para>Avulsed teeth: dental emergency
Time is of the essence for reimplantation of avulsed teeth.
If primary tooth: Do not reimplant. If unsure whether tooth is a primary or permanent tooth, place tooth in Hanks solution, saline, or milk and consult dentist ASAP.
If permanent tooth: Avoid touching tooth root, handle only by the crown; rinse with normal saline. Minimize trauma to socket. If dirt or large clot in socket, perform gentle irrigation of the socket with normal saline and light aspiration of blood clot before implantation.
After implantation, have patient bite down on gauze while transporting to dentist.
If unable to implant at scene, transport in Hanks solution, milk, or saline (not water) or the buccal sulcus if patient is alert and age-appropriate.
If tooth is outside of socket <20 minutes, attempt implantation of tooth and stabilize with resin/metal splint, or, if not available, zinc oxide (Coe-Pak) splint. Refer to dentist ASAP.
If tooth is outside of socket 20 to 60 minutes, soak tooth in Hanks solution for 30 minutes to preserve pH. If Hanks solution is not available, use saline. Attempt implantation and stabilization.
If tooth is outside of socket >60 minutes, soak tooth in citric acid and fluoride for 30 minutes; attempt reimplantation and stabilization. If citric acid/fluoride not available, use Hanks solution or saline.
Consult dentist for follow-up and for any questions.
Soft foods are only for 10 to 14 days, depending on injury (6)[A].
Oral hygiene may be difficult: Brush with a soft-bristled toothbrush after meals; apply chlorhexidine gluconate (0.12%) mouth rinse topically to the affected area(s) with cotton swabs BID for 1 week (1)[A].
Systemic antibiotics are recommended after reimplantation of an avulsed tooth. Doxycycline is first line in patients >12 years old. Penicillin for younger children; clindamycin for penicillin allergy (6)[A]
Jaw fracture
Assess for displacement.
If nerve impingement, immediate surgery is needed. Contact oral surgeon ASAP.
If not displaced or no indication of nerve impingement, have patient see oral surgeon within 24 hours for fixation.
MEDICATION
First Line
- Acetaminophen, NSAIDs, and opioids are all beneficial (4)[A].
- Ibuprofen: 600 to 800 mg (or 10 mg/kg) q6h, or acetaminophen 650 to 1,000 mg (10 to 15 mg/kg) q4-6h
- For more severe pain, consider acetaminophen or ibuprofen plus opioids.
- Can consider local anesthetic nerve block with long-acting anesthetic (bupivacaine)
- Antibiotics for fractures or avulsions to prevent complications.
- Penicillin VK: 500 mg QID for 7 days in adults; for children, 25 to 50 mg/kg/divided TID
- Clindamycin: 150 to 300 mg TID (or 5 to 7.5 mg/kg/dose) in penicillin-allergic patients
- Note: The evidence for benefit for antibiotics for avulsed teeth is equivocal, but experts recommend antibiotics (6)[A].
Second Line
Clindamycin: 150 to 300 mg TID (or 5 to 7.5 mg/kg/dose)
ISSUES FOR REFERRAL
- All patients should be referred to a dentist for follow-up; x-rays to assess permanent nonerupted teeth for damage in children. Monitor q6months for 3 years or indefinitely.
- Splints are typically maintained in place for 7 to 10 days for subluxed teeth and 1 to 6 weeks for avulsed teeth. Alveolar fractures should be splinted for 3 to 4 weeks and can take up to 6 months to heal (6)[A].
- Avulsed teeth continue to deteriorate up to 36 months after injury and typically require root canal therapy. Warn patient of this possibility, which includes discoloration of tooth. Requires close evaluation by dentist
- Oral surgeon should follow jaw fractures in consultation with general dentist.
ADDITIONAL THERAPIES
Tetanus booster should be considered if tetanus coverage is uncertain, if tooth has been in contact with soil, or if deep soft tissue lacerations are present.
SURGERY/OTHER PROCEDURES
Oral surgeon consultation within 1 hour if patient has alveolar bone fracture or jaw fracture with nerve involvement
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Acupuncture for pain
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Swelling compromising airway, mental status change due to concussion or hypoxia, aspiration of teeth, or unstable vital signs
IV Fluids
IV fluid resuscitation with normal saline may be indicated in septic patients.
Nursing
Ensure excellent oral hygiene. Rinse mouth with chlorhexidine gluconate. Nutrition: liquid or soft diet
Discharge Criteria
Discharge patient when
- Abscess and sepsis have been eliminated.
- Patient is able to take in adequate PO and ambulate.
- Cleared from concussion
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up with dentist or oral surgeon within 24 hours after any dental trauma.
- Restrict use of pacifiers if dental injuries are involved.
- Ellis III fractures in children <12 years are likely to get infected; clinicians should consider antibiotic coverage.
