Sink Your Teeth Into this TIME SENSITIVE Topic!

http://www.dentaltraumaguide.org/permanent_avulsion_treatment.aspx

******PLEASE ALSO REVIEW VIA THE REX WEBSITE LIBRARY THE TOOTH AVULSION CHAPTER IN UPTODATE, WHICH HAS SUPERB PICTURES******

While we are obviously not dentists, facial and dental trauma are a part of urgent care practice. I will be the first to admit that a medical provider can quickly get lost in the dental terminology of dental concussion, subluxation, intrusion, extrusion, and avulsion. Here are the imperative points though:

• With a facial trauma, and a "knocked out tooth", in the mayhem of patient and understandable parent panic, don't lose sight of the forest for the (tooth) trees. In other words, make sure that the c-spine is alright, assess for loss of consciousness and intracranial injury risk factors that take precedence over the tooth, and do a quick body survey and history for potential child abuse.
• The most dreaded and time sensitive is a full tooth avulsion. These injuries, for PERMANENT TEETH, need care within 1 hour and if not placed in proper medium, the tooth and its essential periodontal ligament have a zero percent survival rate. 

      As such, our main focus is:
1. Is this a permanent tooth? Here is a basic guide:
-All teeth are primary for kids less than 5.
-Permanent incisors usually erupt around age 6-7. Note the frontal maxillary incisors are the 2 most commonly injured teeth.
- Mixed dentition occurs in ages 6-12. As such, this will be the "tough group."
-Most kids over 13 have all permanent teeth.

2. Is this an avulsion? Again, I suggest the UptoDate pictures, but in non dental language the tooth is totally knocked out at the gumline, the periodontal ligament is severed, and a fracture of the alveolar ridge may also be present. AVULSION NEEDS REIMPLANTATION AS SOON AS POSSIBLE. NOTE THAT FROM THE TRAUMA UNTIL REIMPLANTED AND SEEN BY A DENTIST, COLD MILK IS THE BEST TRANSPORT SOLUTION, OR IF THE CHILD IS OLD ENOUGH TO NOT ASPIRATE IT, INSIDE THE BUCCAL MUCOSA.
Per UptoDate, here is the basic-and doable-guide to reimplant the avulsed tooth and quickly being sent to the ER or dentist. Again, the 1 hour window applies to reimplantation, so you can make a big difference here...

• handle the tooth carefully by the CROWN and avoid the ligament
• remove debris by gentle rinsing with saline or tap water (again, milk is the preferred storage medium over saline for transport). DO NOT ATTEMPT TO STERILIZE OR SCRUB THE TOOTH, as you want to keep the periodontal microfibers.
• manually reimplant the tooth in the socket- see picutre 8 in up to date.
• keep the tooth in place by having the child bite down on a clean gauze or towel.
• see the dentist or pediatric ER as soon as possible.   

Again new things are always intimidating, but here is the cheat sheet summary:
1. SEE ALL DENTAL INJURIES ASAP IN THE CLINIC. 
2. IF A PARENT CALLS IN ROUTE, OR IF THE PATIENT HAS THE TOOTH IN HAND, PLACE IT IN COLD MILK OR THE BUCCAL MUCOSA. NO SCRUBBING.
3.IF A PERMANENT TOOTH, REIMPLANT IT TO MAINTAIN VIABILITY AND SEND TO THE DENTIST ASAP.