Trauma to primary teeth: Setting a steady management course for the office


Evaluate and treat a toddler&s injured loose tooth or lacerated gum in your practice? Or refer these cases to a dental specialist? It all depends?on the injury, the child, and you.


Trauma to primary teeth:
Setting a steady management course for the office

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Choose article section... Looking at epidemiology, incidence, and clinical experience Treating injury to the oral cavity: Available billing codes Variables in the landscape of oral trauma A spectrum of injury Intervention begins with information Steps in examining the patient What should treatment achieve? Establishing priorities in treatment Down in the mouth: Long-term consequences Offering anticipatory guidance

By Arthur J. Nowak, DMD, and Rebecca L. Slayton, DDS, PhD

Evaluate and treat a toddler's injured loose tooth or lacerated gum yourself—knowing that much is at stake because damage can go deep to developing permanent teeth? Or refer these cases to a dental specialist? It all depends—on the injury, the child, and your skills.

Oral and dental trauma are common in infants and pre-school children. Treatment is often delayed, however, because parents cannot ascertain the seriousness of the injury or are unsure where to seek treatment. And although some types of oral injury in young children can be easily treated by the parent by applying pressure to stop bleeding and ice to control swelling, others require immediate professional intervention in—depending on the nature of the injury—the pediatrician's or dentist's office or the community hospital's emergency department (ED) or trauma center.

A potential barrier to providing care for patients who are brought to a pediatrician's office with any degree or type of injury to the teeth or mouth is that most lack formal training in the management of oral trauma, and that their offices—and even community EDs—lack the appropriate equipment for diagnosing and treating such injury. This strikes us as unfortunate, because we believe that it is important for pediatricians to be familiar with the common types of oral injuries, to know when referral is necessary, and to understand current management principles.

In this article, we review what decisions need to be made during the evaluation of trauma to the primary teeth and surrounding structures of preschool- and early school-age children—toward the goal of maintaining and protecting the integrity of those teeth and minimizing injury to developing underlying permanent dentition and surrounding soft tissue. Why focus on trauma to primary dentition and possible effects on developing (unerupted) permanent teeth? Because most children have made their first visit to a dentist before permanent anterior teeth erupt, and parents are most likely to visit their child's established dentist or the ED of a local hospital for emergency treatment of trauma to those permanent teeth.

Looking at epidemiology, incidence, and clinical experience

National statistics are available on injuries to the face and head secondary to trauma, but few reports touch specifically on injury to the oral cavity or, especially, the teeth. Regrettably, the ICD-9-CM (International Classification of Disease—9th revision—Clinical Modification) codes that physicians use and the so-called E codes used in EDs often do not accurately convey the extent of injury—even though codes are available to provide these data (see table). The problem is compounded by the fact that few nonacademic EDs have a dentist on staff who is available to provide treatment and who is familiar with these specific codes.


Treating injury to the oral cavity:
Available billing codes

Condition or injury
Loss of tooth
Disturbance of tooth formation
Disturbance of tooth eruption
Ankylosis of tooth
Injury or location of injury
Buccal mucosa
Broken tooth
Tongue and floor of mouth
Buccal mucosa
Broken tooth
Tongue and floor of mouth


It is regrettable, too, that the concept of the so-called dental home1 is not as well developed as the medical home. More than 75% of children between birth and 3 years of age have not had a nonemergency first dental visit, reports suggest; those children are not, therefore, registered as a patient in a dental office.2 This situation makes it highly likely that their parents will contact a primary care provider or the ED of the local hospital for advice or treatment when an emergency arises involving primary teeth.

No national study of pediatricians' knowledge of, or clinical experience with, managing oral trauma has been conducted. In one regional survey of pediatricians' knowledge of dental care, the greatest percentage of responders—34.7%—said that they felt that they lacked the confidence to manage a traumatic oral injury; 20.6% reported that they would rather refer such cases to a dentist; and only 17.4% felt confident about managing dental trauma.3 Reports of the adequacy of participatory experiences and learning opportunities during pediatric residency training show that most residents (76% and 78% in two studies) found their residency experience in dentistry insufficient (no explanation was offered about why they think this way).4

The head, face, neck, and mouth are frequently reported sites of injury in child abuse, but no clear indication has been made in the data reported of the frequency of tooth and oral tissue injury. We do know that, when a dentist is a member of a child abuse evaluation team, examination reports show that the incidence of oral trauma (mostly torn frena, bruised lips, and luxated anterior teeth) is as high as 50% to 75%.5 When dentists do not participate in the team's work, the reported incidence falls as low as 2.76% to 11%.6,7

Although all primary teeth are at risk of a variety of injuries, the maxillary anterior primary teeth are affected most often.8 A toddler who has protrusive anterior teeth with minimal lip coverage is at greater risk.

