Dental trauma refers to trauma (injury) to the teeth and/or periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.
Dental trauma is most common in younger people, accounting for 17% of injuries to the body in those aged 0–6 years compared to an average of 5% across all ages. It is more frequently observed in males compared to females. Traumatic dental injuries are more common in permanent teeth compared to deciduous teeth and usually involve the front teeth of the upper jaw.
- Enamel infraction
- Enamel fracture
- Enamel-dentine fracture
- Enamel-dentine fracture involving pulp exposure
- Root fracture of tooth
- Concussion (bruising)
- Subluxation of the tooth (tooth knocked loose)
- Luxation of the tooth (displaced)
- Avulsion of the tooth (tooth knocked out)
Injuries to supporting bone tissues (alveolar fractures)Edit
- 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
- Fracture of the mandible
Trauma injuries involving the alveolus can be complicated as it does not happen in isolation, very often presents along with other types of tooth tissue injuries.
Signs of dentoalveolar fracture:
- Change to occlusion
- Multiple teeth moving together as a segment and are normally displaced
- Bruising of attached gingivae
- Gingivae across the fracture line often lacerated
Investigation : Require more than one radiographic view to identify the fracture line.
Treatment : Reposition displaced teeth under local anaesthetic and stabilise the mobile segment with a splint for 4 weeks, suture any soft tissue lacerations.
Soft tissues injuries are presented commonly in association with dental trauma. Areas normally affected are lips, buccal mucosa, gingivae, frenum and tongue. The most common injuries are lips and gingivae. For lips, important to rule out presence of foreign objects in wounds and lacerations through careful examination. A radiograph can be taken to identify any potential foreign objects.
Gingivae lacerations that are small normally heals spontaneously and do not require any intervention. However, this can be one of the clinical presentation of an alveolar fracture. Gingivae bleeding especially around the margins may suggest injury to the periodontal ligament of the tooth.
The facial nerve and parotid duct should be examined for any potential damage when the buccal mucosa is involved.
Deep tissue wounds should be repaired in layers with sutures that are resorbable.
- Age, especially young children
- Primary dentition stage (2–3 years old, when children's motor function is developing and start learning how to walk/ run)
- Mixed dentition stage (8–10 years old)
- Permanent dentition stage (13–15 years old)
- Male > Female 
- Season (Many trauma incidents occur more in summer compared to winter)
- Sports, especially contact sports such as football, hockey, rugby, basketball and skating 
- Piercing in tongue and lips
- Military training
- Acute changes in the barometric pressure, i.e. dental barotrauma, which can affect scuba divers and aviators
- Class II malocclusion with increased overjet and Class II skeletal relationship  and incompetent lips are the significant risk factors
"The oral region comprises 1% of the total body area, yet it accounts for 5% of all bodily injuries. In preschool children, oral injuries make up as much as 17% of all bodily injuries. The incidence of traumatic dental injuries is 1%–3%, and the prevalence is steady at 20%–30%.”
Almost 30% of the children in pre-school have mostly experienced trauma to primary teeth. Dental injuries involving the permanent teeth happen to almost 25% of children in school and 30% of adults. The incident varies in different countries as well as within the country itself. Dental traumatic accidents depends on one's activity status and also the surrounding environment factor but these are the main predisposing risk factor compared to a person's age and gender.
Trauma is the most common cause of loss of permanent incisors in childhood. Dental trauma often lead to the main complication such as pulpal necrosis, and it's nearly impossible to predict the long-term prognosis of the injured tooth and often results in long term restorative problems.
Prevention in general is relatively difficult as it's nearly impossible to stop accidents from happening, especially in children who are quite active. Regular use of a gum shield during sports and other high-risk activities (such as military training) is the most effective prevention for dental trauma. They are mainly being fitted on the upper teeth as it has higher risk of dental trauma compared to the lower teeth. Gum shields ideally have to be comfortable for users, retentive, odourless, tasteless and the materials should not be causing any harm to the body. However, studies in various high-risk populations for dental injuries have repeatedly reported low compliance of individuals for the regular using of mouthguard during activities. Moreover, even with regular use, effectiveness of prevention of dental injuries is not complete, and injuries can still occur even when mouthguards are used as users are not always aware of the best makes or size, which inevitably result in a poor fit.
