Dental Trauma in Children: What to Do for a Broken or Knocked-Out Tooth

Dental injuries are among the common events of childhood. Falls are the most frequent cause in toddlers, while play and sports accidents predominate at school age. What is done in the first minutes after such an event can directly affect the tooth's future. In this article we look at the types of trauma, the decisive difference between baby and permanent teeth, first response and treatment options.

The Most Critical Distinction: Baby Tooth or Permanent Tooth?

First response changes completely according to this distinction, and confusing the two can cause harm.

• A BABY tooth that has been knocked out is not put back. The root of a baby tooth lies next to the developing permanent tooth bud beneath it; attempting to reinsert the tooth can damage that bud and lead to a lasting defect in the shape or colour of the permanent tooth. What should be done is to control the bleeding and take the child to a dentist.
• A PERMANENT tooth that has been knocked out is a race against time. The likelihood of being able to replant the tooth is closely related to the time spent outside the mouth and how the tooth was stored. The first minutes are decisive.

If you are not sure which of your child's teeth are baby and which are permanent, store the tooth without scrubbing it in a suitable liquid and see a dentist immediately; the dentist will make the distinction.

First Response for a Knocked-Out Permanent Tooth

1. Hold the tooth by the crown — the white part visible in the mouth. Do not touch the root surface; the thin layer of cells on the root is needed for the tooth to reattach.
2. Do not scrub, brush or use disinfectant. If the tooth is dirty, rinse it gently for a few seconds with cold water or saline only.
3. Put the tooth back if you can. If the child is calm and it is possible, seat the tooth gently into its socket in the correct orientation and hold it in place by having the child bite on clean gauze. This keeps the tooth in the most suitable environment.
4. If you cannot reinsert it, transport it in a suitable liquid. In order of suitability: milk, saline, or the child's own saliva (holding the tooth inside the cheek is only considered in older children where there is no risk of swallowing). Do not leave it in tap water — water is not a suitable environment for the cells on the root surface.
5. Get to a dentist without losing time. The first hour is decisive in this type of injury; the earlier you attend, the wider the range of options available at assessment.

Other Types of Trauma

Fracture (Crown Fracture)

If only the enamel layer is fractured there may be few complaints, but if the fracture reaches the dentine or the nerve, sensitivity to hot and cold and pain follow. If the fractured fragment is found it should be brought to the dentist in milk or saline; in some cases the fragment can be bonded back onto the tooth. Fractured surfaces are usually repaired with composite filling; for details see our article on composite bonding.

Displacement (Luxation)

The tooth may not have come out but may have shifted forwards, backwards or sideways, and is sometimes pushed into the bone. Do not try to reposition the tooth by hand in these cases. After assessing the tooth's position and root development, the dentist repositions it and, where needed, splints it to the neighbouring teeth.

Concussion

There is no visible displacement of the tooth, but it is tender to touch. Monitoring and a soft diet are generally advised. Assessment is still needed: the nerve tissue of a tooth that has taken a blow can be affected weeks or even months later.

Gum and Lip Injuries

Cuts in soft tissue are controlled by applying pressure with clean gauze. Because a tooth fragment may be lodged in the lip or cheek, these areas also need to be examined by a dentist.

What Happens Afterwards? Why Monitoring Takes So Long

The nerve tissue of a tooth that has taken a blow can be affected later, even if it appears healthy at the time. Teeth that have suffered trauma are therefore checked at intervals. The main findings looked for during monitoring are:

• Colour change: Darkening of the tooth can indicate a change in the nerve tissue; see our article on nerve death in a tooth.
• Inflammation at the root tip: Followed on radiographs; root canal treatment comes into consideration where needed.
• Root development: In children the root of a permanent tooth may not yet be complete, and the treatment option changes accordingly.
• Root resorption: A situation requiring monitoring particularly in teeth that were knocked out and replanted.
• The permanent tooth after baby tooth trauma: Whether there is any change in shape or colour in the permanent tooth beneath is followed until it erupts.

Where a baby tooth is lost early, a space maintainer may be needed to preserve room for the permanent tooth.

Prevention

• A mouthguard during sport: The most practical measure for reducing dental injuries in contact sports. Custom-made ones fit better.
• Home safety: Sharp corners and slippery floors are the most frequent causes of falls in toddlers.
• Assessing protruding teeth: Children whose upper front teeth are markedly angled forward are at higher risk of trauma. This is one of the reasons for early orthodontic assessment.
• Helmets for cycling and skateboarding: Models protecting the chin and face region can be preferred.

When You See the Dentist

How and when the event happened and where the tooth was found all directly affect treatment. You will also be asked about the child's tetanus vaccination status and whether there was loss of consciousness, vomiting or headache — where head injury is suspected, medical assessment takes priority. Regular check-ups matter so that a child's first meeting with a dentist does not coincide with an injury; our article on the first dental visit for children may be a useful guide.

Summary

The first minutes matter in childhood dental trauma. A baby tooth that has been knocked out is not put back; a permanent tooth in the same situation should be held by the crown, not scrubbed, and either reinserted or transported in milk and taken to a dentist immediately. Fractures, displacement and concussion also require assessment, and because the nerve tissue of an injured tooth can be affected later, monitoring continues over a long period.

This article is for general information and does not replace emergency medical assessment. Dental trauma requires clinical examination as soon as possible.