Complicated crown and root fractures are possible but not common. The force of trauma is most often transferred through the tooth, reducing the risk of fracture.

Because of the direction of force and the elasticity of alveolar bone surrounding primary teeth, the most common injury is luxation, or displacement, with gingival hemorrhage. Lateral luxation (usually palatal) is the most common trauma to the tooth, followed by intrusion and then avulsion. These terms are defined later under "A spectrum of injury."

Alveolar bone fracture is always possible with a luxation injury, but the prevalence has not been reported in the literature. Fracture of the mandible has been reported, with condylar fracture the most common subtype.8

Variables in the landscape of oral trauma

At least one third of preschool children suffer a trauma that affects their primary teeth.9 Although data do not exist on children who have special health-care needs, our clinical experience and the experience of others leads us to conclude that those children are, at the least, affected to a similar degree, and that children who have a neurologic deficit may be at even higher risk of trauma to primary teeth.

The peak period for trauma is 18 to 40 months of age, most likely because this is a time of constant change in a toddler's environment and mobility. Only a small difference between the risk of oral injury to boys and to girls has been reported during the first 12 months of life, although the risk to boys increases proportionately after infancy.

At one time, seasonal variation was reported in the prevalence of oral trauma because cold weather restricted outdoor activity during the winter. Today, however, activities once limited to the outdoors have also come inside—into homes with family rooms and game rooms, community indoor recreational facilities, and commercial sports and game centers—where children participate even during the most inclement weather and are at risk of oral trauma year-round.

A spectrum of injury

Children who are learning to walk or are still relatively uncoordinated often suffer trauma to the teeth or face as the result of a fall. Trauma to orofacial structures may be limited to soft or hard tissue, or may involve both types. The degree of trauma is influenced by how far a child falls, how fast he (or she) is moving when he falls, and what object or surface he lands on. It is common to see a traumatic injury to a young child in which only the upper front teeth are involved; even so, a thorough examination should be performed to identify any other consequences of the fall.

Soft tissue trauma. Lips often cushion the teeth during a fall, and may therefore be bruised or lacerated by the impact of teeth against tissue. The upper and lower lips should be examined carefully for laceration; if laceration is present, determine whether or not a foreign body, such as a tooth fragment or gravel, has been introduced to the wound. Swelling and bruising of the lips are common findings after oral trauma, even in the absence of laceration (Figure 1).



Frena—particularly the maxillary labial frenum—may be torn as a result of trauma to the mouth or teeth (Figure 2). The extent of the tear also depends on the degree of the original attachment of the frenum. Although this type of injury can be the result of uncomplicated trauma, it is often associated with child abuse; in an infant who does not yet walk or crawl, for example, a torn frenum is less likely the consequence of an accident than the result of an object being forced into the child's mouth, and should be investigated as a potential finding of child abuse. Once a child is mobile, any fall that causes trauma to the mouth is very likely to result in a torn maxillary frenum. In all cases of a torn frenum, obtain a thorough history of the injury to determine if the description of the event matches the outcome.



Trauma to the tongue can include laceration (Figure 3) or puncture, usually caused by the teeth. The extent of a laceration should be determined by careful examination. In general, suturing a laceration of the tongue does not improve the outcome,10 except that it is required when the laceration is severe. Suturing of a tongue laceration should be performed by a practitioner experienced at the procedure, which includes most oral surgeons, some pediatric dentists, and otolaryngologists. Prompt referral to one of these specialists is recommended.



Bleeding around the gingiva is common after traumatic luxation injury to the teeth (Figure 4). Often, the teeth will be slightly mobile as a result of the trauma. Gingival tissue may also be lacerated adjacent to traumatized tooth. Perform an examination to determine the extent of the laceration and whether foreign objects are present.



