Nice play, but does it hurt?

Aug. 1, 2003
The treatment of dental trauma requires immediate attention, as well as a little preparation before the game even starts.

by Cathleen Terhune Alty, RDH

It was a warm, sunny day — the birds were singing and the bases were loaded. In right outfield, hat pulled down tight on his forehead, a boy waited. A loud crack echoed over the field as a small cluster of players jumped to their feet to watch the ball as it took flight high into right field. The boy was ready, upturned face scanning the sky. The ball completed its arc and began falling as his glove hovered, waiting. The boy smiled as he raised his glove, confident of the catch. But the ball bounced from the glove and descended into his face, hitting him in the mouth.

Any injury is dreadful, but, as hygienists, we probably all share the fear of watching someone we love suffer from a dental injury. Prevention is always best, and mouthguards do a great job of preventing dental injuries, if they are inserted into the mouth.Unfortunately, many kids skip the mouthguard for sports when not specifically required for play, or wear chewed up or otherwise damaged guards that don't offer as much protection. Dental trauma is a possibility at any age, at any time, in any place, and can have harmful anatomic, cosmetic, and psychological consequences. Trauma can range from small chips to shattered alveolar bone and lost teeth.

The most common victims are children. Studies show about 50 percent of children will experience a dental injury. While injuries in deciduous teeth usually happen to children learning to walk, older children tend to damage permanent teeth (usually the maxillary anterior teeth) while in sports or other activities such as skating and bicycling. Young adults tend to receive injuries from auto accidents and fighting. Family violence including child or spousal abuse can cause tooth damage and needs to be considered when evaluating an injured patient.

Common injuries

The most common dental injury reported is a single tooth, usually the maxillary central incisor. The next most common teeth damaged in trauma are the maxillary lateral incisors, followed by the mandibular central and lateral incisors. Accident statistics show 75 percent of tooth fractures on permanent teeth are of the crown of the tooth and about 7 percent are root fractures. Approximately 25 percent of injuries occur on deciduous teeth. High velocity impacts usually cause crown fractures while low velocity impacts usually cause more damage to soft and supporting tissue.

Crown fractures can be a simple crown infraction with vertical or horizontal craze lines to fractures in enamel only; enamel and dentin; or enamel, dentin, and pulp. Because of large pulp chambers in children with emerging permanent teeth, quick action to seal exposed dentin and maintain pulp vitality is important. A fractured tooth with exposed pulp usually requires root canal treatment.

Root fractures are seen in fully formed permanent teeth and not often on developing or deciduous dentition because of short roots. Although difficult to detect even on radiographs, changes in angulation of the X-ray beam may better show the fracture line.

Horizontal root fractures are benefited by splinting within 24 hours. After this time, it may be impossible to get tooth segments properly lined up and the bone will not be able to heal properly. Vertical root fractures are difficult to detect. A patient who experienced dental trauma may complain of pain when clenching, biting or releasing, and sensitivity to hot or cold foods.

Tooth concussion

Besides fracture, a tooth that is injured may have suffered concussion, displacement or avulsion. Concussion is damage to the periodontal support structures without loosening. Usually there is bleeding present and the tooth may be temporarily sore to percussion. Most concussion injuries do not require splinting or immediate dental treatment.

Teeth that are loosened from trauma are termed "displaced." The pulp of a displaced tooth often is disconnected from its blood supply and may necrose. Displaced teeth are usually splinted for several days until stabilized. There are three classifications of displacement: extrusive, lateral, and intrusive.

Extrusive displacement is when the tooth is partially removed from the socket and it sticks up above the occlusal plane. Lateral displacement is when the tooth is angulated or in an unusual position from its normal anatomic position. As the tooth is often locked into place, local anesthesia may be necessary to get it back into its proper position.

Intrusive displacement is when the tooth is pushed deeper into the socket, which can cause extensive damage to the periodontal ligament, blood supply, and bony socket. The tooth may be impressed into the jaw slightly to complete embedding and a permanent tooth usually will require oral surgery or orthodontics to move the tooth back into position. In young children, the intruded tooth may damage the permanent one underneath. In a permanent tooth with incomplete root development, the intruded tooth may re-erupt on its own.

