LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Murphy Date: 8/21/09 Region: Providence
Article title: Treatment of Crown Fractures With Pulp Exposure in Primary Incisors
Author(s): Holan, Gideon, Kupietzky, Ari.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 25:3, 241-247
Year: 2003
Major topic: Treatment modalities of Primary incisor crown fracture
Type of Article: Comparative Treatment Study
Main Purpose: To present indications and contraindications of the various treatment modalities for primary incisors w/ complicated crown fractures, and to suggest that partial pulpotomy(PP) is the best treatment option, if indicated.
Overview of method of research: Discussed the four treatment options for fractured teeth w/ a pulp exposure, referencing a case for each option.
Findings: A complicated crown fracture is defined as a fracture involving enamel and dentin w/ pulp exposure. 3% of all injured primary teeth have complicated fractures. Treatment options include direct pulp capping, pulpotomy, pulpectomy, and extraction. Most clinical guides suggest that formocresol pulpotomy or pulpectomy are the best options, even in cases of minor exposures, with extraction being a possibility. While this article discusses all treatment options, it focuses on partial pulpotomies, or Cvek pulpotomies, which are usually used in permanent teeth.
Partial Pulpotomy
A small pulp exposure of up to 14 days old in a non-carious tooth is an indication for a PP. While some clinicians prefer a direct pulp cap, a PP is preferred. There must be sufficient tooth structure remaining to ensure a seal of the exposure site. PP’s are highly indicated in “young” teeth with an open apex and thin root walls. The tooth should be asymptomatic and non-inflamed. The procedure for a PP includes normal prep. For a pulpotomy, however pulpal amputation should not exceed more than 2mm. Good hemostasis should be attained. Follow up at 1 month, 3 months, and 6 months. Dentin bridge formation should be visible at 6-8 weeks. The main advantage of a PP is that after removal of the infected tissue, the remaining tissue is capable of healing, and the tooth can continue normal development/maturation. In capping, the infected tissue is left, possibly hindering complete healing. Also, with PP’s, there is no change in color of the tooth. Contraindications of PP’s are if the exposure is large, more than 2 weeks old, and if the infection is more than 2-3mm into the tissue. If this occurs, a full cervical pulpotomy is indicated.
Cervical Pulpotomy
Indications include a large exposure, with inflamed pulp not extending into the canals, and no excessive bleeding. The big question regarding pulpotomies is what agent to use, FC, CH, ferric sulfate, glutaraldehyde, and bone morphogenetic protein, with FC and CH being most common. CH is usually not used in primary teeth because it has been known to cause internal root resorption. However in this article, it stated that this was true in primary molars, but not necessarily primary incisors. A difference of primary incisors and molars is that incisors have larger canals, which could help fight against the resorption when using CH. FC is the most commonly used agent. While its mechanism is not fully understood, its use results in decreased inflammation, bleeding, and retreatment. However, the pulp may become necrotic when using FC, although staying asymptomatic. Cervical pulpotomy technique includes removal of all coronal portions of the pulpal tissue, good hemostasis, and a tight seal/coronal restoration.
Pulpectomy
If bleeding cannot be controlled, or if the inflammation extends into the canals, a pulpectomy should be performed. Pulpectomy treated primary teeth should resorb at the same rate that a normal tooth physiologically resorbs. Materials used in pulpectomies include, ZOE, iodoform pastes (vitapex), and CH. A good material should be antiseptic, radiopaque, not discolor the tooth, and should be absorbed if any is expelled beyond the apex. The most frustrating aspect of pulpectomies is that discoloration of the tooth often occurs, which parents do not like. The color can range from grey to dark brown. Parents must be told of this possibility before the treatment is started, and that it may occur many months after treatment. Some parents would rather extract the tooth rather than save a discolored tooth. Another option would be a Nu-Smile crown. Contraindications for pulpectomies include insufficient coronal tooth structure remaining, esthetic(parental) concern, and infection possibly involving the succedaneous tooth. The tooth should be accessed in via a conservative exposure, cleaned of all tissue with files, and filled w/ one of the previously mentioned materials.
Extraction
When all else fails, or when you just don’t have a good feeling about postoperative cooperation/success, extract. While space maintenance is a big concern in the primary dentition, the incisor region is extremely stable from canine to canine, even with early loss of teeth. There may be some rearrangement of space, however a space maintainer is rarely necessary. An esthetic appliance may be placed if warranted/requested. The timeline of permanent teeth erupting early/later than expected should be discussed with the parents.
Summary of conclusions: This article drove home the point that a PP is the best treatment with the most advantages, if indicated. It’s quick, easy, and the tooth is expected to maintain its vitality and continue its root development. Successful PP is expressed by a dentinal bridge forming w/I a few months, apex closure, and the root wall thickening. The drawback of PP’s is a lack of reporting on its successful use.
Assessment of article: Overall a good article. I think it was a bit idealistic. Off course we would all love it if a tooth had minimal to no caries, with a tiny, needlepoint pulp exposure. If this were the norm, PP’s would be great and used almost all of the time. Unfortunately, this isn’t the norm, and we see teeth with huge cavities and large exposures. A good clinical application for use of a PP would be a trauma case, as listed in the article. A good review on how to treat a tooth with various levels of trauma, and why to do it.
Wednesday, August 19, 2009
Intrusion injuries of primary incisors. Part II: Sequelae affecting the intruded incisors
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 8/21/09
Article title: Intrusion injuries of primary incisors: Part II: Sequlae affecting the intruded primary incisors
Author(s): Diab, Mai et al.
Journal: Quintessence International
Volume #; Number; Page #s): 31; 5; 335-340
Month / Year: Nov. 2000
Major topic: Sequelae and management of intruded primary incisors
Type of Article: Review
Summary of Article:
-Intrusion injuries to primary incisors are common (4.4-22%)
-Radiographic exam will often show widened PDL / alveolar bone fx.
-Must assess condition of developing tooth bud with regard to intruded incisor
-Intrusion injuries of this kind may result in: coronal discoloration, pulpal obliteration, pulpal necrosis, root resorption, and ankylosis
Coronal Discoloration:
-Happens to 35%-40% of intrusion injuries; Gray color means damage to pulpal tissue (reddish gray at first then turns gray in 1-2 weeks), reversible, if debris is not absorbed through dentin tooth will remain discolored. Disagreement regarding prognosis among dentists; some believe color change of this kind indicates irreversible pulpitis while others don’t thin it’s enough to confirm pulpal necrosis. If no treatment is provided. Should be followed.
Yellow Discoloration:
-Indicates calcification or accelerated deposition of secondary dentin resulting in pulpal obliteration; monitor teeth for overretention
Pulpal Necrosis:
-22-35% of intruded primary incisors
-Difficult to dx.; clinical signs include discoloration, spontaneous pain, increased mobility 6-8 wks after injury; radiographic changes widening of PDL space, PA radiolucency, internal / external root resorption
-2-5 year olds have lower chance of pulpal necrosis
-Intitiate tx quickly to avoid damage to developing tooth bud
-Some authors believe that pulpal therapy is an option, others believe extraction should be done to avoid damage to developing tooth from overinstrumentation and overfilling the canal.
