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What 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
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 (ie 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.
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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.
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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.
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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.
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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:
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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.
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Place the tooth is a cup of clean saline (salt
water). You may make saline 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.
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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.
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A commercial product 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. It is called Save-A-Tooth, and can be ordered by
clicking
here.
Instructions for the dentist
1. If the tooth has been properly replaced in the socket at the
site of the accident:
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Do not extract the tooth to treat the root.
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Clean the effected area with water spray, or chlorhexidine
mouth rinse.
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Verify proper alignment of the tooth by the following
methods:
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Have the patient bite down and verify that the tooth is
not in traumatic occlusion and remains in acceptable alignment with neighboring teeth.
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Take a periapical x-ray
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if the tooth is in traumatic occlusion, remove the tooth
from the socket and proceed to step 2 below.
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Suture gingival lacerations
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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.
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prescribe a suitable antibiotic (doxycycline is ideal).
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Refer to physician for evaluation of tetanus immunization.
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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.
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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:
3. Spilinting the tooth in
position:
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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 involve bonded orthodontic brackets and 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
flexiblity 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 vehemently.
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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.
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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):
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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.
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The splint should be removed in 7 to 10 days unless the
radiograph shows serious bony involvement along the lateral edges of the
root.
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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.
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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.
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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.
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