One of my son’s friends was bouncing on a bouncy castle last week and one slip, and her mouth met her knee, causing her front wobbly tooth to come out, and to our horror, the two teeth next to it to partially disappear up inside her gum. Her mother rushed her to the dentist, where they were advised that the teeth could possibly work their way back down into place on their own, but failing that, she’d need surgery. We asked our resident paediatric dentist John Roberts to answer some gruesome questions on accidents and children’s teeth, while we cross our fingers and hope that our friend’s teeth start making their way down on their own.

What should I do if my child’s tooth has been knocked loose?

It is generally advisable to seek advice from a dentist. All teeth are mobile to a degree, to allow them to cushion for example the forces of heavy biting. If the injured tooth is more wobbly than the adjacent ones, the appropriate treatment will vary from just allowing it to become firm again in 10-14 days if it is only mildly mobile, to being extracted if there would be no chance of repair to the damaged fibres between the tooth and the bone which hold it in place. An x-ray may be needed to help in the diagnosis of the extent of damage. This applies both to permanent teeth and baby (deciduous, primary) teeth.

My child’s tooth has turned grey following a bump. What should I do?

If it is a permanent tooth, then almost certainly the tooth will require root canal treatment (RCT) to save it. The dentist will monitor the tooth and when there are sufficient diagnostic pointers to indicate that the nerve/blood supply has been irrevocably damaged he will advise RCT.

If it is a primary tooth then simply being discoloured following trauma merely shows that a ‘bruising’ has occurred within the tooth. If there are no other complicating factors such as excess mobility, crown or root fracture or being moved from its original position (displacement), then there is a good chance the tooth will fully recover. The situation will need to be monitored and hopefully within 9 months or so the colour will revert closely to normal; it may end up being rather more yellow than before, but this is a healthy reaction to the trauma.

If the tooth remains discoloured this may indicate that the situation has worsened and the dentist may advise its removal, because if the baby tooth becomes infected, that infection could affect the quality of the enamel of the permanent tooth taking its place.

My child has fallen from his bike. There is a lot of blood from his mouth. Should I take him to the dentist or A&E?

It may be quicker to be seen by the dentist! If the dentist feels the damage is outside his field, he will refer you to A&E.

The bleeding may come from cuts to the lips or tongue, and if so, especially if the vermillion border of the lip is involved, A&E or a plastic surgeon may give the best result. However, often the bleeding is from the space between the tooth and gum, caused by damage to the fibres that support the tooth, holding it in position; the dentist will advise on further appropriate treatment.

My child’s tooth has been chipped. What will my dentist recommend?

As with all aspects of dental trauma, it all depends on the degree of damage. There are three ‘layers’ of tooth, enamel on the outside, then another hard substance named dentine, and the inner layer where the nerves and blood supply are, the so-called dental pulp. If the chip only involves enamel, no treatment may be necessary; there may be no cosmetic concerns, and it is rare for the broken edge to cause damage to lips or tongue.

When the fracture extends into the dentine the tooth may be sensitive, as the dentine has small tubes which lead into the dental pulp. This has potential to further damage the pulp, and so it may be necessary to cover the exposed dentine and at the same time to restore the tooth to its original shape for aesthetic reasons and to allow the tooth to function normally.

If the fracture involves the dental pulp, treatment for a baby incisor is usually extraction, as the risk of an abscess formation is high. The permanent incisor begins to be formed soon after birth, and remains in very close approximation to the root of its baby tooth predecessor. The abscess material from the baby incisor can interfere with the quality of enamel formation of the permanent incisor, which occurs over an extended period until shortly before that tooth erupts. RCT is possible with baby incisors, but does not seem to reduce the possibility of damage to the permanent tooth enamel.

My toddler fell and knocked his front tooth backwards. How serious is this, and what will be done now?

Of all the directions a baby incisor can be moved, this is the most favourable, as its root moves forwards, away from the developing permanent successor, which would therefore not have been damaged by the accident itself. If the tip of the baby tooth has been pushed back behind the lower incisor, sometimes the child cannot close his mouth. If the injured tooth is still very wobbly it may be possible for you to push it back into a more favourable position with your fingers. Displaced baby incisors normally return to approximately their original position spontaneously, although it may be a week or so before this process commences.

