First, if the tooth is only fractured part of the way off, call your dentist immediately. The child will need an x-ray, evaluation and treatment right away to help prevent further complications.

If the tooth has come all the way out (called and avulsed tooth), there are a few things which need to be done and all must be done quickly for the tooth to have any chance of surviving. First, find the tooth and lightly wipe it off with a moist, clean cloth to remove any debris. Ideally, the tooth should be placed in the child or parent’s cheek in an area where it won’t be accidentally swallowed or inhaled. (I know, pretty gross, but it is for the sake of your child). If this is too upsetting or you are afraid it will be swallowed, the tooth can be placed in a glass of milk.

You should immediately take your child to the dentist, ideally within the first 10 minutes of the occurrence. The dentist will likely try to place the tooth back into the socket once it is clean and lacking debris which might cause later infection. The tooth will then likely be splinted to the adjacent teeth for support, to help minimize movement. This support will help the tooth re-tighten back into the socket and is sometimes left for up to two to three weeks. The tooth will likely need a root canal since the nerve was severed, but this likely won’t be done for two or three days after.

If the tooth has been out of the mouth for longer than fifteen minutes, your child still needs to see the dentist immediately to avoid more complication or possible permanent loss of the tooth. Bring the tooth with you as mentioned above.

If you are far from the dentist, the tooth is clean and you feel that the tooth is intact, you can attempt to put it back in the socket yourself. Be sure that if you are going to attempt this, you place it in the correct way! The child should immediately be taken to the dentist for an evaluation. If the tooth cannot be found, the dentist may refer you to the emergency room for a chest x-ray to be sure that it has not been inhaled during the accident.

I won’t go into great discussion about the further treatment sequence in dealing with an avulsed tooth, as it is varies with the child and the extent of the injury. The biggest point being that you should take your child to the dentist immediately to avoid further complications which can be both emotionally and financially draining.

The other item I want to discuss is something called “Hank’s Solution” or “Hank’s Balanced Salt Solution.” This is a special liquid formulated by a scientist that is extremely compatible with living tissues and can help to stabilize an avulsed tooth until it can be placed back in the mouth. This solution is better than milk or any others that I am aware of and can help to increase the likelihood that the tooth will be successfully re-implanted. The only catch is that you have to have it before the injury happens! A great addition to your home first-aid assortment is the “save-a-tooth” kit. It Uses the specially formulated pH balanced solution, as well as a unique removable basket and net container that protects tooth root cells crucial to the success of the re-implantation process.

The good news is that it could also be nothing. There are other causes of tooth pain which may be transient. If your dentist can find no apparent source for the pain, then they will likely search for other possible sources for it. Some of these may include simple things, such as night-time grinding (to be discussed later), food impacting in the gum, and irritation from flossing (this is not typical, since kids in the range usually refuse to floss)!

There are other reasons for tooth pain that can be a sign of something more serious. This is unusual, however, the possibility should not be overlooked. Your dentist should be aware of these and will likely evaluate for them if the problem continues with no apparent cause for the pain.

This problem doesn’t occur too frequently, but when it does it leaves parents scratching their heads in curiosity. There are a few reasons this can occur and all will require a trip to the dentist for an x-ray and evaluation.

As mentioned in the second section, developing permanent teeth can be affected by a variety of things including high fevers, certain antibiotics and trauma to the baby tooth (transmitting trauma to the underlying permanent tooth). Permanent teeth can also be affected when they are traumatized directly once in the mouth.

How these “damaged” teeth will react really depends on the type and severity of the trauma. Some teeth will still “survive” but may appear malformed or have some kind of distinguishing mark on them. Others may not have been able to tolerate the trauma and eventually “die.” This “death” simply means that the living tissue inside the tooth (called the pulp) are damaged to the extent that they cause death to that tissue. That living tissue, or “pulp” is the nerve and blood vessels which supply the tooth sensation and sometimes, outward color.

When a tooth “dies” or is in the process of “dying,” the entire tooth undergoes multiple changes which can have many effects, many of which differ slightly depending on the individual.

Occasionally, a traumatized tooth may undergo a reaction with the fancy name of “calcific metamorphosis.” Wow-what a word! It simply means that the tooth felt the trauma and reacts to it by laying down extra layers of minerals within the tooth. This layering of extra minerals (which is really just extra tooth structure), results in a “squeezing” down of the pulp or living tissue located inside the tooth. This frequently, but not always, causes death to that living nerve tissue inside the tooth (the pulp).

