Oral Injury

8/16/2019 Oral Injury

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1 www.aap.org/oralhealth/pact

Protecting All Children’s Teeth

Oral Injury


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2www.aap.org/oralhealth/pact

Introduction

Dental injuries are very common, and up to 30% of children injure their primaryteeth. These injuries occur most often during the toddler years when children areactive, but unsteady on their feet.

These injuries become common again in the midelementary school years !ages "to #0$ as children join sports teams and become more independently activeoutdoors !eg, bicycles, playgrounds, trampolines$.

n adolescence, motorvehicle accidents and assault become increasinglyimportant in the epidemiology of dental injury.

&verall, tooth injury is more common in males !greater than a '(# ratio$, and

almost half of all children will incur some type of tooth damage by the time theyreach adolescence.

)sed with permission from *ontent +isionary


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3

Learner Objectives

)pon completion of this presentation, participants will be able to(

Describe the incidence and epidemiology of dental injury in the)nited tates.

&utline a proper e-amination following an oral injury.

ist and describe the categories of tooth injury, their basicmanagement, and possible seuelae.

Discuss in detail the proper management of an avulsed tooth.

1rovide appropriate anticipatory guidance for oral injury prevention. *ompare and contrast the 3 basic types of mouth guards and

summari2e the 1D recommendations on mouth guard use inathletics.



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Patterns and Risk Factors

The most common injury site is the ma-illary !upper$ centralincisors,

which account for more than 40% of all dental injuries.

&ral injuries typically result from falls !most common$, bi5e andcar accidents, sportsrelated injuries, and violence.

The mouth is also a common site for nonaccidental trauma, andchild abuse should always be considered in a child presentingwith oral trauma.


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Patterns and Risk Factors

1ediatricians should be aware of the following ris5 factors fororal trauma(

*hildren with compromised protective re6e-es or poorcoordination 8yperactivity ubstance abuse !by the adolescent or within the family$

*hild abuse or neglect 9alocclusion with protruding front teeth :ailure to use protective face and mouth gear


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7/507 www.aap.org/oralhealth/pact

Ea!ination Follo"ing Oral Injury#

continued

#. rrigate to remove blood and debris and to improve visuali2ation.

'. >-amine soft tissues for edema, tenderness, and lacerations.

3. >-amine bony structures for pain or malocclusion.

@. ssess patient-amine the tooth ridge for AstepoBsC, which can indicate a

fracture of the underlying alveolar bone.. >-amine the teeth for tenderness and mobility.

. ccount for all teeth and determine if injury has occurred to the

primary or permanent dentition.



$issing Teeth

9issing teeth should be accounted for.

Do not assume that missing teeth were lost at the scene of theaccident because they may be imbedded in soft tissues, intruded

into the alveolar bone or sinus cavity, aspirated, or swallowed.

?adiographs !soft tissue and chest Erays$ should be done to

loo5

for missing teeth.



%ental Trau!a

t is important that clinicians be familiar

with the diBerent types of dental trauma

and be able to appropriately triageinjured patients.

Dental followup is necessary for all

tooth trauma because even seemingly

minor injuries can result in tooth death.

n general, management of primary

tooth injury is dictated by concern for

the safety of the permanent dentition.

)sed with permission from ?ocio ;. Fuinone2, D9D, 9, 918G ssociate1rofessor Department of 1ediatric Dentistry, chool of Dentistry



Ty&es o' Tooth Injury

Tooth injury can be divided into main categories(

#. *oncussion

'. ublu-ation

3. ateral u-ation

@. ntrusion

4. >-trusion. vulsion

. :racture )sed with permission from 9artha nn Heels, DD, 1hDG Division 8ead of Du5e 1ediatricDentistry,

Du5e *hildrenIs 8ospital


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Concussion

*oncussion involves injury to supporting structures ofthe

tooth, without loosening or displacement.

Tooth is tender to percussion.

?ecommended Treatment(

tic5 to a soft diet for ' wee5s.

9onitor for changes in tooth color.

?efer to dentist for nonurgent evaluation.


