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August 1, 2006 By Family Dental Ctr Of Connecticut
MANAGEMENT OF DENTAL TRAUMA IN CHILDREN
Injuries to children’s teeth can be very distressing for children as
well as their parents. Dental trauma may occur as a result of a
sports mishap, an altercation, a fall inside of the home, or other
causes. Prompt treatment is essential for the long-term health of an
injured tooth. Obtaining dental care within 30 minutes can make the
difference between saving or loosing a tooth.
Causes and frequency of dental trauma
Approximately 30% of children have experienced dental injuries.
Injuries to the mouth include teeth that are: knocked out,
fractured, forced out of position, pushed up, or loosened. Root
fracture and dental bone fractures can also occur.
The peak period for trauma to the primary teeth is 18 to 40 months
of age, because this is a time of increased mobility for the
relatively uncoordinated toddler. Injuries to primary teeth usually
result from falls and collisions as the child learns to walk and
run.
With the permanent teeth: school-aged boys suffer trauma almost
twice as frequently as girls. Sports accidents and fights are the
most common cause of dental trauma in teenagers. The upper
(maxillary) central incisors are the most commonly injured teeth.
Maxillary teeth protruding more than 4 mm are two to three times as
likely to suffer dental trauma than normally aligned teeth.
Types of dental trauma
Dentoalveolar trauma may be classified into categories based on
treatment protocols. These categories include: dental avulsion,
dental luxation and extrusion, enamel and crown fracture, dental
intrusion, dental concussion and subluxation, root fracture, and
alveolar bone fracture.
Clinical evaluation of dental trauma
- Medical history
Take a complete medical history. Assess the need for SBE
prophylaxis. Determine if the child has a bleeding disorder, or is
immunocompromised. Record any current medications. Question the
parent about allergies to medications. Obtain a history of any
prior surgeries. Determine if the child’s tetanus immunization is
up-to-date. Determine if the child lost consciousness due to the
injury.
- Dental history
The clinician should determine how, when, and where the injury
occurred. “How” is important because it provides information on
the severity of the injury. “When” is important, because the
prognosis for the injured tooth worsens with every minute of delay
in treatment. “Where” is important, because it may determine
whether or not tetanus prophylaxis is warranted.
- Physical examination
A thorough examination is necessary to assess the full extent of
all injuries. Important information to be gathered for each
patient includes: vital signs, review of all systems, head and
neck exam, and accident information. It is important to rule out
head injury, ocular damage, and cervical spine injury. An
evaluation of pupil size and reaction to light may establish the
presence of head injury.
- Extraoral examination
The location and size of all extraoral and intraoral injuries must
be recorded. Palpate the mandible, zygoma, TMJ, and mastoid
region. Ensure that no mandibular or maxillary fractures are
present. Find any mandibular fractures by palpating the lower
border of the mandible for a “step-down” fracture. Record any
extraoral lacerations, bruises, or swelling. If a laceration is
present in the upper or lower lip, the area must be inspected for
foreign bodies such as gravel or tooth fragments. Any foreign
bodies must be debrided from the soft tissue.
The mandibular condyles and maxilla should be carefully palpated.
Check jaw movements for normal range of movements. Chin
lacerations require careful evaluation of the cervical spine and
mandibular condyles. Indications of condylar fractures include: an
anterior open bite, a malocclusion, or limited mandibular opening.
Confirmation of condylar fractures requires a panoramic radiograph
with closed – and open – mouth views.
- Intraoral examination
All extraoral and intraoral clots and debris must be removed prior
to examining the oral soft and hard tissue. Palpate the alveolus
to detect any fractures. Have the patient clench the teeth so that
the dental occlusion can be evaluated. Each tooth should be
examined for damage or mobility.
The labial mucosa, maxillary frenum, gingival tissues, and tongue
should be examined for bruising or lacerations. All intraoral
lacerations must be cleaned and explored, looking for any foreign
bodies. The oral frenum, when torn, will heal without long-term
consequences. A tongue laceration should be sutured if the tissue
edges are not self-approximating. Most intraoral impalement
injuries will heal on their own – except for soft tissue avulsion
injuries.
- Radiographic examination
For evaluating injuries to the maxillary or mandibular teeth, an
occlusal radiograph is the film of choice. If a root fracture is
suspected, radiographs at two different angles are required for a
definite diagnosis. For intruded teeth, a lateral anterior
radiograph provides additional useful information. A panoramic
radiograph helps to evaluate suspected mandibular or condylar
fractures.
