Management of Dental Trauma in the Primary Dentition

Dental trauma is very common in children. Falls and accidents happen frequently, and the oral structures are amongst the most frequent sites of injury. Hence, it is important to understand the current guidelines and recommendations on looking after traumatised primary teeth.

Traumatic Injuries to the Primary Dentition

Trauma to baby teeth is treated differently to adult permanent teeth. Treatment options are more limited and often observation rather than treatment is the best option. I have included recommendations from the International Association of Dental Traumatology (IADT) and Children's Health Queensland Hospital and Health Service, to develop the following summaries. It is essential to note that the recommendations were designed to optimise for favourable outcomes, but unfavourable outcomes may still occur.

General Advice for all paediatric dental trauma

• Check for soft tissue damage

  • If a large wound (>1cm) or grossly contaminated, discuss with the maxillofacial team regarding ongoing management.

  • If small, irrigate with saline or 0.2% chlorhexidine (local anaesthesia may be required for comfort) and leave to heal spontaneously.

• Be careful eating to avoid further damage. Try to stick to soft diets and avoid hard foods.

• An alcohol free 0.1 – 0.2% chlorhexidine gluconate mouth rinse can be applied topically twice a day for 1 week to maintain oral hygiene.

• Watch out for unfavourable symptoms

• Treatment depends on child’s maturity to tolerate procedures. Therefore discuss treatment options with the parents. In cases of high dental anxiety, it is best to refer to a child-oriented team with experience and expertise in managing paediatric dental injuries.

• Radiographic follow-up indicated when clinical findings are suggestive of pathosis or unfavourable outcomes

Antibiotics

Systemic antibiotics are not recommended to manage luxation injuries. However, if there are accompanying soft tissue injuries, it is up to the clinician.

A tetanus booster may be required if environmental contamination of the injury occurred.

·      Deep, penetrating wounds from splinters, nails or bites

·      Contamination with soil, dust or manure

If in doubt, refer to a medical practitioner within 48 hours.

What type of dental trauma is it?

Dental Trauma Diagnosis Tree

Types of Dental Trauma

Management depending on type of dental injury

Enamel fractures

Clinical findings

Enamel may be damaged

Radiographs

None needed

Treatment

Smooth over sharp edge + follow general advice

Review

Not necessary

Enamel dentine fractures (with no pulp exposure)

Clinical findings:

• Fractured confined to the exposed tooth with loss of tooth structure

• Visual loss of enamel, darker discolouration suggested dentine exposure, bleeding signifies pulp involvement

• If tender to percussion consider possible luxation injury or root fracture

• Normal mobility  

Radiographs:

• Baseline radiograph optional

• Radiograph of the soft tissues if suspect that tooth fragments have been embedded in soft tissues

• Consider possibility of lodged tooth fragment if laceration in lip of cheek

Treatment

• Cover all exposed dentine with glass ionomer or composite

• Lost tooth structure can be restored with composite at a later appointment

• Primary tooth fragments should never be bonded back into place (only a small subset of permanent tooth fractures)

Review

Clinical examination after 6 – 8wk

Radiographic follow up only when clinical findings suggest unfavourable outcomes

Complicated crown fracture with exposed pulp

Clinical Findings

Enamel and dentine and may be fractured

Radiographs

Occlusal radiograph with size 2 sensor OR

Periapical with size 0 sensor

Treatment

Preserve pulp by partial pulpotomy. LA will be needed Non setting calcium hydroxide will be needed and then a composite resin.

Cervical pulpotomy indicated for teeth with large pulp exposures

Review

Clinical examination after:

• 1 wk.

• 6-8wk

• 1 y

Radiographic follow up at 1 y following pulpotomy or root canal treatment

Crown - root fractures

Clinical Findings

• Fracture involving the enamel, dentine and cementum with loss of tooth structure.

• Crown fracture extends below gingival margin. Crown is split into 2 or more fragments, 1 of which is mobile

• Tender to percussion, fracture line may or may not pass through pulp

Radiographs

• Occlusal radiograph with size 2 sensor OR

• Periapical with size 0 sensor

Treatment

• Often no treatment may be the most appropriate but only if referral can be made immediately

Option A)

• If restorable and no pulp exposed, cover the exposed dentine with glass ionomer

• If restorable and the pulp is exposed, perform a pulpotomy (see crown fracture with exposed pulp) or root canal treatment, depending on stage of root development

Option B)

• If unrestorable, remove loose fragment carefully so as not to damage the permanent successor. Leave firm root fragment in situ.

Review

Clinical examination after

·       1 wk

·       6 – 8 ek

·       1y

Radiographic follow-up after 1y after pulpotomy

Root fractures

Clinical findings

• Fracture confined to the root of the tooth, involving cementum, dentin and pulp

• Coronal segment is usually mobile and may be displaced

• Transient crown discolouration (red/ grey) may occur

Radiographs

• Occlusal radiograph with size 2 sensor OR periapical with size 0 sensor

• (Fracture usually located mid-root or in the apical third)

Treatment

• If the coronal fragment is not displaced, no treatment required and leave it.

