25.3 Traumatic Injuries to the Primary Dentition and Recognition of Child Abuse and Neglect
Key Takeaways
In the primary dentition the guiding principle is to protect the developing permanent tooth, so avulsed primary teeth are not replanted and intruded primary teeth are allowed to re-erupt spontaneously.
Laterally luxated primary teeth without occlusal interference are left to reposition spontaneously, and alveolar fractures are repositioned and splinted for about 4 weeks.
Gray discoloration of a traumatized primary incisor can fade and is not on its own an indication for pulp treatment; treat only when clinical or radiographic signs of infection appear.
Bruising of the ears, neck, torso or face in a non-mobile infant, injuries inconsistent with the history, and delays in seeking care are warning signs of physical abuse.
Saudi Arabia's Child Protection Law requires anyone aware of abuse or neglect of a child to report it, and domestic violence including child abuse can be reported to the 1919 line of the Ministry of Human Resources and Social Development.
Primary teeth are injured most often at about 2-3 years, as children learn to walk and run. Treatment choices aim to avoid further harm to the developing permanent tooth germ, which lies close to the primary incisor apices.
IADT 2020 Guidance for Primary Teeth
| Injury | Management |
|---|---|
| Enamel or enamel-dentin fracture | Smooth sharp edges or restore with glass ionomer or composite |
| Complicated crown fracture (pulp exposed) | Partial pulpotomy to preserve the pulp if the child cooperates; otherwise extraction |
| Crown-root fracture | Remove the loose fragment and restore if possible; otherwise extract |
| Root fracture | Coronal fragment not displaced: leave and monitor. Displaced: reposition and splint, or extract the coronal fragment only and leave the apical part to resorb |
| Alveolar fracture | Reposition and splint for about 4 weeks; monitor teeth in the fracture line |
| Concussion, subluxation | Monitor; soft diet |
| Extrusion | Minor: allow spontaneous repositioning or reposition gently; severe extrusion of a mobile tooth: extract |
| Lateral luxation | No occlusal interference: allow spontaneous repositioning; minor interference: slight grinding; severe displacement: reposition under local anesthesia or extract |
| Intrusion | Allow spontaneous re-eruption regardless of the direction of displacement; re-eruption usually occurs within about 6 months to 1 year |
| Avulsion | Do not replant (risk to the permanent germ) |
Home care advice (IADT): soft diet; brush gently with a soft brush after meals; apply 0.1% alcohol-free chlorhexidine to the area with a cotton swab twice daily for about a week; limit pacifier use; watch for swelling, increased mobility or a sinus tract.
Follow-up: clinical and radiographic review at intervals (for example about 1 week, 6-8 weeks, and 1 year, depending on the injury) and continuing until the successor erupts.
Sequelae
| Finding | Meaning and action |
|---|---|
| Gray discoloration | Pulpal hemorrhage; may fade over months; no treatment unless infection signs (sinus, swelling, mobility, periapical radiolucency) |
| Yellow discoloration | Pulp canal obliteration: common, no treatment |
| Pulp necrosis with infection | Pulpectomy or extraction |
| Ankylosis and infraocclusion | Extract if it delays the successor |
| Premature loss | Usually no space maintainer needed for incisors once the canines have erupted, but discuss esthetics and speech |
Effects on permanent successors are most likely after intrusion or avulsion in children under about 3 years: white or yellow-brown enamel opacities, enamel hypoplasia (Turner tooth), crown or root dilaceration, odontoma-like malformations and disturbed eruption. Warn parents at the first visit.
Trauma to immature permanent teeth (open apices) is managed by the permanent dentition IADT guidelines in the endodontic trauma section, where pulp preservation (for example partial pulpotomy) is preferred so that roots can continue to develop.
Child Abuse and Neglect
Head, face and mouth injuries are present in a large share of physically abused children, so dentists are well placed to notice them.
Warning signs of physical abuse
- History that is vague, changing or inconsistent with the injury or the child's developmental stage; delay in seeking care.
- Bruises in a non-mobile infant, bruising of the ears, neck, torso, cheeks, eyelids or angle of the jaw, patterned bruises (hand, belt, ligature marks).
- Torn labial frenum in an infant (possible forced feeding or a blow), especially in a child who is not yet walking.
- Human bite marks: an intercanine distance over about 3 cm suggests an adult biter.
- Burns with clear edges (cigarette or immersion), multiple injuries at different stages of healing, unexplained fractured or discolored teeth.
Possible signs of sexual abuse: oral gonorrhea or syphilis, condylomata (HPV), and unexplained petechiae at the junction of the hard and soft palate.
Dental neglect (AAPD): the wilful failure of a parent or guardian to seek and follow through with treatment needed for adequate oral function and freedom from pain and infection, after being informed of the problem. Barriers such as cost, transport and access should be explored first and help offered.
What to do
- Ensure the child's immediate safety and treat urgent dental needs.
- Document objectively: history in the caregiver's and child's own words, injury descriptions with size, color and location, diagrams and photographs.
- Do not confront or accuse the caregiver, and do not examine beyond your role.
- Report through the proper channel: the Child Protection Law (Royal Decree M/14, 1436H) obliges anyone aware of abuse or neglect to report it (see the ethics section). Use the facility's child protection team where one exists, or report to the Ministry of Human Resources and Social Development domestic violence line (1919). Reporters acting in good faith are protected and their identity is kept confidential.
Exam Traps
- An avulsed primary incisor is never replanted.
- An intruded primary incisor is usually left to re-erupt.
- A torn frenum in a 4-month-old with a vague history needs safeguarding action, not only repair.
A 3-year-old fell and intruded tooth 51 by about 3 mm. There are no other injuries, and the parents are anxious. According to the IADT 2020 guidance, what is the usual management?
Allow spontaneous re-eruption and review clinically and radiographically
Reposition tooth 51 surgically and splint it rigidly for six full weeks
Pull tooth 51 down orthodontically, starting the treatment on the same day
Extract tooth 51 at once, because every intruded primary tooth damages the germ
A 2-year-old's avulsed primary maxillary central incisor is brought to the clinic in milk 20 minutes after the injury. What is the correct management?
Replant it and start root canal treatment within 7-10 days of the injury
Store it in saline overnight and replant it the next day under sedation
Do not replant it, because replantation risks harming the permanent tooth germ
Replant it immediately and splint for two weeks, as for permanent incisors
A 5-month-old who cannot yet crawl is brought in with a torn maxillary labial frenum and bruising on both ears. The caregiver says the infant "fell off the sofa" several days ago. What is the most appropriate action?
Document objectively and report the suspected abuse through the proper channel
Confront the caregiver directly and demand an explanation before any treatment
Suture the frenum and discharge the child without further action or documentation
Advise a soft diet only, because torn frenums are common in infants learning to walk
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