Dental Trauma of Primary teeth Flashcards
What is the epidemiology of primary tooth trauma?
- Prevalence is 16-40%
- Male > Female
- Peak incidence 2-4years
- Max primary incisors
What is the aetiology of primary tooth trauma?
- Falls
- Bumping into objects
- Non-accidental (child abuse)
What are the types of “dental hard tissues and pulp” injury?
- Enamel # (uncomplicated crown #)
- Enamel and dentine # (uncomplicated crown #)
- Enamel, dentine and pulp # (complicated crown #)
- Crown-root #
- Root #
What is a crown root fracture?
- Fracture involves enamel, dentine and root
- Pulp may or may be involved
- Complicated or uncomplicated
What are the types of supporting tissue injury?
(periodontal tissue + bone)
- Concussion
- Subluxation
- Lateral luxation
- Intrusion
- Extrusion
- Avulsion
- Alveolar fracture
What is a concussion injury?
- PDL injury
- Tooth TTP but not displaced from arch
- Normal mobility
- No bleeding from gingival sulcus
What is subluxation injury?
- Tooth tender to touch
- Has increased mobility but not been displaced from line of arch
- Bleeding from gingival crevice
- tooth appears elongated
what are the 3 types of luxation injury
- lateral luxation
- intrusion
- extrusion
What is lateral luxation injury, clinical findings?
- Tooth displaced usually in palatal/lingual or labial direction (but not axially)
- with alveolar bone plate #
- tooth immobile
- high ankylotic percussion note
- root apex maybe palpable in sulcus
- bleeding from gingival sulcus
What is intrusion injury and clinical findings ?
- Displacement of tooth into alveolar bone and locked in bone
- with alveolar socket #
- Tooth usually displaced through labial bone plate
- or can impinge on permanent tooth bud
- tooth immobile
- ankylotic high, metallic percussion note
- bleeding from gingivae
- ## shortened crown
What is an extrusion injury?
- Type of luxation injury
- Partial displacement of tooth out its socket
What is an avulsion injury and clinical findings?
- Tooth completely out of the socket
- Tooth totally displaced from socket
Clinical findings;
- Socket empty or filled with coagulum
how to manage avulsion with tooth missing
- Location of missing tooth should be determined in history taking
- Risk of being embedded into soft tissues or more seriously inhaled
- If tooth not found send child for medical assessment in A&E department, esp if child has respiratory issues
What is alveolar fracture injury?
- Fracture involved alveolar bone (labial and palatal/lingual
- May extend to adjacent bone
what is common finding of alveolar fracture
- Mobility and dislocation of segment with several teeth moving together
- Occlusal interference
What is the injury prevalence of different types of injury in primary dentition?
Luxation - 62-69%
Avulsion and ED fracture - 7-13%
Root fracture - 2-4%
Crown root fracture - 2%
What are the steps when managing a patient with trauma?
- Reassurance
- History
- Examination
- Diagnosis
- Emergency treatment
- Important info
- Further treatment and review
What is included in a trauma history?
Injury
- When?
- Where?
- How?
- Any other symptoms or injuries?
- Lost teeth/fragments?
Medical History
- Congenital heart disease (for infection risk)
- History of rheumatic fever or immunosuppression (for infection risk)
- Bleeding disorders (haematology team contact)
- Allergies (short course of antibiotics may be required)
- Tetanus immunisation status (may need booster - contact health advisor)
- (Liase with GP)
-
Dental History
- Previous trauma (may raise concerns about physical abuse or neglect)
- Treatment experience
- Legal guardian/child attitude
What is included in the extraoral part of trauma examination?
Extraoral
- Lacerations/ swelling/ bruising (may require suturing or debridement
- Haematoma
- Haemorrhage / CSF
- Subconjunctival haemorrhage
- Bony step deformities
- Mouth opening (may be jaw #/ dislocation)
What is included in the intraoral part of trauma examination?