A child who falls while holding an object in his mouth—most commonly, a stick, pencil or pen, straw, or toothbrush—often suffers an impalement injury of the oropharynx. Most impalement injuries heal spontaneously, but the wound should be explored for possible foreign bodies, and you should determine whether a prophylactic antibiotic should be prescribed to avoid infectious complications. In some cases of impalement—because of the type of object that caused the injury or the extent of trauma—the injury can be serious and may require additional diagnostic procedures—surgical exploration, examination by a otolaryngologist, additional radiographs—to determine the extent of damage.

Hard tissue trauma. Proper management of trauma to the primary teeth themselves is important for a number of reasons:

• Traumatized teeth often lose their vitality over time and may become discolored or abscessed, or both. (Parents must be made aware of the symptoms associated with an abscessed tooth so that they can seek timely treatment for their child.)

• Some types of traumatic injury to primary teeth result in damage to permanent teeth.

• Dental trauma that causes movement of teeth may interfere with the way a child's teeth fit together—causing pain during chewing that is not be relieved until the tooth is repositioned or extracted.

In any traumatic injury, it is important to determine the cause of the injury (to rule out child abuse) and the full extent of the injury (to rule out fracture of the skull or jaws). Following are specific types of traumatic injuries that can affect primary teeth.

Concussion describes a tooth that is mobile after trauma but has not been displaced. There may be bleeding around the gums.

Luxation involves displacement of the tooth in a labial, lingual. or lateral direction. Soft tissue injury, including damage to the periodontal ligament, and contusion or fracture of the supporting alveolar bone often accompany this trauma.

Intrusion of a primary tooth describes displacement of the tooth into the socket (Figure 5); the tooth may be partially or completely intruded. In some cases, the tip of the root visibly pokes through the gingival tissue. This type of injury causes compression of the periodontal ligament and may result in a fracture of the socket.



Avulsion of a tooth occurs when the tooth is completely displaced out of the socket.

Extrusion is the term often applied when a tooth is only partially avulsed.

A crown fracture (Figure 6) is classified based on the location of the fracture in relation to various dental tissues. A fracture of the crown of the tooth may be limited to enamel or dentin or may involve exposure of pulp tissue.



A crown-root fracture involves tissues of the crown and root. A vertical fracture of a tooth that exposes dentin on the crown but that extends below the gum line, for example, would be classified as a crown-root fracture.

A root fracture is classified based on the level of the fracture in relation to the apex of the root. Such a fracture may occur in the apical third, middle third, or cervical third of the tooth. The prognosis for a tooth becomes worse the farther cervically the fracture. Often, the crown of the tooth is intact. The diagnosis of root fracture can only be made radiographically (Figure 7).



Jaw fracture (Figure 8, left) is an occasional consequence of trauma in young children, and must be ruled out in every child who has sustained an oral injury. The most common locations for trauma to the mandible are in the anterior symphysis and the condylar head. Evidence of a blow to the chin is an important indicator of the risk of a mandibular fracture. Suspect a fracture in the anterior mandible if examination of the lower teeth reveals a step-up or step-down between the lower central incisors. Proper diagnosis of this type of fracture requires a mandibular occlusal or panoramic radiograph, which shows a bilateral "step up" of the anterior segment of the mandible (Figure 8, right), and which most pediatricians and EDs lack the equipment to perform. When this type of fracture is suspected, the child should be referred to a dentist to confirm the diagnosis. Suspect condylar fracture when a child has limited occlusal opening, difficulty biting teeth together properly, facial asymmetry, or paresthesia; refer him to a dentist for confirmation, which requires a panoramic radiograph with closed- and open-mouth views.



Intervention begins with information

Management of oral trauma proceeds stepwise. The evaluation starts with observation and gathering of information.

Does the injury constitute an emergency? Traumatic injury of the face or mouth of a child runs the gamut from relatively mild to very severe. It is important to gauge severity first to determine if emergency medical procedures should be instituted—that is, the customary ABCs of establishing a patent airway, ensuring adequate breathing, and determining the condition of the circulatory system. If the injury has not created a medical emergency, proceed with taking the medical history and evaluating the details of the trauma.

