Evaluation and management of dental injuries in children

INTRODUCTION — 

Nearly one-half of children sustain some type of dental injury during childhood. Many of these injuries are preventable. The injuries that result in the loss of permanent teeth may have long-lasting cosmetic, functional, economic, and psychosocial effects [1-5]. The outcome for a number of dental injuries, which may be uncertain until the permanent dentition is established, is improved by prompt, appropriate treatment and referral.

This topic will cover injuries of the teeth. The anatomy and development of the teeth; intra-oral, lip, and tongue lacerations; and the assessment and management of jaw injuries are discussed separately:

●(See "Anatomy and development of the teeth".)

●(See "Assessment and management of intra-oral lacerations".)

●(See "Assessment and management of lip lacerations".)

●(See "Evaluation and repair of tongue lacerations".)

●(See "Mandibular (jaw) fractures in children" and "Initial evaluation and management of facial trauma in adults", section on 'Mandibular injury'.)

EPIDEMIOLOGY — 

An estimated 30 percent of preschool children suffer injuries to the primary dentition [6]. Dental trauma to the permanent dentition in school-age children is more common in males than females [2,6-9]. These figures underestimate the occurrence of dental trauma because minor trauma is underreported. Thus, a safe assumption is that up to 50 percent of children will sustain a dental injury [10,11]. Dental trauma must not be overlooked as a marker for child abuse. Orofacial injury occurs in as many as 75 percent of abused children [12-15].

The most commonly injured teeth are the maxillary central incisors, followed by the maxillary lateral incisors and the mandibular incisors [2,16-21]. The ability of the upper lip to protect the maxillary teeth is affected by the degree of prominence of the anterior teeth. The normal horizontal distance between the maxillary and mandibular incisors (overjet) is between 1 and 3 mm. Overjets greater than 4 mm increase the likelihood of dental trauma by two to three times (picture 1) [22,23].

Additional risk factors for dental trauma include mobility problems, physical disabilities (eg, cerebral palsy, seizure disorders) [17,24], and the use of fixed orthodontic appliances [25]. The mobility of the incisors in children with localized juvenile periodontitis predisposes them to luxation injuries. (See "Gingivitis and periodontitis in children and adolescents", section on 'Rapidly progressing (high-grade) periodontitis'.)

Falls are the most frequent cause of dental trauma among preschool and school-age children; most falls occur inside the home [11,16,23,26,27]. Sports-related injuries and altercations are more common etiologies in adolescents [4,17,27,28]. (See "Prevention of falls and fall-related injuries in children", section on 'General epidemiology'.)

TERMINOLOGY — 

Dental injuries in children consist of:

●Luxations – Luxation refers to the displacement or increased mobility of a tooth and includes total avulsion (tooth knocked out of the socket). Displacement may be superior, inferior, anterior, posterior, or lateral (table 1).

●Fractures – Fractures may involve the crown or root of the tooth (figure 1). Crown fractures are further classified as:

•Uncomplicated (fracture of the enamel only or enamel and dentin)

•Complicated (pulp exposed)

INITIAL EVALUATION — 

A rapid overview provides the essential historical elements and physical examination findings (table 2).

Stabilization — Most children with dental injuries are awake and alert and stable upon presentation. Children with dental trauma caused by high-force blunt trauma or assault warrant careful examination of the head and neck to identify any serious head trauma or cervical spine injury and stabilization of any other life-threatening injuries prior to treatment of their dental injuries. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Avulsed permanent teeth require emergency replantation when possible and proper storage of tooth when unable to replant immediately (see 'Permanent tooth avulsion' below). To prevent aspiration, the clinician should promptly remove very loose primary teeth in young children.

History — Key historical information includes:

●Mechanism of injury – Most dental injuries in children arise from isolated trauma to the face caused by falls or a direct blow during sports or assaults. High-force injuries to the teeth are associated with the potential for head and neck trauma. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Mechanism of injury' and "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation".)

Serious dental injuries without a plausible explanation are suspicious for child abuse, especially in nonambulatory children. (See "Physical child abuse: Recognition", section on 'Oral or nasal injuries'.)

●Time of injury – The time that has elapsed since the injury took place affects the treatment and, in most cases, the prognosis, especially for children with permanent tooth avulsions [7,10]. (See 'Permanent tooth avulsion' below.)

●Associated symptoms – A history of loss of consciousness, altered mental status, visual disturbance, or other neurologic symptoms after the trauma raises concern for clinically important traumatic brain injury. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History'.)

Neck pain may indicate cervical spine injury. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Jaw pain or pain on opening or closing the mouth suggests a jaw fracture. (See "Mandibular (jaw) fractures in children".)

●Symptoms of serious dental injury – Positive responses to any of the following questions suggest an injury requiring prompt dental referral (see 'Permanent tooth avulsion' below):

•Does the child have spontaneous pain in any teeth as a result of the injury? Such pain indicates pulp exposure or inflammation.

•Are any of the teeth tender to touch or the pressure of eating? Such tenderness indicates periodontal ligament damage or displacement.

•Are any of the teeth sensitive to hot or cold? Such sensitivity indicates pulp exposure or inflammation.

•Is there a change in the child's bite or occlusion? Such a change indicates luxation, jaw fracture, or facial fracture. Oral surgery consultation may also be needed.

