Primary Tooth Trauma

Dental Trauma

• TDIs are common. The mouth is the second most common area to injure.

• 22% of children 0-6 years have sustained TDI

• Injury related to the teeth and/or periodontium (Gingiva, periodontal ligament or alveolar bone) • Many involve soft tissue injury (lips, tongue etc)

• Most common injury in primary teeth: injury to periodontal ligament resulting in luxation

• Non-accidental injuries (50% of children who have suffered physical abuse will have an oro-facial injury)

Aetiology Primary Dentition

• Boys: 30-40%

• Girls: 15-30%

Peak age 2-4 years

Trauma history

• Who are they with? Who has PR?

• Where did the injury occur? Contamination. Legal issues

• How did the injury occur? Impact zone

• When did the injury occur? Essential for appropriate management

• Any other injuries?

• Was there a period of unconsciousness? If so, for how long? Amnesia, nausea and vomiting are all signs of brain damage and require medical attention.

• Is there any disturbance in the bite? An affirmative answer may indicate a luxation injury with displacement, an alveolar or jaw fracture or a fracture of the condylar region.

Non- accidental injury?

• Does the history fit with the injury?

ALWAYS CONSIDER NAI

• 50% of children at risk will have oro-facial injuries

• Repeated episodes of trauma

• Delayed presentation

• Failure to follow up

Medical history

• Full medical history…

Things to particularly consider:

• Condition where there is an infection risk

• Conditions affecting compliance

• Bleeding disorders

• Allergies

• Tetanus status

Examination

• Clean the face and the oral cavity with water or saline. This cleaning will make the patient feel more comfortable and facilitate extraoral and oral examination.

• Photographs are recommended

• Extraoral wounds (bruises or lacerations)

• Palpation of Facial Skeleton

• Palpation of TMJ

• Observation of Mandibular Opening and Closing

IO – Soft Tissue Examination

• Soft Tissue injury

• Missing tooth/fragment in lip?

• Examine and note: Gingiva, fraenum, palate, lips, tongues, cheeks

IO – Hard Tissue Examination

• fractures

• pulpal exposures

• colour changes

• displacement

• disturbance in occlusion

• mobility of teeth

• mobility of segment

• palpation of alveolar process

Dental Trauma Chart

Mobility

Colour

TTP (manual)

Sinus pathology

Vitality test

Percussion sound

Position of displacement

• Sensibility tests are unreliable in primary teeth and therefore not recommended.

Classification of Trauma to Primary Teeth

Essential reading

• IADT 2020

• Trauma guidelines

Enamel Fracture

• No radiograph required

• Smooth sharp edges

• Encourage good OH to prevent plaque accumulation

• Encourage a return to a normal diet as soon as possible.

Enamel/Dentine Fracture

• No pulp exposure – uncomplicated

• Location of missing fragment

• Soft tissue x-ray may be required

• Cover exposed dentine with composite (or GIC)

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Enamel/Dentine/Pulp Fracture

• Pulp involvement – complicated

• Location of missing fragment

• IOPA and soft tissue x-ray may be required

• Pulpotomy or Extraction

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Crown-root Fracture

• With or without pulp involvement

• LA removal of loose fragments to assess restorability – restore or extract

• Possible rapid referral to the Paeds team

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Root Fracture

• Coronal fragments may be extruded and mobile

• There may be premature occlusal contact

• Xray required (most commonly apical or mid-third)

• If the coronal fragment is not displaced – no treatment

• If displaced and not excessively mobile, even with occlusal interference can monitor to spontaneously reposition

• If excessively mobile – extract the coronal fragment

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Alveolar Fracture

• Mobility and dislocation of segment

• Occlusal interference

• Reposition under LA

• Stabilise and splint for 4 weeks

Concussion

• Tender to touch but has not been displaced. Normal mobility

• Observation

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Subluxation

• Tender to touch, increased mobility but has not been displaced.

• May have bleeding from gingiva

• Observation

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Extrusive luxation

• Partial displacement of tooth out of the socket

• Mobile. Occlusal interference may be present.

• IOPA

• If no occlusal interference then allow to spontaneously reposition

• Interference/Excessive mobility/Extruded >3mm extract under LA

Lateral luxation

• Displaced in a palatal/lingual or labial direction

• Immobile

• May have occlusal interference

• No interference – allow to spontaneously reposition (6 months)

• If interference – extraction

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Intrusive luxation

• Displaced through labial bone, can impinge on developing successor

• Allow to spontaneously reposition (6 months – 1 year)

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Avulsion

• Tooth is lost from socket

• Locate missing tooth – environment/soft tissues/ingested/aspiration

• Do NOT reimplant primary teeth

• Encourage good OH to prevent plaque accumulation

• Care to prevent further trauma, but to encourage a return to a normal diet

Follow up

• Simplified follow up:

• Long-term arrangements need to be in place

• 2 weeks, 4 weeks, 3 months, 6 months, yearly to 5 years and beyond

Core Outcome Set (COS)

To be recorded at each review appointment (+/-):

– PDL healing

– Pulp Space healing

– Pain

– Discolouration

– Tooth loss

– Quality of Life

– Aesthetics (Pt perception)

– Trauma-related dental anxiety

– No. of clinical visits

Pulp necrosis: lost vitality, sinus involvement (infection), extract

Advice for parents/guardians

Risk to the primary tooth. The tooth may lose vitality (die)

Look out for:

• Discolouration

• Swelling/lumps on the gum

• Mobility

• Tenderness/pain

Risk of damage to the permanent tooth

Complications to the permanent tooth

• Opacity

• Hypoplasia

• Dilaceration

• Root angulation alteration

• Arrest of root development

• Delayed eruption due to granulation tissue (up to a year)

• Ectopic eruption (lost guidance)

• Impaction to malformation