Arthur J Nowak

Trauma to primary teeth: 
  Setting a steady management course for the office 

By Arthur J. Nowak, DMD, and Rebecca L. Slayton, DDS, PhD 

 Evaluate and treat a toddler's injured loose tooth or lacerated   gum yourselfknowing that much is at stake because damage can go deep to   developing permanent teeth? Or refer these cases to a dental specialist? It   all dependson the injury, the child, and your skills. 

 Oral and dental trauma are common in infants and pre-school children. Treatment   is often delayed, however, because parents cannot ascertain the seriousness   of the injury or are unsure where to seek treatment. And although some types   of oral injury in young children can be easily treated by the parent by applying   pressure to stop bleeding and ice to control swelling, others require immediate   professional intervention independing on the nature of the injurythe   pediatrician's or dentist's office or the community hospital's emergency department   (ED) or trauma center. 

 A potential barrier to providing care for patients who are brought to a pediatrician's   office with any degree or type of injury to the teeth or mouth is that most   lack formal training in the management of oral trauma, and that their officesand   even community EDslack the appropriate equipment for diagnosing and treating   such injury. This strikes us as unfortunate, because we believe that it is important   for pediatricians to be familiar with the common types of oral injuries, to   know when referral is necessary, and to understand current management principles. 

 In this article, we review what decisions need to be made during the evaluation   of trauma to the primary teeth and surrounding structures of preschool- and   early school-age childrentoward the goal of maintaining and protecting   the integrity of those teeth and minimizing injury to developing underlying   permanent dentition and surrounding soft tissue. Why focus on trauma to primary   dentition and possible effects on developing (unerupted) permanent teeth? Because   most children have made their first visit to a dentist before permanent anterior   teeth erupt, and parents are most likely to visit their child's established   dentist or the ED of a local hospital for emergency treatment of trauma to those   permanent teeth. 

 Looking at epidemiology, incidence, and clinical experience 

 National statistics are available on injuries to the face and head secondary   to trauma, but few reports touch specifically on injury to the oral cavity or,   especially, the teeth. Regrettably, the ICD-9-CM 

(International Classification   of Disease9th revisionClinical Modification

) codes that physicians   use and the so-called E codes used in EDs often do not accurately convey the   extent of injuryeven though codes are available to provide these data   (see table). The problem is compounded by the fact that few nonacademic EDs   have a dentist on staff who is available to provide treatment and who is familiar   with these specific codes. 

Treating injury to the oral cavity:
        Available billing codes

 It is regrettable, too, that the concept of the so-called dental home

   is not as well developed as the medical home. More than 75% of children between   birth and 3 years of age have not had a nonemergency first dental visit, reports   suggest; those children are not, therefore, registered as a patient in a dental   office.

 This situation makes it highly likely that their parents   will contact a primary care provider or the ED of the local hospital for advice   or treatment when an emergency arises involving primary teeth. 

 No national study of pediatricians' knowledge of, or clinical experience with,   managing oral trauma has been conducted. In one regional survey of pediatricians'   knowledge of dental care, the greatest percentage of responders34.7%said   that they felt that they lacked the confidence to manage a traumatic oral injury;   20.6% reported that they would rather refer such cases to a dentist; and only   17.4% felt confident about managing dental trauma.

 Reports of the   adequacy of participatory experiences and learning opportunities during pediatric   residency training show that most residents (76% and 78% in two studies) found   their residency experience in dentistry insufficient (no explanation was offered   about why they think this way).

 The head, face, neck, and mouth are frequently reported sites of injury in   child abuse, but no clear indication has been made in the data reported of the   frequency of tooth and oral tissue injury. We do know that, when a dentist is   a member of a child abuse evaluation team, examination reports show that the   incidence of oral trauma (mostly torn frena, bruised lips, and luxated anterior   teeth) is as high as 50% to 75%.

 When dentists do not participate   in the team's work, the reported incidence falls as low as 2.76% to 11%.

 Although all primary teeth are at risk of a variety of injuries, the maxillary   anterior primary teeth are affected most often.

 A toddler who has   protrusive anterior teeth with minimal lip coverage is at greater risk. 

 Complicated crown and root fractures are possible but not common. The force   of trauma is most often transferred through the tooth, reducing the risk of   fracture. 

 Because of the direction of force and the elasticity of alveolar bone surrounding   primary teeth, the most common injury is luxation, or displacement, with gingival   hemorrhage. Lateral luxation (usually palatal) is the most common trauma to   the tooth, followed by intrusion and then avulsion. These terms are defined   later under "A spectrum of injury." 

