Wednesday, October 05, 2005

When to Call the Dentist, When to Go to the Emergency Room

Your child just fell riding his bicycle. There is lots of blood. His mouth is a mess. Who do you call? What do you do? Children will find a way to injure themselves despite our best preventive measures as parents. Some orofacial injuries are serious and some are nothing to worry about. How do you tell? Well, here are some guidelines.

If there is lots of blood, don't panic. Any injury to the mouth bleeds a lot. Check out the situation; hold a cloth (if you can) with pressure to slow the bleeding. Most bleeding stops within 10 -15 minutes whether you do anything or not. Once your heart stops racing so much and the child is not in such a state, look and see what the problem is. First look and see if there are facial cuts or lacerations, fear of a broken jaw, possible head trauma causing loss of consciousness (concussion), multiple knocked out and displaced teeth (an oral surgeon may need to see you at the hospital), or if you just are not too sure, then you need to go to the ER. They can stitch up any facial lacerations and take major X-Rays to check all that other stuff.

Now, if you don't have those bad things, you still might have a scary mess to deal with. If you go to the ER, you are likely to sit there for two hours and then they will call your dentist anyway. You can call your dentist first and he may be able to save you the trip to the ER.

*If a young child has hit his mouth, there is lots of blood especially on his upper teeth lip area, look and see if it might just be a torn maxillary frenum. That's the little piece of tissue that connects the upper lip to the gum between the two front teeth. If it was tight and gets hit and stretched too much it will tear. It bleeds a lot at first, but will likely be fine after 20 minutes or so. Usually no stitches are necessary. In fact there may be no treatment needed at all. This is a very common injury in preschoolers.

If there is a broken tooth, the ER is not likely to be able to do much. If a tooth is knocked out, and if it is a permanent tooth, you need to get the tooth back in soon as possible, your dentist can help. The ER can put a knocked out tooth back in too, but you still may need a dentist to splint the tooth, so you may want to call the dentist first. If the knocked out tooth is a baby tooth, just leave it out and put it under their pillow. A baby tooth can be intruded (pushed up into the gums) where is is difficult to see. Sometimes it can re-erupt on it's own, but still may need to be removed or need other longer term treatments. If your child is in braces and a wire breaks, etc., call your pediatric dentist or orthodontist.

Here is a useful link for quick reference: APDA Dental Emergencies Quick Reference
More here: Fractured Teeth, Knocked out Teeth, and other Pediatric Dental Accidents
More here: My Child's Tooth is Turning Dark!

57 comments:

Anonymous said...

Hi Dr. Brandon,

I am a Pedo resident from UNC Chapel Hill. I am preparing a lecture to MD's about dental emergencies and while searching for material on the web, I came across your webpages. They are well organized and informative. I am wondering if you wouldn't mind letting me use them?

Also, in the Knocked Out Teeth section, you stated that if milk is not available, teeth can be stored in water. From my training here, the endo department believes that storage in water is no different than dry storage because water is too hypotonic and the live cells around the PDL would explode, leaving you no better than dry storage. Do you think that is the case? If so, perhaps your web pages and your first aid instructions would need to be updated.

Thanks for your informative webpages.

Ronald H. Hsu, DDS
Resident
Pediatric Dentistry
UNC Chapel Hill

Dr. Dean Brandon said...

Dr. Hsu,
You are welcome to use my web site material. It's in the public domain. It's not a peer reviewed journal, just my opinions and experience.

On the water/milk thing. Most all the parents I see in this situation use milk. That's what I prefer, as it is easily available. I did have one parent scrub the tooth and use alcohol!..Ouch!

I read, in Andraesen's text you could rinse with water and store up to about 20 minutes after that then there might be problems. I wonder if a tooth left totally dry with a blunderbus root would dry out too much to the point it wouldn't revascularize where otherwise it might? In an article by Dr. Joe Camp(from UNC)(Pediatric Dentistry 1995) says "the tooth must not get dry" with water being the least preferable medium. Well, things are changing all the time. If you have more up to date info, let me know. Thanks for the comment, and good luck!

Anonymous said...

Hello there... I just found your web site after spending the afternoon at the dentist's office, while they reimplanted one of my son's permanent teeth. No trauma here, he pulled it out on his own! No crying, no nothing... I just walked into our home office to find him holding this tooth in his hand. The process of reinserting the tooth, and the three stitches that followed, appeared to be more stressful to him.

