We all know that kids like to test gravity and sometimes suffer the consequences (ex, Tongue Laceration, Eyelid Laceration, and Concussions). One of the most common consequences of testing gravity (or general poor coordination) is dental trauma.  This is true for adults and older children also, but what needs to be done when the trauma involves a young child’s primary dentition?

What follows is based on info from www.dentaltraumaguide.com (which has some excellent graphics) as well as other references, like [Keels, 2014].

Dental Trauma Basics

• Toddlers and Pre-Teens!
  • Dental trauma often occurs in Toddlers (2-4 years) and school-aged children (8-10 years). [Ritwik, 2015]
    • Toddlers – they like to toddle and fall down
    • Pre-Teens – like to partake in activities (like sports), yet often are not as coordinated as their older counterparts.
      • Sports (39%) and Accidental Falls (33%) comprise the majority of cases. [Bruns, 2008]
  • Primary dentition involved in close to half of the cases (~47%). [Ritwik, 2015]
• While often seen in the Emergency Department, a Dental Clinic is the most efficient venue for treating routine dental trauma. [Mitchell, 2014; Wagle, 2014]

• As with all trauma, do not get distracted by/focus only on the obvious injury.
  • It is always best to consider “worse first” and proceed in a organized fashion.
  • Many dental injuries will be isolated, but make sure that there is not evidence of more significant trauma (ex, Raccoon Eyes, Battle Sign, Hemotympanum, Mid-face instability, etc).

• When dealing with children and trauma, always ask whether the mechanism makes sense for the injury.
  • Did the toddler’s stumble really lead to a maxillary fracture?
  • Non-accidental Trauma happens. Be alert for it.

Primary Dentition Basics

• Primary teeth are identified by letters rather than numbers.
  • “A” through “T”
  • Starting with Right Maxillary Second Molar and ending with Right Mandibular Second Molar.
• Primary incisors are smaller than adult incisors.

• Management decisions are different between Primary and Adult dentition, so it is important to know which your patient has injured.
  • In GENERAL (not all patients abide by these generalities):
    • Children < 5 years of age have primary teeth.
    • Children 6 – 12 years have mixed dentition.
      • Most incisors are adult teeth by age 8 or 9 years.
      • Continue to have mixture of primary canine and molars until ~12 years of age.
    • Children > 13 years of age, typically, have lost all of their primary teeth.
  • Ask the patient/parent whether it was a “baby tooth” or an adult one: they will likely know best.

Primary Tooth Trauma: Management

• Most common primary teeth injured are the primary incisors.
• Most common type of injury to primary teeth is luxation. [Flores, 2002]

• Must consider the un-erupted permanent tooth’s health during management of primary tooth.
• With respect to trauma to a tooth, decide whether there is displacement or pulp involvement. [Keels, 2014]

1. Concussion and Subluxation
   • Similar to adult tooth care. No immediate care required.
   • Potential risk for discoloration of tooth or development of gingival abscess – recommend monitoring.
2. Lateral luxation
   • If displacement is minor, can gently reposition. Often will reposition spontaneously.
   • Ensure tooth position does not interfere with bite. If it does, it needs to be repositioned.
3. Extrusive Luxation/Partial Avulsion
   • Vertical displacement of the tooth from its socket.
   • If minor, gentle repositioning is fine.
   • If > 3mm, extraction of tooth is preferred.
4. Intrusive Luxation
   • Tooth is forced into the alveolus.
   • It will appear shortened and may even appear to be missing!
     • If you are unsure whether the tooth in avulsed or intruded, x-rays are warranted.
   • Primary teeth that are intruded will typically re-erupt without intervention.
   • Observation and follow-up is warranted to ensure the tooth re-erupts, as rarely it will become fused to the bone.
   • Families should be informed about the potential damage to the developing permanent tooth (only time will tell).
5. Avulsion
   • Unlike an permanent tooth, an avulsed primary tooth should not be replaced!
   • Most important question to ask: “Where is it?” If location isn’t know, consider Intrusion or Aspiration of it.

1. Infraction / Crack and Enamel Only Fractures
   • No immediate care needed.
   • Rough edges may need to be resurfaced by dentist.
2. Uncomplicated Enamel and Dentin Fracture
   • Referral to dentist in a few days for possible restorative care.
   • May have discoloration and/or gingival abscess formation – needs monitoring.
3. Crown Fracture with Exposed Pulp
   • This requires specialized care (see: pulpotomy, pulpectomy, or extraction).
   • Can be done in your ED or, if Dental services are available, referral is appropriate as well.
4. Root Fracture
   • The closer the fracture is to the apex of the root the better the prognosis.
   • The closer to the crown the fracture is the worse the prognosis.
   • This requires specialized case (see video).

Dental Trauma Basic Home Care

• Oral hygiene is important after (and yes, even before) dental trauma.
• Soft Diet is recommended for the first ~10 days after injury.
• Pacifier or digit sucking should be restricted.
  • If a tooth is extracted / avulsed, patients who suck pacifiers/fingers may require a spacer.
• Antibiotics are NOT needed empirically for most patients.
• Monitor for signs of discoloration, gingival swelling, and/or facial swelling.

References