 Alveolar bone fracture is always possible with a luxation injury, but the   prevalence has not been reported in the literature. Fracture of the mandible   has been reported, with condylar fracture the most common subtype.

 Variables in the landscape of oral trauma 

 At least one third of preschool children suffer a trauma that affects their   primary teeth.

 Although data do not exist on children who have special   health-care needs, our clinical experience and the experience of others leads   us to conclude that those children are, at the least, affected to a similar   degree, and that children who have a neurologic deficit may be at even higher   risk of trauma to primary teeth. 

 The peak period for trauma is 18 to 40 months of age, most likely because   this is a time of constant change in a toddler's environment and mobility. Only   a small difference between the risk of oral injury to boys and to girls has   been reported during the first 12 months of life, although the risk to boys   increases proportionately after infancy. 

 At one time, seasonal variation was reported in the prevalence of oral trauma   because cold weather restricted outdoor activity during the winter. Today, however,   activities once limited to the outdoors have also come insideinto homes   with family rooms and game rooms, community indoor recreational facilities,   and commercial sports and game centerswhere children participate even   during the most inclement weather and are at risk of oral trauma year-round. 

Children who are learning to walk or are still relatively uncoordinated often suffer trauma to the teeth or face as the result of a fall. Trauma to orofacial structures may be limited to soft or hard tissue, or may involve both types. The degree of trauma is influenced by how far a child falls, how fast he (or she) is moving when he falls, and what object or surface he lands on. It is common to see a traumatic injury to a young child in which only the upper front teeth are involved; even so, a thorough examination should be performed to identify any other consequences of the fall.

Lips often cushion the teeth during   a fall, and may therefore be bruised or lacerated by the impact of teeth against   tissue. The upper and lower lips should be examined carefully for laceration;   if laceration is present, determine whether or not a foreign body, such as a   tooth fragment or gravel, has been introduced to the wound. Swelling and bruising   of the lips are common findings after oral trauma, even in the absence of laceration   (Figure 1). 

 Frenaparticularly the maxillary labial frenummay be torn as a   result of trauma to the mouth or teeth (Figure 2). The extent of the tear also   depends on the degree of the original attachment of the frenum. Although this   type of injury can be the result of uncomplicated trauma, it is often associated   with child abuse; in an infant who does not yet walk or crawl, for example,   a torn frenum is less likely the consequence of an accident than the result   of an object being forced into the child's mouth, and should be investigated   as a potential finding of child abuse. Once a child is mobile, any fall that   causes trauma to the mouth is very likely to result in a torn maxillary frenum.   In all cases of a torn frenum, obtain a thorough history of the injury to determine   if the description of the event matches the outcome. 

 Trauma to the tongue can include laceration (Figure 3) or puncture, usually   caused by the teeth. The extent of a laceration should be determined by careful   examination. In general, suturing a laceration of the tongue does not improve   the outcome,

 except that it is required when the laceration is   severe. Suturing of a tongue laceration should be performed by a practitioner   experienced at the procedure, which includes most oral surgeons, some pediatric   dentists, and otolaryngologists. Prompt referral to one of these specialists   is recommended. 

 Bleeding around the gingiva is common after traumatic luxation injury to the   teeth (Figure 4). Often, the teeth will be slightly mobile as a result of the   trauma. Gingival tissue may also be lacerated adjacent to traumatized tooth.   Perform an examination to determine the extent of the laceration and whether   foreign objects are present. 

A child who falls while holding an object in his mouthmost commonly, a stick, pencil or pen, straw, or toothbrushoften suffers an impalement injury of the oropharynx. Most impalement injuries heal spontaneously, but the wound should be explored for possible foreign bodies, and you should determine whether a prophylactic antibiotic should be prescribed to avoid infectious complications. In some cases of impalementbecause of the type of object that caused the injury or the extent of traumathe injury can be serious and may require additional diagnostic proceduressurgical exploration, examination by a otolaryngologist, additional radiographsto determine the extent of damage.

Proper management of trauma to the primary teeth themselves is important for a number of reasons:

  Traumatized teeth often lose their vitality over time and may become   discolored or abscessed, or both. (Parents must be made aware of the symptoms   associated with an abscessed tooth so that they can seek timely treatment for   their child.) 

  Some types of traumatic injury to primary teeth result in damage to   permanent teeth. 

  Dental trauma that causes movement of teeth may interfere with the   way a child's teeth fit togethercausing pain during chewing that is not   be relieved until the tooth is repositioned or extracted. 

