Dental injuries A self-guided overview - PowerPoint Presentation

1. Dental injuriesA self-guided overviewCharlotte Lewis, MD, MPHUW Division of General Pediatrics

2. GoalsProvide an approach to trauma affecting the teeth and other oral structuresUnderstand common injuries of the teeth and surrounding structures and their initial managementUnderstand optimal dental referral timingNot urgent: This can wait a few days to be seenSemi urgent: This should be seen within a day Urgent: This should be seen right away, as soon as possible

3. Remember: The loss of a permanent tooth is a BIG deal! There are significant functional and cosmetic implications to tooth loss.A dental implant can cost thousands of dollars.Prevent injuries when possible.Optimize care when dental injuries occur.

4. Dental injury epidemiologyInjuries to the dentition are very common during childhood.In early childhood, boys and girls sustain dental injuries in equal proportions, most commonly in a fall. It is estimated that about 30% of preschoolers suffer dental injury. Teens injure their teeth more often playing sports or when involved in fights or motor vehicle crashes.Adolescent males are at least twice as likely as adolescent girls to incur dental injuries. 

5. Dental injuries are common in childhood due toFallsSportsFightsMVAs

6. Take home messages (we’ll go over these again at the end) Prioritize permanent teethDings and dents can lead to dental death

7. Primary vs permanent teethInjuries to primary and permanent dentition are often treated differently. When permanent teeth are injured, the goal is maintaining tooth viability and preventing complications.In contrast, when a primary tooth is injured, the goal is protecting the developing permanent teeth. Because of this, injured primary teeth may be extracted instead of restored, and avulsed primary teeth should not be replaced in the socket. Children’s permanent teeth are more likely, relative to those of adults, to survive following an injury. Yet, even when optimal dental treatment is provided for an injured permanent tooth, the tooth still may not survive, ultimately necessitating a root canal. 

8. Anatomy of a ToothEnamel is the hard outer coating of the tooth crownDentine (also spelled dentin) contains tubules for nutrient transferPulp contains the nerves and blood supplyPeriodontal ligament between the tooth and gum, secures the tooth to the surrounding bone

9. Approach to dental and oral injuries

10. Trauma careWhen a child is injured, the airway and cervical spine should be the first things that are assessed and managed. After clinical stabilization, the mouth, teeth, face and oropharynx can be examined

11. Dental injury - historyTAKE HISTORYWhen? Where? How?Relevant past medical historyASSESS TETANUS STATUSConsider tetanus prophylaxis for intrusion, avulsion, deep laceration or contaminated woundASSESS SYMPTOMSpain, hot-cold sensitivity, change in occlusion, difficulty opening mouth

12. Dental injury:  symptomsPAIN: constant pain in a tooth may mean that the tooth’s pulp is affecteddiscomfort with air movement or changes in temperature or touch to the affected tooth suggests the dentine is affectedpain with pressure on the tooth may indicate that the periodontal ligament is damaged or displaced young children may not localize pain very wellif the nerve supply to a tooth is destroyed, there may be little or no painOCCLUSION: change in occlusion (a person’s bite feels “off”) or difficulty with mouth opening could reflect a possible mandible fracture 

13. Dental injury - physical examTRIAGEAirway C-spineOther life-threatening injuriesNeurologic exam (particularly cranial nerves)EXAMINE MOUTHIrrigate with normal saline to remove blood, clots, and debris as neededSoft tissuesTeeth Contiguous / surrounding bony structures

14. Examination of the mouth: soft tissues.  These findings suggest additional evaluation is indicatedLOOK AT: :LipsTongue, frenaBuccal mucosa PalateCHECK FOR:TendernessSwellingLacerationsEmbedded tooth fragments, debris

15. Examination of the mouth: teeth and surrounding structures. Pay attention to the following as they mean additional evaluation is needed:TendernessLoose, fractured, displaced or missing teethA “red dot” on the fractured edge of a tooth means the pulp is exposedAlveolar ridge tenderness, deformityStep-offsMalocclusionPain, limitation and/or deviation on mouth opening

16. Dental injuries can be divided into 2 groupsPeriodontal injuries: result from blows to a tooth or teeth that damage the surrounding tissues and in the process may compromise the neurovascular supply to a tooth.These are more common in children than fractures. Fractures: the tooth itself or surrounding bone may be fractured.

