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What to do when a tooth is knocked out... Avulsed teeth
Contact your dentist immediately - Contact info for Dentists - click here
Every year there are people that present to our office with teeth that are knocked out. It can be very stressful during the time of the accident and proper care must be exercised to help prevent further damage to the avulsed tooth. Most teeth that are knocked out are caused by either fighting accidents or sport related injuries. If the tooth is reimplanted within 15-30 minutes after the accident, there is a greater than 90% chance the tooth will be retained for life. However, practical life experience shows us that may be unrealistic.
What should you do immediately after tooth is knocked out
- Don't Panic!
- Contact a dentist - click here
- if you can't contact us you must try to get a dentist
to help you immediately.
- Handle tooth carefully - do not touch the root end.
- Tooth will have a better survival longevity if it is reimplanted in the first 30 min.
- If the tooth is dirty or contaminated, it should gently be placed in whole cold milk, saline, or saliva.
- Never transport the tooth to the dentist in tissue or gauze. Use water if you have to.
The critical determining factors for success of re-implantation
- Condition of alveolar socket (bone).
- Presence of gum disease will inhibit reattachment.
- Storage medium when transporting tooth.
- How the tooth is handled - do not touch or clean the root.
- Length of time that the tooth is out of socket - 30 min max is best.
- If proper assistance is on-site then replace the tooth in the socket and then proceed to the dental office for splinting.
Once the dentist receives the tooth preserved in this system he/she may precede to implant the tooth and do the proper splinting procedures with a favorable prognosis.
It should be noted that if a primary (baby) tooth is knocked out, it should NOT be replanted as it could damage the permanent tooth bud in formation. Parents should NOT try to place the baby tooth back into the socket, and should immediately seek the advise and treatment of their dentist.
If the tooth cannot be re-implanted or it is rejected then it is possible to fix the missing tooth with other dental treatment such as an implant, a bridge, or a partial. This assessment must be made by a dentist and/or specialist. See Dental info
Head Trauma - If there is any evidence of head trauma head injury, unconsciousness, nausea, or persistent headaches, they should be first evaluated for their head injury by proper medical personnel before going to the dental office. Once a head injury is ruled out, they may precede to the dentist for treatment of the avulsed (knocked out) tooth. This is another reason why a proper storage medium for the tooth is critical.
Treatment of the Avulsed Permanent Tooth Recommended Guidelines of the American Association of Endodontist
I. Management at Site of Injury
Replant immediately, if possible. If contaminated, rinse
with water before replanting.
When immediate replantation is not possible, place tooth in
the best transport medium available.
II. Transport Media
Hank's Balanced Salt Solution (H.B.S.S.)
Milk
Saline
Saliva (buccal Vestibule)
If none of the above is readily available, use water.
III. Management in the Dental Office
Replantation of Tooth
If extraoral dry time is less than one hour with or without
storage in a physiological media (such as Hank's Balanced
Salt Solution, milk, or saline), replant immediately.
If extraoral dry time is greater than one hour, soak in an
accepted dental fluoride solution for 20 minutes, rinse with
saline, and replant.
Management of the Root Surface
Keep the tooth moist at all times.
Do not handle the root surface (hold tooth by the crown).
Do not scrape or brush the root surface or remove the tip
of the root.
If the root appears clean, replant as is after rinsing with
saline.
If the root surface is contaminated, rinse with H.B.S.S. or
saline (use tap water if above are not available). If persistent
debris remains on root surface, gently use cotton pliers to
remove remaining debris and/or gently brush off debris with
a wet sponge.
Management of the Socket
Gently aspirate without entering the socket. If a clot is
present, use light irrigation with saline.
Do not curette the socket.
Do not vent socket.
Do not make a surgical flap unless bony fragments prevent
replantation.
If the alveolar bone is collapsed and prevents replantation,
carefully insert a blunt instrument into the socket to reposition
the bone to its original position.
After replantation, manually compress (if spread apart) facial
and lingual bony plates.
Management of Soft Tissues - tightly suture any soft tissue
lacerations, particularly in the cervical region.
Splinting (indicated in most cases)
Use acid-etch/resin alone or with soft arch wire, or use orthodontic
brackets with passive arch wire. Suture in place only if alternative
splinting methods are unavailable. (circumferential wire splints
are contraindicated.)
Splint should remain in place for 7-10 days; however, if tooth
demonstrates excessive mobility, splint should be replaced
until mobility is within acceptable limits.
