International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth

1 INTRODUCTION

Avulsion of permanent teeth is seen in 0.5%–16% of all dental injuries.^{1, 2} Numerous studies have shown that this injury is one of the most serious dental injuries, and the prognosis is very much dependent on the actions taken at the place of accident and promptly following the avulsion.^3-17 Replantation is, in most situations, the treatment of choice but cannot always be carried out immediately. Appropriate emergency management and a treatment plan are important for a good prognosis. There are also individual situations when replantation is not indicated (eg, severe caries or periodontal disease, an uncooperative patient, severe cognitive impairment requiring sedation, severe medical conditions such as immunosuppression, and severe cardiac conditions) which must be dealt with individually. Although replantation may save the tooth, it is important to realize that some of the replanted teeth have low probability of long-term survival and may be lost or condemned to extraction at a later stage. However, not replanting a tooth is an irreversible decision and therefore saving it should be attempted. In this regard, a recent study has shown that replanted teeth have higher chances of long-term survival after following the IADT treatment guidelines, compared to previous studies.¹⁸

Guidelines for the emergency management of dental traumatic injuries are useful for delivering the best possible care in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after an update of the dental literature and discussions among expert groups. Experienced international researchers and clinicians from various specialties and general dentistry were included in the groups. In cases where the data did not appear conclusive, recommendations were based on best available evidence, consensus opinion, and in some situations majority decisions among IADT Board members. The guidelines should therefore be seen as the current best evidence and practice based on literature research and professional opinion.

Guidelines should assist dentists, other healthcare professionals, and patients in decision-making. Also, they should be clear, readily understandable, and practical with the aim of delivering appropriate care as effectively and efficiently as possible. Guidelines are to be applied with the clinician's judgment of the specific clinical circumstances and patient characteristics, including but not limited to compliance, finances, and understanding of the immediate and long-term outcomes of treatment alternatives vs non-treatment. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the Guidelines, but believes that their application can maximize the chances of a favorable outcome. Guidelines undergo periodic updates. The following guidelines by the International Association of Dental Traumatology (IADT) represent a revision and update of the previous guidelines that were published in 2012.^19-21

In these IADT Guidelines for management of avulsed permanent teeth, the literature has been searched using Medline and Scopus databases utilizing the search words: avulsion, exarticulation and replantation. The task group discussed treatment in detail and reached consensus as to what to recommend as the current best practice for emergency management. This text aims to provide concise and necessary advice for treatment in the emergency situation.

The final decision regarding patient care remains primarily with the treating dentist. However, the consent to implement the final decision rests with the patient, parent, or guardian. For ethical reasons, it is important that the dentist provides the patient and guardian with pertinent information relating to treatment to ensure they are maximally involved in the decision-making process.

2 FIRST AID FOR AVULSED TEETH AT THE PLACE OF ACCIDENT

Dentists should be prepared to give appropriate advice to the public about first aid for avulsed teeth.^{2, 11, 22-27} An avulsed permanent tooth is one of the few real emergency situations in dentistry. In addition to increasing the public awareness by mass media campaigns or other means of communication, parents, guardians and teachers should receive information on how to proceed following these severe and unexpected injuries. Also, instructions may be given by telephone to people at the emergency site. Immediate replantation of the avulsed tooth is the best treatment at the place of the accident. If for some reason this cannot be carried out, there are alternatives such as using different types of storage media.

The poster “Save a Tooth” is available in multiple languages: Arabic, Basque, Bosnian, Bulgarian, Catalan, Czech, Chinese, Dutch, English, Estonian, French, Georgian, German, Greek, Hausa, Hebrew, Hindi (India), Hungarian, Icelandic, Indonesian Bahasa, Italian, Kannada (India), Korean, Latvian, Marathi (India), Persian, Polish, Portuguese, Russian, Sinhalese, Slovenian, Spanish, Tamil (India), Thai, Turkish, Ukrainian, and Vietnamese. This educational resource can be obtained at the IADT website: http://www.iadt-dentaltrauma.org

The IADT’s free app, “ToothSOS” for mobile phones, is another useful source of information for patients, providing instructions on what to do in an emergency situation after a dental injury, including avulsion of a permanent tooth.

3 TREATMENT GUIDELINES FOR AVULSED PERMANENT TEETH

The choice of treatment is related to the maturity of the root (open or closed apex) and the condition of the periodontal ligament (PDL) cells. The condition of the PDL cells is dependent on the time out of the mouth and on the storage medium in which the avulsed tooth was kept. Minimizing the dry time is critical for survival of the PDL cells. After an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable.^{30, 31} For this reason, information regarding the dry time of the tooth prior to replantation or prior to being placed in a storage medium is very important to obtain as part of the history.

