Persons with disabilities are at higher risk of dental trauma due to underlying health conditions such as impaired co-ordination, balance, responsiveness, and safety reflexes.

Neural and/or muscular conditions such as epilepsy, cerebral palsy, autism and attention deficit hyperactivity disorders are known to increase susceptibility to injuries^7-10. Others such as vision and hearing loss as well as developmental disabilities may also affect the ability of an individual to assess the risk of injury.

Dental trauma involves injuries to the teeth, lips, gums, tongue, and jawbones¹. It is one of the major concerns in dental public health after dental caries or tooth decay. Such trauma can affect all age groups and is prevalent with no significant differences across geographical regions. These injuries can directly or indirectly influence lives of individuals, affecting their appearance, speech and teeth position, as well as causing psychological and social problems ⁽²⁾.

Dental trauma can occur from simple falls due to loss of balance to contact sports or motor vehicle accidents. The most common teeth to be affected are the central front teeth or incisors, especially when they protrude more than 4mm. They appear two to three times more likely to suffer dental trauma than normally aligned teeth ⁴.

Types of dental trauma

Our teeth consist of the crown, neck and root. The hard outer layer, called enamel, surrounds a softer layer known as dentine which lies between the enamel and the innermost pulp.

The pulp, consisting of delicate blood vessels, nerve tissues and cells, connects to the body through the tooth’s apex. The tooth is supported by cementum, periodontal ligament and bone. Cementum covers the root and forms a point of attachment to the fibres of the periodontal ligament which attaches itself to the bone on the other side hence securing the tooth in the dental socket¹¹.

Common dental injuries include:

Superficial fractures: A damage to the hard enamel. Such situations may not be very serious unless there is a jagged edge of the tooth harming the soft tissues such as gums, lips, tongue in the mouth¹.

Serious fractures: Dentine or pulp is exposed and becomes sensitive to touch, heat or cold. This increases the risk of bacterial infections, and it requires immediate attention from a dentist¹.

Severe injuries: Tooth may be displaced, which could potentially sink deeper into the socket or hang loosely out of it. The tooth may also be displaced to the side or knocked out completely or supporting bone structure may be fractured. In such cases, the delicate blood vessels supplying the pulp are damaged thus, requiring intensive dental treatment¹.

Dental Trauma Management

Prompt treatment is essential for the long-term health of an injured tooth. Obtaining dental care within thirty minutes can sometimes make the difference between saving or losing a tooth⁴.

When people with disabilities, irrespective of age group, encounter a dental emergency, their caregivers play a huge role in ensuring the right measures are taken. Diagnosis involves dentists examining the tooth using dental tools and x-rays to determine the extent of the damage. Based on this assessment, appropriate treatment plan is done¹.

Below are different types of tooth damage and how caregivers can help to mitigate further damage to the tooth:

Tooth Fracture – broken tooth:

• For milk or primary teeth with superficial damage, the dentist may smoothen the sharp edges since these teeth will eventually be replaced. However, if inner layers of the tooth are exposed, it forms a potential pathway for bacteria to reach the dental pulp.In such conditions the fractured teeth will require a filling or crown, depending on how much tooth structure has been lost. If the fracture extends into the dental pulp, pulp treatment will be done⁴.
• For adult or permanent teeth, both the teeth and the broken piece should be cleaned before quickly bringing them to the dentist¹. Any dirt and debris in the injured area must be washed and a cold compress should be applied on the cheek if there is any swelling¹. Upon analysing the level of trauma, the dentist may recommend filling minor fractures or treatment in the form of a restoration based on extent of damage to the various layers of teeth followed by a full permanent crown. If the trauma is too severe and the tooth has no chance of recovery, treatment might include retention of root part of the tooth to use as a support for crown construction. If extraction is needed, then a complete extraction of the tooth followed by prothesis or an implant for the missing tooth^1,4.

