Paediatric Dentistry Uk1999

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Published by theDental Practice Board

for England and Wales

Paediatric Dentistry - UK

National Clinical Guidelines and Policy Documents 1999


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WHY CLINICAL GUIDELINES?

THE PROCESS OF NATIONAL CLINICAL GUIDELINE PRODUCTION

SECTION 1

Paediatric Dentistry Clinical Guidelines - RCS approved - i.e. Multi-disciplinary Faculty of

Dental Surgery of the Royal College of Surgeons of England approved Guidelines already

published in International Journal of Paediatric Dentistry

1. Prevention of Dental Caries in Children

2. Treatment of Avulsed Permanent Teeth in Children

3. Treatment of Traumatically Intruded Permanent Incisor Teeth in Children

4. Continuing Oral Care - Review and Recall

5. Management and Root Canal Treatment of Non-vital Immature Permanent Incisor Teeth

SECTION 2

Paediatric Dentistry Clinical Guidelines - RCS approved - i.e. Multi-disciplinary FDS approved

Guidelines not yet published in International Journal of Paediatric Dentistry

1. Diagnosis and Prevention of Dental Erosion

2. Stainless Steel Pre-Formed Crowns For Primary Molars

3. Management of the Stained Fissure in the First Permanent Molar

4. The Pulp Treatment of the Primary Dentition

SECTION 3

British Society of Paediatric Dentistry Policy Documents

Definition

1. Sugars and the Dental Health of Children (1992)

2. Toothfriendly Sweets (1995)

3. Sedation for Paediatric Dentistry (1996)

4. Fluoride Dietary Supplements and Fluoride Toothpastes for Children (1996)

5. Dental Needs of Children (1997)

Front cover: pictures 2, 3 and 4 (left to right) courtesy of the Health Education Authority.

CONTENTS


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Why Clinical Guidelines?

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T he purpose of Clinical Guidelines is to improve the effectiveness and efficiency ofclinical care through the identification of good clinical practice and desired clinical

outcomes.

The Guidelines are statements intended to assist clinicians in making decisions about

appropriate management of specific conditions.

This publication,produced by the Faculty of Dental Surgery Paediatric Dentistry Clinical

Effectiveness Committee, contains nine guidelines in selected topics related to Paediatric

Dentistry.

The aim has been to produce Guidelines which deal with commonly encountered clinical

situations and make recommendations on their management. In many areas of practice

there is a shortage of reliable research data, so that while some recommendations are

supported by robust data,others are made with a lesser degree of confidence, and may

represent only best current practice.

It is hoped that these Guidelines, produced by experts who have reviewed the available

evidence, will be welcomed by clinicians and encourage interest in providing the highest

possible standards of care. An anticipated benefit is that shortage of data will be

highlighted, so stimulating research aimed at improving the scientific foundation of our

clinical activity.

It will be important to refine the existing Guidelines as further information becomes

available, and the intention is to add to the number of guidelines in future publications.

John Williams

Chairman of Faculty of Dental Surgery Clinical Effectiveness Committee.


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THE PROCESS OF NATIONAL CLINICALGUIDELINE PRODUCTION

In 1994 the Department of Health requested the Royal College of Surgeons toproduce National Clinical Guidelines. The Faculty of Dental Surgery delegated this

task to the respective Clinical Audit Committees in each of the Dental disciplines of:-

q ORAL AND MAXILLOFACIAL SURGERY q ORTHODONTICS q PAEDIATRIC DENTISTRY

q RESTORATIVE DENTISTRY q DENTAL PUBLIC HEALTH

Draft authors were asked to review the scientific literature on selected topics and produce a draftguideline which was then circulated to an Expert Panel for comment and opinion.Expert panels variedaccording to the subject of the guideline and consisted of individuals who were identified as having aparticular expertise in that subject.

A final Guideline was eventually produced which was assessed, according to the Scottish IntercollegiateGuideline Network (SIGN) classification,as to whether it was based on proven scientific evidence orcurrently accepted good clinical practice with limited scientific evidence (see table below).

Levels of Evidence

Level Type of evidence

Ia Evidence obtained from meta-analysis or randomised control trials

Ib Evidence from at least one randomised control trial

IIa Evidence obtained from at least one well designed control study without randomisation

IIb Evidence obtained from at least one other type of well designed quasi-experimental study

III Evidence obtained from well designed non-experimental descriptive studies, such ascomparative studies, correlation studies and case control studies

IV Evidence from expert committee reports or opinions and/or clinical experience ofrespected authorities

Grading of Recommendations

Grade Recommendations

Requires at least one randomised controlled trial as part(Evidence levels Ia, Ib) of the body of the literature of overall good quality and consistency

addressing the specific recommendations

(Evidence levels Requires availability of well conducted clinical studies but noIIa, IIb, III) randomised clinical trials on the topic of recommendation

Requires evidence from expert committee reports or opinions(Evidence level IV) and/or clinical experience of respected authorities. Indicates

absence of directly applicable studies of good quality.


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Additional Clinical Considerations

& References

Diagnosis & Management

Explanatorynotes

Discussion &References

Diagnosis&

Management

Follow-up

Management

Where applicable each guideline consists of threebroad sections.The first section is a series ofrecommendations for diagnosis andmanagement. Each recommendation is gradedaccording to the SIGN classification and is clearlymarked in the margin - A, B or C.

The second section contains explanatory notesrelating to the evolution of theserecommendations.

The third section contains references andcomments to assist further research into the

subject.

It should be understood that a Clinical

Guideline is intended to assist theclinician in the management of

patients in an effective and efficient

way. It is not intended to restrict clinicalfreedom in the management of an

individual case.

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SECTION 1

Paediatric Dentistry Clinical Guidelines - RCSapproved - ie Multi-disciplinary FDS approvedGuidelines already published in InternationalJournal of Paediatric Dentistry.

1. Prevention of Dental Caries in Children - Draft Author L Shaw.

2. Treatment of Avulsed Permanent Teeth in Children - Draft Authors T A Gregg and

D H Boyd

3. Treatment of Traumatically Intruded Permanent Incisor Teeth in Children -

Draft Author M J Kinirons.

4. Continuing Oral Care - Review and Recall - Draft Author P J Crawford.

5. Management and Root Canal Treatment of Non-vital Immature PermanentIncisor Teeth - Draft Author I Mackie.


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PREVENTION OF DENTAL CARIES IN CHILDREN

INTRODUCTION

Although children are at risk from conditions affect-ing both dental and soft-tissues, by far the common-est of these in childhood is dental caries,therefore,these guidelines consider the preventionof dental caries which is a multifactorial disease.Prevention requires a multifactorial approachincluding dietary factors and eating habits, the useof appropriate fluoride therapy, the application offissure sealants and the implementation of effectiveoral hygiene.

MANAGEMENT

1. Indications for Preventive TherapyPreventive dental care is important for all children

and adults but there are certain circumstanceswhich are indicative of increased risks ofdisease or its consequences.(See table 1.)

1.1 General factors

1.1.1 Low socio-economic group1

1.1.2 Medically compromised patients2, at riskfrom caries and its sequelae

1.1.3 Children with special needs, includinglearning difficulties

1.1.4 Children on long term medicationcontaining sugar3

1.2 Local factors

1.2.1 Evidence of past caries experience

1.2.2 Greater than 3 sugary intakes per day -greater than 10 per cent of energy from non-milkextrinsic sugar consumption4

1.2.3 Poor oral hygiene

1.2.4 Lower salivary flow

1.2.5 Orthodontic appliance therapy

2. Preventive Therapy Methods andTechniques

2.1 Dietary Control

Recommendations:

2.1.1 For at risk children, a 3 - 4 day dietary diaryshould be completed and discussed.

2.1.2 Give dietary counselling which is specific tothe child and family, based on the dietary diary.

2.1.3 Set limited, obtainable targets initially.

2.1.4 Monitor compliance.

2.1.5 Infants should not be left to sleep with abottle containing sugary liquids or those with a lowpH which may also cause erosion. Prolonged useof feeding bottles should be avoided. Fruitflavoured sugar containing drinks should be limitedto meal-times. Thirsty children will drink water.8

2.1.6 Educate the public,particularly throughschool health education programmes about theknown association between frequent consumptionof sugars and dental caries.

2.1.7 Support future research and education topromote balanced diets and the use of sugars inmoderation.

2.1.8 Paediatric medicines should be sugar free.

2.1.9 Prolonged breast feeding should bediscouraged.

2.2 Fluoride Therapy

Recommendations:

2.2.1 Water FluoridationOptimal fluoride in drinking water supplies remainsthe cornerstone of any preventive dentistry strategy.

2.2.2 Fluoride ToothpasteAll children should regularly use a correctlyformulated fluoride toothpaste according to the

manufacturers and dentists instructions.To reducethe risk of opacities, children under the age of 6years and considered to be at low risk of developingdental caries should use a toothpaste containing nomore than 600 ppm of fluoride. Those with ahigher risk of developing caries should use astandard (1000 ppm) paste.10

Children over the age of 6 years should beencouraged to use a standard (1000 ppm) or higher(1450 ppm) fluoride level paste.11

Toothpastes accredited by the British DentalAssociation should be recommended.11

Children under 6 years should use an amount of

toothpaste no greater than a small pea.11

An adult should supervise the amount of toothpasteused and tooth brushing technique,up to at least 7or 8 years.11

Toothpaste packaging must include clear labelling toindicate the amount of fluoride present, expressedconsistently as ppmF.

