What should I do if a tooth suddenly falls out?｜證據鏈

What should I do if a tooth suddenly falls out?｜證據鏈

F-Units (fact-unit ledger)

• F1｜confidence: verified｜basis: internal_dataset｜period: 2025-03 to 2026-08 GSC｜geo: TW｜span: backlog #30 「牙齒掉了怎麼辦」 and 6 query terms, totaling 112,586 impressions, all concentrated on the single site｜caveat: impressions are property-level figures, not deduplicated traffic; this entry is removed at publication
• F2｜confidence: structural compilation (editorial framework, not an external factual claim)｜basis: editorial_framework｜period: 2026-08-06｜geo: universal｜span: the arrangement of “four pathways (traumatic permanent tooth / primary tooth / naturally loosened tooth / not a natural tooth)” and the “red-flag list” is this site’s communication framework compiled from sources F3 through F31｜caveat: not a diagnostic tool and does not replace clinical judgment
• F3｜confidence: verified｜basis: clinical_guideline (IADT 2020 guideline 2, Dent Traumatol 2020;36(4):331-342, DOI 10.1111/edt.12573; PubMed entry in source 1)｜period: current 2020 version｜geo: universal｜span (from section 1 of the Wiley open-access full text, retrieved by ego-browser on 2026-08-06; not in the PubMed abstract): 「the prognosis is very much dependent on the actions taken at the place of accident and promptly following the avulsion」／「There are also individual situations when replantation is not indicated (eg, severe caries or periodontal disease, an uncooperative patient, severe cognitive impairment requiring sedation, severe medical conditions such as immunosuppression, and severe cardiac conditions) which must be dealt with individually」／「However, not replanting a tooth is an irreversible decision and therefore saving it should be attempted」／「The IADT does not, and cannot, guarantee favorable outcomes from adherence to the Guidelines」｜caveat: consensus guideline, not randomized-trial evidence
• F4｜confidence: verified｜basis: clinical_guideline (same source as F3, section 2)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「An avulsed permanent tooth is one of the few real emergency situations in dentistry」／「Dentists should be prepared to give appropriate advice to the public about first aid for avulsed teeth」／「Also, instructions may be given by telephone to people at the emergency site」／「Immediate replantation of the avulsed tooth is the best treatment at the place of the accident」｜caveat: guideline overview of on-site care, not an individual-case recommendation
• F5｜confidence: verified｜basis: clinical_guideline (same source as F3, section 2 on-site checklist)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted) and follow these recommended instructions」／「Keep the patient calm」／「Find the tooth and pick it up by the crown (the white part). Avoid touching the root. Attempt to place it back immediately into the jaw」／「If the tooth is dirty, rinse it gently in milk, saline or in the patient's saliva and replant or return it to its original position in the jaw」／「Once the tooth has been returned to its original position in the jaw, the patient should bite on gauze, a handkerchief or a napkin to hold it in place」｜caveat: the original guideline lists no brushing, wiping, or antiseptic soaking; this card therefore does not state those actions
• F6｜confidence: verified｜basis: clinical_guideline (same source as F3, section 2 on storage media)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「place the tooth, as soon as possible, in a storage or transport medium that is immediately available at the emergency site」／「This should be done quickly to avoid dehydration of the root surface, which starts to happen in a matter of a few minutes」／「In descending order of preference, milk, HBSS, saliva (after spitting into a glass for instance), or saline are suitable and convenient storage mediums. Although water is a poor medium, it is better than leaving the tooth to air-dry」｜caveat: the preference order is guideline wording, not a statistical ranking
• F7｜confidence: verified｜basis: clinical_guideline (same source as F3, section 2)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「The tooth can then be brought with the patient to the emergency clinic」／「See a dentist or dental professional immediately」｜caveat: Taiwan’s pathway for seeking care (emergency department or dental clinic) depends on local access
