By Dr. Chad Wollard, DMD, Valencia Endodontic Associates –
As spring arrives and warm weather activities kick into full swing, the incidence of traumatic dental injuries in children tends to increase. Traumatic injury to the permanent teeth can range from crown fracture, separation injury (in which the tooth either partially or completely comes out of the socket), or a crushing injury (in which the tooth is pushed into the socket). All of these injuries can have an impact on the dental pulp and the overall health of the tooth. Receiving immediate treatment from a dental professional for these types of injuries is often imperative to ensure a good long-term prognosis and retention of the permanent tooth.
Injuries typically affect the anterior dentition. Permanent anterior teeth typically begin to erupt in boys and girls around age 6. When an injury occurs to a baby or deciduous tooth, a course of treatment is taken to help preserve the continued development of the permanent tooth that has yet to erupt. When an injury occurs to a permanent tooth, the course of treatment is to try and preserve the health and retention of the permanent tooth. The following is a brief overview of the different types of traumatic injuries and treatment protocols for permanent teeth.
Types of Traumatic Dental Injuries
Crown fracture is one of the most common forms of traumatic dental injury. This type of injury is often seen in children due to falls, sports related injuries, or a traumatic event. Crown fractures can be described as either limited to the hard tissues of the tooth, (dentin and enamel) or resulting in the exposure of the pulp tissue of the tooth. If the crown fracture is limited to the enamel or dentin and does not expose the pulp tissue (nerve), then a tooth colored bonded restoration or reattachment of the fractured tooth fragment with a dental adhesive will typically resolve the issue. Follow-up visits with a dentist or endodontist should be conducted at 2 month and 1 year intervals. This type of injury typically has an excellent long-term prognosis.
Crown fracture with pulp exposure occurs when the pulp or nerve tissue inside the tooth is exposed to the oral environment. This type of injury will require more immediate treatment. Pulp capping or root canal treatment may be indicated depending on the extent of the crown fracture and pulp exposure. Exposure of the pulp tissue to the oral environment for an extended period of time may result in bacterial infection of the pulp tissue requiring root canal treatment. This type of injury typically has an excellent long-term prognosis.
An intrusion injury occurs when a permanent anterior tooth is pushed up into the socket. When looking at the tooth, it appears as if the tooth has been pushed up into the gum tissue and appears shorter than the other surrounding teeth. In younger patients when the permanent tooth has not fully developed at the time of injury spontaneous repositioning may occur. In older children with fully developed roots, orthodontic repositioning or surgical repositioning may be needed if spontaneous re-eruption does not occur. Root canal therapy is usually needed in this type of injury if the permanent tooth has fully developed roots. The long-term prognosis for this type of injury is fair.
Separation injuries occur when the tooth either partially or completely comes out of the socket. When observing the tooth, it does not look like it is in the correct position. It may be pushed back toward the roof of the mouth, extruded so that it looks longer, or pushed forward of the other dentition. This type of injury requires repositioning of the tooth and splinting with a non-rigid splint often for a period of 2 to 4 weeks. Fully mature permanent teeth typically require root canal therapy due to their inability to reestablish a blood supply.
Avulsion is a separation injury that occurs when the tooth completely comes out of the socket. Unlike other types of traumatic dental injuries, time is of the essence with this particular type of injury. The longer the tooth is out of the socket the worse the long-term prognosis. If a baby tooth or deciduous tooth is avulsed or knocked out do not replant the tooth.
Steps To Follow if a Permanent Tooth is Knocked Out
If a permanent tooth is knocked out of the socket it is important to follow these important steps.
- Keep the patient calm.
- Find the tooth and pick it up by the crown (the white part) and avoid touching the root.
- If the tooth is dirty, wash it briefly (10 seconds) under cold running water and then reposition the tooth in the socket. Have the patient bite on a handkerchief or napkin to hold it in position. If the tooth is not dirty, replant the tooth immediately into the socket.
- If it is not possible to reposition the tooth, place the tooth in a suitable storage medium, e.g. a glass of milk or a special storage media for avulsed teeth if available. The tooth can be transported in the mouth, keeping it between the teeth and the inside of the cheek. Avoid storing the tooth in water.
- Seek emergency dental treatment immediately.
The long-term prognosis for a permanent tooth that has been avulsed is directly related to the time it spends outside of the socket. The longer a tooth remains outside of the socket the greater the chance the periodontal ligament which covers the root surface will die. If the periodontal ligament dies and the tooth is replanted the patient will experience replacement resorption of the tooth root. Replacement resorption results in the body resorbing the root surface and replacing it with bone. As more of the tooth root is lost to resorption the tooth eventually becomes mobile and will need extraction.
Immediate Replanting Aids Tooth Retention
Immediately replanting an avulsed tooth that is free of dirt or debris ensures a greater chance that the periodontal ligament surrounding the tooth will survive. This is paramount to a good long-term prognosis and retention of the tooth. An avulsion is one of the most serious tooth-related injuries and prompt treatment by an endodontist, dentist, or oral and maxillofacial surgeon is critical for a good long-term prognosis.
All traumatic dental injuries have the potential for injury to other areas including the soft tissue and bone that can result in serious complications or infection. It is important to always seek emergency dental treatment following a traumatic event.
Expertise. Skill. Compassion.
Setting the standard for excellence, Valencia Endodontic Associates specializes in non-surgical and surgical Endodontic procedures. As a patient-centered practice, our primary goal is to make our patient’s experience before, during, and after a procedure as enjoyable as possible, providing the highest standard of professionalism in a caring and comfortable environment. Endodontists must complete dental school and an additional two or more years of advanced training in Endodontics. In addition to Endodontics, we are experienced at finding the cause of orofacial pain that can be very difficult to diagnose.
To learn more or to schedule an appointment, please call 816-561-9666, or visit us online at www.valenciaendodontics.com.
Dr. Chad Wollard attended Trinity College in Hartford, Connecticut and graduated with a B.A. in public policy in 1994. He graduated Magna Cum Laude from Tufts University School of Dental Medicine in Boston, Massachusetts in 2000 receiving a D.M.D. Chad received his Certificate in Endodontics from Tufts University’s Post-Doctoral Program in Endodontics in 2002. Chad is a member of the American Association of Endodontists and the American Dental Association.