Avulsed Tooth

6 Interesting Facts of Avulsed Tooth

1. Avulsed tooth is the complete displacement—secondary to trauma—of an entire tooth from the alveolar bone, associated with pulp necrosis and possible attachment damage
2. Diagnosed using clinical and radiographic evidence
3. Treatment depends on length of time tooth has been outside its socket; replantation within 60 minutes is optimal. Procedures vary depending on time out of socket and status of tooth
   • Dentist or someone trained in emergency dental procedures should prepare the involved area and splint the tooth
4. Appropriate tooth hydration medium is vital to successful reimplantation
5. Never replace avulsed primary teeth
6. Follow-up begins with monthly clinical and radiographic monitoring of the reimplanted tooth, with the schedule gradually extending to yearly

Pitfalls

• Transporting the tooth in an unsuitable medium
  • Storing a tooth in water will cause periodontal cell death within a few minutes
• Reattaching the tooth without knowing how long it has been out of the socket
• Not recognizing trauma to other parts of mouth, head, or neck
• When the tooth is not located and aspiration is suspected, a chest radiograph is indicated

• Avulsed tooth is the complete displacement—secondary to trauma—of an entire tooth from the alveolar bone, associated with pulp necrosis and possible attachment damage 
  • Pulp necrosis
    • Always occurs after tooth avulsion
    • Degree depends on how quickly revascularization and endodontic therapy are initiated 
  • Attachment damage
    • Avulsion causes damage to the attachment apparatus of the root, including the periodontal ligament and the cemental layer

Classification

• Primary versus permanent teeth
  • Primary or deciduous (baby) teeth
    • Typically, there are 20 primary teeth
    • Erupt around age 6 months and are usually gone by age 6 years
    • Help child to chew and speak
    • Serve as placeholders for permanent teeth
    • Do not reimplant after avulsion
  • Permanent teeth
    • Typically, there are 32 permanent teeth
    • Closed apex versus open apex permanent teeth 
      • Apex is a small opening at or near the tip of the cone-shaped root through which nerves and blood vessels connect to the tooth pulp
        • Open apex: root tip of avulsed tooth is exposed (revascularization is possible)
        • Closed apex: root tip of avulsed tooth is not exposed (revascularization is not possible)

Clinical Presentation

History

• Patient presents after recent mouth trauma with tooth displaced from its socket
  • Mild to severe constant pain is common
  • Neurapraxia may cause numbness of gingiva
• Important facts regarding the injury
  • Investigate circumstances of injury to assess for other trauma
    • Trip and fall against an object
    • Direct blow to mouth with fist or weapon
    • Motor vehicle accident
    • Seizure
  • Success of treatment depends on length of time between injury and treatment 
    • Dry time of the tooth before it was placed in storage medium
      • After 60 minutes of exposure, periodontal cells are unlikely to be viable
  • Way the avulsed tooth is handled and transported helps predict prognosis and set expectations for successful reimplantation 
    • Length of time tooth was exposed to dry air
    • Solution used to keep tooth hydrated
• Other important factors
  • Developmental stage of tooth (primary or permanent)
  • Any prior injuries to avulsion site
  • Any previous treatment at avulsion site

Physical examination

• Teeth most commonly involved are the maxillary central incisors
• Determine if teeth involved are primary or permanent
• Examine area around mouth and face
  • Swelling may not be present if traumatic force impacted individual tooth only
• Examine socket
  • By definition, avulsed tooth is completely displaced from its socket
  • Socket typically is empty or filled with a bloody coagulum
  • Examination determines whether socket is intact and suitable for reimplantation or requires repair
• Examine injured tooth
  • Apply light pressure on surrounding teeth and palpate socket and surrounding apical areas
    • If segment with multiple teeth moves, it suggests alveolar fracture
  • Gently rinse socket with saline and clear it of clots and debris
    • Inspect socket walls to determine if socket requires repair before reimplantation
  • Determine whether tooth is primary or permanent
    • If permanent, determine whether tooth is closed or open at apex
• Completely examine all teeth
  • Required to identify any additional dental or lingual trauma to rule out other more severe injury (eg, sublingual hematoma, alveolar fracture)
• If tooth is missing and unaccounted for, consider that it may have been swallowed or aspirated

Causes and Risk Factors

Causes

• Trauma (face and mouth) from sports, physical altercation, or motor vehicle accident

