Dental Injuries Tooth fractures pulp problems, trauma to the face or teeth can result

Trauma to the face or teeth can result from auto accidents, falls, and injury from sports such as football, hockey, soccer, volleyball, basketball, and baseball, etc. Patients suffering significant head, neck or facial trauma should be evaluated and treated in hospital emergency rooms. Such trauma may involve bleeding from the nose or ears, concussion, dizziness, lapse of memory, disorientation, severe headache and earache, or breaking (fracture) of the skull and/or jaws. Most hospitals have on their staff oral surgeons who can treat fractures of the upper or lower jaw and perform emergency tooth removal (dental extractions) and reconstruction of the dental arches.

Wear and tear of cavities and chewing hard objects such as pencils, ice cubes, nuts, and hard candies, can also lead to tooth fractures. Dental injury without associated head and neck trauma can be evaluated and treated in a dental office. Such dental injuries include broken (fractured) teeth, teeth totally knocked out of the mouth, or teeth displaced by unexpected external forces. These dental accidents may be associated with swelling of the gum and oral tissue. Cold packs or ice cubes placed either inside the mouth directly above the injured tooth, or outside on the cheeks or lips, can reduce pain and swelling before the patient reaches the dentist.



Tooth fractures can range from minor (involving chipping of the outer tooth layers called enamel and dentin) to severe (involving vertical, diagonal or horizontal fractures of the root). Enamel and dentin are the two outer protective layers of the tooth. The enamel is the outermost white hard surface. The dentin is a yellow layer lying just beneath the enamel. Enamel and dentin both serve to protect the inner living tooth tissue called the pulp. The visible 1/3 of the tooth is called the crown, while the remaining 2/3 of the tooth buried in the bone is called the root. Dental x-rays are necessary in most instances to diagnose, locate, and measure the extent of tooth fracture.



A serious fracture that exposes both the dentin and the pulp tissue should be treated promptly. The tooth may be displaced and loose, and the gums may bleed. To prevent the loose tooth from falling out completely, the dentist can splint the loose tooth by bonding it to the adjacent teeth to help stabilize it while the underlying bone and gums heal. Because of the high risk of pulp death, a root canal procedure is commonly performed during the first visit. Alternatively, the dentist may elect to only apply a anesthetizing dressing on the splinted tooth. The tooth will then be reevaluated in 2-4 weeks for root canal procedure followed by a dental filling or crown. The splint is also removed at that time.

The most serious injuries involve vertical, diagonal or horizontal fractures of the tooth roots. In most instances, fracture of the tooth root leaves the injured tooth very loose, thus necessitating tooth extraction. The extracted tooth is replaced with a removable plate containing a false tooth. Rarely, certain teeth with horizontal fractures near the tip of the root may not need extraction. However, root canal treatment for the injured tooth may be required in the future if symptoms of pulp death and tooth infection appear. Therefore, periodic x- rays of the fractured tooth are performed.



A minor tooth fracture involves chipping of the enamel only. The tooth is not displaced, and there is no bleeding from the gums. The only symptom of such minor chipping may be sharp or rough tooth edges irritating the cheek and tongue. The injured tooth itself may not even be painful or sensitive to food or temperature. The risk of pulp injury is small, and treatment is not urgent. A small amount of orthodontic wax or sugarless gum can be placed over the rough edge until the dentist can be reached. Definitive treatment usually involves placing a dental filling, a porcelain or gold crown, or a "cap" to protect the pulp of the tooth and to restore normal tooth contour.



A deeper fracture can involve both the enamel and the dentin of a tooth. The tooth is still not displaced and the gums are not bleeding. These deeper fractures may be sensitive to cold temperature or food. Prolonged exposure of dentin to oral bacteria can cause the death of the inner pulp tissue. Death of pulp tissue can lead to serious tooth infection and abscess. Therefore, fractures involving the dentin should be treated promptly (within days of the injury). Treatment involves placing an anesthetizing cream over the exposed dentin, followed by a dental filling, a porcelain or gold crown, or a "cap" to protect the pulp of the tooth. A follow up x-ray in 3-6 months may be needed to be sure that the pulp has not died.

If the fracture has already significantly injured the pulp, then treatment involves either extracting the dying tooth or performing a root canal procedure to prevent serious tooth infection. The root canal procedure is used to save the dying tooth from extraction. This procedure involves removing all the dying pulp tissue and replacing it with an inert material.



