Sir, as a pediatric dentist who has followed the literature on replantation of primary teeth for some years, I read the article on complication following replantation of a primary incisor with great interest (BDJ 2005; 198: 687–688). While the case reported here is of great importance and can serve as a springboard for better treatment, I am afraid that the conclusions drawn by the authors are somewhat tendentious.

The authors say and I quote 'Replantation of primary incisors has been carried out in some studies...' and '...the majority of studies contraindicate replantation...' From these statements the readers may get the wrong impression that the authors' conclusions are based on hard evidence, but 'the literature is based on sporadic case reports rather than any scientific evaluation' as the authors correctly cite in the introduction.1

I agree with the authors' opinion that if the dentist, due to parental pressure, is 'forced' to replant an avulsed primary incisor, endodontic treatment and long-term follow-up are crucial. The authors, as opponents of replantation of avulsed primary teeth, do not mention additional necessary steps required to decrease failure of the replantation and complications. Postoperative complications can be anticipated if replantation is not accompanied by the same additional supportive treatment mentioned for replanted permanent teeth, such as splint, strict oral hygiene, antibiotic therapy, and removal of the periodontal ligament if replantation is delayed.

The fact that the authors base their conclusion on outcomes of a single case, in which the treatment can be considered as malpractice, is more than disturbing.

As Al-Khayatt and Davidson state in their case report: '...the majority of articles and chapters in textbooks [NOT studies] contraindicate replantation, due to the high risk of complications to the developing permanent successor'. These, however, are opinions and not evidence-based conclusions. While, as aforementioned, the literature on replantation of primary teeth is based on sporadic case reports, there is not even one single anecdotal report attributing damage inflicted to the permanent tooth to replantation of its primary predecessor, all the more so, a controlled study in which avulsed primary teeth are randomly assigned to be replanted or given to the tooth fairy.2

Thirty-eight to 85% of permanent teeth presented developmental disturbances following avulsion of their primary predecessors,3,4,5,6,7 even when the primary teeth were not replanted. This, however, does not guarantee that the apex of the primary tooth does not inflict additional damage to the developing permanent tooth during insertion of the avulsed primary tooth back to its socket. A simple way to cope with this risk has been suggested in three different reports.8,9,10 The root of the avulsed primary teeth has been shortened by 2-3 mm prior to replantation. The significance of these cases lies in the positive attitude of the operators, who attempted to cope with the challenge by suggesting a creative technique rather than avoiding treatment and hiding behind guidelines.

The authors A. S. Al-Khayatt and L. E. Davidson respond: We would like to thank G. Holan for his/her interest in the recent publication of our paper. The aim of this report was to increase the awareness of practitioners of the potential pitfalls of replanting primary incisors. 11

The literature reviewed identified publications in which the action of replanting primary incisors has been both favourable and unfavourable; however as explained, this is entirely based on sporadic reports and personal opinions rather than scientific evaluation. Indeed there exists very little scientific evidence on the long-term success of replantation of primary incisors 12 and making assumptions based on 'a few successful reports' is not considered evidence-based dentistry. 13, 14

As regards guidelines, their purpose is to improve effectiveness and efficiency of clinical care through identification of good clinical practice and desired clinical outcomes. Inevitably there will be areas of practice where there is a shortage of reliable research data, so that while some recommendations are supported by robust data, others are made with a lesser degree of confidence and may represent only 'best current practice'. 14

The authors neither sought to hide behind such guidelines nor are necessarily opponents of replantation of primary incisors where appropriate case selection has been undertaken. In the emergency situation when it may not be possible to assess compliance with either treatment (splinting, endodontic therapy, radiographs and possible extraction) or future regular attendance and in the absence of a randomised controlled trial it is difficult to justify for no proven functional benefit. 11

This conclusion was not based solely on the untoward outcome described in the current case report but is in accordance with recommendations from those clinically experienced, such as Andreason,15,16 Ravn,15,16,17 Sundstrom15 and Von Arx,18 all of whom ultimately advise against primary incisor replantation.