My question is this - how often do you see young children pulling out their permanent teeth? My son is 7 and mildly autistic (likely Asperger's Syndrome)... how often do you see children doing this? How should I proceed? How can I get him to understand the importance of his permanent teeth, and to leave them alone???

Thank you for any assistance/information you can provide. I intend to also inform his pediatrician about this behavior.

Dr. Dean Brandon said...

Well, I have seen kids pull their braces off, but never pull out a permanent tooth. Although, it is not beyond reason. Being 7 years old means there is not much root development yet and more likely to get knocked loose (which might have happened and you didn't know it). Then, he just started to mess with it till it came out??? Who knows? If the dentist did get it back in then it might be salvagable. --needs to be followed--for any other problems. I know these kinds of behavioral concerns can be frustrating. Good luck.

Dr. Dean Brandon said...

Hey, I just consulted one of the other doctors here and he has seen this before in a child with a similar medical condition. He wiggled out a lower front permanent incisor. It was speculated that the child had a different pain tolerance than most. So, we have seen this before.

taylor said...

My 6yr old's permanant teeth is coming in on the bottom and the baby teeth are still in place. One is loose so my dad pulled outward on it really hard trying to get it out. It made a nasty cracking noise and bled alot. The tooth is still in and she cant eat or touch it cause it hurts and bleeds alot. Did he do any kind of damage and what should I do for her now? Im afraid he has broken the root.

Dr. Dean Brandon said...

Sorry for the delay, I have been out of town.

Loose teeth tend to tighten back up if there is not too much damage or displacement. I'd get it looked at by a pediatric dentist.

April said...

my 7 year old son has a bruise like bump above his eye tooth that is coming in, Is this normal or is it something to be worried about?

Dr. Dean Brandon said...

I would usually recommend to get it looked at if it does not go away in a week or two.

Anonymous said...

On Sunday, my 3-year old fell while attempting to climb into our bed in the middle of the night. He must have hit the wooden rails. He required three stitches in his lower lip and has bruised gums. I was unfortunately out of town when this happened. When I got home last night from my trip, I noticed that many of his upper teeth have white spots on them. I'm waiting for our pediatric dentist to call me back, but in the meantime I'm very concerned what this could mean. I'd appreciate any professional opinions.

Dr. Dean Brandon said...

good to followup with your dentist after an accident like that. I am sure he can evaluate better than me on this one.

Anonymous said...

My 22 month old fell this morning and his right front incisor is slightly loose and displaced a bit forward (<5mm). There was no bleeding, but obviously painful. We are from the US and in Costa Rica traveling. How serious is it that I get him to a dentist immediately? Thank you.

Dr. Dean Brandon said...

I cannot really say, but displacement injuries are worst if they cannot bite down at all-might need to see someone then, but... Otherwise it kind of depends. Might end up loosing the tooth eventually if the displacement is severe enough or (as it typical) it might just tighten back up and be ok. I often tell parents to wait a few weeks to see. See my other posts on trauma as well. Good luck.

Amy said...

My 18-month old son (who has 4 teeth on top and 4 on bottom), fell and landed on his back but somehow ended up bleeding at the mouth. There was a lot of blood, and the middle two teeth on bottom have been displaced forward slightly. The bleeding seems to be coming behind the teeth at the gumline and there are two red "cracks" on the front gums alongside the roots of the two teeth that are pushed forward. What should I do?

Dr. Dean Brandon said...

Well this is hardly the place to get emergency advice, but I'd get a pediatric dentist to take a look--gums heal pretty well in most cases.

Anonymous said...

hi, my 16 mo old fell this evening and pushed his front baby tooth forward, so they are now significantly uneven. We went to the emergency room, but we will not be able to see a ped dentist until tomorrow. I read that it should be reset on the same day...will it be too late if they see us tomorrow morning? It is 10:25 pm.

Dr. Dean Brandon said...

Well, seems like you are doing the best you can. I am sure the pediatric dentist will tell you what to expect tomorrow. I do know little kids heal very well/fast. Displacements sometimes drift back into place.

Anonymous said...

ok, here is a follow up comment- I posted last night re: my 16 mo old. we did visit the ped dentist, and he thought we should just leave the tooth alone and watch for anything abnormal. he prescribed some antibiotics. he also mentioned that my son has a cross bite, but it is too early to treat it as his other teeth are not in yet. what is the earliest we can treat this problem to prevent future issues w permanent teeth? I want to make sure we are ahead of the issue.

Dr. Dean Brandon said...

