Traumatic Injuries to the Teeth

Traumatic Injuries Traumatic Injuries to the Teethto the Teeth

Scott A. Schwartz, Colonel, USAF, DCScott A. Schwartz, Colonel, USAF, DC

Traumatic Injuries to the TeethTraumatic Injuries to the Teeth

Crown FracturesCrown Fractures Crown-Root FracturesCrown-Root Fractures Root FracturesRoot Fractures Luxation InjuriesLuxation Injuries AvulsionAvulsion


Root Fracture UpdateRoot Fracture Update


Root Fracture UpdateRoot Fracture Update Management of the Management of the

Avulsed ToothAvulsed Tooth


Clinical examinationClinical examination– Tooth usually slightly extrudedTooth usually slightly extruded– Tooth frequently displaced Tooth frequently displaced

linguallylingually


Clinical examinationClinical examination– Tooth usually slightly extrudedTooth usually slightly extruded– Tooth frequently displaced Tooth frequently displaced

linguallylingually


Clinical examinationClinical examination– Diagnosis entirely Diagnosis entirely

dependent upon dependent upon radiographic radiographic examinationexamination

Emergency ManagementEmergency Management

Periapical radiographsPeriapical radiographs– Standard XCP radiographStandard XCP radiograph– Increased vertical angulationIncreased vertical angulation


Periapical radiographsPeriapical radiographs– Standard XCP radiographStandard XCP radiograph– Increased vertical angulationIncreased vertical angulation


Reposition coronal Reposition coronal fragmentfragment


Previous Previous recommendationrecommendation– Rigid splinting for 2-3 Rigid splinting for 2-3

monthsmonths


Previous Previous recommendationrecommendation– Rigid splinting for 2-3 Rigid splinting for 2-3

monthsmonths

New recommendationNew recommendation– Splinting for 3 weeksSplinting for 3 weeks

Root Fracture HealingRoot Fracture Healing

Root Fracture ComplicationsRoot Fracture Complications

Pulp necrosisPulp necrosis– Coronal segment Coronal segment 20 to 20 to

44%44%



44%44%– Apical segment Apical segment 0% 0%







Pulp canal obliteration Pulp canal obliteration 69%69%




Pulp canal obliteration Pulp canal obliteration 69%69%

Root resorption Root resorption 60% 60%

Root Fracture TreatmentRoot Fracture Treatment

SummarySummary– Reposition and splint for Reposition and splint for 3 weeks3 weeks !! !!


SummarySummary– Reposition and splint for Reposition and splint for 3 weeks3 weeks !! !!– Monitor with pulp tests and Monitor with pulp tests and

radiographsradiographs


SummarySummary– Reposition and splint for Reposition and splint for 3 weeks3 weeks !! !!– Monitor with pulp tests and Monitor with pulp tests and

radiographsradiographs– Do not initiate endodontic treatment Do not initiate endodontic treatment

unless there are signs of pulp unless there are signs of pulp necrosisnecrosis

Management of the Avulsed Management of the Avulsed ToothTooth

Management of the Management of the Avulsed ToothAvulsed Tooth

OverviewOverview Periodontal Ligament Responses Periodontal Ligament Responses Treatment ConsiderationsTreatment Considerations Pulpal Prognosis/ Endodontic RationalePulpal Prognosis/ Endodontic Rationale Treatment RegimenTreatment Regimen

Avulsed Permanent TeethAvulsed Permanent Teeth

Incidence Incidence – 0.5% to 16% of 0.5% to 16% of

traumatic injuriestraumatic injuries

Main etiologic Main etiologic factorsfactors– FightsFights– Sports injuriesSports injuries– Automobile Automobile

accidentsaccidents


Maxillary central incisor Maxillary central incisor – Most commonly avulsed Most commonly avulsed

toothtooth

Mandibular teethMandibular teeth– Seldom affectedSeldom affected

Most frequently involves a Most frequently involves a single toothsingle tooth


Most common age - 7 to 11Most common age - 7 to 11– Permanent incisors eruptingPermanent incisors erupting– Loosely structured PDLLoosely structured PDL


Associated injuriesAssociated injuries– Fracture of alveolar Fracture of alveolar

socket wallsocket wall


Associated injuriesAssociated injuries– Fracture of alveolar Fracture of alveolar

socket wallsocket wall– Injuries to the lips Injuries to the lips

and gingivaand gingiva

Management of theManagement of theAvulsed ToothAvulsed Tooth

What tissue should What tissue should be our primary be our primary concern?concern?– Pulp?Pulp?


