AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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. 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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• 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%)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• 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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Drug Category: Antibiotics

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

Drug Category: 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.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.¹
• 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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal 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

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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3. Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].
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5. Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].
6. 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].
7. Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].
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11. 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].
12. 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].
13. 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].
14. 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].
15. Robert JR, Hedges JR. Emergency dental procedures. In: Clinical Procedures in Emergency Medicine. 2^nd ed. Philadelphia: WB Saunders Co; 1991:1045-1064.
16. Rosen P, Barkin R. Dental emergencies. In: Emergency Medicine Concepts and Clinical Practice. Vol 3. 3^rd ed. 1992:2381-2398.
17. Schaider J. Rosen & Barkin's: The 5-Minute Emergency Medicine Consult 2003. 2003:202-3.
18. Tintinalli JE, Kelen GD, Stapczynski, JS, eds. Emergency Medicine. In: A Comprehensive Study Guide. 6^th ed. McGraw-Hill Professional; 2003:1490-3.
19. Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].

Article Last Updated: Nov 8, 2007