Risk factors and/or associations

Age

• Most common ages for avulsion of permanent teeth are 8 to 12 years 

Other risk factors/associations

• Class II malocclusion
  • In patients with significant horizontal or vertical overlapping teeth, avulsion can be precipitated by trauma caused by misaligned teeth
• Periodontal disease 

Diagnostic Procedures

Primary diagnostic tools

• History and physical examination are the most important diagnostic and prognostic tools for avulsed teeth
• Diagnostic indicators for pulp necrosis, a sign of unsuccessful reimplantation that indicates poor prognosis:
  • Visual inspection of tooth reveals gray discoloration of crown
    • Caused by infection-related external root resorption 
  • Palpation of tooth demonstrates tenderness
    • Tenderness to percussion and palpation in the vestibule develop after an asymptomatic period of about 3 months 
  • If tooth crown is discolored or palpation of tooth demonstrates tenderness, obtain radiographs
  • If tooth is discolored or there is periapical radiolucency on radiographic evaluation, evaluate with pulp sensitivity test
• Dental radiography
  • Allows periapical radiolucency to be identified
  • When conventional dental radiographs are insufficient, try panoramic radiography or cone-beam CT
• Perform chest radiograph if aspiration of the tooth is suspected 
• Both primary and permanent avulsed teeth require a similar diagnostic process 

Imaging

• Periapical radiograph
  • Obtain immediately for all patients with an avulsed tooth 
  • Radiologic findings that confirm diagnosis:
    • Socket is empty
    • There are fracture lines in the socket
  • Radiologic findings also help to rule out presence of root fragments, alveolar fracture, and intruded tooth 
    • Intruded tooth
      • Displacement of tooth into alveolar bone along the axis of the tooth
      • Accompanied by comminution or fracture of the alveolar socket
• Panoramic radiography
  • Requires specialized equipment
  • Indicated when traditional periapical radiographs (intraoral and bitewing radiographs) are inadequate or patient cannot tolerate them
• Cone-beam CT scan
  • Becoming standard of care in dentistry
  • Requires highly specialized and dedicated equipment
  • Indicated when traditional and panoramic radiographs are inadequate to exclude pulp necrosis
  • Advantages over traditional periapical and panoramic radiographs include more rapid scan time, more limited beam with decreased radiation exposure, and enhanced image accuracy
• Chest radiograph 
  • Indicated when tooth aspiration is suspected:
    • Missing tooth cannot be located after trauma
    • Pediatric patient or patient with decreased level of consciousness
  • Tooth is radiopaque and may appear in bronchial tree

Functional testing

• Testing for pulp necrosis
  • Sensibility testing most commonly used
    • Not recommended in primary teeth owing to unreliability of testing 
    • Tests pulp sensory response/innervation
      • Thermal testing
        • Apply thermal stimuli to tooth and record degree of pain
          • If reinnervation has not occurred within 6 months and there is no response to sensitivity tests: 
            • Revascularization has failed
            • It is evidence of pulp necrosis
      • Electrical testing
        • Place a test probe on reimplanted tooth; apply electric current and gradually increase it until patient feels as if tooth is clicking and buzzing
        • Repeat test on surrounding teeth
        • Absence of sensation indicates pulp necrosis
          • Root canal therapy or dental extraction are indicated
        • Can be done at any time after reimplantation but typically done about 4 to 6 weeks after reimplantation to allow time for healing and neovascularization 
        • Immediate negative response does not signify definitive pulp necrosis
          • Severed neurovascular supply can be reestablished in many cases
  • Vitality testing
    • Tests pulp blood flow
    • Pulse oximetry, Doppler flowmetry, and ultrasonographic Doppler flowmetry
    • Accuracy is favorable over sensibility testing but bias may occur 

Differential Diagnosis

Most common

• Alveolar fracture
  • Physical examination
    • Suspect alveolar fracture when pressure applied to surrounding teeth causes a segment of multiple teeth to move 
  • Radiologic evidence
    • Vertical line of the fracture is seen running along the septum
    • Horizontal line of the fracture may be at any level from marginal bone to root apex 
  • Simple tooth avulsion will not result in movement of more than 1 segment of teeth
• Fractured tooth
  • Part of the tooth remains in the socket
  • Physical examination
    • Physical findings depend on fracture location
    • Classification (Ellis I, II, III) 
    • Physical manipulation of tooth may induce pain, but tooth itself will not shift or move out place
  • Fracture lines are evident on dental radiograph
    • No tooth fragments are visible with simple tooth avulsion