What tissue should What tissue should be our primary be our primary concern?concern?– Pulp?Pulp?– Socket?Socket?


What tissue should What tissue should be our primary be our primary concern?concern?– Pulp?Pulp?– Socket?Socket?– PDL?PDL?


Ultimate goalUltimate goal– PDL healing without PDL healing without

root resorptionroot resorption


Ultimate goalUltimate goal– PDL healing without PDL healing without

root resorptionroot resorption

Most critical factorMost critical factor– Maintaining an intact Maintaining an intact

and viable PDL on and viable PDL on the root surfacethe root surface

Periodontal Ligament Periodontal Ligament ResponsesResponses

Surface ResorptionSurface Resorption Replacement Resorption (Ankylosis)Replacement Resorption (Ankylosis) Inflammatory ResorptionInflammatory Resorption

Andreasen JO, Hjorting-Hansen E.Andreasen JO, Hjorting-Hansen E.Replantation of teeth II. Histological study Replantation of teeth II. Histological study of 22 replanted anterior teeth in humans.of 22 replanted anterior teeth in humans.Acta Odontol Scand 1966;24:287-306.Acta Odontol Scand 1966;24:287-306.


Surface resorptionSurface resorption– Superficial resorption Superficial resorption

cavitiescavities– Mainly in cementumMainly in cementum– Complete repair of Complete repair of

PDLPDL


Replacement Replacement resorption resorption (Ankylosis)(Ankylosis)– Direct union of bone Direct union of bone

and rootand root– Resorption of root - Resorption of root -

Replacement with Replacement with bonebone

– Direct result of loss of Direct result of loss of vital PDLvital PDL


Inflammatory resorptionInflammatory resorption– Resorption of cementum Resorption of cementum

and dentinand dentin– Inflammatory reaction in Inflammatory reaction in

the periodontal ligamentthe periodontal ligament

EtiologyEtiology

Inflammatory Inflammatory resorptionresorption– Surface resorption of Surface resorption of

cementum exposing cementum exposing dentinal tubulesdentinal tubules

EtiologyEtiology



– Pulp necrosisPulp necrosis

EtiologyEtiology



– Pulp necrosisPulp necrosis– Toxic products from Toxic products from

the pulp provoke an the pulp provoke an inflammatory inflammatory response in the PDLresponse in the PDL

Periodontal Ligament ResponsesPeriodontal Ligament Responses

Surface resorptionSurface resorption


Surface resorptionSurface resorption Replacement resorption (Ankylosis)Replacement resorption (Ankylosis)


Surface resorptionSurface resorption Replacement resorption (Ankylosis)Replacement resorption (Ankylosis) Inflammatory resorptionInflammatory resorption

Treatment ConsiderationsTreatment Considerations

Extraoral timeExtraoral time Extraoral environmentExtraoral environment Root surface manipulationRoot surface manipulation Management of the socketManagement of the socket StabilizationStabilization

Extraoral TimeExtraoral Time

Shorter time = Better prognosisShorter time = Better prognosis**< 30 min < 30 min 10% resorption 10% resorption> 90 min > 90 min 90% resorption 90% resorption

Andreasen JO, Hjorting-Hansen E.Andreasen JO, Hjorting-Hansen E.Replantation of teeth I. Radiographic and clinical Replantation of teeth I. Radiographic and clinical

study study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.Acta Odontol Scand 1966;24:263-86.Acta Odontol Scand 1966;24:263-86.

