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Family Health Magazine
CHILDHOOD

Tooth Injuries in Childhood
Your dentist can help

As babies start to crawl and explore the world, they meet many obstacles where they might be hurt. Through the active years of childhood and adolescence, these obstacles become even more common. Injuries causing damage to the teeth, bone, gums, cheeks and lips are common. Childhood dental injuries can have a long lasting and serious effect. They may lead to discomfort, discolouration, altered tooth development, infection (if left untreated) or tooth loss.

The most likely causes of dental injuries in children are falls and tripping over objects. For young children, playing near sharp-edged coffee tables or fireplaces, running at the swimming pool, and wearing socks on slippery linoleum floors are common activities that often cause falls and dental injuries.

Anyone of any age who plays sports without the protection of a mouthguard also risks severe dental injury. A tooth may be knocked out, moved, broken or suffer from a severe blow (concussion) when left unprotected. Other dental injuries seen by dentists result from fights, car accidents, rough play, electrical burns and, unfortunately, child abuse.

Dental injuries can be divided into those involving the baby or primary teeth and those involving the adult or permanent teeth. Baby teeth begin to appear at about six months of age. By two-and-a-half to three years, all baby teeth should be present. The exchange of baby teeth for adult teeth begins at about age six and continues until about age 13. Although baby teeth are not permanent, their presence is valuable in the growth and development of the mouth and its structures. They guide the adult teeth into their appropriate spots, and aid in speech, eating and appearance.

If the early teeth are lost or altered, these important functions can be affected. Even though the permanent teeth cannot be seen when you look into your child’s mouth, injuries to the baby teeth can have a dramatic influence on later tooth development. For this reason, all dental injuries should be evaluated by a dentist. Some injuries, if left untreated, can lead to nerve death with that tooth. In the case of baby teeth this can also damage the developing adult tooth associated with it.

Injuries to Baby Teeth

Bumped front tooth

These injuries may occur as early as the days when a child is learning to crawl. As a result of the concussion, the tooth may be loosened and bleeding may occur around the gums. This type of injury causes concern for dentists because the tooth may be so loose the child could inhale it. The dentist will also want to check the position of the tooth to ensure that it has not been moved in a way that would interfere with the child’s normal bite. Most teeth that have been bumped tighten up on their own within one to two weeks after the injury.

Injured teeth may discolour by turning grey or brown. Because the baby teeth are so white, the colour change is easy to see when compared to the surrounding teeth. The colour change may be the result of normal healing or a sign of an underlying infection developing. Examination by a dentist is important. Your dentist will decide how often the injured tooth should be checked. It may be a schedule such as one week, three weeks, six weeks, three months and six months after the injury occurred, or longer.

Teeth knocked out

For baby teeth only, a knocked out tooth is not replaced into its original spot. Doing so may damage the permanent tooth that is developing. The success rate is also poor for re-implanted baby teeth.

The lost tooth should be located. If it cannot be found, an x-ray should be done to see if the tooth has been pushed into the gums and bone. If it is still not found, an x-ray of the chest and abdomen may be needed to see if the tooth has been swallowed or inhaled. A follow-up with a doctor may be indicated if the tooth is located by an x-ray of the chest or abdomen.

Your dentist will want to make recommendations about the space that results after a baby tooth is lost due to injury. Sometimes no further treatment is necessary. Other times the space will need to be maintained so there will be enough room for the permanent tooth when it comes through. This is done after the injured area heals.

Broken Teeth

For children ages three to six, this is the most common injury. Your dentist will want to take an x-ray to assess the extent of the injury. Dental fractures may involve:

• the enamel or outer layer of the tooth only - often no treatment is needed.
• the enamel and dentin (the layer beneath the enamel but above the nerve or pulp). These need to be seen by your dentist as a sedative dressing is often required to soothe the tooth (for instance, if there is sensitivity to cold). The dressing also helps protect the pulp. A tooth-coloured filling is placed over the sedative dressing and bonded to the tooth to restore the shape and your child’s smile.
• the whole tooth where the nerve is exposed. In this case, you will notice bleeding coming from within the tooth itself. You will want this checked by your dentist as soon as possible after the injury has occurred. The time elapsed since the injury will guide your dentist on the best course of treatment. It may involve placing a sedative dressing over the exposed nerve, or a partial or complete nerve removal. once again, a tooth-coloured filling will be used to restore the appearance. If left untreated, the tooth may become infected and develop an abscess. Your dentist may want to complete a baby root canal or remove the rest of the tooth depending on several circumstances.
• fractures of the root. The tooth portion above the fracture will need to be removed. Your dentist will discuss the option of removing the root below the fracture. If this is done, the developing tooth associated with it may be affected. If the root is left in place, the dentist will monitor it closely in case an infection develops. In the latter case, the remaining root will then need to be removed.

