Protocol for pt with avulsed tooth:

Replantation within 1 hour of avulsion. If immediatereplantation is not feasible, the injured personshould be brought to the dental office and thetooth transported in such a way as to keep itmoist.29 The best transport medium is a commerciallyavailable storage-transport medium or physiologicsaline (usually neither is available); milkis an excellent alternative.28-30 Saliva is acceptable,whereas water is not good for maintaining rootsurfacecell vitality.'When the patient arrives:1. The tooth is placed in a cup of physiologicsaline.2. The area of injury is radiographed, lookingfor evidence of alveolar fracture.3. The avulsion site is examined carefully forany loose bone fragments that may be removed.if the alveolus is collapsed, it isspread open gently with an instrument.4. The socket is gently irrigated with saline toremove contaminated coagulum.5. In the cup of saline, the tooth is graspedwith extraction forceps by the crown toavoid handling the root.6. The tooth is examined for debris, which, ifpresent, is gently removed with gauzemoistened with saline.7. The tooth is replaced into the socket; afterpartial insertion using the forceps, gentlefinger pressure is used or the patient biteson gauze until the tooth is seated.8. Proper alignment is checked, and hyperocclusionis corrected. Soft tissue lacerations

are tightly sutured, particularly cervically.9. The tooth is stabilized for 1 to 2 weekswith a splint (see Figure 25-14).10. It has been suggested that antibiotics beprescribed in the same dosage as that usedfor mild to moderate oral infections . 31 Atetanus booster injection is recommendedif the last one was administered more than5 years previously. 411. Supportive care is given; a soft diet andmild analgesics are suggested as needed.

Root canal treatment is indicated for matureteeth and should be done optimally after 1 weekand before the splint is removed (the splint stabilizesthe tooth during the procedure). The exceptionto routine root canal therapy is immatureteeth with wide-open apices; they may revascularizebut must be evaluated at regular intervals of2, 6, and 12 months after replantation. If subsequentevaluations indicate pulp necrosis, rootcanal treatment, probably including apexification,is indicated . 32

Replantation more than 1 hour after avulsion. If atooth has been out of the alveolar socket for morethan 1 hour (and not kept moist in a suitablemedium), periodontal ligament cells and fiberswill not survive regardless of the stage of root development.Replacement resorption (ankylosis)will probably be the eventual sequela after replantation.Therefore treatment efforts before replantationinclude treating the root surface with fluoride

to reduce (slow) the resorptive process.'

When the patient arrives:1. The area of tooth avulsion is examined andradiographs are examined for evidence ofalveolar fractures.2. Debris and pieces of soft tissue adhering tothe root surface are removed.3. The tooth is soaked in a 2.4% solution ofsodium fluoride (acidulated to pH 5.5) for5 to 20 minutes.

The pulp is extirpated, and the canal iscleaned, shaped, and filled while the tooth isheld in a fluoride-soaked piece of gauze. Oftenthe procedure can be accomplished from anapical direction if the root is immature.5. The alveolar socket is carefully suctioned toremove the blood clot. The socket is irrigatedwith saline.33 Anesthesia may be necessaryfirst.6. The tooth is gently replanted into thesocket, checking for proper alignment andocclusal contact.7. The tooth is splinted for 3 to 6 weeks