Tooth Avulsion

Orofacial injuries, including dental injuries, often occur as a result of trauma related to accidents or participation in sports activities. Dental injuries include tooth fracture, displacement, and avulsion, when the periodontal ligament (PDL) is severed and the tooth is completely displaced from its socket.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9. Tooth avulsion accounts for between 0.5% and 3% of all dental injuries and may be accompanied by fracture of the alveolus.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.,2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. Higher rates of dental trauma are found for individuals with special needs. In an assessment of more than 500 children and adolescents, 39.6% and 30.4% of individuals with cerebral palsy and autism, respectively, were affected by dental trauma. Tooth avulsion accounted for almost a quarter of injuries to primary teeth.3Bagattoni S, Sadotti A, D’Alessandro G, Piana G. Dental trauma in Italian children and adolescents with special health care needs. A cross-sectional retrospective study. Eur J Paediatr Dent 2017;18:23-6.

The sequelae of tooth avulsion include the physical trauma, as well as the impact that this emergency may have on quality of life.4Lee JY, Divaris K. Hidden consequences of dental trauma: The social and psychological effects. Pediatr Dent 2009;31:96-101. Management of avulsed teeth begins at the site of the accident and includes reassurance of the affected person. What occurs next can determine the ultimate outcome of treatment for these injuries.

The sequelae of tooth avulsion include physical trauma, as well as the impact that this emergency may have on quality of life.

Management of Primary Tooth Avulsion

Replantation of avulsed primary teeth is not recommended.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. Patients with avulsed primary teeth should be assessed for damage to adjacent soft and hard tissues, and intraoral radiographs taken to verify that the tooth was completely avulsed.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9. Depending on the child’s age, space maintenance therapy may be required to preserve space for erupting permanent teeth.

Replantation of avulsed primary teeth is not recommended.

Management of Permanent Tooth Avulsion

Immediate replantation is typically the treatment of choice for avulsed permanent teeth.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. (Figure 1) The tooth must be handled only by its crown. If soiled, the tooth should be gently rinsed under cold running water for up to 10 seconds before replantation. After replantation, the patient must bite down on a clean handkerchief, or other clean cloth, held against the tooth.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. Emergency treatment provided in the dental office or emergency clinic includes debridement of the area with water spray, saline, or chlorhexidine, suturing any lacerations, radiographic verification that the replanted tooth position is correct, and provision of a flexible splint that the patient wears for up to 2 weeks.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,5American Association of Endodontists. The recommended guidelines of the American Association of Endodontists for the treatment of traumatic dental injuries, 2013. Available at: http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/index.php#/4 Advice on home care should be provided as well as antibiotics if indicated and a referral for a tetanus booster if current protection through prior vaccination cannot be confirmed.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. (Table 1) Replantation may be contraindicated for patients with severe dental caries, periodontal disease, severe mental disability or who are medically compromised.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.,2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. Severe injury to the alveolus can also preclude replantation.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.

Figure 1. Avulsed tooth (pending image)

Table 1. Key steps for immediate implantation of a permanent avulsed tooth
Handle tooth only by its crown.
If soiled, rinse the tooth gently under cold running water for up to 10 seconds.
Replant tooth.
Patient keeps the tooth stable by biting down on a clean cloth/handkerchief, until further treatment is possible.
Emergency treatment including debridement of the area, suturing of lacerations, verify tooth position radiographically.
Provision of a flexible splint.
Advice on home care, antibiotics and referral for tetanus booster as indicated.

Delayed Replantation

If immediate replantation is not possible, the tooth should be placed in a suitable storage medium within 5 minutes,1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9. and the patient transferred to the dental office, a dental emergency clinic or a hospital emergency department. If the extraoral dry time was less than 60 minutes (i.e., the length of time before the tooth was placed in an appropriate storage medium after avulsion), the replantation protocol and follow-up is similar to immediate replantation except that a splint is worn for 4 weeks rather than 2 weeks. If the extraoral dry time was 60 minutes or longer, the PDL will be necrotic and non-viable soft tissue must be carefully removed from the root before replantation.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.