●Past medical history – Important components of the past medical history include:

•Cardiac conditions warranting antibiotic prophylaxis for bacterial endocarditis (algorithm 1) (see "Prevention of endocarditis: Antibiotic prophylaxis and other measures")

•Current medications

•Drug allergies

•Status of tetanus immunization

Physical examination

Oral examination — The oral examination should assess for signs of:

●Tooth injury – Important findings include the affected teeth including any that are loose, displaced, or missing (figure 2 and figure 3). The clinician should also determine if there is tooth tenderness by tapping them with a tongue blade and having the patient bite down on a tongue blade positioned along the molars. (See 'Specific dental injuries' below.)

●Jaw fracture – Important findings include tenderness over the mandible or temporomandibular joint, trismus, malocclusion, and pain or difficulty with opening or closing the mouth.

●Lip, tongue, and intraoral laceration – The presence of soft tissue injury (lip, intraoral, tongue, and palatal lacerations or bruising) (see "Assessment and management of lip lacerations" and "Assessment and management of intra-oral lacerations" and "Oropharyngeal trauma in children")

Primary versus permanent tooth — It is essential to distinguish between injuries to primary (figure 2) or permanent teeth (figure 3), especially after a dental avulsion. The type of tooth can be determined from the appearance of the tooth and the child's age (figure 4) [21]:

●Permanent incisors are only scalloped during eruption and then they wear to a smooth edge

●Primary teeth are much smaller than secondary teeth

●All teeth are primary for most children <5 years old

●Permanent incisors usually erupt around 6 to 7 years of age

●Mixed dentition (primary and permanent teeth) are present in children 6 to 12 years of age

●All teeth are permanent in most children by 13 years of age

Parental reports of primary teeth shedding also provide important information in children who are at the transitional age for primary and permanent teeth (ie, age 6 to 12).

Specific dental injuries — Clinical findings of specific injuries are as follows:

●Tooth avulsion – Patients with a tooth avulsion will have an empty socket. The tooth is completely displaced from the alveolar ridge; the periodontal ligament is severed, and fracture of the alveolus may occur. The clinician should examine the avulsed tooth to determine if it is a primary (baby) tooth or a permanent tooth. (See 'Primary versus permanent tooth' above.)

Permanent teeth require emergency replantation, ideally within 15 minutes. If replantation is not possible, the tooth should be stored in a suitable solution and emergency dental care obtained. The clinician should not replant avulsed primary teeth. (See 'Permanent tooth avulsion' below.)

If the avulsed tooth is missing, the clinician should assess for any asymmetric lung findings (eg, rales, rhonchi, or decreased breath sounds) that suggest aspiration. In addition, dental radiographs may be necessary to identify a root fracture with a missing crown.

●Other tooth luxation — Patients with luxation injuries have damage to the periodontal ligament or the alveolar bone and are suspected based on the following findings (table 1):

•Concussion – The tooth is neither loose nor displaced; it may be tender with the pressure of biting because of inflammation of the periodontal ligament.

•Subluxation – The tooth is loose, but not displaced from its socket; the periodontal ligament fibers are damaged and inflamed.

•Intrusion – The tooth is driven into the socket, compressing the periodontal ligament and fracturing the alveolar socket. Intruded primary teeth may damage the permanent tooth bud.

•Extrusion – The tooth is centrally dislocated out of its socket; the periodontal ligament is lacerated and inflamed (picture 2).

•Lateral luxation – The tooth is displaced anteriorly, posteriorly, or laterally; the periodontal ligament is lacerated, and the supporting bone is fractured (picture 3). Malocclusion may occur.

●Dental fracture — Findings of dental fractures include (figure 1) [21,29]:

•Infraction – Infracted teeth are intact but display surface cracks on the enamel, which are best appreciated by shining a bright light onto the crown of the tooth.

•Uncomplicated crown fracture – Uncomplicated crown fractures consist of two types:

-Enamel only – The affected tooth is chipped (picture 4). Pain is typically absent but may be elicited with manipulation.

-Enamel and dentin – The chipped tooth has exposed dentin. The tooth is sensitive to touch and temperature.

•Complicated crown fracture – Complicated crown fractures have associated exposure of the pulp (picture 5). These injuries have an increased risk of infection.

•Root fracture – Fractures of the root may or may not also involve the crown (crown-root fracture (picture 6)). If the crown is not involved, a root fracture is suggested by mobility of the crown. Root fractures may be horizontal, vertical, or oblique. Dental radiographs are necessary to confirm a root fracture.

•Alveolar fracture – Fracture of the alveolus causes dislocation of multiple teeth that move together with palpation.

Associated injuries (child abuse) — In addition to a detailed oral examination, stable children with dental injuries should have an evaluation for associated injuries to the head, neck, and jaw as well as a general assessment of likely injuries as needed based on the trauma mechanism as discussed separately. (See "Approach to the initially stable child with blunt or penetrating injury".)