Extraoral TimeExtraoral Time

Shorter time = Better prognosisShorter time = Better prognosis**< 30 min < 30 min 10% resorption 10% resorption> 90 min > 90 min 90% resorption 90% resorption

**depending on storage mediumdepending on storage medium

Andreasen JO, Hjorting-Hansen E.Andreasen JO, Hjorting-Hansen E.Replantation of teeth I. Radiographic and clinical Replantation of teeth I. Radiographic and clinical

study study of 110 human teeth replanted after accidental loss.of 110 human teeth replanted after accidental loss.Acta Odontol Scand 1966;24:263-86.Acta Odontol Scand 1966;24:263-86.

Extraoral EnvironmentExtraoral Environment

Viability of PDL cells is Viability of PDL cells is criticalcritical

Storage MediaStorage Media

Tap WaterTap Water DryDry Saliva Saliva SalineSaline

Andreasen JO.Andreasen JO.

Effect of extra-alveolar period and storage media Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after upon periodontal and pulpal healing after

replantation replantation of mature permanent incisors in monkeys.of mature permanent incisors in monkeys.

Int J Oral Surg 1981;10:43-53.Int J Oral Surg 1981;10:43-53.

Poor Poor resultsresults


Tap WaterTap Water DryDry Saliva Saliva SalineSaline

Andreasen JO.Andreasen JO.

Effect of extra-alveolar period and storage media Effect of extra-alveolar period and storage media upon upon periodontal and pulpal healing after replantation periodontal and pulpal healing after replantation

of mature permanent incisors in monkeys.of mature permanent incisors in monkeys.

Int J Oral Surg 1981;10:43-53.Int J Oral Surg 1981;10:43-53.

Good Good protection for protection for

2 hrs2 hrs

Poor Poor resultsresults

Milk As A Storage MediumMilk As A Storage Medium

Physiologic Physiologic osmolalityosmolality

Markedly fewer Markedly fewer bacteria than salivabacteria than saliva

Readily availableReadily available

Storage Media - Milk vs. SalivaStorage Media - Milk vs. Saliva

Storage for 2 hrsStorage for 2 hrs– Periodontal healing almost as good as immediate Periodontal healing almost as good as immediate

replantationreplantation

Blomlof L, et al.Blomlof L, et al.Storage of experimentally avulsed teeth in milk Storage of experimentally avulsed teeth in milk

prior to replantation.prior to replantation.J Dent Res 1983;62:912-6.J Dent Res 1983;62:912-6.

Storage Media - Milk vs. SalivaStorage Media - Milk vs. Saliva

Storage for 2 hrsStorage for 2 hrs– Periodontal healing almost as good as immediate Periodontal healing almost as good as immediate

replantationreplantation Storage for 6 hrsStorage for 6 hrs

– Saliva Saliva extensive replacement resorption extensive replacement resorption– Milk Milk healing almost as good as immediate replant healing almost as good as immediate replant

Blomlof L, et al.Blomlof L, et al.Storage of experimentally avulsed teeth in milk Storage of experimentally avulsed teeth in milk prior to replantation.prior to replantation.J Dent Res 1983;62:912-6.J Dent Res 1983;62:912-6.

Cell Culture MediaCell Culture Media

Eagle’s MediumEagle’s Medium Hank’s Balanced Salt Solution Hank’s Balanced Salt Solution

Hank’s Balanced Salt SolutionHank’s Balanced Salt Solution

Proper pH and osmolalityProper pH and osmolality Reconstitutes depleted cellular metabolitesReconstitutes depleted cellular metabolites Washes toxic breakdown products from the Washes toxic breakdown products from the

root surfaceroot surface

Organ Transplant Storage MediaOrgan Transplant Storage Media

ViaspanViaspan– Dramatically prolongs the storage of human Dramatically prolongs the storage of human

organsorgans– ExpensiveExpensive– Not readily availableNot readily available

Storage Media ComparisonStorage Media Comparison

ViaspanViaspan– Complete healing after 6 and 12 hrsComplete healing after 6 and 12 hrs– Good for extended storage periods (72 and 96 hrs)Good for extended storage periods (72 and 96 hrs)

Trope M, Friedman S.Trope M, Friedman S.Periodontal healing of replanted dog teeth Periodontal healing of replanted dog teeth

stored stored in Viaspan, milk and Hank’s balanced salt in Viaspan, milk and Hank’s balanced salt solution.solution.

