INTRODUCTION TO BIDS:

Bangalore Institute of Dental Sciences and Hospital and Research centre is a premier dental institution in Bangalore, established way back in 1991 to impart quality dental education, with state of the art teaching program and training facilities. The Institution is well known both at National and International level. At BIDS, our motto is “Commitment to Excellence ”what we emphasize most is on is evidence based dentistry and real life experience based learning.

BIDS has pioneered in establishing postgraduate course in all branches of dentistry, The college has a very progressive and pragmatic environment developed by highly qualified and experienced teaching staff using the most modern and innovative teaching aids and methodology.

Through our social outreach program “Lost Tooth Project” we are conducting a unique awareness drive among all schools across Karnataka. This drive hopes to impact approximately 10 Lakh School Children and their   families. 

Why is the Drive important – Lost Tooth Project(LTP)

Lost Tooth Project(LTP) highlights the lack of awareness among Public and private school teachers and parents in dealing with  playground injuries.   These injuries   include but are not limited to the following - Tooth crown Fracture, luxation injuries,avulsion and /facial and Temporomandibular Joint injuries  etc .

Initial survey results from an ongoing study conducted in BIDS shows lack of knowledge and adequate training regarding emergency care and Management of dental injuries among school teachers and parents.

Many children lose their teeth because of lack of timely attention both from the school and parent.

MISSION AND OBJECTIVE: To conduct a massive project which would sensitize schools and parents across the state towards this issue so that they will be aware, proactive and prepared when these incidents do occur.

FACTS SHEET

TIPS FOR PARENTS AND PE TEACHERS

What to do if a tooth gets knocked out?

If the tooth gets knocked out of the mouth but is intact:

1. Do not panic, Keep the injured person calm.
2. Locate the tooth and pick it up by the crown (the white part). Avoid touching the root as this can damage the membrane which is essential to saving the tooth.
3. If the tooth is dirty, wash it briefly (10 seconds) using cold running water.
4. Store it in  Locally available medias like  Pasteurized milk ,Egg white, coconut water,ORS Solutions  etc or  Commercially available  storage medium like Hank's Balanced Salt Solution (HBSS),Viaspan® .
5. It is important to note the best chances for survival for a knocked out tooth is to implant it back into the socket with in the Golden Hour. The Golden Hour refers to the first one hour where the cells on the root are still alive.The first 20 minutes gives the best prognosis .
6. Do not attempt to place the tooth back into the socket by yourself or an attendant unless there is prior training to avoid risk of aspiration .
7. Seek emergency dental treatment immediately; Call ahead to tell your dentist you are on your way.
8. Chipped out tooth : search for broken tooth fragment, pick it up with a tweezer or a clean Hand, wash it under running water ,store it in normal saline  and schedule an appointment with  the dentist
9. Intrusion (partial displacement of a tooth axially into the socket): Try not to disturb the affected area and contact the dentist for appropriate care.
10. Extrusion (appears elongated and is excessively mobile): make sure the patient does not aspirate and contact the dentist for appropriate care.
11. Alveolar fracture (The fracture involves the alveolar bone and may extend to the adjacent bone.) : Try not disturbing the affected area and contact the dentist for appropriate care as early as possible.            

What should l do with the tooth?

Avoid handling the root of the tooth. If it is very dirty, you can clean it with running tap water gently . Avoid rinsing it with disinfectant or let it dry out.

What if I have only got one part of the tooth?

It is not a good idea to put the tooth back into the socket if it is not complete. Contact your dentist as soon as possible and your dentist will tell you what options are available to restore the tooth. You may need dental x-rays to see if there is root damage.

What if it is a baby tooth?

Reimplanting an avulsed baby tooth is not recommended .It can cause an infection and damage the adult tooth underneath . Dentist may need to examine the child to check if any fragments of the tooth are left in the gum and in the injured site.

Where should I get emergency dental treatment?

It is important to get emergency dental treatment. You can contact your local dentist for advice. If you are unable to find an expert dentist nearby you can call on our helpline , and we will do our best to help you .

What should happen at my emergency visit?

Your dentist will treat you for the immediate situation and also treat any facial injury. However, treatment may be limited if there is any bruising or bleeding. They may take x-rays to check if the tooth can be re-implanted successfully. You may need more appointments for follow up treatment.

What further treatment options will be available to me?