Endodontic Treatment

Endodontic treatment is recommended 7 to 10 days following replantation for teeth with closed apices or may be provided prior to replantation if the extraoral dry time was an hour or longer.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. In teeth with open apices, pulp revascularization may occur following replantation, and root formation may continue. Therefore, in the absence of pulpal necrosis, endodontic therapy should be avoided and can be performed later if required.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,5American Association of Endodontists. The recommended guidelines of the American Association of Endodontists for the treatment of traumatic dental injuries, 2013. Available at: http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/index.php#/4

If the extraoral dry time was 60 minutes or longer, the PDL will be necrotic and non-viable.

Prognosis for Replanted Teeth

Immediate replantation offers the best prognosis, and a higher survival rate has been found for teeth with closed versus open apices.6Petrovic B, Marković D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26(1):52-9. doi: 10.1111/j.1600-9657.2009.00836.x. The most common adverse events are ankylosis and root resorption, with loss of the tooth. Delayed replantation increases the risk of these adverse outcomes.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,4Lee JY, Divaris K. Hidden consequences of dental trauma: The social and psychological effects. Pediatr Dent 2009;31:96-101. In growing children, ankylosis typically results in infrapositioning of the tooth, and disturbed alveolar and facial growth.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.

Factors affecting the prognosis include handling of the tooth, degree of root contamination, extraoral dry time, PDL cell viability, the storage medium and duration of immersion, integrity of the root surface and root maturity.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.,2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,4Lee JY, Divaris K. Hidden consequences of dental trauma: The social and psychological effects. Pediatr Dent 2009;31:96-101.,7Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, de Mendonça MR, Panzarini SR. Storage media for avulsed teeth: a literature review. Braz Dental J 2013;24(5):437-45.,8Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11(2):76-89. Immersing teeth in 2% sodium fluoride for 20 minutes prior to replantation may reduce the risk of resorption over a 5-year period,1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.,2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. and experimentally it was found that recombinant basic fibroblast growth factor may promote PDL formation.9Tuna EB, Arai K, Tekkesin MS, Seymen F, Gencay K, Kuboyama N, Maeda T. Effect of fibroblast growth factor and enamel matrix derivative treatment on root resorption after delayed replantation. Dent Traumatol 2015;31(1):49-56. doi: 10.1111/edt.12141. In addition, pulpal revascularization of teeth with open apices was found in one study to be more likely if immersion in a suitable medium lasted less than 5 minutes, and may be accelerated by immersing teeth in doxycycline solution prior to replantation.1American Association of Pediatric Dentistry. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Reference Manual 2013;39(6):412-9.,10Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995;11(2):59-68.,11Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol 1995;11(2):69-75.

Table 2. Factors affecting the prognosis for replanted teeth
Handling of the tooth Degree of root contamination
Extraoral dry time PDL cell viability
Type of storage medium Immersion time in storage medium
Integrity of the root surface Root maturity

Storage Media

An ideal storage medium would be readily available, biocompatible, antimicrobial, maintain PDL cell viability and periodontal fibers, promote cell proliferation and supply nutrients.12Is Khinda V, Kaur G, G SB, Kallar S, Khurana H. Clinical and practical implications of storage media used for tooth avulsion. Int J Clin Pediatr Dent 2017;10:158-65. Current recommendations are to store avulsed teeth in Hanks balanced salt solution (HBSS) or in tissue culture/transport medium, when possible.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,13Hasan MR, Takebe H, Shalehin N, Obara N, Saito T, Irie K. Effects of tooth storage media on periodontal ligament preservation. Dent Traumatol 2017;33:383-92. However, these and commercial storage media are typically not available where tooth avulsion emergencies occur. As an alternative, it is recommended that milk or another suitable storage medium be used.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,5American Association of Endodontists. The recommended guidelines of the American Association of Endodontists for the treatment of traumatic dental injuries, 2013. Available at: http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/index.php#/4 In a review of the literature, regular pasteurized whole milk was found to be the most frequently recommended alternative storage medium and to offer the best prognosis.7Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, de Mendonça MR, Panzarini SR. Storage media for avulsed teeth: a literature review. Braz Dental J 2013;24(5):437-45. Milk is also readily available. The patient’s saliva is relatively ineffective at maintaining cell viability but may be used if a more suitable medium is not available.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.,5American Association of Endodontists. The recommended guidelines of the American Association of Endodontists for the treatment of traumatic dental injuries, 2013. Available at: http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/index.php#/4 In addition, teeth should only be stored in water as a last resort, i.e., if it is the only option for wet storage.