Endod Dent Traumatol 1992;8:183-8.Endod Dent Traumatol 1992;8:183-8.

Storage Media ComparisonStorage Media Comparison

ViaspanViaspan– Complete healing after 6 and 12 hrsComplete healing after 6 and 12 hrs– Good for extended storage periods (72 and 96 hrs)Good for extended storage periods (72 and 96 hrs)

Hank’s balanced salt solutionHank’s balanced salt solution– Healing results similar to ViaspanHealing results similar to Viaspan

Trope M, Friedman S.Trope M, Friedman S.Periodontal healing of replanted dog teeth Periodontal healing of replanted dog teeth

stored stored in Viaspan, milk and Hank’s balanced salt in Viaspan, milk and Hank’s balanced salt solution.solution.


Recommended Storage MediaRecommended Storage Media

1. Socket (immediate 1. Socket (immediate replantation)replantation)

2. Cell culture 2. Cell culture mediummedium

3. Milk3. Milk

4. Physiologic saline4. Physiologic saline

5. Saliva5. Saliva

Root Surface ManipulationRoot Surface Manipulation

Attempt to retain PDL cell viabilityAttempt to retain PDL cell viability– Do not curette root surfaceDo not curette root surface– Avoid caustic chemicalsAvoid caustic chemicals

Van Hassel HJ, Oswald RJ, Harrington GW.Van Hassel HJ, Oswald RJ, Harrington GW.Replantation 2. The role of the periodontal Replantation 2. The role of the periodontal

ligament.ligament.J Endodon 1980;6:506-8.J Endodon 1980;6:506-8.


Extraoral dry timeExtraoral dry time determines handling determines handling


Extraoral Extraoral drydry time time << 1 hr 1 hr– PDL healing is still possiblePDL healing is still possible– Handling recommendationsHandling recommendations

» Keep root moistKeep root moist» Do not handle root surfaceDo not handle root surface» Gentle debridementGentle debridement


Extraoral Extraoral drydry time > 1 hr time > 1 hr– Loss of PDL cell viability Loss of PDL cell viability

inevitable inevitable – Treatment recommendationsTreatment recommendations

» Remove tissue tagsRemove tissue tags» Soak in accepted dental Soak in accepted dental

fluoride solution for 20 minfluoride solution for 20 min

Fluoride TreatmentFluoride Treatment

1.0-2.4% topical 1.0-2.4% topical fluoride solutionfluoride solution– Sodium fluoride Sodium fluoride

(Andreasen)(Andreasen)– Stannous fluoride Stannous fluoride

(Krasner)(Krasner)

20 minute soak20 minute soak

Management of the SocketManagement of the Socket

Remove contaminated coagulum in Remove contaminated coagulum in socketsocket– Irrigate with sterile saline Irrigate with sterile saline


Examine socket Examine socket If fracture is evidentIf fracture is evident

– Reposition fractured bone with a blunt Reposition fractured bone with a blunt instrumentinstrument


Replant using light digital pressureReplant using light digital pressure

StabilizationStabilization

Splint Splint – Definition Definition a a rigidrigid or or flexibleflexible device used to device used to

support, protect, or immobilize teeth, preventing support, protect, or immobilize teeth, preventing further injuryfurther injury

– TypesTypes• Acid etch compositeAcid etch composite• Cross-sutureCross-suture

Acid Etch Composite SplintsAcid Etch Composite Splints

Interproximal compositeInterproximal composite


Composite with arch wireComposite with arch wire


Composite with monofilament nylonComposite with monofilament nylon


Functional SplintFunctional Splint– 20-30 lb 20-30 lb

monofilament nylonmonofilament nylon– Bonded with Bonded with

compositecomposite– Allows physiologic Allows physiologic

movementmovement

Antrim DD, Ostrowski JS.Antrim DD, Ostrowski JS.A functional splint for traumatized teeth.A functional splint for traumatized teeth.J Endodon 1982;8:328-31.J Endodon 1982;8:328-31.