• F8｜confidence: verified｜basis: clinical_guideline (same source as F3, section 3 on cell-status strata)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Minimizing the dry time is critical for survival of the PDL cells. After an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable」／「The PDL cells are most likely viable. The tooth has been replanted immediately or within a very short time (about 15 minutes) at the place of accident」／「The PDL cells may be viable but compromised. The tooth has been kept in a storage medium (eg, milk, HBSS (Save-a-Tooth or similar product), saliva, or saline, and the total extra-oral dry time has been <60 minutes)」／「The PDL cells are likely to be non-viable. The total extra-oral dry time has been more than 60 minutes, regardless of the tooth having been stored in a medium or not」｜caveat: all three guideline strata use “extra-oral dry time”; this card does not convert it into “time from leaving the mouth to the appointment”
• F9｜confidence: verified｜basis: clinical_guideline (same source as F3, section 3.1.3)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Delayed replantation has a poor long-term prognosis. The periodontal ligament becomes necrotic and is not expected to regenerate. The expected outcome is ankylosis-related (replacement) root resorption」／「Therefore, the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes. Replantation will keep future treatment options open」／「decoronation or other procedures such as autotransplantation might be necessary later if the replanted tooth becomes ankylosed and infra-positioned」｜caveat: the same passage says frequencies of ankylosis and resorption vary widely and are difficult to predict
• F10｜confidence: verified｜basis: clinical_guideline (same source as F3, section 3.1.1)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Verify the correct position of the replanted tooth both clinically and radiographically」／「If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location up to 48 hours after the traumatic incident」｜caveat: 48 hours is a treatment window for a dentist in the guideline, not a deadline for the public to act on its own
• F11｜confidence: verified｜basis: clinical_guideline (same source as F3, sections 3.1.1 and 11.1)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Stabilize the tooth for 2 weeks using a passive flexible splint」／「Replanted teeth should be monitored clinically and radiographically at 2 weeks (when the splint is removed), 4 weeks, 3 months, 6 months, one year, and yearly thereafter for at least five years」｜caveat: the guideline provides a longer splinting period when an alveolar-bone or jaw fracture is present; open-apex teeth are followed more closely
• F12｜confidence: verified｜basis: clinical_guideline (same source as F3, section 9 on patient instructions)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Avoid participation in contact sports」／「Maintain a soft diet for up to 2 weeks, according to the tolerance of the patient」／「Brush their teeth with a soft toothbrush after each meal」／「Use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks」｜caveat: this is the guideline’s patient-education list for clinicians; actual use must follow a dentist’s individual instructions, and this card does not give medication advice
• F13｜confidence: verified｜basis: clinical_guideline (same source as F3, section 8)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Although most people receive tetanus immunization and boosters, it cannot be assumed that this is always the case. Refer the patient to a physician for evaluation of the need for a tetanus booster」｜caveat: the guideline calls for referral to a physician for assessment, not direct vaccination; Taiwan’s schedule is separately noted in F31
• F14｜confidence: verified (the guideline record was retrieved word for word; IADT website entry empirically returned HTTP 200 on 2026-08-06, titled International Association of Dental Traumatology)｜basis: clinical_guideline (same source as F3, section 2)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「available in multiple languages: Arabic, Basque, Bosnian, Bulgarian, Catalan, Czech, Chinese, Dutch, English」／「This educational resource can be obtained at the IADT website」／「for mobile phones, is another useful source of information for patients, providing instructions on what to do in an emergency situation after a dental injury」｜caveat: the IADT home-page content is dynamically loaded; download paths and current contents for posters and the application were not verified word for word. This card records only their existence and role in the guideline.
