Patient education: Mouth and dental injuries in children (Beyond the Basics)

INTRODUCTION — Nearly 50 percent of children will have some type of injury to a tooth during childhood, many of which are preventable. Mouth injuries are also common. Tooth and mouth injuries often occur after a fall, motor vehicle accident, sports injury, or fight.

In most cases, tooth and mouth injuries are not life threatening. Rarely, a child may develop serious complications. Injuries to the teeth and mouth can also have long-lasting effects on the child's appearance and self-confidence.

This topic will review the most common causes, evaluation, and treatment of dental and mouth injuries, including when to seek medical attention. A topic that discusses head injury in children is available separately. (See "Patient education: Head injury in children and adolescents (Beyond the Basics)".)

CAUSES — Falls, sports-related injuries, and fights are the most common causes of tooth injury in children. Mouth injuries can also occur when a child trips or is pushed with an object in the mouth.

EVALUATION

When to seek help — Many parents wonder if their child should receive medical attention after a dental or mouth injury. Children with any of the following symptoms should be evaluated by a healthcare provider. Depending upon the particular circumstances, this may be done over the phone, at the pediatrician's or dentist's office, or in an emergency department:

●If there is pain, tenderness, or sensitivity (to hot/cold or pressure) in a tooth

●If there is a broken, loose, or missing tooth after trauma (the tooth could have been inhaled or swallowed)

●If there is bleeding that does not stop after applying pressure for 10 minutes

●If there is pain in the jaw when opening or closing the mouth

●If there is difficulty swallowing or breathing

●If there is an object stuck in the roof of the mouth, cheek, tongue, or throat (do NOT remove the object)

●If there is a large or gaping cut inside the mouth or on the face

●If the child could have a puncture in the back of the throat

●If there is a cut on the lip that extends through the lip's border into the surrounding skin

●If the child is weak, numb, or has blurred vision or slurred speech

●If the parent is concerned about the child's condition

●If the child develops a fever (temperature ≥100.4ºF/38ºC) or other signs of infection after a mouth or tooth injury (localized redness, pus, increasing pain); signs of more serious infection may include neck pain or stiffness, inability to open the mouth completely, drooling, or chest pain.

Medical history and physical examination — The parent or child should try to describe how the injury occurred. If there is any reason to suspect that another adult or child intentionally injured the child, this should be discussed with the healthcare provider.

During the physical examination, the clinician will examine the child's mouth, throat, head, neck, and body.

Imaging tests — Depending upon the injury, children may need an imaging test (x-ray, computed tomography [CT] scan, magnetic resonance imaging [MRI]). The imaging test can help to determine if there are fractures in a bone, damage to the root of a tooth, damage to a blood vessel, or if the child has swallowed or inhaled a foreign body (ie, a piece of a tooth). Most children with a dental injury will require dental x-rays either in the emergency department or when seen in follow-up by their dentist.

TREATMENT

Dental injuries — The treatment for dental injuries depends upon the child's age, the type of injury and whether the injured tooth is a primary (baby) or permanent (adult) tooth.

Parents often wonder if a child's permanent or primary teeth were injured. Permanent teeth are not usually present before six to seven years of age. Primary teeth look different than permanent teeth.

Long-term follow-up after injury — Injuries to the teeth, especially those involving permanent teeth, will require long-term follow-up care. Even if the injured tooth appears healthy, it is still important for the parents to have their children evaluated by a dentist who is experienced in dental injuries. The length of these follow-ups may range from weeks to years after the injury, depending upon the age of the child and severity of injury.

Dislocated or loose primary tooth — The most common injury to the primary teeth is dislocation of the front teeth. The management of these injuries focuses on preventing future damage to the permanent teeth.

A primary tooth that is loose may be left in place or, if interfering with the bite, it may be removed. In many cases, a loose tooth will heal without treatment. Injured teeth that are very loose may need to be removed if there is a possibility that the tooth could fall out easily or cause the child to choke (eg, while sleeping).

If the primary tooth was knocked out completely, it should not be placed back into the gums because of the risk of damage to the permanent tooth to follow. Losing a front primary tooth early does not typically affect the child's speech or the position of the permanent tooth.

Broken primary tooth — Children with broken teeth should see a dentist promptly. The dentist will determine if the tooth's nerves or blood vessels could be damaged. Treatment may include smoothing the rough edges of the tooth, repairing it with a tooth-colored resin material, leaving the tooth in place, or removing it.