Cross-Suture SplintCross-Suture Splint

IndicationsIndications– No adjacent teeth to No adjacent teeth to

splint tosplint to– Unmanageable Unmanageable

traumatized childrentraumatized children

Cross-Suture SplintCross-Suture Splint

Splinting TimeSplinting Time

Effect of splinting timeEffect of splinting time– 7 days7 days– 30 days30 days

Nasjleti CE, Castelli WA, Nasjleti CE, Castelli WA, Caffesse RG.Caffesse RG.

The effects of different The effects of different splinting splinting times on times on replantation of teeth in replantation of teeth in monkeys.monkeys.

Oral Surg 1982;53:557-66.Oral Surg 1982;53:557-66.

Splinting TimeSplinting Time

Recommended timeRecommended time– 7 to 10 days7 to 10 days

Nasjleti CE, Castelli WA, Nasjleti CE, Castelli WA, Caffesse RG.Caffesse RG.

The effects of different The effects of different splinting splinting times on times on replantation of teeth in replantation of teeth in monkeys.monkeys.

Oral Surg 1982;53:557-66.Oral Surg 1982;53:557-66.

Pulpal PrognosisPulpal Prognosis

Stage of root developmentStage of root development Dry storage timeDry storage time Storage mediaStorage media AntibioticsAntibiotics

Stage of Root DevelopmentStage of Root Development

Mature roots (Mature roots (<< 1.0 mm) 1.0 mm) – Revascularization 0%Revascularization 0%

Kling M, et al. Endod Dent Traumatol Kling M, et al. Endod Dent Traumatol 1986;2:83-9. 1986;2:83-9.

Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.1995;11:51-8.

Stage of Root DevelopmentStage of Root Development

Mature roots (Mature roots (<< 1.0 mm) 1.0 mm) – Revascularization 0%Revascularization 0%

Immature roots (> 1.0 mm)Immature roots (> 1.0 mm)– Revascularization 18-34%Revascularization 18-34%

Kling M, et al. Endod Dent Traumatol Kling M, et al. Endod Dent Traumatol 1986;2:83-9. 1986;2:83-9.

Andreasen JO, et al. Endod Dent Traumatol Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.1995;11:51-8.

RevascularizationRevascularization

Loss of blood Loss of blood supply to pulpsupply to pulp

Revascularization – Day 4Revascularization – Day 4

Coronal pulpCoronal pulp– Extensive ischemic Extensive ischemic

injuryinjury

Revascularization – Day 4Revascularization – Day 4

Coronal pulpCoronal pulp– Extensive ischemic Extensive ischemic

injuryinjury

Apical pulpApical pulp– Initial revascularizationInitial revascularization

Revascularization – 4 WeeksRevascularization – 4 Weeks

Pulp statusPulp status– RevascularizationRevascularization– ReinnervationReinnervation– New odontoblastic layerNew odontoblastic layer

RevascularizationRevascularization

Typical sequelaTypical sequela– Pulp canal obliterationPulp canal obliteration

Dry Storage TimeDry Storage Time

As dry storage time increasesAs dry storage time increases

Pulp survival decreasesPulp survival decreases

Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Andreasen FM. Endod Dent Traumatol 1995;11;59-68.Endod Dent Traumatol 1995;11;59-68.


Nonphysiologic storageNonphysiologic storage– Minimal chance of pulp Minimal chance of pulp

revascularizationrevascularization

Andreasen JO, Borum MK, Jacobsen HL, Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.Andreasen FM.

Endod Dent Traumatol 1995;11;59-68.Endod Dent Traumatol 1995;11;59-68.




Nonphysiologic storageNonphysiologic storage– Minimal chance of pulp Minimal chance of pulp

revascularizationrevascularization Physiologic storagePhysiologic storage

– HBSS, milk, saline, salivaHBSS, milk, saline, saliva– Improved chance of pulp Improved chance of pulp






Pulpal Prognosis - AntibioticsPulpal Prognosis - Antibiotics

Systemic antibioticsSystemic antibiotics– Pulp Pulp

revascularization is revascularization is not increasednot increased

Cvek M, Cleaton-Jones P, Austin J, Lowni J, Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Kling M, Fatti P.


