Dental Trauma

Definition

Dental trauma is injury to the mouth, including teeth, lips, gums, tongue, and jawbones. The most common dental trauma is a broken or lost tooth.

Description

Dental trauma may be inflicted in a number of ways: contact sports, motor vehicle accidents, fights, falls, eating hard foods, drinking hot liquids, and other such mishaps. As oral tissues are highly sensitive, injuries to the mouth are typically very painful. Dental trauma should receive prompt treatment from a dentist.

Causes and symptoms

Soft tissue injuries, such as a "fat lip," a burned tongue, or a cut inside the cheek, are characterized by pain, redness, and swelling with or without bleeding. A broken tooth often has a sharp edge that may cut the tongue and cheek. Depending on the position of the fracture, the tooth may or may not cause toothache pain. When a tooth is knocked out (evulsed), the socket is swollen, painful, and bloody. A jawbone may be broken if the upper and lower teeth no longer fit together properly (malocclusion ), or if the jaws have pain with limited ability to open and close (mobility), especially around the temporomandibular joint (TMJ).

Diagnosis

Dental trauma is readily apparent upon examination. Dental x rays may be taken to determine the extent of the damage to broken teeth. More comprehensive x rays are needed to diagnose a broken jaw.

Treatment

Soft tissue injuries may require only cold compresses to reduce swelling. Bleeding may be controlled with direct pressure applied with clean gauze. Deep lacerations and punctures may require stitches. Pain may be managed with aspirin or acetaminophen (Tylenol, Aspirin Free Excedrin) or ibuprofen (Motrin, Advil).

Treatment of a broken tooth will vary depending on the severity of the fracture. For immediate first aid, the injured tooth and surrounding area should be rinsed gently with warm water to remove dirt, then covered with a cold compress to reduce swelling and ease pain. A dentist should examine the injury as soon as possible. Any pieces from the broken tooth should be saved and brought along.

If a piece of the outer tooth has chipped off, but the inner core (pulp) is undisturbed, the dentist may simply smooth the rough edges or replace the missing section with a small composite filling. In some cases, a fragment of broken tooth may be bonded back into place. If enough tooth is missing to compromise the entire tooth structure, but the pulp is not permanently damaged, the tooth will require a protective coverage with a gold or porcelain crown. If the pulp has been seriously damaged, the tooth will require root canal treatment before it receives a crown. A tooth, that is vertically fractured or fractured below the gumline will require root canal treatment and protective restoration. A tooth that no longer has enough remaining structure to retain a crown may have to be extracted (surgically removed).

When a permanent tooth has been knocked out, it may be saved with prompt action. The tooth must be found immediately after it has been lost. It should be picked up by the natural crown (the top part covered by hard enamel). It must not be handled by the root. If the tooth is dirty, it may be gently rinsed under running water. It should never be scrubbed, and it should never be washed with soap, toothpaste, mouthwash, or other chemicals. The tooth should not be dried or wrapped in a tissue or cloth. It must be kept moist at all times.

The tooth may be placed in a clean container of milk, cool water with or without a pinch of salt, or in saliva. If possible, the patient and the tooth should be brought to the dentist within 30 minutes of the tooth loss. Rapid action improves the chances of successful re-implantation; however, it is possible to save a tooth after 30 minutes, if the tooth has been kept moist and handled properly.

The body usually rejects re-implantation of a primary (baby) tooth. In this case, the empty socket is treated as a soft tissue injury and monitored until the permanent tooth erupts.

A broken jaw must be set back into its proper position and stabilized with wires while it heals. Healing may take six weeks or longer, depending on the patient's age and the severity of the fracture.

Alternative treatment

There is no substitute for treatment by a dentist or other medical professional. There are, however, homeopathic remedies and herbs that can be used simultaneously with dental care and throughout the healing process. Homeopathic arnica (Arnica montana ) should be taken as soon as possible after the injury to help the body deal with the trauma. Repeating a dose several times daily for the duration of healing is also useful. Homeopathic hypericum (Hypericum perforatum ) can be taken if nerve pain is involved, especially with a tooth extraction or root canal. Homeopathic comfrey (officinale) Symphytum may be helpful in treating pain due to broken jaw bones, but should only be used after the bones have been reset. Calendula (Calendula officinalis ) and plantain (Plantago major ) can be used as a mouth rinse to enhance tissue healing. These herbs should not be used with deep lacerations that need to heal from the inside first.

