Oral Health Group
Feature

Oral Health – Primary Trauma: Selected Cases and Treatment Options for the General Practitioner

January 1, 2014
by Joannie Bernier, DMD; Paige Kozak, BEng, BSc, DMD


It’s late on a Friday afternoon, the start of a long weekend, and in through the door of your dental practice rushes a frantic parent with a distraught three-year-old who fell while playing and knocked out a front tooth. We’ve all been there. The purpose of this review article is to demystify the most common treatments and prognoses of traumatic injuries to the primary dentition, so that the clinician may treat with confidence and speed. As an added bonus, you may gain a new patient and get out the door to enjoy your own long weekend sooner.

FIGURE 1: Occlusal radiograph of severely luxated 51 and 61.
 

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Emergency visits to the dentist are emotionally charged. When a toddler is crying and the parent is waving a tiny tooth fragment in your face, it can be easy to forget the importance of the proper sequence of treatment. The importance of obtaining a detailed medical and dental history cannot be overstated. Though it may feel like a burden of time, an accurate history will save you from making costly mistakes in the short and long term, such as inadvertently treating without the provision of prophylactic antibiotics. On the topic of time, the illusion of time constraints in treatment of dental emergencies is just that: an illusion. Often, delaying treatment of a late night trauma to the next morning can make a world of difference to the young traumatized patient (and parent) by allowing them to get a good rest and some pain management. Once the patient arrives and a history has been taken, a radiographic exam is often necessary for diagnosing and establishing a baseline by which to compare future radiographs.1-9 The specific trauma cases discussed below assume that a thorough medical history, clinical and radiographic exam have been done, child abuse ruled out, and that following the proposed treatment, post-op instructions will be given. Typical post-op instructions for primary trauma include, but are not limited to: soft diet, pain management, good oral hygiene, chlorhexidine rinse if required, the possibility of lip-biting due to local anesthetic, and routine follow-up.1,2,4,5,10 Parents should be informed to watch for early signs and symptoms of infection such as swelling, fistulas, pain or fever. It is also important to discuss all the risks and benefits of treatment options with the parents and obtain informed consent prior to beginning treatment. Specifically, parents must understand that any primary trauma may cause damage to the developing permanent tooth.1,2,11,4,12,6,7,8,9,13,10 Three common dental traumas and their proposed treatments with associated prognoses will now be discussed; luxation, intrusion and avulsion. Tooth discoloration, a common sequelae of dental trauma, will also be discussed. These specific traumas have been chosen because their treatments are not entirely straight forward and there exists various opinions, sometimes conflicting, amongst dental professionals.

EPIDEMIOLOGY OF TRAUMATIC INJURIES TO THE PRIMARY DENTITION:
It is very difficult to establish the prevalence of dental trauma in primary dentition due to conflicting statistics reported in various studies and also due to the fact that not all children are brought to the dental clinic after a minor trauma. Traumatic injuries to the primary dentition occur most often as a result of limited motor coordination and inability to evaluate risk.3,4,5,6,7,10 Frequently, injuries to primary dentition occur secondary to falls with the central maxillary incisors being most affected.1,4,5,6,7,10,13 The most frequent injury in primary dentition is luxation due to less dense and less mineralized bone.5,13,14 Dental trauma is more frequent in males (57 percent)3, but according to other authors the trauma incidence is equally high in both sexes7 until approximately age five, when males become more prone to dental trauma.4 Non-nutritive sucking habits and developing Class II malocclusions are associated with increased overjet and may be a risk factor to dental trauma in primary dentition.1,15

LUXATION:
Displacement of the tooth in a direction other than axially with damage to the PDL.1,6,9

In most cases, luxated teeth are not mobile as the apex is forced into the alveolar bone.1,2,6,9,10 An occlusal radiograph is advisable and will often reveal a widened apical region of the PDL.6,9 Besides its diagnostic and baseline benefits, the radiographic examination is used to rule out root fracture.1,7 Malmgren further uses radiographs to asses the direction of luxation; for example, the apex can be visualized and will appear shorter if it is displaced away from, or buccally, to the permanent tooth bud. Conversely, if the apical tip cannot be visualized and the tooth appears elongated, it is likely that the apex is luxated towards the permanent tooth bud.10 Luckily, 80 percent of luxations have the apex displaced away from the permanent tooth bud.1 Suggested treatment for luxations are observation, repositioning or extraction.