Children with dental trauma should also be evaluated for findings suggestive of child abuse (table 3) including (see "Physical child abuse: Recognition", section on 'Red flag physical findings'):

●Bruises in various stages of healing that indicate multiple traumatic incidents

●Bruising of the labial sulcus or torn upper labial frenula in nonambulatory children

●Bruising of the soft tissues of the cheek or neck (accidental falls are more likely to bruise the forehead or chin)

●Human hand marks or pinch marks on the cheeks and ears

Clinical photographs — Whenever feasible, clinical photographs should be part of routine documentation of traumatic injuries to the teeth [30]. Good quality clinical images taken at the initial injury and uploaded into the electronic medical record have great value in diagnosis and documentation of findings. Such images will serve as a baseline to monitor healing at future follow-up visits. Clinical photographs can also be used for consultation with other specialists via telemedicine. When families have pictures of children taken prior to traumatic injury, those images can also be added to the patient's record to serve as a reference in diagnosing the type and severity of injuries to the teeth.

DIAGNOSIS — 

Dental injuries are suspected based on clinical findings (figure 1 and table 1) (see 'Physical examination' above). In children with dental pain, fracture, luxation, or discoloration after an injury, dental radiographs confirm the diagnosis and assess the severity of bony or root fractures or permanent tooth bud displacement [21,31,32]. In addition, these radiographs record the baseline status of the alveolus around the dental roots. Depending upon the severity of the injury, radiographic follow-up may be indicated at monthly intervals to monitor pulpal necrosis and/or root resorption.

Computed tomography (CT) and, in cooperative patients, panoramic radiographs (Panorex) are necessary to assess for an associated jaw fracture in patients with dental trauma and any one of the following findings (see "Mandibular (jaw) fractures in children", section on 'Clinical features' and "Mandibular (jaw) fractures in children", section on 'Imaging'):

●Jaw or temporomandibular pain or tenderness

●Malocclusion

●Malalignment or mobility of mandibular segments

●Difficulty opening and/or pain with opening and closing the mouth

●Numbness of the lower lip and chin

●Ear pain (high condylar fractures)

INITIAL MANAGEMENT

Permanent tooth avulsion — Avulsion injuries of permanent teeth are true dental emergencies [30,33]. Management of these injuries focuses on immediate replantation whenever possible and, when replantation is not possible, maintaining the vitality of the periodontal ligament.

Replantation — Important considerations when replanting a permanent tooth include (table 2) [30,33]:

●Confirm permanent tooth avulsion – Before replantation, carefully examine the tooth to be sure that it is a permanent tooth. Do not replant primary (baby) teeth. (See 'Primary versus permanent tooth' above.)

●Timing – Once the clinician or other capable person (eg, injured child, parent/primary caregiver, teacher, or coach) has determined that the child does not have any more serious injuries (eg, head trauma or cervical spine injury) that require priority over replacing the tooth, they should immediately replant the permanent tooth, ideally within 15 minutes of the injury. If the parent or primary caregiver calls their primary care provider first, the clinician should guide them through the procedure. For patients being evaluated for significant trauma in a pre-hospital or emergency department setting, delay replantation if the child does not have a normal mental status or cannot be upright in the bed.

The prognosis for survival of an avulsed permanent tooth is inversely related to the amount of time spent out of the oral cavity (85 to 97 percent at five minutes and near 0 percent at one hour) [7,34,35]. In one study, a decrease in the number of periodontal ligament progenitor cells was found after an extra-alveolar duration of only 15 minutes [36]. The decreased capacity to reproduce cells may explain in part the impaired survival with delayed replantation [37].

●Hold by the crown – Handle the tooth carefully by the crown to prevent damage to the periodontal ligament (picture 7).

●Gently clean – Remove debris by gently rinsing with milk, saline, or the patient's saliva; do not attempt to sterilize or scrub the tooth.

●Replant the tooth – Manually replant the tooth in the socket (picture 8). The tooth will usually fit into the socket best in its original orientation. However, if that cannot be determined, it is still beneficial to replant the tooth.

If a large clot is making replanting the tooth difficult, gently remove it by irrigation or gentle wiping.

●Keep in place – Have the child hold the tooth in place or bite on a gauze pad, clean napkin, or clean towel.

●Ensure emergency dental treatment – Ensure the child receives emergency treatment by a dentist or other dental professional (eg, oral maxillo-facial surgeon) with pediatric expertise.

●Tetanus prophylaxis — All children who have avulsed teeth should receive tetanus prophylaxis, as needed (table 4). (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules' and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Wound management'.)

●Prophylactic antibiotics – We do not routinely prescribe prophylactic antibiotics in patients with permanent tooth avulsion, although it is reasonable to do so, especially in patients with soft tissue wounds contaminated by dirt or debris. If used, the antibiotic should provide coverage for oral bacteria. Options include oral doxycycline, penicillin, amoxicillin, or cephalexin. Doxycycline can be administered for short durations (ie, 21 days or less) with a low risk of dental staining regardless of the patient's age [38].

Evidence that prophylactic antibiotics improve clinical outcomes of avulsed teeth is lacking, but their use is mentioned as optional by the International Association of Dental Traumatology [30]. In animal models, antibiotic therapy has been shown to decrease the extent of root resorption. However, no effect on pulpal necrosis or periodontal ligament has been demonstrated [34,35,39-41].

