Tooth Avulsion (Knocked Out Tooth) - Emergency Management

Definition

Tooth avulsion is the complete displacement of a tooth from its socket due to trauma. This is a dental emergency requiring immediate action. Success of reimplantation depends on time and proper handling.

Critical Timeline for Success

⏰ Time is Critical:

Time Window	Success Rate	Action Required
0-15 minutes	90-95%	Immediate reimplantation at site or by dentist
15-60 minutes	80-90%	Reimplantation with proper storage
1-3 hours	50-80%	Reimplantation possible with proper storage
3-24 hours	20-50%	Milk storage essential, reimplantation possible
24+ hours	<20%	Reimplantation unlikely to succeed

Immediate First Aid (First 15 Minutes)

1. At the Scene/Home

For the Patient:

Locate the tooth: Find the avulsed tooth immediately
Handle carefully: Hold by the crown ONLY, never touch the root
Rinse gently: If dirty, rinse with cool water for 10 seconds ONLY
DO NOT scrub: Never scrub or clean the root surface
DO NOT dry: Keep the tooth moist at all times
Attempt reimplantation: If trained, gently place tooth back in socket
Bite on gauze: If reimplanted, bite gently to hold in place
Seek emergency dental care: Go to dentist immediately

If Unable to Reimplant at Home:

Place in mouth: Under the tongue or in the cheek pouch (saliva keeps it moist)
Or place in milk: If available, place tooth in cold milk immediately
Or place in saline: Contact lens solution or normal saline
Never use: Tap water (hypotonic - causes cell lysis), alcohol, or dry storage

2. Transport to Dentist

Keep tooth moist: In mouth, milk, or saline during transport
Avoid delays: Go directly to dentist (do not stop for other reasons)
Inform dentist: Call ahead to alert dentist of emergency
Time of injury: Note exact time for prognosis

Storage Media - Ranked by Effectiveness

Optimal Storage Solutions

Storage Medium	Osmolarity	Effectiveness	Duration	Availability
Milk (Cold)	Isotonic	⭐⭐⭐⭐⭐ Excellent	Up to 6 hours	Very common
Saliva (In mouth)	Hypotonic	⭐⭐⭐⭐ Good	30-60 minutes	Always available
Normal Saline (0.9%)	Isotonic	⭐⭐⭐⭐ Good	Up to 3 hours	Clinics, hospitals
Contact Lens Solution	Isotonic	⭐⭐⭐⭐ Good	Up to 3 hours	Pharmacies
Coconut Water	Isotonic	⭐⭐⭐⭐ Good	Up to 3 hours	Common in tropics
Hanks Balanced Salt Solution	Isotonic	⭐⭐⭐⭐⭐ Excellent	Up to 24 hours	Emergency kits

Storage Media to AVOID:

Medium	Why to Avoid	Effect on PDL
Tap water	Hypotonic - causes cell lysis	Severe damage to periodontal ligament
Alcohol	Denatures proteins	Kills PDL cells
Dry storage	PDL cells die within 15 minutes	Complete PDL necrosis
Tissue paper/cloth	Dries out the tooth	PDL damage
Bleach solutions	Toxic to tissues	Severe damage

Clinical Management at Dental Office

1. Examination & Assessment

Assess tooth condition: Check for root fractures, crown damage
Assess socket: Check for fractures or debris
Assess patient: Check for other injuries, systemic conditions
Document time: Record exact time of injury and storage method
Take radiographs: Periapical and occlusal X-rays

2. Socket Preparation

Gentle cleaning: Remove blood clots and debris with saline irrigation
Do NOT curettage: Avoid aggressive cleaning
Check socket integrity: Ensure no fractures
Anesthesia: Local infiltration or block anesthesia

3. Tooth Preparation

Gentle rinse: Rinse with normal saline only
Do NOT scrub: Never touch or scrub the root surface
Do NOT dry: Keep tooth moist
Handle by crown: Only touch the crown, never the root

4. Reimplantation Technique

Gentle insertion: Slowly and gently insert tooth into socket
Correct orientation: Ensure proper alignment with adjacent teeth
Gentle pressure: Apply gentle pressure until fully seated
Check occlusion: Ensure tooth is not in traumatic occlusion
Adjust if needed: Use file to reduce occlusal contact if necessary