Dislocated permanent tooth — A permanent tooth that is knocked out is a dental emergency that requires prompt treatment. The tooth should be placed back into the tooth socket as soon as possible, ideally within 15 minutes and up to one hour (or longer if stored in cold milk). At least 85 percent of teeth that are put back in the tooth socket within five minutes survive, compared with very few teeth that are stored dry and replanted after one hour.

Because of the importance of replacing the tooth quickly, the child, parent, or another adult can (and should) attempt to replant the tooth. The following steps are recommended:

●Handle the tooth carefully by the top (crown) (picture 1).

●Remove any debris by gentle rinsing the tooth with saline or tap water; the tooth should not be scrubbed or sterilized.

●Place the tooth by hand back into the socket.

●Keep the tooth in place by having the child bite on a clean towel or handkerchief.

●The child should see a dentist for treatment as soon as possible.

If it is not possible to replace the tooth in the gums, the tooth should be stored in a container of cold milk. If cold milk is not immediately available then place the tooth in a container of the child's saliva. Do not store the tooth in water, because this will reduce the chances of successful healing of the replanted tooth. The child should see a dentist or other healthcare provider as soon as possible to replant the tooth. The likelihood that the tooth will survive is reduced the longer the tooth is out of the mouth.

Loose permanent tooth — A loose permanent tooth that is interfering with the child’s bite is also a dental emergency that requires prompt treatment. In most cases, the tooth can be returned to its correct position and monitored over time. However, it may be necessary to use anesthesia (to prevent pain) and stitches or splints (to hold the tooth in place). A dentist with experience in treating dental injuries in children is the best person to evaluate and treat children with loose permanent teeth. These teeth should be monitored closely for several months or years as they often require root canal treatment, sometimes long after the injury happened.

Broken permanent tooth — Broken permanent teeth can usually be repaired successfully. For the best possible outcome, the child should see a dentist for treatment as soon as possible or within a day from the time of the injury. Broken teeth that are sensitive to hot or cold need to be treated urgently. Tooth fragments may be saved, if possible, and stored in tap water as they can sometimes be reattached. If tooth fragments cannot be found or cannot be reattached, the tooth may be repaired with a material called composite resin, which is a white tooth filling material.

Mouth injuries — The evaluation and management of mouth injuries depends upon how the injury happened, what areas are injured, and the severity of the injury.

Tears — Small wounds or tears inside the mouth usually do not require stitches. Tears of the flap of skin under the upper lip (the frenulum) also heal without stitches.

Large cuts, especially if near the tip of the tongue or between the teeth, may require stitches. Wounds that involve the outer part of the lips and extend into the skin also frequently require stitches. Such wounds may require care by health care professionals other than dentists.

Puncture wounds — Wounds to the back of the throat can occur if a child falls while holding a pencil, toothbrush, or other object. If the object penetrates the side of the back of the throat, near the tonsils, there is a risk of injury to the carotid artery (a large blood vessel). A child with this type of injury may require an imaging test and/or evaluation by a surgeon. (See "Oropharyngeal trauma in children".)

Home management of minor mouth injuries — Minor injuries to the mouth often bleed, which can be frightening for a child. To stop bleeding inside the lip, press the area against the teeth and hold for several minutes. To stop bleeding of the tongue, hold the injured area between the fingers with a piece of gauze or a clean cloth. Applying pressure should control the bleeding within 10 minutes. It is normal to have small amounts of blood-tinged saliva afterwards.

Small mouth wounds usually heal within three days. The area may appear pale or whitened; this is normal.

Pain relief — If a child has pain related to a mouth or tooth injury, the child may apply a piece of ice or frozen popsicle to the area. A non-prescription pain medication, such as ibuprofen (children's Advil, children's Motrin) or acetaminophen (children's Tylenol) may also be given as long as the child is not allergic to them. These medications should be dosed according to the child's weight rather than age and should follow the instructions on the package.

Antibiotics — Antibiotics are not often required for children with dental or mouth injuries. However, children with complicated mouth wounds, including those that require stitches, may be treated with antibiotics for a few days to prevent infection. Also, children with heart conditions that require antibiotics to prevent a heart infection (endocarditis) after dental work should receive antibiotics.

Tetanus prevention — A dose of tetanus vaccine may be necessary depending upon the child’s tetanus immunization status. (See "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)" and "Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)".)