This death doesn’t always occur, but does eventually in a high percentage of teeth. This strange process of laying down extra layers of tooth actually causes the tooth to turn more yellow that the other teeth. Treating these teeth can be complicated because though they usually do die, they don’t always do so, regardless of how yellow their color becomes.

Typically, if the tooth doesn’t reveal signs of death when the dentist evaluates it, they will choose to do frequent x-rays and re-evaluate at certain time intervals. They will also have the parent keep a watchful eye for any signs of tooth death such as, pain, change in tooth color (grey or further yellowing), swelling, a “bump” on the gum, or a foul odor coming from the child’s mouth.

If the tooth is confirmed to be dead after evaluation by the dentist, then a root canal is usually done to rid the infection that comes with the death. A root canal usually does not hurt, despite popular myth, and is simply the removal of the dead tissue from within the tooth. The tooth is usually numb for the procedure but doesn’t always have to be, depending on the situation. Once the dead tissue is removed, the inside of the tooth is cleaned and sterilized with tooth-friendly substances. The area is then filled with a special rubbery material to seal it off from other possible bacterial invaders.

Unfortunately, this usually will not fix the color change that has occurred, and occasionally it can become more exaggerated. There are several things which can correct the color change, including procedures such as, internal whitening of the single tooth, a veneer or crown. They may also be able to place a simple, tooth-colored filling that is layered on top of the tooth to mask the color. Each of these are too detailed to describe here and require that you discuss the suitable options for your child’s particular circumstance.

Children are not just little adults and so we can’t treat them as such. Baby teeth are shaped much different than adult teeth, which causes some need for modification when treating them. Because of the shape of baby teeth, we cannot place anything but a very small filling in them, otherwise the filling will break and a new cavity will be created.

The guidelines for treating baby teeth are that if a cavity is of moderate or larger size, a procedure called a “stainless steel crown” is done. This little, silver crown or “cap” is glued down over the existing tooth (after it is specially prepared for it). By having this fairly strong metal covering the entire surface of the tooth, the underlying tooth and filling is protected from breaking from the forces of chewing. As mentioned earlier, a filling or stainless steel crown is usually only needed on a baby tooth which is not due to fall out on its own any time soon. The dentist will evaluate the extent of root development on the underlying permanent tooth with an x-ray. This information, combined with the patient’s age, will be used to determine the approximate amount of time until the baby tooth would likely fall out on its own. If the dentist feels that it will be less than six to nine months, they may recommend no treatment of the tooth unless there is infection present. In this case, they may elect to proceed with the crown (and baby root canal) or simply extract the baby tooth.

Images courtesy of Dr. Martin S. Spiller

This stainless steel crown is similar to a crown or “cap” that an adult may have, except that it is cheaper and meant to come out when the baby tooth falls out. They are usually silver but occasionally for cosmetic reasons can be tooth-colored when needed on front teeth. If your child needs a crown on a baby tooth in the front, be sure to tell your dentist BEFORE the start of the procedure if you want it tooth-colored. They won’t always ask and once it is placed it is usually not easily removed.

 
A stainless steel crown may or may not also have a root canal done at the same time. Yes-baby teeth can have a root canals done on them. Once again though, the concept is different from an adult tooth. Your dentist may call the root canal by several names (each meaning something slightly different to the dentist but making no real difference to you as a parent). Some of those names you may hear are: root canal, pulpotomy, pulpectomy, pulpal debridement and pulp therapy. There are others, but these are the most commonly used.

A root canal in simple terms is the removal of nerve or pulp tissue from the inside of the tooth. It can be removed for many reasons, but for children it is usually done because of a cavity that extends into the pulp/nerve tissue or because of a dead nerve/pulp that is causing an abscess. Baby tooth root canals are different from adult teeth in a few ways. Unlike permanent teeth root canals, those performed on baby teeth do not usually have the rubberized material placed in the canals afterward. They usually only receive a sedative paste which hardens inside the tooth and keeps the infection away. This material is also easily deteriorated by the body as the roots of the baby teeth resorb away and prepare for eruption and loss. They are not as exact of a procedure as root canals on permanent teeth and take much less time. They are not painful and nowhere near as expensive.

