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Management of Traumatic Injuries to the Primary & Permanent Dentition


 

Epidemiology

 

Infants and toddlers will often fall when crawling or walking, tumble off a toy or bump into furniture or a wall when running. Fortunately, a few tears and a hug is all that is required and life goes on.

But sometimes injuries occur and oral injuries are quite upsetting to caretakers. What to do and where to go are a real problem, especially if a Dental Home has not been established. Most community hospitals do not have dental attendings available for immediate referral and intervention.

 

Most national statistics report on face and head injuries secondary to trauma and seldom report dental and oral manifestations. Very few infants escape the transition to being a toddler without a bruised lip, a torn frenum or a bumped tooth.

 

Peak periods for trauma are between 18-40 months; with more males involved after 12 months of age. Although reported earlier, there now appears to be no seasonal variations in oral trauma. No longer are activities limited because of weather, with a number of venues available for year long fun and games.

 

The teeth most often affected are the maxillary anterior primary teeth. Although fractured crowns are reported more often, the most common injury to primary teeth is a luxation or displacement injury with gingival hemorrhage. These injuries are most likely due to the direction of the force and the elasticity of the alveolar bone surrounding the primary teeth. Intrusion injuries are often seen where usually one primary tooth is driven into the alveolar bone because of the force. Avulsion of a tooth can also occur and aspiration of the displaced tooth must be considered. (Figure VII-I)

 

 

Trauma -Primary Teeth

Figure VII-I

 

 

With permanent teeth, crown fractures are more common and can involve only a small portion of the crown or the entire crown with pulpal involvement. Root fractures are also possible and depending where the fracture is located on the crown or if it is a horizontal or a vertical fracture the outcomes differ greatly.

 

Besides teeth, all soft tissues of the oral cavity can be involved including lips, tongue, palate, frena and gingiva. Occasionally, impalement injuries occur when a toddler falls with an object in the mouth and penetrates the soft tissues, especially the muco-buccal folds or the soft palate.

 

Jaw fractures are not common in infants and toddlers. Nevertheless, a fracture does need to be ruled out, especially with a significant blow to the face or chin with difficulty in closing the jaws, limited occlusal opening, facial asymmetry or paresthesia.

 

INTERVENTION AND EMERGENCY MANAGEMENT

 

All injuries to the mouth and teeth are important and should be assessed as soon as possible to document the initial findings, provide emergency treatments and arrange a schedule of monitoring and follow up. Non-dental health professionals will be called upon for assistance especially during the younger years when a parent has not yet established a Dental Home. In a study, only 17% of pediatricians felt confident in managing dental trauma. There are no studies reporting on other health professionals and their training of managing dental emergencies.

 

Once it has been assessed that the ABCs of medical emergencies have been fulfilled and no medical problem exists, the teeth and mouth should be evaluated. Facial bones should be palpated, and lacerations, bruises and swellings noted, opening and closing of the mouth attempted, and lateral excursions of the jaw attempted. Teeth should be viewed for missing or fractured crowns and mobility or intrusion. Intraoral soft tissues should be checked for bruising and lacerations.

 

Trauma can be associated with an accident and, for legal reasons, extraoral and intraoral photographs should be taken.

 

Depending on the findings, the age of the patient, anticipated behavior and location of the examination, radiographs may be ordered. Most EDs in community hospitals do not have radiographic units to take intraoral radiographs. A consult/referral to the pediatric dentist should be considered.

 

Because facial and oral injuries are reported in suspected child abuse, it is mandatory that examining health professionals evaluate the mouth and report or rule out oral injuries.

The non-dental health professional has limited ability to diagnose and treat oral trauma. It will be important for them to rule out medical emergencies, assess the needs for tetanus booster, and to make the appropriate referral for treatment and/or follow-up.

 

Contemporary literature does not recommend reinserting an avulsed primary tooth. But an avulsed permanent tooth needs to be replanted quickly with appropriate splinting and follow-up by a dentist.

Depending on the tooth and the extent of crown fractures, emergency management is important to protect the pulp from invading bacteria. If possible an intermediate, esthetically pleasing repair of the crown should be placed to avoid the psychological trauma of the fractured tooth.

 

Radiographs are indicated to determine the status of the roots, the alveolar bone, location of intruded teeth in relationship to unerupted permanent teeth, location of the crown fracture in proximity to the pulp and finally, any alveolar bone or condylar fractures.

 

Outcomes are not always predictable but can be improved with appropriate and early evaluation diagnosis and intervention.

