Pediatric Primary Care Case Studies, 1st Ed.

Chapter 26. Three Cases of Oral Trauma

Prashant Gagneja

John Peterson

Oral trauma frequently occurs during the life of a young child and adolescent. Often, the consequences of this trauma are minor and may even go unnoticed. However, many injuries to the teeth can have long-lasting significance. It is the purpose of this chapter to present three common dental trauma scenarios and their management.

Educational Objectives

1.  Understand the diagnosis and management of the following types of dental trauma:

•  Avulsion of primary incisors

•  Avulsion of permanent incisors

•  Crown fracture of a permanent incisor with no pulp exposure

•  Crown fracture of a permanent incisor with pulp exposure

2.  Describe the primary care provider’s role in management of dental trauma.

  Case Presentations and Discussion

Child #1

Maria Lopez is a 3-year-old Latino female who avulsed the maxillary right primary central incisor 3 hours ago. Her mother reports that Maria was running through the living room when she tripped on the carpet and fell face first into the coffee table. She was not reported to have lost consciousness. After wiping away some of the tears and blood, mom saw that Maria’s upper front tooth was missing. She found it on the floor and called her primary healthcare provider. However, due to logistical complications, she was not able to get to the office for approximately 3 hours. When she does arrive, Maria seems calm and cooperative.

Child #2

Prashant Kumar is a 10-year-old Indian American male who avulsed his maxillary left permanent incisor about 15 minutes ago. Prashant and his family are visiting his cousin’s house where there is a swimming pool. While running around the pool, he slipped and hit his mouth on the concrete. The avulsed tooth fell into the pool, but his sister found it moments later. Since they were vacationing far away from their dentist, his father chose to go to a nearby urgent care center.

Child #3

Johnny Smith is a 12-year-old white male who, upon leaving school, fell off his bicycle. It was a rather minor crash but, after dusting himself off, he realized he had hit the handlebars with his mouth. He felt his maxillary incisors with his tongue and realized that two of them were broken. He quickly went to the school’s healthcare office. The school nurse noticed that, although two teeth were fractured, only one of them showed any blood from the broken area. Mom was called and immediately came to the school.

What questions would you like to ask all three children and parents to help in the development of a diagnosis and treatment plan? image

As with all head injuries, you will want to know the following information:

•  Time of injury

•  Where and how the injury occurred

•  History of neurologic signs or symptoms before arriving at your clinic

image  Loss of consciousness

image  Headache

image  Nausea or vomiting

image  Disorientation, dizziness, or confusion

image  Unexplained sleepiness

image  Bleeding or fluid from ears, eyes, or nose

•  General medical history

•  History of other traumatic injuries

What physical examination data will you collect for all these cases in addition to the observed dental trauma? image

Physical examination for head injuries should include the following assessments:

•  Vital signs.

•  Sign and symptoms of child abuse or possible abuse.

•  Neurological examination:

image  Begin by noting any signs or symptoms of neurological trauma as reported by the caregiver.

image  Loss of consciousness

image  Headache

image  Nausea or vomiting

image  Disorientation, dizziness, or confusion

image  Unexplained sleepiness

image  Bleeding or fluid from ears, eyes, or nose

image  Evaluate functions controlled by the cranial nerves.

•  Evaluate pupils for equality, roundness, reaction to light, and accommodation (PERRLA).

•  Range of motion for the head and neck.

•  Pain in the head and neck that cannot be attributed to the dental trauma.

How would the results from the histories and physical examinations above affect your triage of the children? image

Before we go further, here is some information about various types of oral/dental trauma.

Dental Trauma Background Information

Unfortunately, dental injuries are all-too-frequent events in the life of some children. Dental trauma may happen at home, during sports, in motor vehicles, or as a result of abuse. When dental injuries affect the primary or young permanent dentition, the child may not always report directly to the dentist. Instead, they may first arrive at the emergency department or other primary healthcare facility. Thus, it is important for primary care healthcare providers to be prepared to manage these injuries prior to the child being sent on to the dentist.

Epidemiology

In the primary dentition, the frequency for dental injuries seems to be about equally distributed between females and males. However, later on, in the permanent dentition, boys appear to injure their teeth more often than girls (Bastone, Freer, & McNamara, 2000). In both the primary and permanent dentition, the teeth most commonly traumatized are the maxillary incisors.

Children with a variety of dental injures may present themselves to primary healthcare facilities. Typical injuries include avulsions, intrusions, luxations, fractures of the root, and crown fractures. It is not the purpose of this case study to discuss all of these various types of dental trauma. Instead, three commonly occurring injuries are used to illustrate how the primary healthcare provider can be of help not only to the child, but also to the dentist to whom the case will ultimately be referred.

