What is the best course of action for a patient with a loose tooth due to trauma?

Management of Loose Tooth from Trauma

For a loose tooth due to trauma, immediately classify the injury type (subluxation, extrusive, lateral, or intrusive luxation) and assess occlusion, then reposition if displaced and refer to a dentist based on severity—minor subluxation requires observation only, while significant displacement demands immediate dental referral for splinting. 1

Initial Classification and Assessment

The first step is determining the specific type of luxation injury, as management differs significantly:

• Subluxation: Tooth is loose but not displaced from its position; bleeding from gingival sulcus may be present 2
• Extrusive luxation: Tooth appears elongated and partially displaced out of the socket 3
• Lateral luxation: Tooth is displaced sideways rather than axially 3
• Intrusive luxation: Tooth is pushed into the alveolar bone and appears shortened 2

Critical occlusion check: After any repositioning attempt, verify that the patient can bite down properly and that posterior teeth (molars) can fully interdigitate—failure to do so can result in malocclusion and inability to masticate 3

Management Algorithm by Injury Type

Subluxation (Loose but Not Displaced)

• No immediate treatment is required for a subluxated tooth 2
• Monitor for signs of pulpal necrosis: gray tooth discoloration, gingival abscess (parulis), or localized swelling 2
• Refer to dentist within a few days if tooth discoloration or parulis develops 2
• Immediate dental referral is needed if extensive gingival or facial swelling develops 2

Extrusive Luxation (Tooth Pulled Out)

• For minor extrusion: Apply gentle digital pressure to reposition the tooth back into the socket 3
• For severe extrusion (>3 mm): Immediate dental referral for repositioning with forceps and flexible splint placement for 2 weeks 3
• Extraction is indicated for severe extrusive injuries in primary teeth 2

Lateral Luxation (Sideways Displacement)

• For minor displacement: Gentle repositioning is indicated, or accept the position as spontaneous repositioning will occur 2
• For significant displacement: Immediate dental referral is required 2
• Ensure the tooth position does not interfere with occlusion by asking the patient to bite down gently 2
• Permanent teeth require stabilization with a flexible splint for 4 weeks after repositioning 3
• If the tooth is near exfoliation and interfering with the bite, extraction is indicated 2

Intrusive Luxation (Pushed Into Socket)

• Primary teeth: Observation only, as the tooth will typically re-erupt without intervention 2
• Permanent teeth: Immediate dental referral for more severe intrusions 2
• Obtain intraoral radiograph in cases of severe intrusion to determine tooth location or rule out avulsion 2

Primary vs. Permanent Teeth: Critical Distinction

Primary teeth management differs fundamentally from permanent teeth:

• Avulsed primary teeth should never be replanted to avoid damage to the underlying permanent tooth germ 1, 3
• Significantly luxated primary teeth should generally not be repositioned to protect developing permanent teeth 3
• The guidelines for repositioning and splinting apply primarily to permanent teeth 3

Red Flags Requiring Immediate Dental Referral

Refer immediately for any of the following 1:

• Visible pulp exposure in fractured teeth
• Multiple teeth moving together as a segment (alveolar fracture)
• Severe tooth mobility with aspiration risk
• Inability to close jaw properly or interference with occlusion
• Extensive gingival or facial swelling suggesting abscess

Pain Management and Supportive Care

• First-line: Ibuprofen (NSAIDs) for pain control 1, 4
• Alternative: Acetaminophen if NSAIDs contraindicated 1
• Apply cold compresses to reduce swelling 1
• Maintain soft diet for 10 days after any dental procedure 4
• Avoid temperature extremes with food and beverages 4

Special Considerations and Pitfalls

Aspiration risk: If teeth are unaccounted for or the patient has breathing difficulties, obtain a chest radiograph immediately to rule out aspiration into the tracheobronchial tree 3

Child abuse screening: Consider child abuse as a possible etiology in any child younger than 5 years with trauma affecting the lips, gingiva, tongue, palate, and severe tooth injury 2

Avoid systemic antibiotics for uncomplicated luxation injuries in healthy patients 4

Follow-Up Monitoring

All luxated teeth require ongoing monitoring for complications 3:

• Signs of pulpal necrosis: gray discoloration, gingival swelling with increased mobility, parulis formation 1, 4
• Periodontal pathology 3
• Signs of infection 3
• In primary teeth, potential damage to developing permanent tooth germ 2