What are the next steps in managing a 3-year-old's darkening front tooth, which is not loose, but painful when biting hard food, 3 days after a fall onto a tile floor?

Management of Darkening Primary Tooth After Trauma

This child requires referral to a pediatric dentist within the next few days for evaluation of pulpal necrosis, as tooth discoloration following trauma is a red flag indicating potential pulp death. 1

Immediate Recognition of the Problem

The darkening (gray discoloration) of the tooth 3 days post-trauma indicates likely pulpal necrosis—this is blood breakdown products from damaged pulp tissue infiltrating the dentinal tubules. 1 The pain with biting suggests either:

• Ongoing inflammation within the pulp chamber
• Periodontal ligament inflammation from a concurrent luxation injury that wasn't initially apparent 2

Next Steps in Management

Arrange Prompt Dental Referral

• Refer to a pediatric dentist or general dentist with high competence in pediatric care within the next few days (not emergent, but not delayed). 3, 1
• The American Academy of Pediatrics specifically identifies dental trauma (including tooth fracture, intrusion, and luxation) as requiring referral to a pediatric dental specialist. 3
• While this isn't classified as requiring immediate referral (which would be needed for extensive swelling, multiple mobile teeth, severe displacement, or visible pulp exposure), the development of discoloration is a monitoring red flag that warrants timely evaluation. 1

What the Dentist Will Do

The pediatric dentist will perform:

• Pulp sensibility testing to assess vitality 4
• Radiographic evaluation to assess root development, periapical changes, and rule out root fracture or intrusion 4, 5
• Clinical examination for mobility and percussion sensitivity 2
• Determination of whether endodontic intervention is needed 2, 5

Interim Management While Awaiting Dental Appointment

Dietary modifications:

• Instruct parents to provide soft diet only until dental evaluation 1
• Avoid hard, sharp, or irritating foods 6

Oral hygiene:

• Maintain good oral hygiene with gentle brushing around the affected tooth 1

Activity restrictions:

• Restrict pacifier or thumb sucking if applicable 1

No antibiotics needed unless the child has specific medical conditions requiring prophylaxis 1

Critical Monitoring Instructions for Parents

Educate caregivers to watch for signs requiring more urgent evaluation:

• Gingival swelling near the affected tooth (suggests abscess formation) 1
• Parulis (gum boil/fistula tract) 1
• Increased tooth mobility 1
• Facial swelling 1
• Fever or systemic symptoms 6

Any of these findings would escalate the urgency of dental referral. 1

Important Clinical Pitfall

Do not assume this is "just a bruised tooth" that will resolve on its own. While some traumatized primary teeth do recover, gray discoloration specifically indicates pulpal hemorrhage and potential necrosis. 1 Without dental evaluation, this can progress to:

• Periapical abscess formation
• Damage to the underlying permanent tooth bud
• Chronic infection requiring eventual extraction 7

Child Abuse Consideration

Document the mechanism of injury carefully and assess whether it's consistent with the child's developmental stage. 1 The American Academy of Pediatrics recommends considering non-accidental trauma in any child younger than 5 years with oral/dental injuries, particularly severe tooth injuries. 1, 6 A simple fall onto tile causing isolated tooth discoloration is typically consistent with accidental trauma, but document the history thoroughly. 1

Why Not Immediate Emergency Referral?

This case doesn't meet criteria for immediate dental referral because:

• The tooth is not loose (no severe luxation) 1
• No visible pulp exposure 1
• No extensive gingival or facial swelling 1
• No displacement interfering with occlusion 1
• No multiple teeth moving together 1

However, the discoloration developing 3 days post-injury is a clear sign of pulpal compromise requiring timely (within days) specialist evaluation. 1, 2