Splinting Protocol

Splinting Materials & Techniques

Recommended Splinting Methods:

Splinting Method	Material	Duration	Advantages	Disadvantages
Flexible Wire + Composite	0.4mm wire + composite resin	7-14 days	Flexible, allows some movement, easy removal	Requires composite skills
Acid-Etch Composite Splint	Composite resin only	7-14 days	Simple, no wire needed	Less flexible, can be rigid
Titanium Trauma Splint	Pre-fabricated titanium splint	7-14 days	Flexible, reusable, professional	Cost, may not fit all cases
Periodontal Splint	Wire + composite (circumferential)	14-21 days	Very stable, good for multiple teeth	More complex, longer removal time

Splinting Principles:

Flexible splint: Allows physiologic movement, promotes healing
Immobilize: Splint should immobilize the avulsed tooth and 1-2 adjacent teeth on each side
Do NOT over-splint: Rigid splints can delay healing
Duration: 7-14 days for simple avulsion, 14-21 days for complex cases
Removal: Gentle removal with rotary instrument or file

Post-Operative Management

Medications

Medication	Dose	Frequency	Duration (Days)	Purpose
Antibiotics (Amoxicillin)	500mg	Three times daily (TDS)	7-10 days	Infection prevention
Tetracycline (if available)	500mg	Four times daily (QID)	7-10 days	Reduces inflammatory resorption
Ibuprofen	400-600mg	Every 6-8 hours	3-5 days	Pain relief, anti-inflammatory
Chlorhexidine Rinse	0.12%	Twice daily	7-14 days	Antimicrobial rinse

Patient Instructions

Do's:

Keep splint clean with gentle brushing
Rinse with chlorhexidine 0.12% twice daily
Eat soft foods for 1-2 weeks
Take prescribed antibiotics as directed
Attend all follow-up appointments
Report any pain, swelling, or complications

Don'ts:

Do NOT disturb the splint
Do NOT eat hard, sticky, or hot foods
Do NOT smoke (delays healing)
Do NOT drink alcohol (interferes with antibiotics)
Do NOT engage in contact sports for 2-4 weeks

Follow-Up Schedule

Timeline	Assessment	Action
1 week	Check splint integrity, assess healing	Reinforce oral hygiene, continue medications
2 weeks	Remove splint, check tooth mobility	Take radiograph, assess healing
4 weeks	Assess tooth vitality (if possible)	Consider root canal if no vitality
8-12 weeks	Full assessment, radiographs	Plan definitive treatment if needed
6-12 months	Assess for root resorption	Monitor long-term prognosis

Nutritional Support During Healing

Soft Foods (First 2 Weeks):

Food	Portion	Nutritional Value
Yogurt (plain)	1 cup (245g)	Protein, probiotics, calcium
Mashed potatoes	1 cup (210g)	Carbohydrates, energy
Bone broth	1 cup (240ml)	Collagen, minerals, amino acids
Smoothies (with protein)	1 cup (240ml)	Vitamins, protein
Scrambled eggs	2 eggs	Protein, amino acids

Key Nutrients for Healing:

Protein: 50-100g daily (tissue repair)
Vitamin C: 75-90mg daily (collagen formation)
Zinc: 8-11mg daily (wound healing)
Calcium: 1000-1200mg daily (bone healing)

Prognosis & Complications

Factors Affecting Success:

Time out of socket: Most critical factor
Storage medium: Milk is best, dry storage is worst
Root development: Immature roots have better prognosis
PDL condition: Undamaged PDL essential for success
Patient age: Younger patients have better healing

Possible Complications:

Pulp necrosis: May require root canal treatment
Root resorption: Can occur weeks to months later
Ankylosis: Fusion of tooth to bone
Infection: Periapical abscess
Mobility loss: Tooth may become immobile

Clinical Notes:

This is a reference guide for distressed clinicians - use clinical judgment
TIME IS CRITICAL: Every minute counts for success
Patient education on first aid is essential
Provide written instructions to all patients with reimplanted teeth
Long-term follow-up is essential to monitor for complications
Consider root canal treatment if pulp vitality is lost