Avulsed Tooth (tooth loss)

4.13 Avulsed Tooth (tooth loss)

Presentation
After a direct blow to the mouth the patient may have a permanent tooth knocked from its socket. The tooth is intact, down to its root, from which hangs the delicate periodontal ligament that used to attach to alveolar bone and provide the tooth with its blood supply.
What to do:



In the field, avulsed teeth may be stored under the tongue or in the buccal vestibule between the gums and the teeth. If the patient is unconscious, the tooth can be stored in saline, milk or water until a better preservation solution is available. A child's tooth might be preserved, if necessary, in the parent's mouth.



If the tooth has been out of its socket less than 15 minutes, take it by the crown, drop it in a tooth-preservation solution (Hank's solution, Sav-A-Tooth kit), flush the socket with the same solution, reimplant the tooth firmly, have the patient bite down firmly on a piece of gauze to help stabilize the tooth and when possible secure it to adjacent teeth with wire, arch bars, or a temporary periodontal pack (Coe- Pak). Coe-Pak is a peridontal dressing that comes in the form of a base and catalyst. Mix together and mold the resulting paste, which will eventually set semi-hard, over the gingival line and between the teeth. Put the patient on a liquid diet, prescribe penicillin VK 500mg qid x 2 weeks, and schedule a dental appointment.



If the tooth was out 15 minutes to 2 hours, soak for 30 minutes to replenish nutrients. Local anesthesia will probably be needed before reimplanting as above.



If the tooth was out over two hours, the periodontal ligament is dead, and should be removed, along with the pulp. The tooth sould soak 30 minutes in 5% sodium hypochlorite (Clorox), and 5 minutes each in saturated citric acid, 1% stannous fluoride and 5% doxycycline before reimplanting. The dead tooth should ankylose into the alveolar bone of the the socket like a dental implant.



If the patient is between 6 and 10 years old, also soak the tooth for 5 minutes in 5% doxycycline to kill bacteria which could enter the immature apex and form an abscess.



If you are not able to perform all this right away, simply keep the tooth soaking in the preservation solution until a dentist can get to it. The solution should preserve the tooth safely for up to four days.



If a tooth is lost, obtain a chest x ray to rule out bronchial aspiration.



Add tetanus prophylaxis if required
What not to do:



Do not touch a viable root with fingers, forceps, gauze or anything, or try to scrub or clean it. The periodontal ligament will be injured and unable to re-vascularize the re-implanted tooth.



>Do not overlook fractures of teeth and alvolar ridges.



Do not substitute the calcium hydroxide composition (Dycal) used for covering fractured teeth for the temporary periodontal pack (Coe- Pak) used to stabilized luxated teeth. They are different products.



Do not replace primary deciduous teeth. Reimplanted primary teeth heal by ankylosis: they literally fuse to the bone, which can lead to cosmetic deformity since the area of ankylosis will not grow at the same rate as the rest of the dentofacial complex. Ankylosis can also interfere with the eruption of the permanent tooth. Normal developmental shedding of primary decidual teeth is preceded by absorption of the root, so that if such a tooth is brought to the ED by mistake, there is no root to reimplant in the socket, but a new permanent tooth underneath.
Discussion
Before commercially-available 320mOs, pH 7.2 reconstitution solutions, the best we could offer the avulsed tooth was rapid reimplantation. Without a preservation solution, the chances of successful reimplantation decline one percentage point every minute the tooth is absent from the oral cavity. In mature teeth, over age 10, the pulp will not survive avulsion even if the periodontal ligament does, and at the one-week follow-up visit with the dentist, the necrotic pulp will be removed to prevent a chronic inflammatory reaction from interfering with the healing of the periodontal ligament.
References:



Krasner P: Modern treatment of avulsed teeth by emergency physicians. Am J Emerg Med 1994;12:241-246