BMJ 2016;352:i1394 doi: 10.1136/bmj.

i1394 (Published 25 April 2016) Page 1 of 5

Practice

PRACTICE

10-MINUTE CONSULTATION

Tooth avulsion
1 1
Isabelle Moran dental core trainee year 2 , Martin James dental core trainee year 2 , William Cook
2 1
emergency medicine senior house officer , Michael Perry oral and maxillofacial surgery consultant
1
Oral and Maxillofacial Surgery, Northwick Park Hospital, London HA1 3UJ, UK; 2Emergency Medicine, Northwick Park Hospital

A 7 year old boy has tripped in the playground and knocked his
front tooth out. He attends the emergency department with his
mother, who has the tooth in her hand. He is stable and has no
other injuries of concern.
What you should cover
Permanent dental problems can be avoided by taking a simple
dental history and doing a basic examination. The main question
is whether re-implantation of the tooth is appropriate. Was this
a primary (baby) tooth or a permanent (adult) tooth? At 6-8
years of age, the primary central incisors have usually fallen
out and the larger, permanent incisors have erupted (fig 1⇓).
The associated with avulsion injury of a primary tooth, such as
disturbances in eruption and appearance of the developing
permanent teeth, can be increased if a primary tooth is
re-implanted.1 This is not advised, and monitoring of permanent
tooth eruption is essential following injury.2 3
History
• Establish whether the adult with the child has legal
responsibility.
• Determine what happened, including the mechanism of the
injury and details such as the height of the fall and the
surface onto which the patient fell. This can indicate
associated injuries (eg, facial fractures, head injury).
• Note the time of injury. Re-implantation within one hour
is associated with improved survival of the tooth.2 3 Delayed
re-implantation is still advised but has a less good prognosis
(table 1⇓).
• Explore whether (and how) the tooth has been stored. Water
and dry environments damage avulsed teeth; milk is ideal.2 3
• As you consult, be alert to the possibility of non-accidental
injury, including delayed presentation and an inconsistent
history. Pursue this as necessary.
Examination
• Examine the avulsed tooth:
– Is it complete or fractured?
– Is soft tissue injury evident, possibly indicating impaction
of tooth fragments?
– Are other teeth damaged?
• If no other injuries are suspected, a radiograph of the socket
is not routinely advised.2 3
• A chest radiograph is indicated when tooth fragments
cannot be accounted for.4
• Examine the tooth socket: has the tooth fractured and the
root remains? This does not contraindicate re-implantation.
• Is the surrounding bone mobile on palpation indicating a
fracture?
What you should do
• Manage injuries of greatest concern first.
• Provide analgesia as necessary.
• A tetanus booster is indicated if the tetanus status of the
child is unclear and the tooth has been contaminated.
• Identify any soft tissue injury. Management can often be
postponed until the avulsed tooth has been dealt with.
The most commonly avulsed permanent tooth is the central
incisor.2 3 The tooth is attached to the jaw by small root fibres,
and its blood supply enters through an opening at the root tip
(fig 2⇓). An avulsion injury damages these structures.
Re-implantation within an hour of the incident can preserve the
vascular supply and surface attachments.2 3 Avulsion of the
lateral incisor is also commonly seen (fig 3⇓).
Ideally, dentally qualified professionals should perform
re-implantation. However, as delay will significantly reduce the