• If the coronal fragment is displaced and not excessively mobile, leave the coronal fragment to spontaneously reposition even if there is some occlusal interference

• If the coronal fragment is displaced, excessively mobile and interfering with occlusion, two options are available, both of which require local anaesthesia

  • Option A: extract only the loose coronal fragment. The apical fragment should be left in place to be resorbed

  • Option B: gently reposition the loose coronal fragment. If the fragment is unstable in its new position, stabilise it with a flexible splint attached to the uninjured teeth for 4 weeks

Review

• No displacement of coronal fragment, clinical examination after:

  • 1 week

  • 6 – 8 wk

  • 1 y where there are concerns of unfavourable outcome then continue clinical followup every year until eruption of permanent teeth

• If coronal fragment extracted, clinical examination after 1 y

• If it has been splinted, clinical examination

  • 1 wk.

  • 4 wk. for splint removal

  • 8 wk.

  • 1 y

• Inform patients to watch out for unfavourable outcomes

• Follow up every year until permanent teeth erupt

Alveolar Fractures

Clinical findings

Mobile and dislocated segment of several teeth moving together and interfering with occlusion.

Tenderness to percussion

Radiographs

Periapical with size 0 or occlusal radiograph with size 2

Lateral radiograph may give information about the relationship between maxilla and mandibular teeth

Treatment

Reposition under LA any displaced segment

Stabilise with a flexible splint to uninjured teeth for 4 wks

Followup

Clinical examination after:

• 1 wk.

• 4 wk. for splint removal

• 8 wk

• 1 yFurther follow-up at 6 y to monitor eruption of the permanent teeth

Radiographic follow up at 4 wk. and 1y to assess impact on the primary tooth and permanent tooth gems

Avulsed Primary Teeth

Clinical Findings

• The location of the missing tooth should be explored during the trauma history and examination

• While avulsed teeth are most often lost out of the mouth, there is a risk they can be embedded in soft tissues of the lip, cheek, or tongue, pushed into the nose, ingested or aspirated

• If the avulsed tooth is not found the child should be referred for medical evaluation to an emergency room for further examination, especially when there are respiratory symptoms  

Radiographs

• A periapical (size 0 sensor/ film, paralleling technique) or occlusal radiograph (size 2 sensor/ film) is essential to ensure the missing tooth has not been intruded

• The radiograph will also provide a baseline for assessment of the developing permanent tooth to determine whether it has been displaced

Treatment

• Avulsed primary teeth should not be replanted, as this would involve a lot of treatment, such as splint placement and removal, root canal treatment and can cause damage to the permanent tooth, as well as risk of aspirating the tooth

Review

Clinical examination after:

• 6 – 8 wk.

• Further follow-up at 6y of age is indicated to monitor eruption of the permanent teeth

Concussion

Clinical findings

• Injury to supporting structures, ie. Periodontal ligament

• No increased mobility, no displacement, pain or percussion, no gingival bleeding

Radiographs

• No baseline radiograph required

Treatment

• Observation

Review

• Clinical examination after:

  • 1 wk

  • 6-8 wk

Subluxation

Clinical findings

• Injury to supporting structures (without displacement) resulting in in increased mobility and pain

• Increased mobility, no displacement, pain on percussion, gingival bleeding acutely post injury resolves spontaneously

Radiographs

• Periapical (size 0 sensor film, paralleling technique) or occlusal radiograph (size 2 sensor.)

• Normal to slightly widened periodontal ligament space

Treatment

• Observation

Followup

Clinical examination after:

·       1 wk.

·       6 – 8 wk.

Lateral luxation

Clinical findings

• Tooth usually displaced in a palatal or buccal direction

• Occlusal interference may be present

Radiographs

• Periapical (seize 0) or occlusal radiograph (size 2 sensor)

• Increased periodontal ligament space apically

Treatment

• If there is minimal or no occlusal interference, the tooth should be allowed to spontaneous reposition

• Spontaneous repositioning usually occurs within 6 months

• In situations of severe displacement, two options are available.

  • Option A: Extraction when there is a risk of ingestion or aspiration of the tooth

  • Option B: The tooth is gently repositioned, and if unstable in its new position, splint for 4 wk. using a flexible splint attached to the adjacent uninjured teeth

Review

Clinical examination after:

• 1 wk.

• 6 -8 wk.

• 6 mo.

• 1 y

If repositioned and splinted, review after:

• 1 wk.

• 4 wk. for splint removal

• 8 wk.

• 6 mo

• 1 y

Intrusive luxation

Clinical findings

• Tooth usually displaced through the labial bone plate, or it can impinge on the permanent teeth

• Tooth has almost or completely disappeared into the socket, and can be palpated labially

Radiographs

• Periapical (size 0 sensor/ film, paralleling technique) or occlusal radiograph (size 2 sensor)

• When the apex is displaced toward or through the labial bone plate, the apical tip be seen and the image of the tooth will appear shorter (foreshortened) than the contralateral tooth

• When the apex is displaced toward the permanent tooth germ, the apical tip cannot be visualised, and the image of the tooth will appear elongated

Treatment

• The tooth should be allowed to spontaneously reposition itself, irrespective of the direction of displacement

• Spontaneous improvement in the position of the intruded tooth usually occurs within 6 mo.

• In some cases, it can take up to 1 y

Review

Clinical examination after:

• 1 wk.

• 6 -8 wk.

• 6 mo.

• 1y

Further follow-up at 6yo of age is indicated for severe intrusion to monitor eruption of the permanent tooth