Pathological external root resorption: Incidence is 14%, usually managed with extraction
Abcess or cellulitis formation: requires immediate extraction of intruded incisor, may require antibiotic therapy depending on severity of infection
Failure of re-eruption and ankylosis: 20-22% of intruded incisors fail to re-erupt completely or into alignment (especially with alveolar fxs.), ankylosis occurs in 2-6% of intrusion injuries to primary incisors-presents with dull sound on percussion; manage by extracting to prevent ectopic eruption
Assessment of article: Good review
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 8/21/09
Article title: Intrusion injuries of primary incisors: Part II: Sequlae affecting the intruded primary incisors
Author(s): Diab, Mai et al.
Journal: Quintessence International
Volume #; Number; Page #s): 31; 5; 335-340
Month / Year: Nov. 2000
Major topic: Sequelae and management of intruded primary incisors
Type of Article: Review
Summary of Article:
-Intrusion injuries to primary incisors are common (4.4-22%)
-Radiographic exam will often show widened PDL / alveolar bone fx.
-Must assess condition of developing tooth bud with regard to intruded incisor
-Intrusion injuries of this kind may result in: coronal discoloration, pulpal obliteration, pulpal necrosis, root resorption, and ankylosis
Coronal Discoloration:
-Happens to 35%-40% of intrusion injuries; Gray color means damage to pulpal tissue (reddish gray at first then turns gray in 1-2 weeks), reversible, if debris is not absorbed through dentin tooth will remain discolored. Disagreement regarding prognosis among dentists; some believe color change of this kind indicates irreversible pulpitis while others don’t thin it’s enough to confirm pulpal necrosis. If no treatment is provided. Should be followed.
Yellow Discoloration:
-Indicates calcification or accelerated deposition of secondary dentin resulting in pulpal obliteration; monitor teeth for overretention
Pulpal Necrosis:
-22-35% of intruded primary incisors
-Difficult to dx.; clinical signs include discoloration, spontaneous pain, increased mobility 6-8 wks after injury; radiographic changes widening of PDL space, PA radiolucency, internal / external root resorption
-2-5 year olds have lower chance of pulpal necrosis
-Intitiate tx quickly to avoid damage to developing tooth bud
-Some authors believe that pulpal therapy is an option, others believe extraction should be done to avoid damage to developing tooth from overinstrumentation and overfilling the canal.
Pathological external root resorption: Incidence is 14%, usually managed with extraction
Abcess or cellulitis formation: requires immediate extraction of intruded incisor, may require antibiotic therapy depending on severity of infection
Failure of re-eruption and ankylosis: 20-22% of intruded incisors fail to re-erupt completely or into alignment (especially with alveolar fxs.), ankylosis occurs in 2-6% of intrusion injuries to primary incisors-presents with dull sound on percussion; manage by extracting to prevent ectopic eruption
Assessment of article: Good review
Sunday, August 16, 2009
Subluxation injuries of maxillary primary anterior teeth:epidemiology and prognosis of 207 traumatized teeth
Resident: Jason Hencler
Date: 8/21/09
Article title: Subluxation injuries of maxillary primary anterior teeth: epidemiology and prognosis of 207 traumatized teeth
Author(s): Irwin Fried, DDS; Pamela Erickson, DDS, PhD; Stephane Schwartz, DDS, MsD; Kathleen Keenan, PhD
Journal: Pediatric Dentistry
Volume #18 ; Number 2; Page 145-151 Year: 1996
Major topic: Subluxation
Type of Article: Retrospective case study
Main Purpose: Investigate the epidemiology, sequelae, and prognosis of injuries to the maxillary primary anterior dentition.
Overview of method of research: Retrospective chart audit to identify patients who sustained subluxation injuries to the maxillary primary anterior dentition between 1982 and 1993. Information was gathered pertaining to the child and all aspects of the trauma. All post-traumatic sequelae, treatment or administration of antibiotics were also evaluated. Data were distributed into the following six time intervals of examination post-trauma: 0-10, 11-30, 31-91, 92-183, 184-365, and 366-730 days. A total of 207 teeth were evaluated in 134 patients (81 male, 53 female) sustaining subluxation injuries to the maxillary primary anterior dentition.
Findings: Central incisors involved 66.2%, lateral incisors involved 33.3%, and only one case involved a canine. Age of patients ranged from 0.8 -7.5 years with trauma more common in males. Physiologic root reorption was found in 38.0% and only 6.8% of the study teeth demonstrated pathologic root resorption. Crown fractures were noted in only 5.8% of the study teeth and 91.5% of patients sustained no alveolar fractures. Patient discomfort was not a common complaint at follow-up examinations. Discoloration, however, increased with time. Periapical radiolucencies were uncommon, while pulpal calcification increased with time.
Key points in the article discussion: Trauma to the maxillary primary anterior dentition is very common. Central Incisors were affected most of the time. Mean age of study patients sustaining subluxations was 3.5 years. Most common etiology of traumatic injuries in this study group was simple falls indoors (52%). The high incidence of traumatic falls is consistent with the developing motor coordination in young children. Subluxations are often not the only tooth injury sustained in a particular accident. Avulsions and/or luxations were found 58.2% of the time along with subluxation injuries. Crown and root fractures were found 5.8% and were infrequent probably due to the relative plasticity of bone in young children which absorbs most of the force during an impact. The treatment of subluxated teeth varies and this study found that 80.2% of the time teeth required no dental treatment. Antibiotics were administered only in cases were a potential for systemic infection such as avulsion or luxation where there is an increased likelihood that the gingiva was lacerated. Discoloration has frequently been reported following traumatic injuries to teeth. This study showed an increase of discoloration over time. A yellow discoloration is thought to be due to partial pulp canal obliteration. A pink tooth is due to blood pigments entering the dentinal tubules at the time of trauma. A gray discoloration is generally thought to be significant of pulpal necrosis. Discoloration should be used as an adjunct in diagnosis, but not as the sole predictor of prognosis and in determining the need for EXT. Other studies found discolored primary teeth failed to develop any radiographic and/or clinical pathology. This study found that incidence and severity of pulpal calcification increases with time. Other studies have found that prognosis following pulp obliteration was favorable and normal root resorption usually occurred.
Summary of conclusions:
Highest incidence of trauma occurred in males 3-4 yo. and females 1-3 yo. Central incisors were most commonly affected typically the result of falls.
More than half the patients were seen within 3hrs of the trauma.
The majority of teeth had a mobility ranging between 1.6 and 2.5mm following trauma.
Treatment included occlusal reduction, splinting, and EXT, but most teeth received no treatment.
Tooth discoloration increased with time after trauma.
Mobility improved with time, with the majority of teeth returning to a normal physiological range.
Pulpal calcification increased in incidence and severity with time.
Low patient return was noted on follow-up, indicating low morbidity of subluxation injuries.
Assessment of article: Great article, an easy read. There is a lot of interesting epidemiological information like patient demographics that wouldn’t be particularly useful for clinical treatment of trauma. Conversely, I thought that the prognosis conclusions made by this study would be helpful when considering treatment options in the clinical setting while managing a patient with subluxation trauma.
