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 alAuthors
literature reviewType
International Association of Dental Traumatology,Journal
2013Date

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. Replantation
Treatment of choice
But cannot always
carried out

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

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

9. • 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.

10. Guidelines are to be applied with
judgment of:
clinical
circumstances
patient’s
characteristics
clinician’s
judgments

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

12. • 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.

13. • 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

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

15. FIRST AID FOR AVULSED TEETH
AT THE PLACE OF ACCIDENT

16. • 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.

17. IMMEDIAT
Replantation
Treatment of choice
But cannot always
carried out
USE
STORAGE
MEDIA

18. 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.

19. • 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.

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

21. • 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)

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

23. Seek emergency dental treatment
IMMEDIATLY

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

27. • 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

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

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

30. 1) TREATMENT GUIDELINES
FOR AVULSED PERMANENT
TEETH WITH CLOSED APEX:

31. 1A) The tooth has been replanted before the patient’s arrival
at the clinic:
1. Leave the tooth in place.
2. Clean the area with water spray, saline, or chlorhexidine.
3. Suture gingival lacerations, if present.
4. Verify normal position of the replanted tooth clinically and
radiographically.

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

34. 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 .
1. LA
2. Irrigate the socket with saline.
3. Examine the alveolar socket. If fractured, reposition it with
suitable instrument.

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

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

38. 1C) Dry time >60 min or other reasons suggesting non-
viable cells:
1. Remove attached non-viable soft tissue carefully.
2. Root canal treatment to the tooth can be carried out prior to
replantation or later .
3. 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.
4. LA

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

40. 11. Stabilize the tooth for 4 weeks using a flexible splint.
12. Antibiotic and antitetanus
13. Patient instructions
14. 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)

41. 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)

42. 2) TREATMENT GUIDELINES
FOR AVULSED PERMANENT
TEETH WITH AN OPEN APEX

43. 2A) The tooth has been replanted before the patient’s arrival at
the clinic:
1. Leave the tooth in place.
2. Clean the area with water spray, saline, or chlorhexidine.
3. Suture gingival lacerations, if present.
4. Verify normal position of the replanted tooth clinically and
radiographically.
5. flexible splint for up to 2 weeks .

44. 6. Antibiotic and antitetanus therapy
7. Give patient instructions .
8. 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

45. 2B) The tooth has been kept in a physiologic storage medium
and/or stored dry, the extra-oral dry time has been <60 min
1. Clean the root surface and apical foramen with a stream of
saline.
2. Topical application of antibiotics has been shown to enhance
chances for revascularization of the pulp and can be
considered if available .
3. LA
4. Examine the alveolar socket . If fractured, reposition it with a
suitable instrument.

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

47. 9. Antibiotic and antitetanus therapy.
10. Give patient instructions .
11. 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.

48. 2C) Dry time >60 min or other reasons suggesting non-viable
cells
1. Remove attached non-viable soft tissue carefully.
2. Root canal treatment to the tooth can be carried out prior to
replantation or later.
3. Administer local anesthesia. Remove the coagulum from the
socket with a stream of saline.
4. Examine the alveolar socket. If there is a fracture of the
socket wall, reposition it with a suitable instrument.

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

50. 10. Give patient instructions .
11. 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)

51. 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)

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

53. 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.
• Using vasoconstrictors in the anesthesia may compromising the
healing  WEAK EVIDANCE
• Block anesthesia maybe considered as an alternative to
infiltration.

54. 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.

55. Antibiotic
For systematic administration :
• Tetracycline is the 1st 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.

56. 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)

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

58. 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.

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

60. 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.

61. 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.

62. 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.

63. • 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.

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

65. 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

66. Favorable outcome
Open ApexClosed 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

67. Unfavorable outcome
Open ApexClosed 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

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