Protecting All Children’s Teeth
Oral Injury
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Introduction
Used with permission from Content Visionary
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 (eg, bicycles, playgrounds,
trampolines).
In adolescence, motor-vehicle accidents and assault become
increasingly important in the epidemiology of dental injury.
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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.
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Learner Objectives
Used with permission from Content Visionary
Upon completion of this presentation, participants will be able to:
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Describe the incidence and epidemiology of dental injury in the
United States.
Outline a proper examination following an oral injury.
List and describe the 7 categories of tooth injury, their basic
management, and possible sequelae.
Discuss in detail the proper management of an avulsed tooth.
Provide appropriate anticipatory guidance for oral injury
prevention.
Compare and contrast the 3 basic types of mouth guards and
summarize the AAPD recommendations on mouth guard use in
athletics.
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.
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Patterns and Risk Factors
Pediatricians should be aware of the following risk factors for oral
trauma:
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Children with compromised protective reflexes or poor coordination
Hyperactivity
Substance abuse (by the adolescent or within the family)
Child abuse or neglect
Malocclusion with protruding front teeth
Failure to use protective face and mouth gear
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Examination Following Oral Injury
History and mechanism of injury are extremely important in
predicting the likely type of oral injury.
Airway, breathing, and circulation (ABC’s) are paramount, and life
threatening injuries should be addressed immediately.
A complete neurologic examination is necessary, because oral
injuries are often accompanied by more generalized head trauma.
Significant trauma to the oral-facial region, including the jaw, should
be referred to an Emergency Room or oro-facial surgeon for
evaluation.
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Examination Following Oral Injury,
continued
1. Irrigate to remove blood and debris and to improve visualization.
2. Examine soft tissues for edema, tenderness, and lacerations.
3. Examine bony structures for pain or malocclusion.
4. Assess patient’s ability to open the mouth and laterally deviate the
jaw.
5. Examine the tooth ridge for “step-offs”, which can indicate a
fracture of the underlying alveolar bone.
6. Examine the teeth for tenderness and mobility.
7. Account for all teeth and determine if injury has occurred to the
primary or permanent dentition.
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Missing Teeth
Missing teeth should be accounted for.
Do not assume that missing teeth were lost at the scene of the
accident because they may be imbedded in soft tissues, intruded
into the alveolar bone or sinus cavity, aspirated, or swallowed.
Radiographs (soft tissue and chest X-rays) should be done to look
for missing teeth.
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Dental Trauma
It is important that clinicians be familiar
with the different types of dental trauma
and be able to appropriately triage
injured patients.
Dental follow-up is necessary for all
tooth trauma because even seemingly
minor injuries can result in tooth death.
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor
Department of Pediatric Dentistry, School of Dentistry
In general, management of primary
tooth injury is dictated by concern for
the safety of the permanent dentition.
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Types of Tooth Injury
Tooth injury can be divided into 7 main categories:
1.
2.
3.
4.
5.
6.
7.
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Concussion
Subluxation
Lateral Luxation
Intrusion
Extrusion
Avulsion
Fracture
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry,
Duke Children's Hospital
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Concussion
Concussion involves injury to supporting structures of the
tooth, without loosening or displacement.
Tooth is tender to percussion.
Recommended Treatment:
 Stick to a soft diet for 2 weeks.
 Monitor for changes in tooth color.
 Refer to dentist for non-urgent evaluation.
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Subluxation
Subluxation involves injury to
supporting structures of the tooth
with loosening but no displacement.
The tooth is tender to percussion,
with bleeding at the gingival margin.
Recommended Treatment:
 Stick to a soft diet for 2 weeks.
 Dental follow-up; may splint permanent teeth.
 Monitor for changes in tooth color that may indicate pulp necrosis.
Used with permission from Rebecca Slayton, DDS PhD
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Lateral Luxation
Lateral luxation involves injury to the
tooth and its supporting structures,
resulting in tooth displacement. The
injured tooth is at risk for pulpal necrosis
and root resorption.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
This type of injury requires prompt referral
to a dentist for repositioning of the injured tooth/teeth.
Even primary teeth should be examined by a dentist, because the
Underlying permanent tooth may be injured.
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Intrusion
With intrusion injuries, the tooth is
pushed into the socket and the alveolar
bone. It may appear shortened or barely
visible.
Intrusion has a poor prognosis and
high risk for complications, including
root resorption, pulp necrosis, and
infection. May require a root canal.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
Intrusion injuries may also damage underlying permanent dentition,
especially if an infection develops.