What is the complete medical history? This step takes on particular importance when the patient is not one of record in your practice, as might happen in what the parents perceive is an emergency. Assess the presence of any cardiac disease that necessitates antibiotic prophylaxis against bacterial endocarditis. Determine whether the child has a bleeding disorder or is immunocompromised. Question the parent about medication allergies. Record any current medications. Last, it is important—with all orofacial trauma—to determine whether the child's tetanus immunization is up to date.

What is the history of the presenting trauma? Thorough description of the dental injury must be obtained from the parent and, when possible, the child. This should be well documented. Many offices have a special form to document traumatic injury that facilitates the examination process. Information to be gathered includes:

  • When did the trauma occur? Where?

  • How did the child fall?

  • Did he sustain other injuries?

  • What treatment, if any, has already been given?

  • Did the child lose consciousness?

  • Has he suffered previous dental trauma?

  • If one or more teeth were avulsed, does the parent have possession of the tooth? (If not, consider the possibility of aspiration; parents should then be asked if the child has been coughing since the injury occurred.)

Last, determine whether the injury is consistent with the parent's description, to rule out child abuse.

Steps in examining the patient

Extraoral exam. The entire body should be examined to rule out other injuries. Examine the head and neck to include:

  • palpation of the facial skeleton, including the mandible, zygoma, temporomandibular joint, and mastoid region

  • recording of any extraoral lacerations, bruises, and swelling

  • notation of excursive mandibular movements

  • gauging pain or stiffness in the neck.

In some cases, trauma may have legal implications, making documentation of the child's injuries at the time of trauma important. Extraoral or intraoral photographs, or both, should be taken when possible and with the parents' permission.

Intraoral exam. Oral soft tissues should be examined for bruising or laceration. These include the labial mucosa, maxillary frenum, gingival tissues, and tongue.

The alveolus should be palpated to detect the presence of fracture. Teeth should be evaluated to determine if they have been fractured or displaced. Document the extent of any fracture and the extent and direction of displacement of the teeth. The upper and lower teeth should be evaluated for mobility and the extent of mobility documented. Ask the patient to clench his teeth so that the occlusion can be evaluated. Discrepancies in each arch and in the occlusion between arches should be noted.

Imaging. Radiographs are an essential part of the evaluation of a traumatic injury. They allow the clinician to detect root fracture, the extent of displacement of teeth, position of unerupted permanent teeth, and the presence of foreign bodies in soft tissues. In addition, radiographs made at the time of injury or shortly thereafter provide a baseline against which future radiographs can be compared.11 If it is not possible to make a radiograph at the time of injury, and if the injury appears minor, the child should be referred to his pediatric dentist for evaluation as soon as is possible.

For most injuries to maxillary or mandibular anterior teeth, an occlusal radiograph is the film of choice. It can be made on a young child with minimal discomfort. If a root fracture is suspected, an additional radiograph, at a different angle, is often required. Panoramic radiographs are useful for evaluating a mandibular or condylar fracture. Evaluation of intrusive luxation often utilizes a lateral anterior radiograph.

Other tests. If any sign of head injury is noted, refer the child immediately for appropriate medical assessment. Signs of head injury include loss of consciousness, bleeding from the head or ears, Battle's sign (bruising in the mastoid region), disorientation, altered vision or a unilateral dilated pupil, seizures, and speech difficulties.

What should treatment achieve?

The objective in treating traumatic dental injury in a young child is to prevent serious long-term consequences to developing dentition and rule out other injury. Because most EDs and pediatricians' offices do not have dental instruments or access to equipment to make intraoral radiographs, most children who suffer a dental trauma should be referred to a pediatric dentist. It is important, however, for pediatricians to understand how oral and dental traumatic injuries are managed so that they can provide information and reassurance to parents during initial evaluation of the injury. Here is a summary of the required treatment for various types of injury to primary teeth.

Crown fracture with exposed pulp. Treatment depends a great deal on the behavior of the child: If he is cooperative, pulp tissue can be cleaned out of the tooth in a procedure similar to a root canal. The tooth can then be restored with a tooth-colored composite material. If the child is uncooperative, the tooth must be extracted.

Luxation. If radiographic evaluation shows that the root of the tooth is touching the developing permanent tooth bud, the luxated primary tooth should be extracted; otherwise, it should be repositioned manually. If the patient is being seen for the first time after more than 24 hours have passed since the injury, repositioning the tooth is impossible.

