Dental avulsionMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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517 items

☷ Legend

01Approach to the Critical Patient/attcp54

Immediate priorities

›Airway and bleeding threats

›If airway compromise from facial trauma or expanding oral hematoma, escalate airway management

›Suction readiness for blood and tooth fragments

›If massive oral bleeding, early surgical consultation for hemostasis

›If aspiration risk from missing tooth or fragments, escalate respiratory evaluation

›Focused lung exam for unilateral wheeze or decreased breath sounds

›If persistent cough after trauma, chest imaging pathway

›High-risk injury screen

›Concomitant facial fracture concern

›Malocclusion or step deformity

›Trismus or facial numbness

›Concomitant intracranial or cervical spine injury concern

›Altered mental status or vomiting

›High-energy mechanism

Tooth preservation and replantation clock

›Avulsed tooth time and storage

›Extra-oral dry time estimate

›Best outcomes when immediate replantation at scene

›Prognosis worsens as dry time increases

›Storage medium before arrival

›Hank balanced salt solution if available

›Cold milk

›Saline

›Patient saliva in buccal sulcus

›If avulsed permanent tooth and feasible, immediate replantation

›Crown-only handling

›Avoid root scraping

›Avoid drying the root

›Gentle rinse if gross contamination

›Saline rinse

›No chemical disinfectants in ED

›Replantation technique

›Steady finger pressure into socket

›Bite on gauze for stabilization

›If avulsed primary tooth, no replantation

›Risk to permanent tooth bud

›Iatrogenic damage concern

›Treatment burden without clear benefit

Analgesia and wound care

›Pain control strategy

›Oral NSAID if no contraindication

›Ibuprofen PO weight-based in pediatrics

›Avoid NSAID if significant bleeding risk or renal risk

›Acetaminophen PO as adjunct

›Weight-based dosing in pediatrics

›Hepatic precautions

›Regional anesthesia options

›Infraorbital nerve block for maxillary anterior injuries

›Mental nerve block for mandibular anterior injuries

›Soft tissue injury care

›Lip and gingival lacerations

›Irrigation and removal of embedded fragments

›If through-and-through lip laceration, layered repair plan

›Foreign body concern

›If tooth fragment missing, search soft tissues

›If not found, imaging pathway for retained foreign body

02History/hx56

Injury context and time course

›Mechanism and force direction

›Sports injury

›Mouthguard use

›Collision or projectile

›Fall or assault

›Surface impact details

›Alcohol or intoxication context

›Exact time of injury

›Time since avulsion or fracture

›Minutes since avulsion

›Hours since avulsion

›Time since replantation if already attempted

›At scene replantation

›Prior clinic or urgent care replantation

Tooth-specific details

›Dentition type

›Primary tooth suspected

›Age appropriate eruption pattern

›Small crown size and spacing

›Permanent tooth suspected

›Central incisor common

›History of orthodontics

›Avulsion and handling details

›Tooth recovered status

›Tooth available

›Tooth lost at scene

›Storage conditions

›Dry storage

›Stored in liquid medium

›Fracture symptoms

›Sensitivity to cold or air

›Dentin exposure clue

›Pulp exposure concern if severe pain then relief

›Bleeding from tooth

›Pulp exposure clue

›Associated gingival bleeding

Medical and dental modifiers

›Tetanus status

›Unknown or out of date

›Wound contamination risk

›Update per immunization guidance

›Up to date

›Routine follow-up

›Document date if known

›Infection and healing risk factors

›Immunosuppression

›Steroids or chemotherapy

›Transplant history

›Diabetes mellitus history

›Poor wound healing risk

›Higher infection risk

›Medication and bleeding risk

›Anticoagulants or antiplatelets

›Ongoing bleeding risk

›Hematoma risk

›Antibiotic allergies

›Penicillin allergy details

›Macrolide tolerance

03Physical Exam/exam46

Oral and dental exam

›Tooth inventory and injury classification

›Missing tooth confirmation

›Count compared to expected dentition

›Socket inspection for clot and debris

›Tooth fracture pattern

›Enamel-only fracture

›Enamel-dentin fracture

›Enamel-dentin-pulp exposure

›Socket and gingiva assessment

›Alveolar ridge stability

›Segment mobility suggesting alveolar fracture

›Step-off deformity

›Gingival lacerations

›Active bleeding

›Contamination and debris

›Occlusion and jaw function

›Malocclusion

›New open bite

›Crossbite after trauma

›Trismus

›TMJ pain

›Mandible fracture concern

Associated facial injury exam

›Facial bone and nerve screen

›Infraorbital nerve sensation

›Upper lip numbness

›Cheek paresthesia

›Mental nerve sensation

›Lower lip numbness

›Chin paresthesia

›Soft tissue foreign body screen

›Lip palpation for hard fragments

›Localized tenderness

›Palpable shard

›Tongue and buccal mucosa inspection

›Embedded fragment

›Hematoma or laceration

PITFALLS

›High-risk misses

›Missing tooth not accounted for

›Aspiration possibility

›Embedded in lip possibility

›Alveolar fracture mislabeled as tooth avulsion alone

›Segment mobility clue

›Malocclusion clue

›Primary tooth avulsion mistaken for permanent tooth

›Inappropriate replantation risk

›Damage to permanent successor risk

04Differential Diagnosis/ddx34

Traumatic dental injury spectrum

›Avulsion and luxation injuries

›Tooth avulsion (S03.2XXA)

›Complete displacement from socket

›Empty socket with bleeding

›Extrusive luxation (S03.2XXA)

›Partial displacement

›Increased mobility and elongated appearance

›Lateral luxation (S03.2XXA)

›Displacement with locked tooth

›Occlusal interference

›Tooth fractures

›Traumatic fracture of tooth (S02.5XXA)

›Enamel fracture

›Enamel-dentin fracture

›Crown-root fracture (S02.5XXA)

›Subgingival component

›Mobile coronal fragment

›Root fracture (S02.5XXA)

›Coronal segment mobility

›Pain on biting

Mimics and associated injuries

›Facial skeletal injuries

›Mandible fracture (S02.6XXA)

›Malocclusion

›Lower lip numbness

›Maxilla fracture (S02.4XXA)