See my post on crossbites and other orthodontic treatments (on the sidebar under orthodontics (top ten posts)-- way down the list. Depends on the crossbite when you treat or not.

Heather said...

my 4 yr old slammed her teeth on the bed rail, she bit down and there was quite a bit of blood. she's okay now, its been about an hour, the bleeding stopped and she's watching a cartoon. but her two front teeth are pushed backwards. I cannot get to a doctor right away and when I try to pull them forward, it gets lightly bloody around them. they don't feel loose though. what should I do?

Dr. Dean Brandon said...

Well, I just got in from a very busy day. I can't really advise, but from what you have said--parents in like situations I have them try and pull the teeth forward, but if that doesn't fly just let your dentist check as soon as they reasonably can. I know there is always a sense of panic this soon after such a thing. Good Luck. Her dentist will be the best one to consult.

Anonymous said...

My 7 year old daughter knocked her front tooth out and loosened her other front tooth after falling in the playground when she was 4. The loosened tooth fell out and when the permanent tooth came in it had a white spot and two small areas of pitting. I just wondered what could have happened? I took her to the dentist at the time, he x-rayed her teeth and said all was ok but left the loose tooth in. I just wondered if it could have been infected without my knowledge, It was red and sore in this area but this did go away after a week or two, can infections just go away? The dentist never advised me that there can be a risk of infection or gave antibiotics, its only through reading on the internet I have found out about this sort of thing. I feel awful. I should also mention she had a large cavity on this tooth, could this have caused the pitting?
I just wondered as she had this pitting does this mean her tooth will decay now, I'm really worried, I did take her into her dentist and he said that it would not decay

Dr. Dean Brandon said...

I could not say what happened in your case, but if only one tooth was affected (rather than all permanent teeth which would likely be hypoplasia-

Although festering long term infection of a baby tooth (abscess from a trauma or a large cavity)can damage a perm tooth-the initial trauma/injury is a likely cause as well-especially if it is "bumped" at a critical developmental stage.

Anonymous said...

Thank you for your reply Dr Brandon, just wondered If she had a long term abcess surely I would have seem it? Her gum was red and swollen for a week or two then went.
Please also could you tell me if this area is likely to decay?
Thank you so much for helping me

Dr. Dean Brandon said...

I honestly do not know. Please read more about "white spots on teeth enamel hypoplasia" here in the blog and check with your dentist.

Anonymous said...

Hi Dr. Brandon-

My one-year old daughter fell this past Sunday and hit the side of her mouth. There was some blood but it didn't last long. Her teeth didn't seem loose and weren't pushed up into the gum, as far as I could tell (they're still coming in). This evening I was looking and noticed a small white spot on her gums between her front teeth. I'm not sure if this might be an infection or something else? She hasn't yet been to the dentist and I was going to make an important but wasn't sure how urgent this could potentially be.

Thank you
Laura

Dr. Dean Brandon said...

Swelling is a sign of infection. Most of the time, soft tissues heal quite well after a trauma. Like you indicated, get a dentist to take a look to make sure everything is ok.

Victoria said...

almost 3 weeks ago my 6 year old did a face plant off a scooter and banged up his face pretty good. His front upper teeth were bleeding a bit, but mainly his fenun (sp?). I read they heal well on their own, and whereas it does not look completely normal - it has healed.

When the accident happened I washed out his teeth cause there was dirt in his gums (they were torn above the teeth.) After two days, everything looked pretty normal and he was no longer in any pain etc..

Well the past week, one tooth has turned dark grey/brown. His gums still look okay (although not really sure how they looked before). You can tell they have had some trauma but they dont look infected at all.

Calling the dentist today to see if we can get him in. Is there anything I can do in the meantime? What is a sign of an infection or abcess?

Dr. Dean Brandon said...

I cant really advise, but if it's been 3 weeks there is likely no rush if there is no swelling/infection Still let them take a look. See my post on baby teeth turning dark ( under top ten posts I think). A 6 year old usually looses his front top two incisors at age 7 or 8.

Dr. Dean Brandon said...

Infection is not always apparent but pain swelling a bump on the gum Like a pimple, mobility might be an abscess.

roina said...

Hello Dear
my 2yer baby fill dawn from table
very hardly there was ots of blood
and the front teeth is broke from its
edge whot shold i do?
pleas say samthing deos the teeth growth
agin?

Dr. Dean Brandon said...

A two year old only has baby teeth. Normally they would be replaced later on with permanent teeth. In any accident, I recommend seeing your Pediatric Dentist.

Katie said...

