Avulsion

Question 1

What are the clinical findings of avulsion?

Answer 1

Socket empty or filled with coagulum

Question 2

What are the critical factors immediately after avulsion?

Answer 2

Extra-alveolar dry time (EADT)
Extra-alveolar time (EAT)
Storage medium

Question 3

What emergency advice should be given for avulsion?

Answer 3

Ensure permanent tooth
Hold by crown
Encourage attempt to place tooth immediately into socket (if tooth dirty, rinse gently in milk, saline or in the patient’s saliva and replant)
Bite on gauze to hold in place once replanted
Seek immediate dental advice

Question 4

What storage mediums can be used for an avulsed tooth?

Answer 4

Milk
HBSS
Saliva
Saline
Water

Question 5

What are the factors in managing an avulsed tooth?

Answer 5

Maturity of root
PDL cell condition

Question 6

How should a replanted tooth with a closed apex be managed?

Answer 6

Clean injured area
Verify replanted tooth position and apical status by clinical and radiographic examination
Place splint
Suture gingival lacerations, if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 7

How should an avulsed tooth with an EADT of <60 minutes and a closed apex be managed?

Answer 7

PDL cells may be viable but compromised
Remove debris
History and examination with tooth in storage medium
Replant tooth under LA
Splint
Suture gingival lacerations if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 8

How should an avulsed tooth with an EADT of >60 minutes and a closed apex be managed?

Answer 8

PDL cells likely to be non-viable
Remove debris
Replant under LA
Splint
Suture gingival lacerations, if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 9

Describe endo treatment for an avulsed tooth with a closed apex

Answer 9

Commence within 2 weeks
Intra-canal medicament of CaOH up to 1 month or corticosteroid/antibiotic paste for 6 weeks

Question 10

How does delayed replantation affect an avulsed tooth with a closed apex?

Answer 10

Poor long-term prognosis - ankylosis related root resorption
Decision to replant almost always correct however
May need to refer to paediatric specialist/inter-disciplinary management

Question 11

How should an avulsed tooth with a closed apex be followed up?

Answer 11

Clinical and radiographic evaluation at 2 weeks (including splint removal), 4 weeks, 3 months, 6 months and 1 year
Then annually for at least 5 years

Question 12

How should an already replanted tooth with an open apex be managed?

Answer 12

Clean injured area
Verify replanted tooth position and apical status with clinical and radiographic examination
Place splint
Suture gingival lacerations, if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 13

How should an avulsed tooth with an EAT of <60 minutes and an open apex be managed?

Answer 13

Potential for spontaneous healing
Remove debris
History and examination with tooth in storage medium
Replant tooth under LA
Splint
Suture gingival lacerations, if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 14

How should an avulsed tooth with an EAT of >60 minutes and an open apex be managed?

Answer 14

PDL cells likely non-viable
Likely outcome is ankylosis related root resorption
Remove debris
Replant tooth under LA
Splint
Suture gingival lacerations, if present
Consider antibiotics and check tetanus status
Provide POI
Follow up

Question 15

What is the goal of replanting a tooth with an open apex?

Answer 15

Revascularisation of the pulp
Monitoring development of the tooth against the risk of external IIR
Endo treatment if definite signs of pulp necrosis and infection of root canal system

Question 16

How does delayed replantation affect an avulsed tooth with an open apex?

Answer 16

Poor long-term prognosis - ankylosis-related root resorption - PDL becomes necrotic
Replant to resort aesthetics and function temporarily while monitoring alveolar bone and refer to specialist

Question 17

How should a replanted tooth with an open apex be followed up?

Answer 17

Clinical and radiographic evaluation at 2 weeks (including splint removal), 1 month, 2 months, 3 months, 6 months and 1 year
Then annually for at least 5 years

Question 18

What are the contraindications to replanting an avulsed tooth?

Answer 18

Medical - child immunocompromised, other serios injuries requiring preferential emergency treatment
Dental - very immature apex and EAT >90 minutes, very immature lower incisors and young child finding it difficult to cope

Question 19

What are the 5 year pulp survival rates of replanted teeth?

Answer 19

30% if open apex
0% if closed apex

Question 20

What is the 5 year root resorption rate for replanted teeth?

Answer 20

Root resorption is frequent