Dental Trauma-Paediatric Emmergency Department Clinical Guidelines

Epidemiology
  • 30% of preschoolers suffer dental injury
  • At this age there is no difference between boys and girls.
  • 23% males age 6-20 years and 13% females suffer dental injuries
  • Prevalence and incidence peak at 2-4 years and 8-10 years     
  • The way the tooth is injured is related to the activity level at each age.
  • Patients with chronic conditions and mobility problems
  • Altercations
  • Abuse
  • Most commonly injured teeth
  • Maxillary central incisors
  • Protruding teeth

History: important information to get regarding the injury
  • Incidents surrounding injury
  • Any other injuries
  • How long ago the injury occurred
  • Last time the patient ate
Physical Examination

Extraoral
  • Inspection
  • Asymmetry
  • Nasal or orbital malalignments
  • Lacerations, hematomas, foreign bodies
  • Open and close mouth to evaluate for deviation during function
  • Lip competency
  • Palpation
  • TemporoMandibular joint
  • Equal movements
  • Orbital rim intact
  • Nose for crepitus
  • Note parasthesias or numbness
Intraoral
  • Inspection
  • Color and quality of gums and mucosa
  • Note hematomas
  • Examine teeth
  • Color, chips, cracks, bleeding, absent
  • Palpation
  • Tongue
  • Mobility of teeth
  • Tooth percussion
Imaging
  • Moderate and severe dental trauma
  • 4 views: maxillary anterior and 3 periapical
  • Facial Series
  • Panorex (mandible)

Principles of Management by Type of Injury

Crown Fractures

Ellis Class I
  • Minor fracture of the tooth enamel
  • Rarely painful
  • Does not require immediate treatment
  • Rough edges may need filing

Ellis Class II
  • Enamel and dentin involvement
  • Entry of bacteria into tooth
  • Can see yellow or pink color of dentin
  • Exposed dentin needs to be covered 
  • Apply calcium hydroxide paste
  • Subsequent composite repair
  • Antibiotics
  • Prolonged exposure
  • Dirty wound

Ellis Class III
  • A true dental emergency
  • Dental pulp is exposed
  • Red tinge or bleeding
  • Extremely painful
  • Exposed pulp will become infected
  • More likely if exposed  > 6 hours
  • Primary tooth
  • May need to extract to prevent further injury
  •  Permanent tooth
  • Calcium hydroxide paste 
  • Root canal for prolonged exposure
  • Antibiotics
 Root Fractures

  • Crown luxation, pain, excessive mobility, malocclusion
  • Confirm location with radiographs
  • Primary tooth
  • Extraction
  • Permanent tooth
  • Splint
  • Length of splinting depends upon integrity of remaining root fragment

Periodontal Structural Injuries

Concussion
  • Trauma to the supporting structures of the tooth
  • Inflammation
  • No displacement or mobility
  • Tenderness to percussion
  • No bleeding
  • Management same for primary and permanent
  • No acute intervention required
  • Analgesia as needed
  • Need dental follow up to monitor tooth vitality
Subluxation
  • Mobility of the tooth without displacement
  • Blood may be present in gingival sulcus
  • Pain with percussion
  • Primary Teeth
  • Mobile teeth may need splinting
  • Dental follow-up in 24 hours due to potential for pulp necrosis
  • Soft diet
  • Permanent Teeth
  • Possible splinting
  • Dental follow-up in 24 hours due to potential for pulp necrosis
  • Soft diet

Lateral Luxation
  • Displacement of tooth laterally in socket
  • Buccal, lingual, labial, or lateral
  • Lingual displacement is most common
  • Periodontal ligament is torn
  • Usually accompanied by alveolar fracture
  • Primary Teeth
  • Often no intervention necessary      
  • Passive repositioning
  • Gentle repositioning
  • Splint or extraction
  • Laterally displaced or extreme mobility
  • Refer for dental follow-up
  • Permanent Teeth
  • Immediate dental referral
  • Repositioning
  • Splinting

Intrusion
  • Tooth is driven into socket
  • Crown height is shortened
  • Periodontal ligament is lacerated
  • Bleeding usually present
  • Root & alveolar fractures may occur
  • Must determine if the tooth is truly intruded and not fractured
  • Primary teeth
  • Less than 50% intruded
  • Will usually re-erupt in 3-4 weeks
  • If 100% intruded
  • May contact with underlying tooth bud
  • Extraction
  • Need dental follow up
  • Monitor for potential damage to underlying tooth bud
  • Dental emergency
  • Urgent referral
  • Monitor for injury to root structures & neuro-vascular supply
  • Allow tooth to re-erupt
  • Re-positioning and splinting
Extrusion
  • Tooth is vertically displaced out of bony socket
  • Periodontal ligament is torn
  • Primary Tooth
  • Urgent dental referral
  • Extract if very mobile or nearly avulsed
  • Permanent Tooth
  • Immediate dental referral for re-positioning and splinting
Avulsion
  • Tooth is completely detached from the socket
  • Periodontal ligament severed
  • Possible alveolar fracture
  • Need to find the tooth!
  • Rule out aspiration/intrusion/fracture
  • Determine primary vs. permanent
Primary Teeth
  • No replacement of tooth
  • Children under 6 years of age
  • Control bleeding
  • Dental referral to evaluate potential injury to permanent tooth bud
Permanent Teeth
  • True Dental Emergency
  • Time is essential
  • Best outcome if < 30 minutes to re-implant
  • Viability dependent upon vitality of root
  • Goal is to avoid further damage to periodontal ligament cells
  • Re-implant tooth immediately
  • If delay in re-implantation, place it in transport media
  • Hank’s Balanced Salt Solution
  • Fresh cold milk
  • Saline
  • Saliva (buccal vestibule)
  • Water
  • Minimize handling
  • Do not scrub tooth
Extra-oral time < 1 hr:
  1. Rinse off debris and re-implant
  2. Immediate splinting by dentist
Extra-oral time > 1 hr:
  1. Soak in Hank’s Balanced Salt Solution or dental fluoride solution for 20-30 minutes
  2. Re-implant
  3. Immediate splinting

Disposition

When to see the dentist immediately
  • Ellis II or III
  • Root Fracture
  • Primary
  • 100% intrusion
  • Permanent tooth
  • Luxation
  • Intrusion
  • Extrusion
  • Avulsion
When to see the dentist within 24 hours
  • Ellis I
  • Subluxation
  • Primary
  • Lateral luxation
  • Intrusion
  • Extrusion
  • Avulsion
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