Traumatic dental injury: why the world’s 5th most common condition is flying under the radar

Traumatic dental injuries are incredibly common — yet surprisingly overlooked. With prognosis heavily dependent on prompt action, accurate diagnosis, and skilled treatment, it is essential that dental professionals have the expertise and strategies in place to manage dental trauma. Here’s what you need to know to rise to the challenge and secure positive outcomes for your dental trauma patients.

What is a traumatic dental injury?

Traumatic dental injury (TDI) is a physical injury of the teeth, their supporting structures, and/or the soft tissues of the oral cavity. According to The World Health Organization’s (WHO) 11th Edition of the International Classification of Diseases (ICD-11), TDIs can be mostly organized into two main groups. ⁽¹⁾

1. Injury of hard dental tissues and pulp:

• Enamel infraction — incomplete enamel fracture.
• Enamel fracture — complete fracture confined to the enamel.
• Enamel-dentine fracture — complete fracture confined to the enamel and dentine.
• Complicated crown fracture — complete fracture involving enamel and dentine with pulp exposure.
• Uncomplicated crown-root fracture — complete fracture involving enamel, dentine, and cementum without pulp exposure.
• Complicated crown-root fracture — complete fracture involving enamel, dentine, and cementum with pulp exposure.
• Root fracture — complete fracture involving dentine and cementum, and pulp.

2. Injury of periodontal tissues:

• Concussion of periodontal tissue — injury to tooth-supporting structures without abnormal loosening or displacement of teeth.
• Subluxation of the tooth — injury to teeth-supporting structures with abnormal loosening but no displacement of teeth.
• Extrusive luxation of the tooth — peripheral dislocation and partial displacement of the tooth from its socket.
• Lateral luxation of the tooth — non-axial displacement of the tooth accompanied by alveolar socket fracture. 
• Intrusive luxation of tooth — central dislocation and displacement of the tooth into the alveolar bone, accompanied by alveolar socket fracture.
• Avulsion of tooth — complete displacement of the tooth from its socket.

N.B: Maxillary or mandibular injuries and injuries to the oral mucosa are classified separately.

The true prevalence of TDIs

The true prevalence of TDIs has historically been difficult to establish. The WHO’s ICD-11 is just one of more than 50 systems used worldwide in public health and clinical research to classify, record, and report disease and injury, including TDIs. The variation between systems has led to TDIs being reported inconsistently, incorrectly, or not at all. Were this not the case, it is estimated that TDIs would rank fifth in the Global Burden of Disease (GBD) Study’s list of the 300 most common acute and chronic diseases and injuries. At present, TDIs are not included in this list at all. ⁽²⁾ However, some progress has been made with the success of a recent campaign to update the WHO ICD-11, bringing it in line with the widely used Andreasen classification system. ⁽³⁾

Experts do agree that TDIs occur with great frequency in children and young adults, more often in permanent dentition than primary dentition. ⁽⁴⁾⁽⁵⁾ TDIs represent approximately 5% of injuries for all ages and up to 17% in children aged 0-6 years. ^(5)(6)(7)

Globally, one-third of all pre-school children have suffered a TDI to the primary teeth, while one-fourth of all school-aged children and almost one-third of all adults have sustained a TDI to the permanent teeth. ⁽⁸⁾ Up to 90% of TDIs occur before the age of 19-20 years, with research indicating that those aged 10-14 years are at the greatest risk. ^(4)(6)(7)(9)

There is some variation in prevalence by region, although it remains high worldwide. A national US survey indicated that one in four people aged 6-50 years had sustained a TDI. ⁽⁶⁾ In the UK, one in five school-aged children had experienced a TDI in the permanent anterior teeth. ⁽⁶⁾ In a Danish study cataloging TDIs from birth, 30% of children sustained TDIs in the primary teeth and 22% in the permanent teeth, with every child sustaining a TDI by 14 years old. ⁽⁶⁾ Australia has an annual incidence rate of 20 TDIs per 1000 children aged 6-12, while Sweden’s annual incidence rate is estimated to be between 19 and 29 TDIs per 1000 individuals. ⁽⁶⁾