17. Periodontal injuries

18. Injuries to the periodontal tissues. Blows to the teeth injure the surrounding soft tissue and threaten viability of teeth. From least to most severe:concussionsubluxationintrusionluxationavulsion

19. Injuries resulting from a blow to or fall onto a toothCONCUSSIONtooth is not mobile or displaced, but tender to biting pressureSUBLUXATION tooth is loose, but not displaced from socket

20. Concussions and subluxations Non urgent dental referralAnalgesicsSoft dietTIP: if child says that the bite feels off or different, the injury may be more involved and urgent attention is needed.

21. INTRUSIONTooth is driven up into socket

22. Intrusion—tooth is driven into socketSemi urgent referralMay allow primary teeth to re-eruptIntrusion of a permanent tooth may require orthodontic-assisted management to reposition tooth (see picture)Causes compression of periodontal ligament and fracture of alveolar socketMonitor for complications, which are common with intrusion injuries Tooth death / root resorption /infectionAnkylosis (tooth becomes stuck)

23. Intrusion of primary tooth may result in damage to developing permanent toothhypoplastic enamel of permanent toothintruded primary toothdeveloping permanent tooth bud

24. This primary tooth was intruded by an injury and re-erupted over one year

25. LUXATION  Tooth is loose and displaced from the socketLuxation injuries usually result in damage to the periodontal ligament, threatening the future viability of the tooth.AVULSIONTooth is completely out.Management depends on whether the tooth is  primary or permanent

26. Luxations—tooth is loose and displacedUrgent referralDentist may extract luxated primary toothPermanent tooth requires repositioning and splintingTIP: Have child bite on wet washcloth while headed to dentist. This pushes tooth back into position

27. AVULSION: tooth is completely out of socketAvulsion of primary toothReferral is not urgentDO NOT REPLACE BABY TEETHTooth fairy will visit

28. Avulsion of permanent toothUrgent referralImmediate post injury management is critical.  DO REPLACE AVULSED PERMANENT TEETHRinse off any debris gently in waterDo not scrub - may damage periodontal ligament Handle the tooth only by the crown, and do not touch the root to avoid damaging the periodontal ligament fibers. Reimplant immediately if possible, using gentle pressureMake sure tooth is correctly oriented (facing the right way)Reimplantation within 5 minutes associated with >90% chance of tooth survival Have child bite on wet washcloth to hold replaced tooth in place while on the way to the dentist or ERDentist may splint into place

29. If you cannot immediately reimplant a permanent tooth, you can still save that tooth!Commercially available products for transport of toothYou can transport the tooth in milk or saline (eg, contact lens solution)Do not transport tooth in water

30. Summary of referral timing for periodontal injuriesConcussion: Not urgent Subluxation: Not urgent Intrusion: Semi urgent Luxation: UrgentAvulsion: First ask, is it primary or permanent tooth?Permanent tooth: Urgent (replace immediately if possible and then seek urgent dental care)Primary tooth: Not urgent (do not replace)

31. FracturesOf teeth and/or surrounding bones

32. Tooth fracturesThe tooth crown may be fractured, which will be visible. Ellis classification:Ellis I: transects the enamelEllis II: transects the dentineEllis III: transects the pulpThe tooth root may be fractured, which will not be visible.Ellis Class IEllis Class IIEllis Class IIIRoot fracturePDL=Periodontal ligament

33. This spot of blood indicates that the fracture transects the pulp (ELLIS III)This fracture transects the dentine, which is yellow (ELLIS II)This teenage boy was hit in the mouth with a golf club. OUCH!! The dentist took this picture after he had placed a dental dam (blue) and spacers prior to starting the restoration.

34. Ellis I fracture transects the enamelNon urgent. Can wait a few days to be seen.A dentist can rebond tooth chip if available or file down sharp edges to prevent soft tissue injuries from sharp edges.A dentist may apply a composite to repair tooth.Dental follow up is important because, in the long run, any dental injury can lead to a risk for the tooth dying or developing infection.

