Clinical Rounds

STEAMBOAT SPRINGS, COLO. – Replacing a knocked-out permanent tooth is a far-less-daunting proposition than it sounds, according to Dr. Steven M. Selbst.

"This is an easy procedure that I hope every pediatrician would be comfortable in doing," he said at the meeting sponsored by the American Academy of Pediatrics.

Dr. Steven M. Selbst

Time is critical. A tooth reinserted within 30 minutes after being knocked out has a 90% chance of survival. After that, the success rate drops off considerably.

A common scenario is for a parent to phone the pediatrician from the scene of the mishap, perhaps a playground, the backyard trampoline, or a baseball diamond. The parent should be instructed to immerse the tooth in milk, if immediately available, while transporting the youth to the physician’s office. If milk is not at hand, water is the next best. Failing that, the adult should put the tooth under his or her own tongue, according to Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and an authority on emergency pediatrics.

It’s an excellent idea for every pediatrician’s office – and school nurses’ offices as well – to stock a container of the balanced salt solution known as Save-a-Tooth emergency tooth-preserving system filled with Hank’s balanced salt solution (HBSS). It’s inexpensive, available on the Internet, and extends the salvage time by several hours. As soon as the patient arrives at the office, the tooth can be placed in the HBSS while the treatment team assembles.

The tooth should always be handled by the crown, not the root. And even though the tooth may have been kicked around in the dirt, it shouldn’t be scrubbed clean; that would damage the fine root fibers that are essential to successful reattachment. Instead, the tooth can be gently irrigated with saline or tap water to clean it up.

The tooth socket is a gaping hole, often filled with a blood clot. This, too, should be gently irrigated. Wet gauze can be used to wipe away the clot.

There’s no need to anesthetize the tooth socket with a lidocaine injection.

"When the tooth got knocked out, most of the pain-carrying nerve fibers got knocked out along with it. It’s really not that painful to replace the tooth. The teenager is desperate for this procedure to be successful. He or she is going to do everything possible to help you along the way. They’ll tolerate a bit of pain or discomfort," Dr. Selbst explained.

The procedure itself is remarkably straightforward.

"You don’t need fancy equipment. You don’t need any anesthesia. You just need to have the courage to stick the tooth right back up in that big hole after you’ve cleaned it off," the pediatrician continued.

But first, make sure the tooth is correctly oriented: right side up, front facing forward.

Pretty much the only complication that can occur is if the nervous physician drops the tooth and the patient then swallows it. It’s game over at that point. For this reason, Dr. Selbst said he always has the patient sitting up to at least a 45-degree angle for the procedure rather than lying down.

02/15/12  

---

EXPERT ANALYSIS FROM A MEETING ON PRACTICAL PEDIATRICS SPONSORED BY THE AMERICAN ACADEMY OF PEDIATRICS

---