Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the task group. The guidelines represent the current best evidence and practice based on literature research and professionals' opinion. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of avulsed permanent teeth.

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International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth

The spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in millions of confirmed cases and hundreds of thousands of deaths. Despite all efforts to contain the spread of the disease, the number of infections and deaths continue to rise, particularly in some regions. Given its presence in the salivary secretions of affected patients, and the presence of many reported asymptomatic cases that have tested positive for COVID-19, dental professionals, including Endodontists, are at high risk of becoming infected if they do not take appropriate precautions. As of today, there are no predictable treatments or approved vaccines that can protect the public and healthcare professionals from the virus; however, there is speculation that a vaccine might be available sometime in 2021. Until then, general dentists and Endodontist will need to be able to treat emergency patients in order to relieve pressure on emergency clinics in hospitals or local community hubs. In addition, as the pandemic continues, strategies to manage patients will need to evolve from a palliative to a more permanent/definitive treatment approach. In this article, an update on the treatment considerations for dental care in general is provided, as well as a discussion on the available endodontic guidelines reported in the literature. Recommendations on clinical management of endodontic emergencies are proposed.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/iej.13406

Clinical endodontic management during the COVID-19 pandemic: a literature review and clinical recommendations.

Background/aims The best treatment for an avulsed tooth is immediate replantation If this is not possible, a proper transport medium is required for the maintenance of viability of the periodontal ligament cells (PDL) The aim was to systematically review the efficacy of different storage media used for the survival of PDL cells of avulsed teeth in the in vitro setting Methods The search strategy was based on the MeSH keywords in PubMed/MEDLINE: "Transport media for avulsed teeth," "Storage media for avulsed teeth," "Knocked out teeth," "Tooth avulsion," "Biological transport of avulsed tooth," "Cell survival of avulsed tooth," "Cell viability of avulsed tooth," "Tooth replantation," and "Periodontal ligament in avulsed teeth" The "AND" and "OR" Boolean operators were applied to combine keywords Each study was evaluated for eight criteria, including use of human PDL, in vitro cell culture models, the number of passages, types of storage media, percentages of surviving PDL cells, pH and osmolality of storage media, and the type of test used to asses PDL viability Results In 15 selected studies, nine storage media (HBSS, tap water, DMEM, milk, saliva, 10% and 20% propolis, Gatorade, and Viaspan) were analyzed at six time points For storage up to 2 hours, HBSS, DMEM, milk, 10% propolis, 20% propolis, and Viaspan conserved more than 80% of PDL viability For storage at 24 hours, Viaspan showed best cell survival at 884%, followed by DMEM (709%) and 10% propolis (683%) Milk and HBSS showed similar PDL survival at 24 hours (572% and 573%, respectively) Conclusions Milk remains the most convenient, cheapest, and readily available solution in most situations while also being capable of keeping PDL cells alive Further studies are required to evaluate the efficacy of more commonly found storage media besides milk

https://onlinelibrary.wiley.com/doi/pdf/10.1111/edt.12437

Evaluation of periodontal ligament cell viability in different storage media based on human PDL cell culture experiments—A systematic review

BACKGROUND/AIM The extra-alveolar period and storage medium are important for the survival of replanted teeth. The aim of this study was to evaluate factors affecting the survival of replanted teeth in children. MATERIAL AND METHODS Complete dental records of avulsed teeth including age, gender, extra-alveolar time, storage type and period, stage of root development, crown fracture, gingival laceration, alveolar fracture, antibiotics, and splint type and period were obtained. Kaplan-Meier, Cox regression and chi-square tests were used to analyse the risk factors affecting survival (P < 0.05). RESULTS The study included 196 replanted teeth with a mean follow-up period of 4.0 years. Forty-two (21.4%), 45 (23.0%), and 109 teeth (55.6%) showed functional healing, inflammatory resorption and replacement resorption. The root resorption incidence of teeth with extra-alveolar time longer than 30 minutes was higher vs teeth with a time of less than 30 minutes (P = 0.010). Physiologically stored replanted teeth showed lower incidence of root resorption (19/31, 61.3%) than those stored in non-physiologic media (94/114, 82.5%) (P = 0.025). Root resorption incidence of teeth stored non-physiologically within 30 minutes and then transferred to physiologic media (25/33, 75.8%) was similar to that of teeth stored physiologically (P = 0.127). Teeth stored non-physiologically for longer than 30 minutes had a significantly higher root resorption incidence (99/113, 87.6%) than teeth stored non-physiologically within 30 minutes (55/83, 66.3%) (odds ratio = 1.726, P = 0.001). Pulp canal obliteration occurred in five of the 56 immature teeth (8.9%) but two of them were later extracted because of replacement resorption. The survival of mature teeth (111/140, 79.3%) was significantly higher than that of immature teeth (39/56, 69.6%) (P = 0.007). CONCLUSIONS This study suggested that non-physiologic storage within 30 minutes was critical for the periodontal healing of replanted teeth. Replanted immature teeth had lower survival rates than mature teeth.