 

Soft tissue damage, when managed properly, will usually heal without incident.

A common consequence of primary tooth trauma is a dark tooth. Colors vary from yellow, gray, brown, pink or any combination. Discoloration is due to damage to the pulp, its blood supply and tissue ischemia. Monitoring is indicated and, unless an abscess develops, seldom is treatment provided. (Figure VII-2)

 

 

Trauma- Consequences

Figure VII-2

 

Intruded primary teeth may reerupt, but could take up to six months. A possible sequelae is ankylosis where the tooth and bone join preventing eruption.

 

Early loss of a primary tooth may lead to a tongue habit formation. No reports suggest speech problems. With multiple loss of teeth and a severe non-nutritive sucking habit, the risk of arch width loss increases with possible irregularities in the bite.

 

A very early intruded primary tooth can affect the developing permanent dentition. Depending on the stage of development, the permanent tooth could erupt with a hypoplastic enamel surface or a hypocalcified surface.

Trauma to permanent teeth has many more severe long-term consequences and usually require the supervision of a pediatric dentist and will not be discussed here. The only situation that may involve the primary care medical provider would be the avulsion of a permanent tooth. If the parents or school nurse calls and inquires what to do the following should be recommended:

Find the avulsed tooth.

Hold it only by the crown.

Wash it off under cold water; do not scrub

Place it back into the socket quickly. If not possible to reinsert, place it in cold milk or water and transport both child and tooth to the dentist. Another useful product to have in physicians offices and schools would be the "Save-a-Tooth" preserving system. (Save-A-Tooth -1-800-522-0800.)

Refer the patient to a pediatric dentist for further evaluation, radiographs and treatment.

 

INJURY PREVENTION

 

During anticipatory guidance sessions, caregivers should be advised on how to make a home injury-proof. But no matter what is done, more than likely an infant/toddler will someday suffer a traumatic event that could also involve the face and mouth. Having a dental home for the caregiver to contact immediately will probably be the most important recommendation you can make as the primary care provider.

 

With increasing age, caregivers should be encouraged to purchase appropriate size helmets for children to use when on tricycles and bicycles, scooters and other wheeled toys.

 

Although contact sports are being introduced at earlier ages, there are no guidelines presently that suggest a preschooler should have a mouthguard. As the child ages and the sports get rougher, mouthguards should be recommended. Custom-fitted are the best, but with the frequently changing dentition between six and fourteen years of age, it is difficult to maintain a stable fit with the loss of the baby teeth and the erupting permanent teeth.

 

CHILD ABUSE

 

As a final reminder, oral and facial injuries are frequently reported in child abuse cases. Probably the most common, and a SCAN characteristic, is a torn maxillary frena. Others would be bite marks on the neck, ears, and face. In addition, the red impression of the fingers on the cheeks after a slap are at least questionable signs of abuse and should be investigated.

 

 

REFERENCES

Andreasen JO. Injuries to developing teeth, in Andreasen JO and Andreasen FM. Injuries to Teeth 3rd ed. Copenhagen: Munksgaard Publishers, 1993; 459-491.

Harding A and Camp l. Traumatic injuries in the pre-school child. Dent Clin NA, 1995; 39:817-835.

Krasner P and Rankow H. New philosophy for the treatment of avulsed teeth. Oral Surg, Oral Med, Oral Pathol , Oral Radiol Endod, 1995; 79:616.

Tsamtsouris A and Gavsis v. Survey of pediatricians attitudes towards pediatric dental health. 1 Pedodon, 1990; 14:152-157.

 

 

ADDITIONAL READINGS

Andreasen JO and Andreasen FM. Traumatic dental injuries -a manual. Copenhagen, Munksgaard Publishers, 1999.

Committee on Child Abuse and Neglect. Oral and Dental Aspects of Child Abuse and neglect, Pediatrics, 1999; 104:348-350.

Diab N, Mourino AP. Parental attitudes towards mouthguards. Pediatr Dent, 1997; 19:455-460.

Lee JY , Vann WF et al. Management of avulsed permanent incisors: a decision analysis based on changing concepts. Pediatr Dent; 2001 :23:357-360.

McTigue DJ. Diagnosis and management of dental injuries in children. Ped Clin NA, 2000; 47:1067-104.

Trauma, in The Handbook -Pediatric Dentistry, 2°d ed. Nowak, Al editor, Chicago, American Academy of Pediatric Dentistry, 1999; pp. 93-98.

 

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