MOUTH AND DENTAL INJURIES IN CHILDREN
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, sports injury, or fight. Mouth injuries can also occur when a child trips or is pushed with an object in the mouth.
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.
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 ≥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, some children will need an imaging test (x-ray, CT scan, 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). Not every child with a dental or mouth injury will require an imaging test.
Dental injuries: The treatment for dental injuries depends upon 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.
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 removed, depending upon the severity of the injury. 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 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 to very few teeth that are stored dry and reimplanted after one hour.
Because of the importance of replacing the tooth quickly, the child, parent, or another adult can (and should) attempt to reimplant the tooth. The following steps are recommended:
- – Handle the tooth carefully by the top (crown).
- – 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.
- – 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 or saline, because this will reduce the chances of successfully healing of the reimplanted tooth. The child should see a dentist or other healthcare provider as soon as possible to reimplant 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 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.
Broken permanent tooth: Broken permanent teeth can usually be repaired successfully. For the best possible outcome, the child should see a dentist for treatment within two days from the time of the injury. Broken teeth that are sensitive to hot or cold need to be treated urgently. Tooth fragments should 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 can be matched to the color of the natural tooth.
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 or acetaminophen may also be given. These medications should be dosed according to the child’s weight rather than age.
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 five to seven days of antibiotics to prevent infection.
Tetanus prevention: A dose of tetanus vaccine may be recommended if the child has not had their booster dose (generally given at age 11 to 12 years) or if their last dose was given more than five years ago.
Hygiene and diet: After a tooth or mouth injury, it is important to continue keeping the teeth clean. This includes brushing twice per day and flossing once per day. 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. Children who have stitches in the mouth should avoid spicy or salty food, popcorn, and straws for approximately one week.
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, complete loss of the tooth, or sensitivity to heat/cold. Children who have a permanent tooth successfully replaced in the socket will often require a root canal and placement of a crown in the future.
- – 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 of a major blood vessel.
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 concussion and jaw fracture in 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 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.
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