Avulsed Tooth-A Review

Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. Tooth avulsion or exarticulation is a traumatic injury of dental tissue characterised by complete displacement of the tooth out of its socket. Successful treatment outcome of such an injury is dependent on the survival of the viable periodontal ligament cells attached to the tooth root surface. The viability of the periodontal ligament cells is best preserved either when the tooth is immediately replanted into its socket or if it is stored in an appropriate storage /transport medium till a time, the tooth can be replanted into its socket.


INTRODUCTION
Avulsion is the total dislodgement of an intact tooth from its socket.According to Andreasen and Andreasen, avulsion of permanent teeth accounts for approximately 0.5-3% of all dental trauma.The peak age for avulsion is between 7 to 9 years and mainly involves maxillary anteriors.Losing an anterior tooth at an young age may have severe psychological consequences.The immediate replantation of a permanent avulsed tooth is essential to restore the function and esthetics and critical for long term success of the treatment.Avulsion presents a challenge with regard to its proper emergency management.The principal challenge is to maintain the vitality of periodontal cells, as prognosis of a replanted tooth is directly proportional to the viable periodontal cells.Use of physiological storage media like milk, saliva or saline is critical to maintain the viability of periodontal cells until professional help is obtained. 1oth avulsion mainly occurs during sports, physical violence, road traffic accidents, fall and other physical impacts.Many patients with avulsed tooth visit medical doctors due to lack of awareness or unavailability of a dentist. 2 Avulsion of permanent teeth is seen in 0.5-3% of all dental injuries 3

Storage medium
A storage medium may be defined as a physiological solution that closely replicates the oral environment to help preserve the viability of PDL cells following avulsion. 4e ideal requirements for a storage medium are  Use of such a storage media has been associated with favourable healing outcomes.schools, hospitals and dental offices, and low cost.Milk is an isotonic liquid with a physiologically compatible pH and osmolality (fluid pressure) with the root-surface adhered PDL cells, has low or no bacterial content, contains growth factors and essential nutrients for cells, in addition to being highly available mostly everywhere and having a low cost.Taking together the characteristics, efficacy and availability and accessibility, milk appears as the best indication of a temporary storage medium for avulsed teeth before replantation, and its use is recommended by the International Association of Dental Traumatology and the American Academy of Pediatric Dentistry. 6

Outcomes of avulsion
The speed with which the avulsed tooth is replanted is the most important factor for success.There is not a single product or solution that possesses all the characteristics required to be indicated as the ideal storage medium for avulsed teeth, that is, be capable of preserving the vitality of the PDL and pulp cells, while presenting compatible physiological pH and osmolality, clonogenic capacity, antioxidant property, no or minimal microbial contamination, high availability, ready accessibility at accident sites, homes, submergence results when replacement resorption interferes with the tooth's ability to move with the normal downward growth of the alveolar process.´External inflammatory root resorption: the result of a combination of severely damaged attachment and bacterial contamination of a necrotic pulp.It may rapidly progress.Clinically, it presents as radiolucencies in the root and adjacent bone. 7 Management of an avulsed permanent tooth with closed APEX 8 The above steps in the management of an avulsed permanent tooth with an open apex followed by initiating pulpectomy/debridement within 7 to 10 days. 7oft tissue management: gingival tissue should be tightly secured in the cervical area of the replanted tooth to help prevent the ingress of bacteria.Lip lacerations must be thoroughly cleaned and approximated tension-free before suturing.It is best to consult an oral or plastic surgeon if the laceration extends through the vermilion border into the skin.

Splinting
A flexible (semi-rigid) splint is recommended for 7-10 days.There are many acceptable types of splints available and it is left to the provider to choose one that is effective and easy to use.The splint should allow physiologic movement of the tooth, should not have memory and not impinge on the gingiva.Proper repositioning of the replanted tooth should be verified with a radiograph.Avulsions that have concomitant alveolar fractures should be splinted for 4-8 weeks.

Systemic antibiotics: recommended
If the patient is not susceptible to tetracycline staining, the antibiotic of choice is doxycycline at an appropriate dose for patient age and weight.Penicillin V can be substituted for doxycycline.Adult dosage of doxycycline is 100mg b.i.d.x 7 days.Adult dosage of Penicillin V is 1-2g 8 stat, then 500mg q.i.d.x 7 days.Fractures of the alveolus may have their own indications for antibiotic coverage

Tetanus
Refer the patient to a physician within 48 hours for a tetanus booster if the avulsed tooth contacted soil or if the status of the tetanus coverage is uncertain.

Analgesics
Prescribe if needed.Typically, an over the counter nonsteroidal anti-inflammatory drug suffices.

Diet
Post-operative instructions should include a soft diet for 2 weeks.

Oral hygiene
Instruct the patient to brush with a soft toothbrush after every meal and prescribe a 0.1% chlorhexidine mouth rinse 2x per day for 7 days.Follow-up appointments: include splint removal and initiation of endodontic treatment, if required, at one week.Clinical and radiographic exams should be scheduled at 2-3 weeks, 3-4 weeks, 6-8 weeks, 6 months, 1 year and annually for 5 years.

CONCLUSION
Avulsion is one of the most serious dental injuries.It has psychological, esthetic and functional consequences and the prognosis is mainly related to the injury to periodontal membrane.Knowledge levels of the individuals should be improved related to the emergency management of tooth avulsion.This can be done through targeted education programs.Posters and videos to be designed about the management and should be delivered to the public through camps and mass media.