 Reversible pulpitis (hyperemia): sharp pain, quick reduction within 1 minute, on thermal test, no pain

without stimulation (hot, cold, sweet)

treatment: eliminate the factor causing the pain and the pulp will return to its original state (high filling,
caries, filling without base, sinusitis, pregnancy and menstruation, influenza infection)
 Acute Pulpitis seroza: spontaneous severe pain, at night, on cold, with (sweet, sour) foods, by pressure
from residual food in the cavity, on body movements (lining, lifting).
diffuse, unilateral, non-localized pain, responds lower than normal in EPT
treatment: RCT under local anesthesia
 Acute Pulpitis purulenta: continues pulsative pain, increase with heat, cold relives the pain, caused by
mechanical pressure on the cavity (dentin is not perforated). responds lower than normal in EPT
treatment: RCT under local anesthesia
 Chronic Pulpitis ulcerosa (Devital pulp): asymptomatic. responds high than normal in EPT
treatment: RCT without local anesthesia cause Devital pulp
 Chronic Pulpitis pulyposa: pain on chewing, responds high than normal in EPT
treatment: cutting pulp and RCT under local anesthesia

Treatment of acute apical periodontits and acute apical abcess : first we should remove the source of infection if
there were spreading of infection (swelling or cellulities ) we should use systemic antibiotic ,then we treated by
incision for drainage and root canal treatment with good irrigation and cleaning or extraction to remove the source
of infection and clean the socket .
 From where endodontics word came and what is endodontic?
It came from new Latin endodontia from endo- +Greek Odon teeth
Endodontic: is the branch of dentistry that deals with the diagnosis and treatment of disease and disorders of
tooth root and dental pulp and surrounding tissues.
 The functions of pulp are:
1-formation of dentin, secondary dentin
2- nutrition and innervation because it has vessels and nerves
3-protevtive and defense that it responds to any injury or action and forms secondary dentin
4-sensory
 If you did endo treatment for a tooth had apical lesion, and the patient came after 6 months with same size
of apical lesion what will you do?
6 month is very short time ,we should continue *follow up* by taking x ray after 6 month and one year and
two year till 4th year, if the prognosis is bad after 4 year we should do retreatment.
 If the file was entering normally to the apex 19 mm, and after that it start stopping till it reach 16 MM,
what is the possible reasons?
Not good irrigation, and maybe broken file.
 What is the possible ways to remove the broken files?
ultrasonic devices, make the canal wider and remove it by file, should say at least 3 techniques
 If you had broken file in the canal what should you do and you cannot remove the file?
We should always think first about removal the file but because it is not possible, we go to the most important
was: 1 BY PASS*SHE WANTED TO LISTEN THIS technique* 2 fill the canal till the broken file.
 If you perforated the furcation area which materials you should put in the perforated area?
MTA + CALCIUM HYDROXIDE
 What do you know about the MTA?
preserve the tooth structures and prevent tooth resorption, it usually creating an apical plug in apexification,
repairing root perforation, and treating internal root resorption and can be used as both a root end filling and
pulp capping materials
 WHAT IS THE MOST USED IRRIGATION SOLUTION?
sodium hypochlorite
 What is the most imp features and the percentage and time of using sodium hypochlorite and EDTA?? And
irrigation sequence?
1-sodium hypochlorite 5.25% - for its anti-bacterial effect at least 5 min
2-EDTA 17% 1min - to remove organic structures
3-sodium hypochlorite 5.25%
4-sterile water - neutralize the effect of these irrigants
5-use 2% chloroxidine from 5 to 10 min - elimination of various bacteria
 After you reach the MAF what you should do?
one bigger size file = enter the file 1mm less
 What is the treatment of traumatic teeth?
It depends about the traumatic type, I explained it in the next pages.
 What is temporary filling materials in RCT?
first CALCIUM HYDROXIDE then cotton roll then cement
 Why we used cotton roll between the medication and temporary filling?
to not mix the medication with cement
 What is the permanent filling materials after rct?
A: intracanal: gutta percha, then sealer * calcium hydroxide* in the pulp chamber, then composite
 What are the pulp zone?
1. Odontoblast zone
2. Cell free zone
3. Cell rich zone
4. Pulp
 How to know the fistula from which tooth?
we enter gutta percha to fistula and take x-ray and see where the gutta percha it means this is the tooth
 What is the chemical proprieties of calcium hydroxide?
1- As intracanal dressing is antibacterial, because of its high ph, and it absorbs co2 that is necessary for
anaerobic bacteria, and it also has anti-inflammatory effect
2-as capping material it makes a layer of necrosis on the surface of the pulp which stimulate the formation of
secondary dentin.
 Why we use calcium hydroxide?
Because of high ph*12.5* and its antimicrobial activity, resorn ph which is the source of anaerobic bacteria,
prevent tooth resorption, tissue dissolve ability.
 How many days should calcium hydroxide be left in the canal?
7 days
 How we remove calcium hydroxide from root canal?
By manual irrigation using sodium hypochlorite combined with hand instrumentation with final rinse of EDTA.
 How many visits should root canal treatment finish? When we finish it in one visit?
Standard rct should be done in 2 visits, we can finish it when there is extensive crown fracture and need to do
post and core for esthetic goals, when there is a sealing and isolation problems.
 What are the materials that use for irrigation?
Mentioned above. then we dry and fill
 How to diagnose periodontitis?
Should have pain by percussion and palpation.
 What you will do if pus come out of the cavity?
We should put calcium hydroxide and wait for 1 hour if it does not stop, we put calcium hydroxide again and
wait 2 days then continue the normal treatment.
 Treatment of acute apical periodontitis and acute apical abscess.
First we should remove the source of infection if there were spreading of infection (swelling or cellulitis) we
should use systemic antibiotic, then we treat it by incision for drainage and root canal treatment with good
irrigation and cleaning or extraction to remove the source of infection and clean the socket.
 What size abscess should be drained?
if it less than 5 mm it can resolve itself by using warm compress or antibiotic therapy, but if it is bigger than 5
mm then we should drain it.
 When do we use antibiotics?
A: 1) Treatment of infection in periapical region
2) prophylaxis use penicillin as first choice, if there is allergic of penicillin using metronidazole.

