Management of permanent tooth injuries in children

Injury	Dental referral	Dental management^*
Avulsion	Emergency	Replantation ideally within 15 minutes^¶ Dental radiograph to exclude root fracture Splint replanted tooth Prophylactic oral antibiotics to cover mouth flora Chlorhexidine rinse Soft diet Close follow-up (within 2 to 3 days after replantation) Root canal 7 to 10 days after replantation (most patients)
Extrusion	Urgent (24 to 48 hours)	Dental radiograph to assess for fracture Reposition tooth and splint for 2 weeks
Intrusion	Urgent	Dental radiograph to assess periapical region Depending on degree of intrusion and root apex maturity, observe for re-eruption or perform surgical or orthodontic repositioning Root canal treatment, timing determined by type of treatment
Lateral luxation (malocclusion)	Emergency	Dental radiograph to assess for fracture Reposition and splint within 2 hours, whenever possible Maintain splinting for 4 weeks May require root canal treatment depending on dental root maturity
Lateral luxation (normal bite)	Urgent	As for lateral luxation with malocclusion
Subluxation/concussion	Urgent	Dental radiograph to exclude root fracture Soft diet Repeat radiographs at 4 weeks to assess for pulp necrosis and inflammatory resorption
Uncomplicated crown fracture (pulp not exposed)	Elective (within 7 days)	Dental radiograph to exclude root fracture No dentin exposure – No further treatment unless rough edges that require smoothing Dentin exposure – Bond the tooth fragment, if available, or dental restoration
Complicated crown fracture (pulp exposed)	Urgent	Dental radiograph to exclude root fracture Pulp therapy and coverage Root canal treatment if dental root is mature Crown-root fractures – Remove crown fragment and restore the root or, if significant damage to the root, provide a dental prosthesis
Root fracture (rare)	Urgent	Dental radiograph Apical fracture without increased mobility – No specific treatment Fractures closer to the crown – Prolonged splinting; if persistent mobility, then crown removal and root preservation therapy

This table provides suggested timing and definitive dental management of specific dental injuries to permanent teeth in children and is intended to be used with other UpToDate content. Refer to UpToDate content on evaluation and management of dental injuries in children.

* Tetanus prophylaxis, as needed, is necessary for patients with tooth avulsion, contaminated wounds, or deep intraoral lacerations. Provide antibiotic prophylaxis for bacterial endocarditis in susceptible patients for dental injuries that induce bacteremia (eg, intrusions, extrusions, lateral luxations, and avulsions). Refer to UpToDate content on tetanus and bacterial endocarditis prophylaxis.

¶ Perform replantation of permanent teeth within 30 minutes of avulsion. A clinician or other capable person (eg, injured child, parent/primary caregiver, teacher, or coach) may replant the tooth:

Hold the tooth by the crown.
Gently remove debris by rinsing with milk, saline, or the child's saliva; do not use tap water.
Press the tooth into the socket.
Keep the tooth in place (child holds it or bites on a gauze pad, clean napkin, or clean towel).

For actions to take when replantation is difficult and proper tooth storage when replantation is not possible, refer to UpToDate content on dental injuries and tooth avulsion in children.

Adapted from: Keels MA, Section on Oral Health, American Academy of Pediatrics. Management of dental trauma in a primary care setting. Pediatrics 2014; 133:e466.

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Management of permanent tooth injuries in children