Approximately five million teeth, either children’s (primary)or adult's (permanent), are lost each year due to trauma from accidents and sports injuries making tooth avulsion a common but serious dental injury. Tooth avulsion is a dental emergency requiring immediate attention by a dentist, endodontist or oral surgeon. Some teeth that are knocked out can be replaced (reimplanted) giving the tooth the possibility of being saved, if prompt and proper action is taken.If a severe injury is sustained to the head and face, a life-threatening emergency situation can result causing unconsciousness, seizures, difficulty breathing or respiratory arrest, excessive blood loss, and possible shock. If a traumatic dental or facial injury is believed to be severe or life-threatening, call 911 immediately so that you or the injured person can receive immediate medical care and be transported to a local hospital or trauma center.
Types of Tooth Avulsion and Associated Traumatic injuries
1. Concussion: The tooth has been hit but not noticeably loosened or moved. Part of the crown of the tooth may be fractured or broken off. The tooth may be sore to the touch or sore upon chewing. The tooth should be examined by a dentist, who will also take a radiograph (X-ray) of the tooth to determine if any other damage was caused to the tooth, gum tissue or jaw bone. Restorative treatment – such as a crown – will be needed if the tooth was significantly chipped or fractured. A root canal treatment will be necessary if the fracture extends into the pulp (nerve and blood supply) of the tooth.
2. Subluxation: The tooth has been hit and is noticeably loose, and bleeding may be seen around the tooth at the gumline. Part of the crown of the tooth may be fractured or broken off. The tooth root may also be fractured. The tooth is likely to be painful to the touch or when chewing and the tooth may move when chewing. Immediate attention from a dentist is needed to evaluate the injury and possibly stabilize the loose tooth with a splint. Restorative treatment, including the possibility of root canal treatment, will be needed if the crown of the tooth was chipped or fractured.
3. Partial Avulsion – Extruded Tooth: The tooth has been hit and partially knocked out of the socket. The tooth looks like it is longer than the teeth next to it (extruded), or the tooth has been moved out toward the lip or in toward the tongue. The tooth can be significantly loose with significant bleeding from the gumline around the tooth. The fibers (periodontal ligament) that hold the tooth in the socket have been torn and there is a loss of nerve and blood supply to the tooth due to the trauma. The jaw (alveolar) bone around the tooth may be fractured. Immediate attention from a dentist is needed to evaluate and treat the injury, including treatment such as: Placing the tooth back into the socket properly, performing root canal treatment, and stabilizing/splinting the loose tooth.
4. Intruded Tooth: The tooth has been hit and pushed further into the socket. The tooth looks like it is shorter than the teeth next to it. The tooth may not be loose and there may also be bleeding from the gumline around the tooth. The fibers (periodontal ligament) that hold the tooth in the socket have been torn and there likely is a loss of nerve and blood supply to the tooth due to the trauma. The tooth root as well as the jaw (alveolar) bone around the tooth may be fractured. Immediate attention from a dentist is needed to evaluate and treat the injury, including treatment such as: Moving the tooth back into its proper position, performing root canal treatment and stabilizing/splinting the tooth.
5. Complete Avulsion: The tooth has been hit and completely knocked out of the socket. The tooth may fall out onto the ground or floor, or can be swallowed or aspirated (caught in the airway). If the tooth is swallowed, a radiograph may be needed to confirm this. If the tooth is aspirated, this is an emergency requiring immediate medical intervention. If possible, a permanent tooth that is knocked out should be picked up by the crown, rinsed off with water and placed back in the socket by the patient or parent. If this is not possible, the tooth can be placed in milk or water and taken immediately with the patient to the dentist. The bone around the tooth may be fractured and in more traumatic cases, the jaw may be fractured or dislocated. Immediate attention from a dentist is needed to evaluate and treat the injury, including treatment such as: Placing the tooth back into the socket properly, performing root canal treatment and stabilizing/splinting the loose tooth.
