Patient information: Dental and mouth injuries in children

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, 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 information: Head injury in children and adolescents".)

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, 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.

TREATMENT

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. In addition, x-rays can be used to differentiate primary from permanent teeth, if needed.

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 most 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 infection. 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 those that are stored dry and reimplanted after one hour [1].

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:

• The tooth should be handled carefully by the crown to prevent damage to the periodontal ligament (picture 1).
• Debris should be removed by gentle rinsing with saline or tap water; the tooth should not be scrubbed or sterilized.
• The tooth should be placed by hand back into the socket (picture 2)

• The tooth is kept in place by the child by biting 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 (packed on ice or refrigerated) or a container of the child's saliva. The tooth should NOT be stored in water or saline because this will reduce the chances of successfully re-implanting the tooth in the gums. The child should see a dentist or other health care provider who can reimplant the tooth as soon as possible. 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 one week 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 so they can be reattached. If tooth fragments cannot be found, the tooth may be repaired with a material called composite resin, which can be matched to the color of the natural tooth.

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 of the mouth usually do not require stitches. Tears of the flap of skin under the upper lip (the frenulum) also heal without stitches.

Cuts to the tongue that are large, especially if near the tip of the tongue, may require stitches. Wounds that involve the outer part of the lips and extend into the skin also frequently require stitches [2].

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, and will sometimes require hospitalization or surgery [3]. (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 (Advil®, Motrin®) or acetaminophen (Tylenol®) may also be given. These medications should be dosed according to the child's weight rather than age. Dosing instructions are included for acetaminophen (table 1) and for ibuprofen (table 2).

Antibiotics — Antibiotics are often not 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 [4].

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 5 years ago. (See "Patient information: Immunizations for infants and children age 0 to 6 years" and "Patient information: Immunizations for children age 7 to 18 years".)

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.

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, 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.

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 concussion and 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 3) [5].

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.
• Custom-made mouthguards are made by a dentist. The dentist takes an impression of the athlete's mouth with a material that hardens, then forms plastic around the hardened impression. Custom-made mouthguards provide better protection, are more comfortable, and are more likely to stay in the mouth compared to 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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our Web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Head injury in children and adolescents
Patient information: Immunizations for infants and children age 0 to 6 years
Patient information: Immunizations for children age 7 to 18 years

Professional Level Information:
Evaluation and management of dental injuries in children
Evaluation and repair of tongue lacerations
Oropharyngeal trauma in children

A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• The Nemours Foundation

      (http://kidshealth.org/parent/firstaid_safe/emergencies/tooth_injury.html)

• American Dental Association

      (www.ada.org/public/topics/mouthguards_faq.asp, also available in Spanish)

• Columbia University School of Dental Medicine

      (www.simplestepsdental.com/SS/ihtSS/r.WSIHW000/st.32579/t.32606/pr.3.html)

• Texas Children's Hospital

      (www.texaschildrens.org/Parents/TipsArticles/ArticleDisplay.aspx?aid=860)

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