Date: 8/21/09
Article title: Subluxation injuries of maxillary primary anterior teeth: epidemiology and prognosis of 207 traumatized teeth
Author(s): Irwin Fried, DDS; Pamela Erickson, DDS, PhD; Stephane Schwartz, DDS, MsD; Kathleen Keenan, PhD
Journal: Pediatric Dentistry
Volume #18 ; Number 2; Page 145-151 Year: 1996
Major topic: Subluxation
Type of Article: Retrospective case study
Main Purpose: Investigate the epidemiology, sequelae, and prognosis of injuries to the maxillary primary anterior dentition.
Overview of method of research: Retrospective chart audit to identify patients who sustained subluxation injuries to the maxillary primary anterior dentition between 1982 and 1993. Information was gathered pertaining to the child and all aspects of the trauma. All post-traumatic sequelae, treatment or administration of antibiotics were also evaluated. Data were distributed into the following six time intervals of examination post-trauma: 0-10, 11-30, 31-91, 92-183, 184-365, and 366-730 days. A total of 207 teeth were evaluated in 134 patients (81 male, 53 female) sustaining subluxation injuries to the maxillary primary anterior dentition.
Findings: Central incisors involved 66.2%, lateral incisors involved 33.3%, and only one case involved a canine. Age of patients ranged from 0.8 -7.5 years with trauma more common in males. Physiologic root reorption was found in 38.0% and only 6.8% of the study teeth demonstrated pathologic root resorption. Crown fractures were noted in only 5.8% of the study teeth and 91.5% of patients sustained no alveolar fractures. Patient discomfort was not a common complaint at follow-up examinations. Discoloration, however, increased with time. Periapical radiolucencies were uncommon, while pulpal calcification increased with time.
Key points in the article discussion: Trauma to the maxillary primary anterior dentition is very common. Central Incisors were affected most of the time. Mean age of study patients sustaining subluxations was 3.5 years. Most common etiology of traumatic injuries in this study group was simple falls indoors (52%). The high incidence of traumatic falls is consistent with the developing motor coordination in young children. Subluxations are often not the only tooth injury sustained in a particular accident. Avulsions and/or luxations were found 58.2% of the time along with subluxation injuries. Crown and root fractures were found 5.8% and were infrequent probably due to the relative plasticity of bone in young children which absorbs most of the force during an impact. The treatment of subluxated teeth varies and this study found that 80.2% of the time teeth required no dental treatment. Antibiotics were administered only in cases were a potential for systemic infection such as avulsion or luxation where there is an increased likelihood that the gingiva was lacerated. Discoloration has frequently been reported following traumatic injuries to teeth. This study showed an increase of discoloration over time. A yellow discoloration is thought to be due to partial pulp canal obliteration. A pink tooth is due to blood pigments entering the dentinal tubules at the time of trauma. A gray discoloration is generally thought to be significant of pulpal necrosis. Discoloration should be used as an adjunct in diagnosis, but not as the sole predictor of prognosis and in determining the need for EXT. Other studies found discolored primary teeth failed to develop any radiographic and/or clinical pathology. This study found that incidence and severity of pulpal calcification increases with time. Other studies have found that prognosis following pulp obliteration was favorable and normal root resorption usually occurred.
Summary of conclusions:
Highest incidence of trauma occurred in males 3-4 yo. and females 1-3 yo. Central incisors were most commonly affected typically the result of falls.
More than half the patients were seen within 3hrs of the trauma.
The majority of teeth had a mobility ranging between 1.6 and 2.5mm following trauma.
Treatment included occlusal reduction, splinting, and EXT, but most teeth received no treatment.
Tooth discoloration increased with time after trauma.
Mobility improved with time, with the majority of teeth returning to a normal physiological range.
Pulpal calcification increased in incidence and severity with time.
Low patient return was noted on follow-up, indicating low morbidity of subluxation injuries.
Assessment of article: Great article, an easy read. There is a lot of interesting epidemiological information like patient demographics that wouldn’t be particularly useful for clinical treatment of trauma. Conversely, I thought that the prognosis conclusions made by this study would be helpful when considering treatment options in the clinical setting while managing a patient with subluxation trauma.
Friday, August 14, 2009
Guideline on Management of Acute Dental Trauma
Resident’s Name: Joanne Lewis Date: August 14, 2009
Article title: Guideline on Management of Acute Dental Trauma (focused on primary dentition for this lit review)
Originating Council: AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual 29
Adopted: 2001 (revised 2004, 2007)
Major topic: dental trauma
Main Purpose: to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries.
Overview of method of research: The guideline is based on a review of current dental and medical literature related to dental trauma.
Findings: Greatest incidence of trauma to the primary dentition occurs at 2-3 years of age, when motor coordination is developing. Rapid and thorough assessment of the nature and extent of the patient’s injuries is essential to delivering appropriate treatment. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. It is important to inform parents about possible pulpal complications, such as the development of an abscess or sinus tract or color change of the crown, as well as potential sequelae to permanent teeth, such as enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption. Specific recommendations are as follows:
- Infraction – no treatment indicated
- Uncomplicated crown fracture – for small fractures, rough margins and edges can be smoothed; for larger fractures, lost tooth structure can be restored.
- Complicated crown fracture – decisions are based on life expectancy of the primary tooth and vitality of the pulpal tissue. Treatment alternatives are pulpotomy, pulpectomy, and extraction.
- Crown/root fracture – extract the entire tooth, unless the retrieval of apical fragments may result in damage to the succedaneous tooth.
- Root fracture – extract the coronal segment with or without the removal of the apical fragment.
- Concussion – unless an associated infection exists, no pulpal therapy is indicated.
- Subluxation – no immediate treatment needed, tooth should be followed for pathology – should return to normal within 2 weeks.
- Lateral luxation – allow passive repositioning or actively reposition and splint for 1-2 weeks as indicated, except when the injury is severe or the tooth is near exfoliation.
- Intrusion – allow spontaneous reeruption except when displaced into the developing successor. If the apex is displaced toward the permanent tooth germ, extraction is indicated. 90% will reerupt spontaneously within 2-6 months. Ankylosis may occur.
- Extrusion – reposition and stabilize with a splint for 1-2 weeks or extract.
- Avulsion – do not reimplant primary teeth.
Assessment of article: Concise reference – recommendations are very general.
Article title: Guideline on Management of Acute Dental Trauma (focused on primary dentition for this lit review)
Originating Council: AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual 29
Adopted: 2001 (revised 2004, 2007)
Major topic: dental trauma
Main Purpose: to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries.
Overview of method of research: The guideline is based on a review of current dental and medical literature related to dental trauma.
Findings: Greatest incidence of trauma to the primary dentition occurs at 2-3 years of age, when motor coordination is developing. Rapid and thorough assessment of the nature and extent of the patient’s injuries is essential to delivering appropriate treatment. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. It is important to inform parents about possible pulpal complications, such as the development of an abscess or sinus tract or color change of the crown, as well as potential sequelae to permanent teeth, such as enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption. Specific recommendations are as follows:
- Infraction – no treatment indicated
- Uncomplicated crown fracture – for small fractures, rough margins and edges can be smoothed; for larger fractures, lost tooth structure can be restored.