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Intrusion, continued
With intrusion injuries, teeth may re-erupt. If a primary tooth does
NOT re-erupt, it will require extraction to not interfere with
permanent tooth eruption.
Recommended Treatment:
 Do not attempt to remove intruded tooth. Instead, focus on pain
control and consider antibiotic prophylaxis.
 For a primary tooth, seek dental evaluation within 1 week (or
earlier, for significant symptoms).
 For a permanent tooth, refer to a dentist immediately for
repositioning and splinting.
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Extrusion
With an extrusion injury, the tooth
is partially displaced from its socket.
This type of injury requires
re-positioning and stabilization.
Refer to a dentist promptly to
evaluate the extent of injury, as well
as any associated injury (e.g.
fracture).
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Used with permission from Rama Oskouian
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Avulsion
With this type of injury, the tooth
is completely out of the socket.
Management of avulsion injuries
depends on the tooth type.
Used with permission from Rama Oskouian
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Avulsion of a Primary Tooth
Do NOT re-implant a primary tooth, as this may damage the
underlying permanent tooth.
Instead, refer to a dentist within 24 hours.
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Avulsion of a Permanent Tooth
This is a dental emergency!
Avulsion should be managed as follows:
1. Gently rinse off debris with saline or milk. Hold tooth by crown only.
2. Avoid touching the root. Do not clean or rub it. It is important to
preserve the periodontal ligament for tooth survival.
3. Re-implant an avulsed permanent tooth immediately, ensuring
correct orientation. The tooth should be re-implanted within 20
minutes, but the best outcome is with teeth replaced within 5
minutes.
4. Instruct patient to bite on gauze or a handkerchief or to hold the
tooth in place.
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Avulsion of a Permanent Tooth, continued
5. Send to a dentist or maxillofacial surgeon immediately for
radiographs, splinting, and antibiotic prophylaxis.
6. If the tooth cannot be re-implanted on scene, transport it (ordered
by preference) in: a tooth storage solution, warm milk, saline, or
saliva.
7. A tooth should not be transported dry or in plain water, as this
significantly decreases the chance of ligament survival.
8. Never suggest a child hold the damaged tooth in his or her mouth
because of the risk of aspiration or bacterial contamination.
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Fracture
There are 5 basic types of tooth fracture:
1. Infraction: incomplete fracture (crack) of the enamel without
loss of tooth structure.
2. Uncomplicated Crown fracture: an enamel fracture or an
enamel-dentin fracture that does not involve the pulp.
3. Complicated Crown fracture: an enamel-dentin fracture with
pulp exposure.
4. Crown/root fracture: an enamel, dentin, and cementum
fracture with or without pulp exposure.
5. Root Fracture: a dentin and cementum fracture involving the
pulp
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Uncomplicated Crown Fracture
This type of fracture is a crack of the enamel
or dentin that does not involve the pulp. It
may have a sharp edge.
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Recommended Treatment:
• Inspect injured lips, tongue, and gingiva to
rule out presence of tooth fragments.
• Provide a soft diet, avoiding temperature
extremes.
• If a permanent tooth is injured, refer to a
dentist for evaluation ASAP (within 12 to 24
hours).
• Recommend long-term follow-up to evaluate
for complications, which are uncommon.
Used with permission from:
a. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric
Dentistry, School of Dentistry
b. Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke
Children's Hospital
Complicated Crown Fracture
Complicated crown fracture is an enameldentin fracture with pulp exposure.
Site of a complicated crown fracture has a
reddish tinge or will bleed.
This type of fracture can cause extreme
pain and may lead to pulpal necrosis, root
resorption, or infection in exposed pulp.
Refer to dentist as soon as possible
(within 12 to 24 hours) for evaluation.
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Used with permission from:
a. Rebecca Slatyton DDS, PhD
b. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department
of Pediatric Dentistry, School of Dentistry
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Crown/Root Fracture
Enamel, dentin, and cementum fracture with or without pulp
exposure.
Likely complications include root resorption and pulp necrosis.
Refer to dentist as soon as possible (within 12 to 24 hours) for
evaluation, where diagnosis will be made via radiograph.
Treatment consists of reduction and splinting or extraction.
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Root Fracture
Excessive mobility of the tooth may indicate a
root fracture. This type of fracture includes
pulp exposure. Potential complications for a
root fracture include resorption and pulp necrosis.
Refer to a dentist ASAP (within 12-24 hours) for
evaluation, where diagnosis is made radiographically.