If you suspect any type of dental fracture, your child should be seen by a dentist to have the damage assessed and monitored.

Teeth pushed out of position

Sometimes a tooth will be injured and its position altered. You may find that the tooth is in the way of your child closing the teeth together or the tooth may be pushed into the gums and bone. You will want your child to see a dentist in any case. X-rays will be needed to assess the extent of the injury.

If the crown (the part of the tooth you brush) is angled backwards towards your child’s tongue, it may be a favourable displacement or favourable injured position. This is because the root (the part that holds the tooth in the bone) will have likely moved forward towards the lip. Since most top adult teeth are forming behind the roots of the baby teeth, this root movement will be away from the developing adult tooth. Although the baby tooth may need to be removed, it may not have affected the forming adult tooth.

For teeth that are pushed into the gums and bone, often the tooth will be allowed to return to its original position (re-erupt). It is possible that the adult tooth may have been damaged as the baby tooth was pushed into it. Your dentist will want to monitor this injury to ensure the tooth is re-erupting and to check that infection is not developing.

Fractures of the jaw

Fractured jaws in children account for two to eight per cent of injuries. Children will need emergency care immediately whenever there is significant injury involving the mouth.

Injuries to the Adult Teeth

Several different types of injuries can occur to permanent teeth.

Crown cracks

These are cracks in enamel that may be horizontal, oblique or vertical. There is no treatment recommended other than monitoring by your dentist.

Crown fractures

This fracture involves the crown of the tooth only. It may encompass:

• the enamel only. Here the rough edges are smoothed or a tooth coloured filling is bonded to restore the tooth’s appearance.
• the enamel and dentin (the layer below the enamel). This fracture will require immediate care and should be seen by your dentist. A protective sedative dressing will need to be placed to soothe the tooth and protect the underlying nerve. Your dentist may decide to restore the tooth to its original form that day or place a temporary tooth coloured-filling over the injured area. If this second choice is made it is called a 'band-aid' solution. Once the tooth has had time to heal (three to four weeks) the bonding may be completed.
• the enamel, dentin and pulp (nerve).

Immediate care is necessary by your dentist. Partial or complete nerve removal may be required depending on the length of time the nerve has been exposed. Depending on the tooth’s maturity at the time of injury, your dentist may want to encourage the tooth to develop more quickly than it would normally do, then do a root canal.

Root fractures

This type of injury may involve the crown as well. It may be a horizontal, vertical or oblique fracture. Immediate care by your dentist is necessary. The location of the fracture will dictate if the tooth can be saved and determine the treatment needed. It may involve splinting the tooth for a week to 10 days, or even longer. A follow up root canal may also be required. Because these fractures can be complicated, other treatments may be recommended by your dentist.

Displaced permanent teeth

This type of injury may push the tooth forward, backwards, into the gum and bone or almost completely out of the bone. You will need to see your dentist immediately. Usually the tooth is replaced into its original position and splinted for a select period of time. A root canal may be needed. If the tooth is pushed into the gum, it may be allowed to re-erupt once again. Braces (orthodontics) may also be needed to reposition the tooth.

Knocked out teeth

Here the tooth is completely lost from the socket. From one to six per cent of dental injuries are of this type. Immediate treatment is urgent as the longer the tooth is outside the socket, the poorer the chance it can be saved.

The tooth should be rinsed with water (being held only by the crown, not the root) and replaced into the socket and gently held in position until seen by a dentist. If the tooth cannot be replaced in the socket, it should be placed in milk or under the tongue. The dentist will splint the tooth in place. A root canal is highly likely. Any cuts to surrounding tissues will need to be assessed and treated accordingly.

The Protective Mouthguard and Your Child

Studies show that 22 to 46 per cent of children aged nine to 10 have suffered some form of dental injury. Boys have more injuries than girls and the front teeth are more often injured than the back teeth. Accidents to the mouth may damage the gums, bone, jaw, the temporomandibular joint as well as the teeth.

These guards help cushion the force of an injury and minimize the trauma during an impact. Because a proper, comfortably fitting mouthguard is essential in protecting the teeth and surrounding oral structures, your dentist can discuss making one specifically designed for you or your child. Remember, unless it is worn, the mouthguard cannot reduce or prevent an injury!

Immediate Care

Any injury to the mouth (teeth, gums, bone) should be examined by a dentist as soon as possible after the injury. This increases the chance the dentist’s treatment will be successful. It is better to have an injury checked than to wait and have the situation become worse.

Dental injuries to children may be common but they should not be taken for granted and ignored. Have your dentist check your child’s teeth whenever such an injury occurs. It could make a lifelong difference. No matter what the fracture is, your child should be seen by a dentist to have the damage assessed and monitored.