• F15｜confidence: verified｜basis: clinical_guideline (IADT 2020 guideline 3, Dent Traumatol 2020;36(4):343-359, DOI 10.1111/edt.12576; PubMed entry in source 2)｜period: current 2020 version｜geo: universal｜span (from section 1.10 of Wiley open-access full text, retrieved by ego-browser on 2026-08-06; not in the PubMed abstract): 「An avulsed primary tooth should not be replanted. Reasons include a significant treatment burden (including replantation, splint placement and removal, root canal treatment) for a young child as well as the potential of causing further damage to the permanent tooth or to its eruption. However, the most important reason is to avoid a medical emergency resulting from aspiration of the tooth」｜caveat: primary and permanent teeth have opposite management directions; this card states them separately in four places to prevent conflation
• F16｜confidence: verified｜basis: clinical_guideline (same source as F15, Table 12, primary-tooth avulsion)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「The location of the missing tooth should be explored during the trauma history and examination, especially when the accident was not witnessed by an adult or there was a loss of consciousness」／「While avulsed teeth are most often lost out of the mouth, there is a risk that they can be embedded in soft tissues of the lip, cheek, or tongue, pushed into the nose, ingested or aspirated」／「If the avulsed tooth is not found, the child should be referred for medical evaluation to an emergency room for further examination, especially where there are respiratory symptoms」｜caveat: the original context is primary dentition; when citing it in the red-flag section, this card preserves the original condition “missing tooth + respiratory symptoms”
• F17｜confidence: verified｜basis: clinical_guideline (same source as F15, Table 12, primary-tooth avulsion)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Avulsed primary teeth should not be replanted」／「To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1%-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk」／「Further follow up at 6 y of age is indicated to monitor eruption of the permanent tooth」｜caveat: the original follow-up schedule has a clinical examination at 6-8 wk; imaging follow-up is advised only where clinical findings suggest pathological change
• F18｜confidence: verified｜basis: clinical_guideline (same source as F15, section 1 introduction)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「For children, aged 0-6 years, oral injuries account for 18% of all physical injuries and the mouth is the second most common area of the body to be injured」／「A recent meta-analysis on traumatic dental injuries (TDIs) reveals a world prevalence of 22.7% affecting the primary teeth」／「They most commonly occur between 2 and 6 years of age」｜caveat: these are figures from another meta-analysis cited by the guideline, not Taiwan-local data
• F19｜confidence: verified｜basis: clinical_guideline (same source as F15, section 1.7 and the permanent-dentition-development-impact passage)｜period: current 2020 version｜geo: universal｜span (retrieved as above): 「Clinicians should check whether the history of the accident and the injuries sustained are consistent or match. In situations where there is suspicion of abuse, prompt referral for a full physical examination and investigation of the incident should be arranged」／「Intrusion and avulsion injuries are most commonly associated with the development of anomalies in the permanent dentition」｜caveat: referral processes depend on local rules, which the guideline expressly says are outside its scope
• F20｜confidence: verified｜basis: clinical_guideline (IADT 2020 guideline 1, Dent Traumatol 2020;36(4):314-330, DOI 10.1111/edt.12578; PubMed entry in source 3)｜period: current 2020 version｜geo: universal｜span (from Wiley open-access full text, retrieved by ego-browser on 2026-08-06; the latter sentence is not in the PubMed abstract): 「Crown fractures and luxations of these teeth are the most commonly occurring of all dental injuries」／「back into the tooth socket under local anesthesia」｜caveat: this card uses the source only to state that displacement without complete avulsion belongs to another guideline, and that repositioning is a dentist’s procedure under local anesthesia; it does not cite individual procedural recommendations
• F21｜confidence: verified｜basis: peer_reviewed (PMID 37194850)｜period: followed from 2017-01 to 2021-12; published 2023｜geo: universal｜span: 「Sixty-two permanent replanted teeth were retrospectively assessed」／「Thirty-one teeth (50.0%) remained in their sockets and 31 (50.0%) were lost due to external root resorption. Of the 25 (40.3%) teeth replanted within one hour, 16 (64.0%) remained in their sockets, and 9 (36.0%) were lost. Twenty-two (71.0%) of all 31 lost teeth had an extra-alveolar time of more than one hour」／「The extra-alveolar time of less than one hour was demonstrated to be important to keep the permanent tooth in its socket」｜caveat: single-center retrospective study of 62 teeth; research-level proportions cannot estimate an individual prognosis