If the tip of the incisor has moved forwards, towards the lip, then this is a    different scenario, and there is a high chance that its root is now compressing the developing permanent tooth crown; damage would begin straight away, and your dentist will almost certainly advise extraction of the baby tooth to minimise the damage potential.

My child was recently injured on a bouncy castle, with two baby teeth being pushed up into the gum. What happens now?

This is classified as an intrusion injury and it is a near-certainty that damage would have occurred immediately to the permanent successor. Extraction will be recommended for the baby tooth/teeth, and should be carried out as soon as possible. If there is enough of the tooth visible for the dentist to hold on to, this procedure is easily performed under local anaesthesia; if the tooth has largely disappeared beneath the gum then either a delay will be necessary for the tooth to begin to re-erupt before extraction, or else an operation under general anaesthesia may be needed to enable the tooth to be removed surgically.

The damage to the permanent tooth can vary from a small area of white or yellow     discolouration on the front surface of the crown, or a roughness in the surface of the enamel, to a change in direction the crown develops in relation to the root.

What are the typical signs or symptoms of an infection following an accident?

For an adult tooth, pain or tenderness to pressure can indicate the presence of an infection originating from a tooth. That is because a pressure builds up around the end of the root, and further pressure, be it from biting or pressing on the tooth, causes the pain sensation. The other sign that patients will see is a swelling of the gum in front of the tooth, in the area of the root end, i.e. 15-20 mm from the gum margin. The dentist will perform other diagnostic tests such as an X-ray, or stimulation such as a very cold liquid to the tooth to see if the nerve supply is still viable.

With a baby incisor there are differences; it is not uncommon for the tooth to become infected without any discomfort at all. Discolouration may or may not indicate an infected pulp. A swelling of the gum over the front of the tooth will occur a few weeks after the nerve dies, firstly as a diffuse swelling and then as the condition becomes chronic the appearance will change to a discrete yellow spot, perhaps with pus oozing from it.

My child’s baby tooth has been knocked out. Can it be saved?

It would be unwise to replant a baby incisor tooth that has been knocked out completely (avulsed). The chance of infection developing in the pulp of that tooth is extremely high, and therefore the permanent successor will almost certainly be affected giving a lifetime of disfigurement. The process of the tooth being displaced from the socket will in almost all cases not result in immediate damage to the developing tooth. If the child is very young, not nearing the age when the tooth would have been lost naturally, the dentist could give consideration to providing a fixed partial denture for aesthetic reasons, after a period of healing.

My child’s permanent incisor has been knocked out. What should I do?

It may well be possible to save the tooth for a lifetime; it is essential that the tooth is put back into its socket as soon as possible, after some precautions have been observed. There will be some soft tissue on the root of the tooth, and this must not be allowed to dry out, so holding the tooth by the crown only, not touching the root, it should be rinsed under running water to remove any debris. Do not attempt to scrape the root clean! Then the tooth should be repositioned into the socket, to an approximate position; the presence of a blood clot in the socket may prevent full repositioning. The child can then hold the tooth in that position with his tongue and lips while getting to the dentist at the earliest opportunity.

If you are unable to reposition the tooth yourself, then put it in milk, and if it can be repositioned within half an hour there is an excellent prognosis. If it is out of the mouth for 2 hours there will be failure. Schools or leisure centres may well have an ideal transport medium, a balanced-salt solution such as Hanks, which maintains a physiological pH and osmotic pressure essential for the survival of the soft tissue on the root. Do not place the tooth in alcohol in an attempt to preserve it.

The dentist will, if necessary, complete the repositioning under local anaesthesia, and then splint the tooth for a week or so to prevent it being displaced while the fibres that hold it in place are healing. Depending upon a number of factors, the tooth may need root canal treatment at a later date if the nerve and blood supply do not survive.

Drs Noushin Attari, John F Roberts & Liege Lourenço
Weymouth Street Paediatric Dental Care LTD
33 Weymouth Street
London W1G 7BY
Web: www.paediatric-dentistry.co.uk
E-mail: info@paediatric-dentistry.co.uk
Tel: 0207 580 5370
Fax: 0207 636 3094