Prognosis

When dental trauma receives timely attention and proper treatment, the prognosis for healing is good. As with other types of trauma, infection may be a complication, but a course of antibiotics is generally effective.

Prevention

Most dental trauma is preventable. Car seat belts should always be worn, and young children should be secured in appropriate car seats. Homes should be monitored for potential tripping and slipping hazards. Child-proofing measures should be taken, especially for toddlers. In addition to placing gates across stairs and padding sharp table edges, electrical cords should be tucked away. Young children may receive severe oral burns from gnawing on live power cords.

Everyone who participates in contact sports should wear a mouthguard to avoid dental trauma. Athletes in football, ice hockey, wrestling, and boxing commonly wear mouthguards. The mandatory use of mouthguards in football prevents about 200,000 oral injuries annually. Mouthguards should also be worn along with helmets in noncontact sports such as skate-boarding, in-line skating, and bicycling. An athlete who does not wear a mouthguard is 60 times more likely to sustain dental trauma than one who does. Any activity involving speed, an increased chance of falling, and potential contact with a hard piece of equipment has the likelihood of dental trauma that may be prevented or substantially reduced in severity with the use of mouthguards.

Resources

ORGANIZATIONS

American Academy of Pediatric Dentistry. 211 East Chicago Ave., Ste. 700, Chicago, IL 60611-2616. (312) 337-2169. 〈http://www.aapd.org〉.

American Association of Endodontists. 211 East Chicago Ave., Ste. 1100, Chicago, IL 60611-2691. (800) 872-3636. 〈http://www.aae.org〉.

American Association of Oral and Maxillofacial Surgeons. 9700 West Bryn Mawr Ave., Rosemont, IL 60018-5701. (847) 678-6200. 〈http://www.aaoms.org〉.

American Dental Association. 211 E. Chicago Ave., Chicago, IL 60611. (312) 440-2500. 〈http://www.ada.org〉.

KEY TERMS

Crown— The natural part of the tooth covered by enamel. A restorative crown is a protective shell that fits over a tooth.

Eruption— The process of a tooth breaking through the gum tissue to grow into place in the mouth.

Evulsion— The forceful, and usually accidental, removal of a tooth from its socket in the bone.

Extraction— The surgical removal of a tooth from its socket in the bone.

Malocclusion— A problem in the way the upper and lower teeth fit together in biting or chewing.

Pulp— The soft innermost layer of a tooth containing blood vessels and nerves.

Root canal treatment— The process of removing diseased or damaged pulp from a tooth, then filling and sealing the pulp chamber and root canals.

Temporomandibular joint (TMJ)— The jaw joint formed by the mandible (lower jaw bone) moving against the temporal (temple and side) bone of the skull.

Dental trauma

Definition

Dental trauma is injury to the teeth, gums, and jawbones. The most common dental trauma is a broken or displaced tooth.

Description

Dental trauma may be inflicted in a number of ways: contact sports , motor vehicle accidents, fights, falls, eating hard foods, drinking hot liquids, and other such mishaps. Dental trauma includes teeth that are knocked out (dental avulsion), cracked (fractured), forced out of position (dental luxation, lateral displacement, or extrusion), pushed up into the jawbone (dental intrusion), or loosened by impact (subluxation or dental concussion ). Oral tissues are sensitive, and injuries to the mouth are typically very painful. Dental trauma should receive prompt treatment from a dentist and in some cases is considered a dental emergency.

Demographics

Children between the ages of 1.5 and 3.5 years are most likely to experience dental trauma to their primary (baby) teeth, because this is the age at which they are learning to run. According to the International Association of Dental Traumatology, half of children experience dental injury, with injury occurring most often in children ages eight to 12. Fracture of the tooth crown (the part that is above the gum line) is the most common injury. School-age boys are twice as likely to experience dental trauma as girls.

Causes and symptoms

The cause of dental trauma varies depending on the age of the child. Toddlers are more likely to injure a tooth by falling, while older children are more likely to suffer dental trauma from a sports injury. Teenagers often present with dental trauma as the result of fights. The incisors in the upper jaw are the most commonly injured teeth.

Pain characterizes all dental trauma. The tooth may be knocked out and the socket bleeding, or it may be loose. There may be additional damage to the bones of the jaw and to the soft tissues of the mouth.

When to call the dentist

A permanent tooth that has been knocked out is a dental emergency. The dentist should also be called whenever dental trauma results in pain, dislocation of the tooth, or tooth sensitivity to hot or cold.