35. Ellis II fracture transects the dentineUrgent treatment is not requiredSemi-urgent: be seen within 1 day Ideally, within 12 hours if possibleThis will be uncomfortable and worse with hot/cold exposure so the sooner the exposed dentine is covered the better. Treated by dentists using dentine adhesives and resin-based composites. Possible complications include pulp infection or necrosis

36. Ellis III fracture transects the pulpPain can be significantMay occur in conjunction with other serious injuriesRisk of infection with exposed pulpDental treatment for Ellis Class III fractures includes pulpal capping and/or root canalUrgent referral—patient should be seen right awayOr as soon as other injuries are stab

37. Root fractureDiagnosed radiographically and/or clinicallySuggested by bleeding from gum around toothIf fracture near gum, tooth may be very mobile. Worse prognosis for tooth survival.If fracture near apex (root tip), tooth may not be mobile. This has a better prognosis because less likely to disrupt neurovascular supplyTreated with reduction and splinting Complications: root resorption, pulpal necrosisUrgent referral

38. Radiograph of Root FractureNotice the bleeding at the gingival margin and the tooth displacement.Without an Xray, it would be hard to differentiate a root fracture like this from a luxated tooth. It is OK to push the tooth back into place and have child bite on wet washcloth while on the way to dentist.

39. Alveolar bone fractureMay be associated with gingival lacerationPalpate the alveolar ridge for step-offsSegmental alveolar fractures – segments of jaw move when checking tooth mobilityDiagnosed with radiographsUrgent referral To ED for OMFS or other surgical consultationReduction is easier before swelling occurs

40. Mandibular condyle fractureMay result from blow to the chin/fall onto chinLaceration to chin should raise concernC-spine injuries may occur simultaneouslyPosterior teeth may be fracturedFractured posterior teeth should raise concern for condyle fracture and C-spine injuryOther signs and symptomsPre-auricular swellingPain or limited ability to open mouth Deviation of mandible upon openingNew anterior open bite or other malocclusionUrgent referral To ED for OMFS or other surgical consultation

41. Mandibular condyle fracture (arrow shows fracture and left mandibular head displacement)

42. Summary of referral timing for fracturesDental Crown Fractures:Ellis I: Not urgent (be seen within a few days)Ellis II: Semi urgent (be seen within 12-24 hours)Ellis III: Urgent (be seen right away)Root fracture: UrgentAlveolar bone fracture: UrgentMandibular fracture: UrgentFacial fracture: UrgentThese usually require specialized surgical management for example by oral surgeon

43. Indications for hospital admission due to traumaMandibular fractures (unless simple and non-displaced)Middle third facial fractures (Le Fort II)Zygomatic fractures where there is risk of ocular damage

44. Dental referralDental injuries often initially present to the primary care or emergency medicine provider.Ideally, all dental injuries need professional dental evaluation to determine the extent of injury, clinically and with radiographs, and to implement appropriate treatment and follow up. However, certain dental injuries require urgent evaluation and management; these include Ellis Class III fracturesRoot fracturesPermanent tooth avulsions and luxations. Alveolar and mandibular fractures and more complex facial fractures also require urgent consultation with an oral surgeon, otolaryngologist, or plastic surgeon. 

45. Take home messagesPrioritize permanent teeth When primary teeth are injured, extraction may be the best optionGoal is to avoid damaging developing permanent dentitionFor example, an avulsed primary tooth SHOULD NOT BE REPLACED because underlying permanent tooth could be compromised in the process of replacing the primary tooth.However, an avulsed permanent tooth is a dental emergency. An avulsed permanent tooth SHOULD BE REPLACED WITHIN 5 MINUTES IF AT ALL POSSIBLE.Dings and dents can lead to dental deathEven subtle injuries may lead to irreversible damage to the tooth, causing the tooth to die Injuries may allow entrance of bacteria into pulpMonitor all injuries for longer term complications: tooth dies or becomes infected

46. Thank YouAdditional Reading:Keels MA; Section on Oral Health, American Academy of Pediatrics. Management of dental trauma in a primary care setting. Pediatrics 2014;133(2):e466-76.