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Treatment of the Avulsed Tooth
JA D A LETTERS TO THE EDITOR
the site of the injury: if notified by tele phone, instruct patient, parent, or in volved party on replantation technique; stress importance of seeing dentist im mediately for follow-up splinting and treatment.
Treatment of the avulsed tooth □ The Am erican Association of Endodontists reports the findings of a com mittee established to develop recom mended guidelines for treatment of the avulsed tooth. The committee was com prised of teachers, researchers, and clini cians, all of whom are recognized au thorities in the area of dental injury. Committee members, representing a cross section of the United States, were: Drs. Donald E. Arens, Stuart Fountain, Gerald Harrington, Eric Hovland, Robert Os wald, Milton Siskin, Leif Tronstad, Henry J. Van Hassel, Raymond Webber, and Joe H. Camp, committee chairman. Members of the committee submitted recommendations that represented their respective approaches to treatment of the accidentally avulsed tooth. The recom mendations represent a “working docu ment” that is subject to revision on the basis of additional research. Committee members were unanimous in their as sessment of a need for additional research in this area. It is hoped these guidelines w ill serve to minimize the potential hazards from techniques formally accepted on an em pirical basis. Although it still remains impossible to guarantee permanent reten tion, and neither the association nor the committee expressly or impliedly war rants any positive results associated with the application of the recommended g uide lin e s, tim ely treatment of the avulsed tooth in the proper manner can maximize success. The guidelines are: Extraoral time One of the most critical factors affecting prognosis. If possible, replant the tooth immediately at 706 ■ JADA, Vol. 107, November 1983
Storage media Preferably in the socket. Oral fluids (buccal vestibule, but must be conscious of possibility of aspiration or swallowing, especially in young child). Milk. Water. Management of the socket Leave alone or gently aspirate without enter ing; use light irrigation if a blood clot is present. Do not curet the socket. Do not vent socket. Do not make a surgical flap unless bony fragments prevent replantation. After replantation, manually compress facial and lingual bony plates if spread apart. Management of the root surface Do not handle the root surface—hold tooth by the crown. Do not scrape or brush the root surface or re move any of the root If root appears clean, replant as is. If the root surface is dirty, rinse with tap water or saline solution. If persistent de bris remains on the root, use cotton pliers to gently remove any debris, or a wet sponge to gently brush off debris. No medicaments, disinfectants, or chemi cals are applied to the root surface. When to do endodontic treatment Tooth with an open apex: replant and try for revitalization of the pulp; follow closely every two weeks for signs of pathologic condition; if noted, extirpate pulp and fill canals with calcium hydroxide (apexification procedure). Tooth with a fully formed apex: pulp must be removed between seven to 14 days; the canal is then filled with calcium hydrox ide (same as apexification procedure); re clean the canal and repack the calcium h y d ro x id e every three m o n th s for m inim um of six to 24 months; after this procedure, reclean the canal and fill with a permanent root canal filler. Endodontic treatment is performed in the mouth in all situations. Filling materials Treatment filling of calcium hydroxide for m inim um of six to 24 months. At completion of calcium hydroxide treat ment, permanent obturation with gutta percha. Splinting Use acid-etch resin alone or with soft arch wire, orthodontic brackets with arch wire or large monofilament fishing line or, as last resort, suture in position. Splint left in place seven to ten days. Major bony fractures may require longer splinting times. Diet during splinting: no biting on splinted
teeth; soft foods high in protein; increased fluid intake. Adjunctive drug therapy Refer to physician for tetanus consultation within first 48 hours. Antibiotic therapy not recommended unless medically indicated or in cases of contam inated avulsion. JOE H. CAMP, DDS, MSD CHAIRMAN AD HOC COMMITTEE ON THE TREATMENT OF THE AVULSED TOOTH AMERICAN ASSOCIATION OF ENDODONTISTS
Aseptic techniques for AIDS □ Acquired Immune Deficiency Syn drome (AIDS), the recently discovered breakdown of the immune system that can lead to fatal forms of cancer and op portunistic infections, has been of prime concern to the entire nation. Although there is no specific oral pattern of the dis ease, health professionals should be aware of it, of the possibility of its trans mission, and of the basic precautionary measures to be observed. Recent articles in /ADA and the ADA News have concentrated on the risks to which the dental profession might be ex posed when treating patients with diag nosed or suspected AIDS. The dental community must be aware of early man ifestations of AIDS, especially in the high risk areas of New York City, New York S tate, San F ra n c isc o , a n d Los Angeles. . . . At the Mt. Sinai Medical Center in New York, one hemophiliac patient was diag nosed with AIDS in March 1983. As a long-term patient of the Hemophilia Cen ter, the patient had a documented treat ment history of more than 20 years. The patient had used intravenous drugs dur ing the early years of treatment, but had been rehabilitated for more than 12 years. He had no history of homosexual experi ences. The patient was edentulous and had been wearing complete dentures for ten years. During the course of treatment for AIDS, the patient never had any symptoms or evidence of oral disease as sociate d w ith the u n d e r ly in g im munologic disorder. We have formulated the following list of recommended precautions for use dur ing the treatment of patients with diag nosed or suspected AIDS: General aseptic technique should in clude the wearing of disposable gloves, mask, and gown; the sterilization of all dental instruments, in c lud in g han d pieces; the use of disposable needles; in-
the site of the injury: if notified by tele phone, instruct patient, parent, or in volved party on replantation technique; stress importance of seeing dentist im mediately for follow-up splinting and treatment.
