Knocked-out tooth: replant within minutes

What it is

Avulsion is complete displacement of a tooth out of its socket, most often an upper central incisor in a child or adolescent after a fall, sport or assault. The survival of a replanted permanent tooth depends on the periodontal ligament cells on the root: they die if the root dries or is scrubbed. Replantation within the first minutes gives the best outcome; if that is not possible, the tooth must be kept moist in a suitable medium while the patient reaches a dentist. Primary (baby) teeth are not replanted, because this can damage the permanent tooth developing underneath.

How to recognise it

• Permanent tooth: replant immediately if possible.
• Hold the tooth by the crown, never the root.
• If dirty, rinse briefly in cold milk, saline or water for a few seconds; do not scrub.
• Storage if replantation is not possible: milk, saline, a balanced storage solution, or the patient's saliva (in the cheek, only for older children and adults who will not swallow it); never dry or in water for long.
• Primary tooth: do not replant; check the socket and the child.

What to do at once

1. Check the patient first: head injury, loss of consciousness, other injuries, airway (an aspirated tooth).
2. Confirm the tooth is permanent (age, size, a full root) and find it.
3. Hold it by the crown, rinse briefly if dirty, and push it gently into the socket the right way round.
4. Ask the patient to bite on gauze or a handkerchief to hold it, and go to a dentist at once for splinting.
5. If it cannot be replanted, place it in milk or saline and go to a dentist immediately.
6. Check tetanus immunisation; the dentist decides on antibiotics and follow-up of the pulp.

Costly mistakes

• Every minute the root is dry reduces the chance of the tooth surviving; after about an hour dry, the ligament cells are dead.
• A tooth that cannot be found may have been swallowed, inhaled or intruded into the bone: consider radiographs, including the chest if aspiration is possible.
• Repeated dental injuries without a clear story in a young child can be a sign of abuse.

Next step / Initial management

• Replanted or stored tooth: urgent dental care the same hour for a flexible splint, radiographs and the decision on antibiotics.
• Missing tooth with possible aspiration: chest radiograph and referral as needed.
• Primary tooth avulsion: do not replant; refer to the dentist for follow-up of the permanent successor.

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Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.

Sources: Avulsed Tooth (StatPearls Publishing (NCBI Bookshelf), 2023); Trauma to the Primary Dentition (StatPearls Publishing (NCBI Bookshelf), 2023); Dental Emergencies (StatPearls Publishing (NCBI Bookshelf), 2022).

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