• F22｜confidence: verified｜basis: peer_reviewed (PMID 30720860, Cochrane CD006542.pub3)｜period: searched to 2018-03-08; published 2019-02｜geo: universal｜span: 「Four studies, involving a total of 183 participants and 257 teeth were identified」／「All evidence was rated as being of very low quality due to problems with risk of bias and imprecision of results」／「there is insufficient evidence to support or refute the effectiveness of different interventions for avulsed and replanted permanent front teeth」｜caveat: version chain checked (2010 pub2 PMID 20091594 → 2019 pub3 is the current version; PubMed searched by CD006542 found no newer version); pubtype contains no Retracted Publication
• F23｜confidence: verified｜basis: peer_reviewed (PMID 30193009)｜period: published 2018; 15 studies included｜geo: universal｜span: 「In 15 selected studies, nine storage media (HBSS, tap water, DMEM, milk, saliva, 10% and 20% propolis, Gatorade, and Viaspan) were analyzed at six time points. For storage up to 2 hours, HBSS, DMEM, milk, 10% propolis, 20% propolis, and Viaspan conserved more than 80% of PDL viability」／「Milk remains the most convenient, cheapest, and readily available solution in most situations while also being capable of keeping PDL cells alive」｜caveat: pooled results from in-vitro human periodontal-ligament-cell culture studies, not clinical effectiveness; original adjectives are the researchers’ wording and are relayed neutrally in this card
• F24｜confidence: verified｜basis: peer_reviewed (PMID 40792198)｜period: searched 2014 to 2024; online-first publication 2025-07-31, issue dated September–October 2025｜geo: universal｜span: 「This systematic review and MA suggests that placentrex and aloevera could represent an alternative to HBSS. However, more studies are necessary to obtain a reliable conclusion」｜caveat: used for the timeliness check in incident-log item 9. This card confirmed a 2025 updated review exists for storage media; its conclusion does not overturn the guideline’s on-site medium order. pubtype contains no Retracted Publication
• F25｜confidence: verified｜basis: peer_reviewed (PMID 33648772)｜period: published 2022; 3 studies included｜geo: universal｜span: 「Three studies (4396 extractions in total) could be included for the risk of bias assessment and qualitative data synthesis」／「The reported indications for tooth extraction on dental and medical grounds included caries with the proportion of all extractions ranging from 36.0% to 55.3%, periodontitis from 24.8% to 38.1%, trauma from 0.8% to 4.4%, periapical disease from 7.3% to 19.1%」｜caveat: the statistical population is “indications for tooth extraction,” not “causes of natural tooth loss”; only 3 studies were included, and the authors also state that reliable estimates remain lacking
• F26｜confidence: verified｜basis: peer_reviewed (PMID 29926495, 2017 World Workshop staging-and-grading framework)｜period: published 2018｜geo: universal｜span: 「Stage I to IV of periodontitis is defined based on severity (primarily periodontal breakdown with reference to root length and periodontitis-associated tooth loss), complexity of management (pocket depth, infrabony defects, furcation involvement, tooth hypermobility, masticatory dysfunction)」｜caveat: staging is a clinical diagnostic framework that a dentist must determine from a complete examination; this card does not stage a case
• F27｜confidence: verified｜basis: peer_reviewed (PMID 42131949)｜period: online publication date 2026-05-14 (esummary epubdate checked, before this card’s date 2026-08-06)｜geo: universal｜span: 「Fifty articles comprising 55 population-based cohorts (287 750 participants from 37 countries) were included」／「Individuals with nonfunctional dentition had approximately twice the odds of impaired OHRQoL compared with those with functional dentition」／「odds ratio (OR) = 2.08; 95% CI 1.72-2.52」｜caveat: included studies are mostly cross-sectional; this is associative evidence and cannot infer causation or an individual result
• F28｜confidence: verified (same anchor as card #28)｜basis: peer_reviewed (PMID 30155575)｜period: published 2019｜geo: universal｜span: 「The investigated haemostatics included gauze pressure」／「The interruption of antithrombotics prior to tooth removal because of the fear of bleeding or following postoperative bleeding increases the risk of thromboembolic events」｜caveat: the original research setting was bleeding after tooth removal. This card cites only the category of haemostatic measures and the risk of stopping medication without direction; it does not give management instructions for traumatic bleeding.