In both the primary and permanent teeth, TDIs most commonly involve the maxillary teeth, particularly the incisors, thanks to their vulnerable position and angulation at the front of the mouth. ^(4)(5)(9) Luxation injuries are the most common TDI affecting the primary teeth, while crown fracture — specifically an Ellis class IV fracture, in which the tooth becomes non-vital — is the most common TDI in the permanent teeth.⁽⁴⁾⁽⁷⁾ The most commonly reported accompanying injury is trauma to the soft tissues of the mouth. ⁽⁴⁾ Complete tooth avulsion occurs in 1-16% of TDIs in the permanent teeth and 7-13% in the primary teeth. ⁽⁴⁾

Dental trauma causes and risk factors

The most frequent causes of TDIs are reported to be accidental falls and sports injuries, with less common causes including cycling accidents, traffic accidents, and physical violence. ^(4)(5)(9)

Children in the most at-risk age group (10-14 years) tend to participate in sports and outdoor activities with greater frequency than younger children and may do so independently of adult supervision. ⁽⁹⁾ For younger children, the main risk tends to arise from falls due to a lack of adequate motor control and coordination. ⁽⁴⁾

Among children, boys are approximately twice as likely to experience a TDI than girls. ⁽⁴⁾⁽⁹⁾

This can be explained by the tendency in many social and cultural contexts for boys to be more likely than girls to engage in demanding physical activity, aggressive play, and contact sports. ⁽⁴⁾ There is notably less gender discrepancy in younger children, ostensibly because there is little difference at this stage between their capabilities and behaviors. ⁽⁴⁾

Other predisposing factors to dental trauma are related to the patient’s anatomical features. Increased overjet, inadequate lip coverage, and class II occlusal relationships have all been cited as risk factors for traumatic injury of the anterior teeth specifically. ⁽⁵⁾⁽⁹⁾

The importance of swift diagnosis and management

TDIs have the potential to cause wide-ranging complications beyond the immediate pain and infection risk. The patient may experience pulp necrosis, pulp canal obliteration, ankylotic or inflammatory root resorption, damage to the supporting structures, and, in some cases, complete loss of the affected teeth. ^(4)(10) In primary dentition, TDIs can also result in enamel hypoplasia, discoloration, delayed eruption, impaction, and damage to the developing permanent dentition. ^(9)(11) Complications may appear immediately after the injury, while others can take years to manifest. TDIs can also alter facial aesthetics and impair speech and nutrition. For children, in particular, this can be damaging to psychosocial development, emotional well-being, self-confidence, and quality of life.⁽⁴⁾⁽⁹⁾

With this in mind, accurate diagnosis, management, and follow-up of TDIs are essential for a positive prognosis. However, as dental trauma is a challenging presentation that is not frequently encountered in day-to-day general practice, many practitioners could benefit from further training in, and frequent review of, TDI treatment protocols. ⁽⁵⁾ The International Association of Dental Traumatology (IADT) has published a comprehensive series of best-practice guidelines for the treatment and management of TDIs.⁽¹²⁾ The following summarises a selection of their key recommendations, but we encourage dental professionals to review the guidelines in full.

Clinical examination

While the use of radiographic images should always be carefully considered and justified, it is important to note that some serious injuries, like a tooth root and bone fractures, may present without clinical signs or symptoms. Additionally, the patient may not present until after clinical signs have subsided. The IADT notes that in the case of root fractures, crown/root fractures, and lateral luxations, CBCT can be especially useful in determining the location, extent, and direction of a fracture and should be considered. ⁽¹³⁾