- Stock ready-moulded
- Not recommended as it does not conform the teeth at all
- Poor retention
- Poor fit
- Higher risk fo dislodging during contact sports and airway occlusion which may lead to respiratory distress
- Self-moulded/ Boil and bite
- Limited range of sizes, which may result in poor fitting
- Can be easily remoulded if distorted
- Made with ethylene vinyl acetate
- The most ideal type of gum shield 
- Good retention
- Able to build in multiple layers/ laminations
One of the most important measures is to impart knowledge and awareness about dental injury to those who are involved in sports environments like boxing and in school children in which they are at high risk of suffering dental trauma through an extensive educational campaign including lectures, leaflets, posters which should be presented in an easy understandable way.
Management and future treatment optionsEdit
The management depends on the type of injury involved and whether it is a baby or an adult tooth. The Dental Trauma Guide is an evidence-based and up-to-date resource to aid management of dental trauma. If teeth are completely knocked out baby front teeth should not be replaced. The area should be cleaned gently and the child brought to see a dentist. Adult front teeth (which usually erupt at around 6 years of age) can be replaced immediately if clean. See below and the Dental Trauma Guide website for more details. If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted, and instead the injury site should be cleaned to allow the adult tooth to begin to erupt).
- Reassure the patient and keep them calm.
- If the tooth can be found, pick it up by the crown (the white part). Avoid touching the root part.
- If the tooth is dirty, wash it briefly (10 seconds) under cold running water but do not scrub the tooth.
- Place the tooth back in the socket where it was lost from, taking care to place it the correct way (matching the other tooth)
- Encourage the patient to bite on a handkerchief to hold the tooth in position.
- If it is not possible to replace the tooth immediately, ideally, the tooth should be placed in Hank's balanced salt solution, if not available, in a glass of milk or a container with the patient's saliva or in the patient's cheek (keeping it between the teeth and the inside of the cheek - note this is not suitable for young children who may swallow the tooth). Transporting the tooth in water is not recommended, as this will damage the delicate cells that make up the tooth's interior.
- Seek emergency dental treatment immediately.
The poster "Save a Tooth" is written for the public and is available in several languages—Spanish, English, Portuguese, French, Icelandic, Italian—and can be obtained at the IADT website.
When the injured teeth are painful while functioning due to damage to the periodontal ligaments (e.g., dental subluxation), a temporary splinting of the injured teeth may relieve the pain and enhance eating ability. Splinting should only be used in certain situations. Splinting in lateral and extrusive luxation had a poorer prognosis than in root fractures. An avulsed permanent tooth should be gently rinsed under tap water and immediately re-planted in its original socket within the alveolar bone and later temporarily splinted by a dentist. Failure to re-plant the avulsed tooth within the first 40 minutes after the injury may result in very poor prognosis for the tooth. Management of injured primary teeth differs from management of permanent teeth; an avulsed primary tooth should not be re-planted (to avoid damage to the permanent dental crypt). This is due to the close proximity of the apex of a primary tooth to the permanent tooth underneath. The permanent dentition can suffer from tooth malformation, impacted teeth and eruption disturbances due to trauma to primary teeth. The priority should always be reducing potential damage to the underlying permanent dentition.
For other injuries, it is important to keep the area clean - by using a soft toothbrush and antiseptic mouthwash such as chlorhexidine gluconate. Soft foods and avoidance of contact sports it also recommended in the short term. Dental care should be sought as quickly as possible.
Complications after management of dental traumaEdit
Not all sequelae of trauma are immediate and many of them can occur months or years after the initial incident thus required prolonged follow-up. Common complications are pulpal necrosis, pulpal obliteration, root resorption and damage to the successors teeth in primary teeth dental trauma. The most common complication was pulp necrosis (34.2%). 50% of the tooth that have trauma related to avulsion experienced ankylotic root resorption after a median TIC (time elapsed between the traumatic event and the diagnosis of complications) of 1.18 years. Teeth that have multiple traumatic events also showed to have higher chance of pulp necrosis (61.9%) compared to teeth that experienced a single traumatic injury (25.3%) in the studies (1)
Pulp necrosis usually occurs either as ischaemic necrosis (infarction) caused by disruption to the blood supply at the apical foramen or as an infection-related liquefactive necrosis following dental trauma (2). Signs of pulpal necrosis include
- Persistent grey colour to tooth that does not fade
- Radiographic signs of periapical inflammation
- Clinical signs of infection: tenderness, sinus, suppuration, swelling
Treatment options will be extraction for the primary tooth. For the permanent tooth, endodontic treatment can be considered.