Cvek M, Cleaton-Jones P, Austin J, Lowni J, Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Kling M, Fatti P.



Systemic antibioticsSystemic antibiotics– Pulp Pulp

revascularization is revascularization is not increasednot increased

Topical antibioticsTopical antibiotics– Beneficial effectBeneficial effect

Cvek M, Cleaton-Jones P, Austin J, Kling M, Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Lowni J, Fatti P.





Topical DoxycyclineTopical Doxycycline– Decreased microorganisms in Decreased microorganisms in

pulpal lumenpulpal lumen– Increased pulp Increased pulp







RecommendationRecommendation– Topical DoxycyclineTopical Doxycycline

» 1 mg in 20 ml physiologic saline1 mg in 20 ml physiologic saline» 5 minute soak5 minute soak





Endodontic RationaleEndodontic Rationale

Mature root - 4 weeksMature root - 4 weeks– Very limited Very limited


Endodontic RationaleEndodontic Rationale

Mature root - 4 weeksMature root - 4 weeks– Very limited Very limited

revascularizationrevascularization– Ischemic coronal pulp with Ischemic coronal pulp with

great risk of infection !!!great risk of infection !!!

Endodontic Rationale – Mature Endodontic Rationale – Mature RootRoot

Pulpectomy Pulpectomy 7-14 days 7-14 days


Calcium hydroxideCalcium hydroxide placement placement


Calcium hydroxideCalcium hydroxide– AntibacterialAntibacterial– Increases pH in dentinIncreases pH in dentin– Favors mineralization over resorptionFavors mineralization over resorption

Tronstad L, Andreasen JO, et al.Tronstad L, Andreasen JO, et al. pH changes in dental tissues pH changes in dental tissues

after after root canal filling with calcium root canal filling with calcium hydroxide.hydroxide.

J Endodon 1981;7:17-21.J Endodon 1981;7:17-21.


Treatment recommendationTreatment recommendation– Ca(OH)Ca(OH)22 therapy for as long as therapy for as long as

practical, usually 6-12 monthspractical, usually 6-12 months

Treatment of the Avulsed Treatment of the Avulsed Permanent Tooth.Permanent Tooth.

Recommended Guidelines of the Recommended Guidelines of the American Association of American Association of Endodontists, 1995.Endodontists, 1995.



Specific Treatment RegimenSpecific Treatment Regimen

Treatment of the Avulsed Permanent Tooth.Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Recommended Guidelines of the American

Association of Endodontists, 1995.Association of Endodontists, 1995.

Specific Treatment RegimenSpecific Treatment Regimen

Root DevelopmentRoot Development Closed apexClosed apex Open apexOpen apex

Extraoral Extraoral DryDry Time Time One hour or lessOne hour or less More than one hourMore than one hour





Treatment FlowchartTreatment Flowchart

<< 1 hr 1 hr > 1 hr> 1 hr

ExtraoralExtraoral Dry Dry TimeTime

Apex MaturityApex MaturityClosedClosed OpenOpen Open or ClosedOpen or ClosedPulpectoPulpectomy7-14 my7-14

daysdays

ObservObservee

OptionOption: : Extraoral Extraoral

RCTRCT

PulpectoPulpectomy 7-14 my 7-14

daysdays

Emergency TreatmentEmergency Treatment

Replantation Replantation techniquetechnique– Local anesthetic, if Local anesthetic, if

necessarynecessary– Radiograph to verify Radiograph to verify

positionposition– Check occlusionCheck occlusion– Physiologic splintPhysiologic splint


Additional Additional ConsiderationsConsiderations– AnalgesicsAnalgesics


Additional Additional ConsiderationsConsiderations– AnalgesicsAnalgesics– ChlorhexidineChlorhexidine


Additional ConsiderationsAdditional Considerations– AnalgesicsAnalgesics– ChlorhexidineChlorhexidine– TetanusTetanus

» Refer to physician for tetanus prophylaxis prnRefer to physician for tetanus prophylaxis prn

Rothstein RJ, Baker FJ.Rothstein RJ, Baker FJ.Tetanus: Prevention and Tetanus: Prevention and

treatment.treatment.J Am Med Assoc 1978;240:675-J Am Med Assoc 1978;240:675-

6.6.