Hi, my 25 month old son fell 2 weeks ago, and bloodied up the stretch of gum between his top teeth and upper lip. 2 days later I noticed his top front right tooth was loose. I am having a very difficult time finding a pediatric dentist that will take a 2 year old...I was going to wait and see if it tightens back up, but on Saturday I noticed it's even looser than before, and looks to be turning a gray-ish color near the root. His tooth also looks HUGE now compared to before the accident. I am without a doubt taking him somewhere tomorrow...the question is: Do you think I should keep trying to find a pediatric dentist, take him to his pediatrician, or to the E.R? Thanks!

Dr. Dean Brandon said...

Katie, I am kind of surprised you cannot find a Pediatric Dentist to see a two year old. I have never met one who did not. --Which makes me thing the ones you are contacting may not actually be Pediatric Specialists, If they are, that is kind of puzzling. Maybe there is some kind of insurance reason? (for instance, they will see you, but do not accept Medicaid).

Anyways, if it is turning dark, read my post on that here in the blog. I don't know what you mean by huge, but if the tooth is moving out of position or the gums or lip are swelling, that might be a sign of infection.

A Pediatrician may put a child with such symptoms on an antibiotic, which may help, but they are likely to refer you to a Pediatric Dentist for followup. In fact, if you are confused, I think a Pediatrician may be a good source for a referral to a specialist that can help you. Good Luck.

Katie said...

Thanks so much for your quick reply! Many of the pediatric dentists I contacted takes 2 year old's, but they weren't taking new patients.
And about his tooth looking huge in comparison with the others...It looks to be about twice the size it was before the accident which makes me believe it was possibly knocked out of place quite a bit. He's having a hard time chewing, and when I brush his teeth, he says his tooth hurts so I have to avoid that particular tooth while brushing. Thanks for your insight. I will be calling his pediatrician first thing in the morning. Thank you!

Emelies said...

Hello, I have a 3.5 year old child. She fell on her face yesterday while playing sports and hit her mouth on the wood floor. Her top lip went over her front right tooth and got swollen. Her tooth by looking at it while still swollen got pushed back a bit. She is feeling pain but is able to eat soft things on the side of her mouth. I am concerned what we can do with this tooth. I don't know how bad the trauma is as of yet as I took her to the dentist within 1/2 hour after the injury. They told me to bring her back in a couple of days to see again. My daughter would not let them even touch her mouth at the time. What may be the outcome of this tooth? Can it be pushed back into place to match her other tooth? Will she end up losing the tooth? Did it damage any 2nd potential teeth to come in later? The dentist said she is still young and does not have her 2nd teeth "buds" yet. It just looks awful at this point. Is there anything that we can get later on should she lose this tooth that will give her another? Fake one or something to cover this one if it goes bad?
Thank you.

Dr. Dean Brandon said...

If a baby tooth is pushed back, I like to get it back in place pretty soon (within a few hours, usually with finger pressure). Sometimes, that is just not possible, so we let it heal a bit, and re-evaluate. Followup with your pediatric dentist and see what the options are. Sometimes removal is the best choice to protect the developing permanent teeth (which are developing on a three year old, by the way). Read more here on the blog about trauma, fake baby teeth partials, etc.

Emelies said...

I had thought of maneuvering the tooth back into place before it hardens up again. But, I worried it would loosen it and she would end up losing it. Ugh. Can it still be maneuvered into place if it has been about 2 days now? I hope so. I really don't want her toothless at such an early age. Please advise. I will take her to the dentist again tomorrow. I was waiting for the swelling to go down on her lip and her mouth.

I appreciate your informative information.

Thank you very much.

JT

Dr. Dean Brandon said...

Finger pressure is usually not going to hurt a loose tooth. If it's in good position, it's best to leave it alone. If it's out of position, sometimes it may drift back depending on circumstances. If it's super loose or damaged like a root fracture it may not tighten up. Sorry I don't usually read these posts till I get home after a long busy day at the office. I am sure things will be ok in the long run.

Anonymous said...

Hello, Dr. Brandon, and thanks in advance :)

My three year old's front tooth has been grey since last year, we had it x-rayed and it looked fine but told us to watch for infection. I haven't seen a 'bump' on the gum and she doesn't have cavities. I've noticed for a few months now she has frequently has bad breathe in the morning even after toothbrushing; the dentist didn't address this other to floss. Could bad breath be related to the grey tooth? Just wondering if I should go get a second opinion.

Dr. Dean Brandon said...

