Chipped, broken or cracked tooth

A tooth breaks at the worst possible moment: on an olive stone, on a boiled sweet, on the arm of a pair of glasses, in a fall off a bike. For the first second most people feel nothing except the tongue running into a sharp edge, and from that comes the wrong conclusion — it doesn't hurt, so there is no hurry. Yet what happens in the first hour sometimes decides whether the tooth stays alive. Two things need sorting out: how deep the break goes, and whether anything more serious than a broken tooth has happened alongside it.

What exactly has broken off

A tooth is built in layers, and the sensations tell you fairly accurately which layer the damage has reached.

• A chip of enamel. The outer layer has no nerves, so nothing hurts; the only nuisance is a rough edge that scrapes the tongue and cheek. This is the calmest version.
• A break exposing dentine. Under the enamel lies a layer threaded with microscopic tubules running to the nerve. The tooth starts giving short jolts with cold, with sweet things and with a stream of air. It needs sealing, because infection eventually travels in through open dentine.
• A fracture with the nerve exposed. A red or pink spot shows in the broken surface, sometimes with a bead of blood, and the pain is strong and does not settle. Here it is a matter of hours: the sooner the nerve is covered, the better the chance of keeping the tooth alive.
• A crack. The most treacherous of the lot. Fine surface lines in the enamel are usually harmless and last for years. A genuine crack, though, produces a very characteristic pain: not while you chew but as you let go — a short jab at the moment the jaws come apart. It is not always visible on an X-ray, and meanwhile the tooth is splitting.
• A broken wall or cusp. Usually next to a large old filling. The piece comes away whole, often with part of the filling, leaving a hollow in the tooth.

Two situations stand apart: a tooth broken right at the gum line and a tooth that has become loose after a knock. Both are more awkward than they look.

The first few hours

The order of things is simple, and it is the same for an adult and for a child:

• rinse the mouth with warm water and a pinch of salt, to clear the debris and see what you are dealing with;
• if the gum or the lip is bleeding, press with clean gauze or a handkerchief for ten minutes without lifting it every few seconds;
• find the broken-off piece and do not let it dry out: put it in milk or in your own saliva, spat into a clean pot. It does not need to be kept in water and must not be wrapped in a tissue. A dentist can sometimes bond the fragment back on, and your own enamel looks better than any rebuild;
• cover the sharp edge until the appointment with a piece of sugar-free chewing gum or with dental wax from a pharmacy — within hours the tongue rubs itself raw;
• hold something cold against the outside of the cheek through a cloth for about fifteen minutes;
• eat soft food, chew on the other side and avoid anything very hot or icy;
• if it hurts, take the over-the-counter painkiller you normally use. The tablet must not be held against the gum: that produces a chemical burn of the lining and does nothing whatever for the tooth.

It is worth booking a dentist within days even for a small painless chip: smoothing an edge and sealing dentine is far simpler and cheaper than treating what will grow out of it in six months.

When it is more than a chip

There are situations in which waiting changes the outcome. Get help immediately, without waiting for a convenient appointment, if:

• an adult tooth has been knocked out whole. Pick it up by the crown only, without touching the root and without scrubbing it. If it is dirty, rinse it briefly in milk or saline and put it straight back into its socket, biting on a handkerchief. If that fails, keep the tooth in milk or inside your own cheek and get to a dentist as fast as you can: the chances of it taking fall away sharply after the first half hour;
• bleeding from the mouth does not stop after twenty minutes of pressure;
• the jaws no longer meet as they did, the teeth do not bite together, the mouth is hard to open or the shape of the face has changed;
• the injury involved loss of consciousness, vomiting, severe headache or a gap in memory — then the head comes first and the tooth second;
• the cheek or chin is swelling visibly, there is a temperature and the eye is starting to close with the swelling;
• there is swelling under the tongue or under the jaw and swallowing, speaking or breathing has become difficult — that is an emergency rather than a dental problem;
• the tooth has been driven up into the gum or has visibly shifted;
• a cut in the lip or tongue is deep and gaping, and fragments of tooth may be inside it.

If the accident happened outdoors and the wound is dirty, it is worth recalling when the last tetanus vaccination was given.

What the dentist will do

The tooth is examined, its looseness and sensitivity checked, and an X-ray is almost certain: it matters whether the root is intact and whether the surrounding bone has suffered. What follows depends on how deep the damage goes:

• smoothing and polishing the edge, for a small chip of enamel;
• bonding your own fragment back on, if it was kept and still fits;
• rebuilding the shape with filling material or, where a lot has gone, an onlay or a crown covering the whole tooth;
• root canal treatment when the nerve is exposed or has already died;
• splinting: a loose or replanted tooth is fixed to its neighbours for a few weeks;
• extraction if the tooth is split lengthways into the root, in which case the options for filling the gap are discussed straight away.

Even when a tooth is rebuilt the same day, it is not forgotten. The nerve inside can die months later, and often the only clue is the tooth darkening or aching when bitten on. That is why check-ups with X-rays are arranged after an injury, and they are not worth skipping.

Baby teeth are a separate story

With children the rules change, and the main difference is this: a baby tooth that has been knocked out is not put back. The bud of the adult tooth lies in the bone beneath it, and trying to replace the tooth can damage it. The child should still be seen: the socket is checked, and so is whether the tooth has been driven inwards and whether fragments are lodged in the lip.

A chipped baby tooth is usually just smoothed or sealed. What should worry you is a tooth that darkens after the knock, a gum that swells above it or a small abscess appearing: infection at the root of a baby tooth can also harm the adult tooth behind it. One more thing: after an injury the adult tooth that comes through years later quite often looks different, with a small patch or groove in the enamel. That is nothing to panic about, but it is a reason to tell the dentist about the old injury.

Why teeth break

A sound tooth does not simply shatter. Almost always something weakened it beforehand:

• decay that has undermined it from within while the enamel still looks whole;
• large old fillings: the walls left around them are thin and go first;
• root-treated teeth left without a crown, which turn brittle;
• grinding and clenching, usually at night; the giveaways are worn edges, a tired jaw in the morning and headache at the temples;
• enamel erosion from acid: fizzy drinks, frequent reflux, vomiting;
• the habit of biting ice, nuts in their shells and hard sweets, and of opening bottles and packaging with the teeth;
• sport without a mouthguard, and lip or tongue piercings knocking against enamel for years.

From which follows a dull but effective bit of prevention: a mouthguard for contact sport, a night guard for grinding, giving up the use of teeth as tools, treating reflux, and going to check-ups, where cracks are found before they announce themselves.

Online consultation

A broken tooth is fixed by a dentist, and nothing remote can stand in for that. What an online appointment handles well is everything that happens before the chair. The doctor will work through what exactly happened and how urgent it is: wait for a routine appointment, go today, or head for emergency care. You will hear how to keep the broken-off piece and what to do this minute with a tooth that has been knocked out, what to take for the pain and what not to do. Assessed separately is everything that has nothing to do with teeth but often comes with them: concussion after the fall, tetanus cover, and spreading facial swelling with a temperature, where the clock no longer runs in days. And there is help in deciding what to do if the accident happens away from home, at a weekend or in the middle of the night.

This material is for information only and does not replace medical advice.