She Could Not Put It Back, So She Put It in Milk

Quick answer: If you cannot bring yourself to put a knocked-out tooth back in the socket, put it in cold milk immediately and get to a dentist. Milk keeps the root cells alive for several hours. Water kills them within minutes, and a dry tissue is the worst option of all.

The call

Sunday afternoon on Moshav Zanoach, about twenty-five minutes' drive from Beit Shemesh. Shani, 11, fell off a wall and knocked out an upper front tooth completely.

Her mother phoned us with the tooth in her hand. We talked her through replanting it. She tried, twice, and could not do it — her hands were shaking and Shani was distressed and would not keep still.

That is a normal reaction, not a failure. The important thing is what she did next, which was exactly right: she went to the fridge, poured cold milk into a cup, dropped the tooth in, put Shani in the car and drove.

What we found

Shani arrived 38 minutes after the accident. The tooth had been in milk for roughly 34 of those minutes, and dry for about four.

That extra-oral dry time is the number that governs everything. The periodontal ligament cells on the root surface are what allow a replanted tooth to reattach to bone. They begin dying within about fifteen minutes of drying out, and after an hour dry, essentially none survive.

Storage media differ enormously in how well they preserve those cells:

• The socket itself. Best by a long way. Nothing outperforms putting it straight back.
• Milk. Excellent for up to several hours. Its osmolality, pH and nutrients suit the cells, and it is available in nearly every home and makolet in the country.
• Saline, or a proprietary tooth-rescue solution if you happen to have one. Good.
• Saliva — the child's own mouth, in the cheek pouch (only for an older child who will not swallow it), or a cup of their spit. Acceptable for a short period.
• Water. Actively harmful. It is hypotonic and bursts the cells within minutes. Better than dry, worse than everything else.
• Dry, in a tissue or a bag. The worst option, and the most common.

The rest of the examination: upper right central incisor missing from its socket, socket wall intact on the x-ray, no root fracture, lip grazed, no other teeth displaced.

What we did

Handled the tooth by the crown only, rinsed it gently in saline, and replanted it in the socket under local anaesthetic, checking the position against the neighbouring teeth and the bite.

Flexible splint for two weeks. Tetanus check. Antibiotics, soft diet, chlorhexidine rinses.

Root canal started at day ten, exactly as with any replanted mature tooth — the pulp does not survive an avulsion, and treating it before it becomes infected prevents inflammatory root resorption.

The outcome

At two years the tooth is firm and in normal position, with no resorption visible on x-ray. There is a slight difference in gum height compared with the other side, which is common after replantation and can be addressed cosmetically later if she wants.

Her mother's decision to reach for the milk rather than a tissue is the reason the tooth is still there.

What to do if this happens to you

1. Try to replant it first. Hold by the crown, rinse briefly if dirty, push it gently back into the socket.
2. If you cannot, use milk. Any milk, cold, straight from the fridge. Enough to cover the tooth.
3. Never use water, and never wrap it in a dry tissue.
4. Do not scrub the root or remove tissue attached to it. Those are the cells that matter.
5. Phone ahead while travelling so the clinic is ready when you arrive.
6. Note the exact time of the accident. It genuinely changes the treatment decisions.

Tooth knocked out on a yishuv near Beit Shemesh? Put it in milk and phone Ramat Beit Shemesh Urgent Dental Care while you drive: 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.