When a simple fall interrupts play

Pediatric dental injuries still occur most frequently among children developing motor skills

By Cathy Hester Seckman, RDH

Several years ago, a panicked neighbor called me, saying, "Sarah fell and broke her tooth on the dinner cruise last night! Can you come look at it?"

As soon as I saw 10-year-old Sarah's upper right central, I relaxed. "It's okay," I reassured her parents, holding a small mirror under the tooth. "The tooth feels tight, and it's in its normal position. Look, the nerve isn't even exposed. That vague pink shadow -- see it? -- is the nerve, and there's still plenty of tooth structure covering it. That means she probably won't need a root canal."

"But what can be done? We don't want it to look like that!"

"Not to worry," I said calmly. "Your dentist can fill that corner with tooth-colored material, shape it to match, and you'll never know it was broken."

According to the American Academy of Pediatric Dentistry, falls are the cause of most pediatric dental injuries, followed by traffic accidents, violence, and sports. With sports especially, injuries can occur because of falls, collisions with other players, and contact with hard objects. The most common ages for dental injuries aren't the teen years, as you might expect. The most common are ages 2 to 3, when motor coordination is still developing.¹

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There are 11 types of injuries that can occur, and some of them are much, much worse than what happened to Sarah.

Avulsion

A tooth is knocked completely out of its socket, periodontal ligament is severed, and the alveolus may be fractured. Avulsed primary teeth are never reimplanted, because of possible injury to developing permanent teeth, but reimplantation can be successful for permanent teeth.

If you have a frantic caregiver on the phone who's wondering what to do, see if they'll attempt to place the tooth back in its socket, and anchor it by having the child bite lightly on a wash cloth or piece of gauze. If that isn't possible, they should be directed to rinse the tooth gently in water only, then put the tooth in a wet medium (saliva, milk, salt water, or plain water) for transport to the dental office. If they can keep the tooth wet and get to a dentist within an hour, chances are good for a successful reimplantation.1

Besides the tooth itself, thought needs to be given to revascularization of the tooth and healing of the periodontal ligament. A mature tooth with a closed apex has almost no chance of revascularization, but a developing tooth with an open apex has complete pulpal revascularization in 18% of studied cases.² Periodontal ligament has no chance of long-term survival if the avulsed tooth has been out of the mouth in a dry environment for more than 60 minutes.

When reimplanting a tooth with a poor prognosis, the goal is to avoid ankylosis for as long as possible. A dentist will remove any remaining periodontal ligament from the tooth, then soak it in sodium fluoride for 20 minutes. Research has shown that fluoride reduces the risk of resorption.3

Concussion/Subluxation

Concussion refers to an injury to surrounding structures without loosening or displacement of teeth. Subluxation is similar, but with loosened or displaced teeth.

We see it once or twice a month at our pediatric practice. When a toddler falls on his or her mouth, frenum can be ripped, lips can be split, the tongue can be bitten, or gum tissue can be traumatized, all without visible damage to the teeth. A tooth may later turn dark due to pulpal necrosis if blood vessels were injured, but there's no way to predict or circumvent that process. It's a wait-and-see injury.

With subluxation, teeth may need to be stabilized for a few weeks to encourage healing of the periodontal ligament.1

Crown fracture, complicated

What makes this kind of fracture complicated is that enamel fracture is accompanied by dentin fracture and pulp exposure. For a primary tooth, depending on its life expectancy, treatment can be pulpotomy, pulpectomy, or extraction. A permanent tooth fracture might call for direct pulp capping, partial pulpotomy, full pulpotomy, pulpectomy, or root canal therapy. Those treatments might be done consecutively. Longevity of the tooth, again, depends on whether the periodontal ligament was also injured.4

Crown fracture, uncomplicated

An uncomplicated fracture does not involve the pulp, and might or might not involve the dentin. This is what happened to my neighbor, Sarah. She had her central incisor fixed two days later. It looked beautiful, and she hasn't had any more trouble with it. If the periodontal ligament had been injured, or if more dentin had been exposed, long-term prognosis for the tooth might have been poor.

Crown/root fracture

My husband suffered a crown/root fracture on an upper central as a teenager, and kept the tooth another 25 years. Successive treatments included root canal therapy, a plastic crown, a gold crown with a porcelain facing, an apicoectomy, and finally extraction.