Replantation not possible — Injury to the supporting structures including gums and alveolar bone or lack of patient cooperation may preclude immediate replantation. If immediate replantation is not possible, important actions include (table 2):

●Place the tooth in a storage solution – As soon as possible, place the tooth in a storage solution to maintain the viability of the periodontal ligament on the tooth's surface [42-44]. We suggest cold milk, oral rehydration solution (eg, Ricelyte or Pedialyte), or a cell culture medium (Hank's balanced salt solution or Viaspan) used in avulsed tooth preservation kits. Cold milk is usually most readily available [44]. If milk or specialized mediums are not available, have the child spit into a container or place the tooth in saline instead. Do not have the child hold the tooth in their mouth because it may be further traumatized, swallowed, or aspirated. Avoid tap water because its low osmolality rapidly and irreversibly damages the periodontal ligament [37,45].

●Keep the tooth and storage solution chilled – Place the tooth in a container of milk or cell culture medium with a lid. Then pack the container in ice to keep the tooth cold without diluting or lowering the osmolality of the storage solution [36,37,45].

●Ensure emergency dental treatment – Ensure the child receives emergency treatment by a dentist or other dental professional (eg, oral maxillo-facial surgeon) with pediatric expertise.

Storage solutions are rated by their ability to preserve the vitality of the periodontal ligament cells [42]. Cold, pasteurized milk is the most recommended storage medium for avulsed permanent teeth because it is more commonly available, does not contain bacteria, and has acceptable properties [30,46]. Milk's osmolality better maintains the periodontal ligament vitality compared with saline solution. Because milk is readily available, it minimizes the time that the avulsed tooth remains dry. Cell culture media that may be purchased in an avulsed tooth preservation system (eg, Save-A-Tooth™, EMT Tooth Saver™) are acceptable alternatives to milk [44]. Other media also demonstrating efficacy in small laboratory studies include propolis, oral rehydration salt solutions, rice water, and cling film [42].

Other dental injuries — Initial management for patients with injuries other than avulsion of a permanent tooth includes:

●Remove dangling primary (baby) teeth – Dangling primary teeth pose an aspiration risk and should undergo removal as soon as possible. After placing a bite guard as needed, the clinician should grasp the tooth with clean or sterile gauze and remove the tooth.

●Alveolar fracture – Alveolar fractures indicated by mobility or dislocation of multiple teeth require emergency referral to a dentist or oral surgeon for alignment and stabilization of the segment with a splint.

●Pain control – Dental pain usually responds to the application of a cold pack and oral ibuprofen (acetaminophen for patients with contraindications to ibuprofen). Alternating ibuprofen with acetaminophen every 3 hours is effective for most patients with more severe pain [47,48]. Opioids are rarely necessary unless the patient has associated facial or jaw fractures.

●Tetanus prophylaxis – Children with intraoral lacerations, other contaminated wounds, or markedly luxated teeth should receive tetanus prophylaxis, as needed (table 4). (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules' and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Wound management'.)

●Dental referral or consultation – Prior experience with dental trauma is the most important criterion for identifying a consultant. Pediatric experience is also preferred for children <13 years old. Patients with the following injuries should have urgent referral as soon as possible or the next day at the latest to a dentist or clinician with similar expertise (eg, pediatric dentist, oral surgeon, or endodontist) for definitive care [49]:

•Fractured teeth when dental pulp is exposed (bleeding from central core of the tooth)

•Suspected dental root or alveolar fracture

•Suspected jaw fracture (posterior tooth fracture, jaw tenderness, and/or malocclusion)

•Lateral or extrusive luxation (displaced teeth) interfering with bite or extrusion >3 mm

•Intruded primary teeth

•Fractured permanent teeth (store tooth fragments in tap water to prevent desiccation and send for reattachment)

Dental fractures with injury to the soft tissues, including the lips, frenula, tongue, oral mucosa, and palate may also warrant referral for dental radiography if embedded tooth fragments are suspected [7,50].

When communicating with a dentist, secure transmission of a digital photograph (with parental or primary caregiver consent) can provide a clear and rapid means of describing the injury.

Definitive dental management by type of injury is provided below. (See 'Primary tooth injury' below and 'Permanent tooth injury' below.)

Child protection — Children with findings suspicious for child abuse should undergo diagnostic evaluation in consultation with a multidisciplinary child abuse team. The clinician should also complete mandatory reporting requirements to Child Protection Services according to legal requirements in their region. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

Antibiotic prophylaxis against bacterial endocarditis — Children who are at high risk for developing subacute bacterial endocarditis should receive antimicrobial prophylaxis for dental injuries that induce bacteremia (eg, intrusions, extrusions, lateral luxations, and avulsions) as described in the algorithm (algorithm 1). (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

DEFINITIVE CARE

Primary tooth injury — The table provides definitive management for injuries to primary teeth (table 5).

●Avulsion – Avulsed primary teeth should not be replanted because of the potential for injury to the developing tooth bud [21,31]. The tooth should be examined to ensure the entire crown and root are present [51]. However, if it is not certain whether the tooth is primary or permanent, the tooth should be gently replanted and the patient emergently evaluated by a dentist. (See 'Replantation' above.)

In patients for whom the avulsed primary tooth cannot be located, obtaining radiographs of the head, chest, or abdomen may be indicated to determine if the tooth was ingested or aspirated [32].

A fixed or removable prosthesis can be made for the child if concern exists regarding appearance. However, the early loss of primary anterior teeth does not irreversibly affect speech or the position of the permanent teeth [32,52,53].

●Other luxation injuries – Luxation of the incisors is the most common primary tooth injury (table 1) [21,49,54].