Rothstein RJ, Baker FJ.Rothstein RJ, Baker FJ.Tetanus: Prevention and Tetanus: Prevention and

treatment.treatment.J Am Med Assoc 1978;240:675-J Am Med Assoc 1978;240:675-

6.6.


Additional ConsiderationsAdditional Considerations– AnalgesicsAnalgesics– ChlorhexidineChlorhexidine– TetanusTetanus– AntibioticsAntibiotics

AntibioticsAntibiotics

PenicillinPenicillin– 500 mg qid for 4-7 days500 mg qid for 4-7 days

Andreasen JO.Andreasen JO.Atlas of replantation and Atlas of replantation and

transplantation of transplantation of teeth.teeth.Philadelphia: W.B. Saunders Co., Philadelphia: W.B. Saunders Co.,

1992;57-1992;57- 92.92.


Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin in a replacement resorption modelin a replacement resorption model

– Tetracycline had better anti-resorptive propertiesTetracycline had better anti-resorptive properties

Sae-Lim V, Wang CY, Choi GW, Trope M.Sae-Lim V, Wang CY, Choi GW, Trope M.

The effect of systemic tetracycline on The effect of systemic tetracycline on resorption of resorption of dried replanted dogs’ teeth.dried replanted dogs’ teeth.



Tetracycline vs. amoxicillin Tetracycline vs. amoxicillin in an inflammatory root resorption modelin an inflammatory root resorption model

– Tetracycline had better anti-bacterial propertiesTetracycline had better anti-bacterial properties

Sae-Lim V, Wang CY, Trope M.Sae-Lim V, Wang CY, Trope M.

Effect of systemic tetracycline and amoxicillin on Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted inflammatory root resorption of replanted

dogs’ teeth.dogs’ teeth.



RecommendationRecommendation– ““Tetracycline could be considered as an alternative to Tetracycline could be considered as an alternative to

amoxicillin after avulsion injuries.”amoxicillin after avulsion injuries.”

Sae-Lim V, Wang CY, Trope M.Sae-Lim V, Wang CY, Trope M.

Effect of systemic tetracycline and amoxicillin on Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs inflammatory root resorption of replanted dogs

teeth.teeth.


Tetracycline Use In Young Tetracycline Use In Young ChildrenChildren

Tetracycline stainingTetracycline staining– Not a problem since avulsed maxillary anteriors Not a problem since avulsed maxillary anteriors

have already erupted and are not susceptible to have already erupted and are not susceptible to stainingstaining

– At worst, posterior teeth might be stainedAt worst, posterior teeth might be stained» Remote possibility with 7-10 day prescriptionRemote possibility with 7-10 day prescription

Sae-Lim V, Wang CY, Trope M.Sae-Lim V, Wang CY, Trope M.Effect of systemic tetracycline and amoxicillin Effect of systemic tetracycline and amoxicillin

on on inflammatory root resorption of replanted dogs’ inflammatory root resorption of replanted dogs’ teeth.teeth.


Avulsion SequelaeAvulsion Sequelae

Closed ApexClosed Apex Extraoral dry time Extraoral dry time

1 hour or less1 hour or less


Closed ApexClosed Apex Extraoral dry time Extraoral dry time

more than 1 hourmore than 1 hour


Open ApexOpen Apex Extraoral dry time Extraoral dry time

1 hour or less1 hour or less


Open ApexOpen Apex Extraoral dry time Extraoral dry time

more than 1 hourmore than 1 hour

Avulsion ManagementAvulsion Management

Be prepared - Be prepared - Dental Trauma KitDental Trauma Kit

Immerse tooth in a Immerse tooth in a physiologic storage medium physiologic storage medium to “buy time”to “buy time”

Determine extraoral Determine extraoral drydry time time Follow AAE GuidelinesFollow AAE Guidelines

Documents

Traumatic Injuries to the Teeth