›Midface mobility

›Epistaxis

›Soft tissue and airway complications

›Aspiration of tooth fragment

›Sudden cough and wheeze

›Persistent unilateral findings

›Embedded foreign body in lip or cheek

›Palpable shard

›Persistent focal swelling

05Laboratory Tests/lt22

Routine labs

›Typically not required

›Isolated dental avulsion or fracture without systemic illness

›No lab-driven management change expected

›Focus on time-critical dental steps

›Pain and bleeding controlled

›Stable vitals

›No syncope or shock features

Selective labs by context

›Bleeding concern

›If significant oral hemorrhage or anticoagulation, targeted studies

›Hemoglobin trend if ongoing bleeding

›Coagulation studies if on warfarin or unknown coagulopathy

›Infection risk concern

›If immunocompromised with contaminated wound, targeted studies

›White blood cell count for systemic infection concern

›CRP for severe infection concern

PITFALLS

›Over-testing risks

›Labs delaying replantation window

›Prioritize tooth replantation when appropriate

›Parallel processing with nursing support

›Normal labs not excluding oral infection risk

›Local contamination still clinically relevant

›Follow-up still mandatory

06Diagnostic Tests/dt54

Scoring Systems

›Classification frameworks guiding urgency

›IADT traumatic dental injury classification

›Avulsion pathway emphasis on extra-oral dry time and storage medium

›Follow-up and splinting coordination with dental care

›Ellis fracture classification

›Ellis I enamel-only fracture

›Ellis II enamel-dentin fracture with sensitivity

›Ellis III pulp exposure with bleeding or pink blush

›Decision anchors for ED management

›Permanent tooth avulsion

›Immediate replantation when feasible

›Antibiotics and tetanus update considerations

›Primary tooth avulsion

›No replantation recommendation

›Dental follow-up for monitoring

MRI

›Rare indications

›TMJ internal derangement concern

›Persistent trismus after blunt trauma

›Ongoing TMJ pain with normal CT

›Soft tissue complications

›Suspected deep space infection with equivocal CT

›Suspected osteomyelitis in delayed presentations

›Practical limitations in ED

›Time-sensitive replantation not MRI-dependent

›MRI not delaying definitive dental steps

›Defer to outpatient specialty unless red flags

›Metallic orthodontic hardware artifact

›Image quality limitation

›Alternative imaging favored

›CT maxillofacial indications

›Suspected alveolar or jaw fracture

›Segment mobility

›Malocclusion

›Suspected retained tooth fragment when not visualized

›Deep soft tissue location

›Severe swelling limiting exam

›CT chest indications

›Suspected aspiration of tooth or fragment

›Persistent cough or wheeze

›Abnormal chest radiograph or exam

›Complications of aspiration

›Atelectasis pattern

›Post-obstructive infection concern

Ultrasound

›Soft tissue foreign body evaluation

›Lip or cheek retained fragment

›Hyperechoic focus with shadowing

›Localization for removal

›Guidance for bedside removal

›Marking skin surface for incision planning

›Post-removal confirmation scan

›Adjunct airway complication screening

›Lung ultrasound for focal atelectasis or consolidation suspicion

›Unilateral B-line pattern not specific

›Pleural-based consolidation suggestion

07Disposition/dispo28

Specialist follow-up timing

›Immediate specialty involvement

›Replanted permanent tooth

›Dental or oral surgery within 24 hours

›Splinting and endodontic planning

›Alveolar fracture or jaw fracture concern

›Oral and maxillofacial surgery evaluation

›Possible operative fixation

›Urgent outpatient follow-up

›Ellis II fracture or luxation without instability

›Dental evaluation within 24 hours

›Temporary sealant and analgesia plan

›Ellis I fracture without symptoms

›Dental evaluation within 1 week

›Cosmetic restoration planning

Admission and transfer triggers

›Admission criteria

›Airway compromise risk

›Expanding oral hematoma

›Inability to manage secretions

›Uncontrolled hemorrhage

›Persistent bleeding despite local measures

›Anticoagulation-related bleeding not controlled

›Transfer criteria

›No local dental or OMFS coverage with high-risk injury

›Avulsed permanent tooth requiring splinting coordination

›Suspected mandibular or maxillary fracture

›Pediatric complex trauma

›Multiple luxations with alveolar fracture

