Dental avulsion: Difference between revisions
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==Background== | ==Background== | ||
*Dental emergency | [[File:Enamel.png|thumb|Diagram of the tooth displaying the enamel, dentin, and pulp]] | ||
{{Dental numbers}} | |||
*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> | |||
*Tooth is completely removed from its socket | *Tooth is completely removed from its socket | ||
*Often associated with alveolar ridge fracture | *Often associated with alveolar ridge fracture | ||
== | ==Clinical Features== | ||
[[File:PMC4355813 CRID2015-197202.006.png|thumb|Avulsion of the right upper incisor.]] | |||
[[File:PMC3214533 CCD-2-226-g003.png|thumb|Avulsed tooth]] | |||
*Tooth missing from socket | |||
* | *History of recent trauma | ||
* | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ | {{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 | *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 (no | **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) | ||
**Splint tooth with adjacent teeth | |||
*Storage solution (in order of efficacy): Hank's | *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> | ||
*[[Penicillin]] | *Storage solution (in order of efficacy): '''Hank's Balanced Salt Solution''' or '''Oral Rehydration Solution''' (e.g. Pedialyte) > '''Milk''' > saliva > saline | ||
*[[Doxycycline]] 100mg PO BID x 1week (helps periodontal ligaments heal) | |||
*[[Penicillin]] '''OR''' [[Clindamycin]] are alternatives, especially in pediatrics | |||
*[[Tetanus prophylaxis|Tetanus]] update | |||
===Child=== | ===Child=== | ||
*Do not re-implant primary teeth | *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> | **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 | *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]] | ||
== | ===External Links=== | ||
==References== | |||
<references/> | <references/> | ||
[[Category:ENT]] | |||
[[Category:ENT]] [[category:Trauma]] |
Latest revision as of 19:52, 6 July 2022
Background
Dental Numbering
- Adult (permanent) teeth identified by numbers
- From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine, two premolars (bicuspids), and three molars
- Children (non-permanent) teeth identified by letters
- Common landmarks:
- 1: Right upper wisdom
- 8 & 9: Upper incisors
- 16: Left upper wisdom
- 17: Left lower wisdom
- 24 & 25: Lower incisors
- 32: Right lower wisdom
- 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
- Tooth missing from socket
- History of recent trauma
Differential Diagnosis
Dentoalveolar Injuries
Odontogenic Infections
- Acute alveolar osteitis (dry socket)
- Acute necrotizing ulcerative gingivitis (trench mouth)
- Dental abscess
- Periapical abscess
- Periodontal abscess
- Ludwig's angina
- Pulpitis (dental caries)
- Pericoronitis
- Peritonsillar abscess (PTA)
- Retropharyngeal abscess
- Vincent's angina - tonsillitis and pharyngitis
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 or Oral Rehydration Solution (e.g. Pedialyte) > 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
External Links
References
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ Benko, K. Acute Dental Emergencies in EM. EM Practice. 2003, 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