Diagnosis

Dental trauma is readily apparent upon examination. Dental x rays may be taken to determine the extent of the damage to fractured teeth. More comprehensive x rays are needed to diagnose a broken jaw.

Treatment

There is a possibility that a permanent tooth that has been knocked out can be re-implanted if handled promptly and correctly. If possible, the tooth should be reinserted in the socket and held there until the child sees a dentist or visits the emergency room. If it is not possible to replace the tooth in the socket, the tooth should immediately be placed in milk, saliva, or cool water with a pinch of saline solution (not contact lens solution or plain water). The tooth should be handled only by the crown and never be allowed to dry out. If a dentist can see the child within half an hour and the tooth has been preserved correctly, there is a possibility that it may be successfully re-implanted. Primary teeth are usually not re-implanted.

For lesser dental trauma, soft tissue injuries may require only cold compresses or ice to reduce swelling. Bleeding may be controlled with direct pressure applied with clean gauze. Deep lacerations and punctures may require stitches. Pain may be managed with aspirin or acetaminophen (Tylenol, Aspirin Free Excedrin), or ibuprofen (Motrin, Advil).

Treatment of a broken tooth will vary depending on the severity of the fracture. For immediate first aid, the injured tooth and surrounding area should be rinsed gently with warm water to remove dirt, then covered with a cold compress to reduce swelling and ease pain. A dentist should examine the injury as soon as possible. Any pieces from the broken tooth should be saved and taken to the dentist with the child.

If a piece of the outer tooth has chipped off, but the inner core (pulp) is undisturbed, the dentist may simply smooth the rough edges or replace the missing section with a small composite filling. In some cases, a fragment of broken tooth may be bonded back into place. If enough tooth is missing to compromise the entire tooth structure, but the pulp is not permanently damaged, the tooth will require a protective coverage with a gold or porcelain crown. If the pulp has been seriously damaged, the tooth will require root canal treatment before it receives a crown. A tooth that is vertically fractured or fractured below the gum line will require root canal treatment and protective restoration. A tooth that no longer has enough remaining structure to retain a crown may have to be extracted (surgically removed).

A broken jaw must be set back into its proper position and stabilized with wires while it heals. This is usually done by an oral surgeon. Healing may take six weeks or longer, depending on the patient's age and the severity of the fracture.

Alternative treatment

There is no substitute for treatment by a dentist or other medical professional. There are, however, homeopathic remedies and herbs that can be used simultaneously with dental care and throughout the healing process. Homeopathic arnica (Arnica montana ) should be taken as soon as possible after the injury to help the body deal with the trauma. Repeating a dose several times daily for the duration of healing is also useful. Homeopathic hypericum (Hypericum perforatum ) can be taken if nerve pain is involved, especially with a tooth extraction or root canal. Homeopathic comfrey (Symphytum officinale ) may be helpful in treating pain due to broken jaw bones but should only be used after the bones have been reset. Calendula (Calendula officinalis ) and plantain (Plantago major ) can be used as a mouth rinse to enhance tissue healing. These herbs should not be used with deep lacerations that need to heal from the inside first.

Prognosis

When dental trauma receives timely attention and proper treatment, the prognosis for healing is good. As with other types of trauma, infection may be a complication, but treatment with antibiotics is generally effective.

Prevention

Most dental trauma is preventable. Car seat belts should always be worn, and young children should be secured in appropriate car seats. Homes should be monitored for potential tripping and slipping hazards. Childproofing measures should be taken, especially for toddlers. Parents can place gates across stairs and pad sharp table edges.

Everyone who participates in contact sports should wear a mouth guard to avoid dental trauma. Athletes in football, ice hockey, wrestling, and boxing commonly wear mouth guards. The mandatory use of mouth guards in football prevents about 200,000 oral injuries annually. Mouth guards should also be worn along with helmets in noncontact sports such as skateboarding, in-line skating, and bicycling. An athlete who does not wear a mouth guard is 60 times more likely to sustain dental trauma than one who does. Any activity involving speed, an increased chance of falling, and potential contact with a hard piece of equipment has the likelihood of dental trauma that may be prevented or substantially reduced in severity with the use of mouth guards.

Parental concerns

Parents are sometimes concerned about the appearance of their child after he or she loses a permanent tooth. Cosmetic dentistry and orthodonture can with time and patience correct almost any problems arising from dental trauma.

