Tooth Avulsion

Dental Trauma and Emergencies:

Teeth Avulsion:

• Teeth avulsion is a medical/dental emergency that require prompt recognition and treatment in the emergency department.
• Avulsed teeth are teeth which has be totally dislodge from the socket.
• Avulsion results in hypoxia and necrosis of the pulp of the tooth
• Reimplantation is the main goal of emergency care, to preserve the periodontal ligament attached to the roots.

Dental Anatomy:

Assessing Dental Injuries:

History:

• Mechanism of injuries including associated injuries
• Previous dental history, including previous injuries, crowns or prostheses
• Time since injury; avulsion of a permanent tooth is a dental emergency requiring urgent replacement into its socket, with prognosis is dependent on how swiftly the tooth is reimplanted.
• Location of permanent tooth fragments; suggest someone look for missing fragments or teeth at the site of injury.

Examination:

• Symmetry in the mouth
• Bite; check for malocclusion, subjective or objective
• TMJ’s
• Numbness, intra-or extra oral bruising
• Bony steps in maxilla or mandible
• Lift the lips to look for gingival or oral mucosal injury
• Type of tooth and whether permanent or primary
• Type of dental injury
• All lost teeth and fragments should be accounted for, including examining chest and soft tissues of mouth

Differentiating between primary and permanent teeth:

• Primary teeth: small, very white, bulbous crowns, often worn, flat edges
• Permanent teeth: larger, creamier in colour, jagged edges on newly erupted teeth. Permanent incisors usually erupt sometime between the ages of 6 and 8 years.

Investigations:

• OPG (Orthopantogram) if considering fractured mandible, or TMJ injury
• CXR: if suspicious of aspirated tooth or unconscious trauma patient

Management of the avulsed tooth:

• Reinsertion is best done within a few hours of injury.
• The tooth should be cleaned with saline, then place into storage medium. Avoid touching the root surface. The socket should be packed with sterile gauze.
• Storage medium is more important than time out of mouth.
• Milk is the preferred storage medium, flavoured milk has no use, and tooth should be kept in milk for transport with ice pack around the milk if possible. Saline/saliva can also be used if milk is not available.
• Don’t get the patient to hold the tooth in the buccal pouch, milk has been shown to be just as effective, and some patients have ended up swallowing the tooth.
• The socket should be irrigated with saline, and local anaesthetic can be used to provide analgesia, before reinserting the tooth.
• Once the tooth has been reinserted, it needs to be splinted in place, while awaiting definitive management. Splinting can be achieved by molding Blu-tac or aluminum foil around the tooth to hold in place.
• Advise patient not to eat or drink anything hot or cold, until definitive care.
• Early and prompt referral to dental surgeon or maxillary facial surgeon

Reference

• Doshi, D. & Hogg, K. (2009). Avulsed tooth brought in milk for replantation. BestBETs