Each tooth that is present in the mouth serves one or more important functions and losing any of them may compromise a person’s function and aesthetics.

Traumatic dental injury (TDI) is a neglected condition and could rank fifth if included in the list of the world's most frequent acute/chronic diseases and injuries. ⁽¹⁾ Kids between 7-11 years of age experience the peak incidence of traumatic dental injuries, with a male-to-female ratio of 2:1. ⁽²⁾

Traumatic dental injuries may vary from a crown fracture to a complete loss of a tooth (knocked-out tooth). This article will give some useful insights for a rare and serious traumatic dental injury called a knocked-out tooth.

What Do You Mean by a Knocked-out Tooth?

Healthcare professionals use the term “avulsed tooth” to refer to a knocked-out tooth. When, due to any reason, mostly dentoalveolar trauma, a tooth is completely displaced out of its socket in the oral cavity, it is called an avulsed tooth. An avulsed tooth is a dental emergency and requires immediate assessment and management.

Occurrence of a Knocked-out Tooth

• Tooth avulsion has a prevalence of 0.5% to 16% in permanent dentition. ³

• Tooth avulsion is more frequent in young permanent teeth because roots and their supporting periodontium are still in the developing stage.

• Upper front teeth, called maxillary central incisors, are more likely to experience avulsion most often due to their prominent position in the upper arch. ³

Causes of a Knocked-out Tooth

Some of the causes for an avulsed tooth include:

• Falls: They are the most common reason of traumatic dental injury. Children experience falls every now and then while playing at home, school, or on the playground. This may be one reason why they are at higher risk of tooth avulsion. 

• Cycling Accidents: A slippery road, a sudden brake, or a fall from a bicycle may cause trauma to the dento-facial region, which may result in an avulsed tooth.

• Contact Sports: Sports, particularly contact sports such as ice hockey, taekwondo, boxing, lacrosse, basketball, football/soccer, rugby, volleyball, and skating may cause dental injuries including a knocked-out tooth. ^{2, 4}

• Assaults: Domestic violence or abuse may also be a contributing factor in causing a knocked out tooth.

• Vehicular Accidents: Road traffic accidents may also cause tooth loss due to dental trauma.

MedBound Times connected with Dr. Prakash Patil, MDS (Oral and Maxillofacial Surgery), Director of Face and Dental International Clinic, Pune to share his expertise on knocked-out tooth and its management. He has more than 25 years of experience in dentistry and has treated many complex dental trauma cases. 

“Recently we had a child who fell directly onto his front teeth during a 15th August school parade practice session!” added Dr. Prakash Patil.

The use of mouthguards during sports and other precautionary measures may help prevent such injuries, but they are not 100% preventable, right? So, let’s discuss what first-aid steps you should take before consulting a dentist for a knocked-out tooth.

How Do You Know a Tooth is Knocked Out?

A person who experiences any type of dental or facial injury will probably realize if a tooth is knocked out, but below are some signs and symptoms that may help confirm it:

• A sudden unusual gap in your mouth immediately after a dental trauma

• Bleeding from the gums and the lips

• Swelling in the gums and the lips

• Sharp pain in the gums or area of the dental injury

• Mobility of one or more teeth around the area where a gap is felt

• A crackline or fracture in an adjacent or opposite tooth where a gap is felt

• A bruise or laceration in the gums and/or the lips

• Misalignment of the teeth or change in the bite

First Aid for a Knocked-out Tooth at the Place of an Injury

For a knocked-out tooth, first aid should be started immediately after noticing it.  Knowledge about the first aid for an avulsed tooth is important to everyone, especially parents and teachers, considering the highest occurrence of traumatic dental injuries among children aged 7-11 years. 

What Should You Do in the First 30 Minutes if a Tooth is Knocked Out?

The following are the first-aid steps for an avulsed permanent tooth in particular, but before that, the patient must check for any other major injuries to the body.

Each of the steps below is important because proper handling of an avulsed permanent tooth in the first 30 minutes, followed by an appropriate treatment, plays an important role in saving that tooth.

• Once you notice that the tooth is knocked out, try to find it first.

• If you find the lost tooth, please pick it by its crown portion (the visible part of the tooth when it is in its socket in the mouth) and not by the root portion. 

• If the tooth has become dirty, rinse it gently using clean water without scrubbing it.

• Do not use soap for rinsing the tooth.

• Just wash it, but do not dry it.

• Do not use any cloth to clean it.

• While holding the tooth by the crown, try to place it back in the socket if possible. 

• After placing the tooth back in its position in the mouth, bite on some cotton, gauze, or cloth to support it in place. 

• If you are not able to put the tooth back in its socket for any reason, such as when the patient is unconscious or has dentoalveolar trauma with jaw fractures, etc., put it in milk, normal saline, or the patient's own saliva in a glass bottle. ^{5, 6}

• A special storage medium such as HBSS (Hank’s Balanced Salt Solution) may be used for storing an avulsed tooth, but it may not be readily available. ⁵

• An avulsed tooth can also be stored by putting it in the buccal vestibule (space between the cheek and gums) or the labial vestibule (space between lips and gums). However, take care not to swallow the tooth. 

