Pediatric Dental Trauma. Acute Care Topics Mary Fox Braithwaite June 2008

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1 Pediatric Dental Trauma Acute Care Topics Mary Fox Braithwaite June 2008

2 Dental Injuries in Children Nearly 50% of children experience some type of dental injury during childhood, many of which are are preventable. Some injuries may result in the loss of permanent teeth and may have long-lasting lasting functional, aesthetic, financial, and psychological effects. The outcome for a number of dental injuries may be uncertain until the permanent dentition is established Outcomes may be improved by prompt and appropriate treatment and referral. Dental trauma must not be overlooked as a marker for child abuse; orofacial injury occurs in as many as 75 percent of cases.

3 UNC Hospital Dental ER Visits (Ages 13 mo 19 yr) 338 Injuries in 12 months Falls 62% Sports 13% Bicycles 12% Fights 8% Accidents 3% Car Accidents 1.8% Child Abuse 0.2%

4 Dental Terms Primary Dentition (deciduous teeth) the first set of teeth, comprising 20 in all, that erupt b/w ages months of life Permanent Dentition the adult dentition of 32 teeth, eruption begins b/w ages 5 and 7 years and is completed b/w 17 and 23 years of age Root (8) part located below the neck (5) of the tooth, covered by cementum (9) rather than enamel and attached by the PDL to the alveolar bone (jawbone) (7) Periodontal ligament (PDL) (10) the connective tissue surrounding the tooth root and attaching it to the bony socket; consists of fibers anchored to cementum and extending to the bone Pulp (4) soft tissue consisting of connective tissue, blood vessels, nerves, lymphatics and odontoblasts capable of internal repair of the dentin Dentin (6) ivory forming the bulk of the tooth; calcified tissue that is not as hard as enamel but harder than cementum Enamel (1) the hard, acellular,, inert substance covering the tooth Crown (2) the part of the tooth that is covered with enamel Gingiva/Gums (3) soft tissue overlying the crown of the erupted teeth

5 Classification of Injuries Injuries may involve: Root PDL periodontal ligament Pulp Dentin Enamel Crown (+/-) ) Pulp

6 Classification of Injuries Fractures Trauma to the teeth may cause fractures of the teeth and/or damage to the supporting alveolar bone and periodontium.. Fractures of the crown are classified as complicated (involving the neurovascular pulp) or uncomplicated (involving only the enamel or the enamel and dentin) Horizontal, vertical, and oblique fractures of the root also occur.

7 Classification of Injuries Luxation Injuries Luxation injuries involve the supporting structures of the teeth including the periodontal ligament and alveolar bone. The primary goal in the treatment of luxation injuries is to maintain the vitality of the periodontal ligament, which supports s the tooth in its socket. Luxation injuries are classified as follows (Source: UpToDate): Concussion The tooth is neither loose nor displaced; ; it may be tender with the pressure of biting because of inflammation of the periodontal ligament. Subluxation loosening. An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth. Intrusion central dislocation. Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket. Extrusion peripheral dislocation, partial avulsion. Partial displacement of the tooth out of its socket. Lateral luxation Displacement of the tooth in a direction other than axially. This T is accompanied by comminution or fracture of the alveolar socket. Avulsion Complete displacement of the tooth out of its socket. Children with injuries including dental fractures, luxation,, discoloration, abscess or pain will need dental radiographs and assess the severity of injury Source: Trauma handout for Pediatrics: Pediatric Dental Trauma, WHO classification of dental injuries

8 Epidemiology Dental Trauma Experience Before Age 15 Years Primary dentition 30% Permanent dentition 20%

9 Dentition Primary Dentition Secondary Dentition The most commonly injured teeth are the maxillary (upper) central incisors, followed by the maxillary lateral incisors and the mandibular (lower) incisors

10 Overjets increase risk of trauma The upper lip protects the maxillary teeth. The ability of the upper lip to do so is affected by the degree of protrusion of the anterior teeth. The normal horizontal distance between the maxillary and mandibular incisors (overjet) is between 1 and 3 mm. Overjets greater than 4 mm increase the likelihood of dental trauma by 2 to 3 times.