Treatment Goals

• Maintain tooth viability
• Prevent infection in injured tooth and socket
• Manage pain

Disposition

Recommendations for specialist referral 

• Although avulsed teeth are routinely evaluated and splinted by emergency physicians, urgently refer all patients with avulsed teeth to a dentist for definitive evaluation and treatment
  • Refer children aged 3 years and younger and children who may present a behavior problem to a dentist with experience sedating and managing children
• Refer adults who have significant facial swelling emergently to an oral surgeon

Treatment Options

Handling of the tooth after avulsion affects its viability, specifically: 

• Storage medium used to transport the tooth
• Amount of time tooth remains outside the socket
  • Prognosis is poor for a tooth that has been outside the socket for 60 minutes or more, even in an appropriate solution

Treatment depends on 3 factors: 

• Whether the tooth is primary or permanent
• Duration of air exposure
• Whether tooth apex is open or closed

To maintain viability of the avulsed tooth, instruct patient or caregiver to do the following immediately after trauma: 

• Before arriving at clinical setting:
  • Find tooth and pick it up by its crown
    • Do not touch the root because this may damage the periodontal ligament and decrease the attachment potential
  • If tooth is dirty, wash it briefly (10 seconds) using Hanks’ Balanced Salt Solution, milk or saliva 
  • If tooth can be repositioned into its socket, do so
    • Bite on a handkerchief to hold tooth in position
  • If tooth cannot be repositioned into its socket, place it in a suitable storage medium 
    • Suitable medium maintains hydration and increases survival of periodontal ligament cells on root of the avulsed tooth 
      • Decreases inflammation
      • Improves potential for development of new cementum
    • Storage media
      • Although Hanks’ Balanced Salt Solution is the ideal storage medium, it may be difficult to find 
      • Cold milk is the most recommended storage medium, based on availability as well as cell viability and practicality 
      • Inside the mouth between the molars and inside of cheek (not recommended in children who are at risk of swallowing or aspirating the tooth)
      • Saline
      • Wrap in cling film that retains the thin fluid film on tooth’s surface
      • Oral Rehydration Solution, which may be prepared with local ingredients based on availability in limited resource settings
      • Not water
        • Storing a tooth in water will cause periodontal cell death within a few minutes
• After arriving at clinical setting (medical provider office):
  • Determine if tooth is primary or permanent
    • Primary tooth: never replace avulsed primary tooth
      • Can damage alveolar socket and developing permanent tooth
    • Permanent tooth: determine status of tooth apex and how long tooth was exposed to air 
      • Open apex only: doxycycline increases chance of revascularization
        • Soak tooth in 1% doxycycline solution for 5 minutes
          • Preparation of 1% doxycycline: 1 mg/20 mL doxycycline solution or doxycycline capsule 50 mg dissolved in 1000 mL saline

Provide tetanus prophylaxis, if necessary

Drug therapy

• Start antibiotics and pain medication simultaneously
• Antibiotics
  • Start every patient who has an avulsed tooth on antibiotics, whether tooth is open or closed apex, regardless of extra-oral dry time
  • Tetracycline class antibiotics (doxycycline)
    • First-choice treatment for permanent teeth
      • Doxycycline Hyclate Oral capsule; Children and Adolescents 8 to 17 years: 2 mg/kg/dose PO daily (Max: 100 mg/dose) for 7 days. 
      • Doxycycline Hyclate Oral capsule; Adults: 100 mg PO daily for 7 days. 
  • Amoxicillin is an alternative to doxycycline and recommended for open apex
    • Amoxicillin Oral suspension; Children and Adolescents: 50 mg/kg/day PO in divided doses (every 8 hours) for 7 days. 
    • Amoxicillin Oral capsule; Adults: 500 mg PO 3 times daily for 7 days. 
• Pain control
  • Local lidocaine for tooth reimplantation
  • Only a medical provider should apply local lidocaine to avoid lidocaine toxicity
    • Topical
      • Lidocaine, Prilocaine Gingival gel; Adults: Apply the liquid to the gingival margin; after 30 seconds, fill the periodontal pockets until the gel is visible at the gingival margin. Maximum anesthetic effect is obtained 30 seconds after application. Reapplication is appropriate if anesthetic effect begins to wane.
    • Local infiltration
      • Lidocaine Hydrochloride Solution for injection; Adults: 20 to 100 mg (1 to 5 mL of a 2% solution).
  • Administer pain medication depending on stage of treatment

