Oral Injury
Introduction
Dental injuries are very common and up to 30% of children injure their primary teeth. These injuries occur most often during the toddler years when children are active but unsteady on their feet. These injuries become common again in the mid-elementary school years (ages 8 to 10) as children join sports teams and become more independently active outdoors (e.g., bicycles, playgrounds, trampolines). In adolescence, motor-vehicle accidents and assault become increasingly important in the epidemiology of dental injury. Overall, tooth injury is more common in males (greater than a 2:1 ratio), and almost half of all children will incur some type of tooth damage by the time they reach adolescence.
Patterns and Risk Factors
The most common injury site is the maxillary (upper) central incisors, which account for more than 50% of all dental injuries. Oral injuries typically result from falls (most common), bike and car accidents, sports-related injuries, and violence. The mouth is also a common site for non-accidental trauma, and child abuse should always be considered in a child presenting with oral trauma.
Here are some additional risk factors for oral trauma:
o Children with compromised protective reflexes or poor coordination
o Hyperactivity
o Substance abuse (by the adolescent or within the family)
o Child abuse or neglect
o Malocclusion: An abnormality in the coming together of teeth.
o Malocclusion with protruding front teeth
o Failure to use protective face and mouth gear
Types of Dental Trauma
Concussion
o Injury to the supporting structures of the tooth, without loosening or displacement.
o Tooth is tender to percussion.
o Stick to a soft diet for 2 weeks.
o Monitor for changes in tooth color.
o Permanent teeth should be monitored, but the risk of complication is low.
Subluxation
o Injury to supporting structures of the tooth with loosening but no displacement.
o Tooth is tender to percussion, with bleeding at the gingival margin.
o Stick to a soft diet for 2 weeks.
o Requires follow-up, may splint permanent teeth.
o Monitor for changes in tooth color that may indicate pulp necrosis
Lateral Luxation
o Injury to the tooth and its supporting structures, resulting in tooth displacement.
Injured tooth is at risk for pulpal necrosis and root resorption.
o Requires prompt referral to a dentist for repositioning of the injured tooth/teeth. A
splint may be required to hold the injured tooth/teeth in place
o Even primary teeth should be examined by a dentist, because the underlying
permanent tooth may be injured.
Intrusion
o Tooth is pushed into the socket and the alveolar bone. May appear shortened or
even barely visible.
o Poor prognosis and high risk for complications, including root resorption, pulp
necrosis, and infection. May require root canal.
o May damage underlying permanent dentition, especially if an infection develops.
o Teeth may re-erupt. Approximately 90% of primary teeth re-erupt in
2 to 6 months. Permanent teeth may also re-erupt. If a primary tooth does not
re-erupt, it will require extraction to not interfere with permanent tooth eruption.
Extrusion
o Tooth is partially displaced from its socket.
o Requires re-positioning and stabilization.
Avulsion
o Tooth is completely out of the socket.
o Avulsion most often occurs in children from 7-9 years of age, when the
permanent incisors are erupting, and newly formed tooth attachments provide
only minimal resistance against a blunt force.
Management depends on tooth type.
o Avulsion of a Primary Tooth:
DO NOT re-implant, as this may damage the underlying permanent tooth.
o Avulsion of a Permanent Tooth:
This is a dental emergency! The most common teeth avulsed are the central maxillary incisors.
The best chance for tooth survival occurs if the tooth is re-implanted within 30 minutes. After 1 hour, there is almost no chance for survival.
Re-Implanting an Avulsed Tooth:
o Wash tooth and socket with saline.
o Hold the tooth by the crown
o Rinse with water – don’t scrub
o Insert the tooth using adjacent teeth as a reference. Have child bite down on
gauze to hold it into position.
o There is NO wrong way to do this…the best chance of survival for the tooth is to
have the tooth in the socket and get the child to a dentist ASAP!
o If the tooth cannot be placed back in the socket, it can be placed inside the
cheek of the patient (if they won’t swallow it).
o The tooth can be placed in a "tooth saver" solution (Save-A-Tooth), milk or saliva.
o Time is of the essence so get to the dentist!
Fracture
Fractures can be confined to the enamel, or they can involve an entire tooth.
o Small fractures may need to be smoothed or repaired with a small filling.
o Large fractures may involve the placement of a pin, placing a large restoration or
a crown, and if the pulp is involved a root canal may be necessary.
Fractured teeth will be monitored at each 6 month check up. If there was trauma to the root, the tooth may discolor over time. An x-ray will be taken to check the vitality of the tooth and a referral to an Endodontist may be required.