Pulp condition and vitality

Every effort should be made to preserve the pulp, particularly in the immature permanent tooth in order to allow continued root development and apex formation. ⁽⁷⁾ In fractures and luxations, sensibility should be assessed as soon as possible with cold testing and electric pulp testing, and reassessed during follow-up. ⁽¹³⁾ Vitality should be assessed using pulse oximetry or laser/ultrasound Doppler flowmetry. ⁽¹³⁾

Avulsion of teeth

In the avulsion of a permanent tooth, the treatment and prognosis are largely dependent on the maturity of the root and the viability of the periodontal ligament. First aid protocol calls for the tooth to be either replanted in the socket or kept in an appropriate storage medium, e.g. milk, saline, saliva, or a tooth salvage box. If the tooth is replanted within 15 minutes, the periodontal ligament cells will most likely be viable. If appropriately stored for up to 60 minutes, there is likely to be some compromise of the periodontal ligament cells. However, after 60 minutes, whether stored or not, the cells are unlikely to be viable. ⁽¹⁴⁾ As TDIs happen outside of the dental environment, the prognosis, therefore, depends on rapid, appropriate action by the patient, guardian, or first aid provider.

It is generally agreed that an avulsed primary tooth should not be replanted due to the burden of treatment on the child, the risk of damage to the permanent tooth germ, and the risk of tooth aspiration. ⁽¹¹⁾

Trauma to primary teeth

The apex of the primary tooth root and the germ of the permanent tooth lies in close proximity to each other. Previous guidance has supported the immediate extraction of the primary tooth if the root is displaced in the direction of the germ, but the IADT now advises against this as there is evidence it can cause further damage to the germ. ⁽¹¹⁾

Distress and anxiety

Treatment of TDIs in children may be complicated due to a young patient’s fear and inability to cope with distress. Dental professionals should also keep in mind that this may be one of the child’s first dental encounters. Given the difficult circumstances, the risk of dental anxiety onset should be taken into consideration. The IADT notes that the “knee-to-knee” examination technique can be helpful in smaller children, and recommends that the child is followed up by a specialist paediatric team with experience in minimizing pain and distress in young patients. ⁽¹¹⁾ You can find more advice on these topics in our articles Shaping Pain Perception and How to Deal with Young Patients’ Pain.

The challenge of preventing TDIs

By their nature, it is difficult to predict or prevent TDIs entirely. However, dental professionals can help by raising awareness of common TDI risk factors. In younger children, that may involve educating parents on common causes of TDIs and preventative steps like the safe use of baby walkers, safe play behaviors, and adequate head/facial protection during play activities. With a significant number of TDIs occurring while engaging in sporting activities, players can reduce their risk by using mouthguards, while parents, teachers, and coaches can encourage or mandate their use by children. In Australia, where sports injuries account for nearly 40% of TDIs, the New South Wales branch of the Australian Dental Association runs the Game On campaign to encourage this practice. ⁽¹⁵⁾ Dental professionals can do the same by getting involved in similar local campaigns and forming partnerships with local sports teams, schools, and student sports associations.

While we may not be able to prevent a TDI, we can improve the prognosis by raising awareness of how to appropriately respond. As the majority of childhood TDIs occur at home and in school, parents and teachers specifically must be educated on the correct way to deal with a TDI. ⁽⁴⁾⁽⁵⁾ The following are examples of how dental professionals can support awareness and encourage preparedness:

• Implementing media campaigns.
• Providing educational resources for the home and classroom, such as the IADT’s Save Your Tooth posters.
• Liaising with first aid providers regarding best practices and offering training in school or community settings.
• Providing tooth salvage kits to schools and sports associations, or making them visibly available in the practice.
• Directing patients, parents, educators, and guardians to the IADT’s free ToothSOS mobile app, which offers emergency guidance in case of a dental emergency (available for iPhone and Android).

While we don’t see dental trauma every day in practice, the high prevalence means that a TDI is never far away. By proactively raising awareness and arming yourself with best-practice treatment protocols, you can ensure that when you do encounter a TDI, you’ll be ready to secure the best possible outcome for your patient.