1)Treatment of an infection in periapical region:

-only pain, localized swelling, symptomatic pulpitis, chronic apical abscess(drainage from the sinus tract)
-antibiotics are only used as adjuncts to treatment with RCT & drainage
-in the presence of clinical manifestations suggesting the possibility of (systemic spread of the infection) or in
the presence of (widespread and unhealed infections)
-systemic symptoms: 1) fever, chills, chills within 24 hours 2) malaise, tiredness, fatigue, dizziness, rapid
breathing 3) trismus 4) lymphadenopathy 5) cellulitis (non-localized widespread infection in soft tissue)
Acute apical abscess:
-when its associated with diffuse swelling leading to develop cellulitis with infectious process dissemination to
other anatomic spaces, or when its exhibits evidence of systemic involvement such as fever, malaise, regional
lymphadenitis or trismus, antibiotics are necessary as adjuvant treatment to drainage because the patient’s
immune system is incapable of stopping the infection advance.
-antibiotic treatment may be applied in the case of (flare-up) which defines pain and swelling after RCT in
accordance with the criteria stated
-antibiotics are necessary in severe (traumatic injury) cases and after replantation of the (avulsed teeth)
-another condition requiring systemic antibiotics use in periapical (actinomycosis) which is a persistent
periapical infection. In these cases it’s necessary to apply apical surgery with penicillin application.
-if the (sodium hypochlorite solution) used for irrigation in delivered to the periapical region, or if its
accidentally injected instead of the anesthetic solution as a more serious complication, antibiotics should be
given to prevent secondary infection of the tissues, which is likely to become necrotic, in addition, to
emergency procedures.

