Avulsion
Adult Teeth and Dental Trauma
In this section, we will cover:
- What is an avulsion?
- What should I do after the injury?
- Will I need treatment?
- What can I do to help the area heal at home?
- Will I need any follow up appointments?
- What should I look out for?
- What are the long term complications?
What is an avulsion?
This is when the whole tooth (including the root) has been knocked out of the mouth following a physical injury.
What should I do after the injury?
It can be very distressing if you/your child has suffered trauma to the teeth. The first thing to do is stay calm.
Dental trauma is very common and there are a few steps you can follow to get the best outcome after the injury.
You should:
- Take a second to collect yourself and check you/your child hasn't blacked out.
If you/your child has hit their head and you think they may have lost consciousness (even for a few seconds) or they feel nauseous or dizzy, you should get this checked out by your doctor or local A&E department to rule out a concussion (head injury). - Follow the steps in the diagram below. It is important to act quickly after a tooth has been knocked out of the mouth. The quicker it is put back in the socket (the hole from which it came out), the better the prognosis of the tooth!
- Call your dentist as soon as possible so they can arrange to check the teeth and provide any necessary treatment.
- If the injury happened in a place thought to be unclean, and there has been a cut to the skin/lip/gum, you should check all tetanus vaccinations are up to date with your GP. You may need a tetanus booster vaccination.
Will I need treatment?
Treatment will be needed as soon as possible after the injury for the best prognosis of the tooth.
Firstly your dentist will need to ask you some questions, check the teeth and take some xrays. Xrays are taken to ensure there are no other injuries to the teeth and to compare any future xrays against.
If the tooth has not been replanted (put back in the mouth), your dentist will leave the tooth in milk/salt water (or saliva if you have brought the tooth in this) until they are ready to replant it themselves.
Treatment at the first appointment will depend on whether the tooth has been replanted correctly before seeing the dentist. Following the initial appointment, you will often be referred to a paediatric dentist (specialist in children's dentistry) for shared long term care.
If the tooth has been replanted before seeing dentist, treatment will include:
- Local anaesthetic to make the procedure more comfortable
- The area is cleaned with (salt) water or chlorhexidine (an antiseptic solution, commonly used as mouthwash)
- If the tooth/teeth have been replanted in the incorrect position, they can be repositioned up to 48 hours after the trauma first happened.
- A splint (flexible metal wire) is placed on the injured tooth and the teeth either side of it for 2 weeks. If there has been damage to the surrounding bone, the tooth will need to be splinted for another 4 weeks.
- If there are any injuries to the soft tissue, you can see here for more information.
If the tooth has not been replanted before seeing dentist, treatment will include:
- Local anaesthetic to make the procedure more comfortable
- The tooth and the injured area are cleaned with (salt) water or chlorhexidine (an antiseptic solution, commonly used as mouthwash)
- The tooth is replanted with slight pressure and the position will be checked with a further xray.
- A splint (flexible metal wire) is placed on the injured tooth and the teeth either side of it for 2 weeks. If there has been damage to the surrounding bone, the tooth will need to be splinted for another 4 weeks.
- If there are any injuries to the soft tissue, you can see here for more information.
Antibiotics, commonly amoxicillin or penicillin, will be prescribed by your dentist. If you are allergic to penicillins, doxycycline can be prescribed. Doxycycline is avoided in children under 12 years old as it can discolour the adult teeth whilst they are developing under the gum.
If your tetanus vaccinations are not up to date, you will need to see your GP who made advise you have a tetanus booster.
For teeth which have been replanted within 15 minutes of the injury, or teeth where the root has not fully formed, no further treatment is needed unless there are signs of long term complications (see below). No treatment is recommended at this stage as there is a chance for the tooth to heal by itself.
Teeth with a fully formed root which were replanted more than 15 minutes after injury will require root canal treatment. This should be started within 2 weeks of initial injury to reduce the risk of complications.
There are a few situations in which a tooth should NOT be replanted following injury. These are for patients with:
- compromised immune system (immunocompromised or immunosuppressed)
- severe heart condition
- severe gum disease or dental decay
For these patients, or patients where the tooth was not found, options for replacing the gap must be considered instead. Options include:
What can I do to help the area heal at home?
To help the area heal at home, you should:
- Brush the teeth after every meal with a soft toothbrush
- Gently brush the injured area to prevent build up of plaque
- Carry out salt water or alcohol-free chlorhexidine mouthwash (corsodyl) twice a day.
For a young child who isn't able to use a mouthwash, use a cotton swab/handkerchief moistened in salt water or alcohol-free chlorhexidine mouthwash (Corsodyl) to clean the gum twice a day - Have a soft diet
- Take medicine to help manage any discomfort (ibuprofen or paracetamol)
- Avoid contact sports
- Don't smoke
Will I need any follow up appointments?
The risk of complications after an avulsion is high so the tooth/teeth must be monitored closely and frequently for at least 5 years.
The frequency of dental check ups and xrays depends on whether root canal treatment was carried out or if the tooth was left to heal on its own.
