Lesson

Dental avulsions

Dental avulsion is the complete traumatic displacement of a tooth from the alveolar (bony) socket. The optimal treatment is to immediately replace and stabilise the avulsed tooth back into the socket. Primary teeth (deciduous/”baby” teeth) should not be replanted due to the risk of damage to the adult tooth bud.

Immediate treatment (ideally within five minutes) of the avulsion is the most important factor to achieving a successful replantation. Therefore, it is necessary for the touchline doctor to begin replantation treatment prior to transferring the athlete to an emergency facility or dental office.

The avulsed tooth should be handled only by the crown of the tooth and not the root. It should be quickly rinsed (not scrubbed) with cold water, saline or milk and immediately placed back into the bony socket. If the avulsed tooth is not immediately placed back into the socket, coagulation or blood clotting within the socket may prevent the tooth from properly seating into its original position.

As mentioned above, replantation done within the first five minutes of the injury produces the best results. Any drying of the cells on the root surface drastically reduces success. If you can’t replant immediately, place the tooth in physiologic saline, milk, or Hank’s balanced salt solution (HBSS). Milk is often the most readily available solution. Do not store in water. Water has been shown to damage the tooth root periodontal ligament cells. The osmolality and pH of water is very low compared to normal cell pressure and will cause the periodontal ligament cells of the root to become damaged.

If the injured person is unconscious, do not attempt to re-implant the tooth for fear of aspiration. The tooth can be stored in milk until the athlete has regained a normal level of consciousness.

Once the tooth has been replanted, the athlete must be immediately referred to a qualified trauma dentist for splinting of the teeth and suturing of any associated gingival lacerations. Upon arrival at the dental office, the dentist will radiograph the avulsed area, apply a flexible splint and initiate and complete root canal treatment. The splint is kept in place for two weeks or longer depending on the severity of the injury and damage to the alveolar bone.

If needed, systemic antibiotics (clindamycin or amoxicillin) may be prescribed as well as confirming the athlete’s tetanus prophylaxis status. After between two and six weeks, the splint may be removed. The tooth will be monitored both clinically and radiographically at six months and then yearly.

External inflammatory resorption and replacement resorption are factors that may present themselves years after the avulsion injury. This negative result is more likely to occur the longer the avulsed tooth was kept out of the mouth. The storage medium used may also influence this process. This replacement resorption may ultimately result in the loss of the tooth. This is why it is critical to replant the tooth immediately at the site of injury and complete root canal therapy within a few days of the injury.

Click on the following images to view examples of avulsion injuries.

  • Athlete following avulsion injury

    The injured athlete is often quite distressed

  • Avulsed tooth

    This must be handled with care – by the crown only

The development of root resorption is related to the damage of the periodontal ligament fibres at the time of trauma and how well they were preserved. This is directly related to the quickness of the replantation followed by successful root canal treatment. The more timely the tooth is replanted and root canal completed, the less chance of resorption and tooth loss.

Dr Ray Padilla

Sports dentist