- Photographic documentation
The use of preoperative and postoperative photography is very
useful for documentation purposes.
 Tooth displacement (luxation, lateral displacement, extrusion)
A. DIAGNOSIS
- Luxation involves displacement of a tooth in a labial,
lingual, or lateral direction. If the displacement is less than 5
mm, the dental pulp will remain vital in about 50% of the cases.
- Lateral luxation is an angular displacement of the tooth while
it remains within the socket. There is usually an associated
fracture of the supporting alveolar bone, especially with labial
and palatal luxations.
- An extrusion occurs when a tooth is only partially removed
from the socket. In the primary dentition, the alveolar bone
surrounding the tooth is relatively elastic, so the most common
injury in toddlers is a dental luxation (displacement injury) –
with gingival hemorrhage. The primary upper incisors are often
pushed toward the palate during a fall.
B. FIRST AID
I. PRIMARY TOOTH
Place a cold wet cloth over the mouth, and bring the child to a
dentist. Provide pain relief by giving children’s Tylenol.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief. Try to
reposition the luxated tooth back to its normal position using
gentle to moderate finger pressure. The patient is then instructed
to gently hold the tooth in position. Obtain definitive dental
care as soon as possible.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
- A primary tooth with a luxation in the labial direction needs
to be extracted, to avoid further damage to the developing
permanent tooth bud.
- In other cases, however, it is possible to splint the luxated
primary tooth back into normal position using a resin-modified
glass ionomer cement. The cement is mixed fairly thick, and placed
on the labial and lingual surfaces of the luxated tooth – and a
few adjacent teeth. The luxated tooth is held in the ideal
position while the cement is setting. The splint is removed after
10 days using a composite finishing bur.
II. PERMANENT TOOTH
- For any severe luxation injury: an anti-inflammatory agent
(Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic
(Penicillin) are prescribed.
- For a lateral luxation, treatment includes: repositioning
after local anesthesia, and applying a semi-rigid splint for 2-3
weeks. A post-treatment radiograph should be performed to assure
proper position of the tooth in the socket.
- For an extrusive luxation, treatment includes: immediate
repositioning and placement of a semirigid (flexible) splint for
7-14 days.
Tooth fracture (infraction, Ellis class I, Ellis class II or
III)
A. DIAGNOSIS
- Crown fractures comprise about 33% of injuries to primary
teeth, and about 75% of injuries to permanent teeth. A crown
fracture is classified based on the location of the fracture in
relation to the enamel, dentin, or pulp tissue of the tooth.
- If the fracture of the crown is incomplete, or if it produces
cracks in the enamel, it is referred to as an enamel craze, crack,
or infraction. The craze lines begin at the enamel surface and end
at the enamel-dentin junction.
- The Ellis fracture classification has six categories, but only
the first three are commonly described in medical literature. An
Ellis class I fracture involves the enamel portion of the tooth,
is rarely painful, and is not a true emergency.
An Ellis class II fracture involves enamel as well as dentin,
allowing the entry of bacteria into the dentin tubules, as well as
chemical or thermal irritation of the pulp canal. Ellis class II
fractures are recognized by the yellow to pink color of the
dentin.
- In an Ellis Class III fracture (severe), the dental pulp is
exposed – requiring immediate care. The fracture site will have a
reddish tinge or will show bleeding. In an Ellis class III dental
fracture, exposure of the pulp’s nerve endings can cause extrement
pain – even if exposed only to air. Exposure of the pulp in an
Ellis class III fracture will eventually lead to pulpal necrosis
from bacterial infection, if left untreated.
B. FIRST AID
I. PRIMARY TOOTH
Have the child rinse with warm water. Use a cold cloth or ice pack
to reduce swelling. Use acetaminophen for pain, not aspirin. Cover
any severe fracture with a biocompatible cement or dressing until
a dentist can treat the problem.
II. PERMANENT TOOTH
Have the child rinse with warm water. Use a cold cloth or ice pack
to reduce swelling. Use acetaminophen for pain, not aspirin. Cover
any severe fracture with a biocompatible cement or dressing until
a dentist can treat the problem.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
- Treatment options for an enamel-dentin crown fracture with
pulpal exposure in the primary dentition include:
direct pulp capping, Cvek pulpotomy, cervical-depth pulpotomy,
pulpectomy, or extraction.
- The indication for a partial (Cvek) pulpotomy is: a small and
recent pulpal exposure less than 2 weeks old. A diamond bur or a
330 carbide bur is used to amputate the pulp to a depth of 2 mm.
