eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Dental, Avulsed Tooth

Author: Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California; Rebecca Cheng, University of California at San Diego
Contributor Information and Disclosures

Updated: Aug 12, 2009

Introduction

Background

Losing a tooth can be physically and emotionally trying, as the resulting empty site is not aesthetically pleasing and is difficult to fill and difficult to replace. Long-term sequelae include shifting of remaining teeth with resulting misalignment and periodontal disease.

As early as 400 BCE, Hippocrates suggested that displaced teeth should be replaced and fastened to adjacent teeth with wire. Modern emergency departments focus on reimplanting teeth as soon as possible, minimizing periodontal damage, and preventing infection of the pulp tissue.

Pathophysiology

The usual cause is a directed force sufficient to overcome the bond between the affected tooth and the periodontal ligament within the cradling alveolar socket. Avulsion results in hypoxia and eventual necrosis of the pulp. The primary goal of rapid reimplantation is to preserve the periodontal ligament, not the tooth. The avulsed tooth inevitably requires a root canal; however, if the periodontal ligament survives, the degree and timeliness of root resorption is improved and ankylosis is decreased.

Frequency

United States

The prevalence of avulsion from traumatic injury of primary dentition is 7-13%. In permanent teeth, the prevalence is 1-16%.

International

A study conducted in Sweden showed approximately 7% of all physical injuries involved the oral cavity. In patients aged 0-19 years, 9% of all injuries involved the oral cavity. In the same study, more than 50% of physical trauma in child abuse cases occurred in the head and neck region.

Facial injuries are common during war. During the Korean War, maxillofacial injuries numbered 3,000.

Mortality/Morbidity

Trauma to the teeth is not life threatening; however, associated maxillofacial injuries and fractures can compromise the airway. Morbidity to the teeth may be individualized to primary or permanent teeth. Teeth with avulsion actually continue deteriorating, even at the 36-month follow-up appointment.

  • Primary teeth
    • Failure to continue eruption
    • Color changes
    • Infection
    • Abscess
    • Loss of space in the dental arch
    • Ankylosis
    • Injury to the permanent teeth
    • Abnormal exfoliation
  • Permanent teeth
    • Color changes
    • Infection
    • Abscess
    • Loss of space in the dental arch
    • Ankylosis
    • Resorption of root structure
    • Abnormal root development

Sex

The male-to-female ratio is 2-3:1.

Age

The average age of injury varies. A recent study from Beijing, China noted that most dental trauma occurs in children aged 7-15 years.1 In youths, falls and sporting activities account for most injuries. In later teenaged years, motor vehicle collisions (MVCs) and assaults account for most injuries.

Clinical

History

The following are considerations in patients with avulsed teeth:

  • Patient's age: Anterior primary teeth are usually present until age 6-7 years.
  • Mechanism of injury: Rule out concomitant injuries.
  • Location of the tooth when recovered: This helps assess contamination.
  • Time out of socket: If the tooth was absent for less than 20 minutes, the prognosis is better. All periodontal ligament cells die if the tooth is out of the socket longer than 60 minutes.
  • Storage media: Determine if the tooth was stored dry or in solution.
  • Transport method: Determine how the tooth was carried. Holding it by the root is typically worse.
  • Primary or permanent tooth: Do not replace primary teeth, because loss of these teeth early does not hinder development of succedaneous teeth. When loss of a primary tooth is early, eruption of permanent successors may be delayed.
    • If replaced, primary teeth have a high likelihood of fusing to underlying alveolar bone, which causes dentoalveolar ankylosis and can result in facial deformities.
    • Histologically, dentoalveolar ankylosis is characterized by direct contact between bone and cementum without separation by the periodontal ligament.

Physical

  • Inspection
    • Evaluate the surrounding soft tissue area for laceration, discoloration, ecchymosis, and embedded foreign bodies (eg, chipped teeth).
    • Evaluate teeth for fractures, chips, and other deformities. Embedded tooth fragments may lead to chronic infection or fibrosis.
  • Palpation
    • Determine if the tooth or if an entire segment is mobile.
    • If possible, have patients bite down to further localize the suspected area.
  • Percussion and sensitivity
    • Percuss with a tongue blade to evaluate overall sensitivity.
    • Evaluate the patient's sensitivity to air and hot and cold solutions.
  • Missing tooth: If the tooth is not found, consider complete intrusion of the tooth into underlying alveolar bone.