Re-implantation important

When a permanent tooth is avulsed or knocked out, immediate re-implantation is important. Studies show that a tooth re-implanted within 30 minutes of avulsion has the best prognosis for retention. The maxillary central incisors are the most common avulsed teeth, especially when erupting (ages 7-9) because of the short developing roots.

If the tooth is found on the ground, handle by the crown only. If dirt is on the root, rinse gently in tissue medium, saline solution (contact lens solution), or milk. Tap water may be used but only as a last resort. Do not rinse the root with any sterilizing agent or medicament. Do not scrub or pick tissue off the avulsed tooth.

The socket should only be cleaned with a gentle stream of saline or water if necessary. Do not force the tooth back into the socket. If the tooth will not easily implant, the alveolar bone socket may be damaged. If it is not possible to implant the tooth, a proper storage medium is critical. Hank's balanced salt solution (HBSS) and Viaspan (a medium used to transport transplant organs) have been proven to keep periodontal cells viable for up to 96 hours. A product called "Save-A-Tooth" is available that contains HBSS in a small container with a three-year shelf life for transporting avulsed teeth and is good to have in emergency first aid kits at any sporting event. In addition, SmartPractice offers EMT ToothSaver. Fresh, whole milk also can be an effective carrier for a tooth for up to six hours. Powdered or reconstituted milk is inappropriate for this task. Storage of a tooth in the buccal vestibule is less advantageous than other mediums and may be impossible with an upset child. Studies show water is a last option because the periodontal cells cannot survive long in hypotonic solutions.

The psychological impact also should be considered. A missing deciduous tooth in a child or a fractured crown in a teen certainly can interfere with self-esteem and peer acceptance. Prompt dental treatment and cosmetic considerations for restoration are important.

As with so many other issues in dentistry, injury prevention is important. Place furniture to avoid tripping; install safety gates for toddlers; and use sports mouth guards, bike helmets, and seat belts when in automobiles. Always stress the importance of a thorough checkup when you witness a dental injury, even when relatively minor. Make sure your child's sport team is equipped with the knowledge and tools needed to react properly to a dental injury.

Hygienists can volunteer to be a resource person for local coaches about dental emergencies. Then when that baseball lands in a players' face, the coach and umpires know just what to do, thanks to your expertise.

Steps for dental trauma in the field

• Remain calm. Remember that a little blood in a lot of saliva looks like a lot of blood.

• Check the victim carefully. Did the patient lose consciousness? Are vision and eye movement normal? Is the airway compromised from bleeding? If so, get emergency medical assistance.

• Next, check the patient's mouth carefully. Are any teeth or sections of teeth mobile? Are any teeth missing? If absent, they could be intruded (pushed back up into the socket) or on the ground nearby.

• If a tooth is found on the ground, handle by crown only. If dirt is on the root, rinse gently in tissue medium, saline solution (contact lens solution), or milk. Tap water may be used but only as a last resort. Do not rinse root with any sterilizing agent or medicament. Do not scrub or pick tissue off the avulsed tooth. The socket should only be cleaned with a gentle stream of saline or water.

• Do not force the tooth back into the socket. If tooth will not easily implant, the alveolar bone socket may be damaged. If it is twisted or in some unusual position in the socket, attempting to reposition it could be very painful without anesthetic. Place tooth in a storage medium if it can't be re-implanted. If no storage medium is available, wrap tightly in plastic. Irreversible damage to periodontal cells begins after about 30 minutes of dry storage and after about 60 minutes in a moist environment.

• Offer ice for swelling or bleeding lips or face, or gauze to protect sensitive teeth surfaces from air or cold liquid.

• A thorough dental exam, including X-rays to check for root and jaw fractures as well as other bony fractures, is critical, even when the trauma appears to be minor.

Cathleen Terhune Alty, RDH, is a frequent contributor. She is based in Clarkston, Mich.