2) Prophylaxis:
-(transient bacteremia) due to viridans group streptococci
1) manipulation of gingival tissue 2) manipulation of gingival region 3) all dental procedures involving oral
mucosa perforations
-(dental antibiotic prophylaxis) is the administration of antibiotics to a dental patient for prevention of harmful
consequences of bacteremia, that may be caused by invasion of the oral flora into an injured gingival or
periapical vessel during dental treatment
-it’s used to prevent the development of complications such as (infective endocarditis) or (post-surgical
infection) in dentistry
-antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions
associated with the highest risk of adverse outcomes from endocarditis, including:
1) prosthetic cardiac value or prosthetic material used in value repair
2)previous endocarditis
3) congenital heart disease (CHD)
4) cardiac transplantation recipients with cardiac valvular disease
 Which antibiotic? (These factors should be evaluated together)
1) detection of microorganisms 2) the severity of infection 3) general health status of the patient
-endodontic infections are (polymicrobial) and most of these isolated microorganisms are (obligate) or
(facultative anaerobic) bacteria
-(spectrum of the antimicrobial activity) is the range of bacterial types against which the antibiotic is effective
-selection the (narrowest spectrum antibiotics) sensitive to the causative microorganisms
-ideally, pre-treatment specimens should be taken to identify the causative microorganisms by (culture) and to
give the appropriate antibiotic according to the (susceptibility test) result
-takes several days to weeks –we know approximately the microorganisms found in endo infection
-empiric selection of (antibiotic)
-persistent infection → cultivation methods
-preferred antibiotics for endodontic infections:
1) penicillin V
2) amoxicillin
3) clarithromycin or azithromycin
4) metronidazole
5) clindamycin
Tooth Fractures
Enamel Fracture

• A complete fracture of the enamel. Loss of enamel. No visible sign of exposed dentin
• Not tender. If tenderness is observed, evaluate the
• Tooth for a possible luxation or root fracture injury.
• Normal mobility.
• Sensibility pulp test usually positive.
• Enamel loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposures. They are recommended in order
to rule out the possible presence of a root fracture or a luxation injury.
• Radiograph of lip or cheek to search for tooth fragments or foreign materials.

TREATMENT

• If the tooth fragment is available, it can be bonded to the tooth

• Contouring or restoration with composite resin depending on the extent and location of the fracture.
• FOLLOW-UP
• 6-8 weeks – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.

Uncomplicated Crown Fracture (Enamel-Dentin)

• A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or root
fracture injury.
• Normal mobility.
• Sensibility pulp test usually positive.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth displacement or
possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.

TREATMENT

• If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform a provisional treatment
by covering the exposed dentin with glass Ionomer or a more permanent restoration using a bonding
agent and composite resin or other accepted dental restorative materials.
• If the exposed dentin is within 0.5 mm of the pulp (pink, no bleeding), place calcium hydroxide base and
cover with a material such as a glass ionomer.

FOLLOW-UP

• 6-8 weeks – Clinical and radiographic examination.

• 1 year – Clinical and radiographic examination.
Complicated Crown Fracture (Enamel-Dentin-Pulp)

• A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or root
fracture injury.
• Normal mobility.
• Exposed pulp sensitive to stimuli.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth displacement or
possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.

TREATMENT

• In young patients with immature, still developing teeth, it is advantageous to preserve pulp vitality by
pulp capping or partial pulpotomy. Also, this treatment is the choice in young patients with completely
formed teeth.
• Calcium hydroxide is a suitable material to be placed on the pulp wound in such procedures.
• In patients with mature apical development, root canal treatment is usually the treatment of choice,
although pulp capping or partial pulpotomy also may be selected.
• If tooth fragment is available, it can be bonded to the tooth.
• Future treatment for the fractured crown may be restoration with other accepted dental restorative

FOLLOW-UP

• 6-8 weeks – Clinical and radiographic examination.

• 1 year – Clinical and radiographic examination.

