Guideline on Management of Acute Dental Trauma

Resident: Cho Author(s): AAPD Journal: Reference Manual Year. Volume (number). Page #’s: 2010-2011. V32. 202-212. Major topic: Dental TraumaType of Article: AAPD Guidelines Main Purpose: To define, describe appearances, and set forth objectives for general management of acute traumatic injuries. Methods: Electronic search was conducted using the following parameters: “teeth”, “trauma”, “permanent teeth”, “primary teeth”. Key points: - Greatest incidence of trauma to primary teeth occurs at 2-3 years when motor co-ordination is developing. - Greatest incidence of trauma to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports. - The AAPD encourages the use of protective gear, including mouthguards. - Dentists have ethical obligation to ensure emergency dental care is available. - History, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing nonabusive injuries from abuse. - Compromised airway, neurological manifestations such as altered orientation, hemorrhage, nausea/vomiting, or suspected loss of consciousness requires further evaluation by a physician. - Assessment includes a thorough medical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. - The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is incomplete. Recommendations: Infraction: incomplete fracture (crack) of the enamel without loss of tooth structure, complications are rare. Crown fracture (uncomplicated): fracture that does include the pulp, look for fragments of tooth in gingiva, lips, tongue, small fracture – smooth margins, larger fractures – restore tooth structure Crown fracture (complicated): fracture that includes pulp exposure, look for fragments of tooth in gingiva, lips, tongue, primary tooth – pulpotomy, pulpectomy, extraction, permanent tooth – direct pulp cap, partial pulpotomy, full pulpotomy, and pulpectomy. Crown/root fracture: enamel, dentin, and cementum fracture with or without pulp exposure, mobile coronal fragment attached to the gingiva, primary tooth – entire tooth should be removed unless retrieval of apical fragments may result in damage to succedaneous tooth, permanent tooth – remove coronal fragment, supragingival restoration or gingivectomy, osteotomy, or surgical or ortho extrusion to prepare for restoration, most fractured permanent teeth can be saved as long as fracture not too subgingival. Root fracture: Dentin and cementum fracture involving the pulp, mobile coronal fragment attached to the gingiva, multiple xrays taken at different angles may be necessary, primary tooth – extraction of coronal portion only, permanent tooth – reposition and stabilize coronal fragment. Concussion: injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth, watch tooth. Subluxation: injury to the tooth-supporting structures with abnormal loosening but without tooth displacement, primary tooth – watch for pathology, permanent tooth – stabilize tooth and relieve any occlusal interferences, splint for no more than 2 weeks. Lateral luxation: displacement of the tooth in a direction other than axially, tooth is displaced laterally with the crown usually in a palatal or lingual direction, widened PDL, displacement of apex toward or through the labial bone plate, primary tooth - allow passive or spontaneous repositioning if no occlusal interference, gentle repositioning if occlusal interference, extraction if tooth is nearing exfoliation, permanent tooth – reposition ASAP, splint 2-4 weeks may be needed. Intrusion: apical displacement of tooth into alveolar bone, if tooth appears shorter in xray than contra-lateral then apex is displaced labially, if tooth appears longer in xray than contra-lateral then apex is displaced palatally toward permanent tooth bud, primary tooth: allow spontaneous reeruption unless displaced toward permanent tooth bud, immature permanent tooth (½ to ¾ root formed): wait for reeruption, mature permanent tooth: actively reposition tooth with ortho or surgical extrusion, stabilize with splint for up to 4 weeks, initiate endo within first 3 weeks. Extrusion: partial displacement of the tooth axially from the socket (partial avulsion), widened PDL apically on xray, primary tooth – allow tooth to spontaneously reposition or reposition and allow for healing for minor extrusion of <3mm in immature developing tooth, extract for fully formed tooth, severe extrusion or mobility, child uncooperative, permanent tooth – reposition ASAP, stabilize with splint for up to 2 weeks. Avulsion: complete displacement out of socket, primary tooth – do not replant, permanent tooth – replant ASAP and flexible splint for 2 weeks, tetanus prophylaxis, antibiotic coverage, exceptions for replantation: a) child’s stage of dental development where considerable alveolar growth has to take place, high risk of ankylosis b) compromising medical condition - immunocompromised health, severe congenital cardiac anomalies, severe uncontrolled seizure disorder, severe mental disability, severe uncontrolled diabetes c) compromised integrity of avulsed tooth or supporting tissues d) PDL has no chance of survival if in dry environment greater than 60 minutes Orthodontic movement of traumatized teeth: Concussion, subluxation, extrusion, simple crown/root fracture – wait 3 months before beginning ortho; moderate to severe trauma to periodontium – wait 6 months, root fracture – wait 1 year. Light intermittent forces are recommended along with avoidance of prolonged tipping forces and contact with buccal and lingual cortical plates. Assessment of Article: Great article. Lots of information – has assessment of acute traumatic injuries chart in the back, good overview of trauma.