Chapter 1

History, Examination, Diagnosis and Treatment Planning

Aim

To provide a framework for assessing patients presenting after trauma.

Outcome

After studying this chapter the reader should have a raised awareness of trauma aetiology, and be able to assess patients who have suffered trauma.

Introduction

This book largely focuses on children in whom the majority of dental injuries occur and where management is evidence-based. However, most issues also translate to the management of trauma to permanent teeth in older people.

Trauma to children’s teeth occurs quite frequently. Previous studies in the UK (Todd and Dodd, 1985) suggested that the incidence of trauma to teeth was increasing, but more recent studies have indicated a fall in incidence (O’Brien, 1994). It is suggested that this may be related to a more sedentary lifestyle for children, with less active participation in organised sport and more recreational interest in computer games. It is evident from the world literature however that dental trauma is a global entity. At the age of five years some 31–40% of boys and 16–30% of girls will have suffered dental trauma. By the age of 12 years, the corresponding figures are 12–33% of boys and 4–19% of girls. Traumatic injuries are twice as common in boys in both the permanent and the primary dentitions.

The majority of dental injuries in the primary and permanent dentitions involve the anterior teeth – in particular, the maxillary central incisors. The mandibular central incisors and maxillary lateral incisors are less frequently involved. Concussion, subluxation, and luxation are commonest in the primary dentition, while uncomplicated crown fractures are commonest in the permanent dentition.

Aetiology

The most accident-prone times are between two and four years for the primary dentition and seven and 10 years for the permanent dentition. In the child in the primary dentition, coordination and judgement are incompletely developed and the majority of injuries are due to falls in and around the home – in particular as the child becomes more adventurous and explores its surroundings. In the permanent dentition most injuries result from falls and collisions while playing and running, although bicycles are a common accessory. The place of injury varies in different countries, according to local customs, but accidents in the school playground remain common.

Sports injuries usually occur in teenage years and are commonly associated with contact sports such as soccer, rugby, ice hockey and basketball.

Injuries related to road traffic accidents and assaults are most commonly associated with the late teenage years and adulthood, and are often closely related to alcohol abuse.

One form of injury in childhood that must never be forgotten is child physical abuse or non-accident injury (NAI). This topic will be covered in Chapter 12.

The exact mechanisms of dental injuries are largely unknown and without experimental evidence, but injuries can be the result of either direct or indirect trauma. Direct trauma occurs when the tooth itself is struck. Indirect trauma is seen when the lower dental arch is forcefully closed against the upper, e.g. a blow to chin. Direct trauma implies injuries to the anterior region, while indirect trauma favours crown or crown-root fractures in the premolar and molar regions, as well as the possibility of jaw fractures in the condylar regions and symphysis. The factors which influence the outcome, or type of injury, are a combination of:

• energy of impact

• resilience of impacting object

• shape of impacting object

• angle of direction of the impacting force.

Increased overjet, with protrusion of upper incisors, and insufficient lip closure are significant predisposing factors to traumatic dental injuries. Injuries are almost twice as frequent among children with protruding incisors. The number of teeth affected in a particular incident is also increased by an increased overjet.

The second major group of children predisposed to traumatic injuries are the accident-prone. These children sustain repeated trauma to their teeth. Frequencies have been reported to range from 4–30%.

Another group that has recently been shown to have a higher incidence of dental injuries are those children who are overweight. It is thought that the cause is their lack of athleticism during falling.

Classification

The classification of dento-alveolar injuries based on the World Health Organization (WHO) system is summarised in Table 1-1.

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