Sunday, May 21, 2017

Guidelines for the management of traumatic dental injuries: 2 Avulsion of Permanent Teeth

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Brian Darling                                                                     Date: 5/24/17
Article Title: Guidelines for the management of traumatic dental injuries: 2 Avulsion of Permanent Teeth
Author(s): Andersson L, et al
Journal: Pediatric Dentistry
Date: 2014/15; 36 (6) pg 328-335
Major Topic: Management of avulsed permanent teeth
Type of Article: AAPD Guideline
Main Purpose: This article aimed to describe how to manage avulsed permanent teeth.
Key Points: (2 lines Max):
·      Replantation is usually the treatment of choice
·      Contraindications to replantation
o   Severe caries
o   Severe periodontal disease
o   Non-cooperative patient
o   Severe medical conditions – immunosuppressed, cardiac conditions
·      First aid at the scene
o   Pick up tooth by crown and rinse in water (no more than 10 seconds)
o   Replant tooth is ideal treatment. Could also place in HBSS, vestibule (if not aspiration risk – conscious, older patient), skim or low fat milk; avoid placing tooth in water.
o   May bite on handkerchief to hold tooth in place after replantation
o   Seek dental treatment immediately.
·      PDL cells viability
o   Likely if replanted shortly after avulsion
o   Compromised if kept in adequate storage medium or extraoral dry time <60 min
o   Non-viable if extra-oral dry time >60 min or inadequate storage medium or in storage medium for too long
·      Tooth with likely/compromised PDL viability
o   Suture gingival lacerations
o   Clean wound. Replant tooth (if not already).
§  If tooth has open apex, remove coagulum from socket before replanting tooth
o   Verify tooth position with radiograph
o   Splint up to 2 weeks
o   Antibiotics and check tetanus status
o   Closed apex – initiate RCT within 7-10 days after replantation but before splint removal
o   Open apex – consider regenerative endodontics, apexification, or traditional RCT
§  Topical application of antibiotics may enhance chance for revascularization and periodontal healing for immature teeth  
·      Minocycline or doxycycline 1mg per 20 ml of saline for 5 min soak
§  If tooth hasn’t been replanted, instigate bleeding in socket before replanting
§  Must weigh the chance of revascularization with risk of inflammatory root resorption
§  Avoid RCT unless there is clinical or radiographic evidence of pulp necrosis
·      Tooth with nonviable PDL cells – expected to ankylose and trying to maintain alveolar bone height
o   Remove non-viable soft-tissue from root
o   May consider soaking tooth in 2% NaF for 20 min before replanting to slow osseous replacement
o   Clean wound. Replant tooth
o   Verify position with radiograph
o   Splint for 4 weeks
o   Antibiotics and check tetanus status
o   May perform RCT outside of mouth or within 7-10 days after replantation
o   Consider decoronation when infraposition >1mm
·      Evidence is weak about using non-vasoconstrictor containing local anesthetic for trauma in thoughts that it may compromise healing
·      Benefits of systemic antibiotics is questionable
o   Tetracycline is 1st choice if >12 years old
o   <12 years old use penicillin or amoxicillin
·      Post-operative instructions
o   Avoid contact sports
o   Soft diet for 2 weeks
o   Brush with soft toothbrush after each meal
o   Chlorhexidine 0.1% rinse BID for 1 week
·      Must initiate RCT in teeth with closed apices within7-10 days
o   Calcium hydroxide for up to 1 month recommended.
o   May also use antibiotic-corticosteroid paste as intra-canal medicament for anti-inflammatory and anti-clastic properties
·      Follow-up
o   2 weeks for splint removal on cells with likely/compromised PDL viability
o   4 weeks for clinical and radiographic evaluation and remove splint if PDL non-viable
o   3 months for clinical and radiographic evaluation
o   6 months for clinical and radiographic evaluation
o   1 year and then yearly thereafter
·      Favorable outcomes
o   Closed apex: asymptomatic, normal mobility, percussion sound, no radiographic evidence of resorption or periapical osteitis, normal lamina dura
o   Open apex: asymptomatic, normal percussion, normal palpation; radiographic evidence of arrested or continued root formation and eruption. Pulp canal obliteration is expected
·      Unfavorable outcomes
o   Closed apex: symptomatic, excessive mobility/non-mobile; ankylotic percussion sounds; radiographic evidence or resorption (inflammatory, infection-related or ankylosis-related replacement resorption)
§  Ankylosis in growing patient can lead to infraposition of tooth and disturbance in alveolar and facial growth over time
o   Open apex: symptomatic; excessive mobility/non-mobile; ankylotic sounds; radiographic evidence of inflammatory, infection related resorption or ankylosis-related replacement resorption; abscess of continued root formation
·      Best to consider treatment options for a tooth expected to be lost before hand
o   Decoronation, autotransplantation, resin-retained bridge, denture, orthodontic space closure

Assessment of Article:  Level of Evidence/Comments: III

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