2.2.3 Fluoride SupplementsFor children at risk of dental caries (see table 1)dietary fluoride supplements should be considered.The small potential risk of mild enamel opacitiesmay be outweighed by the benefits of fluoridesupplements.7

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When fluoride is given as tablets, these should beallowed to dissolve slowly in the mouth in order togive a topical as well as a systemic effect. Theyshould preferably be given at a time separated fromtoothbrushing to help to reduce the peaks offluoride ingestion and to maximise the topicaleffect.

For children living in an area where there is nomore than 0.3 ppm fluoride in the drinking water,the currently recommended dosage schedule shouldbe used (as of 1995).11

2.2.4 Professionally applied topical fluoridetreatmentTopical fluoride varnishes are of proven benefit inpreventing caries and in helping to arrest caries inchildren with nursing bottle caries and cervicaldecalcification. These are highly concentratedvehicles for fluoride and the recommended dosemust not be exceeded.9,12

Other forms of professionally applied fluoride gels(1.23 per cent acidulated phosphate fluoride APF)and solutions (8 per cent stannous fluoride) arerecommended by some authorities6 but have beenshown to be of poor cost benefit,9,12 althoughclinically beneficial.Children at high caries riskshould be considered for application of topicalfluorides twice yearly.

2.2.5 Self or parent-applied fluoride for childrenat high caries risk.

Home fluoride treatments using mouthrinses can berecommended for daily use in children over 6years.

If a high caries risk patient cannot comply withhome fluoride therapy then frequent professionalfluoride treatments should be substituted.

2.3 Fissure sealants.

Recommendations:

2.3.1 Patient selectionChildren with special needs are a priority for theuse of fissure sealants.They should be consideredfor those who are medically compromised,physically or dentally disabled,together with thosehaving learning difficulties or those fromsocio-economically disadvantaged backgrounds.

Children with extensive caries in their primary teethshould have all permanent molars sealed as soon aspossible after eruption.

Children with caries free primary dentitions andwho do not fall into one of the categoriesabove do not need to have first permanent molarssealed routinely.

2.3.2 Tooth selectionFissure sealants have greatest benefit on the occlusalsurfaces of permanent molar teeth.However, othersurfaces with pits,particularly the buccal pits inlower molars and cingulum pits in upper incisors,should also be considered.

Fissure sealing of primary molars is not normallyadvised.Sealants should usually be applied as soon as theteeth have erupted sufficiently to permitmoisture control.

Any child with occlusal caries in one firstpermanent molar should have the other molarssealed. Occlusal caries affecting one or more firstmolars indicates a need for the secondpermanent molars to be sealed.

2.3.3 Clinical circumstancesWhen there is doubt about the integrity of anocclusal surface on clinical examination abite-wing radiograph should be taken.

If early dentine involvement is suspected the fissureshould be investigated using small burs. If minimalcaries is discovered, a composite resin restorationshould be placed and the whole surface sealed.

If extensive caries is discovered a moreconventional occlusal restoration should be placed.

2.3.4 Long term follow upSealed teeth should be monitored clinically atappropriate intervals supported by radiographs.Defective sealants should be investigated andre-sealed if appropriate.

Fissure sealants need to be maintained and this mustbe explained to parents.

2.4 Oral Hygiene

Recommendations:

2.4.1 Toothbrushing skills should be taught tochildren of all ages. The precise technique is lessimportant than the effectiveness of removal ofplaque, the use of disclosing tablets or liquids ishelpful.

2.4.2 Use of a fluoride toothpaste with effectivetoothbrushing is important (see 2.2.2).

2.4.3 Parents should supervise toothbrushing.

EXPLANATORY NOTES

2.1 The Committee on Medical Aspects of FoodPolicy has validated the relationship betweensugar and dental caries in the clearest terms.5

This has been reinforced by reports such as theScientific Basis of Dental Health Education andthe Oral Health Strategy for England.7

Children who have already experienced dentalcaries or who are at risk from the consequences ofdental caries should have a dietary diarycompleted over a 3 to 4 day period. Analysis ofthis should enable dietary counselling to be givenwhich is specific and matched to the needs andcircumstances of the child and family.Non-sugar sweeteners are safe for teeth and usefulsubstitutes for sugar when it is not possible to

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discourage a liking for sweetness. They are notpermitted for use in foods and drinks for infants.

2.2 The use of fluorides for the prevention andcontrol of dental caries is documented to be bothsafe and highly effective. Optimising fluoride inwater supplies is an ideal public health measurebecause it is effective, relatively inexpensive, is notsocially divisive and does not require consciousdaily co-operation from individuals.9

In many areas of the UK, however, failure toimplement this measure means that fluorideneeds to be supplied as a dietary supplement, asfluoride toothpaste, and in children at risk ofdeveloping dental caries, as topical applications.

There has been some concern regarding enamelmottling and the ingestion of fluorides. It must bemade clear that it is the misuse, rather than theuse, of such fluoride agents as toothpastes andsupplements which consti tutes the main fluorosis

risk.

2.3 The British Society of Paediatric Dentistrypublished revised guidelines on the use of fissuresealants in 1993.13 First and second molar teethcontinue to be the most caries susceptiblepermanent teeth with the pattern of caries nowprincipally involving the pits and fissures.

The decision to carry out fissure sealants shouldbe made on clinical grounds, based on a thoroughclinical examination of both the child and his/herteeth, supported by radiographs where appropriateand taking into consideration the patientsco-operation, medical history, past cariesexperience and the family environment.

2.4 The achievement and maintenance of highlevels of oral hygiene are particularly importantas far as a healthy periodontium is concerned.There is little scientific evidence to support thetheory that toothbrushing per se will preventdental caries, as normal brushing inevitablyleaves some plaque in fissures and otherstagnation sites where caries occurs. However, theuse of a fluoride toothpaste with the toothbrush isobviously of benefit.Children cannot cleaneffectively until they are able to undertake suchtasks as writing their own names legibly. Untilthis time parents should clean their childs teeth.

REFERENCES

1. OBrien M 1994 Childrens DentalHealth in the United Kingdom 1993.London: Office of Population,Censuses and Surveys.1994.

2. Moore R S and Hobson P 1989, 1990A classification of medicallyhandicapping conditions and the healthrisks they present in the dentalcare of children. Journal of Paediatric DentistryPart 1 5:73-83 Part 2 6:1-14.

3. Maguire A and Rugg-Gunn A J 1994Medicines in liquid and syrup form usedlong-term in Paediatrics: a survey in theNorthern region of England.International Journal of Paediatric Dentistry4:93-99.

4. Department of Health. Weaning andthe weaning diet. HMSO London 1984.

5. Department of Health. DietarySugars and Human Disease. Committee onMedical Aspects of Food Policy. Report on Healthand Social Subjects 37 London HMSO 1989.

6. The Scientific Basis of Dental HealthEducation. A Policy Document.Health Education Authority Fourth Edition,1996.

7. An Oral Health Strategy for England.Department of Health. HMSO. London 1994.

8. Department of Health. Present daypractice and infant feeding: Thirdreport HMSO. London 1988.

9. American Board of PaediatricDentistry 1994 Special Issue Reference Manual16:7-27.

10. Rock W P 1994 Young children andfluoride toothpaste. British Dental Journal177:17-20.

11. British Society of PaediatricDentistry: Fluoride Dietary Supplementsand Fluoride Toothpastes for Children.1996 International Journal of Paediatric

Dentistry.

12. Murray J J, Rugg-Gunn A J andJenkins G N 1991 Fluorides in cariesprevention. 3rd edition published byButterworth-Heinemann 179-208.

13. British Society of PaediatricDentistry A policy document on fissuresealants 1993. International Journal ofPaediatric Dentistry 3:99-100.

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Table 1 FACTORS THAT AFFECT THE LEVEL OF CARIES RISK IN CHILDREN

LOW RISK HIGH RISK

GENERAL

Social Mothers education: Mothers education: secondary only

secondary, tertiary

Good attendance pattern Poor attendance pattern

Family:nuclear, social Family:single parent, social class IIIM,

class I, II, IIINM,employment IV,V, unemployment

General health Good health Poor health/chronically sick

No sugar-containing medication Medication containing sugar

LOCAL

Oral hygiene Good oral hygiene, Poor oral hygiene,

regular brushing irregular brushing

twice per day with assistance without assistance

Diet 3 sugary intakes per day 3 sugary intakes per day

Fluoride Regular brushing with Irregular use of fluoride

experience fluoride toothpaste toothpaste

Optimally fluoridated water No fluoridated water supply

Past caries dmft 1, DMFT 1 dmft 5,DMFT 5

experience

No initial lesions 10 initial lesions

Caries free first permanent Caries in first permanent molars at

molars at 6 - 8 years of age 6 years of age

3 year caries increment 3 3 year caries increment 3

Orthodontic

Treatment No appliance therapy Fixed appliance therapy

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TREATMENT OF AVULSED PERMANENT TEETH INCHILDREN

INTRODUCTION

The following guidelines are intended to assist inthe management and treatment of avulsed teeth inchildren. They should be used by practitioners incombination with their own professional judge-ment.Although it is impossible to guarantee a goodlong term prognosis or permanent retention of atooth which has been re-implanted following avul-sion, timely treatment of the tooth in the appropri-ate manner maximises the chance of success.Further detail is available under ExplanatoryNotes.

INITIAL MANAGEMENT

1. Management at Site of Accident

1.1 If telephone advice is sought, andre-implantation is appropriate (see AdditionalConsiderations) advise re-implantation of the toothimmediately. If the tooth is contaminated,rinse inmilk or tap water prior to re-implantation. Thetooth may be held in place by gently biting on aclean folded handkerchief until splinting can becarried out. Advise to attend a dental surgeonimmediately.

1.2 If immediate re-implantation is not possible,place tooth in a vessel containing suitable storagemedium - in order of preference:

cold fresh milknormal salinesaliva (in buccal sulcus)

Advise to attend a dental surgeon immediately.

