Avulsed Teeth (When a tooth gets knocked out)-DoctorSpiller.com

 

avulsed_LargeWhat if you or your child knocks out a front tooth?

Step by step instructions for patients and for dentists

The accidental loss of an adult tooth is a grave event and very tricky to treat.  Even the best techniques sometimes fail to permanently save the tooth.  As you read the rest of this page, bear in mind that there is a distinct possibility that you or your child may loose the tooth even though every step is religiously followed!

Instructions for the patient
Procedures for the dentist
If patient presents with tooth already reimplanted in socket
If patient presents with tooth in hand or improperly reimplanted
If tooth has open apex (blunderbuss)
If tooth has fully formed root (apex)
Splinting the tooth in position
Managing the tooth after the reimplantation

Instructions for the accident victim or parent

1. If the tooth is one of the four front baby teeth (deciduous teeth), there is NO NEED to reimplant it (i.e. do not replace it in the socket).  Front baby teeth do not hold space for the adult teeth that will begin to erupt at age six, and the early loss of one of these teeth rarely causes harm to the adult dentition.

2. If the root of an adult tooth is broken, (especially if part of the root remains in the socket) reimplantation is not possible.  Any attempt will fail.  This means that the trip to the dentist, though necessary, may be put off until it is convenient.  The only things a dentist can do under such circumstances it to prescribe antibiotics, and to place artificial bone in the socket for possible implant placement at a later date.  The placement of artificial bone is a bit involved for an off hours emergency.  The placement of artificial bone is generally best done under the auspices of an oral surgeon or a periodontist.  These specialists have become the de-facto implantology specialists.

3. Any avulsed tooth must be reimplanted in the socket within 60 minutes if the reimplantation is to have a reasonable chance of working. 

This may be done at the site of the accident by any adult including the patient himself provided the tooth is fairly clean and provided it slips back into the socket easily with light finger pressure.  If the tooth goes back into its proper position so that the patient may bite down without pushing the tooth out of its normal alignment, then the process has been successful.

If the tooth is dirty, simply have the patient remove all dirt with their own saliva.  Have the patient suck fairly hard on the tooth.  Be sure that the patient spits out blood and debris after each sucking action.  This removes dirt and will hopefully dislodge any clot that may have formed in the socket making it easier to reimplant the tooth.

If the patient cannot remove the dirt him/herself, simply wash it off in cold water before replacing the tooth back in the socket.

You still must take the patient to a dentist, but the major emergency has been averted and there is less urgency associated with the emergency.

4. If the tooth cannot be replaced in the socket (for any reason), then there are three ways to transport the tooth to the dentist’s office:

Have the patient remove dirt and debris by sucking on the tooth as above and then have the patient store the tooth in their own mouth in the pouch between the cheek and the top back teeth.  Transport the patient to a dentist ASAP.

This is NOT advisable if the child is under the age of six since the child may swallow the tooth.  If this is the case, proceed to the next two options.

Place the tooth is a cup of clean saline (salt water).  Contact lens solution is ideal.  Otherwise, you may make saline yourself by placing one and a half teaspoons of salt in four cups of clean water.  Tap water is acceptable, but bottled water may be cleaner if it is IMMEDIATELY available.  The saline has the advantage of acting to clean off the tooth.  Transport the tooth and patient to the dentist ASAP.

Place the tooth in a cup of fresh milk (any fat content).  This has nearly the same advantages as saline.  Transport the tooth and the patient to the dentist ASAP.

A commercial product called Save-A-Tooth is available for the storage of an avulsed tooth if you, or someone you know happens to have it in their medicine cabinet.  The manufacturer states that the tooth may be reimplanted up to 24 hours after the avulsion if it is kept in this solution.

Instructions for the dentist

1. If the tooth has been properly replaced in the socket at the site of the accident:

Do not extract the tooth to treat the root.

Clean the effected area with water spray, or chlorhexidine mouth rinse.

Verify proper alignment of the tooth by the following methods:

Have the patient bite down and verify that the tooth is not in traumatic occlusion and remains in acceptable alignment with neighboring teeth.

Take a periapical x-ray

if the tooth is in traumatic occlusion, remove the tooth from the socket and proceed to step 2 below.

Suture gingival lacerations

Splint the tooth with (preferably) a flexible splint.  Have the patient bite into occlusion to eliminate traumatic bite prior to splinting.  The splint will be kept on the tooth for 7 to 10 days.

prescribe a suitable antibiotic (penicillin or doxycycline).

Refer to physician for evaluation of tetanus immunization.

If the tooth has an open apex (blunderbuss) avoid doing a root canal unless an abscess develops or there is radiographic evidence of pulpal necrosis.

Proceed to the Post-emergency procedures.

2. If the tooth has not been replaced in the socket, or if it must be removed due to traumatic occlusion or misalignment:

If the tooth has an open apex (not fully formed root)

If the tooth has been out of its socket for much more than an hour, or especially, if the tooth has dried out during transportation, the reimplantation procedure is unlikely to be successful, and the patient or parents should be so informed.  It is still permissible to attempt reimplantation since survival is always possible, even if unlikely. It is, however unlikely that the root will continue to form its apex and apexification will be necessary.  There is also a very substantial chance that the root will experience external resorption or become ankylosed and will fail to further erupt as the child grows.  The most reasonable course of action is to warn the parents of this outcome and to avoid the procedure altogether.

If the tooth has been out of its socket for an hour or less, and has been properly transported to the dental office, then the procedure has a better chance of working.  This implies that the blunderbuss root will continue to form an apex and the tooth will continue to erupt normally after the reimplantation procedure.

Clean the effected tooth with water spray or saline.

