Dental avulsion

Background
  • Dental emergency; for every minute that a permanent tooth remains out of the socket, the chance of successful reimplantation goes down by 1% [1]
  • Tooth is completely removed from its socket
  • Often associated with alveolar ridge fracture

Clinical Features
Avulsion of the right upper incisor.
Avulsed tooth
  • Tooth missing from socket
  • History of recent trauma

Differential Diagnosis

Dentoalveolar Injuries

Odontogenic Infections

Other

Evaluation

Work-up
  • Consider facial films, abdominal films, or CXR if possibility of tooth aspiration or ingestion

Evaluation
  • Determine when avulsion occurred and what storage solution used
    • If re-implanting, best viability with immediate storage in Hank's Balanced Salt Solution, worst viability without any storage medium
  • Account for all teeth
    • Aspiration or swallowed
    • Rule out fragments in lacerations/oropharyngeal space, or significant intrusive luxation/impaction
  • Determine if tooth is primary or secondary
  • Tetanus status

Management

Adult
  • Replace avulsed tooth as soon as possible with local analgesia ± dental block (as long as no alveolar ridge fracture or severe socket injury)
    • If reimplanted within 1hr 66% chance of good outcome
    • Rinse (no scrubbing!) tooth in saline
    • Manipulate tooth only by the crown (Avoid touching root to minimize damage to periodontal ligament)
    • Splint tooth with adjacent teeth
  • If extraoral time > 60 min, soak in citric acid/fluoride and consult dentist[2]
  • Storage solution (in order of efficacy): Hank's Balanced Salt Solution > Milk > saliva > saline
  • Doxycycline 100mg PO BID x 1week (helps periodontal ligaments heal)
  • Penicillin OR Clindamycin are alternatives, especially in pediatrics
  • Tetanus update

Child
  • Do not re-implant primary teeth
    • Increased risk of interference with the eruption of the permanent tooth[3]
  • Refer to pediatric dentist for space maintainer within 1-2 weeks.[4]

Length of Periodontal Ligament Cell Viability Based On Storage Medium [5]
Storage Medium Length of Periodontal Ligament Viability
Dry (no storage medium)< 60 minutes
Milk3 to 8 hours
Oral rehydration solution12 to 24 hours
Hanks’ balanced salt solution12 to 24 hours

Disposition
  • Discharge with dental follow-up on liquid diet
  • Should be seen within 24-48 hours as splint only lasts up to 48 hours

See Also
  • Dental Problems

References
  1. Amsterdam JT. Oral medicine. In: Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Mosby, Inc. 2014; (Ch) 70:895–908.
  2. Mayersak, RJ. Facial trauma, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 42: 368-81.
  3. Amsterdam JT: Oral Medicine, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 68:p 853-856
  4. Benko, K. Acute Dental Emergencies in EM. EM Practice. 2003, 5(5)
  5. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th edition, Ron M. Walls, Robert S. Hockberger, Marianne Gausche-Hill, et al. Oral Medicine. Copyright 2017
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