Luxation – tooth is pushed out of position:

• When primary teeth are slightly displaced and not interfering with the child’s bite (occlusion), they may be left to spontaneously align itself. However, those which are severely displaced or displaced toward the developing permanent tooth may require extraction⁴.
• When permanent teeth are displaced, it is considered best to reposition them into the correct position, to provide patient comfort and restore function⁴. Therefore, its best to put it back to its normal position using very light finger pressure without forcing the tooth. Bite down to keep the tooth from moving and visit the dentist immediately. The dentist may splint the tooth in place of the two healthy teeth next to it¹.

Avulsion – dislodged tooth:

• Avulsion injuries can occur both in primary and permanent teeth. When the primary tooth dislodges, it is not replanted in the socket as this may cause further injury to the developing permanent tooth. Nonetheless, it is best to seek emergency treatment at the earliest opportunity to rule out other injuries. Injuries to the primary teeth may have long term consequences on the development and eruption of their permanent successors⁴. Immediate care can be provided by replacing the tooth in the socket and keeping it down by biting on a gauze¹.
• The dislodged permanent tooth must either be reinserted into the socket or brought to the dentist for further treatment immediately^1,4.
• The best way to preserve a dislodged permanent tooth is to gently rinse off any dirt with water, hold it by the crown, and reinsert it into its socket as quickly as possible to avoid damaging the periodontal ligament fibers. This can be performed at the accident scene before dental consultation. If the tooth cannot be replaced, store the tooth in saline solutions available in pharmacies, or in a container with cold milk, or patient’s saliva and bring them to the dentist to prevent drying out¹.
• Apply cold compress to the cheek to relieve any pain or swelling¹.

If there is injury to soft tissues such as lips, gums, or tongue:

• Immediately rinse with cold water to remove any dirt.
• Apply cold compress to the cut area to stop bleeding.
• Go to a hospital emergency department. Stitches may be required if bleeding does not stop.
• Injuries to the face or lips are often presented together with tooth injuries and may range from bruises to cuts / lacerations. Depending on how severe the injury is, stitches may be required to help stop the bleeding and optimise healing^1,4.

Prevention

Most dental trauma is preventable, and precautions can be taken to minimise such risks.

• Car seat belts should always be worn to protect from injuries during accidents and young children should be secured in appropriate car seats^1,4.
• Homes should be monitored for potential tripping and slipping hazards which increase the risk of dental trauma⁴.
• Child-proofing measures should be taken, especially for toddlers. Measures include placing gates across stairs, padding sharp table edges and tucking the electrical cords^1,4.
• To reduce severity of trauma, mouth guards are recommended for those who participate in contact sports such as football or non-contact sports such as skateboarding and in-line skating. ^1,4.
• In addition, orthodontic treatment, commonly known as braces, can be considered to align upper front teeth which are protruding, reducing the likelihood of dental injury to these teeth⁴.

Conclusion

Limited motor co-ordination, involuntary physical movements and reduced agility in people with disabilities can result in dental trauma. Different injuries require varied treatments, and the help of the caregivers is of utmost importance for immediate first aid aside ensuring the emotional wellbeing of the person. It is thus important to know and understand how to support people with disabilities who suffer from dental trauma.

This article is contributed by Dr Sneha Sundar Rajan. Dr Sneha has a master’s degree in Dental Surgery (MDS) from Manipal University, India. She was a researcher with the National University of Singapore at the Faculty of Dentistry and Centre for Advanced 2D materials before taking a break for motherhood.

References

1. https://www.healthhub.sg/a-z/diseases-and conditions/topics_dental_trauma#:~:text=Dental%20trauma%20is%20injury%20to,a%20broken%20or%20lost%20tooth.
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9.  Al-Sehaibany FS. Occurrence of traumatic dental injuries among preschool children with autism spectrum disorder. Pak J Med Sci. 2018;34:859–68.
10.  Sabuncuoglu O, Taser H, Berkem M. Relationship between traumatic dental injuries and attention-deficit/hyperactivity disorder in children and adolescents: proposal of an explanatory model. Dent Traumatol. 2005;21:249–53.
11. https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/dental-pad