Dental trauma
Injury to teeth, gums, and supporting bone from accidents.
Dental trauma encompasses injuries to the teeth, periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the lips and tongue. The field dedicated to its study is known as dental traumatology. It is a notable category of injury because the oral region, despite comprising only 1% of total body area, accounts for 5% of all bodily injuries, with a higher proportion in young children.
Types
Dental injuries include enamel infraction, enamel fracture, enamel-dentine fracture, and enamel-dentine fracture involving pulp exposure. Root fracture of the tooth, concussion (bruising), subluxation (tooth knocked loose), luxation (displaced) in extrusive, intrusive, or lateral forms, and avulsion (tooth knocked out) are also recognized. Alveolar bone injuries comprise five types: communicated fracture of the socket wall, fracture of the socket wall, dentoalveolar fracture (segmental), fracture of the maxilla (Le Fort fracture, zygomatic fracture, orbital blowout), and fracture of the mandible. Trauma involving the alveolus rarely occurs in isolation and often presents alongside other tooth tissue injuries. Signs of dentoalveolar fracture include change to occlusion, multiple teeth moving together as a displaced segment, bruising of attached gingivae, and laceration of gingivae across the fracture line. Investigation requires more than one radiographic view to identify the fracture line. Treatment involves repositioning displaced teeth under local anaesthetic and stabilizing the mobile segment with a splint for 4 weeks, along with suturing soft tissue lacerations. Soft tissue injuries commonly accompany dental trauma, most often affecting the lips and gingivae. For lip wounds, careful examination and radiographs may be needed to rule out foreign objects. Small gingivae lacerations usually heal spontaneously, but gingivae bleeding around margins may indicate injury to the periodontal ligament. When buccal mucosa is involved, the facial nerve and parotid duct should be examined for damage. Deep tissue wounds should be repaired in layers with resorbable sutures. Trauma to primary teeth occurs most commonly at age two to three years; treatment prioritizes the safety of the adult tooth, as the root apex of an injured primary tooth lies near the tooth germ of the permanent successor.
Prevention
Prevention of dental trauma is relatively difficult because accidents, especially in active children, are nearly impossible to stop. Regular use of a gum shield during sports and high-risk activities such as military training is the most effective preventive measure. Gum shields are mainly fitted on the upper teeth, which have a higher risk of trauma. Ideally, they should be comfortable, retentive, odourless, tasteless, and made of non-harmful materials. However, studies in high-risk populations report low compliance with regular mouthguard use, and even with use, effectiveness is not complete due to poor fit from unawareness of best makes or sizes. Types of gum shields include stock ready-moulded (not recommended due to poor fit and risk of dislodgement), self-moulded or boil-and-bite (limited size range, cheap, easily remoulded), and custom-made (made with ethylene vinyl acetate, the most ideal type with good retention and ability to build multiple layers, but expensive). Imparting knowledge about dental injury through educational campaigns using lectures, leaflets, and posters in an easily understandable way is an important measure for those in sports environments and school children.
Management
Management depends on the type of injury and whether it involves a baby or adult tooth. Completely knocked out baby front teeth should not be replaced; the area should be cleaned gently and the child brought to a dentist. Adult front teeth can be replaced immediately if clean. For an avulsed permanent tooth, the patient should be reassured and kept calm. The tooth should be picked up by the crown, avoiding the root. If dirty, it should be washed briefly (ten seconds) under cold running water without scrubbing. The tooth should then be placed back into the socket the correct way, matching the other tooth, and the patient encouraged to bite on a handkerchief to hold it in position. If immediate replacement is not possible, the tooth should ideally be placed in Hank's balanced salt solution; if unavailable, in a glass of milk, a container with the patient's saliva, or in the patient's cheek (not suitable for young children who may swallow it). Transporting the tooth in water is not recommended as it damages the delicate cells of the tooth's interior. Emergency dental treatment should be sought immediately.
Complications
Not all sequelae of trauma are immediate; many occur months or years after the incident, requiring prolonged follow-up. Common complications include pulpal necrosis, pulpal obliteration, root resorption, and damage to successor teeth in primary tooth trauma. Pulp necrosis is the most common complication (34.2%). Teeth with multiple traumatic events have a higher chance of pulp necrosis (61.9%) compared to those with a single injury (25.3%). Pulp necrosis occurs either as ischaemic necrosis from disruption of blood supply at the apical foramen or as infection-related liquefactive necrosis. Signs include persistent grey tooth colour, radiographic periapical inflammation, and clinical signs of infection such as tenderness, sinus, suppuration, or swelling. Treatment for primary teeth is extraction; for permanent teeth, endodontic treatment may be considered. Root resorption appears to follow wound healing events where significant periodontal ligament or pulp has been lost. Pulpal obliteration, characterized by loss of pulpal space radiographically and yellow discolouration of the crown, occurs in 4–24% of traumatized teeth; no treatment is needed if asymptomatic, but symptomatic primary teeth require extraction and symptomatic permanent teeth often present challenging root canal treatment due to calcified material. Dental trauma to primary teeth may damage permanent teeth during development, causing crown dilaceration, odontoma-like malformation, sequestration of permanent tooth germs, root dilaceration, or arrest of root formation.
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