Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Management of 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 pe- diatrician or other physician. In many instances, the injured tooth’s survival is time-dependent. Therefore, it is imperative for the pedia- trician 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,

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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 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- , 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 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 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 in- volving 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 dis- placement. There is no sulcular bleeding (at the margin of the tooth and ).

Subluxation A subluxated tooth presents with ab- normal mobility but no displacement. Sulcular bleeding is present (Fig 4).

Lateral Luxation Clinically, a luxated tooth is displaced laterally, most often in a palatal/lingual direction (Fig 5). The injured tooth may be mobile or firmly locked into the displaced position.

Extrusive Luxation Partial vertical displacement of the FIGURE 2 injured tooth from its socket is clas- Permanent dentition. sified as an extrusive luxation injury or a partial avulsion (Fig 6).

If possible, and with appropriate in- Intrusive Luxation formed consent, digital photographic In this type of luxation, the tooth is documentation of the trauma is helpful forced into the alveolus and usually because it offers an exact documen- locked without any mobility (Fig 7). The tation of the extent of injury and can be tooth appears shortened. In cases of sent electronically to a consulting severe intrusion, the tooth may ap- dentist for guidance in managing the pear to be missing. Bleeding from the FIGURE 3 acute phase of treatment. Photographs gingival sulcus is present. Tooth diagram. can also be used later to facilitate any legal or insurance claims related to Avulsion radiograph selections with dental the injury. An avulsion is the complete displace- trauma, the safety principle of ALARA With the combined information from ment of the tooth out of the socket (as low as reasonably achievable) the clinical and radiographic exami- (Fig 8). The periodontal ligament is should be followed to minimize ex- nations, a diagnosis can be made, and severed, and the alveolus may be posure to radiation.8 treatment can be planned. The man- fractured.

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that is causing irritation to the tongue or lips.

Enamel and Dentin (Uncomplicated) Fracture If the fracture of the tooth is contained within the enamel and dentin layers without exposure of the pulpal tissues, then the injury is classified as an FIGURE 4 uncomplicated fracture of enamel and Subluxation. dentin. When the dentin is exposed, there is frequently sensitivity associ- ated with exposure to air, food, or beverages (Fig 9).

Crown Fracture With Exposed Pulp (Complicated) If the fracture of the tooth exposes the pulpal tissue, the injury is clas- sified as a complicated fracture. Crown fractures with exposed pulp FIGURE 5 are frequently sensitive and in- Lateral luxation. troduce an increased risk of infection because the pulp tissue is exposed to the oral flora(Fig10).Insevere fractures, the root may be involved, creating a crown-root fracture (Fig 11).

Root Fracture When the crown segment of an jured primary incisor displays mobility, there is a risk of a root fracture. This can only be verified with an intraoral dental radiograph (Fig 12).

FIGURE 6 Alveolar Fracture Extrusive luxation. Dislocation of several teeth that move together when palpated suggests that there is a fracture of the alveolus (Fig 13). Infraction (Crack) Enamel Only (Uncomplicated) Crown Fracture An infraction is a crack or craze line in PRIMARY DENTAL TRAUMA thesurfaceoftheenamel.Thetooth If the fracture of the tooth is contained EPIDEMIOLOGY AND MANAGEMENT appears intact, but crack lines may be within the enamel layer only, it is visualized by shining a focused source considered to be an uncomplicated Epidemiology of light, such as the otoscope, onto the fracture. There is generally limited In children 0 to 6 years of age, oral crownofthetoothinanaxialdi- sensitivity associated with this type of injuries are ranked as the second rection. injury unless there is a rough edge most common injury, accounting for

PEDIATRICS Volume 133, Number 2, February 2014 e469 Downloaded from www.aappublications.org/news by guest on September 25, 2021 affecting the lips, gingiva, tongue, , and severe tooth injury.12,13

Concussion No immediate treatment is indicated for a dental concussion. Observing the injured tooth for possible future pulpal necrosis is recommended. Pulpal necrosis in a primary tooth may cause the tooth to appear gray in color or to have a parulis (gingival FIGURE 7 Intrusive luxation. abscess or gum boil) on the gingiva adjacent to the root of the affected tooth. If or a lo- calized parulis forms, then referral to a dentist within a few days is recommended.

