TIME IS OF THE ESSENCE when it comes to an avulsed tooth. The quicker the patient comes in to get it placed back into the socket, the better the prognosis will be. The optimal time is less than 15–20 minutes for good predictable periodontal healing. The prognosis will significantly worsen when the tooth is left out in a dry environment for more than 60 minutes. That is why it is important to inform your receptionists that when they receive a call regarding an avulsed tooth, they should have the patient put it in milk, saline, or Hanks solution right away. If none of these are available, just keeping the tooth in the mouth (where it will be bathed by saliva) will maintain the vitality of the periodontal ligament around the tooth.
When the patient comes in, clean the avulsed tooth with saline and remove the clot that may have formed in the socket with saline also. If the tooth has a closed apex and has been left out for more than 60 minutes, place the tooth in 2 percent stannous fluoride for at least five minutes after the saline rinse. If the tooth has an open apex and was left out for less than 60 minutes, place it in doxycylcine (100mg/ 20ml saline). Examine for any alveolar bone fractures and reposition if necessary. Make sure that you give palatal or lingual anesthesia to reduce the patient’s discomfort when the tooth is being placed back in position. Replant the tooth with slight digital pressure.
Place a flexible splint for one to two weeks. If the tooth has been out dry for more than 60 minutes or there was an alveolar fracture, leave the splint on for four to six weeks.
Prescribe doxycycline twice a day or penicillin V four times a day for seven days. Also have the patient rinse with Peridex twice a day for a week. Inform the patient to eat soft foods for the next two weeks.
See the patient to start root canal treatment in seven to ten days after the incident. If the tooth has an open apex and it was left out for less than 60 minutes, do not do root canal treatment. Do a vitality test (cold test with Endo Ice) every three to four weeks to look for revascularization. When the tooth has an open apex and it was left out dry for more than 60 minutes, replanting the tooth is not recommended because of the high risk of resorption and ankylosis. If the tooth is replanted and there are no problems, apexification needs to be done.
The x-rays are of a patient I saw this past July. She is eight years old and her tooth #8 avulsed while she was playing in a pool (Figure 1). It was left out dry for 45 minutes. I wanted to show this case because it illustrates the importance of taking a periapical x-ray to make sure that the tooth is placed correctly and all the way into the socket. It may look as if it is in the right position (Figure 2). If it is not, reposition and take another x-ray (Figure 3). A splint was placed and removed in two weeks. Root canal was done, and so far the patient and her tooth are doing well.
October - December 2011