Intrusion. A primary tooth that is intruded should be allowed to re-erupt on its own; rarely is there a reason to "go after" an intruded primary tooth. An exception is when the intrusion has caused the root tip to puncture the floor of the nasal cavity; in that case, removing the tooth through the nares is the best course.

Root fracture. The prognosis for a tooth that has been fractured depends on the location of the fracture relative to the crown of the tooth: The closer to the crown, the worse the prognosis. No treatment is indicated initially, but the tooth should be evaluated on a regular basis. If an abscess or mobility develops, the tooth should be extracted; as long as it remains stable, it can be retained. The root fragment will resorb as a part of the normal exfoliation of the tooth.

Avulsion. A primary tooth that has been avulsed should never be replaced. In most cases, premature loss of a primary tooth results in delayed eruption of the permanent successor. In fact, parents should be advised of possible injury to developing permanent teeth in all cases of trauma to primary teeth.12

Establishing priorities in treatment

The most important early priority in managing orofacial trauma is to rule out medical complications, such as head and cervical spine injury and mandibular fracture. Once the possibility of these coexisting injuries has been eliminated, the next step is to control bleeding from intraoral and extraoral lacerations. Sutures should be placed after the injured area has been cleaned and foreign objects have been removed (see "Keeping the child with an oral injury cooperative"). If the injury that remains is limited to the teeth or jaws, or both, the child should be referred to a pediatric or general dentist for definitive diagnosis of the dental injury.

A child who has sustained traumatic oral injury should be monitored on a regular basis, and his parents should be cautioned about potential sequelae so that they know what signs to watch for and how to respond. If soft tissues were injured, requiring sutures, the child should be seen again in approximately seven days to evaluate healing and remove the sutures (unless absorbable sutures were used). Clinical and radiographic examination should be performed by a dentist four, eight, and 26 weeks and one year after injury.

Down in the mouth: Long-term consequences

The uniqueness of primary teeth and their proximity to developing permanent teeth mean that oral trauma in a young child can have distinct sequelae. Young children are fortunate that oral soft tissues heal rapidly and, usually, without ill effects when injury has been properly managed. The oral frena, for example, will, when torn or lacerated, often heal (albeit shortened) without long-term consequences. A facial laceration in a highly visible area that requires suturing, on the other hand, should be attended to by a plastic surgeon after emergency first aid has been provided.

Discoloration of a tooth after trauma (Figure 9) is the most common consequence noted by parents, child, and health-care provider. Pink, reddish gray, gray-black and yellow discolorations are most common. This discoloration can be noted during the weeks immediately after injury or after a delay; it is caused by tissue ischemia secondary to damage to the tooth pulp and its blood supply. If the pulp survives the injury, the tooth may return to normal color or, at the least, to a color that is less objectionable.



Intruded primary teeth commonly re-erupt, but may take as long as six months to do so and may not erupt completely, especially when more than 50% of the crown was intruded. In severe intrusion with alveolar bone fracture, ankylosis (immobility) of the tooth has been reported in as many as 6% of cases.14

Abscess (Figure 10) and cellulitis are possible sequelae of luxated teeth and, especially, intruded teeth.



With complete extrusion (avulsion) a space remains; this can be a major concern for parents, especially if eruption of a permanent tooth to replace the avulsed tooth is years away. Generally, the response to this problem is guided by the practitioner's experiences and the parents' desires. The age of the child, number of teeth lost, presence or absence of nonnutritive sucking habits, and the child's social needs are taken into consideration when planning a replacement tooth or undertaking maintenance of the space.

Permanent teeth may, eventually, exhibit the effects of an earlier traumatic insult by a primary incisor. The type and severity of the damage to the permanent tooth depends on the child's age at injury, the type of injury to the primary tooth, and the treatment at the time of injury. Generally, the younger the child at injury, the greater the risk of damage to the permanent tooth. A severe intrusion injury is most likely to damage the developing permanent tooth; the damage will be evident upon eruption of the permanent tooth as an isolated defect of the enamel. Hypoplasia or hypocalcified areas (or both) of the front surface of the permanent tooth may vary from white chalky areas to deeply pitted brown spots (Figure 11). An isolated defect on one tooth is usually a good indicator of earlier trauma.



