PDF: Treatment guidelines for avulsed permanent teeth

The choice of treatment is related to the maturity of the root (open or closed apex) and the condition of the periodontal ligament (PDL) cells.

The condition of the PDL cells is dependent on the time out of the mouth and on the storage medium in which the avulsed tooth was kept. Minimizing the dry time is critical for survival of the PDL cells.

After an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable. 

For this reason, information regarding the dry time of the tooth prior to replantation or prior to being placed in a storage medium is very important to obtain as part of the history.

From a clinical point of view, it is important for the clinician to assess the condition of the PDL cells by classifying the avulsed tooth into one of the following three groups before commencing treatment: 

1. The PDL cells are most likely viable. The tooth has been replanted immediately or within a very short time (about 15 minutes) at the place of accident. 

2. The PDL cells may be viable but compromised. The tooth has been kept in a storage medium (eg, milk, HBSS (Save-a-Tooth or similar product), saliva, or saline, and the total extra-oral dry time has been <60 minutes).

3. The PDL cells are likely to be non-viable. The total extra-oral dry time has been more than 60 minutes, regardless of the tooth having been stored in a medium or not.

These three groups provide guidance to the dentist on the prognosis of the tooth. Although exceptions to the prognosis do occur, the treatment will not change, but may guide the dentist's treatment decisions. 

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