It is recommended to store avulsed teeth in Hanks balanced salt solution or in tissue culture/transport medium, when possible.

Several studies have evaluated other potential storage media. In one study, coconut water was more effective than buttermilk, but less effective than cow’s milk.14Kokkali VV, Bendgude V, Sharangpani G. Comparative evaluation of post-traumatic periodontal ligament cell viability using three storage media. Eur Arch Paediatr Dent 2017;18:209-14. In a second study, tooth storage in coconut milk did not maintain cell viability.15Saini D, Gadicherla P, Chandra P, Anandakrishna L. Coconut milk and probiotic milk as storage media to maintain periodontal ligament cell viability: an in vitro study. Dent Traumatol 2017;33(3):160-4. HBSS, an HBSS-based commercially available medium and a Special Cell Culture Medium (SCCM) were all effective in maintaining cell viability for up to 6 hours.16Lee W, Stover S, Rasoulianboroujeni M, Sherman K, Fahimipour F. The efficacy of commercial tooth storage media for maintaining the viability of human periodontal ligament fibroblasts. Int Endod J 2018;51:58-68. Other research suggests that egg, propolis and coconut milk may be suitable alternatives for up to 3 hours at 20°C and 5°C. With longer immersion, only HBSS, skimmed and whole milk were effective and, after 24 hours immersion at 5°C, HBSS was less effective than milk.17de Souza BD, Bortoluzzi EA, Reyes-Carmona J, Dos Santos LG, Simões CM, Felippe WT, Felippe MC. Effect of temperature and seven storage media on human periodontal ligament fibroblast viability. Dent Traumatol 2017;33(2):100-5. doi: 10.1111/edt.12311.

Regular pasteurized whole milk is readily available and has been found to offer the best prognosis of all alternative storage media.

Knowledge about Tooth Avulsion

Dental professionals are usually not present when tooth avulsion occurs, and a dental setting may not be the first clinical point of care. However, survey findings highlight varying levels of knowledge about tooth avulsion among parents, teachers and healthcare professionals. In separate surveys, 91% of Turkish parents and 75% of European parents and teachers reported that they lacked knowledge about tooth avulsion emergencies.18Ozer S, Yilmaz E, Bayrak S, Tunc ES. Parental knowledge and attitudes regarding the emergency treatment of avulsed permanent teeth. Eur J Dent 2012;6(4):370-5.,19Tiano L, Barbiero S, Avato FA, Bergmann M, Gaudio RM. Management of facial trauma with tooth avulsion in children and adolescent, investigation on knowledge of parents and teachers. Eur J Pub Health 2015;25(Suppl 3): October 2015. https://doi.org/10.1093/eurpub/ckv176.241 In Virginia, 54% of emergency department physicians suggested milk as a storage medium prior to delayed replantation, while 96% knew that a storage medium was required.20Phelps JLB. Virginia emergency department physician knowledge of the emergent treatment of avulsed teeth. Thesis, Virginia Commonwealth University, 2008. Available at: https://scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=1844&context=etd. Fifty-one percent of nurses and 37% of physicians in an Indian survey did not believe tooth avulsion required immediate care, while 40% and 20%, respectively, suggested milk as a storage medium.21Kotha A, Kumar YV, Prathima V, Pratibha B, Ankitha CH. Evaluation of awareness of first aid of avulsed tooth among physicians and nurses of hospital emergency departments: A short survey. Int J Comm Health Med Res 2017;3(3):74-7. Further, only 7% of Polish school nurses in one survey knew that they could replant avulsed teeth and 16% would choose milk as a storage medium.22Baginska J, Rodakowska E Milewski R, Wilczynska-Borawska M, Kierklo A. Polish school nurses’ knowledge of the first-aid in tooth avulsion of permanent teeth. BMC Oral Health 2016;16:30. Among newly-graduated physicians in Kuwait, 73%, 27% and 83%, respectively, had ‘some’ knowledge, a ‘low’ level of knowledge, or had not received any training on tooth avulsion emergencies.23Abu-Dawoud M, Al-Enezi R, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentist. Dental Traumatol 2008;23(6):348-55. Newly-graduated dentists demonstrated high or moderate levels of knowledge.

