Excerpt from Dental, Avulsed Tooth

Synonyms, Key Words, and Related Terms: 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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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:

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

Internationally: 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: Male-to-female ratio is 2-3:1.

Age: Average age of injury varies. In youths, falls and sporting activities account for the majority of injuries. In later teenaged years, motor vehicle collisions (MVCs) and assaults account for the majority of injuries.