Correspondence to: I Moran isabellemoran@nhs.net

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

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BMJ 2016;352:i1394 doi: 10.1136/bmj.i1394 (Published 25 April 2016)
What you need to know
• Re-implantation within an hour of the injury improves outcomes
• Milk is an ideal storage medium
prognosis, any competent person should attempt re-implantation
as soon as possible (box 1).
If re-implantation cannot be performed immediately, the tooth
must be held by the white crown and placed in an appropriate
storage medium to prolong cell survival.5 Cold milk or Hank’s
balanced salt solution are preferred mediums; if these are not
available, saline can be used as an alternative.5
Considerable damage to the tooth can result in failure of the
blood supply to regenerate and replacement of the root surface
fibres with bone (ankylosis). Ultimately, these teeth will need
root canal treatment and long term follow-up by a dentist.
Differences in treating adolescents and adults
Owing to reduced bone elasticity, adults’ teeth are more likely
to fracture than avulse. The management of tooth avulsion
remains the same. However, by 10-11 years of age, the blood
flow to the incisors is reduced, preventing revascularisation
after re-implantation and necessitating root canal treatment.
Tetracycline (narrower spectrum antibiotic) should be
prescribed, rather than amoxicillin, for patients aged over 12
years to facilitate the healing of tooth tissues.3
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Page 2 of 5
PRACTICE
Competing interests: We have read and understood the BMJ policy on
declaration of interests and declare the following interests: none.
Provenance and peer review: Not commissioned; externally peer
reviewed.
1 Malmgren B, Andreasen JO, Flores MT, et al. International Association of Dental
Traumatology. International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol
2012;28:174-82. doi:10.1111/j.1600-9657.2012.01146.x pmid:22583659.
2 Dental Trauma Guide. Avulsion. 2010. http://www.dentaltraumaguide.org/Permanent_
Avulsion_Description.aspx.
3 Andersson L, Andreasen JO, Day P, et al. International Association of Dental
Traumatology. International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol
2012;28:88-96. doi:10.1111/j.1600-9657.2012.01125.x pmid:22409417.
4 Leith R, Fleming P, Redahan S, Doherty P. Aspiration of an avulsed primary incisor: a
case report. Dent Traumatol 2008;24:e24-6. doi:10.1111/j.1600-9657.2008.00593.x pmid:
18557752.
5 Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk
and Hank’s balanced salt solution. Endod Dent Traumatol 1992;8:183-8. doi:10.1111/j.
1600-9657.1992.tb00240.x pmid:1302677.
Accepted: 24 02 2016
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BMJ 2016;352:i1394 doi: 10.1136/bmj.i1394 (Published 25 April 2016) Page 3 of 5

PRACTICE

Box 1: Procedure to re-implant a tooth

• Administer local anaesthetic to the socket, although this is not essential
• Hold the tooth by the crown and gently wash any debris with running saline for 10 seconds
• Irrigate the socket with saline
• With the convex surface of the tooth facing towards the lips, slowly push the tooth into the socket. Use the adjacent teeth and the
patient’s bite to aid accurate repositioning. If resistance is felt, do not attempt to advance the tooth further.
• Ask the patient to bite gently on gauze to hold the tooth in position
• Prescribe a seven day course of amoxicillin3
• Advise the patient to brush twice daily and use chlorhexidine mouth rinse twice daily for one week, eat a soft diet, and arrange a dental
visit as soon as possible
• Referral to the maxillofacial team before discharge:
– Successful re-implantation—The tooth will need to be splinted to the adjacent teeth through use of a wire
– Unsuccessful re-implantation—Store the tooth appropriately and refer promptly
• Re-implantation of a tooth is contraindicated in severe immunosuppression and severe cardiac conditions (for example, with a high
risk of endocarditis)1

Further clinical guidelines

• The Dental Trauma Guide. Evidence based guidance on tooth avulsion. www.dentaltraumaguide.org2

Education into practice

• How might you ensure that all clinical and reception staff are aware that re-implantation of a tooth within one hour improves outcome?
• Does your department have appropriate storage solutions available?

Table

Table 1| Outcome of tooth avulsion3

Treatment at time of injury Chance of tooth loss at 3 years (%)

Immediately re-implanted 0
Transported in appropriate medium before re-implantation 11
Kept dry for >1 hour 58

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BMJ 2016;352:i1394 doi: 10.1136/bmj.i1394 (Published 25 April 2016) Page 4 of 5

PRACTICE

Figures

Fig 1 Diagram highlighting difference in size between primary and permanent incisors. The primary central incisor is
approximately 16 mm in length, two thirds the size of its permanent successor

Fig 2 Anatomy of central incisor (upper front tooth)

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BMJ 2016;352:i1394 doi: 10.1136/bmj.i1394 (Published 25 April 2016) Page 5 of 5

PRACTICE

Fig 3 Photograph of avulsion injury to upper left lateral incisor

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