Patient Monitoring
Biannual cleaning and follow-up. First 36 months are most critical to long-term prognosis.
PATIENT EDUCATION
- Use a soft-bristled toothbrush and soft diet for 10 to 14 days after dental trauma. Rinse with chlorhexidine 0.012% BID for 1 week to prevent plaque and debris accumulation (7)[A].
- If tooth avulsion occurs, handle tooth only by the crown, so as to not crush periodontal ligament cells on root. If damage is severe to these cells, tooth will not reattach.
- Cold milk or Hanks solutions are the best transportation mediums before coming to the emergency room; they maintain periodontal ligament for ~3 hours and have pH and osmolality to maintain vitality of cells. Saline or saliva is a good substitute. Water is the least desirable transport medium.
- Stress use of helmets and mouth guards for risk-taking activities (8)[A].
PROGNOSIS
- <20 minutes of tooth separation from socket: good prognosis
- >60 minutes of tooth separation: poor prognosis for tooth reattachment but always try to reimplant
- Alveolar fracture: poor prognosis for teeth involved
- Jaw fracture: good prognosis with proper reduction/fixation
COMPLICATIONS
- Tooth loss
- Infection
- Cosmetic and/or functional deformity
- Anesthesia/paresthesia of nerve entrapment with fractured jaw, especially mandibular fracture
REFERENCES
11 Andersson L. Epidemiology of traumatic dental injuries. J Endod. 2013;39(3)(Suppl):S2-S5.22 Levin L, Zadik Y. Education on and prevention of dental trauma: it's time to act! Dent Traumatol. 2012;28(1):49-54.33 Lauritano D, Petruzzi M, Sacco G, et al. Dental fragment embedded in the lower lip after facial trauma: brief literature and report of a case. Dent Res J(Isfahan). 2012;9(Suppl 2):S237-S241.44 Glendor U. Aetiology and risk factors related to traumatic dental injuries-a review of the literature. Dent Traumatol. 2009;25(1):19-31.55 Zaleckiene V, Peciuliene V, Brukiene V, et al. Traumatic dental injuries: etiology, prevalence and possible outcomes. Stomatologija. 2014;16(1):7-14.66 Keels MA. Management of dental trauma in a primary care setting. Pediatrics. 2014;133(2):e466-e476.77 Andreasen JO, Lauridsen E, Gerds TA, et al. Dental trauma guide: a source of evidence-based treatment guidelines for dental trauma. Dent Traumatol. 2012;28(5):345-350.88 Sigurdsson A. Evidence-based review of prevention of dental injuries. J Endod. 2013;39(3)(Suppl):S88-S93.
ADDITIONAL READING
- Andreasen JO, Bakland LK, Flores MT, et al. Traumatic Dental Injuries: A Manual. 3rd ed. New York, NY: Wiley; 2011.
- Clark MB, Douglass AB, Maier R, et al. Smiles for life: a national oral health curriculum. 3rd ed. Society of Teachers of Family Medicine. 2010. www.smilesforlifeoralhealth.com.
- Dental trauma guide. http://www.dentaltraumaguide.org/
CODES
ICD10
- S02.5XXA Fracture of tooth (traumatic), init for clos fx
- S02.5XXB Fracture of tooth (traumatic), init encntr for open fracture
- K08.119 Complete loss of teeth due to trauma, unspecified class
- S02.609A Fracture of mandible, unsp, init encntr for closed fracture
- K08.111 Complete loss of teeth due to trauma, class I
- K08.112 Complete loss of teeth due to trauma, class II
- K08.113 Complete loss of teeth due to trauma, class III
- K08.114 Complete loss of teeth due to trauma, class IV
- S02.402A Zygomatic fracture, unsp, init encntr for closed fracture
- S02.69XA Fracture of mandible of oth site, init for clos fx
ICD9
- 873.63 Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication
- 873.73 Open wound of tooth (broken) (fractured) (due to trauma), complicated
- 525.10 Acquired absence of teeth, unspecified
- 802.20 Closed fracture of mandible, unspecified site
- 802.4 Closed fracture of malar and maxillary bones
- 525.9 Unspecified disorder of the teeth and supporting structures
SNOMED
- Dental trauma
- fracture of tooth (disorder)
- acquired absence of teeth (disorder)
- Fracture of mandible
- Jaw injury (disorder)
- Fracture of maxilla
CLINICAL PEARLS
- Do not reimplant primary teeth.
- Avulsed permanent teeth are a medical emergency. Reimplant permanent teeth ASAP.
- Milk is the best transportation medium before coming to emergency room; Hanks solution, saline, or saliva is a good substitute. Water is the least desirable.
- Consider child or domestic abuse in dental trauma cases.
- Young children are more likely to get infection after Ellis fractures; consider antibiotic coverage.
- Antibiotic coverage are needed for avulsed teeth and jaw fractures.
- Ensure tetanus vaccination is updated.