The management of these injuries focuses on the prevention of damage to the permanent teeth because the secondary anterior teeth develop in close proximity to the apices of the primary incisors as follows:

•Extrusion – Children who have severely displaced or loose extruded anterior primary teeth (>3 mm) should be referred to a dentist for immediate care (picture 2). Injured primary teeth may be removed manually by the primary care provider by grasping the tooth with dry gauze and pulling if a dentist is not available immediately. Removal of the primary tooth is essential when it poses an aspiration risk [39,55,56]. This situation may be of particular concern for children who are fed by bottle [51].

If the extrusion is ≤3 mm, then gentle repositioning may be performed [21].

•Intrusion – Intruded primary teeth warrant urgent evaluation as soon as possible or within the next day at the latest by a dentist and intraoral radiographs to assess whether the underlying permanent tooth bud is involved. If the permanent tooth bud is involved, then extraction of the primary tooth is necessary.

Intruded primary teeth that do not involve the permanent tooth bud will typically re-erupt spontaneously and require no further treatment [21,55,56]. Routine dental follow-up and observation of intruded teeth are necessary to assess for potential damage to or interference with eruption of underlying permanent teeth.

•Lateral luxation – Lateral tooth displacement that does not interfere with the bite (ie, permits full closure with normal interdigitation of the molars and the ability to chew food) may be observed [21]. In most instances, spontaneous repositioning will take place.

Lateral luxation that interferes with biting warrants repositioning, extraction, or urgent referral to a dentist [21,55]. Extraction of the primary tooth is appropriate if it is close to shedding.

•Concussion or subluxation – Pain with chewing or percussion is the sole clinical finding of concussion injuries [51]. Subluxation injuries typically present with increased mobility and gingival bleeding at the base of the crown. For both injuries, a soft diet should be provided until the child is able to tolerate his or her normal diet without pain. Routine dental follow-up is necessary to observe for the development of pulpal necrosis [32].

Tooth discoloration or a localized gum abscess or boil (parulis) suggests pulpal necrosis [21]. Patients with these findings should be referred to a dentist within a few days. (See 'Complications' below.)

●Fractures – Proper care of primary tooth fractures requires accurate identification of the injury using clinical examination. When root or alveolar fractures are suspected, dental consultation or referral for radiography is indicated.

Management by dentoalveolar injury classification (figure 1) is as follows [21,31,32,49,51]:

•Infraction – Cracks of primary teeth do not require urgent treatment. Dental referral within a few days for application of a dental sealant to prevent staining is appropriate for large obvious cracks. Otherwise, routine dental follow-up is necessary to monitor for pulpal necrosis which may present with gray tooth discoloration or a localized gum abscess or boil (parulis). (See 'Complications' below.)

•Crown fracture – Crown fractures are managed according to type as follows:

-Uncomplicated – Children with crown fractures that only involve the enamel do not require specific treatment unless there is a sharp or rough edge that poses a risk of injury to the oral mucosa or gums. In this instance, referral to a dentist within a few days is appropriate for smoothing of the fracture site.

If the fracture also exposes dentin, then referral to a dentist within a few days for potential restoration is warranted to prevent infection.

Once treated, all uncomplicated crown fractures require routine dental follow-up and monitoring for possible pulpal necrosis.

-Complicated – Complicated fractures (fractures with pulp exposure) require prompt, same-day dental referral for pulpotomy or pulpectomy followed by restoration or, if the child cannot tolerate these procedures, extraction. Extraction is also indicated if the crown fracture extends into the root. Restored complicated crown fractures also need routine dental follow-up and monitoring for pulpal necrosis.

•Root fracture – Root fractures of the primary teeth are typically suspected based upon excessive tooth mobility or the presence of a complicated crown fracture. They are rare primary tooth injuries. If there is concern that a portion of the tooth may be extruded and aspirated, then emergent dental consultation or referral is indicated. Otherwise, evaluation within a few days is appropriate.

The approach depends upon the location of the fracture as determined by dental radiography as follows:

-Apical one-third – The tooth can be left in place if the fracture is in the apical one-third (near the dental root) and the crown segment is stable.

-Middle and coronal root fractures – Teeth with roots fractured in the middle or coronal one-third (towards the crown) should be extracted because the crown segment is unstable and the fracture site may be contaminated with bacteria from saliva and become infected. The root portion of the fracture is sometimes left if attempts at extraction will damage the underlying permanent tooth. In these patients, the remaining root portion will typically resorb.

Permanent tooth injury — The table provides definitive management of permanent teeth injuries (table 6).

●Avulsions – Definitive management of replanted permanent teeth usually includes splinting and, for most patients, a root canal 7 to 10 days after replantation [21,30,36,37,45].

●Other luxation injuries – There are no high-quality studies that address the optimal approach to luxation injuries in permanent teeth (table 1) [57]. Dental treatment is based upon consensus and clinical experience as follows [21]:

•Concussion – Concussion injuries in the permanent teeth typically warrant elective dental follow-up within a few days for radiographs to document the baseline periapical condition. Subsequently, the clinician and dentist should provide ongoing monitoring for signs of pulpal necrosis as part of routine care [58].

•Subluxation – Subluxation injuries must be followed closely because the prognosis for survival of pulp in mature permanent teeth is significantly worse than in primary teeth. Initial dental care within a few days of injury consists of dental radiographs to assess for root fracture. Radiographic monitoring by a dentist at four weeks is also recommended to rule out pulp necrosis and inflammatory resorption [7].