If the tooth has re-implanted completely you may not need any further treatment, apart from regular checkups. If you find the tooth becoming loose, contact your dentist. In such a condition, it can be splinted to the teeth next to it. This means the loose tooth will be temporarily attached to keep it firm until your dentist can tell whether it has re-implanted successfully.
If the tooth is lost or cannot be implanted successfully, it can be replaced with a denture initially. When the affected socket heals you can have a bridge or dental Implant.

What can I do to avoid getting a tooth knocked out?

You could wear a mouthguard. It is a rubber-like cover that Fits over your teeth that protects you against a blow to the mouth. Your dentist can make for you by taking an impression of your teeth and sending it to a laboratory. Mouthguards can be clear or colored — for example in the colors of your team kit.

DONT’S ABOUT DENTAL TRAUMA

• Don’t touch the tooth root. After comforting the child, locate the dislodged tooth as quickly as possible. When you find it, pick it up gently and avoid touching the root of the tooth.
• Don’t scrub the tooth. If the dislodged tooth fell on the ground, your instinct might be to clean it thoroughly. However, scrubbing a tooth– and particularly removing pieces of attached tissue– can reduce its chances of reattaching.
• Don’t wrap the tooth up. It might be tempting to wrap the rinsed tooth up in a paper towel, but doing so can dry it out. Instead, gently try to replace the tooth in your child’s socket. If that doesn’t work, don’t force it; instead, place the tooth in a bowl of milk or other commercially available storage solution.

GUIDE FOR DOCTORS

 Closed Apex:

Tooth replanted prior to the patient’s arrival at the dental office or clinic

Treatment

• Leave the tooth in place.
• Clean the area with water spray, saline, or chlorhexidine.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both clinically and radiographically.
• Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.

Follow-up

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

 Closed apex:

Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank’s Balanced Salt Solution) and/or stored dry less than 60 minutes

Treatment

• Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both, clinically and radiographically.
• Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.

Patient instructions

• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.

Follow-up

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

 Closed apex:

Extraoral dry time exceeding 60 min or other reasons suggesting non-viable cells.

Treatment

Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and can not be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour. However, the expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually.

• Remove attached non-viable soft tissue carefully, with gauze.
• Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.

To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Ankylosis is unavoidable after delayed replantation and must be taken into consideration. In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome. Decoronation may be necessary when infraposition (> 1 mm) is seen. For more detailed information of this procedure the reader is referred to textbooks.

 Open apex:

Tooth replanted prior to the patients arrival at the dental office or clinic.

Treatment

• Leave the tooth in place.
• Clean the area with water spray, saline, or chlorhexidine.
• Suture gingival laceration if present.
• Verify normal position of the replanted tooth both clinically and radiographically.
• Apply a flexible splint for up to 1-2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
• The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment is recommended.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

 Open apex:

Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank’s Balanced Salt Solution) and/or stored dry less than 60 minutes.

Treatment

• Clean the root surface and apical foramen with a stream of saline.
• Topical application of antibiotics has been shown to enhance chances for revascularization of the pulp and can be considered if available (minocycline or doxycycline 1 mg per 20 ml saline for 5 minutes soak).
• Administer local anesthesia.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
• Irrigate the socket with saline.
• Replant the tooth slowly with slight digital pressure.
• Suture gingival lacerations, especially in the cervical area.
• Verify normal position of the replanted tooth clinically and radiographically.
• Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.

The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space. The risk of infection-related root resorption should be weighed up agains the chances of revascularization. such resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

 Open apex:

Dry time longer than 60 min or other reasons suggesting non-viable cells

Treatment

Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in delayed replantation is to restore the tooth to the dentition for esthetic, functional , and psychological reasons and to maintain alveolar contour. The eventual outcome will be ankylosis and resorption of the root.

• Remove attached non-viable soft tissue with gauze.
• Root canal treatment can be carried out prior to replantation or later.
• Administer local anesthesia.
• Irrigate the socket with saline.
• Examine the alveolar socket. if there is a fracture of the socket wall, reposition it with a suitable instrument.
• Replant the tooth slowly with slight digital pressure.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil or if tetanus coverage is uncertain, refer to physician for evaluation of the need for a tetanus booster.

To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.

Patient instructions

• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Follow-up

• For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
• Splint removal and clinical and radiographic control after 4 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Disclaimer: Source taken from https://dentaltraumaguide.org/free-dental-guides/permanent-teeth/avulsion/