Treatments for managing knocked out and replanted permanent front teeth

Review question

The aim of this Cochrane Review was to find out which treatment for managing knocked out and replanted permanent front teeth was the most effective.

Background

Injuring your front teeth is common. One of the most severe injuries occurs when the tooth is knocked totally out of the mouth (avulsed). Often the best option is to replant the tooth as quickly as possible. This is true only for permanent teeth. Once replanted the tooth can heal in one of two ways if managed correctly. Ideally the ligaments around the root repair and the tooth can be expected to last as long as any other tooth, this is known as 'periodontal healing'. When there is too much damage to the ligaments, healing occurs by bony replacement. Over a number of years, the adjacent bony socket will remodel the tooth (replace the root with bone) leaving the tooth with no root. Once the root is replaced the visible part of the tooth, the crown, will eventually give way and be lost. This is called 'bony healing'. Bony healing causes significant problems in the medium term for children and treatments for this are the subject of a different Cochrane Review. A missing front tooth or teeth, as a result of not replanting an avulsed tooth, or as a result of bony healing over the medium to long term, can have a major effect on dental and facial 'good looks'. This can affect the individual's self-esteem and general social interaction, as well as how others think and see them.

Study characteristics

Authors from Cochrane Oral Health carried out this review and the evidence is up to date to 8 March 2018. The review investigated what treatments encourage the tooth to repair by periodontal healing. A total of four studies were included with a total of 183 participants with 257 teeth. One study involved children and young adults, with the other three involving children only. Each study evaluated a different treatment: hyperbaric oxygen, root canal pastes (Ledermix versus Ultracal), removal of the nerve of the tooth (pulp extirpation), and soaking the knocked out tooth in thymosin alpha 1. Each of the interventions aimed to reduce infection or change the inflammatory response or both, at the time of or shortly after the tooth or teeth were replanted.

Key results

The evidence currently available is insufficient to draw reliable conclusions regarding the superiority of different interventions for knocked out and replanted permanent front teeth. There is urgent need for further well-designed randomised controlled trials.

Quality of the evidence

We judged the quality of the evidence to be very low due to problems with the design of the studies.

Authors' conclusions: 

Based on the results of the included studies, there is insufficient evidence to support or refute the effectiveness of different interventions for avulsed and replanted permanent front teeth. The overall quality of existing evidence was very low, and therefore great caution should be exercised when generalising the results of the included trials. There is urgent need for further well-designed randomised controlled trials.

Read the full abstract...
Background: 

Traumatic dental injuries are common. One of the most severe injuries is when a permanent tooth is knocked completely out of the mouth (avulsed). In most circumstances the tooth should be replanted as quickly as possible. There is uncertainty on which interventions will maximise the survival and repair of the replanted tooth. This is an update of a Cochrane Review first published in 2010.

Objectives: 

To compare the effects of a range of interventions for managing traumatised permanent front teeth with avulsion injuries.

Search strategy: 

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 March 2018), Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 2) in the Cochrane Library (searched 8 March 2018), MEDLINE Ovid (1946 to 8 March 2018), and Embase Ovid (1980 to 8 March 2018). The US National Institutes of Health Ongoing Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

Selection criteria: 

We considered randomised and quasi-randomised controlled trials that included a minimum follow-up period of 12 months, for interventions for avulsed and replanted permanent front teeth.

Data collection and analysis: 

Two review authors independently selected studies, extracted data and assessed the risk of bias. Authors were contacted where further information about their study was required.

Main results: 

Four studies, involving a total of 183 participants and 257 teeth were identified. Each of the interventions aimed to reduce infection or alter the inflammatory response or both at the time of or shortly after the tooth or teeth were replanted. Each study assessed a different intervention and therefore it was not appropriate or possible to numerically synthesise the data. All evidence was rated as being of very low quality due to problems with risk of bias and imprecision of results. This means that we are very uncertain about all of the results presented in this review.

One study at high risk of bias with 69 participants (138 teeth) compared a 20-minute soak with gentamycin sulphate for both groups prior to replantation with the experimental group receiving daily hyperbaric oxygen for 80 minutes for the first 10 days. There was some evidence of a benefit for the hyperbaric oxygen group in respect of periodontal healing, tooth survival, and pulpal healing.

One study at unclear risk of bias with 22 participants (27 teeth) compared the use of two root canal medicaments, Ledermix and Ultracal. There was insufficient evidence of a difference for periodontal healing or tooth survival. This was the only study to formally report adverse events with none identified. Study authors reported that Ledermix caused a greater level of patient dissatisfaction with the colour of avulsed and replanted teeth.

A third study at high risk of bias with 19 participants compared extra- or intra-oral endodontics for avulsed teeth which were stored dry for longer than 60 minutes before replantation. There was insufficient evidence of a difference in periodontal healing.

The fourth study at high risk of bias with 73 participants compared a 10-minute soak in either thymosin alpha 1 or saline before replantation followed by daily gingival injections with these same medicaments for the first 7 days. There was some evidence of a benefit for thymosin alpha 1 with respect to periodontal healing and tooth survival.

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