Difference between revisions of "Dental avulsion"

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==Background==
 
==Background==
#Dental emergency
+
*Dental emergency; for every minute that a permanent tooth remains out of the socket, the chance of successful reimplantation goes down by 1% <ref>Amsterdam JT. Oral medicine. In: Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Mosby, Inc. 2014; (Ch) 70:895–908.</ref>
#Often associated with alveolar ridge fracture
+
*Tooth is completely removed from its socket
 +
*Often associated with alveolar ridge fracture
  
==Diagnosis==
+
==Clinical Features==
*Where is the tooth?
+
[[File:PMC4355813 CRID2015-197202.006.png|thumb|Avulsion of the right upper incisor.]]
**It may be intruded, aspirated, swallowed, or embedded in the oral mucosa
+
[[File:PMC3214533 CCD-2-226-g003.png|thumb|Avulsed tooth]]
**Consider facial films, CXR
+
*Tooth missing from socket
*Additional Injuries?
+
*History of recent trauma
*Age and head bleed risk?
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Template:Dental Problems DDX}}
 
{{Template:Dental Problems DDX}}
 +
 +
==Evaluation==
 +
===Work-up===
 +
*Consider facial films, abdominal films, or CXR if possibility of tooth aspiration or ingestion
 +
 +
===Evaluation===
 +
*Determine when avulsion occurred and what storage solution used
 +
**If re-implanting, best viability with immediate storage in Hank's Balanced Salt Solution, worst viability without any storage medium
 +
*Account for all teeth
 +
**Aspiration or swallowed
 +
**Rule out fragments in lacerations/oropharyngeal space, or significant intrusive luxation/impaction
 +
*Determine if tooth is primary or secondary
 +
*Tetanus status
  
 
==Management==
 
==Management==
#Adult
+
===Adult===
##Replace avulsed tooth as soon as possible (as long as no alveolar ridge fx, no severe socket injury)
+
*Replace avulsed tooth as soon as possible with local analgesia ± dental block (as long as no alveolar ridge fracture or severe socket injury)
###If reimplanted within 1hr 66% chance of good outcome
+
**If reimplanted within 1hr 66% chance of good outcome
###Rinse tooth in saline, suction socket (if necessary), reimplant tooth, bond tooth to neighboring teeth
+
**Rinse ('''no scrubbing'''!) tooth in saline
###Manipulate tooth only by the crown
+
**Manipulate tooth '''only by the crown''' (Avoid touching root to minimize damage to periodontal ligament)
##Storage solution (in order of efficacy): Hank's balanced salt solution > Milk > saliva > saline
+
**Splint tooth with adjacent teeth
##Penicillin or clindamycin
+
*If extraoral time > 60 min, soak in citric acid/fluoride and consult dentist<ref>Mayersak, RJ. Facial trauma, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 42: 368-81.</ref>
#Child
+
*Storage solution (in order of efficacy): '''Hank's Balanced Salt Solution''' > '''Milk''' > saliva > saline
##Do not reimplant primary teeth
+
*[[Doxycycline]] 100mg PO BID x 1week (helps periodontal ligaments heal)
###Refer to pedodontist for space maintainer
+
*[[Penicillin]] '''OR''' [[Clindamycin]] are alternatives, especially in pediatrics
 +
*[[Tetanus prophylaxis|Tetanus]] update
 +
 
 +
===Child===
 +
*Do not re-implant primary teeth
 +
**Increased risk of interference with the eruption of the permanent tooth<ref>Amsterdam JT: Oral Medicine, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 68:p 853-856</ref>
 +
*Refer to pediatric dentist for space maintainer within 1-2 weeks.<ref>Benko, K. Acute Dental Emergencies in EM. EM Practice. 2003, 5(5)</ref>
 +
===Length of Periodontal Ligament Cell Viability Based On Storage Medium <ref>Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th edition, Ron M. Walls, Robert S. Hockberger, Marianne Gausche-Hill, et al. Oral Medicine. Copyright 2017</ref>===
 +
{| {{table}}
 +
| align="center" style="background:#f0f0f0;"|'''Storage Medium'''
 +
| align="center" style="background:#f0f0f0;"|'''Length of Periodontal Ligament Viability'''
 +
|-
 +
| Dry (no storage medium)||< 60 minutes
 +
|-
 +
| Milk||3 to 8 hours
 +
|-
 +
| Oral rehydration solution||12 to 24 hours
 +
|-
 +
| Hanks’ balanced salt solution||12 to 24 hours
 +
|}
 +
 