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Lateral Luation

ateral lu-ation involves injury to the

tooth and its supporting structures,

resulting in tooth displacement. The

injured tooth is at ris5 for pulpal necrosis

and root resorption.

This type of injury reuires prompt referral

to a dentist for repositioning of the injured tooth/teeth.

>ven primary teeth should be e-amined by a dentist, because the

)nderlying permanent tooth may be injured.

)sed with permission from 9artha nn Heels, DD, 1hDG Division 8ead ofDu5e 1ediatric Dentistry, Du5e *hildrenIs 8ospital


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Intrusion

Jith intrusion injuries, the tooth is

pushed into the soc5et and thealveolarbone. t may appear shortened orbarely visible.

ntrusion has a poor prognosis and

high ris5 for complications,including

root resorption, pulp necrosis, and

infection. 9ay reuire a root canal.ntrusion injuries may also damage underlying permanent dentiespecially if an infection develops.

)sed with permission from 9artha nn Heels, DD, 1hDG Division8ead of Du5e 1ediatric Dentistry, Du5e *hildrenIs 8ospital


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Intrusion# continued

Jith intrusion injuries, teeth may reerupt. f a primary tooth does

K&T reerupt, it will reuire e-traction to not interfere with

permanent tooth eruption.


Do not attempt to remove intruded tooth. nstead, focus on pain

control and consider antibiotic prophyla-is.

:or a primary tooth, see5 dental evaluation within # wee5 !orearlier, for signi=cant symptoms$.

:or a permanent tooth, refer to a dentist immediately for

repositioning and splinting.


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Etrusion

Jith an e-trusion injury, the tooth

is partially displaced from its soc5et.

This type of injury reuires

repositioning and stabili2ation.

?efer to a dentist promptly to

evaluate the e-tent of injury, as well

as any associated injury !e.g.

fracture$. )sed with permission from ?ama &s5ouian


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Avulsion

Jith this type of injury, the

tooth

is completely out of the soc5et.

9anagement of avulsion

injuriesdepends on the tooth type.

)sed with permission from ?ama &s5ouian


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Avulsion o' a Pri!ary Tooth

Do K&T reimplant a primary tooth, as this may

damage the underlying permanent tooth.

nstead, refer to a dentist within '@ hours.


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Avulsion o' a Per!anent Tooth

This is a dental emergencyL

vulsion should be managed as follows(

#. Gently rinse oB debris with saline or mil5. 8old tooth by crown only.

'. void touching the root. Do not clean or rub it. t is important to

preserve the periodontal ligament for tooth survival.

3. ?eimplant an avulsed permanent tooth immediately, ensuring

correct orientation. The tooth should be reimplanted within '0

minutes, but the best outcome is with teeth replaced within 4 minutes.

@. nstruct patient to bite on gau2e or a hand5erchief or to hold the

tooth in place.


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Avulsion o' a Per!anent Tooth#

continued

4. end to a dentist or ma-illofacial surgeon immediately for

radiographs, splinting, and antibiotic prophyla-is.

. f the tooth cannot be reimplanted on scene, transport it !orderedby preference$ in( a tooth storage solution, warm mil5, saline, or

saliva.

. tooth should not be transported dry or in plain water, as this

signi=cantly decreases the chance of ligament survival.

". Kever suggest a child hold the damaged tooth in his or her mouth because of the ris5 of aspiration or bacterial contamination.


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Fracture

There are 4 basic types of tooth fracture(

#. In'raction( incomplete fracture !crac5$ of the enamelwithout loss of tooth structure.

'. )nco!&licated Cro"n 'racture( an enamel fracture oran enameldentin fracture that does not involve the pulp.

3. Co!&licated Cro"n 'racture( an enameldentinfracture with pulp e-posure.

@. Cro"n*root 'racture( an enamel, dentin, and cementumfracture with or without pulp e-posure.

4. Root Fracture( a dentin and cementum fractureinvolving the pulp


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)nco!&licated Cro"n Fracture

This type of fracture is a crac5 of the enamel ordentin that does not involve the pulp. t may havea sharp edge.


