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35591_trauma layout_rev804

Recommended
Guidelines of the
American Association
of Endodontists for the
Treatment of
The Recommended Guidelines of the American Associationof Endodontists for the Treatment of Traumatic Dental Injuries are intended to aid the practitioner in the management and treatment of dental injuries. Practitionersmust always use their own best professional judgment. The AAE neither expressly nor implicitly warrants any positiveresults associated with the application of these guidelines.
Although it is impossible to guarantee permanent retention of a traumatized tooth, timely treatment of the tooth usingrecommended procedures can maximize the chances for success.
The AAE gratefully acknowledges the cooperation of theInternational Association of Dental Traumatology andBlackwell-Munksgaard who granted permission for the AAEto use substantial portions of the IADT RecommendedGuidelines for the Management of Traumatic DentalInjuries in the development of the AAE trauma guidelines.
The Association grants a limited license to members of the Association to copy the Recommended Guidelines ofthe American Association of Endodontists for the Treatmentof Traumatic Dental Injuries for their own personal use andfor no other purpose. The Recommended Guidelines of theAmerican Association of Endodontists for the Treatment ofTraumatic Dental Injuries may not be reproduced for saleand may not be amended or altered in any manner. Thislicense is not assignable.
2004 American Association of Endodontists
211 E. Chicago Ave., Suite 1100, Chicago, IL 60611-2691
■ TABLE 1. Treatment guidelines for luxated permanent teeth
Extrusion
Diagnosis and
Tooth tender to touch Tooth is tender to touch Elongated mobile tooth.
The tooth is displaced Tooth is displaced deeper (no displacement, no and mobile, but not axially and is usually into the alveolar bone.
locked into bone.
Not tender to touch, not Not tender to touch, not gingival crevice possible.
Percussion test: high, Percussion test: high, (ankylotic tone).
(ankylotic tone).
Take one radiograph Take two radiographs Take four radiographs Take four radiographs and findings
(2). No radiographic (1, 2). No radiographic radiographs (1-4).
abnormalities will be abnormalities will be Increased periodontal Increased periodontal Radiographs not always space apically.
space is best seen on eccentric or occlusal Flexible splint is optional – Flexible splint is optional – Reposition.
Reposition the tooth into Slightly luxate the tooth can be used for the can be used for the Stabilize the tooth with a normal position (local with forceps.
comfort of the patient for comfort of the patient for flexible splint for up to 3 Spontaneous re-eruption 7-10 days, or according 7-10 days, or according The tooth must often be (teeth with incomplete to trauma diagnoses of to trauma diagnoses of extruded (occlusally past root formation) is possible adjacent teeth (SA).
adjacent teeth (SA).
the bony lock prior to but not predictable, Take one radiograph (2) (teeth with completed root formation) or surgical Stabilize tooth with a repositioning is performed.
flexible splint for up to 3 In case of completed root formation, perform In case of marginal bone prophylactic extirpation breakdown, usually of the pulp 1-3 weeks observed radiographical y after injury (SA).
(don't probe!) after 3 weeks, add 3-4 weeks extra splinting time Brush teeth with a soft toothbrush after each meal.
Use of chlorhexidine mouthrinse (0.12%) twice a day for 2 weeks.
Follow up (see Table 2) (1) occlusal (2) periapical central angle (3) periapical mesial eccentric (4) periapical distal eccentric Treatment urgency: A = Acute (within a few hours) SA = Subacute (within 24 hours) D = Delayed (more than one day) ■ TABLE 2. Follow up procedures for luxated permanent teeth
Yearly for 5 years S = Splint removal NA = Not applicable C = Clinical radiographic examination. Success/Failure includes some but not necessarily all of the following: Success – asymptomatic, positive sensitivity, continued root development (immature teeth), intact lamina dura periradicularly Failure – symptomatic, negative sensitivity, root does not develop (immature teeth), periradicular radiolucencies Success – minimal symptoms, slight mobility, no excessive lucency periradicularly Failure – severe symptoms, excessive mobility, clinical and radiographic signs of periodontitis. Initiate endodontics if closed apex and extent of displacement will likely result in necrosis.
(2A) Success – asymptomatic, clinical and radiographic signs of normal or healed periodontium. Marginal bone height corresponds to that seen radiographically after Failure – symptoms and radiographic sign consistent with periodontitis, negative sensitivity, breakdown of marginal bone – splint for additional period 3-4 weeks; initiate endodontic treatment if not previously initiated, chlorhexidine mouthrinse.
Success – tooth in place or erupting, intact lamina dura, no signs of resorption. Failure – tooth locked in place/ankylotic tone; radiographic signs of apical periodontitis, external inflammatory resorption or replacement resorption.
■ TABLE 3. Treatment guidelines for avulsed permanent teeth with closed apex
Diagnosis and clinical situation
The tooth has already been replanted.
The tooth has been kept in special
Extra-oral dry time is >60 minutes.
storage media, milk, saline or saliva. The
extra-oral dry time is <60 minutes.
Clean affected area with water spray, If contaminated, clean the root surface Remove debris and necrotic periodontal saline or chlorhexidine.
and apical foramen with a stream of Do not extract the tooth (SA).
Remove the coagulum from the socket Remove the coagulum from the socket with a stream of saline.
with a stream of saline.
Examine the alveolar socket. If there Examine the alveolar socket. If there is is a fracture of the socket wall, a fracture in the socket wall, reposition reposition it with a suitable instrument.
it with a suitable instrument.
