Management of Dental Trauma in a Primary Care Setting Abstract

Guidance for the Clinician in Rendering Pediatric Care CLINICAL REPORT Management of Dental Trauma in a Primary Care Setting Martha Ann Keels, DDS, PhD, and THE SECTION ON ORAL abstract HEALTH The American Academy of Pediatrics and its Section on Oral Health have KEY WORDS developed this clinical report for pediatricians and primary care physi- dental trauma, dental injury, tooth, teeth, dentist, pediatrician cians regarding the diagnosis, evaluation, and management of dental ABBREVIATION trauma in children aged 1 to 21 years. This report was developed CT—computed tomography through a comprehensive search and analysis of the medical and den- This document is copyrighted and is property of the American tal literature and expert consensus. Guidelines published and updated Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American by the International Association of Dental Traumatology (www.dental- Academy of Pediatrics. Any conflicts have been resolved through traumaguide.com) are an excellent resource for both dental and non- a process approved by the Board of Directors. The American dental health care providers. Pediatrics 2014;133:e466–e476 Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this report does not indicate an exclusive INTRODUCTION course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be By 14 years of age, 30% of children have experienced a dental injury.1 appropriate. Many of these children are taken directly to their medical home, an urgent care center, or an emergency department for evaluation and treatment. Few of these facilities employ a dentist; therefore, the primary care provider for the injured child will most likely be a pediatrician or other physician. In many instances, the injured tooth’s survival is time-dependent. Therefore, it is imperative for the pediatrician to manage the acute dental injury properly to afford the child’s dentition the best possible outcome. Pediatricians can also advocate for dental injury–preventive measures, as they provide other injury- prevention messages for caregivers of children and preparticipation www.pediatrics.org/cgi/doi/10.1542/peds.2013-3792 sports physicals. doi:10.1542/peds.2013-3792 All clinical reports from the American Academy of Pediatrics DENTAL TRAUMA PREVENTION automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Pediatricians can advocate for dental injury–preventive measures as PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). they provide other injury-prevention messages during well-child visits. Copyright © 2014 by the American Academy of Pediatrics Caregivers should be counseled about participation in sports and activities that are appropriate for the child’s age and development, general household safety measures such as stairway gates and re- moval of trip hazards, and adult supervision of activities that could lead to dental trauma. Although these measures will not prevent all dental injuries, they can reduce their incidence and severity. As part of a preparticipation sports physical, physicians should recommend sports mouth guards to prevent sports-related mouth injuries. Currently, the US National Collegiate Athletic Association requires mouth guards for 4 sports (ice hockey, lacrosse, field hockey, e466 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS and football).2 The American Dental immediate medical evaluation should teeth. The permanent teeth follow Association recommends the use of be prioritized.5 Specific to the teeth, a numbering system (Fig 2). Discussion mouth guards in 29 sports/exercise disturbances in the occlusion (bite) with the parent/caregiver as to activities. Sports mouth guards can should be assessed because this may whether the child has lost any primary be made of a variety of materials: reveal a displaced tooth or an alveolar teeth from natural exfoliation can help polyvinyl acetate-polyethylene or ethyl- or jaw fracture. Lastly, inquiring about identify whether the child is in full ene vinyl acetate copolymer, polyvinyl- tooth sensitivity or pain to hot and/or primary dentition or mixed dentition. chloride, latex rubber, or polyurethane. cold exposures may indicate that the Primary incisor teeth are considerably Mouth guards can be custom made in dentin and/or pulp tissue are exposed, smaller in size than permanent teeth. the dental office from an impression of requiring immediate referral to a den- Physicians can use their own dentition the patient’s maxillary arch and can tist. as a point of reference to estimate the also be purchased, typically in a store The clinical examination should in- size of permanent teeth for compara- that carries sports-related items. Pur- clude thorough evaluation of the face, tive purposes. In addition to proper chased mouth guards can be custom- lips, and oral musculature for soft tooth identification, the direction