M nspect injured lips, tongue, and gingiva to ruleout presence of tooth fragments.

M 1rovide a soft diet, avoiding temperaturee-tremes.

M f a permanent tooth is injured, refer to a dentistfor evaluation 1 !within #' to '@ hours$.

M ?ecommend longterm followup to evaluate forcomplications, which are uncommon.

)sed with permission from:a. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric

Dentistry, Schoo of Dentistry

b. 9artha nn Heels, DD, 1hDG Division 8ead of Du5e 1ediatric Dentistry,Du5e *hildrenIs 8ospital


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Co!&licated Cro"n Fracture

*omplicated crown fracture is an enameldentin fracture with pulp e-posure.

ite of a complicated crown fracture hasa reddish tinge or will bleed.

This type of fracture can cause e-tremepain and may lead to pulpal necrosis, root

resorption, or infection in e-posed pulp.

?efer to dentist as soon as possible!within #' to '@ hours$ for evaluation.

)sed with permission from(a. ?ebecca latyton DD, 1hD

!. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department

of Pediatric Dentistry, Schoo of Dentistry


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Cro"n*Root Fracture

>namel, dentin, and cementum fracture with or without pulpe-posure.

i5ely complications include root resorption and pulpnecrosis.

?efer to dentist as soon as possible !within #' to '@ hours$for evaluation, where diagnosis will be made via radiograph.

Treatment consists of reduction and splinting or e-traction.


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Root Fracture

>-cessive mobility of the tooth may indicate a

root fracture. This type of fracture includes

pulp e-posure. 1otential complications for aroot fracture include resorption and pulp necrosis.

?efer to a dentist 1 !within #''@ hours$ forevaluation, where diagnosis is made radiographically.

Treatment consists of reduction and splinting for

permanent teeth or e-traction, depending on the e-tent of the

traumatic lesion.

)sed with permission from 9artha nn Heels,DD, 1hDG Division 8ead of Du5e 1ediatric

Dentistry, Du5e *hildrenIs 8ospital


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Co!&lications and Conse+uences o'

Tooth Injury

There are many possible conseuences of an oral injury(

1ain, which can be severe. nfection, including abscess. n5ylosis. n6ammatory root resorption. esthetic conseuences. Kegative impact on selfesteem. mpaired oral or phonetic function. 8igh cost.

:or these reasons, prevention of tooth injury is paramount.


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Prevention

1revention is the most eBective intervention.

1rimary care clinicians are in a uniue positionto help families prevent accidental trauma,including oral trauma, by providing

anticipatory guidance at routine visits.


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Accident Prevention

uggestions for accident prevention speci=cally related to oral

trauma(

#. dvise parents about possible injury to developing permanent teeth from trauma if a primary tooth is injured.

'. ?eview and anticipate developmental milestones.

3. *ounsel about the ris5s of wal5ers and trampolines.

@. Discuss childproo=ng the home.

4. ?eview safety measures for outdoor activities and sports.

. tress the importance of adeuate supervision at all times,

especially on furniture, stairs, at the playground, and at athletic

events or practices.


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(&orts and Protective ,ear

ports participation poses a signi=cant ris5 for trauma

The highest ris5 sports for oral trauma are baseball, soccer, football,bas5etball, and hoc5ey.

5ateboarding, rollerblading, and bicycling injuries are also common.


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(&orts and Protective ,ear#

continued

8elmet and face mas5s should be properly =tted and worn

during all games and practices for the sports in which theyare

recommended.

tatistically, children are more often injured in practice than

during a game, so all protective gear should be worn duringpractice as well.


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$outh ,uards

9outh guard use is mandatory for football, icehoc5ey, lacrosse, =eld hoc5ey, and bo-ing.

everal states have passed regulations mandating

mouth guards for soccer, bas5etball, andwrestling.


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Facts About $outh ,uard )se

#. 9outh guards help to protect the teeth and soft

tissues ofthe mouth from injury.

'. The better the =t, the more protection oBered.