CROWN-ROOT FRACTURES

• Crown root fracture involves enamel, dentin and cementum with or without the involvement of pulp
• It is usually oblique in nature involving both crown and root.
• Crown fracture extending below gingival margin
• Percussion test: Tender.
• Coronal fragment mobile.
• Vitality test usually positive
• Apical extension of fracture usually not visible.
• Radiographs recommended: periapical and occlusal exposure.

TREATMENT

• Fragment removal only.

• Fragment removal and gingivectomy (sometimes ostectomy) Removal of the coronal fragment with
subsequent endodontic treatment and restoration with a post-retained crown.
• Orthodontic extrusion of apical fragment
• Surgical extrusion
• Extraction

FOLLOW-UP

• 6-8 weeks – Clinical and radiographic examination.

• 1 year – Clinical and radiographic examination
Root Fractures

• These are uncommon injuries

• Involvement of dentin, cementum, pulp and periodontal ligament
• They form the 3 percent of the total dental injuries.
• The coronal segment may be mobile and may be displaced.
• Tender to percussion.
• Bleeding from the gingival sulcus may be noted.
• Vitality testing may give negative results initially, indicating transient or permanent neural damage
• The fracture involves the root of the tooth and is in a horizontal or oblique plane.
• Fractures that are in the horizontal plane can usually be detected in the regular periapical 90o angle film
with the central beam through the tooth. This is usually the case with fractures in the cervical third of the
root.
• CBCT  Useful

TREATMENT

• Reposition, if displaced, the coronal segment of the tooth as soon as possible.

• Check position radiographically.
• Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the
tooth, stabilization is beneficial for a longer period of time (up to 4 months).
• It is advisable to monitor healing for at least 1 year to determine pulpal status.
• If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is
indicated to preserve the tooth.

FOLLOW-UP

• 4 weeks – Splint removal, clinical and radiographic examination.

• 6-8 weeks – Clinical and radiographic examination.
• 4 months – Splint removal in cervical third fractures, clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
• 5 years – Clinical and radiographic examination.

PROGNOSIS

• Healing with calcified tissue in which fractured fragments are in close contact.
• Healing with interproximal connective tissue in which radiographically fragments appear separated by a
radiolucent line.
• Healing with interproximal bone and connective tissues.
• Interproximal inflammatory tissue without healing,
• radiographically it shows widening of fracture line
Classification (Andreasen, WHO, International Association of Dental Traumatology)
Luxation Injuries (Periodontal Tissue Injuries)

• Tooth concussion
• Subluxation
• Extrusive luxation (Extrusion)
• Lateral luxation
• Intrusive luxation (Intrusion)
• Avulsion

Concussion

• The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility.
• Tooth is not displaced.
• Mobility is not present
• Tooth is tender to percussion because of edema and hemorrhage in the periodontal ligament.
• No radiographic abnormalities.

TREATMENT

• No treatment is needed.
• Monitor pulpal condition for at least one year.

FOLLOW-UP

• 4 weeks – Clinical and radiographic examination.

• 6-8 weeks – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination

Subluxation

• The tooth is tender to touch or tapping and has increased mobility; it has not been displaced.
• Bleeding from gingival crevice may be noted.
• Sensibility testing may be negative initially indicating transient pulpal damage.
• Monitor pulpal response until a definitive pulpal diagnosis can be made.
• No radiographic abnormalities.

TREATMENT

• Normally no treatment is needed, however, a flexible splint to stabilize the tooth for patient comfort can
be used for up to 2 weeks.

FOLLOW-UP

• 2 weeks – Splint removal, clinical and radiographic examination.

• 4 weeks – Clinical and radiographic examination.
• 6-8 weeks – Clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
Extrusion

• The tooth appears elongated and is excessively mobile.

• Sensibility tests will likely give negative results.
• Increased periodontal ligament space apically.

TREATMENT

• Reposition the tooth by gently reinserting it into the tooth socket.

• Stabilize the tooth for 2 weeks using a flexible splint.
• In mature teeth where pulp necrosis is anticipated, or if several signs and symptoms indicate that the pulp
of mature or immature teeth is becoming necrotic, root canal treatment is indicated.

