There is perhaps no single dental disturbance that has a greater psychological impact on both parent and child than the loss or fracture of a child’s anterior teeth. This is especially true if the injury affects the permanent dentition and involves the extensive loss of tooth structure. Every dentist who treats children must be prepared to meet these emergencies. It is incumbent upon the dentist to preserve the vitality of injured teeth whenever possible and to restore them to their original appearance.
Appropriate treatment is based on the correct diagnosis. Essential to arriving at an accurate diagnosis are a proper history and physical examination. Information obtained from the history and the oral and radiographic examination are essential in determining the type of treatment required at the emergency visit as well as subsequent necessary treatment. It is important to record this information for future reference with regard to clinical management of the patient and for administrative purposes. Accidental injuries are frequently covered by insurance carriers who will require detailed information before payment is made.
Basic Emergency Procedures: History
|Step 1||Document the time of the injury. The time interval between injury and treatment can significantly influence the prognosis of traumatized teeth. This is especially true for avulsed teeth.|
|Step 2||Document the place of the injury. The place of the injury may indicate the need for tetanus prophylaxis. Also, both time and place are frequently required when completing insurance forms.|
|Step 3||Document the cause of the injury. The nature of the accident may provide valuable information regarding the type of injury to be expected. A blow to the chin can cause a jaw fracture or crown-root fractures in the premolar/molar regions. Accidents in which a child has fallen with an object in the mouth, such as a pacifier or toy, tend to cause displacement of teeth. Child abuse should be considered when a young child has multiple soft tissue injuries or bone fractures, or when there is a marked discrepancy between the clinical findings and the history provided by the parents. In such cases, appropriatereferral should be initiated.|
|Step 4||Review the history of previous injuries. Has there been previous trauma to the traumatized tooth or the adjacent or opposing teeth? Clinical and/or radiographic findings may relate to a previous injury and not to the present one.|
|Step 5||Document the presence of neurological signs and symptoms. Determine if the injury has caused any of the following: dilated and unreactive pupil(s), severe headache, drowsiness, vomiting, convulsions, blurring of vision, dizziness, or loss of smell, taste, hearing, or sight.|
|Trauma to the oral cavity is a part of the larger consideration of trauma to the head itself. The most common type of accident resulting in injury to the teeth and head is one in which a moving blunt object strikes the head, or the head is flung against a hard surface. Injuries of this type are referred to as blunt head injuries. They can result in skull fracture and/or contusion, laceration , hemorrhage, and swelling of the brain. The preceding signs and symptoms characterize brain injury and suggest that follow-up by a physician is necessary.|
|Step 6||Document dental symptoms. Is the tooth (teeth) painful to touch, to bite, or to temperature changes, or spontaneously painful? Is the tooth (teeth) mobile? Is there a disturbance in the occlusion?|
|Step 7||Document health history. A complete medical/dental history should be obtained for new patients and the previous history updated for patients of record. Particularly important in the review of the health history is the date of the last tetanus booster. The basic immunization (DTP) is generally given at age 2, 4, and 6 months. The first booster is given at about 18 months and then again at 4 to 5 years of age. A toxoid booster should then be given every 10 years. However, if the last booster was given more than 5 years previously and the child receives a wound that may have been contaminated by soil, a toxoid booster should be given. Half of the cases of tetanus in the United States involve wounds so trivial they are disregarded by the patient and/or the physician.|
Basic Emergency Procedures: Physical Examination
After the history is secured, the dentist must complete a thorough oral examination.