6. Alveolar Fracture: When a tooth is partially or completely knocked out of the socket, part of the bone that makes up the socket (the alveolus) may become fractured due to the force of the injury. This type of bone fracture may not be visible on a radiograph (X-ray). Alveolar fractures can result in permanent bone loss around the affected tooth and may require specialized treatment by a periodontist or oral surgeon to replace or rebuild the lost/damaged bone.
6. Jaw Fracture: In cases of significant trauma to the face, one or more teeth can be knocked out and the upper and/or lower jaw can be broken (fractured). In some cases, this amount of trauma can also result in a fracture to one or more vertebrae in the neck. Jaw fractures can produce malocclusion (problems with the upper and lower teeth not coming together properly), inability to open the mouth, pain in front of the ear and significant pain and swelling where the fracture is located. Some jaw fractures can cause numbness of the face and vision problems. Jaw and facial bone fractures are serious injuries that require immediate treatment by an oral and maxillofacial surgeon. If the jaw fracture causes difficulty breathing or uncontrolled bleeding, this is an emergency and possibly life threatening situation – call 911 immediately so the injured person can receive immediate medical care and be transported to a local hospital or trauma center.
7. Jaw Dislocation or Jaw Joint (TMJ) Trauma: In cases of significant trauma to the face where one or more teeth have been knocked out, knocked loose or knocked into the socket, the jaw may become dislocated. A jaw dislocation is caused by trauma to the jaw and the temporomandibular joint (TMJ) – the joints that connect the lower jaw (mandible) to the head. A dislocated jaw is often “locked” open, making it impossible to close the mouth. Jaw dislocations are serious injuries and can become emergencies, because other trauma to the head and neck may be present that the injured person is unaware of. Immediate attention by an oral and maxillofacial surgeon is recommended, so that the full extent of the injury/injuries can be determined and the jaw placed back in its proper position.
Symptoms of Tooth Avulsion Injuries Following Trauma to the Mouth
Pain, bleeding, swelling, bruising at the affected site.Laceration (cut) to the lip, tongue, mouth or face.A tooth, or teeth that are loose.A tooth that has been partially knocked-out and appears longer than the teeth next to it.A tooth that has been partially knocked-out and pushed out toward the lip, or pushed in toward the tongue.A tooth that has been knocked up into the socket – the tooth looks shorter than the teeth next to it.Loss of a tooth or teeth – tooth has been completely knocked-out.After being hit, the crown of the tooth has been partially or completely broken off.Possible infection (if the injury is not treated promptly).Jaw pain, pain in front of one or both ears.Inability to open or close the mouth.Jaw is “locked open.”Unusual looseness/mobility of the jaw.Malocclusion: When biting, teeth do not meet together normally, teeth are misaligned and bite feels "off."Action Needed in Case of an Avulsed (Knocked-Out) Tooth:
In Case of Bleeding:
Help control bleeding by biting down on a piece of sterile or clean gauze (if available – if not available, bite down on a washcloth) over the socket where the tooth was knocked out. Place a cold pack on the face/lip in the area of the knocked out tooth for 5-10 minutes per hour to help control bleeding and help reduce swelling at the injured site.
For Children:
If your child has been struck in the mouth from an accident or other injury and one or more teeth have been partially knocked out (teeth have become loose) or completely knocked out (tooth/teeth have fallen out of the socket), take your child to your family dentist immediately.
Baby/Primary Teeth:
If the tooth/teeth that are knocked out are “baby” (primary) teeth, these teeth cannot be reimplanted, but still take them to the dentist. The dentist will examine your child’s mouth and may take a radiograph (X-ray) to see if any part of the tooth has broken off in the mouth.
