Ask a Specialist: When Should Primary Care Providers Refer Dental Injuries to the Emergency Department?

Ask a Specialist: When Should Primary Care Providers Refer Dental Injuries to the Emergency Department? 150 150 Ehsan N. Azadani, DDS, MS

An expert reveals the most common red flag dental injuries that should be referred to the ED and what precautions PCPs can take before sending the child.


The most time-sensitive dental injury is the avulsion of a permanent tooth; that is, when the permanent tooth is completely knocked out of its socket (and the mouth).

The most important determining factor in the outcome of an avulsed permanent tooth is rapid replantation of the avulsed tooth in its socket! This will preserve the vitality of cells covering the root surface.

If your patient presents with avulsed permanent teeth, these steps can help ensure a successful replantation:

  • First calm the patient and reassure the patient and family. Place the patient in semi-supine position and sit at the 9-to-11 o’clock position to the side of the patient’s head.
  • To replant the avulsed tooth, it is important not to scratch the root surface. The tooth must be handled carefully from the crown. If there is any visible dirt on the root, the tooth may be cleaned with a stream of normal saline before replantation.
  • A 2×2 gauze may be held in the anterior palate area as a screen to prevent aspirating or swallowing in case the tooth falls from the hand of the provider. The tooth should be placed into the socket gently followed with continued gentle pressure until fully inserted back into the socket.
  • After replantation, the patient may gently bite on a wet 2×2 gauze and be referred to the dentist immediately for splinting.

If immediate replantation is not feasible (for example, uncooperative child, other dental injuries with unstable adjacent teeth, other bodily injuries and concern for aspiration or swallowing, provider’s comfort level), the tooth should be stored in cold milk or Hank’s Balanced Salt Solution (Save-A-ToothTM) and the patient be referred to the dentist or emergency department where a dentist is present. Water is not recommended as a storage medium.

In cases where the tooth has been outside of the socket for long period of time (hours), the long-term prognosis is going to be poor. Therefore, immediate replantation is likely not going to improve the outcome anymore. However the patient should still be referred to the dentist for evaluation and treatment.

Replantation of avulsed primary teeth is not recommended. However, if there is any doubt whether the avulsed tooth is permanent or primary, replantation is recommended followed by evaluation by the dentist.

Similar to any other traumatic injury, a full evaluation of the patient, ruling out traumatic brain injury and child abuse and checking the status of tetanus immunization are necessary.


Ask a Specialist is an email channel that connects physicians to pediatric specialists. 


Fouad, AF, Abbott, PV, Tsilingaridis, G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology. 2020;36:331-342.

About the author

Ehsan Azadani, DDS, MS, is an assistant professor of Pediatric Dentistry at The Ohio State University College of Dentistry and Nationwide Children's Hospital. His research is focused on traumatic dental injuries in children and adolescents.