So, we can see that sometimes both procedures may be done simultaneously or independently, depending on the child’s unique situation. Your dentist should discuss options with you and don’t be afraid to ask questions. You are your child’s advocate and so you should always attempt to keep yourself informed of any procedure being done

So, what happens if you don’t have the root canal or don’t treat the tooth in any way? Well, if you refuse treatment and also refuse then to have the baby tooth taken out, many things can happen, most of which are bad. The child can end up in the hospital with an infection, particularly if the child is diabetic. I have been unfortunate to have been witness to this and it is truly heartbreaking for me. Not only is this sad for the child, but it puts the dentist in an uncomfortable situation regarding appropriate care and treatment of a child. Proper authorities have to be notified if the child is put in danger. Thankfully this is not extremely common but it does occur.

If hospitalization does not occur, then the abscess will find a way to drain, usually by a small hole made in the gum to relieve pressure and drain puss-right into the mouth. This can cause bad breath and an upset stomach, not to mention it is just disgusting. The other major concern is that an infection left in the tooth can cause damage to the permanent tooth below the offending tooth. Damage may appear as a misshapen, malformed or discolored permanent tooth. It can also cause defects to the underlying developing jaw bone. The affected permanent tooth may then need treatment when the child is older to correct cosmetic problems which may arise as a result.

The first and most obvious answer is to take the child to the dentist as soon as possible so an exam and x-ray can be done.  A mistake I see parents make all the time is delaying a visit to the dentist because the tooth is “just a baby tooth.”  As we discussed previously, baby teeth are incredibly important to the overall health and relationship of the permanent teeth.  Not only are the baby teeth vital to future orthodontic relationship of permanent teeth, they can also have a devastating effect on the shape and color or the erupting adult tooth.  They also decay and abscess (the nerve in the tooth dyes, causing a localized infection) at a much faster rate than permanent teeth.

Baby teeth are no different from their permanent counterparts with respect to their ability to abscess and cause life threatening infections.  Of course we are worried about future orthodontics and damage to the underlying tooth, but I think we can all agree that a life-threatening infection in our children would rock our worlds.  Teeth can cause these scary abscesses because of their close proximity to the brain, spinal cord and neck.   These infections can be extremely difficult to treat because it is challenging to get antibiotics past certain barriers that are located in the head and neck.

So, if your child is complaining of a tooth ache, treat it seriously.  The dentist will generally take an x-ray to see if the baby tooth can be fixed or to see if it is due to fall out soon anyway.  If it is not close to falling out and the tooth looks to have a favorable prognosis with the proposed treatment, then your dentist will likely do whatever it takes to keep it.  I know it will feel like heroics for such a little tooth, but again, the goal is to save it for all the reasons we discussed earlier.  Some of the treatment options may be as follows: extraction of the tooth (with or without a space maintainer to hold the space for the permanent tooth), baby tooth root canal, and/or possibly a stainless steel crown.

If the dentist feels that the prognosis with treatment is poor and/or the chance for re-infection is high, they will likely opt for extracting the tooth.  If the underlying tooth is not due to erupt fairly soon after the extraction, the dentist may propose placing an appliance in the area of the extracted baby tooth to hold open the space.  This space is necessary in order to keep an open path for the permanent tooth to enter into normal alignment in the mouth.  Sometimes, the drifting of already erupted teeth into the extracted space can block the path of the permanent tooth and trap it permanently beneath the gums.  Once this occurs, extensive orthodontics and surgery are usually needed to bring it out.

This special appliance is called a “space maintainer” and is usually permanently glued to adjacent teeth so that the child can’t remove it.  If we gave them something removable, you would be throwing your money away due to noncompliance.  If you have had a teenager with braces who is now wearing a retainer, you know exactly what I am talking about!

There are many types of space maintainers and they are selected based on the needs of the child.  Some will only hold the space for one missing baby tooth while others may hold the space for multiple missing teeth and may even hold the space on both sides of the mouth.  Each space maintainer is custom built for the child’s particular needs.  The maintainer is usually removed once the permanent teeth make their appearance and the dentist feels confident that the space is no longer compromised

Two types of space maintainer devices:

Often, yes. Occasionally, no.  Sensitivity to sweets in children (and adults) can mean that there is a cavity lurking.  The presence of sugar in the sweets will cause a chemical reaction within a decaying tooth. This reaction causes that “twinging nerve pain” or sensitivity, which may or may not linger for a little while after the sweet treat.   It is best to take your child to the dentist and let them examine the tooth and take an x-ray if needed to see if a cavity is causing the sensation.