3. 9outh guard use may reduce the ris5 or severity of a

concussion.


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Ty&es o' $outh ,uards

There are 3 types of mouth guards(

#. toc5.

'. 9outhformed, or Aboilandbite.C

3. *ustom =t.

)sed with permission from 9artha nn Heels, DD, 1hDG Division 8ead ofDu5e 1ediatric Dentistry, Du5e *hildrenIs 8ospital


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(tock $outh ,uards

These preformed, overthecounter, readyto

wear mouth guards are generally the leastcomfortable and, therefore, the least li5ely to beworn.

;ecause of poor =t, they also oBer the leastprotection and reuire constant biting down tostay in place.


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-oil and -ite $outh ,uards

9ade of thermoplastic material that conforms to theshape of

the teeth after being placed in hot water, these mouthguards

are commercially available and the most common typeused by

athletes.

They vary in =t, comfort, and protection.



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Custo! Fit $outh ,uards

This type of mouth guard must be made by a dentist for theindividual.

t is the most e-pensive, but also oBers the most protection and

comfort.

*ustom mouth guards are preferred by dentists and usually preferred

by athletes because of their increased comfort, wearability, and

retention, as well as ease of spea5ing when worn.

This type of mouth guard is particularly important for adolescents

with orthodontic appliances.


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Reco!!endations 'or $outh ,uards

The merican cademy of 1ediatric Dentistry!1D$ recommends properly =tted mouth

guards for all children participating in organi2edand unorgani2ed contact and collision sports.

The 1D supports mandated for use of athletic

mouthguards in any sporting activity containinga ris5 of orofacial injury.