• F29｜confidence: verified (National Laws and Regulations Database page checked word for word with ego-browser on 2026-08-06; existing VERIFIED-FACTS anchor)｜basis: law｜period: current text｜geo: TW｜span: 《全民健康保險法》第 51 條「十一、義齒、義眼、眼鏡、助聽器、輪椅、拐杖及其他非具積極治療性之裝具。」｜caveat: individual benefit determinations follow current National Health Insurance Administration announcements; this card makes no benefit determination
• F30｜confidence: verified (word-for-word check with ego-browser on 2026-08-06)｜basis: law｜period: current text｜geo: TW｜span: 《醫療法》第 81 條「醫療機構診治病人時，應向病人或其法定代理人、配偶、親屬或關係人告知其病情、治療方針、處置、用藥、預後情形及可能之不良反應。」｜caveat: statutory quotation, not legal advice. Official English translation: Taiwan Medical Care Act; Chinese text prevails.
• F31｜confidence: verified (retrieved by ego-browser on 2026-08-06; page shows update date 2026/4/21)｜basis: official_statement｜period: current page｜geo: TW｜span: Taiwan Ministry of Health and Welfare Centers for Disease Control, “Tetanus — Disease Introduction”: “民眾若發現傷口有被土壤、塵土或動物及人類糞便污染，或生鏽器具割傷，需至醫院進行適當之治療，並於治療時告知醫師傷口有被污染。”／“完成基礎接種後，每隔10年應給予追加1劑減量破傷風、白喉、百日咳疫苗(Tdap)。”｜caveat: the page has no separate section for dental-trauma situations; need for a booster is determined by a clinician from the individual vaccination history
• F32｜confidence: verified (retrieved by ego-browser on 2026-08-06; drop-down options read one by one)｜basis: official_statement｜period: current page｜geo: TW｜span: Taiwan Ministry of Health and Welfare National Health Insurance Administration “NHI-contracted Healthcare Institution Search” page (page title exactly “衛生福利部中央健康保險署-健保特約醫事機構查詢”); search criteria include city/county, township/district, institution level / contract category, and its “participating plans” option list includes “牙醫急診醫療不足區獎勵試辦計畫-醫院(牙醫急診試辦中心)”｜caveat: the plan name itself indicates an incentive pilot for areas with insufficient medical resources, not a nationwide dental-emergency directory; actual clinic hours must still be confirmed by calling each institution　[On the official page the label appears in Chinese only: 「已加入計畫」]
• F33｜confidence: verified (checked with ego-browser on 2026-08-06; same card #9 anchor, C3 family)｜basis: official_statement｜period: current dataset (metadata updated 2026-07-13)｜geo: TW｜span: Government Open Data Platform dataset “臺北市醫療收費標準,” provided by Taipei City Government Department of Health｜caveat: a single-city example; pages for other cities and counties must be verified one by one before scale-up

• F34｜confidence: n/a｜basis: editorial (structural compilation, not derived from literature)｜period: 2026-08-06｜geo: universal｜content: the default safe action when a parent cannot identify a primary versus permanent tooth at an emergency scene (do not force it back; put it in a storage medium; seek care immediately for a clinician to determine).｜caveat: this is this site’s conservative compilation from the management difference in the IADT permanent- and primary-tooth guidelines, not an original guideline clause, and must not be cited as literature evidence.

