PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: DENTAL TRAUMA

Epidemiology 30% of preschoolers suffer dental injury At this age there is no difference between boys and girls. 23% males age 6-20 years and 13% females suffer dental injuries Prevalence and incidence peak at 2-4 years and 8-10 years The way the tooth is injured is related to the activity level at each age. Patients with chronic conditions and mobility problems Altercations Abuse Most commonly injured teeth Maxillary central incisors Protruding teeth History: important information to get regarding the injury Incidents surrounding injury Any other injuries How long ago the injury occurred Last time the patient ate Physical Examination Extraoral Inspection Asymmetry Nasal or orbital malalignments Lacerations, hematomas, foreign bodies Open and close mouth to evaluate for deviation during function Lip competency Palpation TemporoMandibular joint Equal movements Orbital rim intact Nose for crepitus Note parasthesias or numbness Intraoral Inspection Color and quality of gums and mucosa Note hematomas Examine teeth Color, chips, cracks, bleeding, absent Palpation Tongue Mobility of teeth Tooth percussion Imaging
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PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: DENTAL TRAUMA

Moderate and severe dental trauma 4 views: maxillary anterior and 3 periapical Facial Series Panorex (mandible)

Principles of Management by Type of Injury Crown Fractures Ellis Class I Minor fracture of the tooth enamel Rarely painful Does not require immediate treatment Rough edges may need filing Ellis Class II Enamel and dentin involvement Entry of bacteria into tooth Can see yellow or pink color of dentin Exposed dentin needs to be covered Apply calcium hydroxide paste Subsequent composite repair Antibiotics Prolonged exposure Dirty wound Ellis Class III A true dental emergency Dental pulp is exposed Red tinge or bleeding Extremely painful Exposed pulp will become infected More likely if exposed > 6 hours Primary tooth May need to extract to prevent further injury Permanent tooth Calcium hydroxide paste Root canal for prolonged exposure Antibiotics Root Fractures Crown luxation, pain, excessive mobility, malocclusion Confirm location with radiographs Primary tooth Extraction Permanent tooth Splint Length of splinting depends upon integrity of remaining root fragment Periodontal Structural Injuries Concussion Trauma to the supporting structures of the tooth Inflammation No displacement or mobility Tenderness to percussion No bleeding Management same for primary and permanent No acute intervention required Analgesia as needed Need dental follow up to monitor tooth vitality
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PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: DENTAL TRAUMA

Subluxation Mobility of the tooth without displacement Blood may be present in gingival sulcus Pain with percussion Primary Teeth Mobile teeth may need splinting Dental follow-up in 24 hours due to potential for pulp necrosis Soft diet Permanent Teeth Possible splinting Dental follow-up in 24 hours due to potential for pulp necrosis Soft diet Lateral Luxation Displacement of tooth laterally in socket Buccal, lingual, labial, or lateral Lingual displacement is most common Periodontal ligament is torn Usually accompanied by alveolar fracture Primary Teeth Often no intervention necessary Passive repositioning Gentle repositioning Splint or extraction Laterally displaced or extreme mobility Refer for dental follow-up Permanent Teeth Immediate dental referral Repositioning Splinting Intrusion Tooth is driven into socket Crown height is shortened Periodontal ligament is lacerated Bleeding usually present Root & alveolar fractures may occur Must determine if the tooth is truly intruded and not fractured Primary teeth Less than 50% intruded Will usually re-erupt in 3-4 weeks If 100% intruded May contact with underlying tooth bud Extraction Need dental follow up Monitor for potential damage to underlying tooth bud Dental emergency Urgent referral Monitor for injury to root structures & neuro-vascular supply Allow tooth to re-erupt Re-positioning and splinting Extrusion Tooth is vertically displaced out of bony socket Periodontal ligament is torn Primary Tooth Urgent dental referral Extract if very mobile or nearly avulsed
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PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: DENTAL TRAUMA

Permanent Tooth Immediate dental referral for re-positioning and splinting Avulsion Tooth is completely detached from the socket Periodontal ligament severed Possible alveolar fracture Need to find the tooth! Rule out aspiration/intrusion/fracture Determine primary vs. permanent Primary Teeth No replacement of tooth Children under 6 years of age Control bleeding Dental referral to evaluate potential injury to permanent tooth bud Permanent Teeth True Dental Emergency Time is essential Best outcome if < 30 minutes to re-implant Viability dependent upon vitality of root Goal is to avoid further damage to periodontal ligament cells Re-implant tooth immediately If delay in re-implantation, place it in transport media Hanks Balanced Salt Solution Fresh cold milk Saline Saliva (buccal vestibule) Water Minimize handling Do not scrub tooth Extra-oral time < 1 hr: Rinse off debris and re-implant Immediate splinting by dentist Extra-oral time > 1 hr: Soak in Hanks Balanced Salt Solution or dental fluoride solution for 20-30 minutes Re-implant Immediate splinting Disposition When to see the dentist immediately Ellis II or III Root Fracture Primary 100% intrusion Permanent tooth Luxation Intrusion Extrusion Avulsion When to see the dentist within 24 hours Ellis I Subluxation Primary Lateral luxation Intrusion Extrusion
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PEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: DENTAL TRAUMA

REFERENCES: 1. AAPD, Pediatric Dental Trauma Card Primary Teeth. Permanent Teeth; American Academy of pediatric Dentistry Chicago, 11 2002 P.2. 2. Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. Munksgaard and Mosby; 2000:9-154. 3. Andreasen JO, Raven JJ. Epidemiology of traumatic dental injuries in primary and permanent teeth in a danish population sample. Int JOral Surg 1972; 1:235. 4. 287-298. Flores MT. Traumatic injuries in the primary dentition. Dental Traumatol 2002:18; Avulsion

5. Hsu SS, Groleau G. Tetanus in the emergency department: a current review. J Emerg Med 2001;20:357-65. 6. Kaste LM, gift HC, Bhat M. Prevalence of incisor trauma in persons 6-50 years of age; United States, 1998-1991. J Dent res 1996: 75 Spec No: 696. 7. McTigue DJ. Introduction to dental trauma: Managing traumatic injuries in the primary dentition. Ped. Dentistry; 1999:213-224. 8. Tapias MA, Jimenez- Garcia R, Lamas F. Prevalence of traumatic crown fractures to permanent incisors in a childhood population: Mostoles, Spain. Dental Traumatol 2003:19:119-122. DISCLAIMER: This clinical guideline has been developed for the purpose of unifying the general emergency care of infants with bronchiolitis. It is intended to aid, rather than substitute for, professional judgment. It is not intended to serve as a rigid protocol or a written proxy for the standard of care. Failure to comply with this guideline does not represent a breach of the standard of care.

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