How to manage a 3-year-old who fell on their face, resulting in upper teeth gum injury and nasal bleeding?

Management of 3-Year-Old with Facial Fall, Upper Gum Injury, and Nasal Bleeding

For this 3-year-old with facial trauma, immediately control the nasal bleeding with firm sustained compression to the nose for 10-15 minutes while the child sits upright and leans forward, then perform a thorough oral examination to classify the dental injury and determine if immediate dental referral is needed. 1

Immediate Nasal Bleeding Management

• Apply firm sustained compression to the nasal alae (sides of the nose) for 10-15 minutes continuously without releasing pressure. 1
• Position the child sitting upright with head tilted forward to prevent blood from draining into the oropharynx and reduce aspiration risk. 1
• After bleeding stops, avoid nose-blowing, picking, or strenuous activity for the next 24 hours. 1

Common pitfall: Many providers incorrectly tilt the head backward, which increases aspiration risk and does not improve hemostasis. 2

Dental and Oral Injury Assessment

Classification of Injury Type

After controlling nasal bleeding, examine the upper gum and teeth systematically to identify the specific injury pattern, as management differs significantly based on injury type. 1

Key examination steps:

• Look for missing teeth - determine if tooth is avulsed (completely out) versus intruded (pushed into gum). 1
• Check for tooth mobility - gentle palpation reveals luxation injuries. 1
• Assess tooth position - lateral or extrusive displacement requires repositioning. 1
• Examine for gum bleeding - bleeding from gingival sulcus indicates luxation or more severe injury. 1
• Inspect for visible tooth fractures - look for exposed pink pulp tissue in crown fractures. 1

Age-Specific Context

This 3-year-old is in the highest-risk age group for primary tooth trauma - the peak incidence occurs at 2-3 years when motor coordination is developing, and luxation injuries are the most common type in primary dentition. 1

Management Based on Injury Type

For Luxation Injuries (Most Common)

Subluxation (loose tooth, no displacement):

• No immediate treatment required. 1
• Observe for signs of pulpal necrosis: gray tooth discoloration or gingival abscess (parulis). 1
• Refer to dentist within a few days if discoloration or parulis develops. 1

Lateral luxation (tooth displaced sideways):

• If displacement is minor, gently reposition with digital pressure or accept the position as spontaneous repositioning will occur. 1
• Immediate dental referral if displacement interferes with the child's bite - ask the child to gently bite down to assess occlusion. 1

Extrusive luxation (tooth pushed out >3mm):

• Immediate dental referral for extraction. 1

Intrusive luxation (tooth pushed into gum):

• Observation only - primary teeth typically re-erupt without intervention. 1
• Immediate dental referral for severe intrusion to rule out avulsion and assess for potential damage to permanent tooth germ. 1

For Avulsion (Tooth Completely Out)

Critical management difference for primary teeth: DO NOT replant an avulsed primary tooth - replantation risks damage to the underlying permanent tooth germ. 1

• If tooth is not found at scene, perform clinical examination to confirm it's not intruded. 1
• Consider chest radiograph only if child has breathing difficulties to rule out aspiration. 1

For Crown Fractures

Uncomplicated fracture (no pulp exposure):

• Refer to dentist within days for smoothing sharp edges. 1

Complicated fracture (pink pulp tissue visible):

• Immediate dental referral - exposed pulp increases infection risk from oral flora. 1

Post-Injury Care Instructions

Provide these specific instructions to caregivers for the next 10 days: 1, 3

• Soft diet only - avoid hard, sharp, or crunchy foods. 3
• Restrict pacifier or thumb sucking if applicable. 3
• Maintain good oral hygiene with gentle brushing. 3
• No routine antibiotics needed unless specific medical condition requires coverage. 1

Red Flags Requiring Immediate Dental Referral

• Extensive gingival or facial swelling. 1
• Multiple teeth moving together when palpated (suggests alveolar fracture). 1
• Tooth displacement interfering with bite/occlusion. 1
• Visible pulp exposure in fractured tooth. 1
• Severe extrusion (>3mm) or severe intrusion. 1

Monitoring for Complications

Educate caregivers to watch for signs of pulpal necrosis over subsequent weeks: 1

• Gray tooth discoloration
• Gingival swelling near affected tooth
• Parulis (gum boil/abscess) on gingiva
• Increased tooth mobility

Children may not report pain from necrotic primary teeth, so visual monitoring by caregivers is essential. 1

Child Abuse Screening

Important consideration: Child abuse should be considered in any child younger than 5 years with trauma affecting lips, gingiva, tongue, or palate, especially with severe tooth injury. 1, 3 Document mechanism of injury and assess for consistency with developmental stage and injury pattern.