Incidence and prevalence of trauamtic injuries : by 15 years old , 33% of children have experienced at least 1 episode of dental trauma , boys tend to have twice the incidence or trauma compared to girls for obvious reasons .
Prone times : between 2 and 4 in primary dentition , between 7 and 10 in permanent dentition
Most injuries are caused by falls and play accident . Prognosis is increased with good immediate treatment . Therefore , if a a patients comes in for treatment , it is a dentist's reponsibility to treat them or at least refer them to a specialist straight away .
- When ?
- Where ? - If outdoors , consider anti-tetanus status . Tatenus booster should be considered if injury involves contamination of the wound with soil , if child has completed his immunization schedule , then a booster is not required .
- How ? - Possiblity of presence of other injuries
- Have any lost teeth been accounted for ? consider X-ray
- Any other signs and symptomes ?
- Previous traumatic event ?
- Cooperation and parent's attitude .
- medical conditions - Cardiac defect , epilepsy , allergies , tetanus immunization status
Examination ; General - Head injuries , Maxillofacial fractures or other assocaited injuries . , extra oral ( Mouth opening , haematoma , bleeding ) and intra-oral ( Bone discrepencies , teeth positions , teeth colour , teeth percussion , teeth mobility )
Investigations : Radiographs - very important to investigate PDL space , and root injuries . For Dental-alveolar injuries : anterior maxillary / mandibular occlusal , periapicals , True lateral maxilla for intrusice luxations of primary teeth and to detect foreign bodies within soft tissues .
Intraoral investigations - Mobility , reaction to percussion ( luxated tooth will be papinful to percussion and metallic sound indicates likelihood of ankylosis ) , and also colour of tooth , early colour change assocaited with pulp breakdown is visible on the palatal surface of gingival third .
Pulp assiessment tests - EPT or thermal tests . or transillumination to assess cracks . Note : Vitality test may not be reliable as the tooth may have undergo " pulpal shock " after serious trama .
Traumatic injuries to primary teeth
Accident prone time around 2-4 years old , usually caused by falls or collision , the risk of damage to permanent successors is high and unfortunately there are minimal treatment options . ( traumatized primary tooth should be removed if jeopardising developing tooth bud )
also , Retained Traumatized primary teeth should be checked regularly for lcinical and radiographical signs of pulpal or periodontal complications .
Types of trauma to primary teeth :
- Intact / Infraction
- Enamel Fracture
- Pulp Expose
- Crown / root fracture
- Root Fracture
- Tooth displaced
- Extrusion and lateral displacement
Treatment procedures :
- For intact/infraction : which means no fracture but enamel cracked , ( should be kept under strict observation )
- Enamel Fracture : sharp edges smoothen down and restored ( also should be kept under observation )
- Primary dentine fractured : Restore teeth and keep it under regular observation . Restored using Direct bonding technique is also possible based on recent updates , but prefebly with Dycal . ( keep under strict observation )
- Primary crown fracture : Remove coronal fragment but DO NOT remove root fragment unless is loose and easily visible
- Primary Root fracture : if child is cooperative , can be splinted .
- Primary root displaced : No treatment is neccessary , but monitor clinically and radiographically as appropriate , ask child to have soft diet for a week and advice parents of the possible sequela such as pulp necrosis
- Palatal Luxation : If occlusion is not affected , under LA , use finger pressure to position the tooth back in place . ( if there's a danger of child swallowing the tooth , extract it . advise soft diet and review after 2 days with regular intervals later on )
- Extrusion : usually requires extraction
- Lateral Displacement : If crown is displaced buccally , then it will affect the permanent tooth germ ( extraction is needed )
- Intrusion : Provided the tooth is firm and not affecting the occlusion , leave the tooth to re-erupt. moving the intruded tooth may cause damage to the underlying permanent tooth germ .
- Avulsion : Reimplantation of avulsed primary tooth is NOT advisable because of risk of damage and/or infection to the permanent teeth .
Sequelae of injuries to the primary dentition :
Tooth discolorations , Pulpal necrosis , pulpal obliteration , root resorption , injuries to develping permanent teeth .
Injuries to Periodontal tissues : COncussion , subluxation , extrusive luxation , lateral luxation , intrusive luxation and avulsion .
Special case : Avulsed Permanent tooth ---
Avulsion or permanent tooth should be treated as a dental emergency that requires immediate ( appropriate and skillful ) treatment . Whenever possible , the tooth should be immediately implanted as studies have shown that they have good prognosis .
Timing is of importance here : replant the tooth immediately if clean , hold tooth in plac with aluminium foil , if dirty , rinse it with fresh milk then replant it , if unable to replant , store in isotonic media to prevent dryness DO NOT use water ( it is hypotonic and will cause the lysis of ligamental cells ) after replantation , make sure to splint it with ortho wires .
Endodontics should be done on an avulsed tooth if : the root apex is already matured . ( RCT commenced within 10 days . initial dressing of ledermix paste for 3 months followed by calcium hydroxide , RCT should be completed afer 6 -12 months .
Complications in endodontic treatment on an avulsed tooth :
- External inflammatory root resorptiong : it is a progressive loss of tooth structure by an inflammatory process caused by the presence of infected and necrotic debris in the root canal , Prevented by Antibiotics after avulsion for 2 weeks and pulp extirpation in the mouth within 10 days . Dressed with ledermix for 3 weeks and then followed by calcium hydroxide dressing for another 3 months until no progression of root resoprtion .
- External Replacement root resorption : Loss of tooth along with Bone . ( prevention : never transport tooth dry , Periodontal ligaments will be all dead within 1 hour . )
A very good reading material on this topic ( which is up-to-date 2011 ) : http://www.iadt-dentaltrauma.org/GUIDELINES_Book.pdf