What is Avulsed Tooth?

Dento-alveolar trauma refers to injuries caused by a hard hit to the teeth and the nearby structures. These injuries could be mild, like a bruise on the tooth, or severe, like the complete dislocation of the tooth from its socket, known as tooth avulsion, which is a rare type of dental injury. Usually, it takes a lot of force to cause tooth avulsion. Other injuries to nearby structures like fractures in the alveolar bone (the bone that contains the tooth sockets) and bruises on the gums might also occur.

The best treatment for tooth avulsion is replantation, where the tooth is put back into its socket. Quick action and how the dislodged tooth is stored before replantation are key factors for a successful recovery. Antibiotics and corticosteroids are used in a new technique called anti-resorption therapy, which helps to combat the typical inflammation that happens when a tooth is replanted. Stabilizing the tooth (splinting) and prescribing antibiotics are part of the treatment, too. Checking up on the patient regularly after the treatment is very important. At these follow-up visits, the tooth will be examined physically and with x-rays to ensure it’s healthy and to exclude any possibility of the tooth root getting dissolved or the tooth getting fused to the bone (ankylosis).

What Causes Avulsed Tooth?

Dentoalveolar trauma, or dental injuries, commonly occur because of falls, especially in kids, cycling accidents, contact sports, car crashes, and physical attacks. These types of injuries mostly happen at home, schools, and sports facilities.

Certain physical characteristics can make a person more likely to experience these dental injuries. These include having upper teeth that stick out, having a large gap between the upper and lower teeth when the mouth is closed, a condition where the front teeth don’t meet when biting (known as anterior open bite), an irregular alignment of teeth (known as malocclusion), lip incompetence, and breathing through the mouth.

Risk Factors and Frequency for Avulsed Tooth

Dental trauma, or injuries to the teeth, often happens in children between the ages of 7 and 11. Boys are twice as likely as girls to experience these types of injuries. Most of the time, the injuries affect permanent teeth more than temporary ones, approximately 60% to 40% respectively.

A study of 800 kids aged 11 to 13 found that just over half had an injury to their permanent front teeth. However, about 10% of them didn’t remember ever having a dental injury. In another study, involving 1,298 people who got treatment in emergency rooms due to trauma, 24% had dental injuries – two-thirds of these were cases where a tooth had been knocked out.

Falling down is the most common way people get dental injuries. Other common causes include cycling accidents, contact sports, and assaults. A study found that at least 32% of athletes playing contact sports had some kind of tooth injury. The sports with the highest risk of dental injury are ice hockey, football, lacrosse, rugby, martial arts, and skating. Despite the use of helmets, dental injuries are still common. However, using mouth guards can help reduce dental injuries.

In younger children, if dental trauma happens, one should always consider the possibility of abuse.

Dental trauma occurs most often between ages 7 and 11 with boys being more affected than girls.
Permanent teeth are more likely to get injured than temporary teeth.
Half of kids aged 11 to 13 have had a dental injury to their permanent front teeth.
24% of trauma patients in an emergency room study had dental injuries, where two-thirds were tooth avulsions.
The most common causes of dental injuries are falls, cycling accidents, contact sports, and assaults.
32% of contact sports athletes have experienced some form of dental injury.
Despite the use of helmets, dental injuries in sports are common; but mouth guards can help prevent them.
Dental trauma in young children could be a sign of abuse.

Signs and Symptoms of Avulsed Tooth

If someone has injured their tooth, it’s important to record the details of the injury. This might include how the injury happened, how long ago the tooth was knocked out, where the tooth has been kept since then, and whether the tooth was a baby tooth or an adult tooth. By the time a person is 14 years old, all of their baby teeth should have fallen out and been replaced by adult teeth.

A physical examination of the mouth should be performed, checking the socket from where the tooth was removed for any foreign objects or pieces of tooth. These could interfere with replacing the tooth. The surrounding area should also be examined for other injuries, such as cuts, bruises on the gums, and fractured bones. If the tooth that has been knocked out cannot be found, it must be determined whether the tooth might have been breathed in or swallowed, or pushed back into the gum or jaw.

Testing for Avulsed Tooth

Different types of imaging methods like X-rays taken outside the mouth (extraoral), X-rays taken inside the mouth (intraoral), and CT scans can help in checking for damages to the teeth, the sockets they sit in, and the surrounding regions. This kind of imaging is also handy for finding a lost tooth that might have been pushed into the jaw or gums.

Treatment Options for Avulsed Tooth

The best treatment for a dislodged tooth, if possible, is to put it back in its original place– this is known as replantation. The first 30 minutes after the tooth is dislodged are critical for tooth survival, and having a clear treatment plan can help to save the tooth. Treatment aims to preserve the tooth or keep a functional tooth in the socket to reduce the growth delay of the bone that holds the root of the tooth. This bone is essential for a future dental implant.

