Case Summary

A 32-year-old male presented after a fall from standing. He had a right lateral incisor (tooth number 7) avulsion and presented with his tooth in hand. It had not been stored in any liquid media prior to arrival at the emergency department. Emergency department (ED) staff placed the tooth in milk until evaluation by the treating physician. The tooth was then reapproximated by placing it back into the socket and two 2-0 silk sutures were tied around neighboring teeth to anchor the tooth (Figure 1). The patient was discharged with a course of antibiotics and dental referral.

Figure 1: Lateral incisor replaced within 1 hour of avulsion.

Discussion

Avulsed permanent teeth are a true dental emergency and represent up to 11 percent of all cases of dental trauma.¹ The International Association of Dental Traumatology recommends immediate first aid in the setting of an avulsed permanent tooth. This includes handling the avulsed tooth by the crown only (to avoid touching the root and to minimize contamination), washing in cold running water to remove loose debris, and immediate reimplantation, if possible, in a conscious patient.² Otherwise, the guidelines recommend placement in a suitable solution to prevent drying of the root of the tooth. In order of decreasing preference, the guidelines recommend milk, Hanks, Balanced Salt Solution, saliva (have the patient spit into a clean container), or saline. Water is not recommended but is better than leaving the tooth to air dry. Dry time should be less than 60 minutes to prevent loss of viability of periodontal ligament cells.

Figure 2: Follow-up over a year after the original injury.

After the patient comes to the ED, the physician can attempt re-implantation and flexible splinting to secure the tooth until definitive dental care can be obtained. Local anesthesia may be needed to facilitate re-implantation. In a study of three different methods—periodontal pack, wire, and bondable reinforcement ribbon—to secure an avulsed tooth in the emergency department, dentists preferred the bondable reinforcement ribbon technique for optimal long-term outcomes.³ Alternative methods, including using tissue adhesive bonded to the pliable metal from a non-rebreather mask, or nylon fishing wire bonded with composite materials, have also been described.^4,5

After splinting, the physician should verify the normal position of the re-implanted tooth both clinically and radiographically. A flexible splint should remain in place for up to two weeks. Update tetanus protection in the ED, if necessary. Prescribe the patient a course of oral antibiotics and use a chlorhexidine (0.1 percent) mouth rinse twice a day for one week. Patients should also be advised to avoid participation in contact sports, to consume a soft diet for up to two weeks, and to brush teeth with a soft toothbrush after meals.

In this case, which describes using silk suture to secure an avulsed tooth in the emergency department, we offer another method to provide flexible splinting with good long-term outcomes in the setting of dental trauma. This patient had successful re-implantation on follow-up over a year after the original injury (Figure 2).

Dr. Dark (@RealCedricDark) is associate professor of emergency medicine at Baylor College of Medicine and the medical editor in chief of ACEP Now.

Dr. Brock is a pediatric dentist in Houston, Texas.

Dr. Miksanek is an emergency physician at OSF Saint Francis Medical Center.

References

1. Bustamante-Hernández N, Amengual-Lorenzo J, Fernández-Estevan L, et al. What can we do with a dental avulsion? A multidisciplinary clinical protocol. J Clin Exp Dent. 2020;12(10):e991-e998.
2. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36(4):331-342.
3. McIntosh MS, Konzelmann J, Smith J, et al. Stabilization and treatment of dental avulsions and fractures by emergency physicians using just-in-time training. Ann Emerg Med. 2009;54(4):585-92.
4. Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-7.
5. Kahler B, Hu JY, Marriot-Smith CS. Splinting of teeth following trauma: a review and a new splinting recommendation. Aust Dent J. 2016;61 Suppl 1:59-73.