Treatment for a tooth fracture:
o Have child rinse and spit with warm water.
o Save the tooth pieces. The dentist may be able to cement the tooth back
together. No need to place in milk or water.
o If an area is bleeding, have child bite on a piece of gauze for about 10 minutes or
until the bleeding stops.
o Apply a cold compress to the lips. This will help reduce swelling and relieve pain.
Complications of Tooth Injury
There are many possible outcomes with tooth injury:
o Pain, which can be severe.
o Infection, including abscess, Ankylosis (fusion of the alveolar bone with tooth
cementum)
o Inflammatory root resorption.
o Aesthetic consequences. These include tooth loss or discoloration and
malalignment of permanent dentition due to the shifting of remaining teeth or
abnormal eruption.
o Negative impact on self-esteem.
o Impaired oral or phonetic function.
o High cost. Tooth repair can be very expensive.
Prevention
Following is a list of suggestions for accident prevention specifically related to oral trauma
1. Be aware that that injury can occur to developing permanent teeth if a primary tooth is injured.
2. Review and anticipate developmental milestones. For example, when your child is learning to walk, falls are very frequent and front teeth can be easily injured.
3. Counsel about the risks of walkers and trampolines. The American Academy of Pediatrics recommends banning the use of all walkers due to safety and developmental concerns and recommends against the use of trampolines in all environments.
4. Childproof your home. Concentrate on safety gates, window locks, and furniture corner protectors.
5. Review safety measures for outdoor activities and sports:
-Mandatory bicycle helmets. Helmets should also be used with scooters, skateboards, and in-line skates.
-Mouth guards and masks or helmets, when recommended.
6. Stress the importance of adequate supervision at all times, especially on furniture, on stairs, at the playground, and at athletic events or practices.
Sports Mouth Guard
Sports participation poses a significant risk for trauma. More than 3 million children and adolescents are injured annually while participating in sports in the United States. Approximately 25% to 30% of all sports injuries occur in youth involved in organized activities, whereas another 40% occur in youth playing unorganized sports, such as pick-up games.
Sports accidents account for 10% to 39% of all dental injuries, with the highest risk sports for oral trauma being baseball, soccer, football, basketball, and hockey. The risk for dental injury for American football players has been estimated at 10% per playing season. Skateboarding, rollerblading, and bicycling injuries are also common.
Mouth guard use is mandatory for football, ice hockey, lacrosse, field hockey, and boxing, and several states have passed regulations to mandate mouth guards for soccer, basketball, and wrestling.
Consider the following facts about sports guards:
o They help to protect the teeth and soft tissues of the mouth from injury.
According to the American Dental Association, “An athlete is 60 times more
likely to suffer harm to the teeth when not wearing a mouth guard.”
o The better the fit, the more protection offered.
o Generally, a mouth guard covers only the upper teeth. However, adolescents
undergoing orthodontic treatment are at increased risk for oral injury, especially
to the soft tissues, and trauma may damage expensive brackets or fixtures. A
dentist may recommend a custom-fit mouth guard to cover and protect both the
upper and the lower teeth.
o Mouth guard use may reduce the risk or severity of a concussion.
What is a professionally made mouth guard?
o When a dentist makes a custom mouth guard they start the process by taking a
dental impression of the patient.
o The impression material is a paste-like substance that sets within a few minutes
after having been mixed, and it is placed in a tray.
o Once the impression material has solidified the assistant will remove the tray
from the patient's mouth (even when set impression materials are still flexible).
o The dental impression is then filled with plaster so to form a cast.
o The net result is that the dentist now has a three-dimensional representation of
the patient's hard and soft tissues that the mouth guard needs to cover over.
o The mouth guard will be made so it fits on the plaster cast accurately.
o Once the mouth guard has been fabricated (the time allowed for the fabrication
process may be just a few days or even a few weeks) the dentist will have the
dental patient return to their office so they can evaluate the guard's fit and refine
it as is necessary.
What is a boil and bite mouth guard?
o A "boil and bite" mouth guard refers to a type of guard that is made out of
thermoplastic materials.
o The idea is that the athlete customizes the fit of the mouth guard by immersing it
in hot water (until it becomes soft and pliable) and then placing it in their mouth
and subsequently using their fingers, lips, tongue, cheeks, and biting pressure
to seat and form the contours of the guard.
o These can also be used at night for grinding.
o Boil and bite mouthpieces are the most used type of mouth guard.
o If choosing this type of mouthpiece a size must be chosen that covers all of the
patients front and back teeth.
