Treating the Avulsed Permanent Incisor with Partially Formed Root

Now, since we are working with an incomplete developed root, we are hoping ideally for revascularization and or apexogenesis over the next 12 to 18 months. That would be ideal, but that may not happen. So let's talk about some of the alternative outcomes. Welcome to Austin, Texas for the Phil Klein Dental Podcast. So in today's podcast, we're going to be talking about the evolved tooth related to a child who... as at the age where their tooth is, their root is not fully formed. So we're talking about a partially formed root. So in this case, Susie shows up with her mother. You can see the dried blood on Susie's lips. She's got blood on her cheek. She's obviously upset and a little disoriented. She certainly wasn't planning on visiting the dentist this afternoon when she took her bike out to the park with her mom. So as her dentist, you have several things running through your mind, several questions running through your mind. First, other than the evolved tooth, is Susie suffering or showing symptoms of any other serious issues, specifically neurological issues, that may be the result of falling off her bicycle. So that's a pretty big concern. So you want to rule that out quickly. And that's why it's so important to take a good medical history and do a careful intra and extra oral exam as you try to rule out anything more serious than the tooth evolved in itself. The second thing that's going to be running through your mind is how long has the tooth been out of the mouth? In other words, what's the approximate dry time? And as we know, the longer the dry time, the worse the prognosis. And this has to do with the state or health of the PDL cells. This was covered in an earlier podcast that I released where I discussed the management of the mature avulsed permanent tooth. And that one covers the basic protocol, as I mentioned, regarding avulsion of a permanent incisor that has fully mature root formation. 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Third question that's running through your mind, how was the tooth transported to the office? Did the mother bring the tooth in wrapped in a napkin, a cup of water, container of milk, etc.? So how did she bring it to the office? And was the root cleaned or scrubbed after being picked up from the ground? So we need to get all this information in order to manage this case properly and discuss the prognosis with the patient in the most realistic manner. So let's go over what we do at this emergency visit. First, you want to take a medical history. and rule out any neurological and non-dental injuries so you do that with a careful physical exam of the face the mouth the head and the neck along with asking the patient a variety of questions that might tip you off that something neurological is actually going on so once you rule that out you want to rule out an alveolar fracture so you do a careful extra and intraoral physical exam and take some radiographs if there's an alveolar fracture you may want to refer the patient to an oral surgeon you may want to continue doing the case yourself. If you feel comfortable handling that, that's up to you. But you do want to make sure you know if there's actually an alveolar fracture. Now, you also want to rule out root fractures that may have occurred as a result of the fall. So the clinical scenario of vertical root fracture may also resemble that of periodontal disease or of a failed root canal treatment. Now, in this case, with an eight-year-old child, we're probably not looking at any period disease. And most likely, none of her teeth have been treated with root canal therapy. But this should be part of your protocol in this kind of emergency visit. Now, related to vertical root fractures, it should be kept in mind that the accuracy of radiographs, the accuracy of radiographic diagnosis, also depends on the proper radiographic angulation. It depends on the contrast, density, and also the clinician who's interpreting the radiographic findings. You need to have a lot of things aligned in order to make a definitive or a fairly confident diagnosis of a root fracture. Having said that, recent studies have shown that CBCT has a very high accuracy and sensitivity in detecting vertical root fractures. So if you don't have access to CBCT, my recommendation would be to take three radiographs, angulate it differently. to see if you can detect any root fractures. So again, we're trying to rule out root fractures. So just to recap what we just talked about, in that initial part of the emergency visit, we want to rule out neurological issues, non-dental injuries. We want to rule out alveolar fracture. And we want to rule out root fractures in other teeth that may have been involved with this trauma. Now, to finish off your initial exam at the emergency visit, it wouldn't be a bad idea to do some vitality testing of the teeth. they may have been traumatized as a result of the fall. This way you have these test results in the patient's chart. At a later date, you can see if there was any questions of vitality in the adjacent teeth. And this is obviously going to be very useful down the road as you continue to follow up this patient after what