Conclusions

Favorable treatment outcomes following tooth avulsion are dependent on proper management of these emergencies. Parents, patients, teachers, caregivers and healthcare professionals should be educated on the management of tooth avulsion emergencies. Dental professionals can help educate the public and other healthcare professionals on these emergencies, and can also provide immediate advice remotely by phone or the internet.2Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96. In addition, continuing education on this topic is required for all healthcare professionals, and more research is required on techniques and alternative storage media that will improve the prognosis for replanted teeth.

References

  • 1.U.S. Department of Health and Human Services. Oral health in America: A report of the Surgeon General, Executive summary. Rockville, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research. 2000.
  • 2.Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence of early childhood caries among 5-year-old children: A systematic review. J Investig Clin Dent 2019;10(1):e12376. doi:10.1111/jicd.12376
  • 3.Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018;307. Available at: https://www.cdc.gov/nchs/data/databriefs/db307.pdf.
  • 4.Dye B, Thornton-Evans G, Li X, Iafolla T. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197.
  • 5.Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat Rev Dis Primers 2017;25(3):17030.
  • 6.World Health Organization. Risk factors. Available at: https://www.who.int/topics/risk_factors/en/
  • 7.Tagliaferro E, Pardi E, Ambrosano V, Meneghim G, Pereira, MAC. An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007). Braz J Oral Sci 2008;7(27):7.
  • 8.Bibby BG, Krobicka A. An in vitro method for making repeated pH measurements on human dental plaque. J Dent Res 1984;63:906-9.
  • 9.American Dental Association. Caries Risk Assessment Form (Age 0-6). Available at: https://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.pdf.
  • 10.American Dental Association. Caries Risk Assessment Form (Age >6). Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx.
  • 11.AAPD. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf
  • 12.AAPD. Best Practices. Perinatal and Infant Oral Health Care. 2016.. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_perinataloralhealthcare.pdf.
  • 13.Dasanayake AP, Warnakulasuriya S, Harris CK, Cooper DJ, Peters TJ, Gelbier S. Tooth decay in alcohol abusers compared to alcohol and drug abusers. Int J Dent 2010;2010:786503.
  • 14.Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 2005;39(1):41-7.
  • 15.Opal S, Garg S, Jain J, Walia I. Genetic factors affecting dental caries risk. Aust Dent J 2015;60:2-11.
  • 16.Gomez A, Espinoza JL, Harkins DM, Leong P, Saffery R, Bockmann M et al. Host genetic control of the oral microbiome in health and disease. Cell Host Microbe 2017;22:269-78 e263.
  • 17.Featherstone JDB, Alston P, Chaffee BW, Rechmann P. Caries Management by Risk Assessment (CAMBRA)*: An Update for Use in Clinical Practice for Patients Aged Through Adult. In: CAMBRA® Caries Management by Risk Assessment A Comprehensive Caries Management Guide for Dental Professionals. (2019) Available at: https://www.cdafoundation.org/Portals/0/pdfs/cambra_handbook.pdf.
  • 18.Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health 2018;18(1):123. doi: 10.1186/s12903-018-0585-4.
  • 19.Malmö University. Cariogram – Download. Available at: https://www.mah.se/fakulteter-och-omraden/Odontologiska-fakulteten/Avdelning-och-kansli/Cariologi/Cariogram/.
  • 20.Petsi G , Gizani S, Twetman S, Kavvadia K. Cariogram caries risk profiles in adolescent orthodontic patients with and without some salivary variables. Angle Orthod 2014;84(5):891-5. doi:10.2319/080113-573.1.
  • 21.Martin J, Mills S, Foley ME. Innovative models of dental care delivery and coverage. Patient-centric dental benefits based on digital oral health risk assessment. Dent Clin N Am 2018;62:319-25.
  • 22.Chapple L, Yonel Z. Oral Health Risk Assessment. Dent Update 2018;45:841-7.
  • 23.American Dental Association. Electronic oral health risk assessment tools. SCDI White Paper No. 1074, 2013. Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ADAWhitePaperNo1074.pdf?la=en.