Immerse the tooth in any available Replant slowly with slight digital sodium fluoride solution for a pressure (A).
minimum of 5 minutes.
Replant slowly with slight digital pressure (SA).
Suture gingival laceration, especially in the cervical area.
Suture gingival laceration, especially Verify normal position of the replanted tooth radiographically.
in the cervical area. Verify normal Apply a flexible splint for 1-2 weeks.
position of the replanted tooth radiographically. Apply a flexible splint for 4-6 weeks.
Administer systemic antibiotics: Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight, or penicillin 4x 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 in contact with soil or if tetanus coverage is uncertain.
Soft diet for 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine mouthrinse (0.12%) twice a day for 1 week.
Follow up (see Table 5) Treatment urgency: A = Acute (within a few hours) SA = Subacute (within 24 hours) D = Delayed (more than one day) ■ TABLE 4. Treatment guidelines for avulsed permanent teeth with open apex
Diagnosis and clinical situation
The tooth has already been replanted.
The tooth has been kept in special
Extra-oral dry time is >60 minutes.
storage media, milk, saline or saliva. The
extra-oral dry time is <60 minutes.
Clean affected area with water spray, If contaminated, clean the root surface Replantation usually is not indicated.
saline or chlorhexidine rinse.
and apical foramen with a stream of Do not extract the tooth (SA).
Place the tooth in doxycycline ( 100 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 (A).
Suture gingival laceration, especially in the cervical area.
Verify normal position of the replanted tooth radiographically.
Apply a flexible splint for 1-2 weeks.
Administer systemic antibiotics: Penicillin V 4x per day for 7 days at appropriate dose for patient age and weight; or, for patients not susceptible to tetracycline staining, Doxycycline 2x 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 tetanus coverage is uncertain.
Soft diet for 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine mouthrinse (0.12%) twice a day for 1 week.
Follow up (see Table 5) Treatment urgency: A = Acute (within a few hours) SA = Subacute (within 24 hours) D = Delayed (more than one day) ■ TABLE 5. Follow-up procedures for avulsed permanent teeth
Closed apex
Open apex
S; Initiate endodontic treatment S; Intiate endodontic treatment or monitor for revascularization Yearly for 5 years S = Splint removal C = Clinical 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 (>2x 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 when an
intact lamina dura can be traced around the entire root surface. Usually, if the root canal 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 obliteration is very 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.
■ TABLE 6. Treatment guidelines for tooth fractures and alveolar fractures in the permanent dentition
Complicated
Diagnosis and
Enamel fracture or Enamel-dentin fracture, The coronal fragment is The coronal fragment is The bone segment enamel-dentin fracture; with pulp exposure.
attached to the gingiva usually mobile and containing the involved no pulp exposure.
and mobile. The pulp may sometimes displaced.
tooth/teeth is mobile.
or may not be exposed. The apical segment is usually not displaced.
Radiographic and clinical
Take one radiograph (2).
Take one radiograph (2).
Take four radiographs (1-4).
assessment and findings
Evaluate size of pulp Evaluate the size of pulp Radiographs taken at different angulations are useful.
chamber and stage of chamber and stage of Sensitivity test.
root development.
root development.
Sensitivity test.
Sensitivity test.
Account for fractured In immature tooth: In an emergency, stabilize Reposition the coronal Reposition the fragment.
Perform pulp capping or the coronal fragment with fragment as soon as Stabilize the fragment to Radiograph soft tissue partial pulpotomy and an acid etch/resin splint possible. Check position adjacent teeth with a lacerations for tooth bacteria-tight coronal seal. to adjacent teeth.
fragments or other In mature tooth: Expose subgingival Stabilize the tooth with a foreign bodies. Provide a As with immature tooth or fracture site by: splint (A/SA).
temporary glass-ionomer pulpectomy and root cement bandage or a canal filling (SA).
b) Orthodontic or surgical permanent restoration using a bonding agent If root formation is and composite resin.
complete, root canal If very close to pulp, treatment is indicated.
consider Ca(OH)2 base. If Otherwise, pulp capping an intact fragment exists, or pulpotomy, and wait a bonding procedure may for completion of root be carried out (SA/D).
formation (SA).
Brush teeth with a soft toothbrush after each meal.
Use chlorhexidine mouthrinse (0.12%) twice a day for 7 days.
Follow up (see Table 7) (1) occlusal (2) periapical central angle (3) periapical mesial eccentric (4) periapical distal eccentric Treatment urgency: A = Acute (within a few hours) SA = Subacute (within 24 hours) D = Delayed (more than one day) ■ TABLE 7. Follow-up procedures for fractured permanent teeth and alveolar fractures
Yearly for 5 years S = Splint removal C = Clinical and radiographic examination (1) Success – positive sensitivity, root development continues (immature teeth). Continue to next evaluation Failure – negative sensitivity, signs of apical periodontitis, root development does not continue (immature teeth). Start endodontic therapy (2) Success – positive sensitivity (false negative possible at 3-4 week evaluation). Signs of repair of fractured segments. Continue to next evaluation Failure – negative sensitivity (false negative possible at 3-4 week evaluation). Clinical signs of periodontitis. Radiolucency adjacent to fracture line. Start endodontic therapy to level of fracture line (3) Success – positive sensitivity (false negative possible at 3-4 week evaluation). No signs of apical periodontitis. Continue to next evaluation Failure – negative sensitivity (false negative possible at 3-4 week evaluation). Signs of apical periodontitis or external inflammatory resorption. Start endodontic therapy.

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