What is the optimal therapy for a 14-year-old with an avulsed tooth and copious oral bleeding due to a hockey injury?

Optimal Management of Avulsed Permanent Tooth in a 14-Year-Old Hockey Player

The avulsed tooth should be immediately replanted at the scene by rinsing it briefly under cold water for less than 10 seconds (handling only the crown), then repositioning it in the socket and having the patient bite on a cloth to hold it in place until emergency dental care is obtained. 1

Immediate On-Site Management

First Priority: Locate and Handle the Tooth Correctly

• Handle the tooth by the crown only—never touch the root surface, as it is covered with fragile periodontal ligament fibroblasts essential for successful reattachment 1
• Confirm this is a permanent tooth (not primary); at age 14, this will be permanent 1

Second Priority: Immediate Replantation (Best Option)

• If the tooth is dirty, rinse it briefly under cold running water for less than 10 seconds 1
• Immediately reposition the tooth in the socket at the ice arena 1
• Have the patient bite down on a clean cloth or gauze to hold the tooth in position 1
• The likelihood of successful reimplantation decreases rapidly with every minute the tooth remains out of the socket, particularly as the periodontal ligament cells die 1

This immediate replantation approach is supported by both the 2024 American Heart Association/Red Cross Guidelines and the 2014 Pediatrics guidelines, which emphasize that the treatment of choice is immediate replantation at the site of injury 1.

If Immediate Replantation Is Not Possible

Storage Medium Hierarchy (in order of preference):

Tier 1 (Best):

• Hanks Balanced Salt Solution 1
• Oral rehydration salt solutions 1
• Propolis 1
• Rice water (if preprepared) 1
• Cling film wrap to prevent dehydration 1

Tier 2 (Acceptable):

• Cold cow's milk (any fat percentage) 1
• Saliva (patient can drool into a container) 1

Tier 3 (Last Resort):

• Probiotic 1
• Egg white 1
• Almond milk 1

Never use tap water—it causes osmotic lysis of the root fibroblasts and significantly worsens prognosis 1

At an ice arena, cold milk is likely the most readily available appropriate storage medium and should be used if immediate replantation cannot be accomplished 1.

Managing the Oral Bleeding

• Apply direct pressure with clean gauze or cloth to the bleeding socket 1
• The copious bleeding is expected from the gingival tissues and alveolar socket 1
• Control bleeding while simultaneously managing the avulsed tooth

Immediate Transport and Follow-Up

• Seek emergency dental care immediately, whether or not replantation was successful 1
• Bring the tooth if it was not replanted 1
• A flexible splint will need to be placed by the dentist for up to 2 weeks 1
• Most avulsed teeth will require root canal therapy within 7-10 days after replantation 1

Antibiotic Prophylaxis

For this 14-year-old patient, doxycycline is the recommended systemic antibiotic after reimplantation (for children >12 years) 1. For children <12 years, penicillin would be indicated, or clindamycin if penicillin-allergic 1.

Critical Pitfalls to Avoid

• Do not delay replantation to search for storage media—immediate replantation is always superior 1
• Do not scrub or handle the root surface—this damages the periodontal ligament cells 1
• Do not store in tap water—this is specifically contraindicated 1
• Do not replant primary teeth (not applicable here given patient age) 1
• Do not allow the tooth to dry out—extra-alveolar dry time is the most critical prognostic factor 1

The 2024 AHA/Red Cross Guidelines represent the most current evidence-based approach and emphasize that successful tooth survival depends primarily on minimizing the time the tooth remains outside the socket 1.