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PM Pediatrics
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Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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Chipped, Loose, and Broken Teeth 101

Right now I want to think about something other than the flu.

Lots of kids chip their teeth, and most people don’t know what to do. Let’s change that today. Whether it’s part of a fall or a forceful bite on hard candy, these injuries can really run the gamut from needing absolutely nothing at all to significant dental work. A few variables dictate what needs to happen after tooth trauma, so let’s get it all straight so that YOU will be someone who knows what to do should this happen in your presence.

I’m not a dentist so definitely on the JV team as far as the details and finesse of tooth repair, but I did learn a little bit about teeth during my medical training, and when I first came across the topic of broken and chipped teeth I found it very helpful to be familiar with the layers and anatomy of the tooth. This helps put the injuries into perspective.

I think the main things to know are:

1. Primary or secondary tooth. Baby tooth or permanent, right? Starts off easy.
2. Layers of a tooth. There’s the outside layer, or the enamel; then inside of that is the dentin, and then the pulp, which is part of the root. This becomes important when we assess a chipped tooth.

tooth anatomy detailed illustration

First, the obvious.

If a tooth gets COMPLETELY KNOCKED OUT, called a dental avulsion, AND YOU CAN LOCATE IT (which sometimes doesn’t happen), then the best thing to do is to put it in milk or saline or saliva immediately without rinsing the tooth. Even better, if you can, stuff it back into the socket in the mouth and make your way to the dentist or nearest emergency center that has emergency dental backup. BIG CAVEAT here: this is ONLY for secondary or permanent teeth. If a baby tooth gets knocked out we typically just leave it out- there’s usually no reason to have any dental work to insert it back in place because eventually it will just fall out as the secondary tooth erupts. There’s no downside to leaving the space open in the mouth until the new tooth comes in. But the secondary tooth that gets knocked out needs to be evaluated immediately. Sometimes the tooth can be “splinted” between the 2 adjacent teeth to stabilize it temporarily until a definitive decision can be made on repair. The longer the tooth is out, the less likely it will be viable and be successfully replaced. So don’t delay, do NOT scrub the tooth, and please do not put the tooth in water or another liquid other than milk or saline/saliva.

Now onto the more subtle trauma.

Chips in teeth are referred to as fractures, even if small. There’s a handy classification system that dentists use to describe them, named after a rockstar dentist named Dr. Ellis:

1. Ellis I: This type of fracture involves the outer layer of the enamel only—it’s the kind of chip that doesn’t hurt but the edges feel rough. Typically there’s no discoloration of the tooth either.
2. Ellis II: Both the enamel AND the dentin are involved. 2 layers. Sometimes you can see the yellow dentin layer in contrast to the whiter enamel. These injuries cause some pain and sensitivity to air exposure.
3. Ellis III: All 3 layers of the tooth are exposed, and the hallmark of this type of fracture is that you can often see some red or pink color in the chipped part, which is the tooth pulp, that contains the blood supply. This injury causes tenderness and sensitivity as well. These are especially susceptible to infection.

Ok, fine. A swell classification, and….? What you really need to know is that Ellis I fractures are injuries that can wait whereas Ellis II and III fractures typically require immediate evaluation, pain control, and sometimes antibiotics. Avoidance of hot and cold foods is an important comfort measure, so keep that in mind regardless.

What about a loose tooth?

That’s known as a dental subluxation (25 cents!). While these teeth are still in the socket, they are definitely mobile, and sometimes are quite painful and might bleed a little. Usually they can simply be pushed back into place and will heal without any difficulty. However, if the tooth is pushed up into the gum/jaw (“intrusion”), or elongated/displaced out into the mouth beyond the rest of the tooth line (“extrusion”),in the majority of cases the tooth needs to be repositioned and splinted, so if the tooth is significantly out of position then a prompt evaluation should be pursued. This is one of those “better safe than sorry” situations.

So do you feel like you now know more than you ever wanted to about chipped teeth, loose teeth, broken teeth, and knocked out teeth? There’s some vocabulary and nuance, but if you come away knowing the following:

A. A big deal is never made about baby teeth that are chipped, loose or fall out.
B. Permanent teeth that get totally knocked out should not be agitated but should be put back in the mouth or milk/saliva/saline and dental/medical attention should be sought right away.
C. Different types of tooth fractures require different treatment; but if you can see red or pink in the middle of the broken part of the tooth then dental/medical attention should be sought right away.
D. Loose teeth do pretty well but it never hurts to get them checked out if they are significantly displaced…

Then you will be solidly ready to handle any fall, sports injury, or hard candy encounter that results in a dental injury, and I’ll be proud of ya.

What objects/foods have YOU heard of /experienced that have caused tooth trauma?

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