Tooth left to heal, should be reviewed after:
- 2 weeks
- 1 month
- 2 months
- 3 months
- 6 months
- 1 year
- Yearly for 5 years (minimum)
Tooth root canal treated, should be reviewed after:
- 2 weeks
- 4 weeks
- 3 months
- 6 months
- 1 year
- Yearly for 5 years (minimum)
Teeth which were given a chance to heal (without root canal treatment) are monitored more frequently. This is because any complications can progress very quickly. The earlier they are picked up, the better the prognosis.
What should I look out for?
The long term consequences of dental trauma are unpredictable. You should monitor your/your child's teeth for any signs of infection.
Favourable outcome
- No pain
- Normal mobility of tooth
- Not tender
- Normal colour
- Xray: root continues to develop, possible pulp canal obliteration (PCO)*
*PCO is the mechanism by which the tooth heals itself after injury. It can be seen as narrowing of the root canal on an xray and can usually be seen within the first year after injury. It does not need root canal treatment. Sometimes the tooth looks more yellow/brown. This can be managed with tooth whitening.
Unfavourable outcome
- Pain
- Swelling
- Tooth excessively mobile, or
- Tooth not mobile at all (ankylosis**)
- Tooth starts to look shorter than surrounding teeth (infraocclusion***)
**Ankylosis is where the root fuses to, and is replaced by, the surrounding bone. It occurs due to damage to the periodontal ligament (PDL) which is a spongy layer surrounding the root. This is more common in teeth with fully formed roots.
***Infraocclusion is a sign of ankylosis in a growing patient. The surrounding jawbone/teeth continue to grow but the ankylosed tooth remains where it is. This means it will start to look shorter than the surrounding teeth. The gumline will also be at a different level to the surrounding teeth.
What are the long term complications?
Avulsion is one of the most severe forms of dental trauma. It often requires careful long term assessment and planning by a team of specialists (multidisciplinary team). This will usually include orthodontists, paediatric dentists and restorative dentists.
If an adult tooth has been injured, possible long term complications include:
1) Nerve dies causing pain and infection.
- The tooth may look grey/brown and be tender to bite on.
- This can be managed with root canal treatment.
- Once the tooth has been treated, it can be whitened to improve the appearance. You can find about more about tooth whitening here.
2) If the nerve dies, the root stops growing.
- This is only relevant if the injured tooth has erupted in the last 3 years, as the root is not fully formed yet.
- If the root stops growing, the tip of the root is left wide open.
- A special material called MTA is used to "plug" the hole at the tip of the root during root canal treatment. This is usually only carried out by a specialist children's dentist (paediatric dentist) or endodontist (root canal specialist) who has access to the equipment needed.
3) External inflammatory root resorption
- This is where the outer surface of the root starts to "dissolve" away due to infection.
- Root canal treatment should be started immediately to try to stop it progressing.
- Your dentist may refer you to a specialist children's dentist (paediatric dentist) or root canal specialist (endodontist) to continue treatment.
4) Ankylosis
- This is also known as "external replacement resorption" and is a condition in which the root is replaced by, and fuses to, the surrounding bone. This is more common in teeth with fully formed roots.
- The tooth will not be mobile at all and it will sound "metallic" when tapped.
- It occurs due to damage to the periodontal ligament (PDL) which is a spongy layer surrounding the root.
- Unfortunately there is no treatment for this condition to stop it from progressing.
- Management requires careful planning by a team of specialists (multidisciplinary team). This will usually include orthodontists, paediatric dentists and restorative dentists.
5) Infraocclusion
- This is a sign of ankylosis in a growing patient.
- The tooth will start to look shorter than the surrounding teeth. The gumline will also be at a different level to the surrounding teeth.
- This happens because the surrounding jawbone/teeth continue to grow but the ankylosed tooth remains where it is.
- Management requires careful planning by a team of specialists (multidisciplinary team). This will usually include orthodontists, paediatric dentists and restorative dentists.
- You can see the flowchart below for management of ankylosis and infraocclusion.
- Space closure with braces + composite bonding
For children who have crowded teeth (not enough space in their mouth for all the teeth) or an increased overjet (top teeth stick out much further than lower teeth), the space can be closed with braces. This is where the tooth next door is moved into the space. It can then be camouflaged with composite bonding to look like the original tooth. This requires careful planning by a team of specialists (multidisciplinary team). This will usually include orthodontists and paediatric dentists and may include a restorative dentist as well. - Autotransplantation (for patients where the tooth was not found)
For children who need a tooth removed for orthodontic treatment, an autotransplantation can be considered. This is where another tooth (usually a premolar) is removed and placed in the gap where the tooth is missing/removed. This requires careful planning by a team of specialists (multidisciplinary team). This will usually include orthodontists and paediatric dentists and may include a restorative dentist as well. - Removable partial denture
This is a good short term, immediate option. It gives the gums/bone time to settle after the tooth has been lost. This usually takes 3-6 months. - Resin retained bridge
This is a good option for both children and adults. It is often used to replace the missing tooth once the gums/bone have settled. Many people are happy with a bridge as a long term, definitive option. - Implant
This is only suitable for patients who have stopped growing (this is usually after 21 years old). In the right patient, this is a good long term option.