2. Initial Management by DentalSurgeon

2.1 HistoryDuring examination place tooth in cold fresh milkor normal saline to prevent unnecessary drying.Elicit careful medical, dental and accident history,clearly written. Be alert to concomitant injuryincluding head injury,facial fracture or lacerations.

Seek medical examination as necessary. Avoidunnecessary delay before re-implantation.

2.2 Re-implantationReplant as soon as possible if re-implantation isappropriate (see Additional Considerations). Localanaesthesia is required if there is alveolar fractureand manipulation is required. Local anaesthetic isalso preferable in some cases to enable accurate re-implantation but it is still possible to re-implant atooth if patient compliance prevents the administra-tion of local anaesthetic.Preparation of socket - avoid unnecessary manipula-tion. If clot is present gently irrigate socket withsaline in syringe and use suction to remove clot, butavoid curettage.

Handling of tooth - handle by crown NOT root. Donot scrape or scrub root surface. If contaminatedwash in normal saline, and only if necessary gentlydab with gauze soaked in saline to remove stubborndebris.

If alveolar bone fragments prevent re-implantationwithdraw tooth and replace in saline. Introduce ablunt instrument into the socket to reposition bone,and once again attempt re-implantation.

DO NOT COMMENCE ROOT CANAL TREATMENTPRIOR TO RE-IMPLANTATION except in specialcircumstances - see 4.4 Additional Considerations.

2.3 SplintingSplint to adjacent teeth non-rigidly for 7-10 days.Acid etch/resin either alone or in combination with

soft arch wire is most commonly recommended,however other types such as a removable acrylicsplint or orthodontic brackets and wire are alsoacceptable.

All patients should be reviewed followingre-implantation within 48 hours, at which time thesplint is checked and modified if necessary.

Home care advice during splinting includes avoid-ance of biting on splinted teeth,consumptionof a soft diet, and maintenance of good oral hygieneby tooth brushing and rinsing with chlorhexidinemouthwash.

If excessive mobility persists after ten days replace

splint until mobility acceptable.

2.4 Antibiotics and TetanusPrescribe appropriate systemic antibiotics tocommence as soon as possible. A tetanus boostermay be required if environmental contamination hasoccurred. If in doubt refer to physician within 48hours.

3. Follow-up Management by DentalSurgeon

3.1 Endodontic Treatment - Open apex teeth inyoung patients - short extra-oral timeIn open apex teeth in young patients when thetooth has been out of the socket for a short period

only it is acceptable to delay endodontic interven-tion to allow for the possibility of pulprevascularisation.

Review in two weeks then at three to four weekintervals; at review look for clinical signs of non-vitality (tenderness, tooth discolouration,swelling/sinus), test vitality and take intra-oralradiograph.If clinical and radiographic signs of non-vitality develop commence endodontic treatment.Thorough mechanical cleansing of the canal isessential regardless of which dressings are used.Clean canal mechanically and fill with calciumhydroxide. An antibacterial intra-canal dressing maybe placed for one to two weeks prior to placementof calcium hydroxide to help to ensure that the

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canal is free from infection. If calcium hydroxide isused alone then this should be placed no soonerthan 7 days following re-implantation. The accesscavity should be temporarily sealed with fast settingzinc oxide and eugenol or glass ionomer cement.Calcium hydroxide is left inside the canal untilapexification has occurred. Regular clinical andradiographic review is necessary. It may benecessary to place fresh calcium hydroxide iffollow-up radiographs reveal that there are voids inthe existing calcium hydroxide root canal dressing.Some authorities recommend renewing the calciumhydroxide root canal dressing every 3 months butthis is not proven to be absolutely necessary.

3.2 Endodontic Treatment - All other teethCommence endodontic treatment in all teeth withclosed or almost closed apex regardless of extra-oraltime and open apex teeth with prolonged extra-oraltime.

Remove pulp as soon as tooth stable enough for

access cavity to be prepared - ideally within 10 days.If an acid etch/resin splint has been used endodon-tic treatment can be commenced prior to itsremoval.

Thorough mechanical cleansing of the canal isessential regardless of which dressings are used.Clean canal mechanically and fill with calciumhydroxide. An antibacterial intra-canal dressing maybe placed for one to two weeks prior to placementof calcium hydroxide to help to ensure that thecanal is free from infection. If calcium hydroxide isused alone then this should be placed no soonerthan 7 days following re-implantation. The accesscavity should be temporarily sealed with fast settingzinc oxide and eugenol or glass ionomer cement.

Calcium hydroxide is left inside the canal for a peri-od of 6 - 12 months before final obturation withgutta percha. Regular clinical and radiographicreview is necessary. It may be necessary to placefresh calcium hydroxide if follow-up radiographsreveal that there are voids in the existing calciumhydroxide root canal dressing. Some authoritiesrecommend renewing the calcium hydroxide rootcanal dressing every 3 months but this is not provento be absolutely necessary.

4. Additional Considerations

4.1 When NOT to replant - in most casesre-implantation of an avulsed tooth is the besttreatment.However, in a few cases re-implantation isnot appropriate. These are as follows:q Primary toothq Where other injuries are severe and warrant

preferential emergency treatment/intensive careq Where medical history indicates that the patient

would be put at r isk by re-implantation of a toothq Where an immature permanent tooth with a

short root and wide open apex is involved, andthe extra-oral time is extremely prolonged, theprognosis is very poor.

In many of these cases re-implantation may not bewarranted (see explanatory notes 4.1).

4.2 Replanted permanent teeth require follow-upevaluation for a minimum of 2 - 3 years to deter-

mine outcome. Inflammatory resorption,replacement resorption, ankylosis, infraocclusion,and discolouration are all potential complicationswhich may occur. If progressive resorption occursprosthetic assessment,and/or orthodontic assess-ment may be required.

4.3 At follow up visits adjacent teeth should alsobe examined as these may have been damaged as aresult of the same accident and should not be over-looked.

4.4 In cases of extremely prolonged periods ofextra-oral time in teeth with closed apices, where anundesirable storage medium has been used (i.e. tapwater, or dry storage) a different method of treat-ment has been suggested. The treatment involvescomplete removal of the periodontal membrane andimmersion of the tooth in a fluoride solution. Asfurther drying and handling of the tooth root isunlikely to worsen the prognosis in such a case,some authors suggest that endodontic treatmentmay be completed extra-orally beforere-implantation.

4.5 Some recent articles have suggested soaking ofavulsed teeth in a pH balanced solution prior to re-implantation to reconstitute periodontal ligamentcells. Further,it has been suggested that soaking ofavulsed teeth in an antibiotic solution prior to re-implantation improves the prognosis and may bemore effective than systemic antibiotics. Thesesuggestions remain controversial.

EXPLANATORY NOTES

The incidence of traumatic avulsion of teeth hasbeen reported as 0.5 - 16 per cent of all trauma-tised teeth.1, 2 Upper central incisor teeth are mostfrequently avulsed, and in the age group 7 - 9years.1,3. It has long been recognised that it ispossible to replant a tooth following avulsion, andthat replanted teeth may function for many years.Andreasen found in monkeys that, under idealconditions, complete healing of the pulp andperiodontal ligament of replanted teeth can occur.1

However such conditions do not occur in the reallife situation and healing of replanted teeth issubject to complications. The main complicationis that of root resorption which is related tonecrosis of part or all of the periodontal ligamentand may be further complicated by necrosis of thepulp and/or infection. Although the damagecaused directly by the injury is beyond the controlof the clinician, the provision of appropriatetreatment both immediately and upon reviewimproves the prognosis of replanted teeth.

1.1 The period between tooth avulsion and re-implantation is normally outwith the control of adentist but this period is important with regard tothe prognosis of the tooth. It has been reportedthat the length of time that a tooth spends out ofthe mouth influences the development of rootresorption and pulpal healing. Andreasen andHjorting-Hansen found that 90 per cent of teethreplanted within 30 minutes did not develop rootw

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resorption when reviewed at an interval rangingbetween 1 - 13 years, however this much quotedfinding was based on 10 teeth and as such thereporting of this as a percentage may be mislead-ing.4Andersson and Bodin found that teethreplanted within 15 minutes following theavulsion have a favourable long term prognosis,and furthermore that most of the teeth with noresorption had been replanted within 10minutes.5 Andersson, Bodin and Sorensenconcluded that teeth replanted after 60 minuteswould become ankylosed and resorbed within 3 -7 years in young patients whereas a tooth replant-ed under similar conditions in older patientsmight remain in function for a considerablylonger time.6 However Mackie and Worthingtonfound no significant relationship between the timethat the avulsed tooth was out of the mouth androot resorption.7 In terms of pulpal healingAndreasen et al found that the liklihood ofpulpal revascularisation was reduced as the extra-oral dry time increased, and similarly with storagein a moist medium for longer than 5 minutes.8

1.2 The medium in which the tooth has beenstored prior to re-implantation has been shown toaffect the incidence of root resorption and pulphealing. Prolonged drying of the root presents theworst prognosis because of loss of vitality of theperiodontal ligament9, 10, 11 and dehydration of thepulp.8Ideally the tooth should be re-implanted intothe socket as soon as possible, but in cases wherethis cannot be carried out, maintaining the rootin a moist environment has been shown toimprove the prognosis. However storage in tapwater has been demonstrated to be an unsatisfac-tory medium.9 A critical period of dry storage hasbeen reported to be between 18 and 30 minutes

after which a marked increase in root resorptionis seen.12 Cold fresh milk appears to be the bestmedium for storage of the tooth during trans-portation to a dentist13 although alternatives suchas saliva, blood, saline and an emergency toothpreserving system have all been suggested.14 Theemergency tooth preserving system contains apH-balanced cell reconstitution fluid called HanksSolution. Recent U.S.A. literature has found thatavulsed teeth soaked in this solution prior to re-implantation suffer less resorption.15 Also,increased pulp revascularisation has been claimedfollowing soaking of avulsed teeth in a 5 per centdoxycycline solution prior to re-implantation.16

2.1 As with all cases of trauma it is essential to

record details of the accident clearly in writingbecause of the possibility of legal action on thepart of the patient. A thorough history should betaken and examination should exclude facialfracture. Mucosal lacerations may require sutur-ing. The parent/carers should be alerted to besuspicious of any subsequent dizziness, neck pain,amnesia, headache or symptoms of head injury.If there are symptoms of head injury a medicalassessment should be arranged immediately.

