Dental Oral Facial Trauma

Objectives: Participants will...

  • Learn the required emergency course of action in orofacial trauma cases.
  • Be able to advise parent of best course of action following the injury.
  • Recognize that other orofacial structures may have been damaged.
  • Understand the significance of early referral to a pediatric dentist for careful assessment of the injury.
Almost half of our children will injure their teeth or their orofacial structures by the time they reach adolescence. A large number of these injuries will appear at the pediatrician’s office or in the emergency room. The ability to assess the injury, to refer the patient properly and to allay the parent’s fears and panic is paramount.

Labially displaced intruded tooth
In every traumatic injury, it is important to recognize that other structures may have been damaged and to always keep in mind the possibility of child abuse. With injuries to the head, every child needs to have a quick neurological assessment to assure no significant damage has occurred. If the child has passed out, vomits, or is very sleepy, more severe damage may have happened and the child should immediately be brought to their pediatrician or nearest hospital for assessment.

Injuries to the toddler often occur as the child develops motor skills. When an injury occurs to a young child’s mouth from a fall, it is most often a primary tooth is displaced in the jaw, broken, or is lost completely. Soft tissue damage such as bruises and cuts must be assessed and treated as well. Controlling the bleeding and attention to severe lacerations are the immediate actions required.

Follow-up one year after injury. Not fully erupted, but normal crown color, no sign of pathology.
The very close proximity of the developing permanent successor to the root of primary teeth makes trauma to the permanent teeth a very likely event. The direction and force of the trauma (F) may lead to different types and severity of the injury to the child’s mouth. The root of the primary tooth may be pushed through the bone (A) or forced against the developing permanent tooth (B). Fifty percent of all primary tooth injuries result in some disturbance of the permanent tooth bud including a small white spot, severe crown damage, root damage, and delaying the eruption of the permanent tooth. Therefore, the primary goal in young children is to protect the permanent dentition. Although most damage appears to occur at the time of trauma, damage often occurs as a result of delayed treatment.

The most common injury that occurs when a pre-school child falls is a front tooth is moved into the jaw.

Many times a toddler or young child is moving around with a toy or pacifier in their mouth which then injuries their mouth and teeth when they fall. Often, the shape of the toy or pacifier is seen as a bruise inside the child’s mouth with a fall injury. In all cases referral to a pediatric dentist is critical for a complete survey of orofacial structures, a careful assessment of possible damage to the developing permanent teeth, and appropriate treatment.

Laterally and palatally displaced upper primary central incisor. Further assessment is warranted.
1&Mac218;2 hour post trauma to 4 year old child. Note palatally displaced primary centrals.
Laterally and palatally displaced upper primary 1/2 hour post trauma to 4 year old child.

central incisor. Further injury assessment is warranted. Note palatally displaced primary centrals.

Fracture/discolored teeth: Sometimes the primary tooth is broken, or changes color from the injury. Both require follow-up care as it can damage the permanent tooth.

Sometimes an injury is severe enough to force a primary tooth out of the child’s mouth. It is in the best interest of the child NOT to place the back into the socket, as it may further damage the developing tooth. If this were an older child with permanent teeth involved, the treatment would be very different.

Avulsed tooth:

Severe burns of lips and mouth from biting electric cords and placing the mouth in contact with an electric outlet are occasional occurrences. These should be referred to the emergency room, preferably that of a hospital with a dental residency. New parents should be made aware of safety measures for a safe household environment.

In this era of physical fitness and safety, and children’s involvement in all sorts of sports, the potential for traumatic injury to the teeth and orofacial structures suggests many opportunities for prevention. This includes child proofing your home, the use of car restraints, use of seat belts in a moving vehicle (including strollers), use of helmets when on a bicycle or scooter, and also suggests the urgency of wearing a sports mouthguard. Parents should be advised that a mouthguard can protect against and may prevent serious damage to the teeth, the surrounding hard and soft tissues and other orofacial structures. It has been shown in older children to help decrease the number of concussions that occur with head injuries. Any child participating in organized sports or individualized sports, even a pre-schooler, should be using a mouthguard. A mouthguard fabricated through your child’s dentist will protect them better than an over the counter self-fabricated one because it usually is better adapted to the child’s teeth and allows them to speak and breathe better. Parents should be sure to “play it safe” and add a mouthguard to the athletic gear of their children.

Child Abuse and Maltreatment

Recognition and reporting any suspected instances of child abuse and maltreatment is the responsibility of every health care provider, teacher, and child care workers among others. In New York State there is a mandated training program that includes the information to identify and report cases found at http://69.3.158.146/nurse/nysna/catalog.cfm and through Child Protective Services reporting information including the Hot Line can be found at www.ocfs.state.ny.us/main/cps

It has been reported that over 60% of abused children have some injury in the head and neck area, many times clearly visible. A full history of a claimed accident is absolutely necessary as well as a full examination of the child’s body to look for other bruises and lacerations, when the history is questionable. Repetitive injuries should also be evaluated thoroughly. If a child is old enough, the health care provider should look for discrepancies in the child/parent reports.

Oral facial injuries that are often seen with abuse and maltreatment include bruised and torn frenum (attachment of the lip to the jaw), burns or bruising in various stages of healing, and bite marks. Unexplained burns including circular ones, as with a cigarette, or other facial bruising should be cause for alarm. Fractured or displaced primary teeth without appropriate explanation may also be cause for reporting and investigation.

Once diagnosed, dental caries is considered neglect of health care and reporting is mandated if care is not provided. A child who may present with dental pain or facial swelling due to untreated dental caries, if left untreated is a neglected child. If a child has been treated for a dental emergency and additional treatment is required, the primary care provider must have the care completed or dental neglect must be reported. A parent who continually breaks dental appointments also requires counseling and support, with the eventual requirement of submitting a report if the child is not treated.

In the Head Start Programs, every child is required to have a dental examination within 45 days of entering the program to assure the status of the child’s oral health and assess the need for care. As part of your role in providing care for Head Start children, you should be aware of this mandate and help facilitate this process.