These three groups provide guidance to the dentist on the prognosis of the tooth. Although exceptions to the prognosis do occur, the treatment will not change, but may guide the dentist's treatment decisions.

4 ANESTHETICS

The best treatment for an avulsed tooth is immediate replantation at the site of the accident, which is usually not painful. While local anesthesia is not available when teeth are replanted at the site of injury, once the patient arrives at a dental or medical facility, pain control by means of local anesthesia is always recommended.^50-55 There are concerns as to whether there are risks of compromising healing by using a vasoconstrictor in the anesthetic solution. However, there is little evidence to support omitting a vasoconstrictor in the oral and maxillofacial region. Regional anesthesia (eg, infraorbital nerve block) may be considered as an alternative to infiltration anesthesia in more severe injury cases and must be determined by the clinician's experience of providing such block injections.^{51, 52}

5 SYSTEMIC ANTIBIOTICS

Even though the value of systemic administration of antibiotics is highly questionable, the periodontal ligament of an avulsed tooth often becomes contaminated by bacteria from the oral cavity, the storage medium, or the environment in which the avulsion occurred. Therefore, the use of systemic antibiotics after avulsion and replantation has been recommended to prevent infection-related reactions and to decrease the occurrence of inflammatory root resorption.^{34, 35} Additionally, the patient's medical status or concomitant injuries may warrant antibiotic coverage. In all cases, appropriate dosage for the patient's age and weight should be calculated. Amoxicillin or penicillin remain the first choices due to their effectiveness on oral flora and low incidence of side effects. Alternative antibiotics should be considered for patients with an allergy to penicillin. The effectiveness of tetracycline administered immediately after avulsion and replantation has been demonstrated in animal models.³⁵ Specifically, doxycycline is an appropriate antibiotic to use because of its antimicrobial, anti-inflammatory and anti-resorptive effects. However, the risk of discoloration of permanent teeth must be considered before systemic administration of a tetracycline in young patients. Tetracycline or doxycycline are generally not recommended for patients under 12 years of age.⁵⁶

6 TOPICAL ANTIBIOTICS

The effect of topical antibiotics placed on the root surface prior to replantation with respect to pulp revascularization remains controversial.^{8, 57, 58} While animal studies have shown great potential,^59-61 human studies have failed to demonstrate improved pulp revascularization when teeth are soaked in topical antibiotics.⁶² Therefore, a specific antibiotic, duration of use, or methods of application cannot be recommended based on human studies (see future areas of research).

7 TETANUS

Although most people receive tetanus immunization and boosters, it cannot be assumed that this is always the case.^{36, 63, 64} Refer the patient to a physician for evaluation of the need for a tetanus booster.

8 STABILIZATION OF REPLANTED TEETH (SPLINTING)

Avulsed teeth always require stabilization to maintain the replanted tooth in its correct position, provide patient comfort and improve function.^{32, 47, 65-72} Current evidence supports short-term, passive and flexible splints for stabilization of replanted teeth. Studies have shown that periodontal and pulp healing are promoted if the replanted tooth is subjected to slight mobility and function,⁶⁶ achieved with stainless steel wire up to a diameter of 0.016” or 0.4 mm³² or with nylon fishing line (0.13-0.25 mm), and bonded to the teeth with composite resin. Replanted permanent teeth should be stabilized for a period of 2 weeks depending on the length and degree of maturation of the root. An animal study has shown that more than 60% of the mechanical properties of the injured PDL return within 2 weeks following injury.⁶⁹ However, the likelihood of successful periodontal healing after replantation is not likely to be affected by splinting duration.⁴⁷

Wire (or nylon line) and composite stabilization should be placed on the labial surfaces to avoid occlusal interference and to enable palatal/lingual access for endodontic procedures. Various types of wire (or nylon line) and acid etch bonded stabilization have been used to stabilize avulsed teeth as they allow good oral hygiene and they are well tolerated by patients.⁷² It is critically important to keep the composite and bonding agents away from the marginal gingiva and interproximal areas to avoid plaque retention and secondary infection, and to allow relatively easy cleaning by the patient. The patient and parent should be advised that on removal of the splint, the injured tooth may be mobile. An additional week of splinting is appropriate only if excessive trauma from the opposing dentition might further traumatize the tooth or if the avulsed tooth is unable to remain in the correct position. An assessment of this should be made after the splint is removed and the occlusion checked.