›Procedural sedation requirement beyond local capability

08Treatment/t86

Avulsed permanent tooth

›Replantation bundle

›If tooth available and patient stable, immediate replantation

›Crown-only handling

›Avoid touching root surface

›Avoid scrubbing periodontal ligament

›Socket and tooth rinse strategy

›Brief saline rinse for gross debris

›No prolonged soaking in water

›Stabilization after replantation

›Bite on gauze

›Urgent dental splinting arrangement

›If immediate replantation not feasible, storage optimization

›Preferred storage media

›Hank balanced salt solution

›Cold milk

›Acceptable alternatives

›Saline

›Saliva in buccal sulcus if conscious and cooperative

Antibiotics and infection prevention

›Systemic antibiotics after replantation

›Adult options

›Doxycycline PO

›100 mg PO twice daily

›Typical course 7 days

›Amoxicillin PO

›500 mg PO three times daily

›Typical course 7 days

›Pediatric options

›Amoxicillin PO

›40 to 50 mg per kg per day divided three times daily

›Typical course 7 days

›If penicillin allergy, macrolide option per local guidance

›Azithromycin PO weight-based option

›QT risk consideration in predisposed patients

›Topical oral antisepsis

›Chlorhexidine 0.12% mouth rinse

›15 mL swish and spit twice daily

›Typical duration 1 to 2 weeks

›If unable to rinse

›Chlorhexidine swab to gingiva twice daily

›Avoid swallowing in pediatrics

Tetanus prophylaxis

›Immunization update pathway

›Contaminated wound or unknown status

›Tetanus vaccine per age schedule

›Tetanus immune globulin per immunization guidance when indicated

›Up-to-date immunization

›No additional prophylaxis beyond routine

›Document last booster if known

Tooth fracture management

›Ellis I enamel-only

›Smooth edge protection

›Dental wax or temporary cover for sharp edge

›Soft diet guidance

›Routine dental follow-up

›Cosmetic restoration options

›Monitor for sensitivity

›Ellis II enamel-dentin

›Dentin protection

›Temporary sealant

›Glass ionomer if available

›Calcium hydroxide base if available

›Sensitivity reduction

›Avoid temperature extremes

›Analgesics as needed

›Urgent dental follow-up within 24 hours

›Definitive restoration

›Pulp vitality monitoring plan

›Ellis III pulp exposure

›Infection and necrosis risk

›Immediate dental or OMFS consultation when available

›Cover pulp exposure if materials available

›Antibiotics based on contamination and clinician judgment

›Consider systemic antibiotics if gross contamination

›Follow local dental trauma pathways

Luxation and alveolar fracture supportive care

›Luxation injury stabilization

›Gentle repositioning only when clearly displaced and feasible

›Avoid excessive manipulation

›Definitive splinting by dental care

›Soft diet and avoidance of biting on injured teeth

›Soft foods for 1 to 2 weeks

›Avoid contact sports until cleared

›Alveolar fracture support

›Immediate OMFS or dental consultation

›Segment stabilization and splinting

›Imaging for fracture mapping

›Hemostasis measures

›Pressure with gauze

›Local hemostatic agent if available

09Special Populations/sp42

Pregnancy

›Medication selection

›Antibiotic choices

›Penicillins and cephalosporins generally preferred

›Avoid doxycycline

›Analgesia choices

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Imaging considerations

›Shielding and dose minimization

›Dental radiographs with appropriate shielding

›CT only if fracture concern changes management

›Specialist coordination

›Dental follow-up without delay for avulsion

›Obstetric input if severe trauma

Geriatric

›Bleeding and anticoagulation considerations

›Anticoagulant medication review

›Prolonged oral bleeding risk

›Hematoma risk in floor of mouth

›Comorbidity impact

›Diabetes and delayed healing risk

›Dementia affecting aftercare compliance

›Prosthetics and implants

›Dental implant trauma

›Peri-implant soft tissue injury

›Implant mobility suggesting bone injury

›Denture-related injury

›Mucosal lacerations

›Underlying fracture concern

Pediatrics

›Primary teeth management

›Avulsed primary tooth

›No replantation recommendation

›Monitor for damage to permanent successor

›Luxation injuries in primary dentition

›Dental follow-up for observation versus extraction decisions

›Feeding and pain control planning