- Complicated crown fracture – decisions are based on life expectancy of the primary tooth and vitality of the pulpal tissue. Treatment alternatives are pulpotomy, pulpectomy, and extraction.
- Crown/root fracture – extract the entire tooth, unless the retrieval of apical fragments may result in damage to the succedaneous tooth.
- Root fracture – extract the coronal segment with or without the removal of the apical fragment.
- Concussion – unless an associated infection exists, no pulpal therapy is indicated.
- Subluxation – no immediate treatment needed, tooth should be followed for pathology – should return to normal within 2 weeks.
- Lateral luxation – allow passive repositioning or actively reposition and splint for 1-2 weeks as indicated, except when the injury is severe or the tooth is near exfoliation.
- Intrusion – allow spontaneous reeruption except when displaced into the developing successor. If the apex is displaced toward the permanent tooth germ, extraction is indicated. 90% will reerupt spontaneously within 2-6 months. Ankylosis may occur.
- Extrusion – reposition and stabilize with a splint for 1-2 weeks or extract.
- Avulsion – do not reimplant primary teeth.
Assessment of article: Concise reference – recommendations are very general.
Thursday, August 13, 2009
Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Resident: Jason Hencler
Date: 8/14/09
Article title: Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Author(s): M. K. Borum, J. O. Andreasen
Journal: Endodontics and Dental traumatology
Volume #14; Page 31-44
Year: 1998
Major topic: Trauma and primary maxillary incisors
Type of Article: Clinical case study
Main Purpose: Investigate the immediate and long term consequences of trauma to the primary maxillary incisors.
Overview of method of research:
Study group was 287 children who sustained trauma to maxillary primary central and lateral incisors. Patients exhibited 545 traumatized maxillary primary incisors; 428 central and 117 lateral incisors. Parameters of the study included color changes, pulp necrosis (PN), pulp canal obliteration (PCO), gingival retraction, permanent displacement after luxation, pathological root resorption, and premature loss of the traumatized tooth. After initial trauma evaluation, follow-up visits were planned at 4wk, 8wk, and 1 yr as well as when the child was 6 and 10yo. All visits included radiographs and clinical exam.
Findings:
Color changes-Transient gray discoloration (TGD) was seen in 15.2% and 78% of the teeth later turned yellow. The relationship between TGD and later PCO as well as the relationship between TGD and the absence of PN are highly significant. Permanent gray discoloration (PGD) was seen in 18.1%. PCO was seen in 8.6% of the PGD teeth and 65.7% developed PN. Yellow discoloration was seen in 31% in which PCO was seen in 81.5%.
Pulp necrosis-Type of luxation seemed to be an important factor in the development of PN. Age at time of injury seemed to be a significant factor for developing PN, as younger children showed a lower frequency of PN than older children. Pulp Canal Obliteration-None of the teeth with PCO developed PN. The type of luxation also was an important factor in developing PCO. Frequency of PCO in older children was very low. Gingival retraction-The only variable found to be significant for the development of gingival retraction was the presence of gingival injury associated with the trauma. Pathological root resorption: Inflammatory root resorption was found to be associated with PN. Physiological root resorption-PN was significantly related to both accelerated and delayed physiological root resorption. No connection was found between PCO and changes in physiological resorption rates. Premature loss of traumatized Primary teeth-Of the 287 children, 167 experienced premature loss of 1 or more teeth.
Key points in the article discussion:
More than half of the traumatized teeth developed transient or permanent color changes. Transient color changes were associated with PCO while permanent color changes were associated with PN. Yellow discoloration was strongly associated with pulpal obliteraton. Although these findings are significant, color changes alone are not a reliable predictor of pulpal health. The age of the child at the time of injury seems to be very important in the development of PN. A very young child has a high vascular supply to the wide open and very short pulp along with resilient alveolar bone, the pulp is able to survive severe injury. Physiologic resorption in older children can be advanced to a point where the pulp becomes degenerated and vulnerable to even minor injuries. PCO in the primary dentition was highly associated with concussion, subluxation, and intrusion but less associated with lateral luxation. Conversely, PN is highly associated with lateral luxation. Gingival retraction was most often found after gingival trauma associated with tooth trauma. For laterally luxated teeth primary teeth, spontaneous repositioning with in the first days or weeks of trauma can be expected. A tooth that fails to realign within the first weeks of trauma is less likely to regain a healthy pulp, as ingrowth of new pulp tissue is blocked by clot formation between the most apical part of the original socket and the apical foramen of the tooth. Delayed physiologic root resorption may be associated with PN because resorption also takes place from the pulpal side of the root, which may be affected if the pulp is necrotic. PCO was not found to be associated with delayed resorption.
Summary of conclusions: Effects of premature loss of traumatized primary teeth on eruption and alignment of the permanent successors should be considered against the possible damage to the development of the successors by treatments aimed at preserving traumatized teeth. Increase in awareness and research on these problems has been essential in the development of treatment guidelines for the traumatized primary dentition.
Assessment of article: I did think this article was quite long with confusing statistics and tables. But once you’ve picked out the important points and read through the tables and pie charts, this article presented some very relevant information that could easily be useful in clinical situations when seeing patients with trauma.
Date: 8/14/09
Article title: Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Author(s): M. K. Borum, J. O. Andreasen
Journal: Endodontics and Dental traumatology
Volume #14; Page 31-44
Year: 1998
Major topic: Trauma and primary maxillary incisors
Type of Article: Clinical case study
Main Purpose: Investigate the immediate and long term consequences of trauma to the primary maxillary incisors.
Overview of method of research:
Study group was 287 children who sustained trauma to maxillary primary central and lateral incisors. Patients exhibited 545 traumatized maxillary primary incisors; 428 central and 117 lateral incisors. Parameters of the study included color changes, pulp necrosis (PN), pulp canal obliteration (PCO), gingival retraction, permanent displacement after luxation, pathological root resorption, and premature loss of the traumatized tooth. After initial trauma evaluation, follow-up visits were planned at 4wk, 8wk, and 1 yr as well as when the child was 6 and 10yo. All visits included radiographs and clinical exam.
Findings:
Color changes-Transient gray discoloration (TGD) was seen in 15.2% and 78% of the teeth later turned yellow. The relationship between TGD and later PCO as well as the relationship between TGD and the absence of PN are highly significant. Permanent gray discoloration (PGD) was seen in 18.1%. PCO was seen in 8.6% of the PGD teeth and 65.7% developed PN. Yellow discoloration was seen in 31% in which PCO was seen in 81.5%.
