillin 500 mg x 3 days for 7 days (children =50 mg/kg/day)
- Doxycycline 100 mg 1 a day for 7 days (children 2 mg/kg/day)
- Chlorhexidine rinses is prescribed and strict hygiene instruction during splinting and treatment
- Avulsed tooth should be placed special storage medium such as milk, saline solution or Hank’s Balanced salt solution
- If the avulsed tooth has been in contact with soil, clean the tooth with saline solution. If Tetanus vaccine is uncertain, refer to physician for a tetanus booster shot
- Eliminate all necrotic tissue inside the socket by curettage or irrigate with EDTA 24%, citric acid or sodium hypochlorite for at least 20 secs.
- Before re-implanting, soak the tooth in a sodium fluoride 2.4% solution for 20 minutes.
CLOSED APEX AVULSED TOOTH MANAGEMENT
NOTE: Tooth replanted prior to the patient’s arrival at the dental office or clinic
Treatment
- 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 both clinically and radiographically.
- Apply a flexible splint for up to 2 weeks.
- If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
- Prescribe antibiotics
- Initiate root canal treatment 7-10 days after replantation and before splint removal.
Patient Instructions
- Avoid participation in contact sports.
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a Chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.
Follow-Up
- Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
- Splint removal and clinical and radiographic control after 2 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
AVULSED CLOSED APEX TOOTH (Extraoral dry time < 60 min) MANAGEMENT
Treatment
- Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
- Administer local anesthesia
- Irrigate the socket with saline.
- Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
- Replant the tooth slowly with slight digital pressure. Do not use force.
- Suture gingival lacerations if present.
- Verify normal position of the replanted tooth both, clinically and radiographically.
- Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
- Administer systemic antibiotics.
- Initiate root canal treatment 7-10 days after replantation and before splint removal.
Patient instructions
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.
Follow-up
- Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
- Splint removal and clinical and radiographic control after 2 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
AVULSED CLOSED APEX TOOTH (Extra oral dry time > 60 min) MANAGEMENT
Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and can not be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour. The expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually.
Treatment
- Remove attached non-viable soft tissue carefully, with gauze.
- Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
- Administer local anesthesia
- Irrigate the socket with saline.
- Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
- Replant the tooth slowly with slight digital pressure. Do not use force.
- Suture gingival lacerations if present.
- Verify normal position of the replanted tooth clinically and radiographically.
- Stabilize the tooth for 4 weeks using a flexible splint.
- Administer systemic antibiotics.
- 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.)
Patient Instructions
- Avoid participation in contact sports.
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a Chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-Up
- Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
- Splint removal and clinical and radiographic control after 4 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
Ankylosis is unavoidable after delayed replantation and must be taken into consideration. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome.
OPEN APEX MANAGEMENT
NOTE: Tooth replanted prior to the patients arrival at the dental office or clinic
Treatment
- Leave the tooth in place.
- Clean the area with water spray, saline, or chlorhexidine.
- Suture gingival laceration if present.
- Verify normal position of the replanted tooth both clinically and radiographically.
- Apply a flexible splint for up to 1-2 weeks.
- Administer systemic antibiotics.
- The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment is recommended.
Patient Instructions
- Avoid participation in contact sports.
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a Chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-Up
- For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
- Splint removal and clinical and radiographic control after 2 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
OPEN APEX (Extraoral dry time < 60 min.) MANAGEMENT
Treatment
- Clean and remove necrotic tissues in the root surface and apical foramen with currette or a stream of saline, EDTA, citric acid or sodium hypochloride.
- Topical application of antibiotics has been shown to enhance chances for revascularization of the pulp and can be considered if available (minocycline or doxycycline 1 mg per 20 ml saline for 5 minutes soak).
- Administer local anesthesia.
- Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
- Irrigate the socket with saline.
- 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.
- Administer systemic antibiotics.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space. The risk of infection-related root resorption should be weighed up against the chances of revascularization. Resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.
Patient Instructions
- Avoid participation in contact sports.
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a Chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-Up
- For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
- Splint removal and clinical and radiographic control after 2 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
OPEN APEX TOOTH (Extraoral dry time > 60mins) MANAGEMENT
Treatment
Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and can not be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour. The expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually.
- Remove attached non-viable soft tissue with gauze.
- Root canal treatment can be carried out prior to replantation or later.
- Administer local anesthesia.
- Irrigate the socket with saline.
- Examine the alveolar socket. if there is a fracture of the socket wall, reposition it with a suitable instrument.
- Replant the tooth slowly with slight digital pressure.
- Suture gingival lacerations if present.
- Verify normal position of the replanted tooth clinically and radiographically.
- Stabilize the tooth for 4 weeks using a flexible splint.
- Administer systemic antibiotics.
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.
Patient Instructions
- Avoid participation in contact sports.
- Soft food for up to 2 weeks.
- Brush teeth with a soft toothbrush after each meal.
- Use a Chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-Up
- For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
- Splint removal and clinical and radiographic control after 4 weeks.
- Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
CONCLUSION
In conclusion, treating emergency cases to save a tooth is one of the most important and significant treatments we can do in our dental practice. After all, this is the reason why we became dentists in the first place, to preserve the natural teeth as much and as long as we can. Hence, knowing how to assess and manage treatments like this is something worthwhile to learn and remember.
Contributors:
Dr. Bryan Anduiza - Writer
Dr. Jean Galindez - Editor
References:
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