Oral hygiene and diet — After a tooth or mouth injury, it is important to continue keeping the teeth clean even if the teeth and gums are sensitive or tender or if brushing causes slight gum bleeding. This includes brushing twice per day with a soft-bristled toothbrush. Occasionally, a mouthwash will be prescribed to prevent swelling and infection.

If a child's tooth is loose or the mouth is sore, a soft diet is recommended for several days. Sucking on a pacifier or a finger should be restricted for the first 10 days following a tooth injury. Children who have stitches in the mouth should avoid spicy or salty food, popcorn, and straws for approximately one week.

Returning to physical activity — Depending on the type and extent of dental or mouth injury, the child may need to avoid activities with risk of re-injury for days, weeks or months. Such activities include but are not limited to organized sports. If participating in activities with risk for oral injury, mouthguards are also recommended. (See 'Mouthguards' below.)

Orthodontic treatment (braces) — Depending on the type and extent of dental injury, treatment with braces may need to be paused or delayed for weeks or months. This delay permits adequate healing around the roots of the injured teeth.

POTENTIAL COMPLICATIONS — Most children recover completely from mouth and dental injuries without complications. However, prompt treatment and regular follow up will help to ensure the best possible outcome.

In a small number of cases, complications can occur, including:

●Damage to the permanent teeth – This may include discoloration of the tooth, sensitivity to heat and cold, or complete loss of the tooth. Children who have a permanent tooth successfully replaced in the socket will often require root canal treatment.

●Scarring – Wounds to the lip, especially those that cross into the skin, may heal with a scar. Tears of the tongue that do not heal properly can affect speech and swallowing.

●Infection – This may include infection of the teeth, gums, and deep spaces of the neck and chest (which contain vital structures, such as the carotid artery and trachea).

●Excessive bleeding – This complication is not common but may occur if there is injury to a major blood vessel.

PREVENTION — One of the ways that parents can reduce the chances of mouth and dental injuries during recreational and sports activities is to have the child wear a mouthguard.

Mouth injuries can be prevented by teaching children not to put anything except food or drinks in their mouth. It is also important that children learn to sit while eating and drinking, particularly while using a straw or eating food on a stick (eg, popsicles, lollipops). Eating in the car can also lead to injuries, especially if the child is in a seat where an airbag could deploy.

Mouthguards — Mouthguards can significantly reduce the risk of mouth injuries and the incidence of jaw fracture in athletes. The American Dental Association (ADA) and the Academy for Sports Dentistry (ASD) recommend properly fitted mouthguards for a variety of recreational activities and sports that place participants at risk for oral injury (table 1).

There are three main types of mouthguards:

●Stock mouthguards fit loosely over the upper teeth; they are not individually shaped. Stock mouthguards may interfere with breathing and speech because the wearer must hold the upper and lower teeth together to prevent the guard from moving.

●Self-adapted mouthguards, also known as "boil and bite" mouthguards, can be individually shaped. The wearer heats the guard in boiling water and bites into the warmed plastic for a customized fit. Self-adapted mouthguards are moderately priced and usually stay in place. However, they are subject to bite-through problems and are not as strong as custom-made mouthguards over time. Given the quality of available self-adapted mouthguards, they may be the most cost-effective solution to prevent tooth injuries in children who participate in sports.

●Custom-made mouthguards are made by a dentist. The dentist takes an impression of the athlete's mouth, makes a cast and then hen forms plastic around the cast. Custom-made mouthguards provide better protection, are more comfortable, and are more likely to stay in the mouth compared with other models. However, they may be more expensive than some athletes can afford. Self-adapted mouthguards are a reasonable alternative in this case.

Mouthguards should be stored in a plastic protective container. They should be regularly inspected for distortion, bite-through, and tears. They should be rinsed with water before use and washed after each use in cold or lukewarm water. They also may be cleaned with toothpaste and a soft-bristle toothbrush and rinsed with mouthwash. Daily washing minimizes build-up of saliva, bacteria, and debris.

WHERE TO GET MORE INFORMATION — Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Mouth and dental injuries in children (The Basics)
Patient education: Mouth and dental injuries in adults (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Head injury in children and adolescents (Beyond the Basics)
Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)
Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Evaluation and management of dental injuries in children
Evaluation and repair of tongue lacerations
Oropharyngeal trauma in children

The following organizations also provide reliable health information.

●The Nemours Foundation (http://kidshealth.org/en/parents/tooth-sheet.html)

●American Dental Association (https://www.mouthhealthy.org/en/dental-care-concerns/dental-emergencies)

●The Dental Trauma Guide (https://dentaltraumaguide.org/)

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