Pulp necrosis-Type of luxation seemed to be an important factor in the development of PN. Age at time of injury seemed to be a significant factor for developing PN, as younger children showed a lower frequency of PN than older children. Pulp Canal Obliteration-None of the teeth with PCO developed PN. The type of luxation also was an important factor in developing PCO. Frequency of PCO in older children was very low. Gingival retraction-The only variable found to be significant for the development of gingival retraction was the presence of gingival injury associated with the trauma. Pathological root resorption: Inflammatory root resorption was found to be associated with PN. Physiological root resorption-PN was significantly related to both accelerated and delayed physiological root resorption. No connection was found between PCO and changes in physiological resorption rates. Premature loss of traumatized Primary teeth-Of the 287 children, 167 experienced premature loss of 1 or more teeth.
Key points in the article discussion:
More than half of the traumatized teeth developed transient or permanent color changes. Transient color changes were associated with PCO while permanent color changes were associated with PN. Yellow discoloration was strongly associated with pulpal obliteraton. Although these findings are significant, color changes alone are not a reliable predictor of pulpal health. The age of the child at the time of injury seems to be very important in the development of PN. A very young child has a high vascular supply to the wide open and very short pulp along with resilient alveolar bone, the pulp is able to survive severe injury. Physiologic resorption in older children can be advanced to a point where the pulp becomes degenerated and vulnerable to even minor injuries. PCO in the primary dentition was highly associated with concussion, subluxation, and intrusion but less associated with lateral luxation. Conversely, PN is highly associated with lateral luxation. Gingival retraction was most often found after gingival trauma associated with tooth trauma. For laterally luxated teeth primary teeth, spontaneous repositioning with in the first days or weeks of trauma can be expected. A tooth that fails to realign within the first weeks of trauma is less likely to regain a healthy pulp, as ingrowth of new pulp tissue is blocked by clot formation between the most apical part of the original socket and the apical foramen of the tooth. Delayed physiologic root resorption may be associated with PN because resorption also takes place from the pulpal side of the root, which may be affected if the pulp is necrotic. PCO was not found to be associated with delayed resorption.
Summary of conclusions: Effects of premature loss of traumatized primary teeth on eruption and alignment of the permanent successors should be considered against the possible damage to the development of the successors by treatments aimed at preserving traumatized teeth. Increase in awareness and research on these problems has been essential in the development of treatment guidelines for the traumatized primary dentition.
Assessment of article: I did think this article was quite long with confusing statistics and tables. But once you’ve picked out the important points and read through the tables and pie charts, this article presented some very relevant information that could easily be useful in clinical situations when seeing patients with trauma.
Department of Pediatric Dentistry
Lutheran Medical Center
Date: 08/14/2009
Article title: Traumatic injuries in the primary dentition
Author(s): Flores MT
Journal: Dental Traumatology
Volume (number): Vol 18
Month, Year: 2002
Major topic: Trauma to primary teeth
Minor topics: epidemiology, preschool, primary dentition
Type of Article: Review of Literature
Main Purpose: Review types of injuries to the primary dentition and present evidence based treatments
Overview of method of research: Review of Literature from 1984 to 2001, including 75 articles.
Findings:
Most luxation injuries heal spontaneously and conservative treatment for preschool aged kids is suggested. Good pain control, ability to cope with the child's anxiety and good hygiene can help save many injured teeth.
Key points/Summary :
- Epidemiology: Many children will experience trauma to their teeth, especially between 18 and 30 months. Some studies show incidences as high as 30%.
- Classification: The WHO has classified traumas based on work from Andreasen & Andreasen which can be seen in the article.
- Treatment: Luxation is the most common injury and there are few long-term studies to base treatment protocols on. The best decisions are going to be guided by evidence, biological and conservative, damage limiting principles.
- Emergency Management: Soft tissue injuries can often obscure tooth damage. Clean the soft tissue first and suture starting with the skin first moving towards mucosa lastly.
- Non-complicated crown fracture: Simple to fix with composite or ionomer. Take a PA to rule out any other pathology and to have as a baseline.
- Complicated crown fracture: Take a baseline PA and then treatment is partial pulpotomy if the apex is not closed. If the primary tooth has not yet started the root resorption process pulpotomy is an option, root canal treatment with ZOE fill, or finally extraction.
- Crown-root fracture: PA xray as a baseline, extract mobile portions and if it is not easily removed, leave root tip to avoid damage to tooth germ.
- Root fracture: PA xray, wire splint if coronal portion is still in place. The crown may be lost in the future. Also, if the crown is very mobile it is acceptable to remove it and leave the remaining root.
- Alveolar fracture: Xray, splint to adjacent teeth for up to 4 weeks. If it is not stable, splint for 2-3 more weeks or extract.
- Concussion: (tooth is tender to the touch only) Keep under observation and do not perform root treatment even if discoloration exists unless infection develops.
- Subluxation: (tooth is mobile without displacement, sulcar bleeding may be present) Good hygiene and infection control will usually lead to normal healing.
- Lateral luxation: (displaced tooth, usually with the crown palatal) Take 2 PAs. If there is no occlusal interference, leave the tooth to heal spontaneously. If occlusal interference was present you can reposition and splint for 2-3 weeks, but that has a higher incidence of pulpal necrosis.
- Intrusion: Take a PA, no need for extra-oral radiographs. If the tooth is displaced with the apex toward the labial bone plate, leave it. If the tooth is displaced with the apex toward the succedaneous tooth germ, extract with the forcep mesio-distally.
- Extrusion: No clinical studies of conservative treatment, reposition and splint or extract.
- Avulsion: Take a PA to rule out intrusion. Do not re-implant.
- Instructions for parents: Excellent hygiene is a must for proper healing. Soft diet for 2 weeks, chlorhexidine rinse, etc.
- Follow-up: the type of follow-up and frequency depends on the type of injury. For crown fractures it is 6-8 weeks; alveolar fracture 3-4 weeks, 6-8 weeks, 6 months, 1 year; Root fracture 2-3 weeks, 6-8 weeks, 1 year (assumes incomplete or no extraction); Lateral Luxation 2-3 weeks, 6-8 weeks, 6 months, 1 year; Intrusion once a week for the first 3 weeks, 6-8 weeks, then as needed.
Assessment of article: A good review that is essential to being able to treat the emergencies that we see. I found this one very useful when I started covering call and also very helpful in our clinic. The follow-up schedule is good to know and follow, especially in cases of litigation I would imagine.
The diagnostic value of coronal dark-gray discoloration in primary teeth follwing traumatic injuries
Resident: Roberts
8/14/09
Article: The diagnostic value of coronal dark-gray discoloration in primary teeth following traumatic injuries
Author: Holan, Gideon
Journal: Pediatric Dentistry
Volume# 18:3 pages: 224-227
Year: 1996
Type of article: retrospective study
Major topic: evaluation of primary teeth following traumatic injury
Key pts: This article attempted to examine the condition of the pulp of primary incisors with dark gray discoloration following traumatic injury. Previous research suggested controversial opinions concerning the matter. Some authors of research suggested that a gray or bluish color indicated pulpal degeneration and suggested that upto 82 percent of gray discolored traumatized teeth develop periapical pathology within 1 month of the trauma. Other authors suggested that dentist not predetermine the fate of primary teeth and that the dark discoloration was in part due to the hemorrhaging of the dentinal tubules followed by hemoglobin breakdown with no possibility of final absorption of the hemosiderin deposits or disappearance of the stain. The only thing that seemed to be agreed upon among the various authors of the published research was that a tooth with a pink or yellow hue did not reflect devitalization of the pulp. For this authors assessment, 48 gray, caries-free, traumatized primary incisors were examined clinically and radio graphically and were found to be free from any signs of pulpal necrosis, for the exception of the discolored crown. This article concluded like previous authors had reported that upto 82 percent of injured primary incisors with gray discoloration developed periapical pathology within 1 month of the trauma, indicating a development towards pulpal necrosis. These teeth even when found to be necrotic often times showed no signs of sensitivity to percussing, or no sign of increased mobility. Nearly half of the teeth showed signs of discoloration within the first 2 weeks following trauma.