Avulsion of a Primary Incisor

The avulsion of a primary incisor is an event that is traumatic not only to the child, but also to the parent. When a beautiful upper front baby tooth is lost suddenly and unexpectedly, it is not hard to imagine that the first thing a parent would like is for the tooth to be replaced in the socket. However, this is not the recommended treatment. In fact, the most appropriate treatment is to leave the tooth out (Andreasen & Andreasen, 1994; Andreasen, Andreasen, Bakland, & Flores, 2003) and manage the other components of the injury, including the emotional one. This advice to not replant the primary tooth can be disconcerting to parents because the popular press may have led them to think that all avulsed teeth should be replanted. It is important for the primary care provider to help the parents understand the differences in treating an avulsed primary incisor versus a permanent incisor. In most cases, only a permanent incisor should be replanted as soon as possible. Of great importance when considering the appropriate management for an avulsed primary incisor is the effect that the initial trauma, and any subsequent treatment, may have on the underlying permanent incisor. (See Figure 26-1.) The initial displacement of the primary incisor or an attempt at replantation may damage the developing permanent tooth lying underneath it in the jaw (Christophersen, Freund, & Harild, 2005; Zamon & Kenny, 2001). In addition, consideration should also be given to the long-term health of a replanted primary incisor. The possible negative sequelae of replantation include, but are not limited to, an abscess of the primary tooth itself (Zamon & Kenny). Thus, in review, the recommended treatment for an avulsed primary incisor is to not replant it.

Avulsion of a Permanent Incisor

The avulsion of a permanent incisor is also a very traumatic event in the life of an adolescent and parent. (See Figure 26-2.) However, the dental management for an avulsed permanent incisor is entirely different from that of a primary incisor. The goal here is to replant the tooth and have it physiologically reattach to the dental socket. The two parts of an avulsed tooth that are most susceptible to damage are the cells and tissues of the dental pulp and those in the periodontal ligament. Thus, to maintain viability of these cells and enhance the possibility for successful replantation, time is of the essence. In fact, if more than 1 hour of extra-alveolar time passes, there is considerable damage to the periodontal ligament tissues and the chance for successful replantation is significantly reduced. The best way to decrease the extra-oral time is to replant the tooth immediately after the injury. To do this, the child or an adult first washes off any contaminates with cold tap water and then replants it into the tooth socket (Andreasen et al., 2003). If this is not possible, the tooth should be placed in an appropriate storage medium and taken as quickly as possible to the primary healthcare provider or dentist. A variety of storage media have been suggested to help maintain the viability of periodontal ligament cells until the tooth can be replanted, including Viaspan, Hank’s balanced salt solution, cold milk, saliva, physiologic saline, and water (American Academy of Pediatric Dentistry, 2008). Of these, milk is usually the most available to a layperson and thus is probably the liquid of choice in which to transport the tooth to the primary healthcare provider. Once the tooth has been replanted, it should be stabilized with a splint attached to the adjacent teeth. (See Figure 26-3.) In addition, it is suggested by some to start the child on a regimen of oral antibiotics at the time of replantation (Andreasen et al., 2003). Subsequently, the pediatric dentist or endodontist will usually begin root canal therapy within the first week after the avulsion and continue to follow the child for an extended time thereafter.

image

Figure 26-1  Skull of 4 year old showing proximity of primary teeth roots to developing primary incisors.

image

Figure 26-2  Avulsion of permanent central molars.

image

Figure 26-3  Same patient as Figure 26-2 with teeth reimplanted and splinted.

Fractured Permanent Incisor

When a permanent incisor is injured, it can also take the form of a fractured crown. In this case, the traumatic forces may be dissipated by breaking part of the crown rather than displacing the entire tooth. The least damaging fracture is that involving just the enamel; however, more severe fractures will include the enamel and dentin, with the most harmful of these involving the dental pulp. (See Figure 26-4.) The immediate and long-term consequences become increasingly significant when the pulp is involved (Cavalleri & Zerman, 1995). The tooth with a crown fracture can be restored in a variety of ways including esthetic crowns, composite restorations, or the reattachment of the broken crown fragment. Fortunately, in most cases, bonding on a composite resin or reattaching the broken fragment provides a very functional and esthetic restoration. If the broken crown fragment is used, it should be kept moist until it arrives at the dentist. Usually the pulp will respond well, without complication, when it is not exposed; however, when the pulp is exposed, there is an entirely different treatment protocol and potential outcome.