Nondrug and supportive care

Treatment algorithm for open or closed apex tooth with extra-oral dry time of 60 minutes or less 

• Irrigate socket with saline
• Examine alveolar socket
  • If there is fracture of the socket wall, reposition with a suitable instrument
• Replant tooth slowly with gentle digital pressure; do not use force
• Verify normal position of the replanted tooth both clinically and radiographically

Closed apex (permanent)

• Tooth replanted before arrival at clinic
  • Leave tooth in place
  • Clean area with saline, chlorhexidine, or water spray
  • Suture any gingival lacerations
  • Apply a flexible splint
  • Chlorhexidine rinse must be prescribed and strict hygiene instructions given; it is used during entire splinting period 
  • Administer antibiotics
  • Initiate root canal treatment 7 to 10 days after replantation and before splint removal
• Tooth kept in physiologic or osmolality balanced medium (ie, milk, saline, saliva, Hanks’ Balanced Salt Solution) 
  • Clean root surface and apical foramen with a stream of saline and soak tooth in saline to remove contamination and dead cells from root surface
  • Administer local anesthetic
  • Irrigate socket with saline
  • Examine alveolar socket for fracture and, if noted, reposition
  • Replant tooth slowly with slight digital pressure
  • Suture gingival lacerations
  • Apply a flexible splint for up to 2 weeks, keeping splint away from gingiva
  • Chlorhexidine rinse must be prescribed and strict hygiene instructions given; it is used during entire splinting period 
  • Administer antibiotics
  • Initiate root canal treatment 7 to 10 days after replantation and before splint removal
• Extra-oral dry time 60 minutes or more, or nonviable cells
  • Soak tooth in 3% citric acid for 3 minutes and rinse well with saline to remove periodontal ligament
    • After extra-oral dry time of 60 minutes, the periodontal ligament will become necrotic and not heal
  • Remove attached nonviable soft tissue carefully with gauze
  • Place tooth in 1.23% sodium fluoride (eg, acidulated phosphate fluoride) for 5 to 20 minutes
  • Treat root surface with fluoride before replantation to slow down osseous replacement of the tooth (2% sodium fluoride solution for 20 minutes)
  • Reimplant tooth and stabilize for 4 weeks using a flexible splint; root canal treatment can be done before or 7 to 10 days after replantation
  • Chlorhexidine rinse must be prescribed and strict hygiene instructions given; it is used during entire splinting period 

Open apex 

• Tooth replanted before arrival at clinic
  • Leave tooth in place
  • Clean area with saline, chlorhexidine, or water spray
  • Suture gingival laceration, if present
  • Verify normal position of replanted tooth clinically and radiographically
  • Apply a flexible splint for up to 2 weeks
  • Chlorhexidine rinse must be prescribed and strict hygiene instructions given; it is used during entire splinting period 
  • Administer antibiotics; if tooth left the mouth and tetanus coverage is unknown, administer tetanus booster
  • Replantation of a still-developing tooth (open apex) allows for possible revascularization of the tooth pulp
• Extra-oral dry time under 60 minutes, tooth kept in physiologic or osmolality balanced medium (ie, milk, saline, saliva, Hanks’ Balanced Salt Solution)
  • Clean root surface and apical foramen with saline stream and soak tooth in saline to remove contamination and dead cells
  • Administer local anesthesia
  • Irrigate socket with saline
  • Examine alveolar socket. If fracture exists in socket wall, reposition
  • Replant tooth slowly with slight pressure; do not force
  • Suture lacerations
  • Verify tooth positioning visually and radiographically
  • Apply a flexible splint for up to 2 weeks
  • Chlorhexidine rinse must be prescribed and strict hygiene instructions given; it is used during entire splinting period 
  • Administer systemic antibiotics
    • Tetracycline class antibiotics (doxycycline)
    • Tetracycline may discolor permanent teeth, so use discretion
  • For open apex teeth, applying topic antibiotics increases changes of pulp revascularization
    • Soak in minocycline or doxycycline 1 mg/20 mL saline for 5 minutes

Follow-up for all types of avulsed teeth 

• Patient instructions
  • Avoid participating in contact and high-risk sports for 4 weeks
  • Soft food only for 2 weeks
  • Brush teeth with a soft toothbrush after each meal
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week

Procedures

Root canal

General explanation

• Removing damaged pulp, cleaning and disinfecting tooth, and filling and sealing tooth 
• 7 to 10 days after replantation
  • Use calcium hydroxide intracanal for up to 1 month