Used with permission from Martha Ann Keels, DDS,
PhD; Division Head of Duke Pediatric Dentistry, Duke
Children's Hospital
Treatment consists of reduction and splinting for
permanent teeth or extraction, depending on the extent of the
traumatic lesion.
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Complications and Consequences of
Tooth Injury
There are many possible consequences of an oral injury:
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Pain, which can be severe.
Infection, including abscess.
Ankylosis.
Inflammatory root resorption.
Aesthetic consequences.
Negative impact on self-esteem.
Impaired oral or phonetic function.
High cost.
For these reasons, prevention of tooth injury is paramount.
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Prevention
Prevention is the most effective intervention.
Primary care clinicians are in a unique position to help
families prevent accidental trauma, including oral
trauma, by providing anticipatory guidance at routine
visits.
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Accident Prevention
Suggestions for accident prevention specifically related to oral
trauma:
1. Advise parents about possible injury to developing permanent
teeth from trauma if a primary tooth is injured.
2. Review and anticipate developmental milestones.
3. Counsel about the risks of walkers and trampolines.
4. Discuss childproofing the home.
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5. Review safety measures for outdoor activities and sports.
6. Stress the importance of adequate supervision at all times,
especially on furniture, stairs, at the playground, and at athletic
events or practices.
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Sports and Protective Gear
Sports participation poses a significant risk for trauma
The highest risk sports for oral trauma are baseball, soccer,
football, basketball, and hockey.
Skateboarding, rollerblading, and bicycling injuries are also
common.
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Sports and Protective Gear, continued
Helmet and face masks should be properly fitted and worn
during all games and practices for the sports in which they are
recommended.
Statistically, children are more often injured in practice than
during a game, so all protective gear should be worn during
practice as well.
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Mouth Guards
Mouth guard use is mandatory for football, ice hockey,
lacrosse, field hockey, and boxing.
Several states have passed regulations mandating mouth
guards for soccer, basketball, and wrestling.
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Facts About Mouth Guard Use
1. Mouth guards help to protect the teeth and soft tissues of
the mouth from injury.
2. The better the fit, the more protection offered.
3. Mouth guard use may reduce the risk or severity of a
concussion.
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Types of Mouth Guards
There are 3 types of mouth guards:
1. Stock.
2. Mouth-formed, or “boil-and-bite.”
3. Custom fit.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
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Stock Mouth Guards
These pre-formed, over-the-counter, ready-to-wear
mouth guards are generally the least comfortable and,
therefore, the least likely to be worn.
Because of poor fit, they also offer the least protection
and require constant biting down to stay in place.
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Boil and Bite Mouth Guards
Made of thermoplastic material that conforms to the shape of
the teeth after being placed in hot water, these mouth guards
are commercially available and the most common type used by
athletes.
They vary in fit, comfort, and protection.
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Used with permission from Content Visionary
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Custom Fit Mouth Guards
This type of mouth guard must be made by a dentist for the individual.
It is the most expensive, but also offers the most protection and
comfort.
Custom mouth guards are preferred by dentists and usually preferred
by athletes because of their increased comfort, wear-ability, and
retention, as well as ease of speaking when worn.
This type of mouth guard is particularly important for adolescents
with orthodontic appliances.
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Recommendations for Mouth Guards
The American Academy of Pediatric Dentistry (AAPD)
recommends properly fitted mouth guards for all
children participating in organized and unorganized
contact and collision sports.
The AAPD supports mandated for use of athletic
mouthguards in any sporting activity containing a risk
of orofacial injury.
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Question #1
Which teeth are most commonly affected by oral injury?
A. Central maxillary incisors
B. Central mandibular incisors
C. Canines
D. Molars
E. There is no common pattern to oral injuries
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Answer
Which teeth are most commonly affected by oral injury?
A. Central maxillary incisors
B. Central mandibular incisors
C. Canines
D. Molars
E. There is no common pattern to oral injuries
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Question #2
Which of the following is not a risk factor for oral trauma?
A. Malocclusion
B. Child abuse or neglect
C. Early childhood caries
D. Hyperactivity
E. Substance abuse within the family
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Answer
Which of the following is not a risk factor for oral trauma?
A. Malocclusion
B. Child abuse or neglect
C. Early childhood caries
D. Hyperactivity
E. Substance abuse within the family
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Question #3
Which of the following is most likely following intrusion of a
primary tooth?