Treatment of the exposed pulp will range from sealing it with various medications to performing a root canal. The dentist will make these treatment decisions based on how long the pulp has been exposed, how extensive the pulp exposure is, and whether the tooth has an incompletely or completely formed root apex. Although all crown fractures should be referred to the dentist, the most urgent referral is for fractures that involve the pulp. The role of the primary healthcare provider is, unfortunately, limited and, in most cases, consists of calling the dental care provider to the emergency department or immediately referring the child to the dental clinic.

Other Dental Trauma

In addition to the dental trauma presented here, the primary healthcare provider may encounter other types of injuries to the primary and young permanent dentition. The most common of these is the displacement or luxation of an incisor. The initial injury may or may not be noticeable enough to the parent to bring the child to the primary healthcare provider. However, traumatic luxation of a primary incisor may lead to a variety of consequences including changes in the color of the crown, gingival recession around the tooth, necrotic pulp tissue, and resorption of the root and early loss of the tooth that is not attributable to regular exfoliation (Borum & Andreasen, 1998). If signs or symptoms such as color change, pain, inflammation, or abscess formation are recognized by a primary healthcare provider, the child should be referred to a dentist.

image

Figure 26-4  Tooth fracture of permanent central incisors.

Continuing on with the three children, how would you diagnose and manage each case? image

Child #1: Avulsion of a Primary Incisor

Summary of trauma findings:

image  No signs or symptoms of nondental trauma or child abuse.

image  Complete avulsion of the maxillary right primary central incisor.

image  No other hard or soft tissue trauma except minor damage to the gingival tissue immediately surrounding the tooth socket.

Making the Diagnosis

Maria has an avulsed primary incisor. The extra-oral time has been about 3 hours. There are no other hard or soft tissue injuries and no medical contraindications to treatment.

Management

Recommended dental treatment for an avulsed primary incisor is as follows:

•  If the avulsed tooth was not retrieved, obtain a dental radiograph to confirm that the missing tooth has not been intruded, out of sight, into the gingiva and alveolar bone.

•  Do not replant. Avulsed primary teeth are not replanted, in contrast to avulsed permanent incisors.

•  Confirm that tetanus immunizations are up to date.

•  Immediately refer the child for dental care.

After explaining the plan, you proceed. Immunizations are not needed. The family has a dentist that they can take her to. They feel badly that she has lost a tooth but are glad it was a “baby tooth.”

Prognosis

The prognosis is good for Maria. Generally, the premature loss of a maxillary anterior primary incisor will not have long-term adverse effects on speech (Gable et al., 1995) or the ability to chew. The effect the initial trauma has on the developing permanent incisors is unknown until these teeth develop further.

Child #2: Avulsion of a Permanent Incisor

Summary of trauma findings:

image  No signs or symptoms of nondental trauma or child abuse.

image  Complete avulsion of maxillary left permanent central incisor.

image  No other hard or soft tissue trauma except minor damage to the gingival tissue immediately surrounding the tooth socket.

Making the Diagnosis

Prashant has an avulsed permanent incisor with an extra-oral time of only 15 minutes. There are no other hard or soft tissue injuries and no medical contraindications to treatment.

Management

Recommended dental treatment: Despite Prashant’s pain, you go ahead and put the tooth back into the socket after first rinsing it off carefully with tap water to remove a bit of debris and being careful to hold the tooth by the crown, without touching the root. You then have him hold the tooth in place. You confirm with his father that his tetanus immunization is up to date.

If you hadn’t been able to get Prashant’s cooperation or, due to other problems, you couldn’t replant the tooth, you would have stored the tooth in milk (or Hank’s balanced salt solution) and sent him to the dentist immediately. Note: if the tooth is left to dry for an extended time, it may be contraindicated to attempt replantation.

You next call a nearby dentist with the family’s permission and send them to that dental office immediately for stabilization, pulp therapy, and management of any other complications. If the tooth hadn’t been retrieved, you would have obtained a dental radiograph to confirm that the missing tooth has not been intruded, out of sight, into the gingiva and alveolar bone.

Prognosis

The prognosis for replanted permanent teeth is very dependent on the amount of extra-alveolar time. This is especially true if the root is left to dry during this time. With extended extra-oral time, the possibility for the root to ankylose directly to the alveolar bone is significantly increased.

Complications

At least two significant complications may occur with replanted permanent teeth (American Academy of Pediatric Dentistry, 2008). First, if the tooth becomes ankylosed, the root usually begins to resorb over a period of time. In addition, a tooth that is ankylosed and cannot be moved orthodontically might necessitate a compromise to the orthodontic treatment plan. Secondly, the tooth will need root canal treatment. If this is not done, the pulp will usually abscess. You tell the father that when he returns home, he will need periodic dental follow-up to be sure the replanted tooth is not developing complications.