FOLLOW-UP

• 2 weeks – Splint removal, clinical and radiographic examination.

• 4 weeks – Clinical and radiographic examination.
• 6-8 weeks – Clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination yearly.
• 5 years – Clinical and radiographic examination

Lateral luxation

• The tooth is displaced, usually in a palatal/lingual or labial direction.

• It will be immobile and percussion usually gives a high, metallic (ankylotic) sound.
• Fracture of the alveolar process present.
• Sensibility tests will likely give negative results.
• The widened periodontal ligament space is best seen on eccentric or occlusal exposures.

TREATMENT

• Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it
into its original location.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Monitor the pulpal condition.
• If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.

FOLLOW-UP

• 2 weeks – Clinical and radiographic examination.

• 4 weeks – Splint removal, clinical and radiographic examination.
• 6-8 weeks – Clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
• Yearly for 5 years – Clinical and radiographic examination.
Intrusion

• The tooth is displaced axially into the alveolar bone.

• It is immobile and percussion may give a high, metallic (ankylotic) sound.
• Sensibility tests will likely give negative results.
• The periodontal ligament space may be absent from all or part of the root.
• The cemento-enamel junction is located more apically in the intruded tooth than in adjacent non-injured
teeth, at times even apical to the marginal bone level.

TREATMENT

Teeth with incomplete root formation:

• Allow eruption without intervention.

• If no movement within few weeks, initiate orthodontic repositioning.
• If the tooth is intruded more than 7 mm, reposition surgically or orthodontically.

Teeth with complete root formation:

• Allow eruption without intervention if the tooth is intruded less than 3 mm. If no movement after 2-4
weeks, reposition surgically or orthodontically before ankyloses can develop.
• If the tooth is intruded 3-7 mm, reposition surgically or orthodontically.

Teeth with complete root formation:

• If the tooth is intruded beyond 7 mm, reposition surgically.

• The pulp will likely become necrotic in teeth with complete root formation. Root canal therapy using a
temporary filling with calcium hydroxide is recommended and treatment should begin 2-3 weeks after
repositioning.
• Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a flexible splint
for 4 weeks.

FOLLOW-UP

• 2 weeks – Clinical and radiographic examination.

• 4 weeks – Splint removal, clinical and radiographic examination.
• 6-8 weeks – Clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
• Yearly for 5 years – Clinical and radiographic examination.
Avulsion

• It is defined as complete displacement of the tooth out of socket.

First aid for avulsed teeth

• Keep the patient calm.

• Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
• If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try to
encourage the patient/parent to replant the tooth. Bite on a handkerchief to hold it in position.
• If this is not possible, place the tooth in a suitable storage medium, e.g. A glass of milk or a special
storage media for avulsed teeth if available (e.g. Hanks balanced storage medium or saline). The
tooth can also be transported in the mouth, keeping it between the molars and the inside of the cheek. If
the patient is very young, he/she could swallow the tooth- therefore it is advisable to get the patient to
spit in a container and place the tooth in it.
• Seek emergency dental treatment immediately.

Closed Apex:
(IF 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 amoxicillin, 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.
• 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.
CLOSE APEX (IF 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 amoxicillin, 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.
• 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
cannot 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 ankyloses 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,
• 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. Reposition it with a suitable instrument.
• 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

• 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 immediately 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
AVULSION:
Factors affecting the success of reimplantation:

1. Periodontal ligament
2. Extraoral time
3. Transportation
4. Splinting
5. Root Canal Treatment Timing
6. Calcium Hydroxide Therapy
7. Fluoride Application

PROGNOSIS:

1. Periodontal ligament healing

2. Surface resorption
3. Replacement resorption (ankylosis)
4. Inflammatory resorption

Storage media for avulsed tooth (from the best to the worst)

1. In its own socket

2. Hank’s Balance Salt Solution
3. Milk
4. Saline
5. Intraorally
6. Saliva
7. Tap Water
8. Dry