8/14/09
Article: The diagnostic value of coronal dark-gray discoloration in primary teeth following traumatic injuries
Author: Holan, Gideon
Journal: Pediatric Dentistry
Volume# 18:3 pages: 224-227
Year: 1996
Type of article: retrospective study
Major topic: evaluation of primary teeth following traumatic injury
Key pts: This article attempted to examine the condition of the pulp of primary incisors with dark gray discoloration following traumatic injury. Previous research suggested controversial opinions concerning the matter. Some authors of research suggested that a gray or bluish color indicated pulpal degeneration and suggested that upto 82 percent of gray discolored traumatized teeth develop periapical pathology within 1 month of the trauma. Other authors suggested that dentist not predetermine the fate of primary teeth and that the dark discoloration was in part due to the hemorrhaging of the dentinal tubules followed by hemoglobin breakdown with no possibility of final absorption of the hemosiderin deposits or disappearance of the stain. The only thing that seemed to be agreed upon among the various authors of the published research was that a tooth with a pink or yellow hue did not reflect devitalization of the pulp. For this authors assessment, 48 gray, caries-free, traumatized primary incisors were examined clinically and radio graphically and were found to be free from any signs of pulpal necrosis, for the exception of the discolored crown. This article concluded like previous authors had reported that upto 82 percent of injured primary incisors with gray discoloration developed periapical pathology within 1 month of the trauma, indicating a development towards pulpal necrosis. These teeth even when found to be necrotic often times showed no signs of sensitivity to percussing, or no sign of increased mobility. Nearly half of the teeth showed signs of discoloration within the first 2 weeks following trauma.
Rapid neurologic assessment and initial management for the patient with traumatic dental injuries.
Resident: Adam J. Bottrill
Region: Providence
Author(s): Croll, Theodore P. et al.
Journal: JADA
Volume #; Page #s: Volume 100 pp: 530-534
Year: 1980
Major topic: Rapid neurological assessment
Minor topic(s): None
Type of Article: Topic review and summary
Main Purpose: Suggested technique for dentists to assess neurological status.
Overview of method of research: Topical summary
Findings: N/A
Key points in the article discussion: The family dentist may be the first health professional to treat a pt who has sustained head trauma. Despite urgent dental needs, overall medical welfare of the patient should always be the primary concern. This paper proposes a protocol to aid the dental practitioner in an effective, yet rapid, neurologic evaluation. DENTAL TREATMENT SHOULD ONLY BEGIN AFTER A SATISFACTORY NEUROLOGIC STATE IS EVIDENT.
A. Sequelae to head trauma
1. Lacerations,
2. Linear/depressed skull fractures (with possible dural laceration and arachnoid herniation)
3. Hematoma (sub or extradural, intraventricula)
4. Brain stem injury
5. Vertebral fracture (with or without spinal cord injury)
B. Facts and figures (1975) 1. 10 mill people in US required med attention due to head injury.
2. 10% of school age children will suffer significant head injury
a. 33% of these children will require hospitalization.
3. NOTHING can be done to avoid the effects of the primary injury… (unless you want to wear a helmet all the time)
a. Therefore, neurosurgeons and neurologists can only direct their course of management towards preventing and treating the secondary injuries associated with trauma.
4. Dx tools include CAT scan, continuous ICP monitoring, MRI etc.
5. The tx of pediatric pt’s vs. adult pt’s varies significantly.
C. Categories and criteria: 1. Jennet and Bond (Long-term sequelae)
a. Good recovery (normal life)
b. Moderately disabled (independent but impaired)
c. Severely disabled (totally dependent on others)
d. Vegetative survival
e. Death
2. Meltzner and Frew (five diagnostic criteria)
a. Airway
b. State of consciousness
c. Vital signs
d. Reflexes (Oppenheim, Gordon, Gonda, Babinski, Chaddock)
e. Pupils
3. Taesdale and Jennet (Glasgow coma scale)
a. Recommend immediate referral for a pt who does not score optimally in any category.
4. Tyler (???)
a. Recommends cranial nerve exam by all dentists.
D. Recommendations: The authors don not believe a prolonged exam is either practical or required. HOWEVER, the dentist should be able to determine whether a pt should be immediately referred for neurological reasons.
1. Look for unusual motor activity or difficulties in communicating (Glasgow coma scale).
2. Assure pt’s airway
3. Hx of the injury
a. Updated tetanus? Cardiac Hx? Etc…
4. Vital signs
5. Observe for rhinorrhea or otorrhea
6. Cranial nerve exam
7. Neurologic impairment must be ruled out before analgesics are prescribed or inhalation sedation is commenced.
8. Follow-up and discharge recommendations
Assessment of article: Applicable and well organized.
Region: Providence
Author(s): Croll, Theodore P. et al.
Journal: JADA
Volume #; Page #s: Volume 100 pp: 530-534
Year: 1980
Major topic: Rapid neurological assessment
Minor topic(s): None
Type of Article: Topic review and summary
Main Purpose: Suggested technique for dentists to assess neurological status.
Overview of method of research: Topical summary
Findings: N/A
Key points in the article discussion: The family dentist may be the first health professional to treat a pt who has sustained head trauma. Despite urgent dental needs, overall medical welfare of the patient should always be the primary concern. This paper proposes a protocol to aid the dental practitioner in an effective, yet rapid, neurologic evaluation. DENTAL TREATMENT SHOULD ONLY BEGIN AFTER A SATISFACTORY NEUROLOGIC STATE IS EVIDENT.
A. Sequelae to head trauma
1. Lacerations,
2. Linear/depressed skull fractures (with possible dural laceration and arachnoid herniation)
3. Hematoma (sub or extradural, intraventricula)
4. Brain stem injury
5. Vertebral fracture (with or without spinal cord injury)
B. Facts and figures (1975) 1. 10 mill people in US required med attention due to head injury.
2. 10% of school age children will suffer significant head injury
a. 33% of these children will require hospitalization.
3. NOTHING can be done to avoid the effects of the primary injury… (unless you want to wear a helmet all the time)
a. Therefore, neurosurgeons and neurologists can only direct their course of management towards preventing and treating the secondary injuries associated with trauma.
