What is the recommended treatment for a 2-year-old child who tripped and fell, hitting their face on the ground, resulting in a tooth penetrating the upper lip with minimal bleeding?

Management of Tooth Penetration Through Upper Lip in a 2-Year-Old

For a 2-year-old with a tooth penetrating the upper lip and minimal bleeding, immediately assess the tooth for luxation injury, control bleeding with direct pressure, and refer to a dentist within 24-48 hours for evaluation of both the soft tissue laceration and potential dental trauma. 1

Immediate Assessment and Management

Soft Tissue Injury Management

• Apply direct pressure with clean gauze or cloth to control any bleeding from the lip laceration. 2 While the scenario describes minimal bleeding, this is the first priority for any oral soft tissue injury.

• Examine the lip laceration carefully to determine if it is a through-and-through injury (penetrating both the inner and outer surfaces of the lip). 1

Dental Injury Assessment

• Systematically examine the tooth that caused the penetration for any luxation injury (mobility, displacement, or change in position), as this is the most common dental injury in 2-year-olds. 1

• The greatest incidence of dental trauma to primary teeth occurs at 2-3 years of age when motor coordination is developing, with luxation injuries being most common. 1

• Check if the tooth is mobile, displaced, or appears shorter/longer than adjacent teeth to classify the injury type (subluxation, lateral luxation, extrusive luxation, or intrusive luxation). 1

• Verify that the child can bite down normally by asking them to gently close their teeth together, ensuring the injured tooth does not interfere with occlusion. 1

Specific Management by Injury Type

If Tooth Shows Minimal or No Displacement (Subluxation)

• No immediate repositioning is required. 1

• Observe for signs of future pulpal necrosis (tooth turning gray or development of a gum boil/parulis adjacent to the tooth). 1

• Refer to dentist within a few days if tooth discoloration or parulis develops. 1

If Tooth is Displaced Laterally or Extruded

• For minor displacement, gentle digital repositioning is appropriate by applying gentle pressure to return the tooth to its normal position. 1

• For more severe displacement (>3mm extrusion), immediate dental referral is required for professional repositioning and possible extraction. 1

• Ensure the repositioned tooth does not interfere with the bite, as this affects the child's ability to masticate properly. 1

If Tooth Appears Shorter or Missing (Intrusion or Avulsion)

• Intruded primary teeth typically re-erupt spontaneously without intervention and should be observed rather than repositioned. 1

• If the tooth is completely avulsed (knocked out), do NOT replant a primary tooth, as replantation risks damage to the underlying permanent tooth germ. 1, 2

• Immediate dental referral is indicated to rule out avulsion versus severe intrusion. 1

Critical Considerations for This Age Group

Child Abuse Screening

• Child abuse must be considered as a possible etiology in any child younger than 5 years with trauma affecting the lips, gingiva, tongue, palate, and severe tooth injury. 1

• Document the mechanism of injury carefully and assess for consistency with the reported history. 1

Primary vs. Permanent Teeth Distinction

• At 2 years of age, these are definitively primary (baby) teeth, not permanent teeth. 1

• Management differs significantly from permanent teeth—primary teeth are NOT replanted if avulsed and are managed more conservatively with luxation injuries. 1, 2

Dental Referral Timing

• Immediate referral (same day) is indicated for: severe displacement interfering with bite, extensive gingival/facial swelling, severe extrusion (>3mm), or inability to determine if tooth is intruded versus avulsed. 1

• Referral within a few days is appropriate for: minor subluxation, tooth discoloration, or development of a parulis (gum boil). 1

• All dental trauma in this age group warrants dental follow-up to monitor for pulpal necrosis and potential damage to the developing permanent tooth germ. 1

Common Pitfalls to Avoid

• Do not replant an avulsed primary tooth, as this can damage the permanent tooth developing underneath. 1, 2

• Do not ignore the possibility of child abuse in a 2-year-old with facial/oral trauma, particularly if the mechanism seems inconsistent with developmental abilities. 1

• Do not assume the tooth is "just loose" without systematic assessment for luxation type, as management varies significantly. 1

• Do not delay dental referral for severe displacement, as proper occlusion is critical for normal feeding and development. 1