•Extrusion, lateral luxation, and intrusion – Luxation injuries in which the teeth are extruded or laterally displaced with malocclusion typically are reduced promptly so that the tooth is returned to its normal position and does not interfere with occlusion [21,31,58]. Reduction may require local anesthesia, splinting, and/or gingival suturing, and children with these injuries receive emergency dental care as the best outcome occurs if significant luxation is reduced and splinted within two hours [33]. Subsequent root canal treatment may also be necessary depending upon the maturity of the dental root [21].

Intrusion injuries without malocclusion may require surgical or orthodontic repositioning depending upon the degree of intrusion and maturity of the root apex [31,58]. Prompt dental evaluation is typically needed for these injuries.

●Fractures – Fractures of the permanent teeth (figure 1) are managed according to the type of fracture as follows [21,33]:

•Infractions – Cracking of permanent teeth may be electively treated with a sealant to prevent staining of the fracture line.

•Crown fractures – Management of crown fractures is determined by the specific injury as follows:

-Uncomplicated – Uncomplicated crown fractures warrant elective referral within a few days for dental radiographs to exclude a root fracture. Smooth, uncomplicated fractures only involving the enamel do not require further treatment. In patients with a rough edge, smoothing by a dentist is indicated to prevent soft tissue injury.

In addition to the management above, crown fractures with dentin exposure can be repaired by bonding the tooth fragment, if available, or by dental restoration. Timing for dental referral depends upon the degree of patient discomfort but should typically occur within a few days.

Although animal studies have shown that crown fragments may be reattached up to 90 days after the injury [59], guidelines recommend prompt restoration of the lost crown structure or covering the fracture with temporary filling material to improve outcomes. The child should be referred as soon as possible, ideally within seven days, to optimize comfort and functional and cosmetic outcomes [60]. Tooth fragments from crown fractures can be reattached if they are retrieved and kept properly hydrated [61,62]. Special solutions are not necessary because they have no fibroblasts to keep viable. However, the fragment should be kept hydrated in tap water because desiccation occurs which can hinder the bond. The fractured tooth can also be restored with composite resin materials if the fragment is not retrieved [59,63]. Bonded fragments are not as retentive as a composite resin restoration, and re-fracture of the tooth is more likely.

Patients with uncomplicated crown fractures require routine dental follow-up and ongoing monitoring of symptoms and signs of pulpal necrosis (spontaneous pain, gray tooth discoloration or a localized gum abscess or boil [parulis]).

-Complicated – Patients with an exposed pulp warrant prompt referral to a dentist for pulp therapy that day. Teeth with mature roots should subsequently undergo root canal treatment.

Fractures that involve the root ("crown-root fractures" (picture 6)) are managed by removal of the crown fragment followed by restoration of the root or dental prosthesis depending upon the degree of injury to the root.

•Root fractures – Permanent tooth root fractures typically affect permanent incisors and should be suspected when there is tooth mobility after an injury. Prompt referral to a dentist for radiography is indicated. Apical root fractures without increased mobility usually do not require specific treatment (image 1). Fractures closer to the crown of the tooth typically undergo splinting for several weeks or months (image 2). However, if crown mobility remains after splinting, then crown removal followed by root preservation therapy is generally necessary.

AFTERCARE — 

Aftercare for children with dental injuries includes:

●Pain management – Children frequently have moderate pain after dental avulsion and complicated crown fractures or face or jaw contusions related to the trauma itself. In these patients, pain management consists of [47,48]:

•Cold therapy (ice pack) applied to the cheek or jaw for 20 to 30 minutes every two to four hours, as needed

•Ibuprofen (acetaminophen for patients with contraindications to ibuprofen) as first-line

•Acetaminophen and ibuprofen for breakthrough pain

The clinician should avoid prescribing opioid medications in these patients. Individuals whose pain is not controlled by the above measures require reevaluation.

●Soft diet – Caregivers of children with tooth injuries should provide a soft diet for up to 10 days and limit sucking (pacifier or digit) as much as possible [21].

●Oral hygiene – Maintenance of oral hygiene, consisting of thorough brushing with a soft-bristled toothbrush, is essential. Flossing should be avoided until healing has occurred.

Patients with luxation injuries of permanent teeth, including avulsions, should also be prescribed chlorhexidine gluconate 0.12 percent (oral) mouth rinse.

●Anticipatory guidance – Parents or primary caregivers should monitor for signs of infection such as fever, increased pain, or facial swelling and seek urgent dental care if they occur.

They should also watch for signs of pulpal necrosis (tooth discoloration or localized gum abscess or boil [parulis]) following injuries to primary teeth and as needed, for injuries to permanent teeth. (See 'Permanent tooth injury' above.)

Due to potential complications, it is important that traumatized teeth be monitored for healing after injury. Some complications, such as pulp necrosis or root resorption, take place long after the initial injury. Therefore, it is imperative that clinicians educate caregivers on the importance of adherence to the recommended follow-up regimen as detailed above to optimize treatment outcomes. Monitoring traumatized teeth may be required for months to years, depending on the type of injury [30,58,64].