A. Root resorption
B. Re-eruption of the primary tooth
C. Pulpal necrosis with possible root infection
D. Fracture of the underlying permanent tooth
E. Damage to the underlying tooth and failure of permanent tooth to
erupt
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Answer
Which of the following is most likely following intrusion of a
primary tooth?
A. Root resorption
B. Re-eruption of the primary tooth
C. Pulpal necrosis with possible root infection
D. Fracture of the underlying permanent tooth
E. Damage to the underlying tooth and failure of permanent tooth to
erupt
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Question #4
Which of the following is the proper management of an
avulsed primary tooth?
A. The tooth should not be re-inserted
B. The tooth should be transported in milk and the child rushed to a
dentist or ER for re-insertion
C. The tooth should be transported in water and the child rushed to a
dentist or ER for re-insertion
D. It should be re-inserted immediately
E. None of the above
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Question #4
Which of the following is the proper management of an avulsed
primary tooth?
A. The tooth should not be re-inserted
B. The tooth should be transported in milk and the child rushed to a dentist
or ER for re-insertion
C. The tooth should be transported in water and the child rushed to a dentist
or ER for re-insertion
D. It should be re-inserted immediately
E. None of the above
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Question #5
Which of the following is a consequence of oral injury?
A. High cost
B. Impaired oral or phonetic function
C. Pain
D. Infection, including abscess
E. All of the above
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Answer
Which of the following is a consequence of oral injury?
A. High cost
B. Impaired oral or phonetic function
C. Pain
D. Infection, including abscess
E. All of the above
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References
1. American Academy of Pediatric Dentistry. Decision Tree for an Avulsed Tooth.
Resource Section, pg 236. Available online at:
http://www.aapd.org/media/policies_guidelines/ rs_traumaflowsheet.pdf.
Accessed May 25, 2012.
2. American Academy of Pediatric Dentistry. Prevention of Sports-Related
Injuries. 1999. pg. 38. Available online at: http://www.aapd.org/pdf/sports.pdf.
Accessed January 15, 2007.
3. American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline
on Management of Acute Dental trauma; Reference Manual; revised 2004: 135140. Available online at:
http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf. Accessed January
15, 2007.
4. American Academy of Pediatric Dentistry Council on Clinical Affairs Policy on
Prevention of Sports-related Orofacial Injuries. revised 2006, pg: 48-50. Available
online at: http://www.aapd.org/media/policies_guidelines/p_sports.pdf. Accessed
January 15, 2007.
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References, continued
5. American Academy of Pediatrics: Injuries Associated With Infant Walkers.
Committee on Injury and Poison Prevention. Pediatrics. 2001; 108(3): 790-792.
Available online at:
http://pediatrics.aappublications.org/cgi/content/full/108/3/790. Accessed
January 15, 2007.
6. American Academy of Pediatrics: Trampolines at Home, School, and
Recreational Centers. Committee on Injury and Poison Prevention and Committee
on Sports Medicine and Fitness. Pediatrics. 1999; 103(5): 1053-1056. Available
online at: http://pediatrics.aappublications. org/cgi/content/full/103/5/1053.
Accessed January 15, 2007.
7. Cohen S, Burns RC. Pathways of the Pulp. Eighth edition.
8. Conference on Sports Injuries in Youth. Bethesda, MD: National Institutes of
Health; 1992. NIH Publication No 93-3444.
9. Hergenroeder AC. Prevention of Sports Injuries. Pediatrics. 1998; 101(6):
1057-1063.
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References, continued
10. Hsu SS, Groleau G. Tetanus in the Emergency Department: A Current
Review. Journal of Emergency Medicine. 2001; 20(4):357-65.
11. Newsome PR, Tran DC, Cooke MS. The role of the mouthguard in the
prevention of sports-related dental injuries: a review. Int J Paediatr Dent. 2001;
11(6):396-404.
12. Protecting Teeth with Mouth guards. Patient Information Pamphlet. JADA.
2006; Vol. 137: 1772. Available online at:
http://www.ada.org/prof/resources/pubs/jada/patient/patient_69.pdf. Accessed
January 15, 2007.
13. The Society of Teachers of Family Medicine Group on Oral Health. Smiles for
life: A national oral health curriculum for family medicine. 2006.
www/smilesforlifeoralhealth.org. Accessed June 4, 2012.
14. US Department of Health and Human Services. Oral health in America: A
Report of the Surgeon General. Rockville MD: US Department of Health and
Human Services, National Institute of Dental and Craniofacial Research, National
Institutes of Health; 2000. Available online at: http://www.nidcr.nih.gov/
DataStatistics/SurgeonGeneral.
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