Tooth Avulsion

In this article, you’ll learn more about tooth avulsion, especially in children using a case study.

It’s always easier to understand something with an actual example. So we’ve added that here. In this worked example, we’ve tried to bring together some of the teaching covered so far into a real-life case.

Look at the image and consider the attached bio of this patient.

The patient MF is a 9-year-old boy who has attended your surgery as an emergency appointment

History of the presenting complaint

He was hit by a ball in the face 30 minutes ago. He has come straight to the surgery. The teeth (UR1, UL1 FDI: 11, 21) are stored in milk and appear to be intact.

Medical History

Nil relevant

Social History

Came with elder brother. three siblings, no reported dental problems

Diet History

Drinks water and milk. Likes cheese

Toothbrushing

Two x daily with adult fluoride paste

Now, we need to think about formulating a plan. We will walk through this step by step, outlining what factors we consider. This is urgent. The minute these teeth were avulsed, the clock started ticking. Even though they are in milk, they still need to be replanted as soon as possible. So bear this in mind when we go through the assessment – whatever you do, you need to do it fast.

What other factors from the history might be important

This is a trauma, so where/when/how is important. We also need to find out about tetanus immunisation status. Finally don’t forget about other injuries, particularly head injuries. If there is any suggestion of loss of consciousness or nausea/vomiting they need to get off to Accident and Emergency as soon as possible. Depending on the severity of the potential head injury you might even decide to forget about replanting the teeth first.

Then we need to make some sort of assessment of potential cooperation. This child is going to need local anaesthetic and replanting of the avulsed teeth. Often these children have never had any dental treatment before. Which can work for us (they don’t know what to expect!) and against us (fear of the unknown).

This child has come with an elder brother, so we have an issue with consent. But we also need to consider the best interest of the child in this case. So where are the parents? Can they be contacted by phone? Can we get consent that way?

Special tests/investigations There’s not much point in doing sensibility tests at this point — it’s too soon after the injury for them to be meaningful. Radiographs of the teeth on either side of the affected area will be useful to check for other injuries like root fractures etc. However don’t let that delay replantation – this is not the time for them to be sat outside x-ray for half an hour!

What is the likely diagnosis?

Pretty obvious here — avulsion of upper central permanent incisors. We’re lucky in this case because the teeth have been identified, so we don’t need to worry about where they might be. Obviously if the teeth couldn’t be accounted for you need to work out where they are. This might even mean you need to think about a chest x-ray, but normally we would be advised by an emergency physician.

What is the plan

We need to replant these ASAP. The steps for that are:

1. Local anaesthetic. A buccal infiltration should be enough.
2. You may need to rinse out the sockets if there is a blood clot.
3. Replant the teeth and then ask the child to bite on a swab to hold them in place
4. Splint as required, checking tooth position as you place the splint. We often find they can ‘pop out’ a little bit between replantation and splinting, so make sure the child keeps biting on the swab. Cotton wool roll isolation should be enough.

Once that’s done, you might want to repeat the radiograph to check they are in place. Then it’s reviewed as recommended by IADT. Remember to warn the family as well that long-term complications are likely (particularly ankylosis), it’s better to be a little bit pessimistic about the prognosis.