Root resorption following traumatic dental injuries, whether located along the root surface or within the root canal appears to be a sequel to wound healing events, where a significant amount of the PDL or pulp has been lost due to the effect of acute trauma.
4-24% of traumatized teeth will have some degrees of pulpal obliteration that is characterized by the loss of pulpal space radiographically and yellow discolouration of the clinical crown. No treatment is needed if it is asymptomatic. Treatment options will be extraction for symptomatic primary tooth. For symptomatic permanent tooth, root canal treatment is often challenging due to pulp chamber is filled with calcified material and the ‘drop off’ sensation of entering a pulp chamber will not occur.
Damage to the successor teethEdit
Dental trauma to the primary teeth might cause damage to the permanent teeth. Damage to the permanent teeth especially during development stage might have following consequences:
- Crown dilaceration
- Odontoma-like malformation
- Sequestration of permanent tooth germs
- Root dilaceration
- Arrest of root formation
Trauma to the primary dentitionEdit
Trauma to primary teeth occurs most commonly at the age of 2 to 3 years, during the development of motor coordination. When primary teeth are injured, the resulting treatment prioritises the safety of the adult tooth, and should avoid any risk of damaging the permanent successors. This is because the root apex of an injured primary tooth lies near the tooth germ of the adult tooth.
Therefore, a displaced primary tooth will be removed if it is found to have encroached upon the developing adult tooth germ.If this happens, parents should be advised of possible complications such as enamel hypoplasia, hypocalcification, crown/root dilaceration, or disruptions in tooth eruption sequence.
Potential sequelae can involve pulpal necrosis, pulp obliteration and root resorption. Necrosis is the most common complication and an assessment is generally made based on the colour supplemented with radiograph monitoring. A change in colour may mean that the tooth is still vital but if this persists it is likely to be non-vital.
- Textbook and Color Atlas of Traumatic Injuries to the Teeth, Fourth Edition, edited by Andreason J, Andreasen F, and Andersson L, Wiley-Blackwell, Oxford, UK, 2007
- Zaleckiene V, Peciuliene V, Brukiene V, Drukteinis S (2014). "Traumatic dental injuries: etiology, prevalence and possible outcomes". Stomatologija. 16 (1): 7–14. PMID 24824054.
- Kania MJ, Keeling SD, McGorray SP, Wheeler TT, King GJ (1996). "Risk factors associated with incisor injury in elementary school children". The Angle Orthodontist. 66 (6): 423–32. doi:10.2319/110109-612.1. PMID 8974178.
- Granville-Garcia AF, de Menezes VA, de Lira PI (December 2006). "Dental trauma and associated factors in Brazilian preschoolers". Dental Traumatology. 22 (6): 318–22. doi:10.1111/j.1600-9657.2005.00390.x. PMID 17073924.
- "Permanent teeth – Dental Trauma Guide". Retrieved 2019-01-20.
- "Primary teeth – Dental Trauma Guide". Retrieved 2019-01-20.
- Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T (June 2007). "Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth". Dental Traumatology. 23 (3): 130–6. doi:10.1111/j.1600-9657.2007.00605.x. PMID 17511833.
- Tagar H, Djemal S (September 2017). "Oral surgery II: Part 1. Acute management of dentoalveolar trauma". British Dental Journal. 223 (6): 407–416. doi:10.1038/sj.bdj.2017.805. PMID 28937097.
- Durham J, Moore UJ, Hill CM, Renton T (December 2017). "Oral surgery II: Part 6. Oral and maxillofacial trauma". British Dental Journal. 223 (12): 877–883. doi:10.1038/sj.bdj.2017.995. PMID 29269898.
- Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland LK, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T (August 2007). "Guidelines for the management of traumatic dental injuries. III. Primary teeth". Dental Traumatology. 23 (4): 196–202. doi:10.1111/j.1600-9657.2007.00627.x. PMID 17635351.
- "Guideline on Management of Acute Dental Trauma" (PDF). Council on Clinical Affairs. 2011.
- Jesus MA, Antunes LA, Risso P, Freire MV, Maia LC (January 2010). "Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil". Brazilian Oral Research. 24 (1): 89–94. PMID 20339720.
- Ivancic Jokic N, Bakarcic D, Fugosic V, Majstorovic M, Skrinjaric I (February 2009). "Dental trauma in children and young adults visiting a University Dental Clinic". Dental Traumatology. 25 (1): 84–7. doi:10.1111/j.1600-9657.2008.00711.x. PMID 19208016.