2.2 The handling of the tooth prior to re-implan-tation is highly important to avoid further dam-age to the periodontal membrane.1 Therefore dur-ing examination of the patient prior to re-implan-

tation the tooth should be placed in a safe place inmilk or saline. Re-implantation of a tooth may becarried out without local anaesthesia, especially ifpresentation to the dentist is soon after avulsion,and a soft blood clot only is present. In manycases local anaesthetic is desirable to enableadequate socket preparation and positioning ofthe tooth. If there is a clot present in the socketthis can be washed out with a syringe and salineand an aspirator. It is not desirable to curette thesocket as this will cause further damage to orremoval of the periodontal ligament cells whichremain in the socket.

A past favoured method of treatment involved car-rying out root canal treatment of avulsed teethprior to re-implantation. In most cases thismethod of treatment is no longer acceptable as itimparts a poorer prognosis because of increaseddamage to the periodontal ligament cells byprolonged drying and handling. It is alsodesirable to maintain a patent root canal as avehicle for application of medicaments to reduceinfection and/or resorption. However, in a fewspecial cases it may be acceptable to completeendodontic treatment prior to re-implantation -see section 4. Additional Considerations.

2.3 It has been suggested that minimising thetime duration of splinting and using a non-rigidsplint will improve the outcome of the re-implant-ed tooth and reduced the occurrence of ankylosis.8,17,18There are a number of suitable types of non-rigid splint19,20,21,22 which will depend on thefacilities available. Care must be taken in applica-tion i.e. avoid impinging on gingivae or creatingareas of stagnation. The immediate splint is oftenplaced in an emergency situation and requires to

be simple but effective. In such cases a reviewappointment should be arranged ideally within 48hours of the accident. At this review the splintshould be checked and if necessary modified orremoved and replaced.

2.4 It has been suggested that the provision ofsystemic antibiotics reduces the occurrence of rootresorption and in particular inflammatoryresorption if taken promptly.23, 24 In cases ofenvironmental contamination a tetanus boostermay be required.

3.1 Early removal of the pulp has been advocatedas this will prevent the production of inflam-matory products by a necrotic pulp, and thus

minimise the chance of inflammatory resorption.25

Although the advice regarding teeth with a wideopen apex is to delay endodontic treatment on thebasis that revascularisation of the pulp ispossible1, this involves a risk of failure due toinflammatory root resorption26, and cliniciansmust be aware of the consequences of tooconservative an approach. Inflammatoryresorption appears to occur more rapidly in youngpatients and the proposed reason for this is thatthe dentine tubules, which have not yet becomeless patent as is the case with advancing age,readily transmit inflammatory products from thepulp to the root surface.27 Therefore it isproposed only to delay endodontic treatment in

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those cases where the apex is wide open and thetooth has been re-implanted promptly. In caseswhere delay of endodontic treatment has beenchosen, the clinician must carry out careful reviewof the patient so that pulp removal can be carriedout at the first sign of inflammatory resorption.All other re-implanted teeth should have endodon-tic treatment. Pulp removal as soon as the tooth isstable enough for an access cavity to be preparedis advisable, and ideally within 10 days. It maybe helpful to do this prior to removal of the splint.A past favoured method of treatment involved car-rying out root canal treatment of avulsed teethprior to re-implantation. This method of treatmentis no longer acceptable as it imparts a poorerprognosis because of increased damage to the peri-odontal ligament cells by prolonged drying andhandling. It is also desirable to maintain a patentroot canal as a vehicle for application of medica-ments which may help to reduce infection and/orresorption. However, in only a few special cases itmay be acceptable to complete endodontic treat-ment prior to re-implantation - see section 4.Additional Considerations.

3.2 Use of an intra-canal medicament has beenadvocated as this has been shown to reduce theoccurrence of root resorption.23, 24Inflammatoryresorption may be arrested by endodontic treat-ment which removes the source of inflammation,but ankylosis may still occur because ofirreversible damage to the periodontal ligament.27

The high pH of calcium hydroxide renders it bacte-riostatic and therefore a suitable intra-canal dress-ing where inflammatory resorption has occurred.It may be that placing calcium hydroxide in theroot canal encourages healing1, however there isno conclusive evidence regarding this and some

authors have shown that presence of calciumhydroxide in the root canal may in some circum-stances increase the occurrence of ankylosis.28, 29

Also, in experimentally induced inflammatoryresorption placement of an intra-canal antibioticand corticosteroid paste was found to eliminatethe inflammatory resorption.30 Some authoritiesrecommend the use of an intra-canal polyantibiot-ic paste used containing neomycin sulphate,polymyxin B sulphate, nystatin, polyethylene glycol1300 and polyethylene glycol 1500. This is alsoacceptable. If an antibiotic dressing is used thisshould be replaced by calcium hydroxide after aperiod of 1 - 2 weeks. If calcium hydroxide isplaced as the sole dressing this should not beplaced until the tooth has been replanted for over7 days as insertion of calcium hydroxide anysooner than this can in fact cause damage to thehealing periodontal ligament.1,31 Different authorshave suggested varied periods of placement of cal-cium hydroxide. Some suggest that in closedapices early obturation with gutta percha is asacceptable as delaying this until calcium hydrox-ide has been placed for several months.32 Althoughthis is controversial, most still advise the latter,therefore it is recommended that calcium hydrox-ide should be left in the root canal for 6 to12months before obturation, and changed duringthis time if indicated. An indication to replacewith fresh calcium hydroxide would be if radi-ographically there was no evidence of any

material present in the root canal, or if there arevoids in the existing dressing. Some authoritiesrecommend renewing the calcium hydroxide rootcanal dressing every 3 months but this is notproven to be absolutely necessary. As well aspreventing inflammatory resorption, calciumhydroxide stimulates apexification in open apexcases. No matter which medicaments are used itis of the greatest importance that the root canal isthoroughly mechanically cleansed.

4.1 Although in many cases a replanted toothsurvives only a matter of years, during this periodit serves as a natural space maintainer whilstgrowth occurs, and also enables alveolar height tobe preserved.Therefore in most cases re-implanta-tion of an avulsed tooth is the best treatment.However, in certain instances of excessivelyprolonged extra-oral time/poor storage medium,or where the tooth is grossly carious/ general oralcondition is poor, or patient co-operation is poor, aclinician may judge that re-implantation is better

not to be attempted. In a few cases re-implanta-tion is clearly not appropriate. These are asfollows:

Primary teeth - these should not be replantedbecause of the possibility of damage to anunderlying developing permanent tooth.

Other injuries - where other injuries are severeand require preferential emergency treatment orintensive care.

Medical history - avulsed teeth should not bereplanted in cases where to do so would place thepatient at risk. For example, patients withdepressed immunity as in acute lymphoblastic

leukaemia who are at risk from infection. It maybe possible in some cases to safely re-implant teethin such individuals but this should only be carriedout in liaison with the specialist physician incharge of their medical care, and a follow-upreview and treatment regime must be strictlyadhered to.

Immature permanent tooth with short root, wideopen apex and prolonged dry extra-oral time - ifthe dry extra-oral time is long then replacementresorption is inevitable. As replacement resorptionoccurs at a higher rate in a young person, andthese teeth already have a short root, the prognosisis very poor. In most of these cases reimplant-ation is not warranted, however in some cases

one may feel that for psychological reasons it isworth replanting even though the tooth will onlylast for a short time.

4.2 Inflammatory resorption may be detected asearly as two weeks post-re-implantation.1

Radiographically inflammatory resorption ischaracterised by loss of root surface accompaniedby loss of adjacent bone and an area ofradiolucency. Clinically a tooth withinflammatory resorption may be mobile andtender.

Replacement resorption may be diagnosed withintwo months of re-implantation, however


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frequently is not detected until more than 6months have elapsed.1 Radiographically replace-ment resorption is characterised by loss of rootsurface with loss of periodontal ligament spaceand lamina dura, and bone is seen to be in directcontact with the root surface. Clinically the toothhas no physiological mobility and may give ahigh note on percussion. If no form of resorptionhas been detected in the first two years followingre-implantation then the risk of root resorptionoccurring is considerably reduced.1 Successivevisits for radiographs to identify root resorptionare required so that any necessary plans may bemade for prosthetic replacement of the toothshould its loss become inevitable.

4.3 It is necessary at follow up visits to examineadjacent teeth which may also have suffereddamage as a result of the same accident andshould not be overlooked. They should beexamined for signs and symptoms of loss ofvitality.