of any ized by boiling the mouth guard to tissue lesions. To facilitate an accurate tooth displacement as well as any pulp soften the material and then biting into extraoral and intraoral examination, involvement should be noted. Famil- the mouth guard to create an impres- the face and oral cavity should be iarity with tooth anatomy will assist in sion of the upper teeth, which helps cleansed with water or saline. The determining the extent of injury pres- fi create a better t. Stock mouth guards facial skeleton should be palpated for ent (Fig 3). can also be purchased, but they are signs of fractures. The dental trauma After the initial clinical assessment and not as well adapted to the teeth. Im- region should be inspected for frac- administration of first aid, the injured pact studies have shown that wearing tures, abnormal tooth position, and region should be examined with the any type of mouth guard reduces the tooth mobility. Identifying whether the most appropriate radiographic techni- risk of tooth injury compared with not injured tooth is a primary versus ques. Radiographic assessment of an wearing a mouth guard. a permanent tooth is important in the injured tooth is best accomplished with management of certain types of dental conventional intraoral dental radio- DENTAL TRAUMA ASSESSMENT injuries. In general, children younger graphs instead of computed tomogra- than 5 years are in the primary den- phy (CT). There is considerably less For all dental injuries, it is important to tition (Fig 1).* The 20 primary teeth radiation involved with conventional follow a systematic approach.3 Before are named alphabetically starting intraoral dental radiographs than with initiating treatment, an abbreviated with tooth A in the upper right pos- a head CT scan. Several clinical studies medical and dental history should be terior quadrant. From ages 6 through have demonstrated that multiple dental obtained to gain information vital to 12 years, children are in the mixed radiographs from different angulations urgent care. Questions with respect to dentition in which they are exchang- are needed to detect displacement of how, when, and where the dental injury ing the primary teeth for the perma- the tooth in its socket as well as pres- occurred are important for determining nent teeth. After 8 or 9 years of age, ence of root fractures.6,7 If a lip lacer- the need for a tetanus booster, the most of the incisors are permanent ation is present, an intraoral soft tissue possibility of child abuse, and the pos- teeth, with a mixture of primary 4 radiograph may be indicated to visual- sibility of a head injury. Physicians canines and molars until the age of have the legal obligation to explore and 12 years. By 13 years of age, most ize any foreign bodies, including tooth report reasonable suspicions of child children have exfoliated all of their fragments. These types of radiographs abuse. Given the proximity of the den- primary teeth and have 28 permanent are more feasibly obtained by a dentist tition to the cranium, it is important to because a general emergency de- complete an age-appropriate neuro- *All black and white drawings are reproduced partment or radiologist’s facility may logic assessment, which may include with permission from Fisher M, Keels MA, McGraw not be equipped to perform radiog- inquiring whether the child experi- T, Neal C, Pinkerton K. Dental trauma. In: Marcus raphy, and a dentist’s evaluation may JR, Erdmann D, Rodriguez ED, eds. Essentials of enced loss of consciousness, dizziness, Craniomaxillofacial Trauma. St Louis, MO: Quality be required to order the correct ra- headache, or nausea and vomiting. If Medical Publishing; 2012:313–321. All color draw- diographic studies. If a maxillary or a concussion or a more severe in- ings and clinical photographs and radiographs mandibular fracture is suspected, are reproduced from www.dentaltraumaguide. fi tracranial injury is suspected, then com with written permission from Dr Jens Ove a panoramic lm, cone-beam CT, or protection of the cervical spine and Andreasen. CT scan may be indicated. For all PEDIATRICS Volume 133, Number 2, February 2014 e467 Downloaded from www.aappublications.org/news by guest on September 25, 2021 agement of dental trauma is described here in 2 parts: trauma involving the primary dentition and trauma involving the permanent dentition. Depending on the type of dental injury, there can be distinct differences in how a primary tooth is managed compared with a permanent tooth. DENTAL TRAUMA CLASSIFICATIONS Concussion FIGURE 1 Primary dentition. A concussed tooth is tender to touch, but there is no increased mobility or displacement. There is no sulcular bleeding (at the margin of the tooth and gums). Subluxation A subluxated tooth presents with abnormal mobility but no displacement. Sulcular bleeding is present (Fig 4).

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