• An avulsed tooth can also be stored in water. Although water is considered a poor storage medium, it is still better than letting the tooth dry and become dehydrated. ^{5, 6}

• A patient with a repositioned tooth or the stored tooth must visit the dentist without delay for further management and treatment of a knocked-out tooth.

• Do not try to put back an avulsed primary tooth, as it may harm the developing permanent tooth or tooth bud which is below the socket of a primary tooth.

“It is important to handle the knocked-out tooth from the crown surface and keep it wet to preserve the pluripotent stem cells in the periodontal ligament area around the root surface which can help in reattachment of avulsed tooth,” explained Dr. Prakash Patil.

Management and Treatment of an Avulsed Tooth in Dental Operatory

• The first step in the management of a knocked-out tooth is its replantation (putting an avulsed tooth back into its socket).

• If the patient has already repositioned the tooth, the dentist will check for proper alignment of the tooth in its socket and provide support to the tooth by splinting it to an adjacent tooth for about 2 weeks. ⁵

• If the patient comes with the stored tooth, the dentist will replant it in the socket and splint it to the adjacent tooth for stabilization. ⁵

• In case of an avulsed tooth associated with a jaw fracture, a more rigid splint may be placed for a duration of 4 weeks. ⁵

• Depending on the stage of development of an avulsed tooth (whether root formation is complete or not), further treatment varies.

• In case of an avulsed tooth with complete root formation, a dentist will perform a root canal treatment, mostly within 2 weeks of replantation. ⁵

• The dentist will prescribe a course of medications including antibiotics and anti-inflammatory drugs after replantation of a knocked-out tooth.

• Regular follow-up of a replanted tooth is necessary and important.

The extraoral time (the time for which a tooth remains outside the mouth) and the type of the storage medium are important factors for a favorable prognosis of a replanted tooth.

In such cases, a replanted tooth may help maintain contour, height and width of the alveolar bone (the bone that holds the teeth) temporarily. ⁵

Instructions to Follow after Replantation of a Knocked-out Tooth

• Take a soft diet and avoid chewing any hard food for up to 2 weeks. ⁵

• Avoid participating in contact sports.

• Maintain good oral hygiene by brushing your teeth twice daily using a soft toothbrush.

• Gargle using a chlorhexidine (0.12%) mouthwash twice a day for 2 weeks. ⁵

Complications of a Replanted Tooth

According to a study, tooth avulsion is a severe dental injury with an unpredictable prognosis. ⁷ Replanting the knocked-out tooth at the earliest (ideally within 30 minutes of avulsion) may increase the chances of its survival. 

Complications of a replanted tooth include:

• Excessive mobility and signs of infection, such as swelling of the gums and pus discharge, called inflammatory resorption 

• An ankylosed tooth, the tooth becomes fused to the alveolar bone

Therefore, a patient with a replanted tooth must maintain regular follow-up appointments to check for such problems.

Treatment Options For a Knocked-out Tooth That Can’t Be Replanted

In dentistry, the goal is always to preserve the natural tooth. However, if a knocked-out tooth can not be replanted or if a tooth has a failed replantation, there are options to replace the lost tooth which include:

• A removable partial denture to replace the missing tooth, which is the cheapest and simplest option.

• A dental bridge, which replaces the missing tooth by taking support from the adjacent teeth.

• An implant to replace the missing tooth. 

Key Takeaway

Although a knocked-out tooth is a rare type of dental injury, knowledge of the first-aid steps for a knocked-out tooth may help save a person’s natural tooth. The successful replantation of an avulsed tooth depends on immediate action, proper repositioning, appropriate treatment based on the maturity of the tooth, proper aftercare, and regular long-term follow-ups.

References:

1. Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis—One billion living people have had traumatic dental injuries. Dent Traumatol. 2018; 34: 71–86. https://doi.org/10.1111/edt.12389

2. Alotaibi S, Haftel A, Wagner ND. Avulsed Tooth. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539876/

3. El Kharroubi S, Drouri S, Doumari B, Dhoum S, El Merini H. Management of 3 Avulsed Permanent Teeth: Case Report of a 3-Year Follow-up. Case Rep Dent. 2022;2022:2081684. Published 2022 Mar 16. doi:10.1155/2022/2081684

4. https://doi.org/10.5005/jp-journals-10015-1897

5. 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: 331–342. https://doi.org/10.1111/edt.12573

6. Adnan S, Lone MM, Khan FR, Hussain SM, Nagi SE. Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review. Dent Traumatol. 2018;34(2):59-70. doi:10.1111/edt.12382

7. Müller DD, Bissinger R, Reymus M, Bücher K, Hickel R, Kühnisch J. Survival and complication analyses of avulsed and replanted permanent teeth. Sci Rep. 2020;10(1):2841. Published 2020 Feb 18. doi:10.1038/s41598-020-59843-1