- Perez R, Berkowitz R, McIlveen L, Forrester D (October 1991). "Dental trauma in children: a survey". Endodontics & Dental Traumatology. 7 (5): 212–3. PMID 1687388.
- Young EJ, Macias CR, Stephens L (May 2015). "Common Dental Injury Management in Athletes". Sports Health. 7 (3): 250–5. doi:10.1177/1941738113486077. PMC 4482297. PMID 26131303.
- Levin L, Zadik Y, Becker T (December 2005). "Oral and dental complications of intra-oral piercing". Dental Traumatology. 21 (6): 341–3. doi:10.1111/j.1600-9657.2005.00395.x. PMID 16262620.
- Zadik Y, Levin L (December 2008). "Orofacial injuries and mouth guard use in elite commando fighters". Military Medicine. 173 (12): 1185–7. doi:10.7205/milmed.173.12.1185. PMID 19149336.
- Zadik Y, Levin L (February 2009). "Oral and facial trauma among paratroopers in the Israel Defense Forces". Dental Traumatology. 25 (1): 100–2. doi:10.1111/j.1600-9657.2008.00719.x. PMID 19208020.
- Zadik Y (Jul–Aug 2009). "Dental barotrauma". The International Journal of Prosthodontics. 22 (4): 354–7. PMID 19639071.
- Zadik Y, Drucker S (September 2011). "Diving dentistry: a review of the dental implications of scuba diving". Australian Dental Journal. 56 (3): 265–71. doi:10.1111/j.1834-7819.2011.01340.x. PMID 21884141.
- Zadik Y (January 2009). "Aviation dentistry: current concepts and practice". British Dental Journal. 206 (1): 11–6. doi:10.1038/sj.bdj.2008.1121. PMID 19132029.
- Borzabadi-Farahani A, Borzabadi-Farahani A (December 2011). "The association between orthodontic treatment need and maxillary incisor trauma, a retrospective clinical study". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 112 (6): e75–80. doi:10.1016/j.tripleo.2011.05.024. PMID 21880516.
- Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipour F (October 2010). "An investigation into the association between facial profile and maxillary incisor trauma, a clinical non-radiographic study". Dental Traumatology. 26 (5): 403–8. doi:10.1111/j.1600-9657.2010.00920.x. PMID 20831636.
- Otuyemi OD (June 1994). "Traumatic anterior dental injuries related to incisor overjet and lip competence in 12-year-old Nigerian children". International Journal of Paediatric Dentistry. 4 (2): 81–5. PMID 7748855.
- Andersson L (March 2013). "Epidemiology of traumatic dental injuries". Journal of Endodontics. 39 (3 Suppl): S2–5. doi:10.1016/j.joen.2012.11.021. PMID 23439040.
- Glendor U (December 2008). "Epidemiology of traumatic dental injuries--a 12 year review of the literature". Dental Traumatology. 24 (6): 603–11. doi:10.1111/j.1600-9657.2008.00696.x. PMID 19021651.
- Marcenes W, al Beiruti N, Tayfour D, Issa S (June 1999). "Epidemiology of traumatic injuries to the permanent incisors of 9-12-year-old schoolchildren in Damascus, Syria". Endodontics & Dental Traumatology. 15 (3): 117–23. PMID 10530154.
- Naidoo S, Sheiham A, Tsakos G (April 2009). "Traumatic dental injuries of permanent incisors in 11- to 13-year-old South African schoolchildren". Dental Traumatology. 25 (2): 224–8. doi:10.1111/j.1600-9657.2008.00749.x. PMID 19290905.
- Andreasen FM (May 2001). "Pulpal healing following acute dental trauma: clinical and radiographic review". Practical Procedures & Aesthetic Dentistry. 13 (4): 315–22, quiz 324. PMID 11402773.
- Zadik Y, Levin L (February 2009). "Does a free-of-charge distribution of boil-and-bite mouthguards to young adult amateur sportsmen affect oral and facial trauma?". Dental Traumatology. 25 (1): 69–72. doi:10.1111/j.1600-9657.2008.00708.x. PMID 19208013.
- McCrory, Paul (2001-04-01). "Do mouthguards prevent concussion?". British Journal of Sports Medicine. 35 (2): 81–82. doi:10.1136/bjsm.35.2.81. ISSN 0306-3674. PMID 11273965.
