Overview
Definition:
Dental avulsion refers to the complete displacement of a tooth from its alveolar socket.
Epidemiology:
Most common dental emergency in children, often resulting from falls, sports injuries, or interpersonal violence
Peak incidence is typically between 2-4 years and 10-14 years old
Affects permanent teeth more frequently than primary teeth in older children and adolescents.
Clinical Significance:
Prompt and appropriate management in the ED is crucial to maximize the chances of successful tooth survival and function, minimizing long-term complications such as ankylosis, replacement resorption, and the need for prosthetic rehabilitation
Early intervention significantly impacts prognosis.
Clinical Presentation
Symptoms:
Sudden onset of tooth loss
Visual evidence of missing tooth
Parental or patient report of trauma
Pain may be present, especially with associated injuries
Bleeding from the socket.
Signs:
Empty alveolar socket
Bleeding from the gingival margin of the socket
Possible associated facial or oral soft tissue lacerations
Presence of the avulsed tooth in the patient's possession or nearby
Assessment of surrounding teeth for other injuries (fractures, luxations).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the history of trauma and the presence of an empty tooth socket with the avulsed tooth absent from the mouth.
Diagnostic Approach
History Taking:
Mechanism of injury (fall, direct blow, collision)
Time elapsed since avulsion
How the tooth was stored (if at all)
Patient's immunization status for tetanus
Medical history, including any bleeding disorders or conditions affecting healing
Last dental visit.
Physical Examination:
Thorough intraoral examination to assess the avulsed tooth socket, surrounding teeth, and soft tissues for further trauma
Extraoral examination for facial fractures or lacerations
Assess the state of the avulsed tooth (dryness, contamination, fracture).
Investigations:
Radiographs (intraoral periapical and occlusal views) are essential to confirm complete avulsion, assess for root fractures, and rule out luxation or intrusion of adjacent teeth
Panoramic radiographs may be considered for complex facial trauma
Tetanus prophylaxis status should be confirmed.
Differential Diagnosis:
Tooth fracture (crown or root)
Luxation (loosening without displacement)
Intrusion (displacement into the socket)
Extrusion (partial displacement out of the socket)
Primary tooth avulsion (often managed differently due to resorption concerns).
Management
Initial Management:
If the avulsed tooth is present, retrieve it immediately
Assess the storage medium if the tooth is not in the mouth
Encourage the patient/guardian to rinse the mouth with saline
Control any active bleeding from the socket by applying gentle pressure with sterile gauze
Assess tetanus prophylaxis status and administer if needed.
Reimplantation Procedure:
For permanent teeth, gently rinse the avulsed tooth with saline (avoid scrubbing or using soap/antiseptics)
Re-implant the tooth into the socket as soon as possible
If re-implantation is not possible in the ED, store the tooth in an appropriate medium
Permanent teeth avulsed less than 60 minutes ago with dry time < 60 minutes: Rinse tooth gently with saline
Re-implant immediately
Splinting will be required
Permanent teeth avulsed > 60 minutes ago or dry time > 60 minutes: May have poor prognosis
consider topical antibiotics and splinting, but survival is unlikely
Some protocols suggest attempting re-implantation after soaking in doxycycline solution (1mg/50ml) for 5 minutes if available, followed by saline rinse and re-implantation
Primary teeth avulsion: Re-implantation is generally NOT recommended due to risk of damage to developing permanent teeth (germs) and potential for ankylosis or inflammatory resorption
Focus on managing the socket and ruling out displaced adjacent teeth.
Storage Medium:
Ideal: Hank's Balanced Salt Solution (HBSS)
Acceptable: Cold milk
Less ideal but usable for short periods: Saliva (e.g., in the patient's mouth if conscious and cooperative)
Avoid: Tap water, dry storage.
Splinting:
After re-implantation, stabilize the tooth with a flexible splint (e.g., composite resin splint) to prevent further displacement and aid healing
This is usually done by a dentist or oral surgeon, but in some EDs, temporary splinting may be initiated
The splint should extend to the adjacent teeth.
Follow Up:
Referral to a dentist or pediatric dentist is mandatory within 24 hours for definitive management, including splinting, monitoring, and antibiotics
Follow-up appointments are crucial for monitoring for complications like infection, ankylosis, and root resorption
Radiographs should be taken at 1 week, 4-6 weeks, and then at 6-12 month intervals.
Complications
Early Complications:
Infection of the socket or surrounding tissues
Pulp necrosis
Bleeding.
Late Complications:
Ankylosis (fusion of tooth root to bone, preventing eruption and leading to infraocclusion)
Replacement resorption (bone gradually replaces the root tissue)
Inflammatory resorption (due to bacterial contamination of the root surface)
Pulpal obliteration
Development of cysts.
Prevention Strategies:
Rapid and appropriate management (short extra-oral dry time)
Proper storage medium
Prompt re-implantation
Adequate splinting
Strict adherence to follow-up dental care
Prophylactic antibiotics may be considered in high-risk cases.
Prognosis
Factors Affecting Prognosis:
Time of extra-oral dry period (most critical factor)
Storage medium
Maturity of the tooth (younger teeth have better pulp vitality)
Presence of infection
Mechanism of injury
Adequacy of subsequent dental care.
Outcomes:
With immediate re-implantation and minimal dry time (< 60 minutes), the prognosis for pulp survival and retention of the tooth is good
However, even with ideal management, pulp necrosis is common, necessitating endodontic treatment (within 7-10 days of re-implantation)
Long-term success depends on preventing complications like ankylosis and resorption.
Follow Up:
Regular dental follow-up is essential for monitoring prognosis
Typically includes clinical and radiographic assessment at 1 week, 4-6 weeks, and then every 6-12 months for several years
Endodontic treatment is often required
Monitoring for signs of ankylosis or resorption is vital.
Key Points
Exam Focus:
Primary goal: Save the tooth
Time is critical
Correct storage medium is vital
Differentiate management of permanent vs
primary teeth
Tetanus status is important
Re-implantation guidelines based on dry time.
Clinical Pearls:
Ask about the exact time of avulsion and how the tooth was stored
Never scrub the tooth or use harsh disinfectants
Milk is a readily available and acceptable storage medium if HBSS is unavailable
Immediate referral to a dentist is paramount
Primary tooth avulsion is usually NOT re-implanted.
Common Mistakes:
Prolonged delay in seeking ED care
Improper tooth storage (tap water, dry)
Aggressive cleaning of the avulsed tooth
Re-implanting primary teeth
Failure to confirm tetanus status
Neglecting immediate dental referral for definitive care.