A retrospective study of survival of 196 replanted permanent teeth in children.

BACKGROUND/AIM It is crucial to store an avulsed tooth appropriately to preserve the viability of the periodontal ligament cells prior to replantation. The aim of this systematic review was to identify the best available evidence for the effectiveness of any technique available to laypeople for storing an avulsed tooth compared with storage in milk or saliva. METHODS The following databases were searched (September 2019): Cochrane Library, MEDLINE, and Embase. Two reviewers independently considered trial eligibility, then extracted and analyzed data, and assessed the risk of bias. The certainty of the body of evidence was appraised according to the GRADE methodology. RESULTS Out of 4118 references, 33 studies were included and reported 23 comparisons of which 10 were synthesized in a meta-analysis. The limited evidence available favors storing an avulsed tooth in Hank's balanced salt solution (pooled SMD 2.47, 95% CI [1.59;3.34], P < .00001), propolis solution (pooled SMD 1.73, 95% CI [1.12;2.33], P < .00001), oral rehydration salts (pooled SMD 4.16, 95% CI [2.10;6.23], P < .0001), rice water, and cling film compared with storage in milk. The cell viability rate was significantly lower in teeth stored in saline solutions (pooled SMD -4.35, 95% CI [-7.55;-1.14], P = .008), tap water, buttermilk, castor oil, GC Tooth Mousse, and turmeric extract than those stored in milk. There is insufficient evidence to recommend for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. The certainty of evidence was considered low to very low due to limitations in study design, indirect study populations and outcome measures, and imprecision. CONCLUSION Although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, the following media have also demonstrated efficacy at preserving the cell viability: Hank's balanced salt solution, propolis, oral rehydration salts, rice water, and cling film.

Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis.

BACKGROUND/AIMS A wide variety of materials has been researched for their use as potential storage media for avulsed teeth, but it is essential to recognize the medium most recommended for improvement of the prognosis of avulsed teeth. The aim of this systematic review was to identify the most recommended medium to store and transport avulsed teeth based on the survival of periodontal ligament (PDL) cells as determined by in vitro studies. METHODS Only laboratory-based experimental studies on PDL cells found on adult permanent teeth were included. Data were collected using PubMed, CINAHL plus (EBSCO host), and the Cochrane Library, along with Google Scholar and a hand search. The key terms employed were permutations of [avulsed permanent teeth* OR dental avulsion* OR knocked out teeth*] AND [storage media* OR transport media* OR biological transport* OR PDL cell viability* OR PDL cell survival*]. A customized data extraction pro forma was used to extract the data and to evaluate the quality and risk of bias. RESULTS The initial search yielded 978 articles, but only 67 were selected. Milk was the most recommended individual medium followed by Hank's balanced salt solution. Among natural products other than milk, propolis and coconut water were most frequently recommended. Recommendations were based on maintenance of PDL cell viability followed by ease of availability, low cost, and long shelf life. CONCLUSIONS Natural products are more effective in maintaining the PDL cell viability compared to synthetic products. Some storage media recommendations were also based upon practical aspects. Although natural products other than milk have more recommendations as a group, milk is the most recommended storage medium individually, based not only on PDL cell viability, but also practical considerations.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/edt.12382

Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review.