9 PATIENT INSTRUCTIONS

10 ENDODONTIC CONSIDERATIONS

When endodontic treatment is indicated (teeth with closed apex),^{17, 73-81} treatment should be initiated within 2 weeks post-replantation. Endodontic treatment should always be undertaken after isolation with the dental dam. This may be achieved by placing the dental dam retainer on neighboring uninjured teeth to avoid further trauma to the injured tooth/teeth. Calcium hydroxide is recommended as an intracanal medicament for up to 1 month followed by root canal filling.^{82, 83} If a corticosteroid or corticosteroid/antibiotic mixture is chosen to be used as an anti-inflammatory and anti-resorptive intracanal medicament, it should be placed immediately or shortly after replantation and left in situ for at least 6 weeks.^{76, 78, 84} Medicaments should be carefully applied to the root canal system with care to avoid placement in the crown of the tooth. Some medicaments have been shown to discolor teeth, leading to patient dissatisfaction.⁷⁷

In teeth with open apices, spontaneous pulp space revascularization may occur. Thus, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis and infection of the root canal system on follow-up examinations. The risk of infection-related (inflammatory) root resorption should be weighed against the chances of obtaining pulp space revascularization. Such resorption is very rapid in children.

In cases where pulp necrosis and infection of the root canal system are diagnosed, root canal treatment, apexification or pulp space revascularization/revitalization should be performed. In cases where ankylosis is expected and decoronation is anticipated, proper consideration of the intracanal materials used and their duration is indicated.

11 FOLLOW-UP PROCEDURES

12 LONG-TERM FOLLOW-UP CARE (LOSS OF TOOTH OR INFRA-OCCLUSION)

Follow-up care requires good coordination between the initial provider of treatment and specialists in secondary care services (eg, an inter-disciplinary team such as an orthodontist and pediatric dentist and/or endodontist) with the appropriate experience and training in the holistic management of complex dento-alveolar trauma. The team will benefit from other specialists who will provide longer-term care such as a bonded bridge, a transplant, or an implant. In situations where access to an inter-disciplinary team may not be possible, dentists can only be expected to provide follow-up care and treatment within their experience, training and competence.

Patients or parents and children need to be fully informed of the prognosis of an avulsed tooth as soon as possible. They should be fully engaged in the decision-making process. Furthermore, the potential costs of and time required for different treatment options should be openly discussed.

In cases where teeth are lost in the emergency phase after trauma, or will likely be lost later, discussions with appropriate colleagues who have expertise with managing these cases are prudent, especially in growing patients. Ideally, these discussions should take place before the tooth shows signs of infra-position. Appropriate treatment options may include decoronation, autotransplantation, a resin-retained bridge, a removable partial denture or orthodontic space closure with or without composite resin modification. Treatment decisions are based on a full discussion with the patient or the child and parents and the clinician's expertise with the aim to keep all options open until maturity is reached. The decision to perform decoronation is made when the ankylosed tooth shows evidence of infra-occlusion that is deemed esthetically unacceptable and cannot be corrected by simple restorative treatment.^{41, 45} After growth is completed, implant treatment can be considered. Readers are referred to relevant textbooks and journal articles for further reading regarding these procedures.

13 CORE OUTCOME SET

The IADT recently developed a core outcome set (COS) for traumatic dental injuries (TDI) in children and adults.⁸⁷ This is one of the first COS developed in dentistry and follows a robust consensus methodology and is underpinned by a systematic review of the outcomes used in the trauma literature.⁸⁸ A number of outcomes were identified as recurring throughout the different injury types. These outcomes were then included as “generic”—that is relevant to all TDI. Injury-specific outcomes were also determined as those outcomes related only to one or more particular TDI. Additionally, the study established what, how, when and by whom these outcomes should be measured. Further information for each outcome is described in the original paper.⁸⁷

14 FUTURE AREAS OF RESEARCH—TOPICS DISCUSSED BUT NOT INCLUDED AS RECOMMENDATIONS IN THESE GUIDELINES

CONFLICT OF INTEREST

The authors confirm that they have no conflict of interest.

ETHICAL APPROVAL

No ethic approval was required for this paper.

DISCLAIMER

These guidelines are intended to provide information for healthcare providers caring for patients with dental injuries. They represent the current best evidence based on literature research and professional opinion. As is true for all guidelines, the healthcare provider must use clinical judgment dictated by the conditions present in any given traumatic situation. The IADT does not guarantee favorable outcomes from following the Guidelines, but using the recommended procedures can maximize the chances of success.