Subluxation No immediate treatment is indicated for a subluxated primary tooth. The injured primary tooth should be fol- lowed for possible future pulpal ne- crosis (as described previously). If FIGURE 8 tooth discoloration develops or a lo- Avulsion. calized parulis appears, then referral to a dentist within a few days is rec- ommended. If more extensive gingival or facial swelling develops, then im- mediate referral to a dentist is rec- ommended.

Lateral Luxation If the tooth displacement is minor, then gentle repositioning is in- dicated, or acceptance of the position FIGURE 9 as spontaneous repositioning will Uncomplicated crown fracture (no pulp exposure). take place. For more severe dis- placement injuries, the child’sability to bite teeth together may be af- almost 20% of all bodily injuries.9 The age. Exfoliation of the maxillary inci- fected. It is important to ensure that greatest incidence of trauma to the sors may vary from 5 to 7 years of the tooth position does not interfere primary teeth occurs at 2 to 3 years age. The most common dental injury with the occlusion (bite). Asking the of age, when motor coordination is to the primary dentition is a luxa- child to say “cheese” or the letter developing.10,11 The most common tion.10 Dental injuries in the primary “e” allows one to visualize the oc- teeth injured in the primary dentition dentition occur more often in boys. clusion and determine whether the are the maxillary incisors. These Child abuse should be considered as luxated tooth is interfering with the teeth are typically present in the a possible etiology in any child complete closure of the bite. If the mouth from 12 months to 6 years of younger than 5 years with trauma child is unable to bite the teeth

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interdigitate and masticate food properly. If the luxated tooth is near exfoliation and interfering with the bite, then extraction of the injured tooth is indicated. Immediate re- ferral to a dentist is recommended.

Extrusive Luxation If the extrusion is minor, then gentle repositioning is indicated. In severe extrusive injuries (>3 mm), extraction FIGURE 10 is indicated. Immediate referral to Complicated crown fracture (pulp exposure). a dentist is recommended.

Intrusive Luxation When a primary tooth is intruded, it will typically reerupt without intervention. In cases of severe intrusion, an intraoral radiograph is indicated to determine the location or absence of the injured tooth. In rare circumstances, the tooth may become ankylosed (fused to bone) and require extraction to prevent blocking of the eruption of the permanent suc- cessor. Observation is indicated for all FIGURE 11 intruded primary incisors. Immediate Crown root fracture. referral to a dentist is indicated for more severe intrusions or to rule out avulsion of the tooth. With any intruded primary tooth, there is a potential for damage to the developing permanent tooth germ.

Avulsion When a primary tooth is avulsed and the tooth was found, there is no treatment indicated. An avulsed primary tooth should not be replanted to avoid damage to the underlying permanent tooth germ.8 If the tooth is not found, clinical and radiographic examination can con- firm that the tooth is not intruded. A chest radiograph may be indicated if FIGURE 12 Root fracture. the child displays breathing difficulties to ensure the tooth was not aspirated. The subsequent avulsion site will need together, then the tooth will need to mediately referred to a dentist. It is to be monitored for healing and po- be repositioned by the urgent care important to ensure that the poste- tential space loss. If the child has an provider, or the child should be im- rior teeth (molars) are able to fully active digit-sucking habit and avulses

PEDIATRICS Volume 133, Number 2, February 2014 e471 Downloaded from www.aappublications.org/news by guest on September 25, 2021 a dentist is indicated for a tooth with a complicated fracture. If the tooth is removed, then a space maintainer may be indicated if the child has an active digit-sucking habit.