Place the tooth in a solution of doxycycline if available (Low concentration, about 1mgm per 20 cc of saline.  Can be made on premises using 1/2 of a 100 mg tablet finely crushed and added to about a liter of saline.  Alternatively, the tooth may be coated with Arestin®, which is commonly found in dental offices. At minimum, clean the tooth with copious saline solution.  Do not use antiseptic solutions on tooth.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket.  If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint.  Have patient bite into occlusion to be certain that the position is correct before applying the splint.  The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation of tetanus immunization.

Do not perform a root canal procedure unless a post op x-ray shows serious periapical involvement.  The idea here is to allow the root apex to form normally.  If the pulp dies at any point during treatment, then a root canal procedure with apexification will be necessary.

If the tooth has a fully formed apex

If the tooth has been out of its socket for an hour or less, and it has been properly handled (as stated above in instructions for patients), the reimplantation procedure is the same as that shown above with the exception of the use of doxycycline rinse.  The instructions are repeated below for clarity and completeness:

Clean the effected tooth with water spray or saline. Do not use antiseptic solutions on tooth.

Coat the root of the tooth with Arestin® or dip it in a solution of doxycycline and saline if available.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket.  If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint.  Have patient bite into occlusion to be certain that the position is correct before applying the splint.  The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation for tetanus immunization.

Proceed to post-emergency procedures.

If the tooth has been out of the socket for well over an hour, or if the tooth has been allowed to dry out during transport, the treatment differs from that above mostly because of changes that have taken place on the surface of the root.  The following procedure is designed to minimize external root resorption during post operative healing.

Rinse off all debris from the tooth with copious water or saline.

Gently and quickly root plane the root of the tooth to remove necrotic periodontal ligament and any foreign debris that has dried onto the surface.

Immerse the tooth in a 2.4% Sodium Fluoride solution acidulated to pH 5.5 for 5 minutes. This item is rarely found in dental offices today.  It has been replaced with various neutralized rinses, gels and foams of lesser concentration. In the absence of the stronger solution, a lesser concentration of fluoride may be used instead.  The idea is to convert surface hydroxyapatite into fluoroapetite to reduce external resorption during healing.  Keep the tooth in the fluoride solution for a minimum of five minutes; 20 minutes if possible.  Wash off the fluoride solution afterwards with copious saline. Click here to see a clinical study recommending this procedure.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket.  If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

If available, apply Emdogain® to the inside of the socket.  This is a specialty item and is not likely to be found in the offices of most general dentists.  It has been found to be helpful in experimental situations but no human studies have been carried out to prove its usefulness in reimplantation of avulsed teeth. If available, it may be useful, but certainly not essential.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint.  Have patient bite into occlusion to be certain that the position is correct before applying the splint.  The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation of tetanus immunization.

Proceed to post-emergency procedures.

3. Splinting the tooth in position:

The ideal splint for avulsed teeth is a flexible splint.  These are typically made using Gortex or other synthetic cloth or metallic mesh strips made for this purpose.  Other types of flexible splint may be made using thin orthodontic wire.  Ideally, the splint should encompass several teeth on either side of the avulsed tooth.  There are quite a few options depending on the comfort level of the practitioner.  The recommendation for flexibility involves theoretical considerations in the formation of the new periodontal ligament.  However, since the splint is kept in place for no more than 7 to 10 days, the flexibility factor may be of little practical significance.   This is my personal opinion.  I’m sure others would argue the point.

The simplest type of splint involves nothing more than a fairly thick strip of light cured composite running across three teeth with the avulsed tooth in the middle.  I have found that this works quite well.  The procedure for upper incisors (the most commonly avulsed teeth) involves having the patient bite into occlusion and keeping his teeth in this position for the entire procedure.  This stabilizes the tooth and guarantees that the tooth will not be in traumatic occlusion.  The three teeth are pumiced and acid etched.  Bond is applied and light cured.  Finally a fairly thick layer of composite is layered over the buccal surfaces of three teeth.  I try to keep it neat, but this is a functional repair and will be removed in a week, so I generally use a color that contrasts with the teeth in order to make removal easier.  I do not spend much time forming it to look like a restoration.

In the case of lower incisors, I place the splint on the buccal surface if the occlusion permits.  Otherwise, I place it lingually

The splint is removed in about a week (10 days tops) and assessed for mobility.  If the mobility is excessive, then reapply the splint for another several weeks.  Otherwise, allow the tooth to function normally.

4. Post-emergency procedures (managing the tooth after reimplantation):

Root canal procedure should be initiated in 7-10 days unless the avulsed tooth has an open apex and the tooth was reimplanted under optimal conditions.

Teeth with an open apex might revascularize and continue forming a complete root.  these teeth should be monitored radiographically every three days for the first week, then weekly for a month, and periodically after that.

The splint should be removed in 7 to 10 days unless the radiograph shows serious bony involvement along the lateral edges of the root.

If the tooth has a closed apex, or if a tooth with an open apex has obviously abscessed or shown radiographic evidence of pulpal necrosis, begin the root canal procedure prior to removing the splint.

At this time, instrument the canal completely and place calcium hydroxide paste in the canal. Allow the paste to remain in the canal for approximately a month prior to obturation of the canal.

The root canal procedure may be completed when an intact lamina dura can be traced all the way around the root.  In most cases this will happen within a month.  If the lamina dura has not begun to form, or if external resorption is apparent on the radiograph, then the calcium hydroxide should remain in the canal.  The status of the lamina dura should be checked one month post op and at three month intervals after that.  At the time of the exam, the calcium hydroxide paste should be washed out and replaced with fresh paste.