Observation alone is indicated in cases where there is no occlusal interference and minimal displacement of the crown.2,4,6,7,9

Repositioning is indicated in cases where there is occlusal interference.2,6,7,8,9,10 When occlusal interference is minimal, the tooth may be adjusted to eliminate the interference.2,6,9,10

Extraction is indicated in cases where the tooth is close to exfoliation6 and/or when the tooth is severely displaced, which represents an alveolar bone fracture.1,2,7,9,10

The prognosis for teeth that have been luxated is generally guarded (Table 1) with coronal discoloration occurring in 62 percent of cases; pulp canal obliteration 41 percent, pulpal necrosis 28 percent12 and 25 percent;14 inflammatory resorption 13 percent; no complications 12 percent; gingival retraction seven percent; physiologic resorptiong five percent; permanent displacement three percent; ankylosis one percent.12 Other authors discuss hypoplastic defects of permanent teeth associated with primary luxations at approximately eight percent.14 This guarded prognosis is based on likely amputation of neurovascular supply (especially after age two when the apex is usually closed),14 PDL compression and severance, and alveolar bone fracture.9 

There are many different suggestions for follow-up. In these authors’ opinion, this emphasizes the importance of follow-up in general rather than a strict rule. That being said, most experts in the field recommend reassessing clinically at approximately two to three weeks, six to eight weeks (in addition to a radiographic exam) and again at one year (with radiographs).2,9,10

FIGURE 2: Intrusion of 51 and 61.

AVULSION: The tooth is completely displaced from the socket with severed PDL.1,6,9
tI is important to obtain a detailed history in order to determine the location of the tooth. Radiographic examination is required to rule out aspiration into the lungs.1,4,9 Radiographic assessment of the area typically reveals an empty socket, however, on occasion, a completely intruded tooth may be mistaken for avulsion if the tooth is missing.2,4,7,9,10 Guidelines generally recommend that avulsed primary incisors not be replanted to prevent any damage to the developing permanent tooth
bud.1,2,4,6,7,9,10 However, a recent study from Holan suggests that if the pediatric patient arrives at the dental office after an avulsed tooth has been replanted by a good Samaritan, it should be observed unless the following indications to remove the primary tooth are encountered: when the crown of the permanent successor is not yet completely developed; a medical history of systemic disease that may hinder the prognosis; compliance issues; more than one avulsion (due to lack of adjacent supporting teeth for splinting); when a fractured root remnant remains in the alveolar bone; severe fracture of the alveolar bone; imminent exfoliation; evidence of previous trauma (root resorption); extensive caries; signs and symptoms of infection in the region.16 The loss of a front tooth can be emotional and partial dentures (fixed or removable) can be fabricated if esthetics is a concern.4,7

Most experts in the field recommend reassessing clinically at approximately one week, six months (in addition to a radiographic exam) and again at one year (with radiographs).2,9,10

FIGURE 3: Intrusion of 51 and 61.

INTRUSION:
“The tooth is driven into its socket. This compresses the PDL and commonly causes a crushing fracture of the alveolar socket.”1

“Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.”9

Intruded teeth exhibit shorter clinical crown or missing crown in severe cases.1,5,6 Intrusive luxations can result in damage to unerupted permanent teeth. Radiographs demonstrate that the PDL is not continuous and the tooth is displaced apically.1

Suggested treatments for intrusions depend on many factors, however, there are two main choices: observation or extraction. Each intrusion should be assessed based on the direction of the intrusion, degree of intrusion and presence of alveolar bone fracture.5

Observation is indicated in cases where permanent teeth are not at risk. For example, when clinical and radiographic exam suggest the maxillary primary incisor has been intruded away from the developing permanent tooth.1,5,6,7,8,9 Also, the degree of intrusion should be less than 50 percent of crown length, with no alveolar bone fracture.5

Extraction is indicated in cases where proximity of the permanent tooth is a critical factor or when the intrusion is more than 50 percent of crown length.5 Alveolar bone fracture associated with intrusion is also an indication for extraction. The imminent exfoliation, limited function of a primary tooth and lack of cooperation should also be considered.5 In these cases extraction is indicated due to low chance of reeruption into the original position and high risk of pulpal necrosis.

The prognosis of teeth that have been intruded is generally guarded (Table 2) with coronal discoloration, occurring in 48 percent of cases; pulp canal obliteration 41 percent; pulp necrosis 38 percent12 and 23 percent;5,11 inflammatory resorption 14 percent12 and 33 percent;5,11 no complications 12 percent;12 gingival retraction 2 percent.12

Recommended clinical follow-up is at approximately one week, three to four weeks (with radiographs), six to eight weeks, six months (with radiographs), one year (with radiographs), and annually until exfoliation.2,9