- Soft tissues (laceration/bruises/foreign bodies etc)
- Alveolar bone #
- Occlusion (traumatic occlusion demands urgent treatment)
- Teeth (mobility may indicate displacement, root or bone fractures)
- Transillumination may show lines in teeth (crazing), pulpal degeneration, caries
- Tactile test with probe may help detect horizontal and or vertical #, pulpal involvement
- Percussion (duller note indicate root #)
What special investigations can be used in a trauma examination?
- Trauma stamp x6
What radiographs can you request in trauma examination?
- Periapical
- Anterior occlusal
- Lateral pre-maxilla (extra -oral)
- OPT
- Soft tissue
What are the possible diagnosis’ that can be made for each traumatic tooth?
Fracture
- Enamel (Uncomplicated crown fracture)
- Enamel-Dentine (Uncomplicated crown fracture)
- Enamel-Dentine-Pulp (Complicated crown fracture)
- Crown-Root (Uncomplicated or complicated)
- Root
- Alveolar
Concussion
Subluxation
Luxation
Lateral / Intrusive / Extrusive
Avulsion
What to do during an emergency situation?
- Observation is often most appropriate option in emergency situation
- Provision of dental treatment depends on child’s maturity and ability to cope - don’t want to make child more anxious
When to interfene/ treat in emergency situation?
when there’s risk of
- aspiration
- ingestion
- occlusal interference
What important info do you need to tell parent/carer ?
- Analgesia - pain relief
- Soft diet for 10-14days (can be normal diet but cut everything small, chew with molars)
- Ensure good oral hygiene
- Brush teeth with soft toothbrush after every meal
- Topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
- Warn about signs of infection
How to manage an enamel fracture (primary tooth)?
- Smooth sharp edges using Sof Lex disc
How to manage an enamel-dentine fracture (primary )?
- Best to cover all exposed dentine with glass ionomer/composite
- Lost tooth structure can be restored immediately with composite resin or at a later visit
-( Gold standard material: composite)
How to manage enamel-dentine-pulp fracture (primary)?
Options
- Partial pulpotomy (LA, non setting CaOH on pulp, thin layer of GI cement, restored with comp)
- Extraction
Both options involve LA and depend on child’s ability to manage treatment
- Discuss options with parent/carer
- Can cause dental anxiety
How to manage a crown-root fracture (primary)?
- Remove loose fragment and determine if crown can be restored
If restorable
- No pulp exposed, cover exposed dentine with GI
- Pulp exposed: pulpotomy or endodontic treatment
If Unrestorable
- Extract loose fragments
- Don’t dig
How to manage a root fracture (primary)?
If coronal fragment not displaced
- no tx indicated
If coronal fragment displaced but not excessively mobile
- Leave fragment to spontaneously reposition even if some occlusal interference
If coronal fragment displaced, excessively mobile and interfering with occlusion
- Option A - Extract only loose coronal fragment
- Option B - Reposition loose coronal fragment with flexible splint
How to manage a concussion injury(primary)?
- No treatment
- Observation
How to manage a subluxation injury(primary)?
- No treatment
- Observation
How to manage lateral luxation injury(primary)?
If minimal / no occlusal interference
- allow to reposition spontaneously
If severe displacement
- Extraction (preferred)
- Reposition with flexible splint (1 tooth either side for 4 weeks )
How to manage an intrusion injury(primary)?
- Allow to spontaneously reposition (appear in 6mo - 1yr), irrespective of direction of displacement
what radiographs should be taken in intrusion injury?
-PA or
- lateral premaxilla (extra-oral film)
Based on radiographs what are the two scenarios of intrusion with respect to direction of displacement?
Scenario 1
- Apical tip of intruded tooth can be seen
- Tooth appears shorter (aka foreshortened) compared to contralateral tooth
- Apex displaced towards/through labial bone plate
- Less likely to impinge on permanent successor
Scenario 2
- Apex of intruded tooth can’t be visualised
- Tooth appears elongated compared to contralateral
- Suggest Apex displaced toward permanent tooth germ and increased risk of damage to permanent tooth developing
How to manage extrusion injury (primary)?
If not interfering with occlusion
- Spontaneous repositioning
Excessive mobility or extruded >3mm
- Extract
How to manage avulsion injury (primary)?
