Guidelines for the evaluation and management of traumatic dental injuries

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Julianna Loreen Cummings
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1 Dental Traumatology 2001; 17: Copyright C Munksgaard 2001 Printed in Denmark. All rights reserved DENTAL TRAUMATOLOGY ISSN Editor s note The International Association of Dental Traumatology (IADT) has developed guidelines for the treatment of traumatic dental injuries. The guidelines presented in this issue of Dental Traumatology continue the series that has been published in the previous issues. In addition, selected cases are shown to illustrate these treatment guidelines. This issue will present guidelines for the treatment of avulsion injuries. These guidelines are intended as an aid to the dentist in the management and treatment of traumatized teeth. Practitioners must always use their own professional judgement. The IADT cannot guarantee any positive results associated with the application of the guidelines although it is felt that timely and proper treatment will maximize the chances of success. for the evaluation and management of traumatic dental injuries Committee: M. T. Flores, J. O. Andreasen, L. K. Bakland Contributors: B. Feiglin, J. L. Gutmann, K. Oikarinen, T. R. Pitt Ford, A. Sigurdsson, M. Trope, W. F. Vann Jr., F. M. Andreasen I. Introduction Epidemiological studies reveal that one out of two children sustains a dental injury, most often between the ages of 8 and 12. Crown fracture is the most frequent type of trauma, generally resulting from accidents, sport activities, or violence. In most dental trauma, a rapid and appropriate treatment can lessen its impact from both an oral health and aesthetic standpoint. New technology and an improved understanding of the inflammatory process have led to a more conservative approach in managing dental trauma. The International Association of Dental Traumatology (IADT), conscious of the variation in the treatment of dental trauma, has developed these guidelines as a type of consensus statement. These guidelines reflect much thoughtful discussion among members of the IADT, as well as a detailed review of international dental literature. In cases where the data did not appear to be conclusive, recommendations were based on the consensus opinion of the IADT board members. are needed to assist dentists, as well as other health care professionals, in delivering the best care possible in the most efficient manner. It is very important to promote public awareness and to educate the population at greatest risk from dental injury. Therefore, this report includes basic information on both prevention and first aid. The correct application of these techniques immediately following the trauma should improve the short and long-term outcome. Because management of injuries to the primary and permanent dentition differs significantly, separate guidelines have been developed for children with primary dentition and for cases where permanent teeth are involved. In addition, these guidelines do not address issues relating to the diagnosis and treatment of major facial trauma of the bone and soft tissue, which is a critical first step in the overall management of trauma patients. The evaluation and treatment of maxillofacial trauma, which may coexist with dental trauma, goes beyond the scope of these recommendations. Classification of diagnosis and therapy (*) The classifications listed below summarize diagnostics steps and therapeutic interventions and will be referenced throughout the guidelines. x Conditions for which there is evidence and/or general agreement that a given procedure or xx treatment is beneficial, useful, and effective. Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. xxx Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful. (*) Ryan et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction. 193

2 General References Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic dental injuries. A manual. Copenhagen: Munksgaard, Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd edn. Copenhagen: Munksgaard, Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1: Blomlof L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J 1981;Suppl 8:1 26 Cvek, M. Endodontic management of traumatized teeth. In: And- reasen JO, Andreasen FM, editors. Textbook and color atlas of traumatic injuries to the teeth. 3rd edn. Copenhagen: Munksgaard, Cvek M. Changes in the treatment of crown-fractured teeth during the last two decades. In: Proceedings of the Second International Conference on Dental Trauma; 1991; Ryan TJ, Anderson JL, Antman EM, Brannif BA, Brooks NH, Califf RM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Management of Myocardial Infarction). J Am Coll Cardiol 1996;28: Tronstad L. Pulp reactions in traumatized teeth. In: Gutmann JL, Harrison JW, editors. Proceedings of the International Conference on Oral Trauma. Chicago: AAE; Table 1. Treatment guidelines for avulsed permanent teeth with closed apex Diagnosis Clinical situation The tooth has already been replanted The tooth has been kept in special Extra-oral dry time 60 min storage media, milk, saline or saliva. The extra-oral dry time is less than 60 min Treatment Clean affected area with water spray, If contaminated, clean the root Remove debris and necrotic saline or chlorhexidine surface and apical foramen with a periodontal ligament (xx) Do not extract the tooth (x) stream of saline. Remove the coagulum from the Remove the coagulum from the socket with a stream of saline. socket with a stream of saline. Examine the alveolar socket. If there Examine the alveolar socket. If there is a fracture of the socket wall, is a fracture in the socket wall, reposition it with a suitable reposition it with a suitable instrument. instrument. Immerse the tooth in a 2.4% sodium Replant slowly with slight digital fluoride solution acidulated to a ph 5.5 pressure (x) for a minimum of 5 min or, if available, fill the socket with Emdogain A. Replant slowly with slight digital pressure (xx) Suture gingival laceration, especially in the cervical area Verify normal position of the replanted tooth radiographically Apply a flexible splint for 1 week (x) Administer systemic antibiotics: Doxycycline 2 per day for 7 days at appropriate dose for patient age and weight (xx). Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come into contact with soil or tetarus coverage is uncertain Initiate endodontic treatment after 7 10 days. Place calcium hydroxide as an intra-canal medicament (x) Patient instruction Soft diet for 2 weeks Brush teeth with a soft toothbrush after each meal Use a chlorhexidine mouthrinse (0.1%) twice a day for 1 week Follow-up (See Table 3) 194

