What is the best way to manage a tooth avulsion (dental avulsion)?

From the Guidelines

The best way to manage an avulsed tooth is to replant it as quickly as possible, ideally within a few minutes, by gently rinsing it with a suitable medium and reinserting it into its socket, and if this is not possible, store the tooth in a preservation medium like Hanks Balanced Salt Solution, milk, or saliva. When managing an avulsed tooth, it is crucial to handle the tooth by the crown (not the root) and gently rinse it with a suitable medium, such as milk, saline, or clean water, without scrubbing, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The tooth should then be reinserted into its socket, making sure it's facing the correct way. If immediate replantation isn't possible, the tooth can be stored in a preservation medium like Hanks Balanced Salt Solution, milk, or saliva (by keeping it in the cheek), as suggested by the 2020 international consensus on first aid science with treatment recommendations 1. It is essential to avoid storing the tooth in plain water, as it damages root cells, and instead, use a suitable storage medium, such as those mentioned above. After replantation, the tooth should be stabilized by biting on gauze, and emergency dental care should be sought immediately. The dentist will likely splint the tooth for 1-2 weeks and may prescribe antibiotics, such as amoxicillin, and recommend chlorhexidine rinses, as noted in the management of dental trauma in a primary care setting 1. Tetanus prophylaxis may be needed if the patient's immunization status is outdated. The success of replantation depends on minimizing the time the tooth is out of the socket and proper storage, as these factors help preserve the periodontal ligament cells that are crucial for reattachment and preventing root resorption. Some key points to consider when managing an avulsed tooth include:

• Handling the tooth by the crown to avoid damaging the root
• Gently rinsing the tooth with a suitable medium to remove debris
• Reinserting the tooth into its socket as quickly as possible
• Storing the tooth in a preservation medium if immediate replantation is not possible
• Avoiding storage in plain water
• Seeking emergency dental care immediately after replantation.

From the Research

Immediate Action

• If possible, replant the avulsed tooth immediately after gentle washing 2
• If replantation is not practical, store the tooth in the best medium available, with preferences being:
  • Hank's Balanced Salt Solution (HBSS)
  • Milk
  • Saline
  • Saliva (buccal vestibule)
  • Water is the least desirable storage medium 2

Treatment in the Office

• Emergency visit: place tooth in HBSS while exam is conducted and history is taken 2
• Prepare socket for gentle repositioning of the tooth and prepare the root 2
• Extraoral dry time considerations:
  • < 20 minutes: closed apex - replant immediately after gentle washing, open apex - soak in 1 mg doxycycline in 20 mg saline for 5 minutes 2
  • 20 to 60 minutes: soak in HBSS for 30 minutes and replant 2

  • 60 minutes: soak in citric acid, 2% stannous fluoride, and doxycycline and replant 2

Endodontic Treatment

• Tooth with open apex and extraoral dry time of < 60 minutes: no endodontic treatment initially, recall every 3 to 4 weeks to examine for evidence of pathosis 2
• Tooth with open apex and extraoral dry time > 60 minutes: start endodontics and follow apexification procedure 2
• Tooth with closed apex: endodontics should be initiated after 7 to 10 days 2

Follow-up Care

• Twice per year for 3 years and yearly for as long as possible 2
• Late complications are common, and a multidisciplinary approach may be necessary for optimal treatment outcomes 3, 4, 5
• A clinical protocol for patients and professionals for the treatment of the avulsed tooth is proposed, including endodontic treatment, splinting, and restoration 5