This experimental study was done on extracted human teeth to compare the fracture and deformation of the two rotary endodontic files system namely K-3 and Protapers. It was conducted at the dental clinics of the Aga Khan University Hospital, Karachi, A log of file deformation or fracture during root canal preparation was kept. The location of fracture was noted along with the identity of the canal in which fracture took place. The fracture in the two rotary systems was compared. SPSS 20 was used for data analysis. Of the 172(80.4%) teeth possessing more than 15 degrees of curvature, fracture occurred in 7(4.1%) cases and deformation in 10(5.8%). Of the 42(19.6%) teeth possessing less than 15 degrees of curvature, fracture occurred in none of them while deformation was seen in 1(2.4%). There was no difference in K-3 and Protaper files with respect to file deformation and fracture. Most of the fractures occurred in mesiobuccal canals of maxillary molars, n=3(21.4%). The likelihood of file fracture increased 5.65-fold when the same file was used more than 3 times. Irrespective of the rotary system, apical third of the root canal space was the most common site for file fracture.

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Comparison of fracture and deformation in the rotary endodontic instruments: Protaper versus K-3 system.

Background: Root canal re-treatment is the procedure of choice when the primary root treatment fails but patient is inclined toward salvage of the tooth. The re-treatment is often a challenging procedure owing to lack to the predictability in the outcomes. Since, there is a no single way of planning and executing such procedure, a study was planned to assess the knowledge, attitude and practice regarding endodontic re-treatment among Pakistani dentists. The effect of clinical experience on the re-treatment planning was also determined. Methods: A survey was conducted by distributing a questionnaire among 240 dentists practicing in four major cities of Pakistan. Frequency distribution of the gender, experience, designation of the participants etc. was determined. A case scenario was also shared and responses upon decision making were noted. Chi square test was applied to see if re-treatment decision of experienced dentists (>5 years’ practice) was significantly different than less experienced dentists. Results: Out of 240 forms, 160 were received (response rate of 66.67%). The most commonly reported reason for endodontic re-treatment was under prepared/ under filled canals. Nearly 40% participants reported doing re-treatment with hand instruments only and 15% did not employ any solvent during re-treatment. There were no significant differences between the less experienced and the more experienced dentists on re-treatment decisions. Conclusions: Almost half of the dentists reported inappropriate decision making in re-treatment. This shows that in endodontic re-treatment practice in major cities of Pakistan falls short of internationally accepted standards. There is a significant difference in treatment planning done by more experienced dentists compared to ones with <5 years’ clinical experience. Keywords: Endodontics; Failed root canals: Re-treatment; Survey; Root canal

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Practice Of Endodontic Re-Treatment In Four Cities Of Pakistan.

The aim of the retrospective study was to assess the clinical and radiographic outcome of the dental implant surgery and prosthetics. It was conducted at the Aga Khan University Hospital, Karachi, and comprised of medical charts and radiographic records of patients visiting between 2010 and 2015. Variables such as implant dimensions, final prosthesis, method of retention, loading protocol and patient factors were analysed. A total of 223 implants (143(64.1%) in maxilla and 80(35.9%) in mandible) were placed in 92 subjects (50(54.3%) males and 42(45.7%) females). All implants were Zimmer tapered screw-vent. Length of 108(48.4%) implants was 11.5mm and diameter of 84(37.7%) implants was 4.7mm. Besides, 6(2.7%) implants failed to osseointegrate, whereas 1(0.4%) implant failed at 12 months of loading. Among the 216(96.9%) successful implants, 140(64.8%) served as bridge abutments, 72(33.3%) were single crown abutments and 4(1.9%) were overdenture abutments. Also, 37(17.1%) implants were immediately loaded. The six-year survival rate of implants was 96.9%.

/pdf/a-6-year-evaluation-of-223-tapered-dental-implants-and-2zl2ll2wz9.pdf

Sana Ehsen Nagi

Papers

Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review.

Comparison of fracture and deformation in the rotary endodontic instruments: Protaper versus K-3 system.

Practice Of Endodontic Re-Treatment In Four Cities Of Pakistan.

A 6-year Evaluation of 223 Tapered Dental Implants and associated prosthesis in 92 patients at a University Hospital.