Root Fracture If a root fracture of a primary tooth is suspected because of excessive tooth mobility, then referral to a dentist for a radiographic examination is indicated. The timing of the referral to the dentist is FIGURE 13 Alveolar fracture. dependent on the amount of crown mobility. If there is concern for aspira- tion of the crown portion, then imme- a maxillary incisor, the potential for Enamel and Dentin (Uncomplicated) diate referral to a dentist is indicated; space loss in the upper anterior re- Crown Fracture subsequent management of the injured gionexists.Anappliancewithanar- A primary tooth with an uncomplicated tooth is dependent on the location of the tificial tooth may be indicated to fracture involving enamel and dentin root fracture. The closer the root frac- prevent space loss.14 Therefore, re- can be restored with tooth-colored ture is to the apex of the root, the better ferral to a dentist within a few days dental material. A referral to a den- the prognosis. This type of root fracture is recommended to provide space tist within a few days is indicated; if the rarely requires treatment. Conversely, management. child’s behavior precludes dental re- the closer the root fracture is to the storative care, then the tooth fracture crown of the tooth, the poorer the Infraction (Crack) area can be smoothed with a dental prognosis. The crown segment is usually If the primary tooth sustains a marked handpiece and polishing bur or left removed, and if the primary root can be crack in the enamel without loss of untreated if the facture site is smooth removed without damaging the un- tooth structure, then placing a resin to touch. The tooth should be moni- derlying permanent tooth bud, then it sealant over the infraction line may be tored by a dentist for signs of pulpal can also be extracted. If removal of the indicated to avoid obvious staining of necrosis until exfoliation. root poses a risk to the developing the line. In many cases, no treatment is Crown Fracture With Exposed Pulp permanent tooth bud, then the residual indicated; however, the tooth should (Complicated) root can be left and monitored for monitored for signs of pulpal necrosis natural resorption. If the fracture of the primary tooth until exfoliation. exposes the pulpal tissue, then a pul- potomy or pulpectomy and restorative Alveolar Fracture Enamel Only (Uncomplicated) Crown care is indicated. If the child’sbehavior Fracture If the trauma involves a fracture of the precludes pulp therapy and dental re- alveolar bone displayed by dislocation If the fracture of the primary tooth is storative care, then extraction of the of several teeth that move together, contained within the enamel surface traumatized primary tooth is indicated. then reposition of the segment and only, then the tooth fracture area can If the tooth is treated, then it will need stabilization with a splint is indicated. be smoothed with a dental handpiece to be monitored for signs of pulpal Immediate referral to a dentist or an and polishing bur or left untreated if necrosis until exfoliation. With severe oral surgeon is recommended. the facture site is smooth to touch. crown fractures, the root may also be This is best accomplished by a dentist involved. If a crown root fracture is and does not require immediate at- suspected, an intraoral periapical ra- Sequelae From Dental Trauma in tention unless there is a sharp edge diograph should be obtained to de- the Primary Dentition causing soft tissue injury. The tooth termine the extent of injury to the tooth To optimize the best healing results should monitored by a dentist for and root. Extraction of the tooth is in- from trauma sustained by the pri- signs of pulpal necrosis until exfoli- dicated if the fracture extends onto the mary dentition, parents and care- ation. root surface. Immediate referral to givers should be advised about the