If brushing is in good order, "bad breath" in young children is more likely to be sinus related: colds, sinus infections, Allergies, or ear infections. Also, sometimes what they eat.

Sarah said...

My 6 yr old has a cavity in her tooth, the tooth is loose and part of it fell out tonight, but part is still there in her gums. Will the rest fall out? or should I visit the dentist?

Dr. Dean Brandon said...

Front baby teeth fall out naturally about 6 years of age. If a tooth has a cavity and breaks down there may be remnants of tooth or root left. That would certainly be something I'd get a dentist to look at.

Imene said...

Dear Dr. Brandon, firstly I'm amazed at how kind and generous you are to answer all the people who ask you questions. Honestly thank you so much for your time... My 10 month old daughter fell off the couch and her two lower front teeth were intruded completely back into the gum. We took her to the dentist and he said to wait and see if they come out. Two weeks later, they have both showed up, their color is still white, but they are not where they used to be. If you pull back the lips to see the gums, they are below the two teeth on the sides, but above the bottom of the gums, so in the middle, and they are coming out at an angle, like 30 degrees outwards. The dentist said that the position of the teeth will get better due to the tongue and lips pushing them back into place. My 2 questions are.. Could the teeth eventually die and have to be removed? And do we need to something to fix the teeth from coming out in the wrong area and wrong angle or will it really fix itself? Thank you for any advice you can give me..

Dr. Dean Brandon said...

Well, we don't do many braces on one year olds. It is generally the case that teeth move around as they come in. I'd have the dentist monitor them as you are evidently doing. The extent of the trauma determines whether they "die" or not. A tooth that ins in the process of erupting usually has a better chance than a tooth that has been there a long time.

Imene said...

Honestly thanks a lot for your information. Bless you. I feel better about my dentist's decisions. Her teeth came out at 6 months, so they've been here for 4 months. I wanted to regularly push them back with my fingers but she doesn't let me.. If they go will she have trouble speaking?
Thanks again :).

Dr. Dean Brandon said...

Even if the front baby teeth are lost early they do not affect speech.

arav34 said...

My 8 year old fell and hit hid front teeth on the cross bar of a wooden dinette chair. His front tooth was knocked out of place. We took him to the ER. They just gave us motrin and told us to wait until Monday to see the dentist for the two teeth knocked loose. Is This good advice?They are both permanent teeth.

Dr. Dean Brandon said...

Sometimes you can move teeth back into place but sometimes you can't due toady factors. Longer term you can move them back with braces. Any traumatized tooth needs to be followed by a dentist for possible problems and followup treatment.

Dr. Dean Brandon said...

Sometimes teeth just a little loose will tighten back up but still need to be seen by a dentist. It is my experience emergency rooms do not do too much

Anonymous said...

My two year old fell and broke her front tooth. There was no blood and the tooth didn't move out of place. She doesn't complain except when she bites into something. It seems to me like there is some nerve exposure. What should I do? It has been two days.

Dr. Dean Brandon said...

-Definitely would get your pediatric dentist to take a look. Untreated fractures can develop into bigger problems.

mom2-3 said...

My 4 year old bumped into another child inside a bouncy house tonight and she came out crying with a bloody mouth. Turns out her tooth behind the incisor is completely cracked down the middle. I gave her children's tylenol and put ice on it. On the phone our dentist suggested seeing her in 3 days (due to the holiday) if she's not in pain. Is it detrimental to wait that long? What effects will this have on her adult teeth?

Anonymous said...

Dr Brandon,
Thanks for taking the time to answer my question. My 9 year old son cut him gum and it (a piece of gum) is hanging down onto the tooth. What can be done? Will the gum reattach on its own or does it need to be stitched? Or does it get snipped and grow back? It is at the top of his front permanent tooth. The tooth is not loose. I hope this makes sense.

Thanks,

Dr. Dean Brandon said...

Dear everyone, I do not check the blog every day, nor can I offer advice or comment in a timely manner for things that really need direct clinical evaluation by your dentist. I do advise contacting your pediatric dentist.

Anonymous said...

My 10 month old son fell on our hardwood floor and busted his lip. When the blood cleared I realized his top right incisor was loose. Is there any concern with a loose tooth at this age? My husband says not to worry and it will be fine but I'm worried about him inhaling or swallowing it. Im also worried about infection. I don't want to waste the dentists time if there is nothing he can do. Should I take him in and what might they do?

Dr. Dean Brandon said...

A dentist's time is never "wasted."