4. Dx tools include CAT scan, continuous ICP monitoring, MRI etc.
5. The tx of pediatric pt’s vs. adult pt’s varies significantly.
C. Categories and criteria: 1. Jennet and Bond (Long-term sequelae)
a. Good recovery (normal life)
b. Moderately disabled (independent but impaired)
c. Severely disabled (totally dependent on others)
d. Vegetative survival
e. Death
2. Meltzner and Frew (five diagnostic criteria)
a. Airway
b. State of consciousness
c. Vital signs
d. Reflexes (Oppenheim, Gordon, Gonda, Babinski, Chaddock)
e. Pupils
3. Taesdale and Jennet (Glasgow coma scale)
a. Recommend immediate referral for a pt who does not score optimally in any category.
4. Tyler (???)
a. Recommends cranial nerve exam by all dentists.
D. Recommendations: The authors don not believe a prolonged exam is either practical or required. HOWEVER, the dentist should be able to determine whether a pt should be immediately referred for neurological reasons.
1. Look for unusual motor activity or difficulties in communicating (Glasgow coma scale).
2. Assure pt’s airway
3. Hx of the injury
a. Updated tetanus? Cardiac Hx? Etc…
4. Vital signs
5. Observe for rhinorrhea or otorrhea
6. Cranial nerve exam
7. Neurologic impairment must be ruled out before analgesics are prescribed or inhalation sedation is commenced.
8. Follow-up and discharge recommendations
(Croll, Theodore P. et al., JADA, Volume 100 pp: 534 )
Summary of conclusions: If approached systematically and logically, the neurological assessment of head-trauma pt’s can be effective and rapid. If neurological impairment is suspected, immediate medical referral is indicated as impending neurological crisis of secondary injury may be prevented with early Dx and treatment.Assessment of article: Applicable and well organized.
Developmental disturbances of permanent teeth following trauma to the primary dentition 8/14/09
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Murphy Date:8/14/09 Region: Prov.
Article title: Developmental disturbances of permanent teeth following trauma to the primary dentition
Author(s): Von Arx, Thomas
Journal: Australian Dental Journal
Volume #; Number; Page #s): 38(1), 1-10
Year: 1993
Major topic: disturbances of permanent teeth following trauma to the primary dentition
Minor topic(s): n/a
Type of Article: Multiple Case review, retrospective
Main Purpose: To investigate developmental disturbances of permanent teeth following trauma to the corresponding primary dentition
Overview of method of research: Re-examination of 114 children with primary tooth trauma
Findings. Up to 45% of all children sustain injuries to their primary teeth. Injuries include crown/root fracture w/ pulpal exposure, w/o pulpal exposure, intrusion, subluxation, partial luxation, avulsion, medications, fever during tooth development, and developmental disturbances. These injuries can present as enamel hypoplasia(the most common), crown dilcaeration, root malformation, odontoma like teeth, and cessation of maturation. Any trauma to primary teeth may disturb the odontogenesis of the permanent teeth. The primary teeth most susceptible to trauma are the maxillary incisors, and consequently, the most affected permanent teeth after primary tooth trauma are the central incisors, with their labial surface being the most affected. The perm. Centrals lie palatally in very close proximity to the roots of the prim. Centrals. The perm. Laterals are behind the perm centrals, thus protecting them from labial traumatic forces. When there is intrusive luxation, there is a 69% chance of tooth malformation on the permanent teeth. In this study, 114 children, with 255 traumatized teeth were reassessed an average of five years after their initial visit. Only 56% of the permanent teeth could be examined clinically and radio graphically , with the remained being checked only by radiographs. A total of 41 teeth showed both clinical and radiographic malformation. Of this 41, 28 teeth had enamel hypoplasia, 4 had root malformation, 7 had crown dilacerations, and 2 had odontome like teeth.
Key points in the article discussion: The basic results of the study illustrate the correlations between the frequencies of developmental disturbances of perm. Teeth and the intensity of the trauma to the primary teeth i.e., intrusion bears the highest risk of damaging a developing tooth bud, while crown/root fracture w/ or w/o pulp exposure show no effect on the perm. tooth. The frequency of permanent tooth malformation following primary tooth trauma can range from 25-69%. Of the 255 traumatized teeth reviewed, only 23% showed developmental disturbances. The most common defect is enamel hypoplasia, which is usually located in the incisal half of the affected teeth. In addition, the effects of breakdown products from areas of hemorrhaging can lead to tooth discoloration. This can also affect adjacent teeth. Odontome like teeth most commonly developed when the permanent tooth was traumatized very early in development, usually when the child is around 1 year of age. Crown dilacerations occurred in cases where the child was between 1.5-3.5 years old, and root malformation between 4-5.
Summary of conclusions: Essentially, perm. Tooth trauma occurs 23% of the time following primary tooth trauma, with intrusion being the most common culprit. ANY type of trauma may lead to tooth malformation, except for fractures of the primary tooth. The extent of how malformed the perm. Teeth are is directly related to the type of trauma, the intensity of the trauma, and the stage of development that at the tooth is currently in. At the time of trauma, the parents of the child should be informed about possible effects on the developing perm. Teeth. All possible outcomes should be discussed as to ensure that the parent will not be “surprised” when you see an odontome like tooth and you need to extract it. Regular recall visits and careful following of the child following trauma is paramount.
Assessment of article: A great review of primary tooth trauma and it’s effects on perm. Teeth. Good table, easy to read.
Pictures
http://images.google.com/imgres?imgurl=http://cudental.creighton.edu/images/tdfect.jpg&imgrefurl=http://cudental.creighton.edu/htm/p_trma.htm&usg=__ykzVPmvvHvZ2ZU4unypPOKc6HtA=&h=329&w=456&sz=20&hl=en&start=13&um=1&tbnid=l2pIbHxPTKHu6M:&tbnh=92&tbnw=128&prev=/images%3Fq%3Dtooth%2Bintrusion%26hl%3Den%26rlz%3D1T4DMUS_enUS317US253%26um%3D1
http://images.google.com/imgres?imgurl=http://cudental.creighton.edu/images/tdfect.jpg&imgrefurl=http://cudental.creighton.edu/htm/p_trma.htm&usg=__ykzVPmvvHvZ2ZU4unypPOKc6HtA=&h=329&w=456&sz=20&hl=en&start=13&um=1&tbnid=l2pIbHxPTKHu6M:&tbnh=92&tbnw=128&prev=/images%3Fq%3Dtooth%2Bintrusion%26hl%3Den%26rlz%3D1T4DMUS_enUS317US253%26um%3D1
Dental Residency Program
Literature Review Form
Resident: Murphy Date:8/14/09 Region: Prov.
