Teeth

Tooth Avulsion

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Tooth Avulsion, Avulsed Teeth, Knocked-Out Tooth, Knocked-Out Teeth

  • See Also
  1. Tooth Luxation
  2. Tooth Fracture
  • Definition
  1. Most severe of Tooth Luxation injuries
  2. Tooth is completely displaced from alveolar bone
  • Epidemiology
  1. Most commonly affects anterior teeth as they are more easily avulsed (single root, cone shaped)
  • Contraindications
  • Reimplantation
  1. Primary alveolar ridge Fracture
  2. Tooth left dry and out of socket for >60 minutes (unlikely to implant successfully
  3. Immunocompromised patient (relative)
  4. Tooth integrity compromised (relative)
  5. Implantation socket integrity compromised (relative)
  • Management
  • General
  1. Avulsed Permanent Teeth (secondary teeth) are a Dental Emergency
    1. Nerve, artery and vein bundle is completely severed on complete Tooth Avulsion
    2. Reimplantation within 5 minutes: 85-97% healing rate
    3. Goal is reimplantation within 15-20 minutes
    4. Reimplantation after dry and out of socket >60 minutes: Tooth rarely heals
      1. May attempt tooth reimplantation if within 1.5 hours of tooth loss
      2. Better chance of successful reimplantation if tooth is clean and socket is bleeding
  2. Avulsed Primary Teeth should not be reimplanted
    1. Children lose Primary Teeth at ages 6-7 years old
    2. First primary tooth loss is anterior followed by posterior (often bottom and then top)
    3. Primary Teeth are small, flat, milky white with little to no root
      1. Contrast with Permanent Teeth that are larger
      2. Permanent Teeth start with ridged cutting edges (mamelons) that gradually wear down
    4. Most common Avulsed Teeth are the top front (Maxillary anterior, incisors)
      1. Compare to bottom teeth, as these are the first typically to be replaced by Permanent Teeth
    5. Dental referral if avulsed primary tooth without an obvious palpable secondary tooth beneath
      1. Routine referral due to the risk of crowding of Permanent Teeth
  • Management
  • Technique for tooth reimplantation
  1. Avoid periodontal ligament (at root) injury (critical for successful reimplantation)
    1. Hold tooth gently by crown
    2. Do not touch, rub or clean root
    3. Do not wipe the tooth
    4. Do not dry the tooth (tooth preservation relies on moisture)
  2. Evaluate tooth
    1. Gently remove debris from tooth
      1. Rinse tooth with saline or Chlorhexidine, or cool Running tap water
    2. Observe for Tooth Fracture
    3. Evaluate for open apex (immature, incompletely developed tooth root with large hole)
      1. Soaking the tooth Doxycycline 1 mg/20 ml for 20 min may improve implantation success
  3. Evaluate dental socket
    1. May require Regional Anesthesia
      1. See Inferior Alveolar Block or Periapical Block (Supraperiosteal Dental Anesthesia)
    2. Remove coagulated blood and debris with saline irrigation
    3. Dry base if bleeding
      1. Consider using Nasal Cannula at 10-15 L blown at tooth base to assist keeping surface dry
    4. Evaluate for alveolar bone Fracture
      1. May occur with Tooth Avulsion
      2. Reduce alveolar Fracture prior to tooth reimplantation
  4. Reimplant tooth as soon as possible
    1. Determine correct position and orientation in dental arch
    2. Insert tooth gently into socket with minimal pressure
      1. Gentle rocking may be needed to orient the tooth correctly in the socket
    3. Align the tooth with adjacent teeth
      1. Check the Occlusion or bite
      2. Patient may bite gently down on a wash cloth to secure in place
  5. Secure tooth with temporary splint to adjacent teeth
    1. See Dental Splint
  6. Additional measures if tooth avulsed and out of mouth for more than 1 hour
    1. Soak tooth in 2% Sodium Fluoride solution for 20 minutes prior to reimplantation attempt
  • Management
  • Reimplantation not possible
  1. Transport tooth to dentist if reimplant not possible
  2. Tranport media
    1. Hank's Balanced Salt Solution (e.g. Save-A-Tooth)
      1. Considered best option by some dentists
    2. Pasteurized Milk packed in ice (not evaporated or condensed)
    3. Normal Saline
    4. Avoid harmful storage media
      1. Do not store in Saliva due to cell lysis, infection
      2. Do not store in patient's mouth (aside from dental socket) due to aspiration risk
      3. Do not store tooth in other person's mouth
      4. Do not store tooth in dry tissue or cloth
      5. Avoid tap water or Gatorade due to risk of Periodontal ligament degradation
  • Management
  • Post-Reimplantation
  1. Dental evaluation as soon as possible
    1. Secure Splinting of tooth
    2. Root canal may be needed at 7-10 days after reimplantation (endodontist)
  2. Antibiotic prophylaxis with Penicillin VK (or Clindamycin) for 7 days
  3. Consider chlorhexadine 0.1% mouthwash twice daily for 7 days
  4. Tetanus Vaccine if not given in last 5 years
  • References
  1. Hehn and Warrington (2016) Crit Dec Emerg Med 30(6):12-3
  2. Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
  3. Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
  4. (2006) Correspondence from Dr. Paul Krasner, DDS
  5. McTigue (2000) Pediatr Clin North Am 47(5):1067-84 [PubMed]