Management of the Avulsed Tooth Flashcards
- What is the incidence and main etiologic factors of tooth avulsion?
Incidence: 0.5% to 16% of traumatic injuries
Main etiologic factors:
- Fights
- Sports Injuries
- Automobile Accidents
What is the most common avulsed tooth?
Maxillary Central Incisor
- Most commonly avulsed tooth
- Mandibular teeth - seldom affected
- Most frequently involves a single tooth
What is the most common age to avulse teeth?
Most common age: 7 - 11
- Permanent Incisors Erupting
- Lossely Structured PDL
What are some common associated injuries of avulsed permanent teeth?
- Fracture of alveolar socket wall
- Injuries to the lips and gingiva
What is the ultimate goal of managing an avulsed tooth?
Manage the PDL!
- PDL healing without root resorption
- MOST CRITICAL FACTOR: Maintaing an intact and viable PDL on the root surface
What 3 ways can the PDL respond to tooth avulsion?
- Surface Resorption
- Replacement Resorption (Ankylosis)
- Inflammatory Resorption
What treatment considerations are there when dealing with a hockey player who stopped the final goal by stopping the puck with his teeth and happen to avulse his tooth?
- Extraoral time
- Extraoral environment
- Root surface manipulation
- Managment of the socket
- Stabilization
How time extraoral time affect resoprtion?
Shorter time = Better prognosis
< 30 min → 10% resorption
> 90 min → 90% resorption
*depending on storage medium
What liquids yield poor results as storage mediums and which offer good protection for 2 hours?
Poor Results…
- Tap Water
- Dry
Good protection for 2 hours
- Saliva
- Saline
What are some characteristics of milk as a storage medium?
- Physiologic osmolality
- Markedly fewer bacteria than saliva
- Readily available
How is Milk compare to Saliva as a storage media?
- Storage for 2 hours - Periodontal healing almost as good as immediate replantation
- Storage for 6 hrs - Saliva → extensive replacement resorption
- Milk → healing almost as good as immediate replantation
What are some characteristics of Hank’s Balanced Salt Solution?
- Proper pH and osmolaity
- Reconstitutes depleted cellular metabolites
- Washes toxic breakdown products from the root surface
What are some characteristics of Viaspan (Organ Transplant Storage Media)?
- Dramatically prolongs the storage of human organs
- Expensive
- Not readily available
- Complete healing after 6 and 12 hours
- Good for extended storage periods (72 and 96 hours)
- Hank’s balanced solution → healing results similar to Viaspan
What are 5 recommended Storage Media?
- Socket (immediate replantation)
- Cell culture medium
- Milk
- Physiologic saline
- Saliva
What things do you NOT do when trying to retain PDL cell viability?
- Do not curette root surface
- Avoid caustic chemicals
How long is milk, saliva, and tap water acceptable to place a tooth in for extra oral handling?
- Milk - 6 hours
- Saliva - 2 hours
- Tap Water - Unacceptable Media
What are 3 handling recomendations for a tooth with extra oral dry time < 1 hour?
PDL healing is still possible
- Keep root moist
- Dnot handle root surface
- Gentle Debridement
What happens to a tooth with an extra oral dry time of > 1 hour?
- Loss of PDL cell viability
- Treatment recomendations: → Remove tissue tags, Soak in accepted dental fluoride solution for 20 minutes
What is an acceptable topical fluoride solution for an avulsed tooth?
- 1.0 - 2.4% fluoride solution
- Sodium Fluoride (Andreasen)
- Stannous Fluoride (Krasner)
- 20 minute soak
How do you manage the socket of an avulsed tooth?
- Remove contaminated coagulum in socket → Irrigate with sterile saline
- Examine socket → IF FRACTURE IS EVIDENT → Reposition fractured bone with a blunt instrument
- Replant the tooth using digital pressure
Define Splint…
A RIGID or FLEXIBLE device used to support, protect, or immoblize teeth, preventing further injury
What are the 2 types of splints?
- Acid Etch Composite
- Cross-Suture
What are some different acid etch composite splints?
- Interproximal Composite
- Composite with arch wire
- Composite with monofilament nylon
Are acid etch composite splints considered fuctional splints?
Yes!
- 20-30 lb monofilment nylon
- Bonded with composite
- Allows phsiologic movement
What are the indications for a cross-suture splint?
- No adjacent teeth to splint to
- Unmangeable traumatized children
What is the recommended amount of days one should splint teeth?
7-10 Days
What is the recommended splinting time for closed apex? Open apex with dry time < 60 minutes? Open apex with a dry time > 60 minutes?
- Closed Apex → 7 - 14 days
- Open Apex with dry time < 60 minutes → 7 - 14 days
- Open Apex with dry time > 60 minutes → 4 weeks
What is the chance of revascularization for mature roots (< 1.0mm) and immature roots (> 1.00)?
- Mature Roots → 0% Revascularization
- Immature Roots → 18-34% Revascularization
What is the sequence of revascularization after a tooth is reimplanted?