4.4 In cases of extremely prolonged periods ofextra-oral time in teeth with closed apices, wherean undesirable storage medium has been used(i.e. tap water, or dry storage) a different methodof treatment has been suggested.1,15,33 In suchcircumstances of delay and poor storage,replacement resorption is inevitable as few or noperiodontal ligament cells remain viable, and assuch treatment is aimed to retard the resorptiveprocess. The treatment involves complete removalof the periodontal membrane and immersion ofthe tooth in a fluoride solution. The fluorideincorporated in the root surface is thought toretard replacement resorption. As further dryingand handling of the tooth root is unlikely to

worsen the prognosis in such a case, some authorssuggest that under these circumstances endodontictreatment may be completed extra-orally beforere-implantation.1,33

4.5 Some recent articles have suggested soaking ofavulsed teeth in a pH balanced solution prior tore-implantation to reconstitute periodontalligament cells.15 Also, increased pulp revascularisa-tion has been claimed following soaking ofavulsed teeth in a 5 per cent doxycycline solutionprior to re-implantation. 16

REFERENCES

1. Andreasen J O, Andreasen F M.Textbook and Colour Atlas of TraumaticInjuries to the Teeth. Copenhagen:Munksgaard 1994.

2. Incidence of dentoalveolar injuries inhospital emergency room patients. Luz JG, Di Mase F. Endodontics and DentalTraumatology 1994;10: 188-190.

3. Replantation of 400 avulsedpermanent incisors. 1. Diagnosis ofhealing complications. Andreasen J O,Borum M K, Jacobsen H L, Andreasen FM. Endodontics and Dental Traumatology 1995; 11:51-58.

4. Replantation of teeth. Radiographicand clinical study of 110 human teethreplanted after accidental loss.Andreasen J O, Hjorting-Hansen E. ActaOdontoligica Scandinavia 1966; 24: 263-286.

5. Avulsed human teeth replantedwithin 15 minutes - a long term clinicalfollow-up study. Andersson L, Bodin I.Endodontics and Dental Traumatology 1990; 6: 37-42.

6. Progression of root resorptionfollowing replantation of human teethafter extended extra-oral storage.Andersson L, Bodin I, Sorensen S.Endodontics and Dental Traumatology 1989; 5: 38-47.

7. An investigation of replantation oftraumatically avulsed permanent incisorteeth. Mackie I C, Worthington H V.British Dental Journal 1992;172: 17.

8. Replantation of 400 avulsedpermanent incisors. 2. Factors relatedto pulpal healing. Andreasen J O,Borum M K, Jacobsen H L, AndreasenFM. Endodontics and Dental Traumatology 1995;11: 59-68.

9. The effect of drying on viability ofperiodontal membrane. Soder P O,Otteskog P, Andreasen J O, Modeer T.Scandinavian Journal of Dental Research 1977;85:164-168.

10. Effect of extra-alveolar period andstorage media upon periodontal and pul-pal healing after replantation of maturepermanent incisors in monkeys.Andreasen J O. International Journal of Oralsurgery 1981;10: 43-53.

11. Replantation of 400 avulsedpermanent incisors. 4. Factors relatedto periodontal ligament healing.Andreasen J O, Borum M K, Jacobsen HL, Andreasen F M. Endodontics and DentalTraumatology 1995;11: 76-89.

12. Influence of osmolality andcomposition of some storage media on

human periodontal ligament cells.Lindskog S, Blomlof l.Acta OdontoligicaScandinavia 1982;40: 435-441.

13. Storage of experimentally avulsedteeth in milk prior to replantation.Blomlof L, Lindskog S, Andersson L,Hedstrom K-G, Hammarstrom L.Journal ofDental Research 1983; 62: 912-916.

14. The treatment of avulsed teeth.Krasner P R. Journal of Paediatric Health Care1990;4(2): 86-90.

15. Modern Treatment of Avulsed Teeth

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by Emergency Physicians. Krasner P.American Journal of Emergency Medicine 1994;12(2): 241-246.

16. Effect of Topical Application ofDoxycycline on pulp revascularisationand periodontal healing in reimplantedmonkey incisors. Cvek M, Cleaton-JonesP, Austin J, et al. Endodontics and DentalTraumatology 1990;6: 170-176.

17. The effect of splinting uponperiodontal healing after replantation ofpermanent incisors in monkeys.Andreasen J O. Acta Odontologica Scandinavia1975;33: 313-323.

18. Cellular colonisation of denudedroot surfaces in viv. Linskog S, BlomlofL, Hammarstrom L.Journal of ClinicalPeriodontology.

19. Stabilising appliances for trauma-tised incisors. Stewart D J. British DentalJournal 1963; 115: 416-418.

20. Removable appliances in thestabilisation of traumatised anteriorteeth - a preliminary report. Saunders ID F. Proc British Paedodontic Society 1972;2:19-22.

21. Use of histoacryl tissue adhesive tomanage an avulsed tooth. McCabe M J.British Medical Journal 1990; 301: 20-21.

22. Emergency treatment of avulsedteeth. Roberts G J. British Medical Journal1990;301: 386-387. (letter)

23. Antibiotics and Endodontics.Abbott P V, Hume W R, Pearman J W.Australian Dental Journal 1990; 35(1): 50-60.

24. Replantation of teeth and antibiotictreatment. Hammarstrom L, Blomlof L,Feiglin B, Andersson L, Lindskog S.Endodontics and Dental Traumatology 1986;2:51-57.

25. Treatment of fractured and avulsedteeth. Andreasen J O.Journal of Dentistry forChildren 1971; 38: 29-31,45-48.

26. Rate and predictability of pulprevascularisation in therapeuticallyreimplanted permanent incisors. KlingM, Cvek M, Mejare I. Endodontics and DentalTraumatology 1986;2: 83-89.

27. Tooth Avulsion and Replantation - Areview. Hammarstrom L, Blomlof L,Feiglin B, Lindskog S. Endodontics and DentalTraumatology 1986; 2: 1-18.

28. Effect of immediate calciumhydroxide treatment and permanent rootfilling on periodontal healing in

contaminated replanted teeth.Lengheden A, Blomlof L, Lindskog S.Scandinavian Journal of Dental Research 1990;99:139-146.

29. Effect of delayed calcium hydroxidetreatment on periodontal healing incontaminated replanted teeth.Lengheden A, Blomlof L, Lindskog S.Scandinavian Journal of Dental Research 1991;99:147-153.

30. The effect of anantibiotic/corticosteroid paste oninflammatory root resorption in vivo.Pierce A. Oral Surgery, Oral Medicine and OralPathology 1987;64: 216-220.

31. Andreasen J and Kristerson L. Theeffect of extra-alveolar root filling withcalcium hydroxide on periodontalhealing after replantation of permanent

incisors in monkeys. Journal of Endodontics1981;7: 349-354.

32. Evaluation of long term calciumhydroxide treatment in avulsed teeth- anin vivo study. Dumsha T, Houland E J.International Endodontic Journal 1995; 28: 7-11.

33. Replantation of avulsed permanentteeth with avital periodontal ligaments:case report. Duggal M S, Russell J L,Patterson S A. Endodontics and DentalTraumatology 1994;10: 282-285.


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INTRODUCTION

There is a lack of general agreement and scientificevidence concerning the best treatment for traumat-ically intruded permanent teeth in children.Although these injuries may be very severe, theyoccur relatively rarely and this factor has made itdifficult to determine the most appropriatetreatment for these injuries.

The following guidelines are intended to be of assis-tance to practitioners who may be involved in themanagement of such cases. It is difficult to predictthe long term prognosis for these injuries as theyare frequently of a severe nature but the appropriatedecisions and treatments can minimise the chancesof difficult complications and consequent loss ofteeth. Further details are available under

Explanatory Notes.

DIAGNOSIS AND MANAGEMENT

1. History and ExaminationA careful medical and dental history should beobtained along with details of the accident and theyshould be carefully recorded. A large degree offorce is required to severely intrude permanentincisor teeth. One should be alert to the possibilityof other injuries, including injuries to the head andfacial region.

In the established dentition, diagnosis is based on adifference in the position of the incisal edges of

affected and unaffected teeth while in the mixeddentition a high metallic note on percussion isindicative of intrusion or lateral luxation.Radiographic examination is needed and may revealdifferences in apical levels, alveolar fractures orsigns of damage to adjacent teeth.

2. TreatmentExtra-oral and intra-oral lacerations and woundsshould be cleaned and sutured as appropriate.Systemic antibiotic treatment and tetanus boostingmay be required if external contamination hasoccured. Decisions regarding treatment varyaccording to the severity of intrusion and whetherthe tooth has a complete or incomplete root. Theaim of treatment is that the tooth be maintained ifpossible, but very severe injuries may require toothextraction in some circumstances.

2.1 Repositioning of teeth with incomplete Apex

2.1.1 Mildly intruded (less than 3mm) incisorswith incomplete apexThese teeth can normally be managed conservative-ly due to their excellent eruptive potential. Leave tore-erupt and review.

2.1.2 Moderately intruded (3-6 mm) incisorswith incomplete apexThese teeth may re-erupt if managed conservatively.Alternatively these teeth may be orthodontically

repositioned by bonding an orthodontic bracket totheir labial or incisal region depending on accessand isolation, and by applying a sufficient force toextrude the tooth to its normal position in approxi-mately 2 weeks. The relative benefits of either treat-ment is unproven scientifically and treatment choiceis by clinical judgment and preference.

2.1.3 Severely intruded (greater than 6mm)incisors with incomplete apexIn this case the alveolus is grossly dilated labiallyand occasionally fractured and there is often severesoft tissue displacement and the crown may becompletely buried. In this instance orthodonticrepositioning is difficult or impossible.Consideration should be given to surgicallyrepositioning the tooth. The childs level ofco-operation should be taken into consideration.

When possible local anaesthesia should be adminis-tered and the tooth should be gently repositioned.Repositioning can normally be accomplished byvery gentle movements using sterile flat plasticinstruments. In resistant cases consider the possibil-ity of bony impaction and release of theimpediment prior to repositioning of the labial plateof bone and soft tissue closure and suturing.