Only saline irrigation is used to achieve hemostasis. Then calcium
hydroxide paste is placed, followed by a glass ionomer cement to
seal the area.
Recalls are scheduled at 1, 3, and 6 month intervals.
- Indications for a deep cervical pulpotomy include:
a large pulpal exposure, pulpal exposures older than 2 weeks, or
if hemostasis cannot be obtained during a Cvek pulpotomy
procedure. Formocresol or ferric sulfate is used to obtain
hemostasis during a deep cervical pulpotomy. ZOE paste or glass
ionomer is used to seal the area.
- When the trauma has resulted in chronic inflammation or
necrosis of the pulp, a pulpectomy should be considered.
II. PERMANENT TOOTH
- Treatment for a case of enamel infraction consists of sealing
the cracks – using any enamel adhesive system.
- For an Ellis class I dental fracture, dental care involves
removing the sharp edges to prevent injury to the soft tissues of
the mouth. Alternatively, the fracture may be restored with
composite material.
- For an Ellis class II fracture, the dentin should be coated
with a protective covering, such as a RMGI or Fuji IX cement – as
an interim measure. Allow up to 8 weeks for the injured tooth to
recover before placing the final composite restoration.
- For an Ellis class III complex fracture of the permanent
tooth, the main goal is to retain a viable dental pulp, and permit
completion of root growth. Therefore, if the pulp exposure is very
recent or very small, a direct pulp cap may be performed. For an
exposure larger than 2mm, a Cvek pulpotomy may be performed,
removing only a millimeter or two of infected pulp tissue. The
Cvek technique consists of using a round diamond bur, amputating
the exposed pulp tissue to a depth of 1-2 mm, passively covering
the healthy pulp with calcium hydroxide. Then, the area is sealed
with a RMGI or composite material.
For an exposure older than two hours, a cervical-depth pulpotomy
may be needed – ideally using only saline irrigation to achieve
hemostasis.
Tooth pushed up (dental intrusion)
A. DIAGNOSIS
- An intrusion injury is the most severe type of luxation
injury. The intruded tooth is impacted into the alveolar bone, and
the alveolar socket is fractured. The forces that drive the tooth
into the socket wall crush the periodontal ligament, and rupture
the blood and nerve supply to the teeth. The tooth may not be
visible, and can be mistaken for an avulsion.
- Some studies have shown that intrusions of up to 3 mmm have an
excellent prognosis, whereas the prognosis of incisors with severe
intrusions (> 6mm) is hopeless. If a permanent tooth is involved,
radiographs may show an alveolar fracture, or tooth displacement
into the nasal cavity. Pulpal necrosis (death of the dental pulp)
occurs in 96% of cases of intruded permanent teeth.
- If a primary incisor is involved in an intrusion injury, a
lateral anterior radiograph (“mini-ceph”) should be taken of the
traumatized region to determine the proximity of the intruded
primary root tip to the developing adult tooth bud.
B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
- Allow the primary tooth to spontaneously erupt over a 2 to 3
month period - as long as the developing permanent tooth bud has
not been injured. If re-eruption does not begin within 2 months,
extraction of the intruded primary tooth will be necessary.
- A very intruded primary incisor, whose root tip is displaced
into the developing permanent tooth should be extracted.
Extraction of the intruded tooth will prevent further damage or
hypoplasia to the adult tooth bud.
II. PERMANENT TOOTH
- Current management strategies for intruded permanent incisors
include:
surgical reduction (immediate repositioning), repositioning with
traction (active repositioning), and waiting for the tooth to
return to it pre-injury position ( passive repositioning).
- Incisors intruded less than 3mm may be allowed to reposition
themselves.
- Incisors intruded between 3 –6 mm are unpredictable, but they
may be orthodontically extruded within 3-6 weeks.
- Incisors that have been intruded beyond 6 mm should be
immediately repositioned (surgically) to their normal position –
followed by root canal treatment.
- Root canal treatment is recommended in permanent teeth with
complete root development. If there is any doubt about pulp
vitality, or if root resorption begins, then a pulpectomy must be
performed, followed by interim placement of intra-canal calcium
hydroxide. After apical closure and root health are confirmed, the
canal is filled with a standard root canal material (gutta percha).
Tooth was hit (subluxation, dental concussion)
A. DIAGNOSIS
Concussion results in mild injury to the periodontal ligament
without tooth mobility or displacement. Subluxation causes
significant injury to the periodontal ligament , resulting in some
tooth mobility. There is usually bleeding at the marginal
gingival, and the tooth is tender to percussion in subluxation.