11 Other Risk Factors Mobility Problems Physical disability Cerebral palsy Seizure disorders Fixed Orthodontic appliances

12 Falls are the most frequent cause of dental trauma among school-age and preschool children Sport-related related injuries are the most commom cause of dental trauma among adolescents

13 Evaluation Obtain a history of how, when and where the injury occurred the time that the injury occurred affects treatment and prognosis A neurologic history and evaluation should also be obtained due to head injury

14 Referral to a Dentist Positive responses to the following questions should prompt a dental referral: Does the child have spontaneous pain in any teeth as a result of the injury? Are any of the teeth tender to touch or the pressure of eating? Are any of the teeth sensitive to hot or cold? Is there a change in the child's bite or occlusion? From UpToDate: Evaluation and management of dental injuries in children

15 Referral to a Dentist Children should also be referred to a dentist if you find the following on exam: Injury to the soft tissues, including the lips, frenula,, tongue, oral mucosa, and palate Fractures of the anterior teeth Fractures of the posterior teeth these fractures may occur after trauma to the chin and are associated with fractures of the mandibular condyles and cervical spine Loose, displaced, or missing teeth From UpToDate: Evaluation and management of dental injuries in children

16 Injuries to Primary Teeth Luxation injuries The most common injuries to the primary teeth are luxation injuries of the incisors. The management of these injuries focuses on prevention of damage to the permanent teeth because the secondary anterior teeth develop in close proximity to the apices of the primary incisors. Children who have severely displaced or loose anterior primary teeth t should be referred to a dentist for immediate care. Injured primary teeth may be removed by the pediatrician if a dentist is not available immediately and the pediatrician is concerned that the injured teeth t may be aspirated. This situation may be of particular concern for children who are fed by bottle. A fixed or removable prosthesis can be made for the child if concern exists regarding appearance. However, the early loss of primary anterior teeth does not irreversibly affect t speech or the position of the permanent teeth. Subluxation injuries typically present with increased mobility and gingival bleeding at the base of the crown. The sole clinical symptom of concussion injuries i is pain with chewing or percussion. Both of these injuries usually resolve spontaneously. A soft diet should be provided until the child is able to tolerate his or her normal diet without pain. Routine dental follow-up is necessary to observe for complications. Avulsed primary teeth should not be reimplanted because of the potential for injury to the developing tooth bud. From UpToDate: Evaluation and management of dental injuries in children

17 Injuries to Primary Teeth Fractures Children with crown fractures of the primary teeth require prompt dental care to prevent further injury and/or infection. Uncomplicated: no pulp exposure Complicated: pulp exposure

18 Injuries to Permanent Teeth Luxation injuries Luxation injuries of permanent teeth are true dental emergencies.. Management of these injuries focuses on maintaining the vitality of the periodontal ligament, and immediate management is necessary to achieve the best possible outcome. Avulsions The prognosis for survival of an avulsed permanent tooth is inversely related to the amount of time spent out of the oral cavity (85 to 97 percent at five minutes and near 0 percent at one hour). Reimplantation Avulsed permanent teeth should be reimplanted immediately by the first capable person (eg( eg,, the injured child, a parent, teacher, coach, or pediatrician). Parents may call the pediatric office before bringing the child in for care. Once the clinician has determined the child does not have any more pressing injuries (eg,, head trauma, cervical spine injury), the parent should be instructed to attempt to reimplant the tooth. From UpToDate: Evaluation and management of dental injuries in children

19 Reimplantation of Avulsed Teeth The reimplantation procedure: - The tooth should be handled carefully by the crown to prevent damage d to the periodontal ligament. - Debris should be removed by gentle rinsing with saline or tap water. w Do NOT attempt to sterilize or scrub the tooth. - The tooth should be manually reimplanted in the socket - The tooth is kept in place by the child through finger pressure or by biting on a gauze pad. - The child should be referred to a pediatric dentist for treatment t as soon as possible. From UpToDate: Evaluation and management of dental injuries in children