e472 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS importance of good oral hygiene considered in assessing the cause of then repositioning with dental forceps practices and injury prevention. For dental trauma. may be indicated, requiring immediate the first 10 days after an injury to referral to a dentist. After reposition- Concussion a primary tooth, the child should eat ing, the tooth should be stabilized with a soft diet, and sucking on a pacifier No treatment is indicated for a con- a flexible splint for 2 weeks. The dentist or digit should be restricted, if pos- cussed permanent tooth. Observing will determine the need for pulp sible.9 The routine use of systemic the injured tooth for possible future therapy depending on the maturity of antibiotics in the postoperative care pulpal necrosis is recommended. the root. of primary tooth trauma is not in- dicated.9 However, the child’smedical Subluxation condition may require antibiotic cov- No treatment is indicated for a sub- Intrusive Luxation erage. Parents/caregivers should be luxated permanent tooth. The injured In cases of mild intrusion, the tooth advised about the potential for crown permanent tooth should be followed will typically reerupt gradually on its discoloration, pulp canal obliteration, or for possible future pulpal necrosis. own. Bleeding from the gingival sulcus pulpal necrosis. Children may not re- is present. If no reeruption is visible port painful symptoms from a necrotic Lateral Luxation after a few weeks, orthodontic or tooth; therefore, parents/caregivers For any amount of displacement, it is surgical repositioning of the intruded should be vigilant regarding the de- important to reposition the tooth to its tooth is necessary. Early involvement velopment of the symptoms of pulpal original position. If the displacement is of a dentist is important to supervise necrosis: gingival swelling, increased minor, then gentle digital apical the repositioning of the intruded in- mobility, and/or parulis. If any of these pressure to reposition the tooth is cisor. In severe intrusion cases, the symptoms develop, the parent/ indicated. For more significant dis- tooth may not be visible clinically, re- caregiver should obtain follow-up care placement, dental forceps may need to quiring intraoral radiography to be with the child’s dentist to determine the be used to reposition the tooth in the performed to assess the position of need for extraction of the previously proper socket position requiring im- the tooth within the alveolus. In rare injured tooth. mediate referral to a dentist. It is circumstances, the intruded tooth may important to ensure that the tooth become ankylosed (fused to bone) and PERMANENT DENTAL TRAUMA position does not interfere with the require extraction to prevent warping EPIDEMIOLOGY AND MANAGEMENT occlusion (bite). Asking the child to say of the alveolar ridge, followed by “cheese” or the letter “e” allows one placement of an artificial tooth. Epidemiology to visualize the occlusion and to en- A 12-year review of the scientificlitera- sure that the posterior teeth (molars) Avulsion ture reports that 25% of all school-age are able to fully interdigitate and children experience some form of den- masticate food properly. The perma- Avulsion of a permanent tooth is the tal trauma.15 The most common injury nent tooth will need to be stabilized most serious of all dental injuries.18 reported in the permanent dentition is with a flexible splint for 4 weeks. The The prognosis of the permanent tooth an uncomplicated crown fracture in- tooth should be followed for possible depends on measures taken immedi- volving the maxillary incisors. Injuries periodontal and pulpal pathology. Af- ately after the accident. The treatment to permanent teeth are most often ter severe permanent tooth luxation, it of choice is immediate replantation. caused by falls, followed by automobile is possible that the tooth will require After the tooth is located, it should be crashes, violence, and sports.16 Sports- . handled by the crown portion only related accidents account for 10% to and not the root because the root is 39% of all dental injures in children.17 covered in fragile fibroblasts impor- During sporting activities, falls, colli- Extrusive Luxation tant for reattachment to the alveolus. sions, contact with hard surfaces, and If the extrusion is minor, gentle digital Before replantation, it should be con- contact with sports-related equipment pressure to reposition the tooth into firmed that the avulsed tooth is place the child at risk for oral facial the socket is indicated. Immediate a permanent tooth; primary teeth injury. Boys sustain more dental inju- referral to a dentist for placement of should not be replanted. If the per- ries to their permanent teeth than girls. a flexible splint if the tooth remains manent tooth is dirty, it should be During the adolescent years, the possi- mobile after repositioning is recom- washed briefly (10 seconds) under bility of abuse exists and should be mended. If the extrusion is excessive, cold running water and repositioned

