Avulsed Tooth 

Updated: Nov 23, 2021
Author: Lynnus F Peng, MD; Chief Editor: Anil P Punjabi, MD, DDS 

Overview

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.

Causes of tooth avulsion include the following:

  • Unknown (17%)

  • Altercations (17%)

  • Contact sports (15.9%)

  • Motor vehicle collision (10.8%)

  • Motorcycle accident (10.4%)

  • Ice hockey (2.3%)

Epidemiology

United States statistics

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

International statistics

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.

Sex- and age-related demographics

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

The average age of injury varies. A 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.

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.

Morbidity/mortality

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

Complications

Complications of tooth avulsion include the following:

  • Loss of tooth

  • Cosmetic deformity

  • Infection

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.[2]

For excellent patient education resources, visit WebMD's Oral Care Center. Also, see WebMD's patient education article Handling Dental Emergencies.

 

Presentation

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 Examination

Inspection

Evaluate the surrounding soft tissue area for laceration, discoloration, ecchymosis, and embedded foreign bodies (eg, chipped teeth).[3]

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.

 

DDx

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.[4]

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.

Poi et al conducted a review the literature on the different storage media that have been investigated for avulsed teeth. The authors concluded that regular pasteurized whole milk is the most frequently recommended and with the best prognosis among other solutions that are likely to be available at the scene of an accident, such as water, saline or saliva. Its advantages include its high availability, ready accessibility, physiologically compatible pH and osmolality (fluid pressure) with the root-surface adhered PDL cells, presence of nutrients and growth factors. More research is necessary as there is not yet a single solution that is ideal for storage.[5]

A retrospective case-controlled study indicated that avulsed permanent teeth soaked in doxycycline did not show a better treatment outcome regarding pulp survival and periodontal healing compared with avulsed teeth placed only in saline solution.[6]

Emergency Department Care

See the list below:

  • Tooth preparation: Handle the tooth by the crown and rinse with normal saline.[7]

    • 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

Medication Summary

The goals of therapy are to relieve pain with analgesics and to prevent complications with antibiotics. The International Association of Dental Traumatology recommends the use of systemic antibiotics after avulsion and replantation to prevent infection-related reactions and to reduce the likelihood of inflammatory root resorption.[8]

Antibiotics

Class Summary

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.

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.

Amoxicillin (Amoxil, Polymox, Trimox)

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

Analgesics

Class Summary

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.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relieving moderate to severe pain.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treating mild to moderate pain.

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.

 

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.