Facial trauma that results in fractured, displaced, or
lost teeth can have significant negative functional, esthetic, and
psychological effects on children. Dentists and physicians should collaborate
to educate the public about prevention and treatment of traumatic injuries to
the oral and maxillofacial region.
The greatest incidence of trauma to the primary teeth occurs
at 2 to 3 years of age, when motor coordination is developing. The most common
injuries to permanent teeth occur secondary to falls, followed by traffic
accidents, violence, and sports. All sporting activities have an associated
risk of orofacial injuries due to falls, collisions, and contact with hard surfaces.
The AAPD encourages the use of protective gear, including mouthguards, which
help distribute forces of impact, thereby reducing the risk of severe injury.
Dental injuries could have improved outcomes if the public
were aware of first-aid measures and the need to seek immediate treatment. Because
optimal treatment results follow immediate assessment and care, dentists have
an ethical obligation to ensure that reasonable arrangements for emergency
dental care are available. The history, circumstances of the injury, pattern of
trauma, and behavior of the child and/or caregiver are important in
distinguishing nonabusive injuries from abuse.
Practitioners have the responsibility to recognize,
differentiate, and either appropriately manage or refer children with acute
oral traumatic injuries, as dictated by the complexity of the injury and the
individual clinician’s training, knowledge, and experience. Compromised airway,
neurological manifestations (eg, altered orientation), hemorrhage,
nausea/vomiting, orsuspected loss of consciousness requires further evaluation
by a physician.
To efficiently determine the extent of injury and
correctly diagnose injuries to the teeth, periodontium, and associated structures,
a systematic approach to the traumatized child is essential. Assessment
includes a thorough medical and dental history, clinical and radiographic
examination, and additional tests such as palpation, percussion, sensitivity,
and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar
trauma. If the area of concern extends beyond the dentoalveolar complex,
extraoral imaging may be indicated. Treatment planning takes into consideration
the patient’s health status and developmental status, as well as extent of injuries.
Advanced behavior guidance techniques or an appropriate referral may be
necessary to ensure that proper diagnosis and care are given.
All relevant diagnostic information, treatment, and
recommended follow-up care should be documented in the patient’s record. A
standardized trauma form can guide the practitioner's clinical assessment and
provide a way to record the essential aspects of care in an organized and
consistent manner. Well-designed and timely follow-up procedures are essential to
diagnose and manage complications.
After a primary tooth has been injured, the treatment
strategy is dictated by the concern for the safety of the permanent dentition. If
determined that the displaced primary tooth has encroached upon the developing
permanent tooth germ, removal is indicated. In the primary dentition, the
maxillary anterior region is at low risk for space loss unless the avulsion
occurs prior to canine eruption or the dentition is crowded. Fixed or removable
appliances, while not always necessary, can be fabricated to satisfy parental
concerns for esthetics or to return a loss of oral or phonetic function.
When an injury to a primary tooth occurs, informing parents
about possible pulpal complications, appearance of a vestibular sinus tract, or
color change of the crown associated with a sinus tract can help assure timely
intervention, minimizing complications for the developing succedaneous teeth. Also,
it is important to caution parents that the primary tooth’s displacement may
result in any of several permanent tooth complications, including enamel
hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in
eruption patterns or sequence. The risk of trauma-induced developmental
disturbances in the permanent successors is greater in children whose enamel
calcification is incomplete.
The treatment strategy after injury to a permanent tooth is
dictated by the concern for vitality of the periodontal ligament and pulp.
Subsequent to the initial management of the dental injury, continued periodic
monitoring is indicated to determine clinical and radiographic evidence of
successful intervention (ie, asymptomatic, positive sensitivity to pulp
testing, root continues to develop in immature teeth, no mobility, no
periapical pathology). Initiation of endodontic treatment is indicated in cases
of spontaneous pain, abnormal response to pulp sensitivity tests, lack of
continued root formation or apexogenesis, or breakdown of periradicular
supportive tissue. To restore a fractured tooth’s normal esthetics and
function, reattachment of the crown fragment is an alternative that should be
considered.
To stabilize a tooth following traumatic injury, a splint
may be necessary.
Flexible splinting assists in healing.
Characteristics of the ideal splint include:
1.
easily fabricated in the mouth without additional trauma;
2.
passive unless orthodontic forces are intended;
3.
allows physiologic mobility;
4.
nonirritating to soft tissues;
5.
does not interfere with occlusion;
6.
allows endodontic access and vitality testing;
7.
easily cleansed;
8.
easily removed.
Instructions to
patients having a splint placed include to:
1.
consume a soft diet;
2.
avoid biting on splinted teeth;
3.
maintain meticulous oral hygiene;
4.
use chlorhexidine/antibiotics if prescribed;
5.
call immediately if splint breaks/loosens.