- Radiograph to confirm avulsion
- In primary dentition a primary tooth should NOT be reimplanted
How to manage an alveolar fracture?
- Reposition segment that is mobile or causing occlusal interference
- Stabilised with flexible splint to adjacent uninjured teeth for 4 weeks
- Teeth may need to be extracted after alveolar stability has been achieved
Which guideline to follow for paeds trauma
- Dental Trauma UK
- Dental Trauma Guide
- IADT
International Association of Dental Traumatology Guidelines
What are the 3 sequelae of trauma to primary tooth?
- Discolouration
- Discolouration and infection
- Delayed exfoliation
what does mild grey discoloration tell?
- intra-pulpal bleeding
- pulp vital
- immediate discoloration may maintain vitality
-discolor may recede
what does opaque/ yellow discoloration tell?
- pulp obliteration
- response of vital pulp
- laying down more dentine for protection
how to manage traumatic primary tooth with discoloration only (no infection)?
- no tx
- review
What is pulp obliteration?
- response of vital pulp,
- deposition of more dentine along internal walls of root canal that fills pulp
- pulp narrowed and restricted
What to do when traumatic tooth presents with discolouration and infection ?
- Extract or endodontic treatment
- caution: time of exfoliation
（Tooth is symptomatic and non-vital）
what are the signs and symptoms assoc. with a traumatised non-vital tooth?
- sinus/ abscess
- gingival swelling
- tenderness to pressure
- increased mobility
- radiographic evidence of periapical pathology
Consequences of delayed exfoliation?
- ectopic eruption of permanent successor,
- delay / prevent eruption,
- Have consequences on occlusion and aesthetics and confidence of child
which type of dental trauma causes most disturbance to permanent successor?
intrusion
How are injuries to permanent teeth related to age of trauma in primary teeth?
0-2 yo has 63% chance of injury to permanent
3-4 yo = 58%
5-6 yo= 24%
7-8 yo= 25%
What injuries can occur to permanent successor following trauma in primary dentition x7?
- Enamel defects (most common)
- Abnormal crown/root morphology (duplication/ dilaceration)
- Delayed eruption
- Ectopic tooth position
- Arrested development
- Complete failure of tooth to form
- Odontome formation
what are the 2 types of enamel defects?
- enamel hypomineralisation
- enamel hypoplasia
What is enamel hypomineralisation, presentation and how to treat?
- Qualitative defect of enamel i.e. normal thickness but poorly mineralised
- White/ yellow defect
Treatment
- No treatment
- Composite masking +/- localised removal
- Tooth whitening
What is enamel hypoplasia, presentation and how to treat it?
- Quantitative defect of enamel i.e. reduced thickness but normal mineralisation
- Yellow/brown defect
Treatment
- No treatment
- Composite masking
What is Dilaceration?
- Abrupt deviation of long axis of crown or root portion of the tooth
What are crown dilaceration management options?
- Surgical exposure and orthodontic realignment
- Improve aesthetics restoratively
What are root dilaceration/angulation/duplication management options?
- Combined surgical and orthodontic approach
what can lead to delayed eruption?
- premature loss of primary tooth
- around 1 year
(due to thickened mucosa)
How to manage delayed eruption due to traumatic primary dentition?
- Radiograph if > 6 month delay compared to contralateral tooth
- Surgical exposure and orthodontic alignment may be required
- (gold chain attach, flap reposition, ortho bracket and arch wire incorportated )
cause of ectopic tooth position
- retention of primary tooth
- primary tooth trauma displacing permanent tooth
How to manage ectopic tooth position?
- Surgical exposure and orthodontic realignment
- Extraction
How to manage arrested development due to traumatic primary dentition?
- Endodontic treatment (with favourable root length)
- Extraction
How to manage complete failure of tooth to form due to traumatic primary dentition?
- Tooth germ may sequestrate spontaneously
- Or require removal
What is an odontome?
- tumour formed by overgrowth or transitory of dental tissue
tx option of odontome
surgical removal
What does complicated and non complicated mean?
Complicated - pulp involved
Non-complicated - pulp not involved