Article title: Developmental disturbances of permanent teeth following trauma to the primary dentition
Author(s): Von Arx, Thomas
Journal: Australian Dental Journal
Volume #; Number; Page #s): 38(1), 1-10
Year: 1993
Major topic: disturbances of permanent teeth following trauma to the primary dentition
Minor topic(s): n/a
Type of Article: Multiple Case review, retrospective
Main Purpose: To investigate developmental disturbances of permanent teeth following trauma to the corresponding primary dentition
Overview of method of research: Re-examination of 114 children with primary tooth trauma
Findings. Up to 45% of all children sustain injuries to their primary teeth. Injuries include crown/root fracture w/ pulpal exposure, w/o pulpal exposure, intrusion, subluxation, partial luxation, avulsion, medications, fever during tooth development, and developmental disturbances. These injuries can present as enamel hypoplasia(the most common), crown dilcaeration, root malformation, odontoma like teeth, and cessation of maturation. Any trauma to primary teeth may disturb the odontogenesis of the permanent teeth. The primary teeth most susceptible to trauma are the maxillary incisors, and consequently, the most affected permanent teeth after primary tooth trauma are the central incisors, with their labial surface being the most affected. The perm. Centrals lie palatally in very close proximity to the roots of the prim. Centrals. The perm. Laterals are behind the perm centrals, thus protecting them from labial traumatic forces. When there is intrusive luxation, there is a 69% chance of tooth malformation on the permanent teeth. In this study, 114 children, with 255 traumatized teeth were reassessed an average of five years after their initial visit. Only 56% of the permanent teeth could be examined clinically and radio graphically , with the remained being checked only by radiographs. A total of 41 teeth showed both clinical and radiographic malformation. Of this 41, 28 teeth had enamel hypoplasia, 4 had root malformation, 7 had crown dilacerations, and 2 had odontome like teeth.
Key points in the article discussion: The basic results of the study illustrate the correlations between the frequencies of developmental disturbances of perm. Teeth and the intensity of the trauma to the primary teeth i.e., intrusion bears the highest risk of damaging a developing tooth bud, while crown/root fracture w/ or w/o pulp exposure show no effect on the perm. tooth. The frequency of permanent tooth malformation following primary tooth trauma can range from 25-69%. Of the 255 traumatized teeth reviewed, only 23% showed developmental disturbances. The most common defect is enamel hypoplasia, which is usually located in the incisal half of the affected teeth. In addition, the effects of breakdown products from areas of hemorrhaging can lead to tooth discoloration. This can also affect adjacent teeth. Odontome like teeth most commonly developed when the permanent tooth was traumatized very early in development, usually when the child is around 1 year of age. Crown dilacerations occurred in cases where the child was between 1.5-3.5 years old, and root malformation between 4-5.
Summary of conclusions: Essentially, perm. Tooth trauma occurs 23% of the time following primary tooth trauma, with intrusion being the most common culprit. ANY type of trauma may lead to tooth malformation, except for fractures of the primary tooth. The extent of how malformed the perm. Teeth are is directly related to the type of trauma, the intensity of the trauma, and the stage of development that at the tooth is currently in. At the time of trauma, the parents of the child should be informed about possible effects on the developing perm. Teeth. All possible outcomes should be discussed as to ensure that the parent will not be “surprised” when you see an odontome like tooth and you need to extract it. Regular recall visits and careful following of the child following trauma is paramount.
Assessment of article: A great review of primary tooth trauma and it’s effects on perm. Teeth. Good table, easy to read.
Pictures
http://images.google.com/imgres?imgurl=http://cudental.creighton.edu/images/tdfect.jpg&imgrefurl=http://cudental.creighton.edu/htm/p_trma.htm&usg=__ykzVPmvvHvZ2ZU4unypPOKc6HtA=&h=329&w=456&sz=20&hl=en&start=13&um=1&tbnid=l2pIbHxPTKHu6M:&tbnh=92&tbnw=128&prev=/images%3Fq%3Dtooth%2Bintrusion%26hl%3Den%26rlz%3D1T4DMUS_enUS317US253%26um%3D1
http://images.google.com/imgres?imgurl=http://cudental.creighton.edu/images/tdfect.jpg&imgrefurl=http://cudental.creighton.edu/htm/p_trma.htm&usg=__ykzVPmvvHvZ2ZU4unypPOKc6HtA=&h=329&w=456&sz=20&hl=en&start=13&um=1&tbnid=l2pIbHxPTKHu6M:&tbnh=92&tbnw=128&prev=/images%3Fq%3Dtooth%2Bintrusion%26hl%3Den%26rlz%3D1T4DMUS_enUS317US253%26um%3D1
Guidelines for the management of traumatic dental injuries. III. Primary teeth.
Resident’s Name: Brian Schmid DMD Date: 8/14/09
Article title: Guidelines for the management of traumatic dental injuries. III. Primary teeth.
Author(s): Flores, Malmgren, Andersson et al.
Journal: Dental Traumatology
Month, Year: 2007
Major topic: management of trauma to the primary dentition
Type of Article: Review
Findings: Five percent of all injuries for which people seek treatment is due to oral problems; head injuries comprise 40% of preschool injuries an among facial injuries, dental are the most common. Recommendations for the parent concerning care of the child: keep calm and concentrate on the well-being of the child, wash the wound carefully and compress the area with clean gauze or cotton for 5 minutes to stop any bleeding, seek emergency treatment with a pediatric dentist. Damage to the lips, tongue, teeth, cheek or palate in a child under 5 y.o. should be examined, including considering the possibility of abuse. Care for primary teeth requires the additional consideration that the root of primary teeth are very close to developing permanent teeth. Tooth malformation, impacted teeth and eruption disturbances in the permanent dentition are all sequelae to trauma in the primary dentition. For trauma to an anterior tooth and depending on the childs ability to cooperate, it is recommended that a standard PA, occlusal film and a film at an obtuse angle are taken to rule out root fractures as well as possible. Post treatment, recommend to the parent soft brushing after every meal, twice daily topical treatment with chlorhexidine and to rinse regularly. See charts below for clinical care and followup for a variety of primary tooth injuries.
Assessment of article: Mostly information geared toward parents. But a useful guideline when performing phone consultations or giving info to parents.
Article title: Guidelines for the management of traumatic dental injuries. III. Primary teeth.
Author(s): Flores, Malmgren, Andersson et al.
Journal: Dental Traumatology
Month, Year: 2007
Major topic: management of trauma to the primary dentition
Type of Article: Review
Findings: Five percent of all injuries for which people seek treatment is due to oral problems; head injuries comprise 40% of preschool injuries an among facial injuries, dental are the most common. Recommendations for the parent concerning care of the child: keep calm and concentrate on the well-being of the child, wash the wound carefully and compress the area with clean gauze or cotton for 5 minutes to stop any bleeding, seek emergency treatment with a pediatric dentist. Damage to the lips, tongue, teeth, cheek or palate in a child under 5 y.o. should be examined, including considering the possibility of abuse. Care for primary teeth requires the additional consideration that the root of primary teeth are very close to developing permanent teeth. Tooth malformation, impacted teeth and eruption disturbances in the permanent dentition are all sequelae to trauma in the primary dentition. For trauma to an anterior tooth and depending on the childs ability to cooperate, it is recommended that a standard PA, occlusal film and a film at an obtuse angle are taken to rule out root fractures as well as possible. Post treatment, recommend to the parent soft brushing after every meal, twice daily topical treatment with chlorhexidine and to rinse regularly. See charts below for clinical care and followup for a variety of primary tooth injuries.
Assessment of article: Mostly information geared toward parents. But a useful guideline when performing phone consultations or giving info to parents.
Subscribe to:
Posts (Atom)