Traumatic dental injuries: classification and first aid guidelines

Trauma represents a significant moment of stress and agitation for anyone when it occurs, both for the person who suffers it and for the people who witness the event and who are able to rush to their aid.

When the trauma affects the face, there is also the added concern that aesthetic damage has been suffered.

In terms of traumatology, teeth play a key role as they are in a position which is very sensitive to impact, protected only by the reduced thickness of the soft tissues of the lips. They are also made of a crystalline material such as hydroxyapatite, which is extremely hard but fragile.

At an epidemiological level, although the mouth area represents only 1% of the total body area, 5% of all injuries are concentrated there; this figure increases when speaking of preschool children, accounting for as much as 17% of all traumas. (1)

Traumatic dental injuries in the paediatric population

In terms of oral traumatic injuries, teeth are involved in 92% of cases. (1) The incidence rate in children is estimated between 1% and 3%. (2) This rate decreases with increasing age and boys are affected more. (3,4)

The prevalence of these injuries in primary dentition is around 30%. (5,6) On the other hand, an extensive American survey has demonstrated that one in four adults shows signs of trauma on the incisors. (7) Nowadays, in the most developed countries, thanks to active primary prevention measures, the incidence of caries has greatly decreased, making traumatic injuries a greater problem in percentage terms than they once were. (2)

This type of accident is very common: knowing what action to take is essential to be able to limit the damage to a minimum and, above all, not make the situation worse.

Traumatic dental injuries in children: first aid measures

The first essential point is to understand whether we are dealing with a permanent or a deciduous tooth. This primary survey will in fact completely change the approach to the intervention. (8-10)

In the vast majority of cases, trauma affects the upper front teeth: the central and lateral incisors. (11) The replacement of central and lateral incisors occurs between the ages of 6 and 8.

Following the provision of first aid, a thorough dental examination always needs to be performed, which includes any necessary records, the correct therapy and the drafting of a follow-up that allows the course of the clinical situation to be monitored over time.

We will now look at what first aid measures to take, not in a dental surgery, depending on whether a deciduous or permanent tooth is involved. (8-10)

Interventions for traumatic injuries affecting deciduous teeth

First of all, when we are faced with a trauma involving a deciduous tooth, we must always consider that the apex, in relation to the age of the child, will probably be close to the follicle of the permanent tooth. Therefore, maximum awareness and attention are required so as not to risk damaging the permanent tooth in this delicate phase of its formation.

Generally speaking, it is therefore risky to perform repositioning manipulations on a deciduous tooth because we could traumatise the permanent follicle, compromising its natural development.

If the trauma has resulted in a fracture, it is advisable to preserve the fragment (if it has been found) so that it can be assessed and possibly glued back once a precise diagnosis has been made and the clinical situation has been understood in detail.

It is therefore not advisable during first aid to put a deciduous tooth back immediately. We should rather gain a precise understanding of the situation, taking into account the extent of the extrusion, the mobility, the root formation and the child’s cooperation before carrying out any manipulation.

If the trauma has caused the complete avulsion of the deciduous tooth, its reinsertion is never recommended under any circumstances.

Traumatic injuries affecting permanent teeth

If the trauma has affected a permanent tooth, just as in the case of a deciduous tooth, it is important to try to find the fragment, which can be cleaned and glued back using adhesive procedures once in the dental surgery.

If the trauma has caused a fracture and the coronal fragment is mobile but still in situ, it must be stabilised as much as possible during the emergency intervention, even simply by pulling a handkerchief tightly between the teeth until a more definitive treatment plan is reached, which will probably include flexible splinting for some time.

Following a root fracture, if the coronal fragment is not in the correct position but is still inside the socket, it must be repositioned as soon as possible. Once at the dental surgery, after checking the position radiographically, it is possible to proceed with splinting the tooth.

Even in the case of more extensive alveolar fractures, it is always advisable to reposition the alveolar fragment and splint it as soon as possible.

If there is no fracture but the tooth has suffered a simple concussion or a subluxation, no special first aid attention is required.

If, on the other hand, the permanent tooth has undergone an extrusive luxation (it appears longer, from a clinical standpoint), it must be repositioned by gently reinserting it in the socket. It will then need to be splinted at a later stage.

If the luxation also has a vestibular vector, the tooth will have to be repositioned manually, then stabilised once in the dental surgery.

If the luxation is intrusive (the tooth re-enters the alveolar bone axially, appearing shorter), it will not be possible to perform any emergency manipulation, in which case the situation will have to be monitored over time, while adopting the right treatment option.

Complete avulsion of a permanent tooth

What action should be taken in the case of complete avulsion of a permanent tooth? (10)

After finding the avulsed tooth and verifying that it is a permanent tooth, be sure to hold it by the crown without touching the root. If the tooth is dirty, it should be rinsed briefly under running water (10 seconds at most) and reinserted in place. Once reinserted, have the patient bite on a handkerchief to stabilise the newly repositioned tooth.

If immediate reinsertion is not possible for some reason, the avulsed tooth must be preserved in a suitable medium such as milk, saline solution or saliva. The avulsed tooth can also be preserved inside the mouth. Do not store it in plain water.

Reinsert the tooth as soon as possible.

The prognosis for an avulsed tooth is closely related to the speed of reinsertion and how it is preserved during the period between the traumatic event and its reinsertion. If the tooth is wrongly kept exposed to air, it will take just 60 minutes for the cells of the periodontal ligament to die. (10)

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References

1. Andersson, L. (2013). Epidemiology of traumatic dental injuries. Journal of endodontics, 39(3), S2-S5.
2. Andreasen, J. O., Andreasen, F. M., & Andersson, L. (Eds.). (2018). Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons.
3. Rocha MJC, Cardoso M. Traumatized permanent teeth in Brazilian children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2001;17:245–9.
4. Traebert J, Peres MA, Blank V, et al. Prevalence of traumatic dental injury and associated factors among 12- year-old school children in Florianopolis, Brazil. Dent Traumatol 2003;19:15–8.
5. Glendor U, Andersson L. Public health aspects of oral diseases and disorders: dental trauma. In: Pine C, Harris R, eds. Community Oral Health. London: Quintessence Publishing; 2007:203–11.
6. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235–9.
7. Kaste LM, Gift HC, Bhat M, et al. Prevalence of incisor trauma in persons 6 to 50 years of age: United States, 1988–1991. J Dent Res 1996;75:696–705.
8. Bourguignon, C., Cohenca, N., Lauridsen, E., Flores, M. T., O’Connell, A. C., Day, P. F., … & Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dental Traumatology, 36(4), 314-330.
9. Flores, M. T., Malmgren, B., Andersson, L., Andreasen, J. O., Bakland, L. K., Barnett, F., … & Arx, T. V. (2007). Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dental Traumatology, 23(4), 196-202.
10. Andersson, L., Andreasen, J. O., Day, P., Heithersay, G., Trope, M., DiAngelis, A. J., … & Tsukiboshi, M. (2012). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental traumatology, 28(2), 88-96.
11. Bauss, O., Röhling, J., & Schwestka‐Polly, R. (2004). Prevalence of traumatic injuries to the permanent incisors in candidates for orthodontic treatment. Dental Traumatology, 20(2), 61-66.