KEY TERMS

Avulsion —The forcible separation of a piece from the entire structure.

Crown —The natural part of the tooth covered by enamel. A restorative crown is a protective shell that fits over a tooth.

Extraction —The removal of a tooth from its socket in the bone.

Pulp —The soft, innermost layer of a tooth that contains its blood vessels and nerves.

Root canal treatment —The process of removing diseased or damaged pulp from a tooth, then filling and sealing the pulp chamber and root canals.

Resources

ORGANIZATIONS

American Academy of Pediatric Dentistry. 211 East Chicago Ave., Ste. 700, Chicago, IL 60611–2616. Web site: <www.aapd.org>.

American Association of Endodontists. 211 East Chicago Ave., Ste. 1100, Chicago, IL 60611–2691. Web site: <www.aae.org>.

American Association of Oral and Maxillofacial Surgeons. 9700 West Bryn Mawr Ave., Rosemont, IL 60018–5701. Web site: <www.aaoms.org>.

American Dental Association. 211 E. Chicago Ave., Chicago, IL 60611. Web site: <www.ada.org>.

WEB SITES

Flores, M. T., et al. "Guidelines for the Evaluation and Management of Traumatic Dental Injuries." International Association of Dental Traumatoloty, 2000. Available online at <www.iadt-dentaltrauma.org/Trauma/guidelines.htm> (accessed November 29, 2004).

Goss, Lisa A. "Tooth Injuries." KidsHealth, May 2004. Available online at <www.kidshealth.org/parent/firstair_safe/emergencies/tooth_injury.html> (accessed November 29, 2004).

Ravel, Daniel. "Management of Dental Trauma in Children." Pediatric Dental Health, August 1, 2003. Available online at <http://dentalresource.org/topic50trauma.html> (accessed November 29, 2004).

Tish Davidson, A.M. Bethany Thivierge

Dental Trauma

Definition

Dental trauma is an injury to the mouth and teeth, including oral structures such as the lips, tongue, and cheeks.

Description

Dental trauma can occur during contact sports, motor vehicle accidents, falling and hitting the face, assaults, and/or from untreated tooth decay. It can be caused by physical abuse or domestic violence.

Causes and symptoms

Injuries to a broken or knocked out (evulsed) tooth can cause severe pain. If the lower jawbone is cracked or broken, the patient will be unable to move the jawbone without pain and discomfort. Broken fillings or old crowns are susceptible to decay. They can weaken and undermine the tooth structure, causing the tooth to break. This could result in sharp edges and corners that may damage the tongue tissue.

Diagnosis

X rays (taken to reveal the extent of dental trauma to hard tissue), together with a thorough examination, aid in finding the source of the trauma.

Treatment

Tooth movement

If the entire tooth is knocked out of the socket (evulsion), the tooth must be found and repositioned back in the socket. If this is done in the first 20 minutes, there is a 90% chance of tooth survival. Thirty to 60 minutes cuts the tooth survival rate to 75%.

• The tooth should be picked up gently and held by the crown, not the root.
• The tooth should be carefully rinsed with water; it should not be scrubbed.
• The tooth should be kept moist; it should not be dried.
• If possible, the tooth should be placed in the socket; if this is not possible, it should be placed in a cup of milk.

If a tooth is bumped and still in the socket, but in the wrong position (luxation), dental help should be sought immediately. The following steps should be followed, depending on the position of the tooth.

• An upper tooth hanging down or lower tooth raised up (extrusion) should be repositioned in the socket using firm pressure. The tooth should then be stabilized by having the patient bite down firmly, or bite on a piece of cloth or a handkerchief.
• A tooth pushed back toward the tongue or pulled forward toward the face (lateral displacement) requires repositioning by using firm pressure. This may cause severe pain and biting down on a piece of cloth or handkerchief will help alleviate some of this pain and help to stabilize the tooth.
• Teeth pushed into the gum tissue or teeth that look short (intrusion) require no intervention. Repositioning may damage both tooth nerve and tissue.

Broken and fractured teeth

The fractured area should be cleaned, and a cold compress outside the cheek area should be applied. Dental help should be sought promptly. If a piece of the outer tooth has chipped off, but the inner soft tissue core (pulp) is undisturbed, the rough edges may be smoothed by the dentist and a simple filling placed. If most of the tooth is missing, but the pulp is not damaged, the tooth will require a protective covering with a crown. If the pulp has been damaged, the tooth will require root canal treatment and a crown. A tooth fractured below the gumline will require root canal treatment and protective restoration. A tooth with little remaining structure to retain a crown may have to be removed (extraction).