For Children, Adolescents or Adults with Permanent Teeth:
If one of your or your child’s permanent teeth has been knocked out, pick up the tooth by the crown (not the root) and wash the tooth off in water. If possible, put the tooth back in the socket in your/your child’s mouth and bite down to try to hold the tooth in place while driving to the dentist. If the tooth has been partially knocked out (the tooth is still in the socket but is loose) leave the tooth where it is, do not attempt to push or pull on the tooth. If it is not possible to put the tooth back in the socket, place the tooth in milk (or water if milk is not available) in a zip-lock type of storage bag, and bring the tooth to your family or pediatric dentist immediately, or at least within one hour after the tooth was knocked out. It is critical to get to the dentist in less than one hour, preferably within 10-20 minutes of the tooth being knocked out, to have an opportunity for the tooth to be reimplanted and saved.
Do not wait to call the dentist for an appointment; the dentist will see you or your child quickly on an emergency basis to attempt to reimplant the permanent tooth. Your family or pediatric dentist may refer you or your child to an endodontist for emergency root canal treatment. If you or your child has other oral/facial injuries, your family or pediatric dentist may refer your child to an oral surgeon or physician, for example, to repair a laceration or evaluate any kind of jaw or facial trauma.
If you feel that your or your child’s injury is severe or life-threatening, call 911 immediately so that you or your child can get immediate medical attention and be taken to your nearest hospital/trauma center. Some signs and symptoms to be aware of that may be associated with a head injury are: nausea, vision problems, headache that does not go away and unconsciousness.
Diagnosis of Avulsed Teeth
Asking Detailed Information:
The dentist will ask you for detailed information about the injury to your tooth/teeth, mouth and face and ask about the symptoms you are experiencing.
Extraoral Exam:
The dentist will inspect the soft tissues and bone structures of the head and neck to determine any injury/trauma such as laceration (cuts), contusion (bruising), swelling, bleeding and bone fractures.
Your jaw joints (TMJ) as well as the ligaments and muscles associated with jaw function will also be examined.
Intraoral Exam:
The dentist will examine your mouth and teeth using techniques such as:
Visual inspection: looking at the oral soft tissues and teeth for signs of trauma; looking at the soft tissues of the lip, gum and inner cheek (mucosa) for signs of any foreign body material that may have become imbedded in the tissues as a result of the injury (material such as glass or metal particles, or a piece of broken tooth or bone).
Palpation: pushing on the tooth/teeth that have been hit to determine the looseness/mobility of the teeth; gently pressing on the bone around the teeth to determine any fracture; gently pressing on the upper and lower jaw inside the mouth to determine any tenderness, swelling or mobility of the jaw.
Checking your occlusion (bite) for signs of malocclusion in order to determine if your teeth meet together properly.
Radiographs (“X-rays”); a panoramic radiograph (“Panorex”) will be taken to allow the dentist to look at the condition of the upper and lower jaws and all the teeth. Radiographs of individual teeth will be taken to examine the condition of teeth, the pulp/root canal and the supporting bone. Conventional radiographs will be shown to you on film, digital radiographs will be shown to you on a computer screen, where the images can be enlarged and enhanced to show the problem in more detail.
If at any time during the exam, your dentist thinks you need additional specialty care from an oral Surgeon, endodontist, periodontist or physician, your dentist will help make a referral to the specialist or physician on an emergency same-day basis if needed. Treatments for Avulsed Teeth
Completely Avulsed Tooth:
If the tooth has been completely knocked out less than an hour before you get to the dentist, the dentist will attempt to reimplant the tooth in its socket. The tooth may require immediate root canal treatment, either performed by the dentist or by an endodontist the dentist referred to you for emergency root canal therapy. The tooth may also be splinted using orthodontic wire, orthodontic brackets and affixed with plastic resin (bonding) material so that the tooth stays properly in place while it is healing. You will be given instructions on how to care for your mouth and may be given a prescription chlorhexidine mouth rinse to keep the area clean, prescriptions for an antibiotic to prevent infection and an analgesic prescription for pain. You may be required to see your physician to have a tetanus vaccination. You will see the dentist for follow-up visits after having your tooth reimplanted to monitor the healing and condition of your tooth and mouth.