In some cases sedation or even general anaesthesiamay be necessary. If in doubt consider gettingadvice from,or referring to, a specialist centre.

2.2 Repositioning of teeth with complete Apex

2.2.1 Mildly intruded (less than 3mm) incisor

with complete rootThese teeth may be orthodontically repositionedover a period of approximately 2 weeks.Alternatively conservative management can be used.The relative merits of these two treatments isunproven and treatment choice is by personalpreference.

2.2.2 Moderately intruded (3-6mm) incisor withcomplete rootThese teeth should be repositioned orthodontically.

2.2.3 Severely intruded (greater than 6mm)incisor with complete apexThese teeth may need to be repositioned surgicallyand appropriate tissue repair carried out and this is

best undertaken in a specialist centre.

3. Splinting of Repositioned TeethIntruded teeth that are surgically repositionedrequire appropriate splinting. There are a number oftypes of non rigid splints 1-3 and the choice maydepend on the facilities available and by the difficul-ties imposed by haemorrhage. An intruded shortrooted tooth with severe damage to the alveolarbone may pose special difficulty.The splinted toothshould be out of traumatic occlusion. In all cases areview appointment should be arranged, ideallywithin five days of the accident. At this review thesplint should be checked and modified if necessary.In line with other forms of severe subluxation,

TREATMENT OF TRAUMATICALLY INTRUDEDPERMANENT INCISOR TEETH IN CHILDREN

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splinting for these injuries would normally varyfrom 1 week to 2 weeks. Splinting for longerperiods with rigid splints should normally be avoid-ed as this may increase the risk of ankylosis.4 Thebenefit of antibiotic treatment is unproven and theiruse is governed by clinical judgment andpreference.

4. Follow-Up Management

4.1 Root Canal TherapyIn view of the very high risk of loss of pulpalvitality, root canal treatment is often indicated incases of severe intrusion. There is a high risk of rootresorption in these teeth. The optimum time toenter the root canal is approximately 2 weeks afterinjury and following thorough mechanical cleaningand debridement, calcium hydroxide paste shouldbe placed in the canal. In severely intruded teeththis early endodontic treatment is facilitated byrapid repositioning. Placement of calcium

hydroxide in severely intruded teeth may inhibitroot resorption and its use in cases where apicaldevelopment is incomplete, should induce apicalbarrier formation. Maintenance of calcium hydrox-ide paste in the root canals for 6-12 months (withappropriate replacement as required) is advised,prior to the final obturation of the root canal.

These cases should be kept under regular review ona 6 monthly basis with occurrences of rootresorption being noted and managed appropriately.Ankylosis as evidenced by disappearance of theperiodontal space with fusion of root surface andbone and is an unfavourable sign.

EXPLANATORY NOTESThe optimal treatment for intruded permanentteeth is not yet clear.4 Treated cases of intrudedincisor teeth have not been reported frequentlyenough nor with sufficiently high numbers fordefinitive protocols to be developed.5,6 The largestseries were 25 teeth reported from Scandinavia 7,8

and 29 cases reported from Belfast.9 In thesereports there was a high experience of loss ofvitality and there was also a high prevalence ofprogressive root resorption. In addition loss ofmarginal bone support was also cited as acomplication in a significant number of cases.Data on the survival of intruded teeth is scantalthough the Belfast study indicated that 20 out of29 were retained after a 2 year period. The natureof the intrusion injury is somewhat unique. Incases of severe intrusion the degree of bonydilatation and displacement of the labial plate isquite marked and soft tissue tears in thesuperficial gingiva and mucosa are common. Inthe case of the severely intruded and buriedincisor tooth, the degree of movement of the apexand apical vessels is 6mm or more and conse-quently there is a high risk of pulpal necrosis. Inaddition damage to the marginal bone is a riskand marginal bone defects are found to be presentin between a quarter and half of all cases.8,9 Thenature of the crush injury to the periodontalmembrane and root surface is quite severe andprogressive root resorption is commonly seen, the

figures varying from 38 per cent to 52 per cent.8,9

2.1 Teeth with incomplete root development willoften re-erupt spontaneously.4,8,10,11 Some authorsadvocate gingival surgery to provide early accessfor root canal treatment in order to preventdevelopment of infection following pulpalnecrosis.11,12 and they report satisfactoryspontaneous eruption provided periapicalinfection is treated promptly. Orthodontic extru-sion is described as an option where the degree ofintrusion is more substantial.4 Turley et alinvestigated spontaneous re-eruption andorthodontic extrusions as options for experimen-tally intruded permanent teeth in dogs. While lessseverely intruded and mobile teeth responded wellto orthodontic extrusion, deeply embedded teethbecame ankylosed and failed to respond to ortho-dontic extrusion. He suggested that elective luxa-tion and surgical repositioning of ankylosed teethmay facilitate orthodontic extrusion in somecases.13,14 If intruded permanent incisors aremanaged conservatively there is a risk of suchankylosis.

2.2 Traditionally many authors advocate a cau-tious approach and suggest they be allowed tore-erupt6,7 and others suggest that surgical reposi-tioning may increase the risk of loss of marginalbone support.4It is important that the toothshould be sufficiently repositioned within threeweeks to allow treatment of necrotic pulps andthus minimise the risk of inflammatory rootresorption.4,12For mature incisors Andreasenadvocates rapid orthodontic movement of suchteeth over a two to three week period and ifthe crown is completely buried (equivalent to oursevere classification) he suggests partial

repositioning to allow orthodontic bracket fixationand subsequent full repositioning via theorthodontic method.4However the Belfast studyindicated that full surgical repositioning ofseverely intruded teeth was not associated with anincreased experience of root resorption ormarginal sequestration of bone.9 Unlike otherforms of injuries long term prognosis seems to bepositively related to the degree of apical c losureand root development i.e. the best prognosis is seenin teeth where root development is mostcomplete.9

REFERENCES

1. Stewart D J. Stabilising appliancesfor traumatised incisors. Brit Dent J 1963;115:416-418.

2. Saunders I D F. Removableappliances in the stabilisation oftraumatised anterior teeth. Proc.Brit PaedSoc 1972;2: 19-22.

3. McCabe M J. Use of histoacryl tissueadhesive to manage an avulsed tooth.Brit Med J 1990; 301 20-21.

4. Andreasen J O. Traumatic injuries tothe teeth (3rd ed). Copenhagen and

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Philadelphia: Munksgaard, 1995.

5. Ravn J J. Dental injuries inCopenhagen schoolchildren, schoolyears 1967-1972. Community Dent OralEpidemiolo 1974;2: 231-245.

6. Ripa L W, Finn S B. The care ofinjuries to the anterior teeth of children.In Finn SB (ed). Clinical paedodontics (4th ed). Pp224-270. St Louis:C.V. Mosby, 1973.

7. Andreasen J O. Etiology andpathogenesis of traumatic dentalinjuries. Scand J Dent Res 1970;78: 329-342.

8. Andreasen J O. Luxation ofpermanent teeth due to trauma. Scand JDent Res 1970; 78:273-286.

9. Kinirons M J, Sutcliffe J.Traumatically intruded permanentincisors "a study of treatment andoutcome" Brit Dent J 1991;170: 144-146.

10. Spalding P, Fields H, Torney, CobbH, Johnson J. The changing role ofendodontics and orthodontics in themanagement of traumatically intrudedincisors. Paediatr Dent 1985; 7: 104-110.

11. Shapira J, Regev L, Liebfeld H.Re-eruption of completely intrudedimmature permanent incisors. Endod DentTraumatol 1986;2: 113-116.

12. Tronstad L, Trope M, Bank M,Barnett F. Surgical access for

endodontic treatment of intruded teeth.Endod Dent Traumatol 1986; 2: 75-78.

13. Turley P K, Joiner M W, Hellstrom S.The effect of orthodontic extrusion ontraumatically intruded teeth. Am J Orthod1984;85: 47-56.

14. Turley P K, Crawford L B, CarringtonK W. Traumatically intruded teeth. Angle0rthod 1987; 57:234-244.


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INTRODUCTION

Although the commonest oral disease of childhoodis dental caries the dental role should encompassthe whole of oral care for children. The aims ofsuch care are firstly to ensure that all children arefree from pain, sepsis and the destruction of dentaltissues; secondly, to monitor the developingdentition; thirdly, to support children and theirfamilies in forming good oral health habits, practicesand behaviours which can be carried forward intoadulthood.

This care should be provided for both thosechildren who are able-bodied and those who haveimpairment,be they physical, mental, medical, socialor emotional.

The cornerstone of preventive care is professionalsupervision. Continuing care, review and recall arean essential part of that supervision and these guide-lines should be read in conjunction with other such,relating to particular items.

Review is defined as an attendance at a furtherappointment within a course of treatment.

Recall is defined as the planned,unprecipitatedreturn of a patient who,when last seen was in goodoral health.

MANAGEMENT

1. Review and recall frequency

Recommendations:1.1 In initiating the continuing care process, thereshould be no lower age limit to the first visit for achild which should, if possible, be within the firstyear of life.

1.2 There is considerable debate,with little factualbasis, regarding the cost benefit of a specified recallperiod. There is such variation in the circumstancespertaining to an individual child that social, ratherthan medical, conventions probably have a greaterimportance in setting such a standard. In this con-text, there should be a recall at least once a year;6months is a convenient interval which provides forcontinuity of care. A proportion of child patients,for whom underlying conditions make additionaldemands, or local disease is progressing rapidly, willneed to be seen at intervals far shorter than this atthe clinicians discretion.