Bony fractures resulting in mobility usually require longer
splinting periods (2-8 weeks).
Home care during splinting period should encompass:
No biting on splinted teeth
Soft diet
Maintenance of good oral hygiene
IV. Adjunctive Drug Therapy Considerations
Systemic antibiotics
Referral to physician for tetanus consultation within 48 hours
Chlorhexidine rinses
Analgesics
V. Endodontic Treatment
Tooth with open apex (divergent apex) and less that one hour
extraoral dry time:
Replant in an attempt to revitalize the pulp.
Recall patient every 3-4 weeks for evidence of pathosis.
If pathosis is noted, thoroughly clean and fill the canal
with calcium hydroxide (apexification procedure).
Tooth with open apex (divergent apex) and greater that one
hour extraoral dry time:
Thoroughly clean and fill the canal with calcium hydroxide.
Recall the patient in 6 - 8 weeks.
Because of poor prognosis, consider alternative treatment
options.
Tooth with partially to completely closed apex and less than
one hour extraoral dry time:
Biomechanically clean the root canal system in 7-14 days.
Medicate the canal with calcium hydroxide for as long as practical,
usually 6-12 months.
Then, obturate canal with gutta percha and sealer unless complications
are apparent.
Tooth with partially to completely closed apex and greater
than 2 hours extraoral dry time:
Perform root canal therapy either intraorally or extraorally.
Prior to replantation, remove tissue tags from the root surface
and soak the tooth in an accepted dental fluoride solution.
VI. Restoration of the Avulsed Tooth
Recommended Temporary Restorations (placed prior to final
obturation)
Reinforced zinc oxide eugenol
Acid etch/composite resin
Recommended Permanent Restorations (placed immediately after
final obturation)
Dentin bonding agent
Acid etch/composite resin
VII. Additional Considerations
Avulsed primary teeth should not be replanted.
Avulsed permanent teeth require follow-up evaluations for
a minimum of 2-3 years to determine the outcome of therapy.
Inflammatory resorption, replacement resorption, ankylosis
and tooth submergence are potential complications when avulsed
teeth are replanted.
The Guidelines are based on a review of the pertinent literature
and clinical experience in managing cases. The literature
is divided into four general categories: (1) clinical trials,
(2) simulated injuries in animal models, (3) case reports
and (4) opinion articles. The AAE recognizes that the most
definitive information is gathered from properly designed
clinical trials. Simulations from animal models are useful,
but not totally conclusive when applied to human subjects.
Case reports and opinion articles have limited application. In studying a subject such as the accidentally avulsed permanent tooth, clinical trials are not always available and in many cases are impossible to perform. Therefore, these recommendations represent the state of the art and science at this moment but are subject to revision as additional research and knowledge become available.
Treatment of the Avulsed Permanent Tooth: Recommended Guidelines
of the American Association of Endodontist are intended to
aid the practitioner in the management and treatment of the
accidentally avulsed tooth. Practitioners must always use
their own best professional judgment. The American Association
of Endodontists neither expressly nor implicitly warrants
any positive results associated with the application of these
guidelines. Although it is impossible to guarantee permanent
retention of a tooth that has been avulsed, timely treatment
of the tooth in the proper manner can maximize the chances
for success.
© 1995 American Association of Endodontists, 211 East
Chicago Avenue, Suite 1100, Chicago, IL 60611-2691 The Association
grants a limited license to members of the Association to
copy the Treatment of the Avulsed Permanent Tooth: Recommended
Guidelines of the American Association of Endodontists for
their own personal use and for no other purpose. The Treatment
of the Avulsed Permanent Tooth: Recommended Guidelines of
the American Association of Endodontists may not be reproduced
for sale and may not be amended or altered in any manner.
This license is not assignable.
Resources
The American Association of Endodontists
SELECTED REFERENCES
The Avulsed Permanent Tooth
Andreasen JO. Effect of extra-alveolar period and storage
media upon periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53.
Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odontol Scand, 1975;33:313-23.
Andreasen JO. Traumatic injuries of the teeth. 2nd ed. Philadelphia; WB Saunders, 1981.
Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth. Munksgaard, Copenhagen. 1190;120.
Andreasen JO, Borum MK, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to root growth. Endod Dent Traumatol 1995; 11:69.
Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Diagnosis of healing complications. Endod Dent Traumatol 1995; 11:51.
Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to pulp healing. Endod Dent Traumatol 1995; 11:59.
Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995; 11:76. Bjorvatn K, Selvig KA, Klinge B. Effect of tetracycline and SnF2 on root resorption in replanted incisors in dogs. J Dent Res, 1989,97:477-82.
Blomlof L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J, 1981;Suppl 8:1-26.
Blomlof L. Storage of human periodontal ligament cells in a combination of different media. J Dent Res 1981;60(11):1904-06.
Blomlof L, Lindskog S, Anderson L, Hedstrom K-G, Hammarstrom L. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912.
Blomlof L, Lindskog S, Hammarstrom L. Periodontal healing of exarticulated monkey teeth stored in milk or saliva. Scand J Dent Res 1981;89:251-9.
Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta percha. A retrospective clinical study. Endodon Dent Traumatol, 1992;8:45.
Cvek M. Tratement of non-vital permanent incisors with calcium hydroxide. II. Effect on external root resorption in luxated teeth compared with effect of root filling with gutta-percha. A follow-up. Odont Revy 1973;24:343-54.
Cvek M. Cleaton-Jones P. Austin J, Lownie J. Kling M and Fatti P. Pulp revascularization in reimplanted immature monkey incisors - predictability and the effect of antibiotic systematic prophylaxis. Endodon Dent Traumatol 1990;5:157-69.
Hammarstrom L, Blomlof L, Leiglin B, Anderson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endodon Dent Traumatol 1986;2:51-57.
Heimdahl A, Von Konow L. Lundquist G. Replantation of avulsed teeth after long extra-alveolar periods. Int J Oral Surg 1983;12:413-17.
Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hanks balanced salt solution and Viaspan storage media. Endodon Dent Traumatol 1991;7(2):69-72.
Kawashima Z. Pineda FR. Replanting avulsed primary teeth. J Am Dent Assoc 1992;123(10):90-1.
Kling M, Cvek M. Mejare I. et al. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endodon Dent Traumatol, 1986;2;83-9.
Kristerson L and Andreasen JO. The effect of splinting upon periodontal and pulpal healing after autotransplantation of mature and immature permanent incisors in monkeys. Int J Oral Surg, 1983;12;239.
Loe H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys. Arch Oral Biol 1961;3:176-84.
Mackie IC, Worthington HV. Investigation of children referred to a dental hospital with avulsed permanent incisor teeth. Endodon Dent Traumatol 1993;9;106-10.
Mackie IC, Worthington HV. An investigation of replantation of traumatically avulsed permanent incisor teeth. Br Dent J 1992;172(1):17-20.
Magura M. Elkafrawy A. Brown C. Newton C. Human saliva coronal microleakage in obturated canals: An in vitro study. J Endodon 1991;17:324-31.
Matsson L. Andreasen J. Cvek M. Granath LE. Ankylosis of experimentally reimplanted teeth related to extra-alveolar period and storage environment. Pediatr Dent, 1982;4:327-9.
Nordenvall KJ. Milk as storage medium for exarticulated teeth: report of case. J Dent Child 1992;59:150-5.
Oswald RJ. A postreplantation evaluation of air-dried and saliva-stored avulsed teeth. J Endodon 1980;6:546.
Ray H. Trope M, Buxt P. Switzer S. Influences of various factors on the radiographic periapical status of endodontically treated teeth. J Endodon 1993;19:187 (Abstract #7).
Skoglund A and Tronstad L. Pulpal changes in replanted and autotransplanted immature teeth of dogs. J Endodon 1981;7:309.
Sjogren M, Figdor D, Spangberg L. Sundqvist G. The antimicrobial effect of calcium hydroxide as a short term intracanal dressing. Int Endodon J, 1991;24:119-25.
Trope M and Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, Milk and Hanks Balanced Salt Solution. Endodon Dent Traumatol, 8:183-8.
Trope M, Moshonov J, Nissan R, Buxt P, & Yesilsoy C. Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth. Endod Dent Traumatol 1995; 11:124.
Trope M. Yesilsoy C, Korem L, Moshonov J, Friedman S. Effect of different endodontic treatment protocols on periodontal repair and root resorption of replanted dog teeth. J Endodon 1992;18(10):492-6.
Wilcox LR, Diaz-Arnold A. Coronal microleakage of permanent lingual access restorations in endodontically treated anterior teeth. Int Endodon J 1990;23(6):321.
Van Hassel HJ, Oswald RJ, Harrington GW. Replantation 2. The role of the periodontal ligament. J Endodon 1980;6:506.