- Loss of blood supply to pulp
- Coronal Pulp (Day 4) - Extensive ischemic injury
- Apical Pulp (Day 4) - Initial Revascularization
- In 4 weeks you will have: Revasculrization, Reinnervation, New odontoblastic layer
What is the typical sequela of revascularization?
Pulp canal obliteration
As dry storage time increases…pulp survival increases or decreases?
Pulp Surival DECREASES
What chance of pulp revascularization do you have with nonphysiologic storage media?
Minimal chance of pulp revascularization
What chance of revascularization do you have if the tooth is placed in physiologic storage like HBSS, milk, saline, or saliva?
Improved chance of pulp revascularization
Does systemic antibiotics increase the chance of pulp revascularization?
No!
Does applying topical Doxycycline affect the pulpal prognosis?
YES!
- Decreased microorganisms in pulpal lumen
- Increased pulp revascularization
What is the recomended topical antibiotic?
Topical Doxycyline or Minocycline
1 mg in 20 ml physiologic saline, 5 minute soak
What is the endodontic raitonale for applying topical antibiotics?
In a mature root at 4 weeks…
Very limited revascularization
Ischmemic coronal pulp with GREAT RISK OF INFECTION!!!
For a mture root, what is the endodontic rationale for using Calcium Hydroxide?
- Antibacterial
- Increaeses pH in dentin
- Favors mineralization over resorption
How long would you apply Calcium Hydroxide for a mature root?
4 Weeks
When do you have wiggle room for EXTRAORAL dry time for a closed apex or open apex?
- Closed apex → One hour or less
- Open apex → More than one hour
For a mture root, when do you do a pulpectomy?
- Immediately after reimplantation or…
- 7-10 days
If the extraoral dry time is < 1 hour, how would you treat a Closed Apex? How would you treat an Open Apex?
- Closed Apex → Pulpectomy immediately after replantation or 7-10 days
- Open Apex → Observe
How would you treat a tooth with an extra oral dry time of > 1 hour for an Open Apex? How about a Closed Apex?
- For Open or Closed → Pulpectomy immediately prior to/aftet replantation or wait until 7-10 days
If extra oral dryt time is > 60 minutes, how do you remove necrotic tissue attached to the root?
Gauze
What is the sequence of event if the extra oral dry time is > 60 minutes for an OPEN APEX?
- Carefully remove necrotic tissue attached to the root using gauze
- Administer local anesthesia
- Irrigate the socket with saline
- Examine the socket for possible fracture and reposition if necessary
- Preferably, root canal treatment should be carries out priot to replantation
- Replant the tooth slowly with slight digital pressure
- Suture gingival laceration, especially in the cervical area
- Verify normal position of the replanted tooth radiogrpahically
- Apply a flexible splint for 4 weeks (up to 0.016” or 0.4mm).
What steps should you use in emergency treatment for replantation?
- Local anesthetic, if necessary
- Radiograph to verify position
- Check occlusion
- Physiologic Splint
What are some additional considerations in emergency treatment to consider as post operative care?
- Analgesics (Motrin & Tylenol)
- Chlorhexidine
- Tetanus → Refer to physician for tetanus prophylaxis prn
What are the sigs for Antibiotics after dental trauma/reimplantation?
- Doxycyline - 50 mg bid for 7 days (appropriate dose per pt age and weight)
- Amoxicillin - 500 mg qid for 7 days (appropriate dose per pt age and weight)
How does tetracycline stack up versus amoxicillin in a repalcement resorption model?
Tetracycline had BETTER anti-resorptive properties
How does tetracycline stack up vs amoxicillin in an inflammatory root resorption model?
Tytracycline had BETTER anti-bacterial properties
What is the bottom line recomendation for tetraycline?
“Tetracycline could be considered as an alternative to amoxicillin after avulsion injuries”
Would you worry about tetracycline stating after prescribing to a child?
- Not a problem since avulsed maxillary anteriors have already erupted and are not susceptible to staining
- At worst, posterior teeth might be stained → Remote possibility with 7-10 day prescription
What is the treatment algorhythm for < 1 hour of extra oral dry time for a Closed Apex and Open Apex?
- Closed Apex → Pulpectomy, immediate 7-10 days Ca(OH)2 tx
- Splint removal: 2 weeks
- Open Apex → Observe
- Splint removal: 2 weeks
What is the treatment algorhythm for > 1 hour of extraoral dry time for both a Closed Apex and Open Apex?
- Closed Apex → Pulpectomy immediate 7-10 days Ca(OH) 2 tx
- Splint Removal: 2 weeks
- Open Apex → Pulpectomy immediate 7-10 days Ca (OH)2 tx
- Splint removal: 4-6 weeks
In summary, there are 4 factors to remember when treating an avulsed tooth…
- Be prepared - DENTAL TRAUMA KIT
- Immerse tooth in a physiologic storage medium to “buy time”
- Determine extraoral DRY time
- Follow AAE Guidelines