2. Variations in recall frequency

Recommendations:

2.1 Milestones in dental development (e.g. theexpected eruption of particular primary and perma-nent teeth, the detection of displaced permanentcanine teeth) should trigger recall in children underregular care. There is merit in the concept ofspecific age milestonesat 3, 6, 9 and 12 years.

2.2 Particular attention should be paid to theeruptive sequence of teeth,especially with regard tosymmetry,or whether an individual tooth is morethan 6 months delayed.

2.3Where a child shows obvious signs of activeoral disease or its predisposing factors - a high levelof individual or family previous decay experience,poor oral hygiene,enamel demineralisation, highsugar intake - review at not greater than four-month-ly intervals is required until the factors arecontrolled.

2.4 Specific oral conditions (e.g.periodontaldisease, other soft tissue disease,eruptive disorders,developmental dental conditions, dental injuries)will require attendance at variable intervals.Readers are referred to the guidelines for thosespecific conditions.

2.5 Compromised children should be seen onreview or recall at intervals directly related to theseverity of their underlying impairment and the oralfindings.

3. The nature of the review and recallprocesses

Recommendations:

3.1 Wherever possible, recall and review should beto the same clinician.

3.2 Recall or review should give adequate time toestablish child confidence and compliance, to

update findings and to reinforce preventiveinstruction where required.

3.3 Records should be maintained in astandardised manner and stored in a recoverableform to make comparison easy and realistic.

EXPLANATORY NOTES2. Children inevitably change in stature, in psycheand in what they eat and drink throughout thefifteen years from infancy to adolescence. Specificsocial, medical, oral or dental conditions willmodify the period of attendance for either reviewor recall. Provision must be made for variationin the frequency of appointments in response tothese pressures. Radiography is of importancein the assessment of disease progress and thereader is referred to the guideline on that subject.

3. Review and recall should give the patient or thecarer both the time and the opportunity topresent any changes in their situation since thelast visit and to discuss the progress of theircondition. It should permit the clinician time tocarry out a clinical examination (sic), todetermine patient compliance with any previousprescription, to make adequate record of progressand to reinforce preventive advice (vide the guide-line Prevention of dental caries for Children).

CONTINUING ORAL CARE - REVIEW AND RECALL

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MANAGEMENT AND ROOT CANAL TREATMENTOF NON-VITAL IMMATURE PERMANENTINCISOR TEETH

1

INTRODUCTION

According to the 1994 Child Dental Health Survey1

children have a one in five chance of traumatisingtheir immature permanent incisor teeth (fordefinition see explanatory note 1).I t is likely that 6per cent of these teeth will become non vital andrequire endodontic treatment,2 the aim of which isto obturate the root canal especially the apical thirdbut not to go through the apex (explanatory note2). However, it has been shown that root canaltreatment of these teeth is seldom of an adequatestandard. Indeed a recent report from the NW ofEngland showed that 92 per cent of root treatedpermanent incisor teeth in children and adolescentswere considered to be unsatisfactory.3

The successful management of non vital immature

incisor teeth requires accurate diagnosis,appropriate emergency treatment, a meticulousendodontic technique and regular follow up. It ismandatory to keep good records(explanatory note 3).

1. INITIAL MANAGEMENT

1.1 Diagnosis of non vital immature permanentincisor tooth.

Before commencing endodontic treatment it isessential to determine whether the pulp is non-vital.This diagnosis is based on signs and symptoms,radiographic examination and the results ofsensibility testing. ( These are detailed inexplanatory note 4.) If there is any uncertaintyabout the viability of the pulp, endodontic treatmentshould not be undertaken. The tooth should bereviewed regularly at either 3 or 6 months, and thespecial tests repeated.

1.2 Emergency Visit

Some patients may present as an emergency withpain and/or swelling. Ideally at this first visit thefirst full stage of endodontic treatment should beundertaken (see 1.3.1). However, time constraintsor an acutely tender tooth may necessitate emer-gency measures. These may include:-

- prescription of antibiotics and/or analgesics.

- establishment of drainage through the tooth(see 1.2.1).

- arranging an appointment in 24 - 48 hours.

- sedative dressing (see 1.2.2).

1.2.1 Open drainage

The only justification for leaving a tooth on opendrainage is if pus is discharging out of the accesscavity. In these instances the tooth should be lefton open drainage for not more than 48 hoursbecause superinfection from the oral cavity canexacerbate the problem.

1.2.2 Sedative dressing

If vital tissue is encountered in the root canal andadequate anaesthesia can not be obtained to allowextirpation of the pulp a sedative dressing, such asLedermix, can be sealed into the root canal. At thenext visit local anaesthesia is usually successful,allowing full extirpation of the pulp.

1.3 Clinical Technique

1.3.1 Commencement of root canal treatment -visit 1.

qRubber dam. It is preferable that the airway isprotected with rubber dam. If the tooth has anextensive coronal fracture or is very tender totouch, the split damor troughtechnique can still

be used.

qAccess cavity. This must be of sufficient size toallow instrumentation of the root canal but not beso large that it weakens the tooth at the cervicalarea.

qExtirpation of the pulp. Barbed broaches can beused, often two or more broaches usedsimultaneously are needed to twist and engage thepulp. If there is sensitive tissue in the apical portionof the root local anaesthesia will be required toextirpate the pulp fully.

qEstimation of full working length. The fullworking length, 1-2mm short of the apex, should be

determined.

qPreparation of root canal. Repeated filing intandem with irrigation of the root canal with salineor sodium hypochlorite is required to remove allnecrotic debris. Reamers are of no value inimmature incisor teeth (explanatory note 5).

qDry the root canal. The root canal should bedried to its full working length using paper points.

qRoot canal dressing(explanatory note 6).Calcium hydroxide paste is placed in the dry rootcanal to completely fill it to the apex.A cotton woolpledget in the access cavity is used to compress thepaste to the apex.Seal the access cavity with a

reinforced zinc oxide eugenol or glass ionomercement.

q Other root canal dressing materials (explanatorynote 7).

q Use of disinfectants. Intra canal disinfectantdressings are not needed. Filing, irrigation andfilling of the root canal full with calcium hydroxidepaste is usually sufficient to control infection.

1.3.2 Interim visits - usually the first at one monthand then each 3 months.

qRemove dressing. Remove the cement and cotton


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wool pledget. File and irrigate to remove thecalcium hydroxide paste. Dry the canal.

q Check for apical barrier(explanatory note 8).Paper points placed up to apex are used to checkfor a calcific barrier. Radiographs are not indicatedto check for the presence of a barrier as it can befelt using a paper point. If no barrier is detectedredress root canal with calcium hydroxide paste. Ifa barrier completely closes the apex there is noevidence of periapical pathology or active rootresorption, obturate with gutta percha and sealer.

qLarge periapical radiolucency. If the tooth has alarge periapical radiolucency it is wise to wait untilthere is definite evidence on follow up radiographsof bony healing before the final GP root filling isplaced.

qPersistent infection. Check carefully that the rootcanal is clear of debris and that there is no foreignmaterial such as a cotton wool pledget at the apex.

1.3.3 GP root filling(explanatory note 9). Thismay be accomplished using an appropriate rootcanal sealer,master GP point and lateralcondensation of accessory GP points. If it is seenthat the root canal walls are divergent towards theapex the master GP point can be inverted so thatthe wide end contacts against the apical barrier.After placement of the root filling a checkradiograph is taken immediately. If the root filling isdeficient it must be modified until satisfactory orremoved and repeated.

Some clinicians prefer to fabricate a custom madeGP point by rolling GP points together after heatsoftening. Injection of heated GP may also be

employed.

1.3.4 Final restoration. Remove GP from thecoronal pulp chamber as far as the cemento-enameljunction and fill the access cavity with glassionomer cement. Acid etch composite is used as thefinal seal for the access cavity.

1.3.5 Follow up visits. Check for symptoms. Takea periapical radiograph to check for periapicalpathology. Also check adjacent teeth as they mayhave been damaged in the original trauma.Traumatised teeth should be followed up for 2-3years following the initial trauma. Radiograph at 6monthly intervals for the first two years.

2. Restoration of Tooth

Root filled immature incisor teeth are poorcandidates for posts and/or crowns. Acid etchcomposite and/or veneers are the treatment ofchoice.

3. Periradicular Surgery

Endodontic treatment and root end closure shouldbe attempted before apicectomy. Apicectomyand/or periradicular curettage is the last resortwhen a tooth with a completely satisfactory rootfilling which could not be improved upon by redo-ing the filling,shows a periapical radiolucency

which has increased in size.

4. Success Rate

Apical closure can be expected to occur in over 90per cent of non vital immature incisor teeth treatedby intracanal dressings of calcium hydroxide paste.4,5

The five year success rate is over 85 per cent forteeth with adequate root fillings.6

Failures are usually due to poor root canal therapy,inadequate coronal seal or further trauma of a toothwith an adequate root canal treatment.

EXPLANATORY NOTES

1. Definition of an Immature PermanentIncisor Tooth

An immature permanent incisor tooth is definedas one where the apex can be considered to be

open. Root canal treatment of these teeth requiresa root end closure technique to form a completecalcific barrier at the apex of the tooth, againstwhich a GP root filling can be condensed withoutthe possibility of sealant or GP going through theapex into the periapical tissues.

2. Aim of Root Canal Treatment of Non-vitalImmature Permanent Incisor Teeth

The removal of the necrotic pulp from the toothand control of infection in the root canal. The useof calcium hydroxide paste in the root canal toproduce a calcific barrier to completely occludethe open apex. Placement of a gutta percha rootfilling with sealer to completely obturate the root

canal.