  • 24.Twetman S, Banerjee A. (2020) Caries Risk Assessment. In: Chapple I, Papapanou P. (eds) Risk Assessment in Oral Health. Springer, Cham.
  • 25.Rechmann P, Chaffee BW, Rechmann BMT, Featherstone JDB. Caries Management by Risk Assessment: Results From a Practice-Based Research Network Study. J Calif Dent Assoc 2019;47(1):15-24.
  • 26.Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract 2017;17(1):1-12.
  • 27.Dou L, Luo J, Fu X, Tang Y, Gao J, Yang D. The validity of caries risk assessment in young adults with past caries experience using a screening Cariogram model without saliva tests. Int Dent J 2018;68(4):221-6. doi: 10.1111/idj.12378
  • 28.Thyvalikakath T, Song M, Schleyer T. Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration. BMC Oral Health 2018;18(1):90.
  • 29.Riley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol 2011;39(6):564-73.
  • 30.Weyant RJ, Tracy SL, Anselmo T, Frantsve-Hawley J, Meyer DM, Beltrán-Aguilar ED et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91. doi.org/10.14219/jada.archive.2013.0057
  • 31.American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 2013;145(2):190-1. doi.org/10.14219/jada.2013.47
  • 32.Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants. A report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016;147(8):672-82.E12. doi.org/10.1016/j.adaj.2016.06.001
  • 33.Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions. A report from the American Dental Association. J Am Dent Assoc 2018;149(10):P837-49.E10. doi.org/10.1016/j.adaj.2018.07.002
  • 34.Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health 2018;18:172. Available at: https://doi.org/10.1186/s12903-018-0640-1.
  • 35.Collins FM. Oral health literacy. Available at: https://www.colgateoralhealthnetwork.com/article/oral-health-literacy/
  • 36.Alian AY, McNally ME, Fure S, Birkhed D. Assessment of Caries Risk in Elderly Patients Using the Cariogram Model. J Can Dent Assoc 2006;72(5):459–63.
  • 37.Edwards AGK, Hood, K, Matthews EJ et al. The effectiveness of one to one risk communication interventions in health care: a systematic review. Med Decis Making 2000;20:290-7.
  • 38.Eden E, Frencken J, Gao S, et al. Managing dental caries against the backdrop of COVID-19: approaches to reduce aerosol generation. Br Dent J. 2020;229:411-416. https://doi.org/10.1038/s41415-020-2153-y
  • 39.Höchli D, Hersberger-Zurfluh M, Papageorgiou SN, Eliades T. Interventions for orthodontically induced white spot lesions: a systematic review and meta-analysis. Eur J Orthod 2017;39(2):122-33.
  • 40.Croll T, Donly K. Enamel microabrasion for removal of decalcification, dysmineralization, and surface defects. Am J Esthet Dent 2013;3:92-9.
  • 41.Knösel M, Eckstein A, Helms HJ. Long-term follow-up of camouflage effects following resin infiltration of post orthodontic white-spot lesions in vivo. Angle Orthod 2019;89(1):33-39.
  • 42.Cazzolla AP, De Franco AR, Lacaita M, Lacarbonara V. Efficacy of 4-year treatment of icon infiltration resin on postorthodontic white spot lesions. Case Reports 2018;2018:bcr-2018-225639.
  • 43.Lee SH, Choi BK, Kim YJ. The cariogenic characters of xylitol-resistant and xylitol-sensitive Streptococcus mutans in biofilm formation with salivary bacteria. Arch Oral Biol 2012;57(6):697-703.
  • 44.Trahan L. Xylitol: a review of its action on mutans streptococci and dental plaque: its clinical significance. Int Dent J 1995;45(suppl. 1):77-92.
  • 45.de Cock P. Erythritol functional roles in oral-systemic health. Adv Dent Res 2018;29(1):104-109.
  • 46.U.S. Food & Drug Administration. Paws off xylitol; It’s dangerous for dogs. Available at: https://www.fda.gov/consumers/consumer-updates/paws-xylitol-its-dangerous-dogs.
  • 47.Mickenautsch S, Yengopal V. Effect of xylitol versus sorbitol: a quantitative systematic review of clinical trials. Int Dent J 2012;62(4):175-88.
  • 48.Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71.
  • 49.Milgrom P, Söderling EM, Nelson S, Chi DL, Nakai Y. Clinical evidence for polyol efficacy. Adv Dent Res 2012; 24(2):112-6.
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