20 Injuries to Permanent Teeth Storage Solutions Immediate reimplantation is not always possible. The vitality of periodontal ligament cells may be preserved by storing the tooth in culture media such h as Hank Balanced Salt Solution (HBSS). HBSS may be purchased in an avulsed tooth preservation system called "Save-A-Tooth". The use of such a system increases the likelihood of survival of the periodontal ligament, even for several hours. Cold milk is the best alternative storage medium for avulsed teeth if cell l culture media are not available. Milk is relatively aseptic, and its osmolality is more conducive to maintaining the vitality of the periodontal ligament than is saline solution or tap water. Extraoral storage of avulsed teeth is improved by using chilled liquid. Thus, the avulsed tooth should be placed in a container of milk that is packed in ice, (maintains the cold temperature without diluting the milk and decreasing its osmolality). Saliva is an alternative if milk or cell culture media are not available le immediately. The tooth should be placed into a container of the child's saliva. If the child can not hold his/her own tooth, do NOT hold the tooth in the child's mouth because it can be further traumatized, swallowed, or aspirated. Tap water should not be used because its low osmolality will cause the cells to rupture within minutes From UpToDate: Evaluation and management of dental injuries in children

21 Injuries to Permanent Teeth Fractures Most fractures of the permanent teeth, even those with exposure of pulp, can be treated successfully hours after the injury, depending upon the level of inflammation and necrosis of the pulp. The child should be referred as soon as possible, ideally within seven days, to optimize comfort and functional and cosmetic outcomes. Tooth fragments from crown fractures can be reattached if they are retrieved and kept properly hydrated. (Special solutions are not necessary because they have no fibroblasts to keep viable.) The fragment should be kept hydrated in tap water because discoloration occurs. From UpToDate: Evaluation and management of dental injuries in children

22 Tetanus Prophylaxis Tetanus prophylaxis Tetanus prophylaxis may be indicated for dirty wounds and should be considered in children who have avulsed teeth, deep lacerations, or intrusion injuries. Tetanus immunization should be administered to children who have completed only the primary series of immunization or who received d a booster immunization more than five years previously. The preferred vaccine preparation depends upon the child's age and previous immunization history: <7 years Diphtheria-tetanus tetanus-acellular-pertussis vaccine (DTaP( DTaP) 7 7 years and <11 years Tetanus toxoid-reduced diphtheria (Td), also known as the adult type diphtheria and tetanus toxoids vaccine 11 through 18 years Tetanus toxoid,, reduced diphtheria toxoid,, and acellular pertussis (Tdap)) is preferred to Td for those who have never received Tdap.. Td is preferred to tetanus toxoid (TT) for those who received Tdap previously or when Tdap is not available. Tetanus toxoid (0.5 ml intramuscularly) and tetanus immune globulin (250 U intramuscularly) should be administered to children with dirty wounds w who have received fewer than three doses of tetanus toxoid or whose immunization status is uncertain. From UpToDate: Evaluation and management of dental injuries in children

23 Antibiotic therapy It is not known whether systemic antibiotic therapy affects outcome in childhood dental trauma. Antibiotic therapy is indicated in the management of secondary infection in adjacent soft tissue. Children who are at risk for developing subacute bacterial endocarditis should receive antimicrobial prophylaxis for dental injuries that induce bacteremia (eg,, intrusions, extrusions, lateral luxations,, and avulsions). From UpToDate: Evaluation and management of dental injuries in children

24 Prevention of Dental Trauma Primary prevention: decrease the incidence of the common causes of injury falls, accidents, and physical altercations Secondary prevention: use of mouth protection during high impact recreation and sports activities regular dental care and maintenance treatment of children with excessive overjet Tertiary prevention: education of parents, teachers, coaches and healthcare providers regarding the proper management of avulsed permanent teeth From UpToDate: Evaluation and management of dental injuries in children

25 Sports Dentistry Mouth Guards Stock ready-made Mouth-formed boil & bite Custom fabricated from model

26 Stock type athletic mouth guard

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28 Custom fabricated mouth guard

29 References McTigue DJ. Evaluation and Management of Dental Injuries in Children. Updated 2/2/08. UpToDate. Trauma handout for Pediatrics: Pediatric Dental Trauma, WHO classification of dental injuries, Provided by Martha Ann Keels, DDS PhD Revisions, Images and UNC data provided by Antonio Braithwaite, DDS MPH

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