3 Table 2. Treatment guidelines for avulsed permanent teeth with open apex Diagnosis Clinical situation The tooth has already been replanted The tooth has been kept in special Extra-oral dry time 60 min storage media, milk, saline or saliva. The extra-oral dry time is less than 60 min Treatment Clean affected area with water spray, If contaminated, clean the root Replantation is not indicated (xx) saline or chlorhexidine rinse. surface and apical foramen with a Do not extract the tooth (x) stream of saline. Place the tooth in doxycycline ( 1 mg/20 ml saline). Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture to the socket wall, reposition it with a suitable instrument. Replant slowly with slight digital pressure (x) Suture gingival laceration, especially in the cervical area Verify normal position of the replanted tooth radiographically Apply a flexible splint for 1 week (x) Administer systemic antibiotics: Penicillin V 1000mg and 500 mg 4 per day for 7 days or for patients not surceptible to tetracylene staining, Doxycycline 2 per day for 7 days at appropriate dose for patient age and weight Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come into contact with soil or tetarus coverage is uncertain Patient instruction Soft diet for 2 weeks Brush teeth with a soft toothbrush after each meal Use a chlorhexidine mouthrinse (0.1%) twice a day for 1 week Follow-up (See Table 3). Table 3. Follow-up procedures for traumatized permanent teeth Time Closed apex Open apex 1 week S S Initiate endodontic treatment 2 3 weeks C C 3 4 weeks C C 6 8 weeks C C 6 months C C 1 year C C 5 years C C SΩSplint removal. CΩClinical and radiographic examination Closed Apex (1) Satisfactory outcome Clinical: asymptomatic, normal mobility, normal sound on percussion. Radiographic: no periradicular radiolucencies indicative of progressive external inflammatory root resorption ( 2 normal lamina dura) or loss of lamina dura indicative of ankylosis and replacement resorption. (2) Unsatisfactory outcome Clinical: symptomatic and/or high pitch percussion sound. Radiographic: periradicular radiolucencies in the root and bone or radiographic replacement of the root with bone. Endodontic treatment: At 7 10 days endodontic treatment should be initiated and calcium hydroxide placed. Calcium hydroxide can be replaced by gutta-percha if or when an intact lamina dura can be traced around the entire root surface. Normally, if the root treatment is initiated at the end of the ideal 7-day period, external inflammatory root resorption is prevented and obturation can take place within a month. If, however, the endodontic treatment is initiated when root resorption is already visible, calcium hydroxide is needed for an extended period before obturation can take place. The status of the lamina dura and the presence of the calcium hydroxide in the canal should be evaluated every 3 months. Open Apex (1) Satisfactory outcome Clinical: asymptomatic normal mobility and eruption pattern, normal sound on percussion. Positive sensitivity test. Radiographic: As with closed apex. Continued root development, pulp lumen obliferation extremely common. (2) Unsatisfactory outcome Clinical: symptomatic and/or high pitched percussion sound. Tooth in infra-occlusion. Radiographic: As with closed apex. Root fails to develop, the pulpal lumen does not change in size. Endodontic treatment: If revascularization is a possibility, avoid endodontic treatment unless obvious signs of failure are present. Sensitivity test may take up to 3 months to respond positively. If endodontic treatment is necessary, follow recommendations for apexification. 195

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$The tooth was retrieved immediately and kept moist in the oral cavity. B. Radiographic picture shows no sign of fracture or contusion of the alveolar socket. C.$

5 Fig. 1. (previous page) Replantation of a closed apex tooth with minimal dry time: A. Clinical presentation after avulsion in a 19-year-old male. The tooth was retrieved immediately and kept moist in the oral cavity. B. Radiographic picture shows no sign of fracture or contusion of the alveolar socket. C. The socket has been flushed with saline to remove the coagulum. Visual examination, probing and manipulation with a blunt instrument ensure that the tooth can be replanted atraumatically. D. The tooth is rinsed with a stream of saline until all visible signs of contamination have been removed. If this is not effective, dirt is carefully removed using a gauze sponge soaked in saline. E. The tooth is replanted as gently as possible and F. an acid etched retained splint is applied. (From Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic dental injuries to the teeth. 3rd edn. Copenhagen: Munksgaard; xxx-xxx) Fig. 2. Replantation of a closed apex tooth after 3 h dry time: A.The radiographic picture shows no sign of fracture or contusion of the alveolar socket. Both adjacent teeth have sustained uncomplicated crown fractures. B. Since time is of no consequence, the endodontic treatment is completed extra-orally. C. The coagulum and debris are removed with a curette and D. flushed with saline. E. Remaining periodontal ligament and debris is removed with acid (PDL removal can be performed in many different ways). F. The root surface is covered and G. the socket is filled with emdogain A (Fluoride can also be used on the root), then the H. radiographic and I. clinical situation is demonstrated after replantation and splinting. (Courtesy Dr. Tom Butke) 197

rbro Malmgren). B. Radiographic presentation of canine tooth undergoing osseous replacement. Most of the root is replaced by bone. Fig. 4.

6 Fig. 3. Ankylosis and osseous replacement: A.Clinical presentation of an ankylosed right maxillary central incisor. The tooth is intruded compared to the adjacent teeth. A metallic sound is heard on percussion. (Case courtesy Drs Ole and Barbro Malmgren). B. Radiographic presentation of canine tooth undergoing osseous replacement. Most of the root is replaced by bone. Fig. 4. External Inflammatory Resorption: Radiographic appearance of external inflammatory root resorption sustained by pulpal infection. Radiolucencies are present in the root and adjacent bone. 198

The Treatment of Traumatic Dental Injuries

The Recommended Guidelines of the American Association of Endodontists for The Treatment of Traumatic Dental Injuries 2013 American Association of Endodontists Revised 9/13 The Recommended Guidelines of