3. Record Keeping

The majority of non vital immature permanentincisor teeth are as a result of trauma. Claimsagainst insurance policies and litigation are onthe increase. It is therefore important thataccurate records are made of the history,examination, diagnostic tests and treatment givenin case of future legal action.

4. Diagnosis of Non-vital ImmaturePermanent Incisor Teeth

Diagnosis of the status of the pulp in previouslytraumatised incisor teeth can often be difficult.There can be a very real diagnostic dilemma. Thenerve supply to the tooth may have been damagedbut the pulp can still be alive because it has avital blood supply. This has been demonstrated inlaser doppler studies, where the pulp has beenshown to be healthy but the tooth has notresponded to traditional sensibility tests.7

Therefore, before embarking on root canaltreatment of immature permanent incisor teeththe operator has to be certain that the pulp isnecrotic. A negative response to traditional vitalitytests must not be the sole reason for opening up apulp chamber. The operator needs to consider the

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history (including previous episodes of trauma)together with all the symptoms, signs and specialtest results:-

4.1 Previous Trauma.History: Treatment.

4.2 Symptoms. History of pulpitis.Continuous pain.Tooth tender to bite on.Tooth loose.Swelling.

4.3 Signs. Swelling.Sinus.Crown darkening in colour.Increased mobility.Tooth tender to pressure.

4.4 Sensibility tests.Ethyl chloride.Electric pulp test.Hot GP.

4.5 Radiographs. Periapical radiolucency.Arrest of root developmentwhen compared withantimere.

If there is doubt about the status of the pulp it isunwise to drill a test cavity in the palatal surfaceof the tooth. It is more appropriate to leave thetooth and reassess it at review.

5. Preparation of the Root Canal

Files are the instruments of choice. The rootcanals of immature incisor teeth are usually ovoidin shape and have thin root walls. The aim is to

clean the root canal walls of debris, not to shapethe root canal. Thus reamers are not indicated.

Filing should be carried out with caution toprevent excessive removal of dentine from the thinroot canal walls. In addition, the files should notpass through the open apex into the apical area soas to avoid damaging any healthy apical tissues.

Filing should be alternated with copious irrigationto wash out the debris. The recommendedirrigants are either saline or sodium hypochlorite.If sodium hypochlorite is used care must be takenso that it does not go into the apical tissues, andthe final irrigation of the root canal should bewith saline so as to remove any hypochlorite from

the root canal.

6. Root Canal Dressing

The dry root canal should be filled with a calciumhydroxide paste.8,9,10 The aim here is to fill the rootcanal completely with the paste. After introducingthe paste into the root canal a lentulo spiral fillerset to the full working length can be used to spinthe paste up the root canal to the apical area.

When the canal is full of paste a cotton woolpledget is gently placed into the access cavity tocompress the paste against the apical tissues. Thepledget is left in the coronal portion of the pulp

3

chamber to act as a dry base onto which thetemporary seal can be placed into the accesscavity. This could be a reinforced zinc oxideeugenol dressing or glass ionomer cement.

7. Other Root Canal Dressing Materials

Other root canal dressing materials have beenadvocated. Polyantibiotic pastes,11 variousantiseptics12 and disinfectants have beenrecommended to control infection in the rootcanal but the scientific evidence to back up theiruse is lacking.

8. Check for Apical Barrier

Paper points can be gently advanced along a dryroot canal. When the apex is reached the paperpoint will either impact against a solid barrier orpress onto soft granulation tissue.

If a barrier is present the paper point can betapped against the barrier and the patient will notfeel it. The paper point end will remain dry.

If the barrier is not yet formed the paper pointwill press against soft spongy granulation tissueand this will be felt by the patient. The end of thepaper point will be wet with tissue fluid or blood.The root canal should be redressed with calciumhydroxide paste and left for a further 3 months.

The average time to achieve apical closure is 6months entailing 3 visits.13

9. Root Filling Techniques

The aim of the root filling is to completely

obturate the root canal. Instead of the lateralcondensation of GP points other methods of fillingthe root canal with gutta percha may beemployed, these include constructing a custom GPpoint14 or use of one of the heated gutta perchatechniques. The method to be employed will bedependent upon operator preference andexpertise.

REFERENCES

1. OBrien M. Children's dental health inthe United Kingdom 1993. London: Office ofPopulation Consensus and Surveys,1994.

2. Andreasen J O, Andreasen F M.Textbook and colour atlas of traumaticinjuries to the teeth. Copenhagen:Munksgaard, 1994.

3. Hamilton F A. An investigation intotreatment services for traumatic injuriesto the teeth of adolescents. PhD Thesis.University of Manchester, 1994.

4. Mackie I C, Bentley E M, WorthingtonH V. The closure of open apices in non-vital immature incisor teeth. Br Dent J1988;165: 169-173.


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5. Yates J A. Barrier formation time innon-vital teeth with open apices. IntEndod J 1988; 21:313-319.

6. Mackie I C, Worthington H V, Hill F J.A follow up study of incisor teeth whichhad been treated by apical closure androot filling. Br Dent J 1993; 175:99-101.

7. Gazelius B, Olgart L, Edwall B.Restored vitality in luxated teethassessed by laser doppler flowmeter.Endod and Traumatal 1988; 4: 265-268.

8. Cvek M. Treatment of non-vitalpermanent incisors with calciumhydroxide. 1. Follow-up of periapicalrepair and apical closure of immatureroots. Odont Rev 1972;23: 27-44.

9. Ghose L J, Baghdady V S, Hikmat B YM. Apexification of immature apices of

pulpless permanent anterior teeth withcalcium hydroxide. J Endod 1987; 13: 285-290.

10. Kleier D J, Barr E S. A study ofendodontically apexified teeth. EndodDent Traumatol 1991; 7: 112-117.

11. Winter G B. Endodontic therapy oftraumatised teeth in children. Int Dent J1977;27: 252-262.

12. Andreasen J O. Traumatic injuriesof the teeth. Copenhagen: Munksgaard, 1981.

13. Mackie I C, Hill F J, Worthington H V.Comparison of two calcium hydroxide

pastes used for endodontic treatment ofnon-vital immature incisor teeth. EndodDent Traumatol 1994;10: 88-90.

14. Stewart D J. Root canal therapy inincisor teeth with open apices. Br Dent J1963;114: 249-254.


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SECTION 2

Paediatric Dentistry Clinical Guidelines - RCSapproved - ie Multi-disciplinary FDS approvedGuidelines not yet published in InternationalJournal of Paediatric Dentistry.

1. Diagnosis and Prevention of Dental Erosion - Draft Authors L Shaw and E OSullivan.

2. Stainless Steel Pre-formed Crowns for Primary Molars - Draft Author S A Fayle.

3. Management of the Stained Fissure in the First Permanent Molar -

Draft Author J Smallridge.

4. The Pulp Treatment of the Primary Dentition - Draft Author D R Lewellyn.

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DIAGNOSIS AND PREVENTION OF DENTAL EROSION

INTRODUCTION

Tooth wear is becoming more commonlyrecognised in both adults and children. The triad ofattrition, abrasion and erosion has been known formany years, but the contribution of erosion to toothsurface loss may be increasing. Dental erosion is theirreversible loss of dental hard tissue due to achemical process not involving bacteria, and notdirectly associated with mechanical or traumaticfactors, or with dental caries. It is,however, fair tosay that erosion usually co-exists with attrition andabrasion, but that one of these three factors is oftenmore significant than the other two. Although thereare no longitudinal studies on the prevalence ofdental erosion, the UK Child Dental Health Surveyof 1993 showed that 52 per cent of 5 year olds hadsignificant erosion1.

The following guidelines are intended to be ofassistance to practitioners in the diagnosis andmanagement of erosion in children and youngpeople. This may be complex and requireinterdisciplinary long term treatment and liaisonwith physicians. Further details are available underExplanatory Notes.

AETIOLOGY

It is essential that the aetiology of erosion isidentified as the clinical management of the patientis based on management of the aetiological factorsbefore definitive restorative care is undertaken.Erosion is undoubtedly a multifactorial process but

the pattern of tooth tissue loss may give some cluesas to the most important of the aetiological factors.All acids, whether from within the body or fromexternal sources,are capable of de-mineralisingtooth tissue and therefore of causing erosion.

1. Intrinsic Acidic SourcesThese are essentially of gastric acid origin and enterthe mouth from gastric reflux, vomiting orrumination.

1.1 Gastric RefluxGastro-oesophageal reflux is more common thanpreviously thought 2,3,4 (see Table 1).

Table 1

Principal Causes of Gastro-Oesophageal Reflux

Sphincter incompetence - Oesophagitis - alcohol- Hiatus hernia- Pregnancy- Diet- Drugs e.g. Diazepam- Neuromuscular e.g.Cerebral Palsy

Increased gastric pressure - Obesity- Pregnancy- Ascites

Increased gastric volume - After meals- Obstruction- Spasm

1.2 Vomiting

Vomiting may be spontaneous or self induced andmay be associated with a variety of medicalproblems. (See Table 2 for the principal causes.)Current estimates suggest that the prevalence ofanorexia and bulimia nervosa is increasing.

1.3 Rumination

This is an uncommon condition in which peopledeliberately induce reflux of a small amount of theirgastric contents and chew this before re-swallowing.Several case reports have been published.5

2. Extrinsic Acid Sources

2.1 Environmental

Various sources of contact with acids as part ofwork or leisure activities have been reported.6

2.2 Dietary

Much emphasis has been placed on healthy foodand drink in recent years and there is now goodevidence that dietary practices and habits arechanging.7 This is particularly the case in relation tothe consumption of soft drinks8with a considerableincrease in quantity and change in age distribution.8,9,10,11,12 Some alcoholic drinks, such as dry wines andal

Paediatric Dentistry Uk1999

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