you do today in this emergency visit. Now, while you're doing this, while you're doing this initial exam that we just went over, your staff is... handling the storage of the evolved tooth. So let's talk about the various scenarios which determine how your staff handles the tooth regarding its storage prior to replantation. Now, the ideal situation is that the tooth was out of the mouth or what we call the extra oral dry time is 20 minutes or less. That's the best scenario. In addition, the other Good scenario would be for the tooth to be transported in a physiologic medium like milk or ideally Hanks balanced salt solution. Okay, so that's the best scenario. To clarify one thing about ideal situation, the ideal situation obviously would be that the tooth was replanted at the scene of the trauma. That's the best scenario. But excluding that, we're talking about the ideal scenario for the patient who's bringing the avulse tooth in a storage medium to your office. under 20 minutes of dry time where the tooth has been out of the mouth, not in any kind of storage for under 20 minutes, and then put into a physiologic medium such as milk or Hanks balanced salt solution. So you have to make the determination of what to do with this tooth based on these different scenarios. Now, another scenario would be extra oral dry time of 20 minutes or less, but brought in water. The tooth showed up in a cup of water. That's a non-physiologic medium. In this case, while the doctor is doing that initial exam, ruling out neurologic issues and everything we talked about, your staff or you want to put that tooth immediately in a physiologic solution. Ideally, Hank's balanced salt solution, which every GP should have in their office. If you don't have that, you can drop the tooth in cold milk. Okay, so now once we get that tooth into milk or Hank's balanced salt solution, if it's not already in that... storage when they show up at the office. We leave it in there for about 10 or 15 minutes. The goal in this situation is to help revitalize the PDL cells if at all possible. And then we remove it carefully by handling it by the crown and irrigate any debris off of the root using sterile saline. So we want to make sure there's no debris. Then we take that tooth and place it into a solution of doxycycline. Concentration of that solution should be 0.005%. All right. So 0.005% solution of doxycycline is what we want to soak that tooth in for about five minutes. Now, if you don't have doxycycline, you can use a Reston. Before we continue, I've got to give a shout out to our sponsor, NSK. These folks are the real deal. Their air and electric hand pieces are not only top tier, they're the highest rated in the industry. peer-reviewed by Dental Product Shopper. Their Timex Z99L electric handpiece actually scored the first ever perfect rating. And the Timex Z990L is the most powerful handpiece on the market. So do yourself a favor, check out everything they offer at nskdental.com and take advantage of their free trial by reaching out to your local NSK rep. I've heard this many times from many dentists. Once you start using NSK handpieces, you'll never look back. So let's talk about one more scenario as far as dry time. If dry time exceeds 60 minutes, now this scenario really does not bode well for the long-term success of our replantation case. In fact, some specialists recommend not even replanting a tooth with incomplete root formation if the dry time exceeds 60 minutes. All right? Others say it's worth a shot. So that's up to you as a clinician to decide what you want to do. If it's a little over 60 minutes, maybe 60 to 80 minutes, maybe it is worth a shot. But once you pass 80 minutes, I'd have to agree with those specialists that say it's not worth replanting. But let's say we replant it and it's at 65 minutes, 70 minutes. So in this case, we no longer trust the PDL cells that live on the root of the tooth. They're going to cause more damage than good. So we do everything against our nature and want to actually strip the tooth clean. Very different than... The other scenario we talked about where we're trying to preserve those PDL cells. So how do we strip the root clean and get rid of these PDL cells? We debride the root with a soft pumice prophylaxis. And then we want to use some sterile gauze to wipe the root. And then we perform a gentle scaling and root planing. And another way to do this is to soak the tooth in a solution of 3% citric acid for three minutes and rinse well to remove the PDL. Once that's done, we can place the tooth. In a solution of sodium fluoride, the concentration is 1.23%, acidulated phosphate fluoride, basically. We soak it in that for about 10 minutes. 