In any traumatic injury, it is important to determine the cause of the injury (to rule out child abuse) and the full extent of the injury (to rule out fracture of the skull or jaws). Following are specific types of traumatic injuries that can affect primary teeth.

 describes a tooth that is mobile after trauma but has not been displaced. There may be bleeding around the gums.

 involves displacement of the tooth in a labial, lingual. or lateral direction. Soft tissue injury, including damage to the periodontal ligament, and contusion or fracture of the supporting alveolar bone often accompany this trauma.

 of a primary tooth describes displacement of the tooth into   the socket (Figure 5); the tooth may be partially or completely intruded. In   some cases, the tip of the root visibly pokes through the gingival tissue. This   type of injury causes compression of the periodontal ligament and may result   in a fracture of the socket. 

 of a tooth occurs when the tooth is completely displaced out of the socket.

 is the term often applied when a tooth is only partially avulsed.

(Figure 6) is classified based on the location of   the fracture in relation to various dental tissues. A fracture of the crown   of the tooth may be limited to enamel or dentin or may involve exposure of pulp   tissue. 

 involves tissues of the crown and root. A vertical fracture of a tooth that exposes dentin on the crown but that extends below the gum line, for example, would be classified as a crown-root fracture.

is classified based on the level of the fracture in   relation to the apex of the root. Such a fracture may occur in the apical third,   middle third, or cervical third of the tooth. The prognosis for a tooth becomes   worse the farther cervically the fracture. Often, the crown of the tooth is   intact. The diagnosis of root fracture can only be made radiographically (Figure   7). 

 Jaw fracture (Figure 8, left) is an occasional consequence of trauma in young   children, and must be ruled out in every child who has sustained an oral injury.   The most common locations for trauma to the mandible are in the anterior symphysis   and the condylar head. Evidence of a blow to the chin is an important indicator   of the risk of a mandibular fracture. Suspect a fracture in the anterior mandible   if examination of the lower teeth reveals a step-up or step-down between the   lower central incisors. Proper diagnosis of this type of fracture requires a   mandibular occlusal or panoramic radiograph, which shows a bilateral "step up"   of the anterior segment of the mandible (Figure 8, right), and which most pediatricians   and EDs lack the equipment to perform. When this type of fracture is suspected,   the child should be referred to a dentist to confirm the diagnosis. Suspect   condylar fracture when a child has limited occlusal opening, difficulty biting   teeth together properly, facial asymmetry, or paresthesia; refer him to a dentist   for confirmation, which requires a panoramic radiograph with closed- and open-mouth   views. 

Management of oral trauma proceeds stepwise. The evaluation starts with observation and gathering of information.

 Traumatic injury of the face or mouth of a child runs the gamut from relatively mild to very severe. It is important to gauge severity first to determine if emergency medical procedures should be institutedthat is, the customary ABCs of establishing a patent 

reathing, and determining the condition of the 

irculatory system. If the injury has not created a medical emergency, proceed with taking the medical history and evaluating the details of the trauma.

 This step takes on particular importance when the patient is not one of record in your practice, as might happen in what the parents perceive is an emergency. Assess the presence of any cardiac disease that necessitates antibiotic prophylaxis against bacterial endocarditis. Determine whether the child has a bleeding disorder or is immunocompromised. Question the parent about medication allergies. Record any current medications. Last, it is importantwith all orofacial traumato determine whether the child's tetanus immunization is up to date.

What is the history of the presenting trauma?

 Thorough description of the dental injury must be obtained from the parent and, when possible, the child. This should be well documented. Many offices have a special form to document traumatic injury that facilitates the examination process. Information to be gathered includes: 

What treatment, if any, has already been given? 

If one or more teeth were avulsed, does the parent have possession of the     tooth? (If not, consider the possibility of aspiration; parents should then     be asked if the child has been coughing since the injury occurred.) 

Last, determine whether the injury is consistent with the parent's description, to rule out child abuse.

 The entire body should be examined to rule out other injuries. Examine the head and neck to include:

 palpation of the facial skeleton, including the mandible, zygoma, temporomandibular     joint, and mastoid region 

recording of any extraoral lacerations, bruises, and swelling 

notation of excursive mandibular movements 

Articles

Evaluate and treat a toddler&s injured loose tooth or lacerated gum in your practice? Or refer these cases to a dental specialist? It all depends?on the injury, the child, and you.

Arthur J Nowak

Articles

Trauma to primary teeth: Setting a steady management course for the office