Cuts, abscesses, and pain

Cut lips, gums, or tongue require mild rinsing with cold water to remove debris. A cold compress should be applied to the injured area. Most cuts and abrasions are minor; a dental visit is not required. Dental care, however, should be sought if bleeding does not stop and the cut is deep. Pain and swelling can be controlled by ibuprofen (e.g., Advil, Motrin), which is an anti-inflammatory and a painkiller.

Abscesses and swollen gums are due to infection in the gum tissue or bone; ice should be placed on the swollen cheek to alleviate discomfort. Antibiotics and painkillers are generally needed to fight infection. If left untreated, the local infection can enter the bloodstream, causing serious illness. It could become life threatening in some cases. Treatment for the cause of an abscess should also be addressed. A periodontal abscess requires therapeutic sealing and root planing. An endodontic abscess requires a root canal and sometimes an apicoectomy (surgical removal of the tooth root).

Severe pain is caused mainly by trauma, but can be caused also by gum abscesses, tooth infection, bone infection, and some dental procedures. Prompt dental care can alleviate worries and aid in pain control.

With jawbone injuries, the jaw should not be moved. A handkerchief or towel should be tied around the jaw and over the head to secure the jaw in place. Immediate dental care should be sought. Severe pain may stem from temporomandibular joint (TMJ) disorders or trigeminal neuralgia.

Prognosis

The key to a good prognosis for a dental trauma is taking quick steps, remaining calm and getting dental attention within the first 20 minutes. Prevention is the best method.

Health care team roles

The dentist may delegate treatment to other staff members (e.g., registered dental assistants), who can take x rays and comfort the patient, while the office manager takes care of all financial matters and billing questions. The registered dental hygienist may administer an anesthetic agent where needed. All team members can alleviate patient fears during a trauma.

Prevention

According to the study by the American Academy of Sports Dentistry, most dental traumas can be avoided if mouthguards are worn. They recommend that athletes, regardless of their age or gender, use mouth guards where facial impact is possible.

The American Dental Association's February 2000 news press release recommended preventive measures for avoiding a dental trauma:

• Yearly dental exams (including x rays).
• Teeth should be brushed and flossed thoroughly at least once a day.
• A mouthguard and helmet should be worn while playing all contact sports (football, soccer, hockey, baseball, boxing, basketball).
• A seatbelt should always be worn when in a moving vehicle.
• Foreign objects (pencils, fingernails, pens) should be kept out of the mouth.

KEY TERMS

Crown— 1. The natural part of the tooth covered by enamel. 2. A restorative crown is a protective shell that fits over a prepared tooth.

Eruption— The process of a tooth breaking through the gum tissue to grow into place in the mouth.

Evulsion— The forceful, and usually accidental, removal of a tooth from its socket in the bone.

Extraction— The surgical removal of a tooth from its socket in the bone.

Intrusion— A condition in which a tooth is forced upward into the bone tissue by a force outside the mouth.

Lateral displacement— A condition in which a tooth is forced out of alignment forward or backward, but remains in its socket.

Luxation— The movement of a tooth still in its bony socket.

Pulp— The innermost soft tissue of a tooth containing blood vessels, lymphatics, and nerves.

Root canal treatment— The process of removing diseased or damaged pulp from a tooth, then filling and sealing the pulp chamber and root canals. Also known as endodontic therapy.

Resources

ORGANIZATIONS

American Academy of Sports Dentistry. 211 East Chicago Avenue, Ste. 700, Chicago, IL 60611-2616. (312) 337-2169. 〈http://www.acadsportsdent.org/〉.

American Dental Association 211 East Chicago Avenue, Chicago, IL 60611. (312) 440-2500. 〈http://www.ada.org〉.

PERIODICALS

Padilla, Ray, DDS. "Oral/Facial Injury Prevention, Treatment and Related Topics" Humboldt-Del Norte Dental Society News (5 January 2001): 3-4.

OTHER

Dental Emergencies. Television show clip. ADA Dental Minutes, October 12, 2000.

Howell, Maria Lopez. "Dental Emergencies." ADA Dental Emergencies Online. 2001. 〈http://www.ada.org/public/topics/emergency.html〉 (Accessed February 2001).