›Permanent teeth in children

›Immature apex considerations

›High priority for rapid replantation

›Close endodontic follow-up for revascularization attempts

›Antibiotic selection

›Avoid doxycycline in young children when possible

›Amoxicillin weight-based regimen

10Background/b49

Epidemiology

›Burden of traumatic dental injuries

›Global prevalence in children often cited around 20% to 30%

›Variation by age, setting, and study design

›Maxillary incisors most commonly affected

›Avulsion proportion among traumatic dental injuries

›Reported range approximately 0.5% to 16% in permanent dentition

›Higher frequency in children and adolescents

›Common settings and mechanisms

›Falls in younger children

›Home environment common

›Underdeveloped coordination

›Sports and collisions in school-aged children

›Contact sports risk

›Mouthguard protective effect

Pathophysiology

›Avulsion biology

›Periodontal ligament viability drives prognosis

›Desiccation causes cell death

›Longer dry time increases ankylosis and resorption risk

›Pulpal outcomes after replantation

›Higher necrosis risk with closed apex

›Revascularization potential with open apex

›Fracture biology

›Dentin exposure

›Tubule exposure causes sensitivity

›Bacterial ingress risk increases over time

›Pulp exposure

›High risk of pulp necrosis and infection

›Time-sensitive need for pulp protection

Therapeutic Considerations

›Time dependence

›Earlier replantation improves outcomes

›Immediate replantation preferred when safe

›Storage medium selection preserves viability

›Definitive care requirements

›Flexible splinting by dental care

›Endodontic follow-up and monitoring

›Antibiotic rationale

›Replanted tooth as contaminated wound

›Oral flora exposure

›Adjunct to local hygiene measures

›Drug selection considerations

›Tetracyclines avoided in young children and pregnancy

›Penicillins commonly used alternatives

›Shared decision-making points

›Permanent versus primary tooth identification

›Avoid primary tooth replantation

›Prioritize permanent tooth replantation when appropriate

›Prognosis counseling

›Replantation does not guarantee long-term retention

›Future procedures often required

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Dental trauma care after ED visit

›Diet and activity

›Soft foods for 1 to 2 weeks

›Avoid biting with injured teeth

›Oral hygiene

›Gentle brushing with soft toothbrush after meals

›Chlorhexidine mouth rinse twice daily if prescribed

›If tooth replanted

›Protection and positioning

›Avoid wiggling or biting hard foods

›Keep gauze pressure only as directed

›Follow-up urgency

›Dentist or oral surgeon within 24 hours for splinting and planning

›Endodontic follow-up may be needed even if pain improves

›If tooth fractured

›Sensitivity care

›Avoid hot and cold extremes

›Temporary cover care if placed

›Follow-up timing

›Within 24 hours for dentin or pulp exposure concern

›Within 1 week for enamel-only fracture

›Return to ED immediately for red flags

›Airway or swallowing issues

›Trouble breathing

›Trouble swallowing or drooling

›Bleeding or infection concern

›Bleeding not stopping with pressure

›Fever or worsening facial swelling

›Aspiration concern

›Persistent cough or wheeze after injury

›Chest pain or shortness of breath

12References/r15

Clinical guidelines and consensus statements

›International Association of Dental Traumatology 2020 guidelines for avulsion of permanent teeth

›Emergency management emphasizes immediate replantation when feasible

›Storage medium and extra-oral dry time drive prognosis

›International Association of Dental Traumatology 2020 guidelines for fractures and luxations of permanent teeth

›Structured classification and follow-up recommendations

›Time-sensitive management for pulp exposure and luxation

›Pediatric guidance for primary tooth avulsion

›Primary tooth replantation not recommended

›Monitor for effects on permanent successor

Evidence-based summaries and clinical references

›Avulsed tooth clinical summary

›Tetanus update considerations

›Soft diet and chlorhexidine hygiene guidance

›Emergency department fracture classification summaries

›Ellis classification features and urgency cues

›Root fracture diagnostic difficulty in ED setting

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.