TOOTH DISCOLORATION:
Coronal discoloration alone is not an indication for extraction or pulp therapy of the primary tooth. At least one additional sign or symptom of infection should be noted prior to treating such a tooth, for example: pain, swelling, radiographic lucency, mobility or presence of a fistula.1,4,7 In primary teeth, a pink discoloration noted soon after trauma implies intrapulpal hemorrhage (bleeding within the pulp chamber). A more reddish discoloration noted long after trauma implies internal resorption (pathologic expansion of the pulp chamber).1 A yellow hue may imply pulp canal obliteration (thickening of the tertiary dentin surrounding the pulp chamber).1,12 Pulp canal obliteration was noted in 82 percent of yellow discolored teeth and only two percent developed pulp necrosis.12 Dark black, gray, and brown discolorations may imply pulpal necrosis or hemorrhage, but these colours do not confirm or deny vitality. Dark coloration results from red blood cell lysis and consequent release of iron, containing hemoglobin derivatives that wick through dentin tubules.1 Often, the more persistent the dark coloration, the higher the likelihood the tooth is non-vital.1,4,12,7 Presence or lack of vitality alone, however, does not change the recommended treatment of follow-up.1,4 Seventy-two percent of temporary gray discoloration showed pulp canal obliteration and three percent showed pulpal necrosis. Nine percent of permanent discolored teeth showed pulp canal obliteration and 66 percent showed pulpal necrosis and 26 percent did not show any complications.12

CONCLUSION:
The majority of trauma in primary dentition occurs between birth and three years of age, while children are developing their motor skills.3 The maxillary central incisor is most commonly affected. Management of trauma to primary dentition differs from permanent dentition. The short period of primary teeth function, the proximity of the permanent tooth and the child’s compliance are major factors that need to be considered before any treatment. Radiographic examination is required to establish a baseline and to assess for further injuries. No matter what injuries are encountered, objectives are to reassure parents, manage pain, minimizing damage to the permanent teeth and ideally avoid dental anxiety in young children and proceed in a safe manner for the child and for the dental team. A follow up after injuries is critical to ensure good healing, and to diagnose complications such as pulp necrosis and external resorption of the primary tooth.

ACKNOWLEDGEMENTS
The authors would like to thank Dr. Edward Barrett, Department of Pediatric Dentistry, Hospital for Sick Children, for essential advice and tutelage during the review of this article. OH


Joannie Bernier and Paige Kozak are residents in the University of Toronto Pediatric GPR program at the Hospital for Sick Children and Holland Bloorview Kids Rehabilitation Hospital.

Oral Health welcomes this original article.

REFERENCES:

1. Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW, Nowak AJ. Pediatric Dentistry: Infancy Though Adolescence. 4th Ed. Rudolph P, editor. Introduction to Dental Trauma: Managing Traumatic Injuries in the Primary Dentition. St. Louis, MO: Elsevier Saunders; 2005. p. 236-256.

2. Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland LK, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent Traumatol 2007; 23: 196-202.

3. Alvine de Jesus M, Azeredo A. Antunes L, de Andrade Risso P, Vinicius Freire M, Cople Maia L. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res 2010; Jan-Mar; 24(1): 89-94.

4. Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th Ed. 19: Injuries to the Primary Dentition. Oxford: Blackwell Munksgaard; 2007. p. 516-541.

5. Gupta M. Intrusive luxation in primary teeth–Review of literature and report of a case. The Saudi Dental Journal 2011; 23: 167-176.

6. Guideline on Management of Acute Dental Trauma. Americ
an Academy of Pediatric Dentistry. 2011;34(6):230-238.

7. McTigue DJ. Managing Injuries to the Primary Dentition. Dent Clin N Am 2009 Oct;53(4): 627-638.

8. McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 8th Ed. Rudolph P, editor. 21: Management of Trauma to the Teeth and Supporting Tissues. St. Louis, MO: Mosby; 2004. p. 453-503.

9. The Dental Trauma Guide [Internet]. Denmark: Internation Association of Dental Traumatology; c2010 [updated 2013 Sept 18]. Available from: www.dentaltraumaguide.org

10. Malmgren B, Andreassen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, Cavalleri G, Cohenca N, Day P, Hicks ML, Malmgren O, Moule AJ, Onetta J, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dental Traumatology 2012; 28: 174-182.

11. Gondim JO, Moreira Neto JJS. Evaluation of intruded primary incisors. Dent Traumatol 2005; 21: 131-133.

12. Borum MK, Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 1998; 14: 31-44.

13. Hirata R, Kaihara Y, Suzuki J, Kozai K. Management of intruded primary teeth after traumatic injuries. Pediatric Dental Journal 2011; 21(2): 94-100.

14. Soporowski NJ, Allred EN, Needleman HL. Luxation injuries of primary anterior teeth: Prognosis and related correlates. Pediatr Dent 1994; 16(2):96-101.

15. Norton E, O’Connell AC. Traumatic dental injuries and their association with malocclusion in the primary dentition of Irish children. Dent Traumatol 2012; 28: 81-86.

16. Holan G. Replantation of avulsed primary incisors: a critical review of a controversial treatment. Dental traumatology 2013; 29:179-184.


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