Tooth Avulsed


Article Author:
Saleh Alotaibi


Article Editor:
Noel Wagner


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
3/23/2019 11:29:30 AM

Introduction

Dentoalveolar trauma are injuries caused by an external impact on the dentition and its surrounding apparatus; they can have multiple outcomes ranging from contusion of the tooth to total dislocation of the tooth from the alveolar bone, termed tooth avulsion. A significant amount of force is usually necessary for avulsion of teeth, and other injuries to the surrounding structures should be suspected.[1]

Etiology

Traffic accidents, violence, full contact sports, and falls, especially in younger patients with poor balance are the most common causes of an avulsed tooth. The maxillary central incisors are the most commonly affected teeth, and often more than one tooth is avulsed.[2] In a systematic review published in 2015, the most common places for dental trauma to occur was found to be in a home setting, followed by school and street settings.[3]

Epidemiology

In a study conducted on 1298 trauma patients that received treatment in the emergency room, 24% included dental injuries. Of which, 16% avulsed teeth most commonly in school-aged patients. [4] Bemelmans reported that at least 32% of athletes involved in full contact sports had experienced some form of injury to their dentition.[5] The highest prevalence of dental trauma was reported in children, mainly due to their weak balance and poor coordination when they start walking.[6] In general, dental trauma showed more gender predilection with male patients having a higher prevalence than females.[7] 

Pathophysiology

The periodontal ligament (PDL) is the soft tissue connecting the cementum that covers the roots of the teeth to the surrounding alveolar bone. When an external impact occurs on a tooth, the fibers of the periodontal ligament can tear causing total displacement of the tooth from the socket.[8]

Histopathology

Maintaining the viability of the periodontal fibers remaining the root of the tooth after avulsion is integral for the long-term prognosis. Immediate replantation will allow the PDL to reform the connections within the socket.[9] The current general consensus is that time lapsed since the avulsion is the most critical factor for the prognosis and immediate replantation and of the avulsed tooth yields the best results, with the prognosis worsening as time increases.[10]

History and Physical

A history of trauma to the tooth will reveal tooth avulsion, and the mechanism of injury can point to other injuries. History should include the length of time since tooth avulsion, the storage medium in which the tooth has been placed, and if the tooth is a primary or permanent tooth. By 14 years of age, a patient's primary teeth should be replaced by permanent teeth. Physical examination involves the assessment of the tooth socket for foreign material, tooth fragments, and lacerations as these can prevent tooth replantation. Evaluation of the surrounding structures for other injuries such as lacerations, fractures, and ecchymoses is also necessary.  If a tooth is avulsed and not found, aspiration of the tooth or an intruded tooth should be a consideration.

Evaluation

Imaging modalities including extra and intraoral radiographs and CT scans can aid in evaluation for alveolar and surrounding fractures, assessment to verify that the tooth is not intruded when not found intraorally, but it can delay tooth replantation.

Treatment / Management

Most often tooth avulsions occur outside of treatment facilities. Avulsed teeth should be handled by the crown to prevent damage to the root surface and PDL fibers. Studies have shown that if the tooth is not going replanted within in five minutes, it should be placed in a storage media such as a balanced salt solution and milk. These can increase the time of viability of avulsed teeth, while media such as water can damage the PDL due to its low osmolality.  If no storage media is available, a tooth may be placed back in the mouth for saliva to act as the storage media. Before replantation, the socket and tooth may be lightly irrigated with normal saline to clean the structures, and the socket may be aspirated gently if a blood clot is obstructing it.  The tooth should be aligned anatomically, and firm pressure applied into the socket to replant the tooth.  Most teeth can be successfully replanted if the extraoral dry time is less than 60 minutes; after this period the survival of the tooth is unlikely. Storage media can increase the viability time of the PDL allowing for more than 60 minutes.  If extraoral dry time is more than 60 minutes, soaking the tooth in agents such as fluoride may decrease resorption rates. Immature teeth where the root has not yet wholly formed have a greater chance of revascularization with soaking in doxycycline, increasing the success rate in these teeth. Dental consultation is recommended in these cases.[11]

Bonding resins and sutures may be needed and a fixable splint two weeks is indicated for securing the tooth in place once replanted. Primary teeth should not undergo replantation as this can damage the underlying permanent tooth germ.[11]

In cases where the dry time was more than 60 minutes, and there was no use of any storage media, removal of the remaining PDL should undertaken as it will become a stimulus for continued inflammation that accelerates infection-related resorption and ankylosis. The remaining PDL can be removed by multiple methods that include; gentle scaling and root planning, soft pumice prophylaxis, gauze, or soaking the tooth in 3% citric acid for 3 minutes. The fluoride treatment must follow this process as it slows down the process of ankylosis and reduces the risk of resorption.[12]

Differential Diagnosis

Differential diagnosis of tooth avulsion includes complete intrusion of the tooth into the alveolar bone. These two conditions can be easily distinguished by the history obtained from the patient/parent and by imaging modalities.