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.uestion /0

1hich teeth are !ost co!!only a2ected by oralinjury3

. *entral ma-illary incisors

;. *entral mandibular incisors

*. *anines

D. 9olars

>. There is no common pattern to oral injuries


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Ans"er

1hich teeth are !ost co!!only a2ected by oralinjury3

. *entral ma-illary incisors

;. *entral mandibular incisors

*. *anines

D. 9olars

>. There is no common pattern to oral injuries


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.uestion /4

1hich o' the 'ollo"ing is not a risk 'actor 'or oraltrau!a3

. 9alocclusion

;. *hild abuse or neglect

*. >arly childhood caries

D. 8yperactivity

>. ubstance abuse within the family


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Ans"er

1hich o' the 'ollo"ing is not a risk 'actor 'or oraltrau!a3

. 9alocclusion

;. *hild abuse or neglect

*. >arly childhood caries

D. 8yperactivity

>. ubstance abuse within the family


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.uestion /5

1hich o' the 'ollo"ing is !ost likely 'ollo"ing intrusiono' a

&ri!ary toothN

. ?oot resorption

;. ?eeruption of the primary tooth

*. 1ulpal necrosis with possible root infection

D. :racture of the underlying permanent tooth>. Damage to the underlying tooth and failure of permanenttooth to

erupt


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Ans"er

1hich o' the 'ollo"ing is !ost likely 'ollo"ing intrusiono' a

&ri!ary toothN

. ?oot resorption

;. ?eeruption of the primary tooth

*. 1ulpal necrosis with possible root infection

D. :racture of the underlying permanent tooth>. Damage to the underlying tooth and failure of permanenttooth to

erupt


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.uestion /6

1hich o' the 'ollo"ing is the &ro&er !anage!ent o' anavulsed &ri!ary tooth3

. The tooth should not be reinserted

;. The tooth should be transported in mil5 and the child rushed to a

dentist or >? for reinsertion

*. The tooth should be transported in water and the child rushed toa

dentist or >? for reinsertion

D. t should be reinserted immediately

>. Kone of the above


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.uestion /6

1hich o' the 'ollo"ing is the &ro&er !anage!ent o' an avulsed

&ri!ary tooth3

. The tooth should not be reinserted

;. The tooth should be transported in mil5 and the child rushed to adentist

or >? for reinsertion

*. The tooth should be transported in water and the child rushed to a

dentistor >? for reinsertion

D. t should be reinserted immediately

>. Kone of the above


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.uestion /7

1hich o' the 'ollo"ing is a conse+uence o' oralinjury3

. 8igh cost

;. mpaired oral or phonetic function

*. 1ain

D. nfection, including abscess

>. ll of the above


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Ans"er

1hich o' the 'ollo"ing is a conse+uence o' oralinjury3

. 8igh cost

;. mpaired oral or phonetic function

*. 1ain

D. nfection, including abscess

>. ll of the above


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Re'erences

#. merican cademy of 1ediatric Dentistry. Decision Tree for an vulsed Tooth. ?esource ection, pg '3. vailable online at(http(//www.aapd.org/media/policiesOguidelines/ rsOtrauma6owsheet.pdf.

ccessed 9ay '4, '0#'.'. merican cademy of 1ediatric Dentistry. 1revention of ports?elatednjuries. #PPP. pg. 3". vailable online at(http(//www.aapd.org/pdf/sports.pdf. ccessed Qanuary #4, '00.

3. merican cademy of 1ediatric Dentistry *ouncil on *linical Bairs.Ruideline on 9anagement of cute Dental traumaG ?eference 9anualGrevised '00@( #34#@0. vailable online at(

http(//www.aapd.org/media/1oliciesORuidelines/ROTrauma.pdf. ccessed Qanuary #4, '00.

@. merican cademy of 1ediatric Dentistry *ouncil on *linical Bairs1olicy on 1revention of portsrelated &rofacial njuries. revised '00, pg(@"40. vailable online at(http(//www.aapd.org/media/policiesOguidelines/pOsports.pdf. ccessed Qanuary #4, '00.


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Re'erences# continued

4. merican cademy of 1ediatrics( njuries ssociated Jith nfantJal5ers. *ommittee on njury and 1oison 1revention. Pediatrics. '00#G#0"!3$( P0P'. vailable online at(

http(//pediatrics.aappublications.org/cgi/content/full/#0"/3/P0.ccessed Qanuary #4, '00.

. merican cademy of 1ediatrics( Trampolines at 8ome, chool, and?ecreational *enters. *ommittee on njury and 1oison 1revention and*ommittee on ports 9edicine and :itness. Pediatrics. #PPPG #03!4$(#043#04. vailable online at( http(//pediatrics.aappublications.org/cgi/content/full/#03/4/#043. ccessed Qanuary #4, '00.

. *ohen , ;urns ?*. 1athways of the 1ulp. >ighth edition.

". *onference on ports njuries in South. ;ethesda, 9D( Kationalnstitutes of 8ealthG #PP'. K8 1ublication Ko P33@@@.

P. 8ergenroeder *. 1revention of ports njuries. Pediatrics. #PP"G#0#!$( #04#03.


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Re'erences# continued

#0. 8su , Rroleau R. Tetanus in the >mergency Department( *urrent?eview. Journal of Emergency Medicine. '00#G '0!@$(344.##. Kewsome 1?, Tran D*, *oo5e 9. The role of the mouthguard in the

prevention of sportsrelated dental injuries( a review. Int J Paediatr Dent .'00#G ##!$(3P@0@.

#'. 1rotecting Teeth with 9outh guards. 1atient nformation 1amphlet. JADA. '00G +ol. #3( #'. vailable online at(http(//www.ada.org/prof/resources/pubs/jada/patient/patientOP.pdf.ccessed Qanuary #4, '00.

#3. The ociety of Teachers of :amily 9edicine Rroup on &ral 8ealth.miles for life( national oral health curriculum for family medicine.'00. www/smilesforlifeoralhealth.org. ccessed Qune @, '0#'.#@. ) Department of 8ealth and 8uman ervices. &ral health inmerica( ?eport of the urgeon Reneral. ?oc5ville 9D( ) Departmentof 8ealth and 8uman ervices, Kational nstitute of Dental and*raniofacial ?esearch, Kational nstitutes of 8ealthG '000. vailableonline at( http(//www.nidcr.nih.gov/ Datatatistics/urgeonReneral.

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Oral Injury