A baby tooth may change color after being subjected to trauma. A
front tooth can be traumatized during a fall, while running into
furniture, while engaging in rough play, or from impact with a
blunt object. Dental trauma affects the blood supply to the tooth,
and therefore its health and color.
Different color changes suggest specific problems with traumatized
baby teeth (primary incisors). Such teeth may turn dark, but in
many cases the color will change back to normal after a few
months. Traumatized primary incisors may develop yellow, grey, or
pink discolorations.
A yellow or yellow-brown discoloration indicates calcification and
obliteration of the dental pulp (nerve canal). No treatment is
usually needed with this type of discoloration.
A grey or black discoloration indicates necrosis (death) of the
dental pulp in 98% of cases. Such teeth will usually require root
canal treatment or extraction.
A pink tooth indicates either internal resorption, or the presence
of blood pigments in the dentinal tubules of the tooth. The pink
tooth needs to be monitored closely.
Treatment of a discolored primary incisor may involve periodic
radiographic and clinical evaluation, root canal treatment, or
extraction of the tooth - depending on the health of the tooth and
the child's ability to cooperate with dental treatment.
B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
Radiographs are taken to rule out root fractures. The child is
then put on a soft diet for a week, at the end of which a recall
exam is performed.
II. PERMANENT TOOTH
If the tooth is very mobile, and can be moved more than 2mm, a
flexible wire and composite splint may be placed for 7-10 days.
Root fracture (apical, mid-root, cervical)
A. DIAGNOSIS
- Root fractures occur in only 7% of dental injuries. Horizontal
root fractures occur in anterior teeth, and are caused by direct
trauma. Vertical root fractures usually occur in molars, and may
be caused by clenching or trauma to the mandible. Vertical root
fractures are more difficult to detect, and may not be found until
extensive tooth destruction has occurred.
- A horizontal root fracture is classified based on the location
of the fracture in relation to the root tip (apex). Horizontal
root fractures may occur in:
the apical third, middle third, or cervical third of the root.
The prognosis worsens the further cervically (towards the crown)
the fracture has occurred. Tooth fractures are often not apparent
during a clinical examination, and can usually only be diagnosed
using appropriate radiographs. Radiographs with at least two views
are required for making this diagnosis.
B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
As long as no abscess or excessive mobility occurs, the primary
tooth with a fractured root can simply be monitored for health. If
a portion of the root is abscessed or extremely mobile, it can be
extracted, and the remaining root fragment will resorb normally.
For coronal third fractures in primary teeth, the coronal third is
extracted, leaving the apical portion of the root to resorb
normally. Do not “chase” apical third fragments.
II. PERMANENT TOOTH
- The most important factor in the success and treatment of a
horizontal root fracture is the immediate reduction of the
fractured segments, and complete immobilization of the coronal
segment. Root fractures must be diagnosed before the body tries to
“repair” the problem, and before the blood clot prevents
apposition of the fractured segments. If more than 24-72 hours
have elapsed, it may be impossible to obtain close apposition of
the segments.
- Treatment for horizontal root fractures consists of rigid
fixation (immobilization) in an attempt to get the cementum and
dentin to heal. The tooth is splinted to the adjacent normal teeth
with a very rigid wire and composite splint for 8 weeks. Serial
radiographs are then taken a 6 month intervals after the splint is
removed.
Dental bone fracture (alveolar process fracture)
A. DIAGNOSIS
The alveolar bone, whichs upports the teeth, may experience a
fracture at:
the alveolar socket wall, the alveolar process, or as a comminuted
(shattered) fracture of the supporting bone. Segmental fractures
involve multiple teeth and their supporting alveolar process.
B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth
to reduce swelling. Give Tylenol for pain relief.
C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
- For any severe luxation injury: an anti-inflammatory agent
(Motrin), an analgesic (Tylenol #3), and an antibiotic
(Penicillin) are prescribed.
- Treatment of alveolar process fractures requires manually
repositioning the segment of displaced teeth back into proper arch
alignment. A very rigid splint is applied for two months.
II. PERMANENT TOOTH
- For any severe luxation injury: an anti-inflammatory agent
(Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic
(Penicillin) are prescribed.
- Treatment of alveolar process fractures requires manually
repositioning the segment of displaced teeth back into proper arch
alignment. A very rigid splint is applied for two months.
Prevention of dental injuries
Dental injuries increase sixfold to eightfold when mouth
protection is not used. Education of athletes and coaches may
encourage greater use of mouthguards. Educating physicians and the
public about first aid for dental injuries may reduce
complications later.
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