- Jennings, D C (September 1990). "Injuries sustained by users and non-users of gum shields in local rugby union". British Journal of Sports Medicine. 24 (3): 159–165. ISSN 0306-3674. PMC 1478784. PMID 2078800.
- Zadik Y, Jeffet U, Levin L (December 2010). "Prevention of dental trauma in a high-risk military population: the discrepancy between knowledge and willingness to comply". Military Medicine. 175 (12): 1000–3. doi:10.7205/MILMED-D-10-00150. PMID 21265309.
- Patrick DG, van Noort R, Found MS (May 2005). "Scale of protection and the various types of sports mouthguard". British Journal of Sports Medicine. 39 (5): 278–81. doi:10.1136/bjsm.2004.012658. PMID 15849291.
- Kerr, I. L. (November 1986). "Mouth guards for the prevention of injuries in contact sports". Sports Medicine (Auckland, N.Z.). 3 (6): 415–427. doi:10.2165/00007256-198603060-00003. ISSN 0112-1642. PMID 3538271.
- Emerich K, Nadolska-Gazda E (July 2013). "Dental trauma, prevention and knowledge concerning dental first-aid among Polish amateur boxers". Journal of Science and Medicine in Sport. 16 (4): 297–301. doi:10.1016/j.jsams.2012.10.002. PMID 23146163.
- Adnan S, Lone MM, Khan FR, Hussain SM, Nagi SE (April 2018). "Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review". Dental Traumatology : Official Publication of International Association for Dental Traumatology. 34 (2): 59–70. doi:10.1111/edt.12382. PMID 29292570.
- Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T (April 2007). "Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth". Dental Traumatology. 23 (2): 66–71. doi:10.1111/j.1600-9657.2007.00592.x. PMID 17367451.
- Cho WC, Nam OH, Kim MS, Lee HS, Choi SC (May 2018). "A retrospective study of traumatic dental injuries in primary dentition: treatment outcomes of splinting". Acta Odontologica Scandinavica. 76 (4): 253–256. doi:10.1080/00016357.2017.1414956. PMID 29228861.
- Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, Cavalleri G, Cohenca N, Day P, Hicks ML, Malmgren O, Moule AJ, Onetto J, Tsukiboshi M (September 2017). "Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the Primary Dentition". Pediatric Dentistry. 39 (6): 420–428. doi:10.1111/j.1600-9657.2012.01146.x. PMID 29179384.
- Lin S, Pilosof N, Karawani M, Wigler R, Kaufman AY, Teich ST (October 2016). "Occurrence and timing of complications following traumatic dental injuries: A retrospective study in a dental trauma department". Journal of Clinical and Experimental Dentistry. 8 (4): e429–e436. doi:10.4317/jced.53022. PMC 5045691. PMID 27703612.
- Love RM (May 1997). "Effects of dental trauma on the pulp". Practical Periodontics and Aesthetic Dentistry : PPAD. 9 (4): 427–36, quiz 438. PMID 9550069.
- Andreasen JO, Andreasen FM (1992). "Root resorption following traumatic dental injuries". Proceedings of the Finnish Dental Society. Suomen Hammaslaakariseuran Toimituksia. 88 Suppl 1: 95–114. PMID 1354871.
- McCabe PS, Dummer PM (February 2012). "Pulp canal obliteration: an endodontic diagnosis and treatment challenge". International Endodontic Journal. 45 (2): 177–97. doi:10.1111/j.1365-2591.2011.01963.x. PMID 21999441.
- Mahesh R, Kanimozhi IG, Sivakumar M (May 2014). "Dilaceration and Eruption Disturbances in Permanent Teeth: A Sequelae of Trauma to Their Predecessors-Diagnosis and Treatment Using Cone Beam CT". Journal of Clinical and Diagnostic Research : JCDR. 8 (5): ZD10–2. doi:10.7860/JCDR/2014/6657.4342. PMC 4080075. PMID 24995254.
- Flores, Marie Therese (2002). "Traumatic injuries in the primary dentition". Dental Traumatology: Official Publication of International Association for Dental Traumatology. 18 (6): 287–298. ISSN 1600-4469. PMID 12656861.
- Welbury RR, Duggal MS, Hosey MT, eds. (2007). Paediatric Dentistry (Third ed.). Oxford, UK: Oxford University Press. ISBN 978-0071445085.