Adult Tooth Falls Out: What to do? (Step-by-step)

Why does the tooth fall out?

Tooth falls out from the mouth for a few reasons like trauma and gum disease. A hit to the tooth can dislodge the tooth out of the socket and fall out of the mouth, and this situation is called tooth avulsion. Research showed that tooth avulsion occurs most commonly at the age between 8 to 12 years. The most common tooth that falls out due to trauma is the upper middle front tooth [1].

Most of the time, an adult tooth that falls out can still be saved if you can provide first aid to the tooth. The first aid aims to keep the cells surrounding the tooth root alive by nourishing them with a suitable medium.

What about baby tooth (primary tooth)? Unfortunately, a baby tooth that falls out cannot be saved. The following Step-by-step guide is only applicable for adult tooth (permanent tooth) that falls out. This guide is based on the International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth.

What to do immediately after the tooth falls out? (Step-by-step)

There are three scenarios which need different management:

1. The tooth that falls out is an adult tooth or permanent tooth:
   This tooth can often be saved by putting it back into the socket as soon as possible with caution as described below.
2. If the tooth that falls out is a primary tooth (baby tooth, or first set of teeth in the mouth): 
   NEVER RE-INSERT the baby tooth into its socket. It will lead to unwanted consequences. Just bring the tooth and the kid to the dentist for further management.
3. You are not sure whether it is an adult tooth or baby tooth:
   Bring the tooth to the dentist by storing it in a suitable transfer medium. You can follow the same steps and SKIP ONLY Step 3.

Step 1: Find the tooth

Make sure the person is free of danger and the any bleeding should be stopped (bite on a clean cloth/handkerchief). Then, find the tooth. Here are two scenarios which can happen:

• The tooth is knocked out, but still in the mouth. DO NOT take it out. Keep it inside the mouth.
• The tooth is knocked out of the mouth. Pick up the tooth by holding its crown. NEVER hold the root.

Step 2: Clean the tooth if it is dirty

The tooth may fall onto dirty ground. Pick it up by holding the crown, and rinse it with your own saliva or milk (or tap water, briefly).

If the tooth is clean or it is never out of the mouth, skip this step and proceed to the next.

Step 3: Insert the tooth back into its socket in the mouth

Yes, it is hard to do, but this is possibly the most important step to keep the tooth “lining cells” alive. To keep them alive, you need to flood them with nutrients, and no other place is better than its own “house” – the socket.

Try to insert it back to its socket by yourself or someone else. Gently bite on a handkerchief after re-insertion. If you are unable to do so, proceed to the next step.

NEVER RE-INSERT the baby tooth into its socket. If you are not sure whether it is a baby tooth or adult tooth, skip this step and proceed to next.

Step 4: Keep the tooth in a suitable storage medium before bringing to the dentist

If you are unable to re-insert the tooth back into the socket, a few storage media can keep the root cells alive for some time. They are arranged below with the most preferable being the first [3]:

• Hank’s balanced salt solution
• Pasteurized fresh milk (NOT condensed or powdered milk)
• Natural products: coconut water, propolis, green tea, or egg white
• Own saliva

Step 5: Bring the tooth in a storage medium to a nearby dentist

Get to the dentist within one hour. Research showed that the faster the avulsed tooth is managed, the higher the chance for the tooth to survive.

If you are unable to do so, keep the tooth in the storage medium. Studies have shown it can keep the root cells alive for hours [2].

The dentist will do the necessary examination of the mouth and the tooth before he or she re-insert or re-implant the tooth.

What will happen to the tooth after re-inserting it into the socket?

If the tooth is inserted back (re-implanted) into the socket in a short time, the tooth will usually heal and the root will attach normally to the bone within two to four weeks.

However, a few undesirable events may occur to the tooth, especially when the tooth is out of the mouth of the storage medium for more than an hour [2].

Pulpal necrosis or dead tooth

Even after the tooth is successfully re-inserted into the socket, it can still turn into a dead tooth. This is because the tooth has been damaged, and the cells inside have been deprived of oxygen and nutrients. When the tooth is dying, you may notice that it gradually darkens and becomes more yellowish or greyish.

When this happens, the tooth will need root canal treatment to prevent future infection of the dead tooth. Sometimes the dentist will start the root canal treatment a week after the re-implantation of the tooth when it is highly suspected that the tooth will become dead.

Ankylosis

Ankylosis is the fusion of the tooth root to its supporting bone. Normally, the tooth is separated from the supporting bone by a thin layer of cushioning tissue, which is called the periodontal ligament.

During a trauma, this layer is often disturbed. When the tooth is inserted back into the socket, the socket bone will fuse with the tooth without this intermediate cushion layer. You may think that the fusion of tooth and bone is good as it makes the tooth more stable. However, this can lead to some undesirable consequences. If it happens in growing children, the ankylosed tooth may not be able to catch up with the growing jaw and the tooth will be “stuck” at a lower level compared to other teeth. Also, tooth extraction will be more complicated in the future because of the fusion of the tooth and bone.

Root resorption

Root resorption happens when the body defence system starts attacking the root of the tooth. This happens especially when the re-implanted tooth is infected by bacteria. Usually, little root resorption will happen to almost all re-implanted tooth. When the resorption is greater, it can cause the tooth to become loose and eventually fall out.

To reduce the chance of root resorption, the dentist may start the root canal treatment to prevent infection of the tooth.

Pulp obliteration

This means that the living tissue in the tooth starts to degenerate and calcified (harden due to mineral deposition). The result is that the root canal will be blocked by that calcified substance.

It may not require treatment. However, the dentist may decide to start the root canal treatment in certain situation.

Therefore, it is important to go for a dental review appointment after re-implantation so that any complication will not be left unnoticed.

Reference

1. Barrett EJ, Kenny DJ. Avulsed permanent teeth: a review of the literature and treatment guidelines. Endod Dent Traumatol. 1997;13:153–63
2. 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.
3. 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 Apr;34(2):59-70. doi: 10.1111/edt.12382. Epub 2018 Feb 6. PMID: 29292570.