Management of the Avulsed Tooth in Emergency and Prehospital Care
Abstract
Background: Tooth avulsion, the complete displacement of a tooth from its socket, is a serious dental emergency, predominantly affecting the maxillary anterior teeth in children and adolescents. Its management is time-critical, as the viability of the periodontal ligament (PDL) cells on the root surface and the long-term prognosis are heavily dependent on immediate and appropriate prehospital and emergency care.
Aim: This article reviews the etiology, pathophysiology, and, most importantly, the evidence-based emergency and prehospital management protocols for avulsed permanent teeth, with the goal of optimizing outcomes through timely intervention.
Methods: A comprehensive narrative review synthesizes current guidelines from dental traumatology, focusing on the critical steps from the moment of injury to definitive dental care. It examines the importance of storage media, handling techniques, replantation procedures, and adjunctive therapies.
Results: Immediate replantation at the site of injury is ideal. When not possible, storing the tooth in a physiologically compatible medium like milk or saline is essential to preserve PDL cell viability. The extraoral dry time is the single most critical prognostic factor; dry storage beyond 60 minutes drastically increases the risk of root resorption and ankylosis. Management involves gentle cleansing, possible anti-resorptive pre-treatment, careful replantation, semi-rigid splinting for approximately two weeks, and systemic antibiotics (e.g., doxycycline). Long-term success requires diligent follow-up, including pulp vitality testing and timely endodontic treatment for mature teeth.
Conclusion: Successful management of an avulsed tooth hinges on a coordinated, rapid response. Public and professional education on proper first-aid (crown handling, use of milk) is vital to improve outcomes. Adherence to established protocols for replantation, splinting, and follow-up care maximizes the potential for long-term tooth retention, preserving function and alveolar bone.
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References
Feliciano KM, de França Caldas A Jr. A systematic review of the diagnostic classifications of traumatic dental injuries. Dental traumatology : official publication of International Association for Dental Traumatology. 2006 Apr:22(2):71-6
Veras SRA, Bem JSP, de Almeida ECB, Lins CCDSA. Dental splints: types and time of immobilization post tooth avulsion. Journal of Istanbul University Faculty of Dentistry. 2017:51(3 Suppl 1):S69-S75. doi: 10.17096/jiufd.93579.
Zaleckiene V, Peciuliene V, Brukiene V, Drukteinis S. Traumatic dental injuries: etiology, prevalence and possible outcomes. Stomatologija. 2014:16(1):7-14
Bemelmanns P, Pfeiffer P. [Incidence of dental, mouth, and jaw injuries and the efficacy of mouthguards in top ranking athletes]. Sportverletzung Sportschaden : Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin. 2000 Dec:14(4):139-43
Zaleckienė V, Pečiulienė V, Aleksejūnienė J, Drukteinis S, Zaleckas L, Brukienė V. Dental Trauma Experience, Attitudes and Trauma Prevention in 11- to 13-Year-Old Lithuanian Schoolchildren. Oral health & preventive dentistry. 2020 Jul 4:18(2):373-378. doi: 10.3290/j.ohpd.a43309.
Zhu W, Zhang Q, Zhang Y, Cen L, Wang J. PDL regeneration via cell homing in delayed replantation of avulsed teeth. Journal of translational medicine. 2015 Nov 14:13():357. doi: 10.1186/s12967-015-0719-2.
Trope M. Avulsion of permanent teeth: theory to practice. Dental traumatology : official publication of International Association for Dental Traumatology. 2011 Aug:27(4):281-94. doi: 10.1111/j.1600-9657.2011.01003.x.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T, International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental traumatology : official publication of International Association for Dental Traumatology. 2007 Jun:23(3):130-6
Kostka E, Meissner S, Finke CH, Mandirola M, Preissner S. Multidisciplinary treatment options of tooth avulsion considering different therapy concepts. The open dentistry journal. 2014:8():180-3. doi: 10.2174/1874210601408010180.
Blomlöf L, Otteskog P. Viability of human periodontal ligament cells after storage in milk or saliva. Scandinavian journal of dental research. 1980 Oct:88(5):436-40
Andreasen JO, Schwartz O. The effect of saline storage before replantation upon dry damage of the periodontal ligament. Endodontics & dental traumatology. 1986 Apr:2(2):67-70
Cvek M, Granath LE, Hollender L. Treatment of non-vital permanent incisors with calcium hydroxide. 3. Variation of occurrence of ankylosis of reimplanted teeth with duration of extra-alveolar period and storage environment. Odontologisk revy. 1974:25(1):43-56
Kahler B, Hu JY, Marriot-Smith CS, Heithersay GS. Splinting of teeth following trauma: a review and a new splinting recommendation. Australian dental journal. 2016 Mar:61 Suppl 1():59-73. doi: 10.1111/adj.12398.
Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dental traumatology : official publication of International Association for Dental Traumatology. 2005 Apr:21(2):93-101
Gopikrishna V, Tinagupta K, Kandaswamy D. Comparison of electrical, thermal, and pulse oximetry methods for assessing pulp vitality in recently traumatized teeth. Journal of endodontics. 2007 May:33(5):531-5
Stewart CJ, Elledge RO, Kinirons MJ, Welbury RR. Factors affecting the timing of pulp extirpation in a sample of 66 replanted avulsed teeth in children and adolescents. Dental traumatology : official publication of International Association for Dental Traumatology. 2008 Dec:24(6):625-7. doi: 10.1111/j.1600-9657.2008.00691.x.
Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. The Cochrane database of systematic reviews. 2019 Feb 5:2(2):CD006542. doi: 10.1002/14651858.CD006542.pub3.
Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, de Mendonça MR, Panzarini SR. Storage media for avulsed teeth: a literature review. Brazilian dental journal. 2013 Sep-Oct:24(5):437-45. doi: 10.1590/0103-6440201302297.
Bastos JV, Côrtes MIS. Pulp canal obliteration after traumatic injuries in permanent teeth - scientific fact or fiction? Brazilian oral research. 2018 Oct 18:32(suppl 1):e75. doi: 10.1590/1807-3107bor-2018.vol32.0075.
Ram D, Cohenca N. Therapeutic protocols for avulsed permanent teeth: review and clinical update. Pediatric dentistry. 2004 May-Jun:26(3):251-5
Authors
Copyright (c) 2025 Abdulrhman Mouhsen Ali Alshammari, Faisal Dhuwaihi Al-Otaibi, Sultan Mansour Matar Alanzi, Fahad Soud Shoei Aliraqi, Naif Mohammed Alhassan, Aeshah Ali Salem Albalawi, Rehab Tayeb Hazazi, Hanan Fahad Alsulami, Maryam Mutairan Ghanaem Alharbi, Hosam Hasan Alzhrani
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