Partially Avulsed Tooth:
If the tooth has been partially knocked-out, the dentist will attempt to move the tooth back into proper position in the socket. Root canal treatment may be required along with splinting, instructions, and prescriptions as described in the information above, about treatment for a completely avulsed tooth.
Tooth Pushed into Socket:
If the tooth has been pushed up into the socket, the dentist will attempt to save the tooth by holding on to the crown of the tooth with forceps and pulling the tooth back down in the socket in its proper position. In some cases the dentist will need to refer you to an oral surgeon and/or endodontist to accomplish this procedure. Surgery may be required to access the tooth to save it. Root canal treatment may be required, along with splinting, instructions and prescriptions as described in the above information for a completely avulsed tooth. If the tooth cannot be recovered in good condition to be replanted (for example, the tooth root is damaged, or the tooth or root are fractured) the tooth will need to be removed and replaced later with a dental implant or bridgework.
Additional Injury with Avulsion:
If additional injury occurred to your lip, gum tissue, bone structure around the teeth, jaw bone or jaw joints (TMJ), your dentist will refer you to the appropriate dental specialist or physician for closure of wounds, management of a broken jaw, injury to the TMJ, and/or for reconstructive treatments caused by bone or tissue damage/loss.
Tooth/Teeth Unable to be Reimplanted:
If the tooth can not successfully be reimplanted, the dentist or dental specialist (periodontist, oral surgeon and/or prosthodontist) will help replace the tooth with a dental implant, or a fixed bridge. If bone damage occurred where the tooth was lost, bone reconstructive procedures will be necessary to allow for proper dental implant placement or fixed bridge tooth replacement.
Complications of Avulsed Teeth
Success rates for survival of avulsed teeth vary and are dependent on the time the tooth had been knocked out before it was reimplanted, as well as the condition of the attachment tissues on the tooth root and condition of the socket.
Ankylosis:
Following reimplantation, the healing process may result in the tooth root to become fused, or ankylosed, to the bone in the socket.
Root Resorption:
Following reimplantation, the healing process may result in resorption of tooth root. This process may occur on the outside or inside of the root. Resorption causes softening and loss of tooth structure, similar to decay and may require root canal treatment, surgical and/or restorative repair of the resorbed area, or removal of the tooth.
Tooth Discoloration:
Following trauma to the tooth and reimplantation, the tooth may become discolored, turning darker than the teeth next to it. If the reimplantation is successful, the tooth discoloration may be treated with bleaching and may also require root canal therapy.
Root Canal Therapy:
If root canal therapy was not performed at, or near the time of tooth reimplantation, root canal treatment may be required to save the tooth after reimplantation due to a number of complications as mentioned above. The injury to the tooth itself, or the complications following reimplantation can result in irreversible damage to the tooth pulp (nerve and blood supply to the tooth), requiring root canal therapy.
Infection:
Following trauma to the tooth, infection may result, requiring antibiotic therapy and also may require root canal therapy. If the infection cannot be resolved, tooth loss may occur.
Cosmetic Alteration:
Due to trauma to the gum tissue and bone supporting the tooth/teeth at the site of injury, changes in the appearance of the teeth and the gum and bone structure around the teeth may occur. These changes may be treated with various cosmetic and restorative dental procedures, as well as periodontal plastic surgical and oral surgical bone reconstructive procedures if necessary.
For More Information Related to Tooth Avulsion:
American Association of Oral & Maxillofacial Surgeons: Treating and Preventing Facial Injury
American Association of Endodontists: Saving a Knocked-Out Tooth
American Association of Endodontists: Guidelines for Treatment of Traumatic Dental Injuries
American Association of Endodontists: Use of Mouthguards to Prevent Dental Injury
American Academy of Pediatric Dentistry: Emergency Dental Care for Children
American Academy of Pediatric Dentistry: Mouth Protectors
Journal Articles:
Clinical Management of Avulsed Permanent Incisors Using Emdogain. In the Journal of the Canadian Dental Association.
Luxation Injuries and External Root Resorption. In the Journal of the California Dental Association.
Contact a Dental School in Your Area
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