Dental avulsion is the complete displacement of a tooth due to it being forcefully knocked out. This type of injury is common, particularly in children. However, it is only necessary to replant a tooth if it is a permanent one. A permanent tooth that has been knocked out can often be successfully re-implanted by a dentist if it is done quickly.
Guidelines
- The first aid provider may temporarily store the tooth in:
> Hank’s balanced salt solution
> propolis (from 0.04 mg to 2.5 mg per mL of 0.4% ethanol)
> oral rehydration salt solutions including Ricetral (a commercial form of oral rehydration salt)
> solutions containing sodium chloride, glucose, potassium chloride, citrate, extruded rice
> cling film. - If none of these options are available, the first aid provider may temporarily store the tooth in cow’s milk (with any per cent fat or form). *
Good practice points
- The first aid provider may encourage the person to apply gentle pressure to the bleeding gum with gauze to stop the bleeding.
- If the avulsion has created any sharp edges in the person’s mouth, have the person apply a compress of gauze or clean cotton to protect their mouth from further injuries.
- When picking up the tooth, it should be held at the crown (the area that sits above the gum), not at the root.
- First aid providers may NOT re-implant the tooth.
- The tooth should NOT be cleaned as this could damage vital tissues still attached to the tooth.
- If cow’s milk is not available, the first aid provider may temporarily store the tooth in the person’s own saliva. Unless there are no alternative options, do NOT let the person keep the tooth in their mouth, as there is a chance that the person will swallow it (e.g., if the person is not fully responsive, or if they are a child). Instead, use a small jar or another container.
- Refer the person to a dentist. Advise them they should get help as soon as possible.
- There is no need to consider emergency dental treatment if the tooth is not a permanent one (such as in young children). However, advise the person to seek dental care anyway, particularly if the tooth’s root has broken off.
Chain of survival behaviours
Prevent and prepare
- Know what solutions are available to you for storing an avulsed tooth and have a suitable container available for transportation.
- Know the phone number of a dentist.
- Wear a mouth guard for contact sports such as boxing, rugby, karate and taekwondo.
- Wear a helmet when riding a motorcycle, bicycle or horse, and for skateboarding.
Early recognition
A tooth has been knocked out.
First aid steps
- Help the person to stop the bleed in their mouth by applying a compress of gauze or clean cotton.
- If the avulsion has created any sharp edges in the person’s mouth, have the person apply a compress of gauze or clean cotton to protect their mouth from further injuries.
- Find the tooth and pick it up carefully by the crown. Store it in Hank’s balanced salt solution, an oral rehydration solution, or plastic cling film. If none of these options are available, store the tooth in cow’s milk, or in the person’s own saliva.
- Advise the person to access a dentist as soon as possible, and to take their tooth with them.
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NOTE
When using plastic cling film, make sure to add enough of the person’s saliva, in order to prevent the tooth from drying out.
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Access help
- If a dentist is not available quickly, access any available medical care.
Education considerations
Context considerations
- The use of the solutions mentioned in the guidelines depends on availability, local laws, and regulations —including liability protection. Facilitators may need to vary their list of recommended solutions accordingly.
- Oral rehydration salts are sometimes provided in first aid kits.
Learner considerations
- Learners who have contact with children or people doing sports might be encouraged to learn how to store an avulsed tooth. Learners can also be encouraged to discuss which storage options are available to them in their context, so they are better prepared.
Facilitation tips
- Emphasise that the role of the first aid provider is to help the person (and their avulsed tooth) get to a dentist.
- Remind learners there might be a lot of blood coming from the person’s mouth and that this can be stemmed with a clean cloth or gauze pressed into the gap where the tooth was.
Learning connections
- Connect this topic to Severe bleeding.
Scientific foundation
Systematic reviews
ILCOR conducted a systematic review in 2020 to identify the best available evidence for the effectiveness of any technique available to first aid providers for storing an avulsed tooth compared with storage in milk or saliva (De Brier, 2020).
The review included 33 studies and reported 23 comparisons. The limited evidence available favours storing an avulsed tooth in Hank’s balanced salt solution, propolis solution, oral rehydration salts, rice water, and cling film compared with storage in milk. The cell viability rate was significantly lower in teeth stored in saline solutions, tap water, buttermilk, castor oil, GC Tooth Mousse, and turmeric extract than those stored in milk. There is insufficient evidence to recommend for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. The certainty of the evidence was considered low to very low due to limitations in study design, indirect study populations and outcome measures, and imprecision.
References
Systematic reviews
De Brier, N., Dorien, O., Borra, V., Singletary, E. M., Zideman, D. A., De Buck, E., … & Cassan, P. (2020). Storage of an avulsed tooth prior to replantation: a systematic review and meta‐analysis. Dental Traumatology.
Singletary, E. M., Zideman, D. A., Bendall, J. C., Berry, D. C., Borra, V., Carlson, J. N., … & Douma, M. J. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation, 142(16_suppl_1), S284-S334.
DOI 10.1161/CIR.0000000000000897
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., Chang, … Lee, C.C., (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Resuscitation. Nov;156:A240-A282. DOI 10.1016/j.resuscitation.2020.09.016
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Published: 15 February 2021
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