Researchers say that most permanent teeth like these can be saved, though treatment is complex and difficult. Treatment includes stabilizing the pulp, if necessary; removing the coronal fragment, if necessary; completing a gingivectomy or osteotomy, if necessary; extruding the tooth orthodontically or surgically, if necessary; and restoring the crown.4

Extrusion

This is a partial displacement of the tooth, with possible tearing of the periodontal ligament. The tooth appears elongated and is mobile. A primary tooth can be repositioned and left to heal, or it can be extracted.

Permanent teeth can be repositioned by applying steady apical pressure, then splinting. For teeth with fully closed apices, there is still risk of pulp necrosis.4

Infraction

Infraction is an incomplete crack in enamel, with no missing tooth structure. We see these all the time, given good light and a good mirror. Anterior teeth, in my experience, often show multiple superficial cracks. Complications are unusual,5 and nothing needs to be done.

Intrusion

Apical displacements of teeth into the alveolar bone are always worrisome, especially with primary teeth, since the underlying permanent tooth can also be damaged. Repositioning can be passive, allowing the tooth to re-erupt on its own, or active, using orthodontic pressure or surgery. The tooth is then splinted to allow ligaments and vascular supply to return to normal.⁴ In mature permanent teeth with closed apices, the risk for pulpal problems and root resorption is significant.6

Lateral luxation

With this injury, the periodontal ligament is torn, and the tooth is displaced side-to-side or front-to-back. Treatment and prognosis are the same as with intrusion.

Root fracture

Though only the root is fractured, treatment and prognosis are similar to that for a crown/root fracture.

A 2013 study of health complications of traumatized permanent teeth in 294 pediatric patients showed these results:

36% of the traumatized teeth showed health complications, most frequently diagnosed three months post-trauma
Pulp necrosis was the most common complication, and was significantly associated with avulsion
Mature teeth with closed apices showed that health complications related to support tissue trauma and avulsion were more frequent than other complications at the three-month mark.7

Another 2013 study looked at adolescents with traumatic dental injuries, concluding, not surprisingly, that those with more severe traumas were more likely to self-report a higher negative impact on their oral health-related quality of life.8

Things happen. Kids fall down, they get hit in the mouth, and they run into things face first. Their frightened and sometimes disgusted parents rush them to the dental office, hoping that their child's teeth can be returned to normal with a minimum of fuss and trouble. Sometimes there's nothing we can do, but most times, there is. As you can see, for a newly erupted permanent tooth that still has an open apex, healing can be complete. Even if the tooth is more mature, quick thinking, fast action, and a close watch on a traumatized tooth are still the keys to a successful and long-term result.

CATHY HESTER SECKMAN, RDH, is a frequent contributor based in Calcutta, Ohio. Besides working in a pediatric dental practice, Seckman is a prolific freelance writer, a book indexer, and a speaker on dental and writing/indexing topics. She can be reached at [email protected].

References

1. http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf
2. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti P. Pulp revascularization in reimplanted immature monkey incisors – Predictability and the effect of antibiotic systemic prophylaxis. Endod Dent Traumatol 1990;6(4):157-69.
3. Coccia C. A clinical investigation of root resorption rates in reimplanted young permanent incisors: A five-year study. J Endod 1980;6(1):413-20.
4. Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. 2nd ed. Copenhagen, Denmark: Munksgaard and Mosby; 2000:9-154.
5. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dental Traumatol 2002;18(3):103-15.
6. Humphrey J, Kenny D, Barrett E. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dental Traumatol 2003;19(5):266-73.
7. Soares TR, Luiz RR, Risso PA, Maia LC. Healing complications of traumatized permanent teeth in pediatric patients: a longitudinal study. Int J Paediatr Dent. 2013 Nov 20. doi: 10.1111/ipd.12082. [Epub ahead of print].
8. Bendo CB, Paiva SM, Varni JW, Vale MP. Oral health-related quality of life and traumatic dental injuries in Brazilian adolescents. Community Dent Oral Epidemiol. 2013 Oct 11. doi: 10.1111/cdoe.12078. [Epub ahead of print].