 +
==Disposition==
 +
*Discharge with dental follow-up on liquid diet
 +
*Should be seen within 24-48 hours as splint only lasts up to 48 hours
  
 
==See Also==
 
==See Also==
 
*[[Dental Problems]]
 
*[[Dental Problems]]
  
[[Category:ENT]]
+
==References==
 +
<references/>
  
== Source ==
+
[[Category:ENT]] [[category:Trauma]]
*ER Atlas
 
*Tintinalli
 
*UpToDate
 

Latest revision as of 20:34, 22 October 2019

Background

  • Dental emergency; for every minute that a permanent tooth remains out of the socket, the chance of successful reimplantation goes down by 1% [1]
  • Tooth is completely removed from its socket
  • Often associated with alveolar ridge fracture

Clinical Features

Avulsion of the right upper incisor.
Avulsed tooth
  • Tooth missing from socket
  • History of recent trauma

Differential Diagnosis

Dentoalveolar Injuries

Odontogenic Infections

Other

Evaluation

Work-up

  • Consider facial films, abdominal films, or CXR if possibility of tooth aspiration or ingestion

Evaluation

  • Determine when avulsion occurred and what storage solution used
    • If re-implanting, best viability with immediate storage in Hank's Balanced Salt Solution, worst viability without any storage medium
  • Account for all teeth
    • Aspiration or swallowed
    • Rule out fragments in lacerations/oropharyngeal space, or significant intrusive luxation/impaction
  • Determine if tooth is primary or secondary
  • Tetanus status

Management

Adult

  • Replace avulsed tooth as soon as possible with local analgesia ± dental block (as long as no alveolar ridge fracture or severe socket injury)
    • If reimplanted within 1hr 66% chance of good outcome
    • Rinse (no scrubbing!) tooth in saline
    • Manipulate tooth only by the crown (Avoid touching root to minimize damage to periodontal ligament)
    • Splint tooth with adjacent teeth
  • If extraoral time > 60 min, soak in citric acid/fluoride and consult dentist[2]
  • Storage solution (in order of efficacy): Hank's Balanced Salt Solution > Milk > saliva > saline
  • Doxycycline 100mg PO BID x 1week (helps periodontal ligaments heal)
  • Penicillin OR Clindamycin are alternatives, especially in pediatrics
  • Tetanus update

Child

  • Do not re-implant primary teeth
    • Increased risk of interference with the eruption of the permanent tooth[3]
  • Refer to pediatric dentist for space maintainer within 1-2 weeks.[4]

Length of Periodontal Ligament Cell Viability Based On Storage Medium [5]

Storage Medium Length of Periodontal Ligament Viability
Dry (no storage medium) < 60 minutes
Milk 3 to 8 hours
Oral rehydration solution 12 to 24 hours
Hanks’ balanced salt solution 12 to 24 hours

Disposition

  • Discharge with dental follow-up on liquid diet
  • Should be seen within 24-48 hours as splint only lasts up to 48 hours

See Also

References

  1. Amsterdam JT. Oral medicine. In: Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Mosby, Inc. 2014; (Ch) 70:895–908.
  2. Mayersak, RJ. Facial trauma, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 42: 368-81.
  3. Amsterdam JT: Oral Medicine, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 68:p 853-856
  4. Benko, K. Acute Dental Emergencies in EM. EM Practice. 2003, 5(5)
  5. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th edition, Ron M. Walls, Robert S. Hockberger, Marianne Gausche-Hill, et al. Oral Medicine. Copyright 2017