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

Dental, Avulsed Tooth: Treatment & Medication

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

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.

Adult

250-500 mg PO q6h

Pediatric

50 mg/kg/d PO divided qid

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

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.

Adult

200-500 mg PO q6h

Pediatric

30-50 mg/kg/d PO divided qid

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

Documented hypersensitivity; hepatic impairment

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.

Adult

250-500 mg PO q8h

Pediatric

20-50 mg/kg/d PO divided q8h

Reduces efficacy of oral contraceptives

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.

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

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

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.

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

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

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

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.

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

Toxicity increases with CNS depressants or tricyclic antidepressants

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.

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

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

Documented hypersensitivity; known G-6-PD deficiency

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

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

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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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