10 minutes, okay? So our goal in this case, where the dry time is over 60 minutes and maybe under 80 minutes, we decide to replant it. We want to remove the PDL. So the idea of understanding these different scenarios allows the clinician to make the right judgment call. First of all, whether we should do the replantation. And second of all, you're going to get a better idea of what the prognosis is. So you can relay that information over to the mother or the parent. So we have to make sure that the expectations of the parent is in line with reality. And again, even if the patient brings the tooth in where the dry time was under 20 minutes and it was in a physiologic medium, does not guarantee that the tooth is going to revascularize. That's our hope. And research shows that we have the best chance of revascularization. based on those conditions. So before we actually do the replantation of the tooth, we want to make sure the socket is properly prepared. The socket should be rinsed with sterile saline. And in the case that the alveolar bone has collapsed, it should be repositioned gently. And please remember, never use air syringe to dry the socket. We don't want to introduce a blast of air anywhere near the open socket. Now, A flap elevation is an option, but only indicated in cases where the bone interferes with the replantation of the tooth. So once we have that socket prepared properly, we are ready to replant the tooth. We want to carefully and gently position the tooth in the socket with a light digital pressure. And we don't want to force the tooth in by any means. We never want to force the tooth, put too much vertical force down on the crown. It should just glide into place and find its way. to be fully seated with gentle digital pressure. Once we feel it is correctly seated, we want to immobilize the tooth with a semi-rigid splint. And that splint should be on, in most cases, for seven to 10 days. Now, the splint should not interfere with the patient's capability to perform home hygiene, correct oral hygiene at home, and should allow a physiologic movement of the tooth. That's going to give you the best results. Now, in cases of bone fracture, where we do have an alveolar fracture, the tooth should be splinted for a longer period, one to two months. And that depends on the clinical situation, and that might be a case for an oral surgeon. Now, rigid immobilization is contraindicated except in cases of root fracture. So after the splint is placed, a radiograph should be taken to verify the correct position of the tooth. Now, at this point, it's recommended to prescribe antibiotic therapy to avoid the onset of infection. during the first week after replantation. That's the last thing we want is to have an infection after we replant a tooth in an eight-year-old child. Also, it is believed and supported by some research that the administration of systemic antibiotics prevents the development of external root resorption. So the antibiotic of choice is doxycycline. And the dose is 100 milligrams once a day for seven days. 100 milligrams once a day for seven days. Now for children, The accepted guide would be two milligrams per kilogram of weight per day. That's two milligrams of doxycycline per kilogram of weight per day. Amoxicillin is also an option. You could prescribe amoxicillin, 500 milligrams, three times a day for seven days. For children, based on their weight, you want to give them 50 milligrams per kilogram per day. So whatever that comes out to, you divide it by three and spread that out over three doses per day. every eight hours okay also chlorhexidine we want to put the patient on chlorhexidine rinses that should be prescribed and strict hygiene instructions given during the entire splinting period in the case of any pain or discomfort analgesics can also be prescribed and i would recommend a soft diet for a few days following the replantation and the research also suggests to consult with a physician about the need for a tetanus booster during the first 48 hours after the accident. And it should be noted that in these kinds of teeth, it goes without saying, it's contraindicated to perform any root canal therapy as a first treatment of choice, right? There's a great deal of evidence to support the possibility of pulp revascularization in these teeth, which would be ideal. So let's talk about follow-up. You want to monitor the patient every four weeks. which includes pulp testing and radiographs. So this is the follow-up after you put the splint on. Now, since we are working with an incomplete developed root, we are hoping ideally for revascularization and or apexogenesis over the next 12 to 18 months. That would be ideal, but that may not happen. So let's talk about some of the alternative outcomes. When we start to see symptoms of pain and our sensitivity or signs of radiographic pathology, we need to initiate endodontic treatment, would include apexification, which would hopefully close the apex, allowing us to perform proper root canal therapy. Now, apexification can be done with a material called MTA, which is mineral trioxide aggregate, or calcium hydroxide slurry. Now, this is normally performed by an endodontist, but a GP can certainly do this. So the idea is to initiate apexification using these materials, continue to follow up with the patient, And once we see evidence of a successful apexification procedure, we feel confident about obturating the tooth. And this, as I mentioned, could take 12 to 18 months. At that point, we then complete our root canal therapy. So I hope this review helped put things in perspective regarding that unexpected emergency visit involving the avulsed permanent tooth with incomplete root formation. You're listening to the Dr. Phil Klein Show. See you on our next podcast.