Dilaceration of the crown and root (an abnormal bend of the root during development) is a more serious problem that is diagnosed only after radiographic determination of why a permanent tooth has not erupted (Figure 12).



Early loss of a primary tooth—usually, before 3 or 4 years of age—will often delay the eruption of the permanent tooth. Loss of a primary tooth after 5 years of age accelerates eruption of the underlying permanent tooth. Inappropriate or delayed management of an ankylosed primary tooth, secondary to intrusion, may also delay eruption of the permanent tooth or cause it to erupt in an ectopic position. Early loss of a primary tooth and an associated nonnutritive sucking habit may lead to space loss and drifting of teeth (Figure 13).



Offering anticipatory guidance

It is difficult to childproof a home or day-care facility against traumatic injury. Nevertheless, parents and caregivers should be reminded of toddlers' risk of injury as they develop and, especially, as they begin to walk, and should be encouraged to take reasonable steps to minimize that risk.

Recommend to parents, for example, that certain areas in a home be designated for, and restricted to, play. Stairs should be barricaded with a gate. Unstable chairs, swings, and walkers should not be used. Sharp or protruding furniture and accessories should be placed in areas that are off-limits to the toddler. In a car, parents should always place young children in an appropriate-sized child seat that is in the proper position and location. A toddler in a stroller should be belted in and never left alone.

Despite anticipatory guidance, accidents happen. For that reason, you should provide to parents information on how to handle an oral emergency in their child, including the daytime and evening telephone number of a health-care professional (or more than one) who treats oral trauma.

What about mouthguards? They are effective in older children who participate in contact sports, but we know of no indications for which they are made for, or should be used by, a toddler. When the time comes for a child to ride a tricycle, bicycle, scooter, or other wheeled riding toy, an appropriately fitted helmet is recommended. Such helmets are available in small sizes for younger children.

Keep in mind that the outcome of all trauma to the face, mouth, and teeth is potentially complicated. Encourage the parents and caregivers of children in your practice, therefore, to contact you, a pediatric dentist, or the hospital's ED for assistance any time their child sustains oral trauma. Too often, parents report having been—wrongly—told by well-meaning people: "Don't worry, those are only baby teeth!" Worse is for a medical professional to have to inform them that no treatment can be performed.

Last, based on current guidelines, make your recommendation to parents for a first nonemergency dental appointment when their child is 12 to 18 months old.16 Once a child is registered with a dentist, he has established a dental home that will reassure his parents not only about routine preventive care but, if ever necessary, emergency evaluation and treatment. To assist families whose circumstances make it impossible for them to establish a dental home, urge your local or regional medical and dental associations to establish—if they have not already done so—a trauma call schedule in cooperation with the community hospital. (For additional recommendations, see "Key points: Managing oral trauma in young children".


1. Nowak A, Cassamassino P: The dental home—a primary care oral health concept. J Am Dent Assoc 2002;133:93

2. Edelstein BL, Manski RJ, Moeller JF: Pediatric dental visits during 1996: An analysis of the federal Medicaid Expenditure Panel Survey. Pediatric Dent 2000;22:17

3. Tsamtsouris A, Gavsis V: Survey of pediatricians' attitudes towards pediatric dental health. J Pedodon 1990;14:152

4. Wender EH, Bijur PE, Boyce WT: Pediatric residency training: Ten years after the Task Force report. Pediatrics 1992;90:876

5. Becker DB, Needlman HL, Kotelchuck M: Child abuse and dentistry: Orofacial trauma and its recognition by dentists. J Am Dent Assoc 1978; 97:24

6. Naidoo S: A profile of the orofacial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000;24:521

7. Jessee SA: Physical manifestations of child abuse to the head, face and mouth: a hospital survey. ASDC J Dent Child 1995;62:245

8. Fried I, Erickson P: Anterior tooth trauma in the primary dentition. Incidence, classification, treatment methods, and sequelae. J Dent Child 1995;62:256

