Pediatric tooth avulsion and other dental injury: Rapid overview of emergency management

Evaluation

When did the injury occur?

Any neck pain or significant head trauma (loss of consciousness or altered mental status by history)?

If present, address potential C-spine or clinically important head injury first.

Are any teeth missing or injured?

Is the affected tooth primary (baby) or permanent teeth?^*

Any tooth pain?

At rest or with exposure to hot or cold (suggests pulp exposure or inflammation)
With gentle tapping using a tongue blade or chewing (suggests periodontal ligament injury)

Which teeth are injured? Are they primary or permanent teeth?^*

Any loose teeth and/or tooth displacement?

Intrusion (pushed into socket)
Extrusion (pulled out of socket)
Luxation (anterior, posterior, or lateral displacement)

Is malocclusion present?

Signs of jaw fracture?

Difficulty or pain with opening or closing the mouth
Tenderness over the mandible or temporomandibular joint

Any concerning findings for child abuse?^¶

Emergency treatment of dental avulsion

Do not replant primary (baby) teeth^*. If uncertain whether the tooth is primary or permanent, gently replant.

Replant avulsed permanent teeth, ideally within 15 minutes:

Handle the tooth by the crown.
Gently rinse the tooth with milk, saline, or the child's saliva. Do not use tap water.
Remove any large clot in the socket with irrigation or a sterile gauze pad.
Insert the tooth into the empty socket.
Keep the tooth in place by having the child hold it or bite a gauze pad or clean towel.
Obtain emergency pediatric dental consultation.

If unable to replant immediately:

Store the tooth in a watertight container and cover it with cold milk, Hank's balanced salt solution, or the child's saliva; do not store the tooth in the child's mouth or in tap water
Place the container on ice and obtain emergency dental care^Δ

Other dental injuries

Remove very loose or dangling primary (baby) teeth^*

Permanent tooth with extrusion >3 mm or luxation with malocclusion: emergency referral to a dentist or oral surgeon, ideally within 2 hours, for repositioning and splinting

Urgent referral to dental or oral surgery (within 24 to 48 hours) for patients with:

Primary tooth with extrusion >3 mm or luxation with malocclusion
Intruded primary (baby) teeth
Fractured tooth with dental pulp exposure (bleeding from central core of the tooth, pain at rest or with exposure to cold or hot liquids)
Fractured permanent tooth; whenever available, permanent tooth fragments may be reattached
Suspected dental root or alveolar fracture (loose tooth or segment with multiple loose teeth)

Other considerations

Provide tetanus prophylaxis, as needed^◊

Give antibiotic prophylaxis for bacterial endocarditis to susceptible patients undergoing invasive dental procedures^§

For suspected child abuse, complete mandated reporting and ensure comprehensive child abuse evaluation in consultation with a multidisciplinary child abuse team^¶

This rapid overview provides guidance on emergency first aid for an avulsed tooth and timing of referral for other dental injuries. It is intended to be used with other UpToDate content; refer to UpToDate topics on dental injuries in children.

* Permanent teeth do not typically erupt before six years of age and are larger than primary teeth. Permanent incisors have a serated edge; primary incisors have a smooth edge. if unsure, also ask the parent/primary caregiver if the child has previously shed a tooth at the avulsed tooth site.

¶ Associated findings concerning for child abuse include:

Absent or implausible history
Torn upper labial frenula or labial sulcus (especially a nonambulatory infant)
Subconjunctival hemorrhage
Any bruise in an infant <6 months old
Bruising of the torso, ear (including behind the ear), neck, angle of the jaw, or face (especially cheek or eyelid)
Patterned bruise (eg, hand print, belt, loop mark, bite mark, or other object

Patients with these findings warrant evaluation in consultation with a child abuse specialist and reporting to Child Protections Services according to local legal requirements. For more information, refer to UpToDate content on recognition, diagnosis, management, and reporting of child abuse.

Δ Emergency dental care is often more rapidly available at a dentist's or oral surgeon's office rather than an emergency department.

◊ Update tetanus status as needed for patients with avulsed teeth, contaminated wounds, or deep intraoral lacerations.

§ Refer to UpToDate content on antibiotic prophylaxis for bacterial endocarditis.

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Pediatric tooth avulsion and other dental injury: Rapid overview of emergency management