Reducing Risk Liability for Dental Injuries at Camps

By Paul R. Krasner, D.D.S.

In a research study of the occurrence of dental trauma in children, it was determined that 25 percent of all school-aged children will experience a dental injury each year (Uji and Teramoto 1988). There are presently 53 million school-aged children in the US. That means there will be approximately 13 million children who will have a dental injury this year in the U.S. Since we are in a litigious society, it can be assumed that a substantial number of these parents will seek restitution for their children’s injuries sustained while attending camps.

Dental injuries to children while at camp functions can result in large amounts of money in reparations and long, costly court endeavors. The proper, immediate treatment of these types of injuries gives parents reassurance that the camp personnel are acting in the child’s best interest and decreases the likelihood of permanent disfigurement and resulting litigation. It is important that all camp personnel are educated with the information they need to properly treat these types of injuries therefore, reducing the camp’s liability exposure related to dental injuries.

Liability Reduction Measures

Being prepared in two different areas can reduce liability: (1) preparing a dental emergency treatment kit and (2) taking administrative measures.

Dental Emergency Treatment Kit
The preparation of an emergency kit is essential for proper, immediate treatment. This kit needs to be placed in several accessible areas including all camp nurse stations, at swimming pools, and in first-aid kits wherever children are active. This kit should include each of the following items:

1. Small bottle of oil of cloves
2. Cotton-tips
3. 2-inch- by 2-inch gauze squares
4. Dental wax
5. Save-A-Tooth® emergency tooth preserving system
6. Wire cutters
7. Topical anesthetic (benzocaine or Anbesol®)
8. Aluminum sulfate (styptic pencil)

Administrative Measures
In order to reduce the damage to the injured child the following administrative actions are recommended:

1. Every camp should establish a list of dentists to whom they can send an injured child in an emergency. The list of dentists should include their hours and what kind of emergency treatment they can perform.
2. In addition to a listing of a child’s physician during registration, a child’s dentist should also be listed with his or her telephone number.
3. Local hospital emergency rooms should be contacted to find out their policy for treating dental emergencies.
4. If possible, camp personnel should obtain permission from parents to permit treatment of dental injuries, in particular, tooth avulsion.
5. Camp staff should be trained in appropriate treatment of dental injuries. In particular, treatment of avulsed teeth must be discussed and known by all staff. As little delay as one hour in treatment of these teeth can cause their loss.
6. Children participating in sports activities should have a written standard for mouth protection and implementation assurance measures.

The creation of a dental emergency kit and the implementation of administrative measures are essential to reduce liability, however, these actions alone are not sufficient. The camp nurse and staff must be trained and prepared to act when a dental emergency occurs. In order for these people to act, they should be trained on identifying and treating the most common dental injuries.

Common Dental Injuries

There are five basic types of dental injuries that may occur while children are at camp. These are described in Table 1.
Depending on the type of causative agent of the trauma, one or more teeth can and usually are damaged. This can result in a combination of any of the above-described injuries. For example, if a baseball strikes a child in the mouth, three teeth could be fractured, one tooth could be luxated, and three additional teeth could be avulsed resulting in damage to a total of seven teeth. It is rare that only a single tooth will be damaged in any traumatic situation.

Proper Emergency Treatment

The person providing emergency care most likely will not be a dentist, therefore, all of the following treatment measures are meant to alleviate distress and place the situation in the best condition to minimize future dental health problems. Acetaminophen can be given in any of the following emergency situations for discomfort. Topical anesthetic, like benzocaine or Anbesol®, can be used whenever the gums or lips are abraided and if bleeding is difficult to stop, aluminum sulfate (styptic pencil) can be used.

Concussion
No definitive treatment for concussion is necessary. Follow-up evaluation by a dentist is imperative because, even though the blow has not caused observable damage, the pulp of the tooth may require treatment.

Fracture
The fragments of the broken tooth should always be retrieved and placed in water or another storage fluid. If a Save-A-Tooth® is used, all of the fragments can be placed in the same container. These fragments should be taken to the dentist who may be able to bond them back onto the tooth.

If the camper experiences pain in the tooth at the site of the fracture, dental wax can be placed over the exposed tooth. If the wax does not adhere or alleviate the pain, oil of cloves on a cotton-tip can be placed on the exposure site.

Luxation
If a tooth is pushed out of position but remains fully in the gum tissue it should be left alone, but if it is dangling or even half way removed from the socket, the tooth should be pushed back into place, and the camper should bite on gauze that is placed between the upper and lower teeth. The biting pressure should be continued until treatment by a dentist is received.

If the camper has orthodontic appliances on the injured teeth and a wire is protruding and cutting the lips or gums it should be cut away with wire cutters.

Intrusion
This is a nontreatable condition for a layperson. The person at the accident scene should make sure that they are not observing an avulsed tooth. They can do this by looking into the site of intrusion and observing if any tooth can be seen. That person should double check to make sure there are no avulsed teeth. The camper should be brought to the dentist immediately.

Avulsion
Look in the mouth and attempt to determine the number of teeth that have been knocked out; do this by counting the number of holes. Pick up all of the avulsed teeth and attempt to put them back into the correct socket. This may be difficult to do for a layperson. If there is concern at determining this or if there is any of the following difficulties that may prevent a replantation, the teeth should be placed in the best storage environment possible, a Save-A-Tooth® system if available (Trope 2002).

The Save-A-Tooth® emergency tooth preserving system is the new standard of care for avulsed teeth. The teeth should be picked up by the crown and placed into the system as quickly as possible. It is not necessary to rinse the teeth before they are placed into the system; the basket and netting will allow for atraumatic cleansing and prevent any further damage to the delicate tooth root cells. The child and teeth should then be taken to the nearest dentist or emergency room. Save-A-Tooth® will protect and nourish the knocked-out teeth for up to 24 hours, so other injuries can be treated before the tooth is replanted if necessary.

If a Save-A-Tooth® is not available, the next best alternative is milk, however, the milk must be obtained quickly and kept fresh and cold. If cold, fresh milk is not easily accessible, the teeth should not be handled in order to take the child to a location with milk. Handling the teeth crushes the tooth root cells and can cause the teeth to be permanently lost. If the teeth are stored in milk, a dentist should replant the teeth as quickly as possible.

Protecting the Camp and Campers

Dental injuries can and will occur while children are at camps. Litigation has been and will continue to be instituted as instruments of reparation for these injuries. In order to reduce the occurrence of dental injuries, reduce the initiation of lawsuits, and lower the judgments for these incidents, camp personnel must be proactive. This article has recommended both administrative measures and emergency kits that can be instituted in preparation for dental trauma. With the utilization of all of these, camp personnel can protect themselves and their campers against the consequences of these occurrences.

Dr. Paul R. Krasner is in private practice of endodontics in Pottstown, Pennsylvania. He is a professor of Endodontology at Temple University, School of Dentistry. Dr. Krasner is the proud parent of four children who all participate in several summer camps each year. For more information, contact the author at 888-788-6684 or mikiesat@aol.com.

Originally published in the 2005 Spring issue of The CampLine.