Avulsion Injuries

 
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Avulsion Injuries

Laura Reynolds

DCT 2, Manchester Dental Hospital and Manchester Royal Infirmary 

An avulsed tooth is one of the few true emergencies in dentistry. It is an acutely stressful and traumatic event for the patient and parent and research suggests that only 46% of General Dental Practitioners (GDPs) would feel confident managing this emergency (1). An avulsion injury requires immediate assessment, treatment and very close follow up, to maximise functional, aesthetic and psychological outcomes for the patient (2). Prognosis is largely determined by the damage sustained to the pulp and periodontal ligament. For this reason, it is critical is elude the extra-alveolar dry time and extra-oral time on presentation to determine the long-term prognosis of the tooth (3).

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What advice should I give over the phone?

  • Ensure the tooth is a permanent tooth not a primary tooth

  • Pick up tooth by crown, do not touch the root

  • If visibly dirty, rinse under cold running water for 10 seconds

  • Hold tooth by the crown and push gently into socket until it is level with the other teeth

  • Bite gently on a handkerchief to maintain in correct position

  • Attend dental clinic immediately

  • If unable to replant tooth, advise patient/parent to store tooth in milk or in oral vestibule and attend dental clinic immediately (2)

When should I not replant a tooth? 

  • Primary teeth (replanting a primary tooth could damage the successor tooth germ)

  • Other more extensive injuries requiring urgent medical treatment such as head injury

  • Extensive carious destruction of the tooth

  • Extensive loss of marginal periodontal support

  • Medically compromised patients (e.g. infectious endocarditis, immunosuppressive treatment) (3)

How would I replant a tooth in practice?

  1. Administer local anaesthesia

  2. Gently irrigate socket with saline

  3. Pick tooth up by the crown and gently irrigate with saline if visibly contaminated – do not scrub the surface

  4. Replant tooth with gentle pressure until the incisal edge is level with the adjacent lateral incisor. Do not force the tooth. If resistance is felt, remove tooth and store in saline whilst you re-examine the socket (Often bony fragments can impede replantation, use a blunt instrument e.g. flat plastic to investigate the socket and remove any bony fragments)

  5. Take a check radiograph to ensure the root is placed correctly in socket

  6. Check the occlusion

  7. Splint the tooth with a semi-rigid splint (splint one uninjured tooth on either side for 4 weeks)

  8. Prescribe antibiotics:

    • If under 12 years old prescribe amoxicillin or penicillin V 250mg (X4/day for 7 days)

    • If over 12 years old prescribe doxycycline 100mg (X2/day for 7 days)

  9. A tetanus booster may be required depending on immunisation status of the patient or if contamination of the tooth has occurred. Refer to medical practitioner within 48 hours if there are any concerns (2)

What advice should I give the patient?

  • Avoid participation in contact sports

  • Soft diet for 2 weeks

  • Excellent oral hygiene using a soft toothbrush and chlorhexidine gluconate (0.1%) mouthwash (if allergic advise hot/salty mouthwashes)

  • Analgesia as required (2)

Should I extirpate? 

Mature teeth should be extirpated within 2 weeks of the avulsion injury. Following extirpation, the tooth should be dressed with calcium hydroxide and obturated within one month4. Immature teeth should be monitored closely for revascularisation. If there are any signs of loss of vitality (pain, sinus, tooth discolouration, periapical inflammation), extirpate and dress with non-setting calcium hydroxide. Always remember to refer if you do not feel confident managing open apices (4).

What if there’s delayed presentation?

The prognosis of an avulsed tooth is time-critical. If presentation is delayed, replantation can still be considered however the patient must be made aware of the very poor outcomes. Sequelae include ankylosis and root resorption, which could lead to premature loss of the tooth.

How frequently should the tooth be monitored?

Follow up radiographs, photos and sensibility testing should be undertaken at:

  • 4 weeks

  • 2 months

  • 6 months

  • 1 year

  • Yearly (2)

What am I looking for at each review?

  • Loss of vitality (pain, sinus, tooth discolouration, periapical inflammation)

  • Arrest of root development (often a reliable indicator of pulp necrosis)

  • External inflammatory resorption. If resorption occurs, the tooth can often be maintained for years as a natural space maintainer to retain bone to facilitate implant placement.

  • Ankylosis. A submerging tooth could indicate ankylosis, if tooth becomes more than 1mm submerged, decoronation may be required.

Where can I find out further information?

Dental Trauma Guide. URL available at: https://dentaltraumaguide.org/free-dental-guides

References

  1. Jackson NG, Waterhouse PJ, Maguire A. 2005. GDPs confidence in treating emergency dental treatment. Br Dent J  198:293-297.

  2. Dental Trauma Guide. 2018. URL available at: https://dentaltraumaguide.org/free-dental-guides

  3. Welbury R, Duggal MS, Hosey MT. 2018. Paediatric Dentistry. 5th Rev Ed.

  4. Andreasen JO, Andreasen FM, Bakland LK, Flores MT. 2003. Traumatic Dental Injuries: A Manual. 2nd Rev Ed.