Treatment of the avulsed tooth □ The Am erican Association of Endodontists reports the findings of a com mittee established to develop recom mended guidelines for treatment of the avulsed tooth. The committee was com prised of teachers, researchers, and clini cians, all of whom are recognized au thorities in the area of dental injury. Committee members, representing a cross section of the United States, were: Drs. Donald E. Arens, Stuart Fountain, Gerald Harrington, Eric Hovland, Robert Os wald, Milton Siskin, Leif Tronstad, Henry J. Van Hassel, Raymond Webber, and Joe H. Camp, committee chairman. Members of the committee submitted recommendations that represented their respective approaches to treatment of the accidentally avulsed tooth. The recom mendations represent a “working docu ment” that is subject to revision on the basis of additional research. Committee members were unanimous in their as sessment of a need for additional research in this area. It is hoped these guidelines w ill serve to minimize the potential hazards from techniques formally accepted on an em pirical basis. Although it still remains impossible to guarantee permanent reten tion, and neither the association nor the committee expressly or impliedly war rants any positive results associated with the application of the recommended g uide lin e s, tim ely treatment of the avulsed tooth in the proper manner can maximize success. The guidelines are: Extraoral time One of the most critical factors affecting prognosis. If possible, replant the tooth immediately at 706 ■ JADA, Vol. 107, November 1983
Storage media Preferably in the socket. Oral fluids (buccal vestibule, but must be conscious of possibility of aspiration or swallowing, especially in young child). Milk. Water. Management of the socket Leave alone or gently aspirate without enter ing; use light irrigation if a blood clot is present. Do not curet the socket. Do not vent socket. Do not make a surgical flap unless bony fragments prevent replantation. After replantation, manually compress facial and lingual bony plates if spread apart. Management of the root surface Do not handle the root surface—hold tooth by the crown. Do not scrape or brush the root surface or re move any of the root If root appears clean, replant as is. If the root surface is dirty, rinse with tap water or saline solution. If persistent de bris remains on the root, use cotton pliers to gently remove any debris, or a wet sponge to gently brush off debris. No medicaments, disinfectants, or chemi cals are applied to the root surface. When to do endodontic treatment Tooth with an open apex: replant and try for revitalization of the pulp; follow closely every two weeks for signs of pathologic condition; if noted, extirpate pulp and fill canals with calcium hydroxide (apexification procedure). Tooth with a fully formed apex: pulp must be removed between seven to 14 days; the canal is then filled with calcium hydrox ide (same as apexification procedure); re clean the canal and repack the calcium h y d ro x id e every three m o n th s for m inim um of six to 24 months; after this procedure, reclean the canal and fill with a permanent root canal filler. Endodontic treatment is performed in the mouth in all situations. Filling materials Treatment filling of calcium hydroxide for m inim um of six to 24 months. At completion of calcium hydroxide treat ment, permanent obturation with gutta percha. Splinting Use acid-etch resin alone or with soft arch wire, orthodontic brackets with arch wire or large monofilament fishing line or, as last resort, suture in position. Splint left in place seven to ten days. Major bony fractures may require longer splinting times. Diet during splinting: no biting on splinted
teeth; soft foods high in protein; increased fluid intake. Adjunctive drug therapy Refer to physician for tetanus consultation within first 48 hours. Antibiotic therapy not recommended unless medically indicated or in cases of contam inated avulsion. JOE H. CAMP, DDS, MSD CHAIRMAN AD HOC COMMITTEE ON THE TREATMENT OF THE AVULSED TOOTH AMERICAN ASSOCIATION OF ENDODONTISTS
Aseptic techniques for AIDS □ Acquired Immune Deficiency Syn drome (AIDS), the recently discovered breakdown of the immune system that can lead to fatal forms of cancer and op portunistic infections, has been of prime concern to the entire nation. Although there is no specific oral pattern of the dis ease, health professionals should be aware of it, of the possibility of its trans mission, and of the basic precautionary measures to be observed. Recent articles in /ADA and the ADA News have concentrated on the risks to which the dental profession might be ex posed when treating patients with diag nosed or suspected AIDS. The dental community must be aware of early man ifestations of AIDS, especially in the high risk areas of New York City, New York S tate, San F ra n c isc o , a n d Los Angeles. . . . At the Mt. Sinai Medical Center in New York, one hemophiliac patient was diag nosed with AIDS in March 1983. As a long-term patient of the Hemophilia Cen ter, the patient had a documented treat ment history of more than 20 years. The patient had used intravenous drugs dur ing the early years of treatment, but had been rehabilitated for more than 12 years. He had no history of homosexual experi ences. The patient was edentulous and had been wearing complete dentures for ten years. During the course of treatment for AIDS, the patient never had any symptoms or evidence of oral disease as sociate d w ith the u n d e r ly in g im munologic disorder. We have formulated the following list of recommended precautions for use dur ing the treatment of patients with diag nosed or suspected AIDS: General aseptic technique should in clude the wearing of disposable gloves, mask, and gown; the sterilization of all dental instruments, in c lud in g han d pieces; the use of disposable needles; in-