Before Replantation:

Immediately after tooth avulsion, you should store the tooth in a liquid similar to body fluids, such as milk, saline, or even saliva. This storage process helps to slow down the death of certain cells on the root of the tooth, although this cell death is eventually unavoidable. In fact, temporarily storing the tooth in this manner may offer better healing results than replanting the tooth without storing it. Among these solutions, milk is often recommended because it has a suitable pH, an abundance of nutrients, and is readily available. However, it’s important to note that storing the tooth in drinking water could harm the tooth due to its low salt content.

Before replantation, the dislodged tooth could be soaked in a solution containing antibiotics. This is thought to prevent inflammation due to dead cells and bacteria. A common approach is to soak the tooth in a solution containing doxycycline and dexamethasone for 20 minutes. During this time, it’s also valuable to gently rinse and aspirate the socket if it’s blocked by blood clots.

Replanting the Tooth:

The tooth should be carefully aligned and replanted using firm pressure. Most teeth can be successfully replanted if they have been out of the mouth for less than half an hour. After this time, cell damage on the tooth root may become permanent, reducing the chances of the tooth’s survival.

After Replantation:

Once replanted, the tooth should be stabilized with a semi-rigid splint to allow for the healing of the damaged fibers that connect the tooth and its socket. Guidelines from the International Association of Dental Traumatology recommend flexible splinting for all dental injuries. Splinting time is usually two weeks, but it could be extended to four weeks if the tooth has been out of the mouth for more than an hour.

Antibiotics, such as doxycycline or amoxicillin for those intolerant to doxycycline, are usually given for five days. The tooth and splint set should be checked and evaluated after two weeks. Various tests will then be conducted to check if the tooth is living and functioning well. If it is not, a root canal treatment may have to be done.

If the tooth was out of the mouth for more than an hour, the residual tissues should be eliminated carefully as it could cause continued inflammation that accelerates tooth resorption and ankylosis, a condition where the tooth becomes fused with the bone. This risk could be reduced by using fluoride treatment after eliminating the residual tissues.

Complications include tooth resorption, which might be avoided with disinfection at the replantation time and systemic antibiotics. If the tooth was dry for more than 90 minutes, soaking it in fluoride may reduce resorption rates.

Teeth that haven’t fully developed have higher chances of recovery after being soaked in doxycycline. However, it’s not recommended to replant primary teeth because it could lead to injury on the permanent tooth that has yet to grow.

When a tooth appears to be completely knocked out, several different things may have happened. The tooth may have been pushed into the jawbone, slightly dislodged, or moved sideways. This can also happen when a tooth seems to be ‘missing’. It could be that the tooth was pushed upward, swallowed, or even inhaled. These situations can all be identified through a patient’s history, a physical examination, and using imaging techniques like X-rays.

What to expect with Avulsed Tooth

A study conducted by Karayilmaz and his team found out that the process of replanting knocked-out teeth is quite successful. However, the success in both the short and long run heavily depends on the amount of time the tooth stayed dry before being replanted. Yet, another study showed that only 20% of replanted knocked-out teeth lasted in the long run. This was mainly due to patients not returning for follow-up treatment.

Possible Complications When Diagnosed with Avulsed Tooth

Replanting a tooth that has been knocked out can lead to several problems. These might include infections, changes in tooth color, sores or holes forming, and inflammation causing the tooth to be absorbed back into your body. The root of the tooth might also fuse to the jawbone, and you might get an infection in the parts of your tooth where a root canal has been done. In the worst cases, the center of your tooth could die.

If the person treating your tooth uses a rigid splint to hold it in place, you’re more likely to have your tooth absorbed back into your body or have it fuse to your jawbone. This can be a bigger problem for younger patients who are still growing because as they grow, the tooth might look like it’s sinking into their jaw.

If a tooth has been knocked out, there’s a big chance it may lose its vitality, particularly if the tooth’s apex (tip of the root) is fully formed. This loss of vitality may lead to the death of the tooth’s pulp (center part) and to inflammation which may cause the root to be absorbed. If this isn’t noticed and treated, it may lead to an infection at the tip of the root which can further complicate the tooth’s healing and prognosis. The obliteration of the pulp canal, noticed from weeks to months after the tooth has been replanted, can be identified through an x-ray showing increased density in the pulp chamber and canal. Even though this is thought to indicate healthy blood flow to the injured areas, around 15-25% of teeth with this condition still end up with the death of the pulp.

Issues associated with tooth replacement:

Infections
Changes in tooth color
Sores or holes
Inflammation causing tooth to dissolve
Root of tooth fusing to jawbone
Root canal infections
Death of center of tooth
Tooth looking submerged for young patients
Risk of loss of vitality
Pulp canal obliteration

Preventing Avulsed Tooth

It’s crucial for coaches, those who lead recreational activities, and first responders to understand the initial steps of handling a knocked-out tooth. If patients and their parents are educated about this, and if they seek medical care promptly, the chances of successful treatment can go up. One way to lessen the chances of such injuries in the first place is to use proper mouthguards during high-risk contact sports.