Sources

All accessed on 2026-08-06. PubMed entries were retrieved with E-utilities efetch and matched to spans one by one. The three IADT guidelines are Wiley open-access articles, opened in ego-browser and checked word for word from innerText (their spans are not in PubMed abstracts, so the corresponding F-Units do not carry a PMID prefix in order to avoid machine checks against the wrong text). Taiwan laws and official pages were likewise checked word for word after live loading in ego-browser.

1. Fouad AF, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36(4):331-342. PMID 32460393
2. Day PF, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2020;36(4):343-359. PMID 32458553
3. Bourguignon C, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020;36(4):314-330. PMID 32475015
4. Roskamp L, et al. Retrospective analysis of survival of avulsed and replanted permanent teeth according to 2012 or 2020 IADT Guidelines. Braz Dent J. 2023;34(2):122-128. PMID 37194850
5. Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. Cochrane Database Syst Rev. 2019;2(2):CD006542. PMID 30720860
6. Adnan S, et al. Evaluation of periodontal ligament cell viability in different storage media based on human PDL cell culture experiments—A systematic review. Dent Traumatol. 2018;34(6):387-402. PMID 30193009
7. Kumar S, et al. The evaluation of periodontal ligament cell viability for an avulsed tooth using various storage media: A systematic review and meta-analysis. J Oral Biol Craniofac Res. 2025;15(5). PMID 40792198
8. Broers DLM, et al. Reasons for Tooth Removal in Adults: A Systematic Review. Int Dent J. 2022;72(1):52-57. PMID 33648772
9. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Clin Periodontol. 2018;45 Suppl 20:S149-S161. PMID 29926495
10. Tooth Loss and Edentulism Are Associated With Poorer Quality of Life: A Systematic Review and Meta-Analyses. J Periodontal Res. 2026. PMID 42131949
11. Ockerman A, et al. Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review. Clin Oral Investig. 2019;23(4):1695-1708. PMID 30155575
12. Taiwan National Health Insurance Act, Article 51 (National Laws and Regulations Database)
13. Taiwan Medical Care Act, Article 81 (National Laws and Regulations Database; official English translation)
14. Taiwan Ministry of Health and Welfare Centers for Disease Control: Tetanus — Disease Introduction
15. Taiwan Ministry of Health and Welfare National Health Insurance Administration: NHI-contracted Healthcare Institution Search
16. Government Open Data Platform: Taipei City Medical Fee Standards (provided by Taipei City Government Department of Health)
17. Internal data: `analysis/reports/km-dental-backlog.md` #30 appendix (term × site × impression records can be reconciled line by line)
18. Editorial framework: this site’s four-pathway triage and red-flag structure (no external source; labelled as a structural compilation)

Internal citation chain

• If what fell out is a crown or denture rather than a natural tooth: What is a prosthetic crown? Can a missing tooth receive a crown? (KM-DENTAL-23)
• How to ask about the cost of remaking a crown and read an estimate: How much does one crown cost? (KM-DENTAL-11)
• Whether and how to replace a tooth that cannot be retained: Can a molar be left unreplaced after extraction? What happens? (KM-DENTAL-34)
• Triage for swollen, painful gums: How can gum swelling and pain be reduced quickly? When should I seek care? (KM-DENTAL-05)
• What happens when caries is left untreated: How long can caries wait? Will it heal by itself? (KM-DENTAL-15)

Publication-gate reminder: This card is a draft. It must not enter km_entries until zh-Hans, en, and ja versions exist. It is a symptom-triage card with emergency red-flag criteria; under layer 5 of the ANK-DENTAL-SPEC review chain, it needs a GM third-opinion review of red-flag completeness, triage consistency, and time-stratification endpoints before publication. The download path for the IADT website resource in F14 was not verified word for word; the sentence remains only a record of the resource’s existence in the guideline and must not be rewritten as a resource referral.