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

Dental, Avulsed Tooth

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
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

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%)

Differential Diagnoses

Dental, Displaced Tooth
Dental, Fractured Tooth

Workup

Imaging Studies

Four films (maxillary anterior, 3 periapical from various angles) are recommended to evaluate dental injury, displacement, or possible complete intrusion.
- Because these specialized films are often not available in the emergency department, a limited facial series and a Panorex may be used to evaluate foreign bodies, displacement, and maxillary and mandibular fractures.
- A Panorex may be used to assess mandibular fracture.

Treatment

Prehospital Care

Guidelines for dental trauma have been updated and were evaluated by military dental professionals.²
Do not touch the root or clean the tooth. Handle the tooth by the crown only. Attempt reimplantation in the field. If unable to reimplant, use one of the following carrier media (in order of preference):
- Hanks solution (Save-A-Tooth, Phoenix-Lazerus, Inc, Pottstown, PA): This pH-preserving fluid is best used with a trauma-reducing suspension apparatus.
- Milk: Shown to maintain vitality of periodontal ligament cells for 3 hours, milk is relatively bacteria-free with pH and osmolarity compatible with vital cells.
- Saline: Saline is isotonic and sterile.
- Saliva: Saliva keeps the tooth moist; however, it is not ideal because of incompatible osmolarity, pH, and presence of bacteria.
- Water: This is the least desirable transport medium because it results in hypotonic rapid cell lysis.

Emergency Department Care

Tooth preparation: Handle the tooth by the crown and rinse with normal saline.
- If extraoral time is less than 20 minutes, gently rinse off the root and reimplant as soon as possible. If the pulp is open, use a bathing solution (doxycycline 1 mg in 20 mL isotonic sodium chloride solution) for 5 minutes to inhibit the amount of pathogens reaching the pulp lumen and enhance vascularization. Consult a dentist prior to use.
- If extraoral time is longer 60 minutes, soak the tooth in citric acid and fluoride to make the root as resistant to resorption as possible. Consult a dentist.
Socket preparation
- Leave the socket alone as much as possible.
- If extraoral time is 20-60 minutes, soak in Hanks solution for 30 minutes before attempting reimplantation.
- Perform light aspiration if a blood clot remains.
- Gently irrigate for foreign bodies.
Tooth stabilization: If untrained in placing arch bars for tooth stabilization, use a zinc oxide preparation (Coe-Pak) for rapid support and stabilization. Mold the zinc oxide mixture over the gingival area and between teeth to provide support.
Provide adequate pain management and tetanus vaccination; ensure follow-up care.

Consultations

Consult a dental or oral maxillofacial surgeon for splinting and further evaluation.

Medication

The goals of therapy are to relieve pain with analgesics and to prevent complications with antibiotics.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin VK (Veetids, Beepen-VK, Betapen-VK)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Dosing

Adult

250-500 mg PO q6h

Pediatric

50 mg/kg/d PO divided qid

Interactions

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal impairment

Erythromycin (EES, E-Mycin, Ery-Tab)

An alternative for patients allergic to penicillin. Advise patients to take with food/milk if GI upset noted.
Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes. This inhibits bacterial growth.

Dosing

Adult

200-500 mg PO q6h

Pediatric

30-50 mg/kg/d PO divided qid

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs

Amoxicillin (Amoxil, Polymox, Trimox)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in a bactericidal activity against susceptible bacteria.

Dosing

Adult

250-500 mg PO q8h

Pediatric

20-50 mg/kg/d PO divided q8h

Interactions

Reduces efficacy of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that benefit patients who have sustained trauma.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn

Interactions

Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relieving moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose should not exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses in 24 h

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; high-altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treating mild to moderate pain.

Dosing

Adult

Based on codeine content: 30-60 mg/dose PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d

Pediatric

0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

Toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)

DOC for treating pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who take oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1,000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in people with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Follow-up

Further Outpatient Care

Advise patients to follow up with a dentist within 24 hours. Document arrangements for follow-up care.
Advise patients to avoid eating solid foods to prevent loss of stabilizing dressing.

Finding the missing tooth is critical because successful reimplantations have occurred even the tooth being in dry storage for 1 week.

Complications

Loss of tooth
Cosmetic deformity
Infection

Prognosis

Immature permanent teeth have a higher chance of survival than older permanent teeth.
Root canal is necessary when necrotic tooth pulp becomes infected. Infection can pass from the pulp through the dentin tubules and stimulate an inflammatory response, resulting in inflammatory root resorption.
The chance of a successful reimplantation is dependent upon the amount of time the tooth has been out of the socket. Education of patients toward self-reimplantation may help to decrease the out-of-socket time.

Patient Education

A dental mouth guard is an effective device for preventing dental injuries, and patients should be advised to wear them during activities where dental injuries are possible.³
For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken or Knocked-out Teeth and When to Visit the Dentist.

Miscellaneous

Medicolegal Pitfalls

Delaying reimplantation
Failure to properly handle and transport tooth
Attempting to reimplant primary tooth
Failure to provide tetanus prophylaxis
Failure to rule out aspiration of tooth chips when unable to recover tooth in the field
Failure to properly examine surrounding traumatized tissue for tooth chips
Failure to recognize domestic or child abuse
Failure to fully evaluate the temporomandibular joint, maxilla, mandible, and associated head or neck injuries
Failure to recognize possible airway compromise
Failure to warn patients that any trauma to teeth may disrupt the neurovascular supply and lead to long-term pulp necrosis or root resorption

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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

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.

Further Reading