Child #3: Crown Fracture of a Permanent Incisor

Summary of trauma findings:

image  No signs or symptoms of nondental trauma or child abuse.

image  Fracture of the enamel and dentin of the maxillary right permanent central incisor.

image  Fracture of the enamel and dentin of the maxillary left permanent central incisor; however, on the left incisor, the fracture is large enough to expose the dental pulp.

image  No other hard or soft tissue trauma.

Making the Diagnosis

Johnny clearly has a crown fracture without pulp exposure of the maxillary right incisor. He also has a crown fracture with pulp exposure of the maxillary left incisor. There do not appear to be other hard or soft tissue injures. Neither are there any medical contraindications to the proposed treatment.

Management

Recommended dental treatment: You send an aide to the school to get Johnny’s bicycle and try to find the broken tooth fragment. If she finds it, you will send it to the dentist in a glass of water. You ask the mother to give you the name of Johnny’s dentist so that you can call ahead and arrange for him to be seen immediately. In the interest of time, and because of your school setting, you will not try to obtain a dental radiograph to confirm the extent of the crown fracture and to rule out additional fractures to the roots and surrounding bone.

The school health aide was not able to find any tooth fragments and Johnny’s mom takes him to the dental office. Before leaving, you alert her that the pediatric dentist will treat each tooth differently in light of the fact that one tooth has the complication of a pulp exposure. Dental treatment will consist of managing the dental pulp conditions and restoring the fractured tooth.

You also confirm with her that his tetanus immunizations are up to date.

Prognosis

The prognosis for this type of trauma is usually good. However, the possible complications are presented in the next section.

Complications

There are two areas for complications. First, the dental pulp may have been irreversible damaged. It is often unknown until some time after this initial period if the pulp will suffer necrosis. If it does, usually it can be treated with root canal therapy. Secondly, the crown of the tooth may need additional repair from time to time because even the best of dental restorations may not last a lifetime.

How would you follow up with these children as a primary care provider? image

The follow-up plan and the educational plan are the same for all three children: Confirm with the child/caregiver that follow-up dental care was obtained and confirm with the dentist that appropriate follow-up care was given.

Educational Plan

•  Counsel the child and caregiver about the appropriate age-related trauma prevention strategies.

•  Encourage the child/caregiver to become proactively established with a pediatric dentist for regular dental care.

Key Points from These Cases

1. The assessment of dental trauma should also consider head trauma findings.

2. The immediate reimplantation of an avulsed tooth depends upon whether it was a primary or permanent tooth.

3. Preservation of an avulsed permanent tooth requires a physiologic medium for transport to the dentist.

4. Fractured teeth are also important to assess; evidence that the pulp has been exposed makes the case more emergent.

REFERENCES

American Academy of Pediatric Dentistry Council on Clinical Affairs. (2008). American Academy of Pediatric Dentistry reference manual: guideline on management of acute dental trauma. Pediatric Dentistry, 29(7),168–172.

Andreasen, J. O., & Andreasen, F. M. (1994). Textbook and color atlas of traumatic injuries to the teeth (3rd ed.). Munksgaard-Copenhagen, Denmark: Mosby.

Andreasen, J. O., Andreasen, F. M., Bakland, L. K., & Flores, M. T. (2003). Traumatic dental injuries (2nd ed.). Munksgaard, Denmark: Blackwell.

Bastone, E. B., Freer, T. J., & McNamara, J. R. (2000). Epidemiology of dental trauma: a review of the literature. Australian Dental Journal, 4, 2–9.

Borum, M. K., & Andreasen, J. O. (1998). Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Dental Traumatology, 1, 31–44.

Cavalleri, G., & Zerman, N. (1995). Traumatic crown fractures in permanent incisors with immature roots: a follow-up study. Dental Traumatology, 1, 294–296.

Christophersen, P., Freund, M., & Harild, L. (2005). Avulsion of primary teeth and sequelae on the permanent successors. Dental Traumatology, 21, 320–323.

Gable, T. O., Kumner, A. W., Lee, L., Creaghead, N. A., & Moore, L. J. (1995). Premature loss of the maxillary primary incisors: effect on speech production. Journal of Dentistry for Children, 62, 173–179.

Zamon, E. L., & Kenny, D. J. (2001). Replantation of avulsed primary incisors: a risk-benefit assessment. Journal of the Canadian Dental Association, 67, 386.