|Step 1||Assess soft tissue damage. The location of extraoral wounds may indicate where dental injuries can be suspected. A wound located under the chin suggests the possibility of dental injuries in the premolar/molar regions. Palpation of the facial skeleton may disclose jaw fractures. Injuries of the oral mucosa should be noted. Suturing may be required.|
|Step 2||Determine mobility of teeth. All teeth should be tested for abnormal mobility in both the horizontal and vertical direction. Remember that teeth in the process of eruption always exhibit physiologic mobility. The same applies to primary teeth undergo ing physiologic root resorption. Disruption of vascular supply to the pulp should be expected in the case of mobility.|
|Step 3||Note displacement of teeth. Displacement of teeth includes intrusion, extrusion, lateral displacement, or avulsion. In the case of displacement (luxation), the extent and the direction of the dislocation should be noted.|
|Step 4||Note fractures of teeth. Infraction lines in the enamel should be diagnosed by directing a light beam parallel to the vertical axis of the tooth. Determine whether the fracture is confined to the enamel or includes dentin. The fractured surface should be care fully examined for exposure of the pulp. If exposure is present, its size and location should be noted. In some cases the dentin layer may be so thin that the pulp outline can be seen as a pink ish tinge. In such cases, care should be taken not to perforate the thin dentin with an explorer (Fig 6-1).|
|Step 5||Investigate evidence of alveolar bone fracture. The typical sign of an alveolar fracture is movement of adjacent teeth when test ing the mobility of a single tooth. Uneven contours of the alveolar bone are another indication of alveolar plate fractures.|
|Step 6||Evaluate pulpal vitality. Pulp testing following traumatic injuries is a controversial issue. The procedure requires cooperation and a relaxed attitude on the part of the patient to avoid false reac tions. This is often not possible during the emergency treatment of children. The principle of the pulp test is the conduction of stimuli to and then registration on the sensory receptors of the pulp. The utilization of the electric vitalometer test in the exami nation of a traumatized tooth provides a reference point against which to evaluate the tooth at subsequent follow-up visits. As such, it can be a valuable diagnostic tool. A positive test result can indicate a vital tooth. A negative test result, however, should not by itself condemn the tooth to pulp therapy.|
|Step 7||Perform radiographic examination. Radiographs of the injured tooth (teeth) and adjacent structures should be obtained and the following observed: the size of the pulp chamber of the injured tooth and the proximity of the fracture to the pulp tissues; the stage of root development; the presence of root or alveolar fractures ; and the presence of pathosis resulting from earlier injuries.|
|The initial radiograph serves as a baseline record for comparison with future radiographs of the teeth in the area of the injury. Comparison of serial radiographs can assist in evaluating root apexification, root resorption, internal resorption, pathologic bone resorption, and reparative deposition (Fig 6-2).|
Trauma to the Young Permanent Dentition
Trauma to the young permanent dentition can result from a blow to the mouth during participation in contact sports or other risk-related activities, such as skating, skateboarding, and biking. Children with large overjets (usually the result of a Class II, Division I malocclusion) are twice as likely to experience trauma to their permanent incisors as are children with normal overjets. The use of mouth protectors or mouth guards can be an effective means of preventing or minimizing trauma. For example, to protect young athletes the National Alliance Football Rules Committee mandates that players wear an intraoral mouth and tooth protector that includes both an occlusal and labial portion. It is recommended that the protector be either constructed and fitted to the individual by impressing the individual’s teeth into the mouth and tooth protector itself, or constructed from a model made from an impression of the teeth.
Crown infractions are commonly overlooked. Fractures can appear as split lines in the enamel substance that do not cross the dentinoenamel junction. They are caused by direct impact to the enamel, which explains the frequent occurrence of infraction on the labial surface of the upper incisors.
|Step 1||Detection of these lines is facilitated by directing a light beam parallel to the vertical axis of the tooth. Infraction may be the only evidence of trauma or may be associated with other injuries.|
|Step 2||These injuries do not require treatment; however, since injuries to the tooth-supporting structures are commonly associated with infraction, vitality tests can be used to monitor the pulpal status.|
Simple Crown Fracture
Treatment of Fracture Involving Little or No Dentin
|Step 1||Immediate treatment is confined to smoothing sharp enamel edges that might prove irritating to the soft tissues, and to reshaping the tooth to provide a pleasing esthetic result.|
|Step 2||If the tooth is sensitive to air, several coats of copal varnish may be applied over the fracture site.|
|Step 3||When the shape or extension of the fracture precludes an esthetic result through reshaping, a small acid-etched resin restoration may be placed.|
|Step 4||The patient should return at 1, 3, 6, and 12 months, and annually thereafter for follow-up evaluation with pulp tests and radio graphs.|
Extensive Crown Fracture
Treatment of Fracture Involving Dentin but Not Pulp
Measures should be taken to protect the exposed dentin, permitting the pulp to create a protective barrier, or reparative dentin. When the dentin is exposed, dentinal tubules come into contact with the oral environment. The pulp may react favorably to such stimuli by walling off the exposed dentinal tubules with reparative dentin. However, there is a risk that the insults may exceed the recuperative power of the pulp, thus leading to inflammatory changes and the ensuing death of the pulp.
|Step 1||Traditionally, it has been recommended that a calcium hydroxide preparation be placed over all the exposed dentin prior to restoring the tooth. Controversy has emerged about this practice, how ever, with some investigators suggesting the use of a calcium hydroxide base only when the remaining dentin thickness is 0.5 mm or less. Others suggest that calcium hydroxide is unnecessary even in these instances. The use of glass-ionomer cement liners to protect exposed dentin has become increasingly popular due to their demonstrated biocompatibility with the dental pulp, their ability to adhere to dentin and enamel, and their fluoride release.|
|Step 2||After determining whether or not to place a protective base, an acid-etched composite resin restoration is placed. To be effective, the restoration should:|
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