PEDIATRICS Volume 133, Number 2, February 2014 e473 Downloaded from www.aappublications.org/news by guest on September 25, 2021 in the socket. The patient/parent and polishing bur or left untreated if the health of the remaining fragment should be encouraged to replant the the facture site is smooth to touch. must be determined. In some cases, tooth at the site of the injury. The child There is generally little or no sensi- the remaining fragment can be ortho- should be instructed to bite on a cloth tivity associated with fractures in- dontically extruded and subsequently to hold it in position until he or she volving enamel, so immediate referral restored with a full-coverage crown, or can get to the doctor’soffice or to a dentist is not necessary. The tooth the remaining root can be submerged emergency department. If this is not should be monitored for signs of to maintain the alveolar bone for a fu- possible, the tooth should be placed in pulpal necrosis. ture implant. For esthetics and space a suitable storage medium (eg, a glass maintenance, the missing crown can of cold milk or balanced salt solution, if Enamel and Dentin (Uncomplicated) be replaced by an orthodontic retainer available). If no storage media are ac- Crown Fracture with a prosthetic tooth or by creating cessible, then the patient can drool sa- a temporary bridge using the original liva in to a container and use that as If the fracture of the permanent tooth crown fragment. a transport medium. Storing an avulsed is contained within the enamel and tooth in water should be avoided be- dentin surfaces without exposure of the Root Fracture pulpal tissues, then the tooth can be cause water causes osmotic lysis of the When the crown segment of an injured restored with tooth-colored dental root fibroblasts. After the tooth has permanent incisor displays mobility, re- material, or if the tooth fragment is beenreplantedorplacedinaproper ferral to a dentist for a radiographic available, it can be rebonded to the storage medium, dental care should be examination is indicated to rule out tooth. When dentin is exposed, there obtained immediately. A flexible splint a root fracture. The subsequent man- may be tooth sensitivity, and the patient will need to be placed by the dentist for agement of the injured tooth is de- should be referred to a dentist within up to 2 weeks. Most teeth will require pendent on the location of the root a few days. The more sensitive the tooth root canal therapy, which will need to be fracture. The closer the root fracture is to is, the more expediently the patient instituted within 7 to 10 days after re- the apex of the root, the better the should be seen by a dentist to cover the plantation. The tooth should be moni- prognosis. This type of root fracture exposed dentin and reduce the dis- tored for the potential of bodily rarely requires treatment. Conversely, the comfort. By covering the exposed dentin, rejection in the form of root resorption. closer the root fracture is to the crown of the risk of pulpal bacterial contamina- Systemic antibiotics are indicated after the tooth, the poorer the prognosis. tion is reduced. The tooth should be reimplantation of an avulsed perma- Splinting is recommended for 4 weeks. If monitored for signs of pulpal necrosis. nent tooth. For children older than 12 crown segment remains mobile after years, doxycycline is the recommended splinting, then the crown segment is Crown Fracture With Exposed Pulp antibiotic, and for children younger removed, and the residual root can be (Complicated) than 12 years, penicillin is indicated. For orthodontically extruded, treated with children who are allergic to penicillin, Ifthefractureofthepermanenttooth root canal therapy, and restored. clindamycin is recommended. exposes the pulpal tissue, then appro- priate pulp therapy should be rendered Alveolar Fracture by a dentist immediately to preserve Infraction (Crack) If the trauma involves a fracture of the pulp vitality (Fig 10).15 The timeliness of If the permanent tooth sustains pulp therapy is important in the young alveolar bone displayed by dislocation of a marked crack in the enamel without permanent tooth. The permanent tooth several teeth that move together, then loss of tooth structure, then placing is considered immature until 3 years reposition of the segment and stabili- a resin sealant over the infraction line after eruption. If the tooth is immature, zation with a splint is indicated. Imme- may be indicated to avoid obvious then it will need to be monitored for diate referral to a dentist or an oral staining of the line. signs of continued root development surgeon for repositioning and place- and the lack of pulpal necrosis. If the ment of a stabilization wire is indicated. Enamel Only (Uncomplicated) Crown tooth has a mature root, then root Fracture canal therapy is usually the treatment Sequelae From Dental Trauma in If the fracture of the permanent tooth of choice. In severe cases, the fracture the Permanent Dentition is contained within the enamel layer line can involve the root—hence, it is To optimize the best healing results from only, then the tooth fracture area can known as a crown-root fracture. The trauma sustained by the permanent be smoothed with a dental handpiece crown fragment must be removed, and dentition, parents and caregivers should