Prognosis

In a study published by Karayilmaz et al., they examined the long-term prognosis of avulsed teeth and concluded that the reimplantation of avulsed teeth is a highly successful procedure. The long and short term prognosis is strongly affected by the dry time.[13]

Complications

The major complications faced with reimplantation of avulsed teeth include; first, ankylosis in which there is PDL loss, and the tooth fuses to the alveolar bone. This condition can be problematic if the patient is growing as the surrounding structures will continue to develop, and the tooth will look submerged. Second, loss of vitality, as the severing of blood vessels occurs when the tooth is avulsed, so there is a high risk of loss of vitality especially if the apex has completely developed. If this goes unrecognized, a periapical abscess may develop and can complicate the healing process and prognoses.

Deterrence and Patient Education

Patient and parental education and the early seeking of medical care can improve the prognosis and success of treatment, as this can reduce the dry time. Using the appropriate protective mouthguards can reduce the incidence of potential injury in high-risk practices such as contact sports.

Pearls and Other Issues

Tetanus immunization should be updated if necessary after tooth avulsion. Dental follow-up is recommended for further treatment after replantation.  Brushing teeth after every meal and using chlorhexidine 0.12% rinse twice daily can decrease infection rates. Often antibiotics are prescribed to prevent infection. Patients should be placed on a soft to chew diet for at least two weeks following tooth avulsion. The success of replantation of the tooth is difficult to predict, and the patient\family should be warned that dental root resorption and tooth loss is possible.[11]

Enhancing Healthcare Team Outcomes

The need for early reimplantation and the appropriate storage medium is an important factor that is less recognized by the patients, parents and medical professionals. It is necessary for primary care providers, nurse practitioners, and the general dentist to educate the public regarding the prognosis and success of reimplantation, how early treatment is important and the preferred storage medium is a balanced salt solution or milk.


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Tooth Avulsed - Questions

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A patient presents to the emergency department after facial trauma. He is found to have a displaced fracture of a segment of the mandibular alveolar process, and the physician notes a freshly empty socket. Which of the following is the most important next step?



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Which of the following is a preferred carrier for an avulsed tooth?



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Which is the least important in the treatment of an avulsed tooth?



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Which of the following is not true about the management of permanent tooth avulsion?



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A 14-year-old male has his frontal maxillary incisors knocked out by a baseball. Select the appropriate management.



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Which teeth are most commonly avulsed?



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What is the critical dry time in an avulsed tooth?



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A 17-year-old male presented to the emergency department with a history of facial and dental trauma. The right mandibular canine is missing. What is the next best step in the management of this patient?



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Tooth Avulsed - References

References

Aetiology, treatment patterns and long-term outcomes of tooth avulsion in children and adolescents., Karayilmaz H,Kirzioglu Z,Erken Gungor O,, Pakistan journal of medical sciences, 2013 Apr     [PubMed]
Andreasen JO, Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scandinavian journal of dental research. 1970     [PubMed]
Bemelmanns P,Pfeiffer P, [Incidence of dental, mouth, and jaw injuries and the efficacy of mouthguards in top ranking athletes]. Sportverletzung Sportschaden : Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin. 2000 Dec     [PubMed]
Sassen H, [Incidence of clinically manifest functional disorders in partial dentition injury]. Deutsche zahnarztliche Zeitschrift. 1982 Dec     [PubMed]
Schützmannsky G, [Statistics on the incidence and severity degree of the accidental injuries on the corona dentis in the frontal teeth of children and adolescents. Examination material of the adolescent dental clinic of the town and district Halle (Saade)]. Zeitschrift fur die gesamte Hygiene und ihre Grenzgebiete. 1970 Feb     [PubMed]
Feliciano KM,de França Caldas A Jr, A systematic review of the diagnostic classifications of traumatic dental injuries. Dental traumatology : official publication of International Association for Dental Traumatology. 2006 Apr     [PubMed]
Zadik D,Fuks A,Eidelman E,Chosack A, Traumatized teeth: two-year results. The Journal of pedodontics. 1980 Winter     [PubMed]
Zhu W,Zhang Q,Zhang Y,Cen L,Wang J, PDL regeneration via cell homing in delayed replantation of avulsed teeth. Journal of translational medicine. 2015 Nov 14     [PubMed]
Tuna EB,Yaman D,Yamamato S, What is the Best Root Surface Treatment for Avulsed Teeth? The open dentistry journal. 2014     [PubMed]
Azami-Aghdash S,Ebadifard Azar F,Pournaghi Azar F,Rezapour A,Moradi-Joo M,Moosavi A,Ghertasi Oskouei S, Prevalence, etiology, and types of dental trauma in children and adolescents: systematic review and meta-analysis. Medical journal of the Islamic Republic of Iran. 2015     [PubMed]
Barrett EJ,Kenny DJ, Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endodontics     [PubMed]
Guideline on management of acute dental trauma. Pediatric dentistry. 2008-2009     [PubMed]
Ram D,Cohenca N, Therapeutic protocols for avulsed permanent teeth: review and clinical update. Pediatric dentistry. 2004 May-Jun     [PubMed]

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