COMPLICATIONS — 

The major complication of injury to the primary teeth is injury to the developing secondary teeth. Intrusion injuries or periapical infection caused by necrotic pulp tissue can irreversibly damage the permanent tooth [19,52,65]. Enamel hypoplasia may occur if the injury occurs between birth and four years of age, the period of calcification of the permanent tooth crown (picture 9). Injury to the primary teeth also can alter the eruption path of the developing tooth [66,67].

The major complication of dental trauma to the permanent dentition is devitalization of the periodontal ligament caused by laceration and/or desiccation that occurs with luxation injuries. The prognosis for survival of the tooth in untreated luxation injuries to the periodontal ligament is poor. Necrotic, infected pulp tissue in the root canal may activate an inflammatory resorptive process that destroys the root in a matter of weeks [34,68].

Another complication of dental trauma to the permanent dentition is devitalization of the dental pulp. Even minor blows may disrupt the thin strand of pulp tissue at the root apex, which is the only neurovascular supply to the permanent teeth. Ischemic necrosis of the pulp, caused by disruption of the neurovascular supply, may be indicated by an abscess in the oral vestibule opposite the tooth root (parulis) and/or by color change in the tooth crown (picture 10). Depending upon the pathologic process, the discoloration can range from pink to yellow to gray or black [69-71]. Discoloration of the teeth should prompt referral to a pediatric dentist for evaluation and treatment, because devitalized teeth may abscess and/or undergo inflammatory resorption of the roots [7,72].

Fractures of the tooth crown may expose the pulp tissue (picture 5) and lead to necrosis of the pulp. Fractures of the enamel and/or dentin can cause inflammation of the pulp if the dentin tubules provide a port for bacteria or thermal or chemical irritants [7]. Uncomplicated fractures also can cause sensitivity to heat and cold, and changes in mastication.

INJURY PREVENTION — 

Prevention of dental injury occurs at several levels (see 'Epidemiology' above and "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'):

●Primary prevention involves decreasing the incidence of the common mechanisms of injury: falls, child abuse, and physical altercations.

●Secondary prevention involves regular dental care and maintenance, treatment of children with excessive overjet, and the use of mouth protection during recreation and sports activities associated with a high risk of dental trauma.

●Tertiary prevention involves education of parents/primary caregivers, teachers, and coaches regarding the proper management of avulsed permanent teeth [30].

Mouthguards — 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 [73]. Pediatric care providers, dentists, and coaches should encourage all children who engage in contact sports to wear mouthguards [74,75].

The criteria for a properly fitted mouthguard include [76]:

●Adequate thickness to reduce the force of impact

●Will not be dislodged with impact (ie, retentive)

●Permits speech as necessary to the demands of the athlete

●Constructed from material that meets US Food and Drug Administration approval

●Will last through one season of play

Three types of mouthguards are:

●Stock mouthguards – Stock mouthguards fit loosely over the upper teeth; they are not individually shaped. The use of stock mouthguards may impair breathing and speech because the wearer must keep the teeth in contact to prevent the guard from being displaced [7].

●Self-adapted mouthguards – Self-adapted mouthguards, also known as "boil and bite" thermoplastic 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 well retained. However, they are subject to bite-through problems and lack structural integrity over time [77].

●Custom mouthguards – Custom-made mouthguards are made by forming plastic on a stone model of an impression of the athlete's mouth that is taken by a dentist. Custom-made mouthguards provide better protection against projectile impact [78-80], are more comfortable, and are more likely to be retained than are the other models [79,81,82]. However, they may be more expensive than some athletes can afford, and in the growing child may require annual replacement. Self-adapted mouthguards are a reasonable alternative for these athletes.

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 insertion and washed after each use in cold or lukewarm water. They also may be cleaned with denture cleaners or, alternatively, toothpaste and a soft-bristle toothbrush followed by rinsing with a mouthwash. Daily washing minimizes the build-up of saliva, bacteria, and debris [77].

Evidence supports the use of mouthguards to prevent oral injuries in athletes. A pilot study compared the proportion of dental injuries in football players who were required to wear mouthguards and basketball players who were not [83]. Dental injuries accounted for less than 1 percent of the injuries in football players and 34 percent of the injuries in basketball players.

Orofacial trauma and the use of mouthguards were assessed in a survey of 1020 male high school basketball players [84]. Orofacial injuries occurred seven times more often among players who did not wear mouth protection. The overall incidence of orofacial injury was 31 percent but decreased to less than 1 percent in players who wore mouthguards. Similar results were reported in a study of female basketball players [74].

Despite the evidence that supports use of mouthguards for the prevention of orofacial trauma, mouth protection is not mandated universally for child athletes [25,85,86]. Use of mouthguards is mandated only for amateur participants in boxing, football, ice hockey, men's lacrosse, and women's field hockey, as well as for professional boxers [87].

Education — In addition to recommending that mouth protection be worn during sports play, patients, parents/primary caregivers, teachers, and coaches should be educated regarding the proper management of avulsed secondary teeth. Advance knowledge of and preparation for this type of injury may help to prevent long-term complications from loss of permanent teeth [88]. (See 'Permanent tooth avulsion' above.)