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be advised on the importance of good TABLE 1 Dental Treatment Plan for Traumatic Injuries in the Primary and Permanent Dentition oral hygiene practices and injury pre- Description Primary Dentition Permanent Dentition vention. For the first 10 days after an Concussion/ Observe, soft foods for 1 wk, dental Observe, soft foods for 1 wk, dental injury to a permanent tooth, the child subluxation radiograph to rule out root fracture radiograph to rule out root should eat a soft diet, and digit sucking fracture Luxation Reposition tooth or extract, Dental radiograph, reposition 15,18 should be restricted, if possible. The do not splint tooth, splint for 4 wk routine use of systemic antibiotics in Extrusion Reposition tooth or extract, Dental radiograph, reposition tooth, the postoperative care of dental trauma do not splint splint for 2 wk Intrusion Dental radiograph, observe and Dental radiograph, observe and is not indicated (except in cases of allow to reerupt, extract if allow to reerupt, surgical or permanent tooth avulsion and reim- alveolar plate is compromised orthodontic repositioning, root plantation).9 The child’s medical history canal treatment may require antibiotic coverage. Uncomplicated crown Restore tooth, smooth sharp edges, Restore tooth, smooth sharp edges, fracture dental radiograph to rule radiograph to rule out root fracture Parents/caregivers should be ad- out root fracture vised about the potential for crown Complicated crown Dental radiograph, pulp treatment, Dental radiograph, pulp treatment, discoloration, root resorption, anky- fracture restore or extract tooth, restore tooth, observe for infection, observe for infection may require root canal treatment losis, or pulpal necrosis. Parents/ Root fracture Dental radiograph, extract if root Dental radiograph, splint, may require caregiversandthechildshouldbe fracture is in middle or root canal treatment; if in cervical vigilant regarding the development cervical third of root third, may need to extract Avulsion Do not replant, dental radiograph Do not handle the root, replant within of the symptoms of pulpal and to rule out intrusion if tooth 30 min or place in recommended periodontal abnormalities sub- is not located transport medium (balanced salt sequent to the dental injury: crown solution, cold milk); dental discoloration, gingival swelling, in- radiograph, replant and splint as soon as possible; systemic creased mobility, and/or sinus tract antibiotics, soft diet, chlorhexidine, (parulis). If any of these symptoms close follow-up develop, the parent/caregiver should obtain follow-up care with the child’s dentist to determine the need for to facilitate the time-sensitive ther- physician with subsequent referral additional treatment of the pre- apies for dental injuries. to a dentist. viously injured tooth. This document is copyrighted and is Suggestions for Pediatricians property of the American Academy of CONCLUSIONS Pediatrics and its Board of Directors. 1. Counsel parents/caregivers about All authors have filed conflict of in- This clinical report provides evidence- ways to reduce the risk of dental terest statements with the American based recommendations for the trauma through injury-prevention Academy of Pediatrics. Any conflicts management of dental trauma in strategies. have been resolved through a process children 1 to 21 years of age. When 2. Establish collaborative relation- approved by the Board of Directors. The dental trauma cannot be avoided ships with local general and pedi- American Academy of Pediatrics has through the use of preventive mea- atric dentists to facilitate referral neither solicited nor accepted any com- sures, it emphasizes the importance of patients with traumatic dental mercial involvement in the development of proper diagnosis, treatment plan- injuries. of the content of this publication. ning, and follow-up care conducive to 3. Understand the differences be- a favorable outcome for an injured The guidance in this report does not tween treatment recommendations tooth in a pediatric patient. The report indicate an exclusive course of treatment for primary and permanent tooth provides decision-making strategies or serve as a standard of medical care. traumatic injuries. to assist pediatricians and other pri- Variations, taking into account individual mary care physicians in diagnosing 4. Recognize when traumatic dental circumstances, may be appropriate. and managing children who experi- injuries require immediate treat- All clinical reports from the American ence dental trauma. Table 1 provides ment by a dentist. Academy of Pediatrics automatically a concise summary of this information. 5. Recognize when traumatic dental expire 5 years after publication unless Close collaboration between the medical injuries can be initially managed reaffirmed, revised, or retired at or and dental home are also important by the pediatrician or primary care before that time.