Sensitivity to hot or cold in a child’s tooth (baby teeth or permanent teeth) can be of concern.  A cavity can also cause sensitivity to hot and cold, however if it is, this is usually a sign that the cavity is already large. This can also be a sign of the nerve dying and/or and abscess of a tooth.  Again, the appropriate treatment would be to see your dentist immediately and let them take an x-ray if needed.  If an x-ray is taken and other tests done confirm that the nerve is dying or that an abscess is present, your dentist will discuss options with you.

Options for treatment of cavities or abscesses (dead/dying nerve) may include procedures such as extraction (with or without a space maintainer to hold the space open for the future permanent tooth), baby tooth root canal, filling or stainless steel crown.  The decision for treatment options is made based on the amount of damage/decay in the baby tooth, the length of time until it would normally fall out and position of the underlying permanent tooth.   Of course, we want to do our best to try to save baby teeth, particularly if it will help the child avoid braces in the future.  But all of these things must be taken into consideration in order to make the best decision for the child.

Occasionally in children, but most often in adults, this sensitivity can be caused by an area where the gum has receded away from the tooth.  You don’t see this too often with children, simply because the baby teeth are actively changing form each day, and they don’t have the sensitive roots that adult teeth have.  It is quite uncommon for gums to recede in children or even in teenagers (unless they have braces).  So, the bad news is that it is likely a cavity causing the pain.

These sensations can also be normal and transient.  Your dentist will likely use a combination of diagnostic procedures to evaluate the offending tooth.  If nothing obvious can be found that explains the source of the pain, they  may opt to “watch” the tooth.  What this means is, they will ask for your help in monitoring your child’s symptoms at home and call if things change (for better or for worse).  Either way, your dentist may decide to take a new x-ray in a few weeks to see if there are any changes.

Teeth are strange in that sometimes they give symptoms disproportionate to their experienced “trauma.”  For example, when eating a chip or popcorn or some crunchy food item, occasionally a piece may break off and get lodged beneath the gum without you or your child even noticing.  The area may then become tender and feel like a toothache, hot and cold sensitive or become painful on chewing.  A trip to the dentist may show nothing and then the sensitivity goes away in a few weeks.

A tooth can also be traumatized by biting into something hard which can cause the ligament which holds the tooth in to be “bruised.”  This may cause biting sensitivity for a week or two which may also go away on its own.  There are many examples of these situations but most commonly, symptoms are actually due to the presence of a cavity or an abscess.  So, always have your dentist check the area rather than assuming there is nothing really wrong.

The body is truly amazing in so many ways (and just plain frustrating in others).  While a visit from the tooth fairy can be exciting for some kids, others are left frustrated that she may never pay a visit.  There are so many variations in how/when/where teeth become loose and actually fall out, that it can be stressful for both parents and kids.  Most kids will go along simply following the “normal” pattern and have regular visits from that darn fairy.  Some parents don’t ever have to lay a hand on those slippery little rascals while others are wondering if they need string or pliers.

In most cases, even if a tooth is loose for awhile, it will come out on its own or with the help of the child wiggling it.  If you are unsure, you really should make a visit to your dentist for an evaluation.  There are times when we elect to extract a baby tooth.  Some teeth are stubborn and when they don’t come out on their own, the permanent one tries to come in around it.  This can create orthodontic problems in the future, so in this instance it is generally recommended to remove the baby tooth.  This is usually only done when the tooth is evaluated and determined that it just isn’t going to come out on its own.

Also, on occasion, we will “help” the little guy out of there if we feel there is a choking hazard.  This is rare, but is done  if the tooth is extremely loose and the child or parent just can’t get it out. It is generally very easy to get out without upsetting the child.  If half of the tooth is broken out and the other half is stuck and not loose, it is wise to bring the child to the dentist for an x-ray.  Your dentist may or may not choose to extract the remnant, depending on what the x-ray reveals and other considerations which  they will discuss with you.

I personally do not recommend string tied to doors (OUCH!) or pliers from the garage.  The one tool I do recommend is patience.  Challenging, I know but it will eventually come out with a little twisting and wiggling and a positive attitude!

