Traumatic Dental Injuries: Knocked-Out and Broken Teeth

Dental trauma is most common in children learning to walk, in school-age children playing sport, and in adults from falls, collisions and accidents. The upper front teeth take the great majority of it.

What makes dental trauma different from most dental problems is that the first hour often determines the outcome. This article covers what to do immediately, what treatment follows, and what the long-term picture looks like.

The knocked-out tooth

A completely avulsed permanent tooth is the one true race against the clock in dentistry. The periodontal ligament cells on the root surface are what allow the tooth to reattach, and they begin dying within minutes of drying out.

Handle the tooth by the crown only, never the root. If it is visibly dirty, rinse it for a few seconds in milk, saline or the patient's saliva. Do not scrub it, do not use soap, and do not use tap water for more than a brief rinse, since its osmolality damages the ligament cells. Do not let it dry.

The best action is to place it back in the socket immediately, orienting it the same way as the neighboring teeth, and have the patient bite gently on a cloth to hold it. If that is not possible, store it in cold milk, which is the most widely available good medium, or in saline, or inside the patient's cheek if they are old enough not to swallow it. Then get to a dentist or emergency department immediately. Replantation within thirty minutes gives the best prognosis; after about sixty minutes outside the mouth and dry, the outlook falls considerably.

A knocked-out baby tooth is not replanted. Doing so risks damaging the developing permanent tooth above it. It still needs evaluation.

Displaced, loosened and intruded teeth

A tooth pushed sideways, forced out of the socket, or driven up into the bone needs prompt professional repositioning, ideally within a few hours. Early repositioning and splinting gives the best chance of the ligament and pulp recovering, and a tooth left displaced begins to stabilize in the wrong position.

Intruded teeth, driven into the bone, are the most serious of these because of the crushing injury to the ligament and blood supply. Depending on the degree and the patient's stage of development, they may be allowed to re-erupt spontaneously, repositioned orthodontically, or repositioned surgically.

A tooth that is merely loosened without displacement is usually splinted for a couple of weeks and monitored. Do not wiggle a loose tooth to test it, and keep to a soft diet.

Fractures

Enamel-only chips are common and can be smoothed or bonded, and are not urgent. When the fracture exposes the yellower dentin underneath, the tooth becomes sensitive and the exposed dentin tubules are a route for bacteria toward the pulp, so it should be covered within a day or two.

If a pink or red spot is visible in the middle of the fracture, the pulp is exposed. This needs treatment quickly. In a young tooth with an incompletely formed root, a procedure that protects and preserves the living pulp is often possible and is strongly preferred, since a living pulp allows the root to finish developing. In a mature tooth, root canal treatment may be needed.

Save any fragments in milk. A clean fragment can frequently be bonded back onto the tooth and is a better esthetic result than composite, because it is the original enamel. Root fractures, below the gum, vary enormously in prognosis depending on where along the root they occur.

Follow-up matters as much as the first visit

Traumatized teeth need monitoring for years, not weeks. The pulp may survive the injury or may die months or even years later, and the only way to know is scheduled review with vitality testing and X-rays, typically at intervals over the first year and then annually.

Warning signs to report between visits are the tooth darkening, a pimple-like swelling on the gum above it, pain on biting, or new sensitivity. A tooth that has darkened has usually lost its pulp, which is treatable with root canal therapy and internal bleaching.

Replanted teeth in particular are monitored for root resorption, where the body gradually replaces the root with bone. When it occurs, it can be slow and the tooth may serve for many years, which is often worth it, especially in a growing child where the alternative timing is poor.

Prevention and preparedness

A properly fitted mouthguard prevents the large majority of sport-related dental injuries, and custom guards are worn more consistently than boil-and-bite ones because they are comfortable. Helmets with face protection matter for cycling and skating.

In the home, the common causes in toddlers are furniture edges and hard floors, and in older adults they are falls, so the general fall-prevention measures apply here too.

Keep a small kit and our number somewhere findable. If an injury happens, call and describe it rather than deciding on your own whether it can wait. Cedar Creek Dentistry in Portland can advise you in the moment, and for an avulsed tooth those minutes are the whole treatment.

Questions about your own care? The team at The Best Dentist In Portland, Oregon is happy to help — call us at (503) 646-1811.

This article is for general information only and is not medical advice.