IADT guidelines on avulsed permanent teeth (2020): replant at the scene, milk or HBSS if you cannot, and a 60-minute dry time that changes the prognosis but not the decision

What it says#

Avulsion, the guideline opens, is seen in 0.5% to 16% of all dental injuries and is one of the most serious, with a prognosis that depends on what is done at the place of the accident and promptly afterward. Replantation is in most situations the treatment of choice; some replanted teeth have a low probability of long-term survival, but not replanting is an irreversible decision, so saving the tooth should be attempted. The text is an IADT consensus after a literature search (Medline and Scopus), with majority decisions of the Board where the data were inconclusive, and it describes itself as a revision and update of the 2012 guidelines.

First aid is a numbered list dentists are expected to teach and to give by telephone. Make sure it is a permanent tooth (primary teeth are not replanted); keep the patient calm; pick the tooth up by the crown, not the root; if dirty, rinse it gently in milk, saline or the patient's saliva and put it back; encourage whoever is there to replant it at once; bite on gauze, a handkerchief or a napkin; if replantation is not possible (an unconscious patient, for instance), put the tooth in a storage medium immediately, because dehydration of the root surface starts within minutes. In descending order of preference the media are milk, HBSS, saliva (spat into a glass) and saline; water is a poor medium but better than air-drying. Then see a dentist immediately. The IADT's Save a Tooth poster and free ToothSOS app carry the same instructions.

Treatment turns on root maturity (open or closed apex) and the condition of the periodontal ligament cells, which depends on the time out of the mouth and the medium. After an extra-alveolar dry time of 30 minutes most PDL cells are non-viable, so the dry time is the history to take. Every avulsed tooth is sorted into three groups before treatment: cells most likely viable (replanted immediately or within about 15 minutes at the scene); viable but compromised (kept in milk, HBSS, saliva or saline, with total extra-oral dry time under 60 minutes); likely non-viable (more than 60 minutes dry, whether or not it was then stored). The groups guide prognosis; the treatment steps barely change.

For a closed-apex tooth already replanted: clean the area with water, saline or chlorhexidine; verify the position clinically and radiographically; leave it in place, correcting a malposition with slight digital pressure; local anesthesia if needed, preferably without vasoconstrictor; if it sits in the wrong socket or is rotated, consider repositioning up to 48 hours after the injury; splint 2 weeks; suture lacerations; start root canal treatment within 2 weeks; give systemic antibiotics; check tetanus status; instruct; follow up. A tooth that arrives in a medium with under 60 minutes dry is rinsed of debris with saline or agitated in the medium, kept in the medium during the history, examination and radiographs, and, after the socket is irrigated with saline and a fractured wall repositioned, replanted slowly with slight digital pressure, never forced. The over-60-minute case follows the same steps, and the guideline is direct about why: delayed replantation has a poor long-term prognosis and the expected outcome is ankylosis-related (replacement) resorption, but replanting restores esthetics and function at least temporarily, maintains alveolar bone contour, width and height, and keeps future options open, so it is almost always the correct decision. Parents are told that decoronation or autotransplantation may be needed later if the tooth ankyloses and infra-positions as the child grows.

The splint is passive and flexible: stainless steel wire up to 0.016 inch or 0.4 mm, or nylon fishing line 0.13 to 0.25 mm (not in a child with only a few permanent teeth to hold it), bonded with composite on the labial surfaces for 2 weeks, with resin kept off the marginal gingiva and contacts; about 4 weeks with a more rigid splint when the alveolus or jaw is fractured. Short immature teeth may need longer, and one extra week is appropriate only if the tooth cannot hold its position once the splint is off. Systemic antibiotics: their value is called highly questionable, but because the ligament is often contaminated they have been recommended, dosed by age and weight, with amoxicillin or penicillin the first choices; doxycycline has anti-resorptive effects in animal models, but tetracycline or doxycycline are generally not recommended under 12 because of discoloration. Topical antibiotics on the root cannot be recommended on human studies. Tetanus: refer to a physician for the booster decision. Local anesthesia is always recommended in the clinic, and the guideline concedes there is little evidence to support omitting a vasoconstrictor. Home care: no contact sports, a soft diet for up to 2 weeks, a soft toothbrush after each meal, chlorhexidine 0.12% twice a day for 2 weeks.

In a closed-apex tooth endodontic treatment starts within 2 weeks, under dental dam retained on neighboring teeth, with calcium hydroxide for up to 1 month before filling or a corticosteroid or corticosteroid/antibiotic mixture placed immediately or shortly after replantation and left at least 6 weeks, kept out of the crown. In an open-apex tooth root canal treatment is avoided unless there is clinical or radiographic evidence of necrosis and infection, because revascularization and continued root growth are the goal; infection-related resorption is very rapid in children, so those reviews are closer together. Replanted teeth are reviewed clinically and radiographically at 2 weeks (splint removal), 4 weeks, 3 months, 6 months, 1 year and yearly for at least 5 years; open-apex teeth at 2 weeks, 1, 2, 3 and 6 months, 1 year and yearly for at least 5 years. Pulp canal obliteration in an immature replanted tooth is the expected sign of healing.

Who it applies to#

Every avulsed permanent tooth, in a child or an adult, at the scene and at the first visit, and every person who might be on the phone when it happens: the guideline expects dentists to give first-aid advice to the public, to parents, guardians and teachers, and by telephone to the emergency site. The three groups and two apex states cover the whole population of avulsed teeth, and the step lists are written so a general dentist can follow them without specialist equipment.

Primary teeth are excluded by the first line of the first-aid list. Replantation is not indicated in the individual cases the guideline names (severe caries or periodontal disease, an uncooperative patient, severe cognitive impairment requiring sedation, severe medical conditions such as immunosuppression, severe cardiac conditions). Long-term care of the ankylosed tooth goes to an inter-disciplinary team where one exists, with decoronation decided when infra-occlusion becomes esthetically unacceptable and implants considered after growth is complete.

What changed#

This is the 2020 revision of the IADT avulsion guideline; the general introduction records first guidelines in 2001 and updates in 2007 and 2012, and the 2020 text cites the 2012 edition (Andersson et al.) as the one it revises. This entry did not compare the two editions line by line. What the 2020 text presents as settled: the three PDL groups keyed to 15 and 60 minutes; the 2-week splint with wire up to 0.016 inch or nylon line as an alternative; the age-12 line on tetracyclines; the 48-hour window to fix a tooth replanted in the wrong socket; the core outcome set (periodontal healing, pulp space healing, pain, discoloration, tooth loss, quality of life, esthetics, trauma-related anxiety, number of visits, and infra-occlusion) for follow-up; and a list of topics discussed but not recommended, including topical antibiotics, intracanal corticosteroids, and splint type and duration.

Where the source is#

The document is Fouad and colleagues, International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth, Dental Traumatology 2020, volume 36, issue 4, pages 331 to 342, published for the IADT by Wiley; the link under the title is the DOI. When this entry was written Wiley's site refused automated access (HTTP 403 to both a browser fetch and curl), so the full text was read from the AAPD's reprint of the published article, made with Wiley's permission in the Reference Manual of Pediatric Dentistry (pages 616 to 624), which carries the complete text and references; the abstract was also read on PubMed (PMID 32460393). The general introduction to the 2020 set (Levin et al., Dent Traumatol 2020;36:309-313) was read in the same reprint series. The IADT's guidelines page links all four parts, the Save a Tooth poster in some 40 languages and the ToothSOS app.