PEDIATRICS Volume 133, Number 2, February 2014 e475 Downloaded from www.aappublications.org/news by guest on September 25, 2021 LEAD AUTHOR Melinda Clark, MD, FAAP LIAISONS Martha Ann Keels, DDS, PhD, Immediate Past Rani Gereige, MD, FAAP Joseph Castellano, DDS – American Academy of Chairperson David Krol, MD, MPH, FAAP Pediatric Dentistry Wendy Mouradian, MD, FAAP Sheila Strock, DMD, MPH – American Dental SECTION ON ORAL HEALTH EXECUTIVE Association COMMITTEE, 2012–2013 Rocio Quinonez, DMD, MPH Adriana Segura, DDS, MS, Chairperson Francisco Ramos-Gomez, DDS STAFF Suzanne Boulter, MD, FAAP Rebecca Slayton, DDS, PhD Lauren Barone, MPH

REFERENCES

1. Andreasen JO, Andreasen FM, Andersson L. root fracture of permanent incisors. Endod 14. American Academy of Pediatric Dentistry. Textbook and Color Atlas of Traumatic Dent Traumatol. 1988;4(5):202–214 Policy on emergency oral care for infants, Injuries to the Teeth. 4th ed. Copenhagen, 8. US Nuclear Regulatory Commission. 10 children, and adolescents. Pediatr Dent. Denmark: Munksgaard; 2007:224–225 CFR, x20.1003 (2013) 2012/2013;234(6):245 2. Knapik JJ, Marshall SW, Lee RB, et al. 9. Malmgren B, Andreasen JO, Flores MT, 15. Diangelis AJ, Andreasen JO, Ebeleseder KA, Mouthguards in sport activities: history, et al; International Association of Dental et al; International Association of Dental physical properties and injury prevention ef- Traumatology. International Association of Traumatology. International Association of fectiveness. Sports Med. 2007;37(2):117–144 Dental Traumatology guidelines for the Dental Traumatology guidelines for the 3. Bakland LK, Andreasen JO. Examination of management of traumatic dental injuries: management of traumatic dental injuries: the dentally traumatized patient. J Calif 3. Injuries in the primary dentition. Dent 1. Fractures and luxations of permanent Dent Assoc. 1996;24(2):35–37, 40–44 Traumatol. 2012;28(3):174–182 teeth. Dent Traumatol. 2012;28(1):2–12 4. American Academy of Pediatric Dentistry. 10. Flores MT. Traumatic injuries in the pri- 16. American Academy of Pediatric Dentistry. Assessment of acute traumatic dental inju- mary dentition [review]. Dent Traumatol. Guideline on Management of Acute Dental ries. Pediatr Dent. 2012/2013;34(6):341–342 2002;18(6):287–298 Trauma. Pediatr Dent. 2012/2013;234(6): 5. Halstead ME, Walter KD; Council on Sports 11. Avs¸ar A, Topaloglu B. Traumatic tooth inju- 230–238 Medicine and Fitness. American Academy ries to primary teeth of children aged 0–3 17. American Academy of Pediatric Dentistry. of Pediatrics. Clinical report—sport- years. Dent Traumatol. 2009;25(3):323–327 Policy on prevention of sports-related oro- related concussion in children and ado- 12. Kellogg N; American Academy of Pediatrics facial injuries. Pediatr Dent. 2012/2013;34 lescents. Pediatrics. 2010;126(3):597–615 Committee on Child Abuse and Neglect. (6):67–70 6. Andreasen FM, Andreasen JO. Diagnosis of Oral and dental aspects of child abuse 18. Andersson L, Andreasen JO, Day P, et al; luxation injuries: the importance of stan- and neglect. Pediatrics. 2005;116(6):1565– International Association of Dental Trau- dardized clinical, radiographic and photo- 1568 matology. International Association of graphic techniques in clinical investigations. 13. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental Traumatology guidelines for the Endod Dent Traumatol. 1985;1(5):160–169 Dental aspects of 1248 cases of child mal- management of traumatic dental injuries: 7. Andreasen FM, Andreasen JO. Resorption treatment on file at a major county hospi- 2. Avulsion of permanent teeth. Dent Trau- and mineralization processes following tal. Pediatr Dent. 1992;14(3):152–157 matol. 2012;28(2):88–96

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Downloaded from www.aappublications.org/news by guest on September 25, 2021 Management of Dental Trauma in a Primary Care Setting Martha Ann Keels and THE SECTION ON ORAL HEALTH Pediatrics originally published online January 27, 2014;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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