ADDITIONAL RESOURCES — 

The International Association for Dental Traumatology (IADT) develops and publishes recommended guidelines for treatment of traumatic injuries to the teeth. A detailed guide for the assessment and management of dental trauma is available at dentaltraumaguide.org.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they 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. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of participants by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Mouth and dental injuries in children (The Basics)")

●Beyond the Basics topic (see "Patient education: Mouth and dental injuries in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Terminology – Dental injuries in children include (see 'Terminology' above):

•Luxation – Luxation refers to the displacement or increased mobility of a tooth and includes total avulsion. Displacement may be superior, inferior, anterior, posterior, or lateral (table 1).

•Fracture – A fracture may involve the crown or root of the tooth (figure 1). Crown fractures are further classified as:

-Uncomplicated (fracture of the enamel only or enamel and dentin)

-Complicated (pulp exposed)

●Evaluation and dental consultation

•History and physical examination – Most children with dental injuries are awake, alert, and stable upon presentation. The rapid overview (table 2) provides key historical information and physical findings. When communicating with a dentist, secure transmission of a digital photograph (with parental or primary caregiver consent) can provide a clear and rapid means of describing the injury. (See 'Initial evaluation' above and 'Permanent tooth avulsion' above.)

•Primary (baby) versus permanent tooth – It is essential to distinguish between injuries to primary (figure 2) or permanent teeth (figure 3). Permanent incisors usually erupt around 6 to 7 years of age, are larger than primary teeth, and are scalloped during and shortly after eruption. In most children, all teeth are permanent by 13 years of age (figure 4). Parental reports of primary teeth shedding also provide important information in children who are in the transitional period for primary and permanent teeth (ie, age 6 to 12). (See 'Primary versus permanent tooth' above.)

•Signs of child abuse – In addition to a detailed oral examination, the clinician should look for sentinel findings suggestive of child abuse (table 3). (See 'Associated injuries (child abuse)' above and "Physical child abuse: Recognition", section on 'Red flag physical findings'.)

●Diagnosis – Dental injuries are suspected based on clinical findings. In children with dental pain, fracture (figure 1 and picture 4 and picture 5), luxation (table 1 and picture 2 and picture 3), or discoloration after an injury, dental radiographs confirm the diagnosis and assess the severity of fractures or, in patients with primary tooth intrusion, permanent tooth bud displacement. (See 'History' above and 'Physical examination' above.)

Computed tomography (CT) and, in cooperative patients, panoramic radiographs (Panorex) are necessary to assess for an associated jaw fracture in patients with dental trauma and suggestive findings as described separately. (See "Mandibular (jaw) fractures in children".)

●Initial management – Important emergency care for physicians or other clinicians to give prior to definitive care by a dentist or oral surgeon is provided in the rapid overview (table 2) and includes:

•Pain control – Apply a cold pack and give oral ibuprofen (acetaminophen for patients with contraindications to ibuprofen). Opioids are rarely necessary unless the patient has associated facial or jaw fractures.

•Avulsed permanent tooth – The first capable person (injured child, parent or primary caregiver, teacher, or coach) should replant avulsed permanent teeth immediately (ideally within 15 minutes) (picture 8). The child should then receive emergency dental care. (See 'Replantation' above.)

If immediate replantation is not possible, place the avulsed tooth in cold milk or cell culture media used in tooth preservation kits (eg, Hank's balanced salt solution or Viaspan) as soon as possible after injury. Saliva or saline are acceptable to use if preferred solutions are not available. Do not use tap water or store the tooth in the child's mouth. (See 'Replantation not possible' above.)

Pack the tooth in a watertight container, place it on ice, and transport the patient and tooth to the nearest available site for emergency dental care. For patients with an isolated tooth avulsion without other serious injuries, a dental or oral surgery office may provide more timely treatment than an emergency department.  

•Avulsed primary (baby) tooth – Do not replant avulsed primary teeth. (See 'Primary tooth injury' above.)

•Loose primary tooth – Remove severely displaced or loose anterior primary teeth that pose an aspiration risk. (See 'Primary tooth injury' above.)

•Permanent tooth extrusion >3 mm or other luxation with malocclusion – Arrange emergency referral to a dentist or oral surgeon for repositioning and splinting.

•Alveolar or jaw fractures – Patients with alveolar fractures (indicated by mobility or dislocation of multiple teeth) or suspected jaw fractures by physical examination require emergency referral to a dentist or oral surgeon for alignment and stabilization. (See 'Specific dental injuries' above and "Mandibular (jaw) fractures in children".)

•Child protection — Children with findings suspicious for child abuse should undergo diagnostic evaluation in consultation with a multidisciplinary child abuse team. The clinician should also complete mandatory reporting requirements to Child Protection Services according to legal requirements in their region. (See "Physical child abuse: Diagnostic evaluation and management" and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

•Tetanus prophylaxis – Children with dental trauma and associated intraoral lacerations, other contaminated wounds, or markedly luxated teeth should receive tetanus prophylaxis, as needed (table 4). (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules' and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Wound management'.)

•Antibiotic prophylaxis against bacterial endocarditis — Children who are at high risk for developing subacute bacterial endocarditis should receive antimicrobial prophylaxis for dental injuries that induce bacteremia (eg, intrusions, extrusions, lateral luxations, and avulsions) as described in the algorithm (algorithm 1). (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

●Definitive care – The tables provide definitive dental management of injuries to primary teeth (table 5) and permanent teeth (table 6). (See 'Primary tooth injury' above and 'Permanent tooth injury' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dennis J McTigue, DDS, MS, who contributed to earlier versions of this topic review.