My Child Injured Their Tooth! What Now?

In the realm of dental trauma, there are 14 kinds of injuries as we classify them, which, considering whether it’s a permanent or primary tooth, means there are 28 treatment recommendations and 28 slightly different follow-up schedules, all dictated by the amazing research done through the International Association for Dental Traumatology (IADT). While a child can sustain an injury any time, we most commonly see primary tooth injuries between 1-3 years of age as we’re “cruising and bruising,” learning how to move and how not to fall, and also between the ages of 8-12 as we’re getting active in sports, but not yet totally coordinated with our bodies or playing with totally coordinated peers. Follow-up after a dental injury takes longer than you might expect. The tooth does not heal the way bone does. It’s a different kind of cellular structure and is supported differently. Your mouth is the only place in your body where it’s normal for “bone” (i.e. teeth) to stick out through your skin. These structures are different in a great many ways, and, sadly, a consequence is that certain things may not heal the same way. Follow-up is based on when we can expect each given health factor to fail after an injury and wanting to evaluate your child at those intervals. We never want a tooth to, for example, need to be extracted or need a root canal but, if it is necessary, then we want to do it ASAP to protect the tooth, the adjacent teeth, the whole body in general and, if it’s a primary tooth that has been injured, we want to protect the developing adult tooth underneath from the harms of infection/inflammation.  

Let’s take a look at the most common baby tooth-age injuries and what typically follows:

1. Injury to gums, lip, tongue, frenum (torn)- Apply pressure to area if bleeding with cold, wet gauze. Popsicles are great as well to encourage both cool comfort, pressure, and swallowing (instead of spitting/drooling) which also helps with hemostasis. Consider contacting your dentist with a photo of the injury.
2. Chipped tooth - When something is hit, either the whole object moves or the part contacted can “give” in some way. When the force on the tooth as a whole is relieved by the fracture of the part of the tooth in contact with the bludgeoning force, it actually is often protective and helps to preserve the other parts of the whole tooth, i.e., the nerve health and the health/connection of the tooth to the surrounding bone and gingiva (“periodontium”). Chipped baby teeth often don’t result in the exposure of the nerve and usually require no treatment except if your child develops callouses on lip/tongue because of irritation in soft tissue to a sharpness from the fractured edge; if this happens, we smooth down the sharp area. Fractures into the nerve on baby teeth can be difficult and one must consider 1) proximity to age of natural exfoliation, and 2) ability to cooperate for treatment. Take note whether there’s a spot of red bleeding coming from the tooth within the cross-section where the fractured bit is missing (as a separate phenomenon from bleeding which might also be occurring from the gum tissues around the tooth) and consider contacting your dentist with a photo of the injury.  
3. Dislocated tooth (“luxation”) – This is when the tooth is hit and the whole tooth moves within the bone (no fractures/chips). When we extract a tooth, for example, I like to say that we don't "pull" teeth, but rather we "push" teeth, back and forth, compressing the bony socket all around the tooth until the socket is bigger than the tooth which then makes the tooth loose within the socket. Then, the tooth can be wiggled out much like a normal classic loose baby tooth. In a luxation injury, the tooth is similarly "pushed" but only once and only in 1 direction, yet with enough force to significantly compress the bone such that, without the tooth itself breaking, the tooth is moved. Sometimes this happens and the tooth can be allowed to heal where it is and, with time, it may even move back to its normal position a little bit. Other times, its new position is causing a traumatic bite where a child tries to close his or her mouth and is unable to do so because the injured tooth is in the way of all the other teeth being able to come together, in which case we try to move the tooth back into position. Sometimes the tooth is moved in such a way as to cause the root of the baby tooth to poke into or towards the yet still developing permanent tooth bud within the bone, and often such baby teeth need prompt extraction to preserve the permanent tooth. Chipped teeth often don’t require immediate intervention. Luxated teeth also don’t often require same-day intervention, except where the luxated tooth is causing that traumatic bite, i.e. a child cannot close their mouth and will therefore struggle to eat and sleep.  
4. Avulsion – This is when a baby tooth is knocked so hard it doesn’t knock back (like luxation) but it rather knocks all the way out. This will be a LARGE section I write about when we discuss permanent teeth. For baby teeth, however, there’s not much to say. We NEVER re-insert a knocked-out baby tooth. At the end of the day, despite being a baby tooth dentist, I care more about your child’s wedding photos than I do about their kindergarten photos. Reimplanting a baby tooth will fail and cause harm to the developing permanent tooth right below it and, again, really isn’t worth it. This is to say nothing of the fact that even if we could replant, many kids5 and under (when kids still have front baby teeth) will not sit and allow the tooth to be splinted. Even still, for peace of mind, PLEASE try to find the baby tooth. While it is not IADT recommended that every child who avulses a tooth receive a chest x-ray to rule out the following (because the following is a rare occurrence and, therefore, the statistics do not support the risk: benefit of ALWAYS doing a chest x-ray), a “missing” tooth could, in fact, not be far away. Normally our choking reflex prevents aspiration of foreign objects into lungs, but the force needed to knock out a tooth often knocks it out with great speed. If you’re unlucky, the tooth will shoot like an arrow precisely in between the vocal cords of the larynx without touching/stimulating them, and therefore bypass your cough reflex. A knocked-out tooth sitting at the base of one of your lungs can sit asymptomatically for weeks or months. Should your child, in that time, experience coughing, wheezing, difficulty breathing, coughing up blood, etc., it could be a sign that the missing knocked-out tooth is, in fact, in their lung. Teeth often have a fair bit of plaque (bacteria) on them and this is NOT good for a lung; a visit to the emergency department for medical and surgical treatment would be required.

No matter what, whenever a dental trauma happens, you can always call your dentist for reassurance. Keep an eye out for upcoming articles as we discuss dental trauma to permanent teeth, as well as other dental emergencies. And do your best to ignore your instinct to buy all the bubble wrap in the world; While you should take appropriate caution around places like the slippery-floor bathroom, many injuries occur from kids playing and bonking heads and in similarly innocent ways against which we cannot always protect. Kids have to play and have to smile. Most baby tooth injuries are minor “emergencies” and your pediatric dentist can help with the rest.

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