The upper front permanent teeth are the most common teeth to be completely knocked out. Children with forward-protruding front teeth that have not had orthodontic treatment to bring them into alignment are at increased risk. Knocked out baby or primary teeth are usually not reimplanted in the mouth, since they will be naturally replaced by permanent teeth later. However, knocked out permanent teeth should be retrieved, kept moist, and placed back into their sockets (reimplanted) as soon as possible. The most important variable affecting the success of reimplantation is the amount of time that the tooth is out of its socket. Teeth reimplanted within one hour of the accident frequently reattach to their teeth sockets.

The knocked out tooth is rinsed in clean water or milk, and placed back (reimplanted) into the socket from which it came. This can be done by the patient or parent and then checked by the dentist. Care should be taken to handle the tooth only by its crown and not by its root. If the parent or patient is unsure about reimplanting the tooth, then the tooth should be stored in milk (if available) or in water and brought to the dentist as soon as possible. Alternatively, in older children and adults who are calm, the tooth may be held within the cheeks inside of the mouth while traveling to the dental office.

After reimplanting the tooth into its original socket, the dentist can then splint this tooth to adjacent teeth for 2-8 weeks. Splinting helps to stabilize it while the bone around it heals. During the splinting period, the patient eats soft foods, avoids biting on the splinted teeth, and brushes all the other teeth diligently to keep the mouth as clean as possible.

In adults, the reimplanted tooth should have a root canal procedure within 1-4 weeks. On the other hand, reimplanted permanent teeth in children (where the tooth root has not yet completely formed) may not need a root canal procedure. These teeth are observed for at least five years for symptoms of dying pulp, such as pain, discoloration, gum abscesses, or abscesses seen on an x-ray.

In most patients who have had tooth reimplantation, over-the- counter medications like acetaminophen (Tylenol) or ibuprofen (Advil) are sufficient for pain relief. Chlorhexidine (Peridex) mouth rinse may be prescribed to prevent and control gum inflammation (gingivitis), since the splinted teeth cannot be brushed normally and the splint usually collects extra dental plaque and food debris. Oral antibiotics and tetanus toxoid injections are considered for patients with accompanying significant soft tissue cuts (lacerations).



Instead of being completely knocked out of the mouth, a tooth can be displaced. A displaced tooth may be pulled out and appear elongated, or be pushed in and appear shorter. A displaced tooth can also be pushed forward, backward, sideways, or rotated. While not an emergency, the sooner the dentist can splint or realign the tooth with orthodontic brackets and wires, the easier it can be brought back into proper alignment. Trauma significant enough to cause tooth displacement can also lead to pulp injury. Therefore, a displaced tooth should be evaluated periodically for several months to determine if a root canal procedure or tooth extraction is needed.



Prevention of dental injuries involves aligning protruding front teeth by dental braces and using face masks and mouthguards while participating in sports. Mouthguards have been shown to reduce trauma not only to teeth, gums, and the surrounding jaw bone, but also to reduce injury to the temporomandibular joints (TMJ) and to reduce the intensity and number of head concussions. Mouthguards also reduce pressure and bone deformation of the skull when a force is directed to the chin.

Before the mandatory use of face masks and mouthguards for high school and college football players in l963, 50% of all football injuries involved the face and the mouth. Since the mandatory use of these protective devices, dental injuries in football players have almost been eliminated. It is now recommended that mouthguards be worn, not only for organized football, but also for unorganized football, baseball, basketball, racquetball, soccer, ice, field, and street hockey, wrestling, boxing, martial arts, volleyball, rollerblading, skating, skateboarding, and bicycling.

Mouthguards can be purchased in pharmacies and sports supply stores and molded at home. They can also be custom made by the dentist. Store-bought mouthguards are less expensive than custom made ones. However, the store bought ones may not fit the athlete’s mouth, may become loose, may be uncomfortably bulky, and may interfere with speech or breathing. The ideal mouthguards are custom made by a dentist. An impression is made of the athlete’s upper dental arch to make a mold of his/her teeth and gums. A custom mouthguard made of a vinyl acetate ethylene copolymer (a special plastic) is then fabricated from this mold in the dental office or by a dental laboratory. A well-fitting custom mouthguard is comfortable and will not interfere with breathing and speech.