9. Cossco PI, Galvey FE, Perez JL, et al: Mandibular fractures in children. Int J Oral Maxillofac Surg 1994; 23:329

10. Andreasen JO, Andreasen FM: Classification, etiology and epidemiology of traumatic injuries, in Andreasen JO, Andreasen FM (eds): Textbook and Color Atlas of Traumatic Injuries to the Teeth, ed 3. Copenhagen, Denmark, Munskgaard, 1993, pp 151–177

11. Lamell CW, Fraone G, Casamassimo PS, et al: Presenting characteristics and treatment outcomes for tongue lacerations in children. Pediatr Dent 1999;21:34

12. Guidelines for prescribing dental radiographs, AAPD Reference Manual 2000-2001. Pediatr Dent 2000;22:65

13. Nowak AJ, (ed): The Handbook. Chicago, Ill., American Academy of Pediatric Dentistry, 1999, p 95

14. Andreasen JO, Andreasen FM, Bakland LK, et al: Traumatic Dental Injuries: A Manual. Copenhagen, Denmark, Munksgaard,1999

15. McTigue DJ: Introduction to dental trauma: Managing traumatic injuries in the primary dentition, in Pinkham JR (ed): Pediatric Dentistry: Infancy through Adolescence. Philadelphia, Pa., WB Saunders, 1999, pp 213–224

16. Borum MK, Andreasen JO: Sequela of trauma to primary maxillary incisor: I. Complications in the primary dentition. Endod Dent Traumatol 1998;14:31

17. Green M., Palfrey JS (eds): Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, ed 2. Arlington, Va., National Center for Education in Maternal and Child Health, 2000, p 115

DR. NOWAK is emeritus professor in the departments of pediatric dentistry and pediatrics, Colleges of Dentistry and Medicine, University of Iowa, Iowa City.
DR. SLAYTON is associate professor in, and chair of, the department of pediatric dentistry, Oregon Health & Science University, Portland.

Keeping the child with an oral injury cooperative

Traumatic injuries to primary teeth can be treated by a pediatric dentist or by some general dentists in the dental office. Strategies for keeping the patient still and cooperative extend to the pediatrician's office, when applicable, in the evaluation and management of oral trauma.

When the patient is a very young, precooperative child, the examination is often performed in a practitioner–parent, knee-to-knee position with an assistant or colleague (if available) directing the light and passing instruments. Conscious sedation can, if indicated, be used to relax the child and make him less combative; oral midazolam is useful in such a situation because it has anxiolytic and amnestic effects. Sedative agents should be used only with appropriate monitoring equipment, however, and by following guidelines of the American Academy of Pediatric Dentistry or the American Academy of Pediatrics for conscious sedation. For a more severe traumatic injury—when deep sedation or general anesthesia is indicated—in-hospital treatment is recommended.

Radiographic examination of a young child can be performed successfully by having him sit on the parent's lap as the parent stabilizes the film in the child's mouth. If necessary—and after obtaining informed consent—films can also be made with the child immobilized on a papoose board or in a PEDI-WRAP immobilizer (The MEDI-KID Co.).

Key points: Managing oral trauma in young children

  • Traumatic injuries to primary teeth are common and require professional management.

  • Pediatricians in practice and community hospital EDs should, we urge, collaborate with community dentists to ensure that a dental emergency service is available within the service area.

  • Toddlers should have their first nonemergency oral health examination by 18 months of age so that, first, parents receive anticipatory guidance on oral trauma and, second, a dental home is established for the child. Children with special health-care needs should be seen even earlier

  • Children in whom child abuse is suspected should have a thorough examination of the oral cavity, including teeth, soft tissue, and facial bones.

  • Appropriate ICD-9-CM Codes and E Codes for oral trauma should be used to record visits for those conditions and interventions that are conducted in the pediatrician's office or the ED.

  • Because so many traumatic episodes occur before a child has had a so-called dental home established, many pediatricians and ED physicians are called on to make recommendations for management and emergency treatment—yet few, if any, physicians have been trained in current concepts in the management of dental trauma, and few private offices or even EDs are equipped with the necessary diagnostic tools to initiate appropriate intervention.

  • We believe that didactic instruction and clinical experiences should be included in pediatric and emergency medicine residency programs so that physicians have an understanding of the management of oral trauma upon completion of their training.


Arthur Nowak, Rebecca Slayton. Trauma to primary teeth: Setting a steady management course for the office. Contemporary Pediatrics 2002;11:99.

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