4.13 Avulsed Tooth (tooth loss)
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agk's Library of Common Simple Emergencies

Presentation
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After a direct blow to the mouth the patient 
may have a permanent tooth knocked from its 
socket. The tooth is intact, down to its root, 
from which hangs the delicate periodontal 
ligament that used to attach to alveolar bone 
and provide the tooth with its blood supply.

What to do:
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- In the field, avulsed teeth may be stored 
   under the tongue or in the buccal vestibule 
   between the gums and the teeth. If the 
   patient is unconscious, the tooth can be 
   stored in saline, milk or water until a 
   better preservation solution is available. A 
   child's tooth might be preserved, if necess- 
   ary, in the parent's mouth.
 - If the tooth has been out of its socket less 
   than 15 minutes, take it by the crown, drop 
   it in a tooth-preservation solution (Hank's 
   solution, Sav-A-Tooth kit), flush the socket 
   with the same solution, reimplant the tooth 
   firmly, have the patient bite down firmly on 
   a piece of gauze to help stabilize the tooth 
   and when possible secure it to adjacent 
   teeth with wire, arch bars, or a temporary 
   periodontal pack (Coe-Pak). Coe-Pak is a 
   peridontal dressing that comes in the form 
   of a base and catalyst. Mix together and 
   mold the resulting paste, which will 
   eventually set semi-hard, over the gingival 
   line and between the teeth. Put the patient 
   on a liquid diet, prescribe penicillin VK 
   500mg qid x 2 weeks, and schedule a dental 
   appointment.
- If the tooth was out 15 minutes to 2 hours, 
   soak for 30 minutes to replenish nutrients. 
   Local anesthesia will probably be needed 
   before reimplanting as above.
- If the tooth was out over two hours, the 
   periodontal ligament is dead, and should be 
   removed, along with the pulp. The tooth 
   sould soak 30 minutes in 5% sodium hypo- 
   chlorite (Clorox), and 5 minutes each in 
   saturated citric acid, 1% stannous fluoride 
   and 5% doxycycline before reimplanting. The 
   dead tooth should ankylose into the alveolar 
   bone of the the socket like a dental 
   implant.
- If the patient is between 6 and 10 years old, 
   also soak the tooth for 5 minutes in 5% 
   doxycycline to kill bacteria which could 
   enter the immature apex and form an abscess.
- If you are not able to perform all this right 
   away, simply keep the tooth soaking in the 
   preservation solution until a dentist can 
   get to it. The solution should preserve the 
   tooth safely for up to four days.
- If a tooth is lost, obtain a chest x-ray to 
   rule out bronchial aspiration.
- Add tetanus prophylaxis if required.

What not to do:
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- Do not touch a viable root with fingers, 
   forceps, gauze or anything, or try to scrub 
   or clean it. The periodontal ligament will 
   be injured and unable to re-vascularize the 
   re-implanted tooth.
- Do not overlook fractures of teeth and 
   alvolar ridges.
- Do not substitute the calcium hydroxide 
   composition (Dycal) used for covering 
   fractured teeth for the temporary 
   periodontal pack (Coe-Pak) used to 
   stabilized luxated teeth. They are different 
   products.
- Do not replace primary deciduous teeth. 
   Reimplanted primary teeth heal by ankylosis: 
   they literally fuse to the bone, which can 
   lead to cosmetic deformity since the area of 
   ankylosis will not grow at the same rate as 
   the rest of the dentofacial complex. Ankyl- 
   osis can also interfere with the eruption of 
   the permanent tooth. Normal developmental 
   shedding of primary decidual teeth is 
   preceded by absorption of the root, so 
   that if such a tooth is brought to the ED by 
   mistake, there is no root to reimplant in 
   the socket, but a new permanent tooth 
   underneath.

Discussion
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Before commercially-available 320mOs, pH 7.2 
reconstitution solutions, the best we could 
offer the avulsed tooth was rapid reimplant- 
ation. Without a preservation solution, the 
chances of successful reimplantation decline 
one percentage point every minute the tooth is 
absent from the oral cavity. In mature teeth, 
over age 10, the pulp will not survive avulsion 
even if the periodontal ligament does, and at 
the one-week follow-up visit with the dentist, 
the necrotic pulp will be removed to prevent a 
chronic inflammatory reaction from interfering 
with the healing of the periodontal ligament.

References
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- Krasner P: Modern treatment of avulsed teeth 
   by emergency physicians. *Am J Emerg Med* 
   1994;12:241-246

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