Of course, we already discussed earlier in the When should I first take my child to the dentist? post that your child should start seeing the dentist early and we also learned that they should go for check-ups and cleaning every six months. At the check up appointment, the dentist may want take a few x-rays.  There are many different types of x-rays that are considered acceptable for a child, and it really depends on what the dental team is looking to evaluate.

Generally speaking, usually around three or four years old, check-up x-rays (also called bite wing x-rays) may be taken if the child does not have spaces or has limited spaces between the baby teeth or if decay is suspected in an area between the teeth. Children at this age have very small mouths, and so typically all is needed are two of these films (understand that this may vary depending on the child).  These films are done every year to eighteen months, again depending on the child.  There really isn’t a minimum age requirement for these check-up x-rays, it is really dependent on the spaces between their teeth and the visibility between them.  These x-rays are done to look for cavities in between the teeth, thus the reason they may not be necessary to take if the child has adequate spaces between their teeth.  If spaces are present, the dentist can usually see the tooth directly without the use of x-rays.

At around age 5 or older, your dentist may choose to take another x-ray called a panorex or “panoramic film.”  This film does not look for cavities but rather is a tool for evaluating possible missing teeth, disorders of the jaw including cysts, tumors (cancerous and non-cancerous) and a myriad of other things.  It may also be used to aid in orthodontic evaluation in the future.  This is a film that is typically done every three to five years or even less depending on the use for the x-ray.

There are other x-rays sometimes done for other reasons.  One more commonly done x-ray is called a “P.A.”, which stands for a periapical x-ray.  It is just a fancy dental word for an x-ray that shows the entire tooth, including the root and the surrounding bone and is usually done on children to evaluate a possible abscess or to determine the length of time until a permanent tooth will erupt.  This is an acceptable x-ray for children at any age if the dentist has a concern about a specific tooth.

Another film that a parent may encounter at the dentist is called an occlusal film.  This is a film that may be taken of either the upper or lower teeth and is meant to see a better three dimensional view of erupting teeth or pinpoint pathology within the jaws.  This kind of x-ray is not done that often, but is very important when trying to determine very specific details that would otherwise not show up.  It is usually only done if the dentist has a very specific reason for taking it.

One question I am frequently asked regarding x-rays and children are about the relative danger to the child.  In general, x-rays in moderation are considered to be safe when precautions are taken to minimize radiation exposure.  This is the same for adults.  In fact, we are often taught in school that we receive more radiation exposure from the sun on a single day then we do in a set of yearly x-rays.

For children, it is especially important that the areas sensitive to radiation are covered during x-rays.  These areas include the thyroid/neck area as well as the reproductive areas of the child.  This shielding is done with a lead apron.  Dental offices are also required to undergo annual testing and evaluation of the radiation equipment (this varies by state) to be sure they are in compliance with state radiation regulations.  In addition, most states require that the staff taking x-rays have completed a regulated x-ray dental safety and technique course in order to take x-rays.  These certificates will usually be posted for patients to see.

If you have never seen an x-ray of a newborns jawbone you may be surprised to see 20 developing teeth. So, even though you can’t see them, they are there. This is one reason that illness or injury as a toddler can have adverse effects on teeth later on. Your toddler’s first teeth are known as”primary” teeth and play an important roll in development. It is important for parents not to treat their child’s primary teeth as “temporary” or “replaceable” . Many preventable problems can be avoided by proper care of your toddler’s primary teeth.

At about six month of age, your toddlers teeth may be starting to erupt. The front four teeth are usually the first to arrive. Remember that ever baby develops at a different rate so if your toddler does not have his or her first tooth at 6 months+one day ,don’t sweat it! It is not uncommon for the first teeth to take 12 to 14 months to come in. Both of our boys seemed to take forever to get/lose teeth.

When your toddler’s teeth begin coming in(erupting), your child may experience sore or tender gums. This is normal. You can help soothe the discomfort by gently massaging the gums with a clean finger or moist gauze pad. Granted this will only provide temporary relief but sometimes that’s enough to help a fussy baby. If you prefer the “hands off” method, you can give your toddler a clean teething ring to chew on. Remember never to put any sugar or syrup on the teething ring. I know it seems obvious but as you may have guessed, there is a reason I mention it!

If your toddler is excessively uncomfortable and cranky, you can call your dentist or pediatrician to ask about over the counter pain remedies. Keep in mind also that contrary to popular belief, if your infant/toddler is running a fever while teething, this is not normal. Any unusually high or persistent fever is an indicator to contact your pediatrician.