Fractured and avulsed teeth are dental emergencies that require immediate treatment.
Tooth fracture
Fractures are divided by depth into those that
Affect only the enamel
Expose the dentin
Expose the pulp
If the fracture involves only the enamel, patients notice rough or sharp edges but are otherwise asymptomatic. Dental treatment to smooth the edges and improve appearance is elective.
If dentin is exposed but not the dental pulp, patients usually exhibit sensitivity to cold air and water. Treatment is a mild analgesic and referral to a dentist. Dental treatment consists of restoration of the tooth by a composite resin (white filling) or, if the fracture is extensive, a dental crown, to cover the exposed dentin.
If the pulp is exposed (indicated by bleeding from the tooth) or if the tooth is mobile, dental referral is urgent. Dental treatment usually involves a root canal.
Root fractures and alveolar fractures are not visible, but the tooth (or several teeth) may be mobile. Dental referral is also urgent for stabilization by bonding an orthodontic arch wire or polyethylene line onto several adjacent teeth (1).
Tooth avulsion
Avulsed primary teeth are not replaced because they typically will become necrotic, then infected. They may also become ankylosed and thus not exfoliate, thereby interfering with the eruption of the permanent tooth.
If a permanent tooth is avulsed, the patient should replace it in its socket immediately (handling it by the crown only) and seek dental care to stabilize it. If this cannot be done, the tooth should be kept immersed in saline or milk, or wrapped in a moistened paper towel and brought to a dentist for replacement and stabilization. If these substances are not available and the patient is conscious and not at risk for aspirating the tooth, the tooth can be placed in the patient's mouth during transport to a dental office. The tooth can be rinsed gently under cold water for a maximum of 10 seconds if dirty but should not be scrubbed because scrubbing may remove viable periodontal ligament fibers, which aid in reattachment.
Additionally, if the tooth came in contact with dirt, the patient's tetanus immunization status should be evaluated. If the avulsed tooth cannot be found, it may have been aspirated, embedded in soft tissue, or swallowed. A chest radiograph may be needed to rule out aspiration, but a swallowed tooth is harmless.
Prophylactic antibiotics are not routinely recommended after reimplantation of avulsed permanent teeth in medically healthy patients (2).
Pearls & Pitfalls
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A partially avulsed tooth that is repositioned and stabilized quickly usually is permanently retained. A completely avulsed tooth may be permanently retained if replaced in the socket with minimal handling within 30 minutes to 1 hour. Both partial and complete avulsions usually ultimately require root canal therapy because the pulp tissue becomes necrotic. When replacement of the tooth is delayed longer than 1 hour, the long-term retention rate drops, and root resorption eventually occurs (1). Long-term retention of reimplanted teeth has an unpredictable survival rate.
References
1. Ogle OE. Controversies in Dental Traumatology. Dent Clin North Am. 2024;68(1):151-165. doi:10.1016/j.cden.2023.07.011
2. Bourgeois J, Carvalho JC, De Bruyne M, Declerck D, Eloot A, Leroy R. Antibiotics at replantation of avulsed permanent teeth? A systematic review. J Evid Based Dent Pract. 2022;22(2):101706. doi:10.1016/j.jebdp.2022.101706
Key Points
Tooth fracture that exposes dentin but not pulp can be treated with a filling or sometimes a dental crown.
Tooth fracture that exposes the pulp will likely require a root canal.
An avulsed primary tooth is not replaced.
An avulsed secondary tooth should be replaced in the socket immediately if possible; otherwise, it can be gently rinsed (but not scrubbed) for ≤ 10 seconds and is placed in saline, milk, a wet paper towel, or the patient's mouth for transport to a dentist for replacement in the socket as quickly as possible.
Avulsed teeth that are quickly replaced are often retained but ultimately will most likely require a root canal.