Causes

  • Unknown (17%)
  • Altercations (17%)
  • Contact sports (15.9%)
  • Motor vehicle collision (10.8%)
  • Motorcycle accident (10.4%)
  • Ice hockey (2.3%)

More on Dental, Avulsed Tooth

Overview: Dental, Avulsed Tooth
Differential Diagnoses & Workup: Dental, Avulsed Tooth
Treatment & Medication: Dental, Avulsed Tooth
Follow-up: Dental, Avulsed Tooth
References
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References

  1. Qin M. [Pulp treatment of young permanent teeth after traumatic dental injury]. Hua Xi Kou Qiang Yi Xue Za Zhi. Jun 2009;27(3):237-40. [Medline].

  2. Zadik Y, Marom Y, Levin L. Dental practitioners' knowledge and implementation of the 2007 International Association of Dental Traumatology guidelines for management of dental trauma. Dent Traumatol. Jul 9 2009;[Medline].

  3. Santos Filho PC, Quagliatto PS, Simamoto PC Jr, Soares CJ. Dental trauma: restorative procedures using composite resin and mouthguards for prevention. J Contemp Dent Pract. 2007;8(6):89-95. [Medline].

  4. Al-Jundi SH. Type of treatment, prognosis, and estimation of time spent to manage dental trauma in late presentation cases at a dental teaching hospital: a longitudinal and retrospective study. Dent Traumatol. Feb 2004;20(1):1-5. [Medline].

  5. Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].

  6. Cobankara FK, Ungor M. Replantation after extended dry storage of avulsed permanent incisors: report of a case. Dent Traumatol. Aug 2007;23(4):251-6. [Medline].

  7. Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].

  8. [Guideline] Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol. Jun 2007;23(3):130-6. [Medline].

  9. Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].

  10. Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. In: The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1996:418-421.

  11. Josell SD. Evaluation, diagnosis, and treatment of the traumatized patient. Dent Clin North Am. Jan 1995;39(1):15-24. [Medline].

  12. Josell SD, Abrams RG. Traumatic injuries to the dentition and its supporting structures. Pediatr Clin North Am. Jun 1982;29(3):717-41. [Medline].

  13. Kinoshita S, Kojima R, Taguchi Y, Noda T. Tooth replantation after traumatic avulsion: a report of ten cases. Dent Traumatol. Jun 2002;18(3):153-6. [Medline].

  14. Krasner P, Rankow HJ. New philosophy for the treatment of avulsed teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. May 1995;79(5):616-23. [Medline].

  15. Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dent Traumatol. Apr 2005;21(2):93-101. [Medline].

  16. Rai P, Gupta U, Kalra N. Self-replantation of an avulsed tooth in torsoversion: a 10-year follow-up. Dent Traumatol. Jun 2007;23(3):158-61. [Medline].

  17. Robert JR, Hedges JR. Emergency dental procedures. In: Clinical Procedures in Emergency Medicine. 2nd ed. Philadelphia: WB Saunders Co; 1991:1045-1064.

  18. Rosen P, Barkin R. Dental emergencies. In: Emergency Medicine Concepts and Clinical Practice. Vol 3. 3rd ed. 1992:2381-2398.

  19. Schaider J. Rosen & Barkin's: The 5-Minute Emergency Medicine Consult 2003. 2003:202-3.

  20. Tintinalli JE, Kelen GD, Stapczynski, JS, eds. Emergency Medicine. In: A Comprehensive Study Guide. 6th ed. McGraw-Hill Professional; 2003:1490-3.

  21. Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].

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Further Reading

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Keywords

tooth loss, tooth avulsion, tooth reimplantation, knocked-out tooth, tooth trauma, missing tooth, losing a tooth, displaced tooth, tooth displacement, periodontal disease, alveolar socket, hypoxia, necrosis of pulp, tooth reimplantation, periodontal ligament, root canal, alveolar bone, dentoalveolar ankylosis, Panorex, maxillary fractures, mandibular fractures, Hanks solution, Save-A-Tooth, zinc oxide preparation, Coe-Pak, root canal, infected necrotic tooth pulp

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Contributor Information and Disclosures

Author

Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Lynnus F Peng, MD is a member of the following medical societies: Alpha Omega Alpha and American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California
Disclosure: Nothing to disclose.

Rebecca Cheng, University of California at San Diego
Disclosure: Nothing to disclose.

Medical Editor

Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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