Indication

• Any pulpal or periapical pathology, including pulp necrosis 
• Elective devitalization
  • To provide posting space or before constructing an overdenture

Contraindications

• Relative contraindications
  • Extreme root canal anatomy (eg, dens in dente)
  • Heavy marginal periodontitis or focal infection
  • Deep root caries

Complications 

• Root fracture or crown fracture
• Perforation of side of the root
• Recurrent decay
• Tooth color changes

Monitoring

• Reimplanted avulsed permanent tooth with open apex
  • Tooth replanted by patient/family before arrival at office
    • Immature teeth: avoid root canal unless there is evidence (clinical or radiographic) of pulp necrosis
    • After 2 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year, clinically and radiographically assess status; then annually
  • Tooth with either extra-oral dry time shorter than 60 minutes or kept in appropriate storage medium
    • Immature teeth: avoid root canal unless there is evidence (clinical or radiographic) of pulp necrosis
    • After 2 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year, clinically and radiographically assess status; then annually
  • Tooth with either extra-oral dry time longer than 60 minutes or other reasons suggesting nonviability
    • Immature teeth: avoid root canal unless there is evidence (clinical or radiographic) of pulp necrosis
    • After 4 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year, clinically and radiographically assess status; then annually
• Reimplanted avulsed permanent tooth with closed apex
  • Replanted by patient/family before arrival at office
    • 7 to 10 days after replantation, refer for root canal (before splint removal)
      • Calcium hydroxide intracanal up to 1 month or
      • Antibiotic corticosteroid paste immediately or just after replantation for 2 weeks
    • After 2 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year, clinically and radiographically assess status; then annually
  • Tooth with either extra-oral dry time shorter than 60 minutes or kept in appropriate storage medium
    • 7 to 10 days after replantation, refer for root canal (before splint removal)
      • Calcium hydroxide intracanal up to 1 month or
      • Antibiotic corticosteroid paste immediately or just after replantation for 2 weeks
    • After 2 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year clinically and radiographically assess status; then annually
  • Tooth with either extra-oral dry time longer than 60 minutes or other reasons suggesting nonviability
    • 7 to 10 days after replantation, refer for root canal (before splint removal)
      • Calcium hydroxide intracanal up to 1 month or
      • Antibiotic corticosteroid paste immediately or just after replantation for 2 weeks
    • After 4 weeks, remove splint and clinically and radiographically assess status
    • At 4 weeks, 3 months, 6 months, and 1 year clinically and radiographically assess status; then annually

Complications

• Fistula (sinus track)
  • Develops in oral mucosa or gingiva
  • Usually after infection or abscess 
• Pain or tenderness in a tooth that was asymptomatic the first weeks after trauma indicates involvement of the pulp (generally with infection)
• Tooth ankylosis is unavoidable if replantation is delayed
  • Tooth ankylosis is pathologic fusion of the cementum or dentin of a tooth root to the alveolar bone 
    • Tooth has characteristic sound when tapped
    • Tooth lacks normal physiologic mobility and later shows radiographic evidence of replacement resorption
    • In children and adolescents, ankylosis is frequently associated with infraposition
      • Decoronation may be necessary when infraposition over 1 mm is seen 
        • Decoronation is a surgical method in which the crown and root filling are removed, leaving the root in situ to be resorbed and covered with a mucoperiosteal flap
        • Surgery is done because early loss of a permanent tooth leads to loss of alveolar bone, especially in buccopalatal width
        • Decoronation preserves not only the width of the ridge but also the height
• If the tooth has been in contact with soil, possible contamination with Clostridium tetani is a concern
  • Ascertain tetanus immunization status
• Loss of reimplanted tooth
• Pulmonary infection can occur with undetected aspiration of tooth 

Prognosis

• Long-term prognoses of avulsed teeth vary greatly. Teeth that have been avulsed for less than 60 minutes and stored in an appropriate medium have the best prognosis 
  • As many as one-third of reimplanted teeth will fail 
  • Viability and success of reimplantation depend on 3 factors
    • Whether the tooth is primary or permanent
    • Duration of air exposure
    • Whether tooth apex is open or closed

Screening and Prevention

• Use of properly designed mouth guard protection

References

Schatz JP et al: Treatment of luxation traumatic injuries: definition and classification in the literature. Pract Periodontics Aesthet Dent. 12(8):781-6; quiz 788, 2000